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Technique Skills in Chiropractic

David Byfield, BSc(Hons) MPhil DC FCC FBCA FFEAC


Head of Division - Chiropractic, Head of the Welsh Institute of Chiropractic, Faculty of Health, Sport and Science,
University of Glamorgan, Pontypridd, (Wales), UK

Churchill Livingstone
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2012 Elsevier Limited. All rights reserved.


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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of each
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administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
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Contributors

Michael Barber, PgCert DC


Senior Lecturer, Welsh Institute of Chiropractic, Faculty of Health, Sport and Science, University of Glamorgan Pontypridd,
(Wales), UK

David Byfield, BSc(Hons) MPhil DC FCC FBCA FFEAC


Head of Division Chiropractic, Head of the, Welsh Institute of Chiropractic, Faculty of Health, Sport and Science, University
of Glamorgan, Pontypridd, (Wales), UK

Brian J. Gleberzon, BA MHSc DC


Professor, Chair of Chiropractic Therapeutics, Department Canadian Memorial Chiropractic, College, Toronto, ON, Canada

B. Kim Humphreys, BSc(UBC) DC(CMCC) PhD


Professor of Chiropractic, Faculty of Medicine, University of Zrich, Zrich, Switzerland.

Annabel Kier, DC
Senior Lecturer, Welsh Institute of Chiropractic, Faculty of Health, Sport and Science, University of, Glamorgan, Pontypridd,
(Wales), UK

F. Stuart Kinsinger, BSc MA DC


Associate Professor, Canadian Memorial Chiropractic College, Toronto, Canada

Michael Kondracki, MSc PhD DC


Senior Lecturer, Anglo-European Chiropractic, College (AECC), Bournemouth, UK

Peter W. McCarthy, BSc(JtHons) PhD


Professor of Chiropractic, Welsh Institute of, Chiropractic, Faculty of Health, Sport and Science, University of Glamorgan,
Pontypridd, (Wales), UK

J. Kim Ross, BSc MSc DC PhD


Associate Professor, Director of Education Year 1, Canadian Memorial Chiropractic College, Toronto, ON, Canada

Mark Webster, DC BSc MSc(ClinChiro) MSc(PainMgt)


Principal Lecturer/Award Leader, Welsh Institute of Chiropractic, Faculty of Health, Sport and Science, University of
Glamorgan, Pontypridd, (Wales), UK

Steve Williams, DC DICS FICS FCC(Paed) FCC(Cranio) FBCA


Chiropractor, St James Chiropractic Clinic, Southampton, UK
Foreword

David Chapman-Smith
David Byfields text Chiropractic Manipulative Skills (1996, Second Edition 2005) has been
highly successful, not only with students but also with practitioners.
Key reasons are its clear and logical progression through foundational concepts for technique
(posture, biomechanics, motor learning), and then specific diversified techniques by region and the
needs of special populations. Others are the superb illustrations and the obvious clinical and
teaching expertise of an established leader in the profession and his co-authors.
However this new, expanded and improved version of the text - re-titled Technique Skills in
Chiropractic - moves to a higher level yet. Reasons for this are many, but include:

New technology Technique Skills in Chiropractic comes with access to a website providing on-
line video clips demonstrating all spinal, pelvic and extremity assessment and treatment
techniques in the book. The reader can compare these with the print photographs, a major advance
in a technique text. In addition the full book is available online allowing quick search, highlighting
and note-making, and efficient use of time.
New authors from Europe and North America, bringing broader expertise from the fields of
education and clinical practice. There are new chapters (e.g. current information on the
biomechanics of the adjustment, technique skills for women, ethics and professionalism) and
revised and expanded chapters (e.g. specialized skills for use with older patients, pregnant
women and children).
The expanded evidence base, with relevant research up to and including 2011. See much important
new research, for example, on the safety and effectiveness of cervical spine manipulation, a field
of technique covered with outstanding clarity and expertise by Byfield in Chapter 11. A core
strength of the text, as with its predecessors, is its evidence-based approach to technique and
practice.

During the past decade recommendations in many national and international clinical guidelines
have supported skilled manipulation as a first line option for patients with the most common forms of
spine-related pain, including acute and chronic mechanical neck and back pain and headache. This
has given new status to and interest in the art and science of manipulation. That is obviously exciting
for the chiropractic profession. However it also raises the bar.
Here is the precise quality of text needed to rise with that bar. As learning is more than ever a
lifetime need for professionals today, this timely print and electronic book will be a boon to both
undergraduate student and seasoned practitioner. A major and timely contribution to the literature
and clinical education warm congratulations to Byfield and his fellow authors.
Video clips of technique skills

The video footage has been produced to support the text and provide a live demonstration of
the psychomotor skill described in detail in each specific chapter. Where you see the above icon in
the margin of the page, this indicates that there is specific demonstration footage for that particular set
of skills or manipulative technique. This will allow you to view and practise the various skills and
techniques in conjunction with the script at hand in order to master their performance.
Acknowledgements
I would like to thank Annabel Kier and Michael Barber for their help and assistance during the
shooting and production of the video material. I would also like to thank Roger Carruthers and his
assistants in the Learning Resources Centre at the University of Glamorgan for their expertise while
filming in the studio and during the hours of editing to complete the final product. Final year students
Rob Palmer, Ben Carraway, Freddie Powell and Lee Taylor were willing models for the video shoot
and their contribution is much appreciated.
Atlas Clinical Ltd UK kindly supplied the table and other equipment used in the production of
this new book and ancillary website. The equipment is versatile and provides comfort for both patient
and practitioner it is a piece of kit I would highly recommend.
I am grateful to the new members of the writing team, including Dr Stuart Kinsinger, Dr Brian
Gleberzon, Dr Kim Ross and Dr Steve Williams, and thank them for their valuable contribution. My
thanks also go to Dr Robert Cooperstein for offering his valued feedback on the Introduction to the
book. It would be an omission not to mention my appreciation of the updated work provided by my
longstanding contributors Professor Kim Humphreys, Dr Mark Webster, Professor Peter McCarthy
and Dr Michael Kondracki. We have been working together for a long time and the book would not be
the same without them.
Last but not least, I extend my thanks to Elsevier and particularly Sheila Black (Development
Editor), Claire Wilson (Commissioning Editor), Sruthi Viswam (Project Manager) and Barbara
McAviney (Copy Editor) for their patience and trust that this project would be completed.
Table of Contents

Instructions for online access


Copyright
Contributors
Foreword
Video clips of technique skills
Section 1: Background Knowledge
Introduction to adjustive techniques and manipulative skills in chiropractic
Chapter 1: The importance of ethics and professionalism to manual therapists
Chapter 2: The learning and performance of chiropractic manipulative skills
Chapter 3: Biomechanics of the spinal adjustment and other clinical biomechanical
considerations in manipulative skills training: an evidence-based investigation
Chapter 4: The physiology underlying skill performance
Section 2: Foundation skills for manipulative/adjustive techniques
Chapter 5: Postural and positional considerations for the practitioner
Chapter 6: Adjustive and manipulative thrust skills, other movements and related exercises
Chapter 7: Identification of important spinal landmarks
Section 3: Basic manipulative/adjustive techniques for the spine and pelvis
Chapter 8: Pelvic/sacroiliac adjustive and manipulative skills
Chapter 9: Lumbar spine adjustive and manipulative skills
Chapter 10: Thoracic spine adjustive and manipulative skills
Chapter 11: Cervical spine adjustive and manipulative skills
Section 4: Specialist adjustive and manipulative skills
Chapter 12: Basic paediatric manual skills

Chapter 13: Basic manual techniques for the pregnant patient

Chapter 14: Spinal adjusting and clinical management of the older adult
Appendix I: Summary of cardinal rules
Appendix II: Recommended sequence of manipulative skills and other considerations
Index
Section 1
Background Knowledge
Introduction to adjustive techniques and
manipulative skills in chiropractic

David Byfield, Brian J. Gleberzon


Chapter contents

Background
Educational perspective
The textbook
Summary
References
Background
It goes without saying that the most significant and recognizable therapeutic intervention employed by
a chiropractor involves the manipulation/adjustment of the articulations of the human body. The
chiropractic profession has remained dedicated to the use of manipulative therapy throughout its
development over the past 100 years or more. This is evidenced by the plethora of distinct
chiropractic technique systems currently in use today. It has been estimated there are somewhere in
the region of 300 discrete chiropractic techniques practised by the profession worldwide
(Cooperstein & Gleberzon 2004). Regrettably, many of these technique systems have never been
subjected to rigorous scientific scrutiny or clinical trials. As a result many practitioners continue to
apply unreliable diagnostic methods, incorporate both the questionable use of X-ray imaging and
serial X-rays, make unsubstantiated clinical claims and expound manipulative procedures that
contravene biomechanical principles. Furthermore, it is only recently that the significance of the joint
crack (or cavitation) has come to light in terms of its clinical and therapeutic significance. It is still
the most universally and clearly perceived favourable response of the patient and practitioner and the
debate continues regarding its significance for successful spinal manipulation. Some regard the
audible crack as an absolute necessity while others consider it to be of no importance at all. Most of
the evidence to date seems to point to the fact that significant neurological responses or reflex
changes following a manipulative thrust occur with or without cavitation. This would seem to suggest
that a cavitation is not necessary to elicit a therapeutic response, although its absence does not seem
as satisfying to either the doctor or patient in terms of clinical efficacy. This will be discussed in
some detail during the course of the text (See Chapter 3), but the authors draw the readers attention
to Walter Herzogs text Clinical Biomechanics of Spinal Manipulation (Herzog 2000) for more
details. From a clinical perspective, Bronfort et al. (2010) have recently published a comprehensive
summary of the scientific evidence regarding the effectiveness of manual treatment for the
management of a variety of musculoskeletal and non-musculoskeletal conditions. This report provides
an excellent up-to-date account of the effectiveness of spinal manipulation/mobilization for a variety
of conditions.
Notwithstanding, it is time for the chiropractic profession to begin the overdue task of evaluating
specific technique procedures and systems using rigorous research enquiry. Not all technique systems
function equally well in musculoskeletal case management. Indeed, champions of many of these
technique systems take great pride in the fact that they focus on wellness or the removal of
subluxation rather than symptom alleviation or restoration of function relative to patient needs. The
irony may simply be that all techniques cause the same neurobiomechanical effects. Triano (2003) has
stated that, regardless of the technique, there are only six ways of mechanically loading the spine and
its related tissues despite any biomechanical claims. These loads can be applied in a variety of
manual and mechanically assisted methods common to chiropractic practice (Triano 2003).
Furthermore, there are clinical issues relating to joint specificity and the presumption that spinal
manipulation must be and can be performed at specific spinal segments for a therapeutic effect. This
topic will be discussed later in the introduction and Chapter 3, but suffice to say, many sceptics have
challenged this particular concept, particularly since we lack a valid gold standard to employ when
isolating a clinical target. The most commonly used manipulative skill is a high-velocity low-
amplitude (HVLA) thrust delivered to a specific osseous contact in a specific direction. There are
many definitions describing this specific manipulative skill. However, whilst chiropractors employ a
wide range of manipulative skills, the exact mechanism of action is still largely undetermined,
although the clinical effectiveness has been well established (Bronfort et al. 2010). Nonetheless,
there are a number of plausible hypotheses that attempt to provide a rational explanation for many of
the observed clinical results (Meeker & Haldeman 2002), but valid research evidence is still sorely
lacking to fully explain the exact nature of these clinical observations. Ongoing investigations will
eventually provide valuable insight into such complex neurophysiological events and patient
perceptions.
Moreover, there is virtually no published research comparing one adjustive system against
another. To the best of our knowledge, the only good-quality study investigating the effectiveness of a
specific chiropractic technique (toggle-recoil) involved a randomized controlled study of the
management of chronic headaches with upper cervical joint dysfunction (Whittingham et al. 1994,
Whittingham & Nilsson 2001). Bearing this in mind, the profession should embark on a research
campaign to undertake a critical analysis of the efficacy of individual techniques or a comparison
between specific techniques with respect to a single disease process and relate this to measurable
clinical outcomes. The effectiveness of spinal manipulation for the treatment of musculoskeletal
dysfunction, particularly low back pain, neck pain and headache can no longer be justifiably
questioned in light of the overwhelming evidence (Bronfort et al. 2010, Lawrence et al. 2008). It is
the opinion of the authors that this evidence represents a positive endorsement for manual therapy as
an effective therapeutic option for a range of musculoskeletal complaints and some non-
musculoskeletal conditions. Likewise, there are several national guidelines that include spinal
manipulation as an option for the management of acute low back pain. The recent National Institute
for Clinical Excellence (NICE 2009) publication regarding the treatment for chronic low back pain is
an excellent example. In addition this reinforces the view that manipulation is a very effective clinical
component of a comprehensive management scheme or package of care (Hartvigsen 2006, Hayden et
al. 2005, UK BEAM Trial 2004) that incorporates a biopsychosocial model of healthcare (Waddell
2004).
Educational perspective
Researchers have been investigating the physical parameters of spinal manipulation and exploring
how these complex skills are acquired, during undergraduate training (Triano et al. 2002, 2003), and
developed, during postgraduate development (McCarthy et al. 2002). These issues will be explored
in more detail throughout the text, particularly in Chapter 1, which deals with the learning and
teaching of manual psychomotor skills. It is the authors opinion that this type of objective
investigation will develop into a very active field of future research and inquiry. There is a necessity
to introduce scientific method and investigation at this stage in the professions educational
development to establish standards and meaningful protocols for both undergraduate and postgraduate
manual skill.
Manipulative procedures are a complex set of learned psychomotor movement patterns requiring
years of training to develop a level of consistency, competency and finesse from beginner to novice
through to mastery/expertise. Some say this is a 1012-year process (Chambers 1995) and the
authors own research indicates that chiropractors appear to become significantly more consistent and
skilful after 5 or more years of practice when compared with those who have been in practice for a
shorter period (McCarthy et al. 2002). This process takes the practitioner through a continuum of
improved abilities from safe, to functionally adequate, to masterful and, finally, to the top of the scale,
innovative (Triano et al. 2003). This is crucial, as the effectiveness of care has been partially
attributed to the clinicians overall skill. Developing clinical expertise is at least a five-stage model;
the student progresses from beginner to a level of competency defined by specific learning outcomes,
eventually becoming a master/expert level following years of continuing professional development.
This will not only provide an area of professional development for newly graduated practitioners, but
it will also offer a challenge to those involved in training, prompting them to improve on their
transition skills acquired by graduation to a level of mastery, so that at the practice interface
standards are raised and patients protected.
At the undergraduate level, we have been teaching manipulative and other manual skills for
decades without valid tools or standardized protocols to objectively assess the progress of students
through their psychomotor skill acquisition. In particular, the authors have been teaching manipulative
skills for a large proportion of their educational careers and the approach for the most part has been
both qualitative and descriptive only. On the whole the qualitative/descriptive or show and tell
approach has been successfully employed, teaching students many subtle skills related to a range of
diversified adjustive procedures throughout the spine, pelvis and extremity articulations. In addition,
we have been meticulous in breaking down complex procedures into their constituent sub-skills,
including patient positioning, practitioner posture, hand contact, support hand contact and other
important pre-thrust psychomotor skills. The emphasis is on detail, which is the underlying theme of
this text and will be presented in all of the chapters pertaining to manipulative skills for the spine and
pelvis. A solid underpinning of core functional and biomechanical knowledge has also been regarded
as essential in the acquisition of these complex skills and has been advocated at the undergraduate
level. A keen understanding of these biomechanical principles provides a foundation for skills
learning and enhances the psychomotor skill learning. This will be covered in more detail throughout
the text and particularly in Chapter 3.
If we are to progress we need to identify our core skills, develop normative standards and
formulate valid and reliable quantification systems to measure student progression and competency
prior to graduation. We also need to provide valuable feedback to ensure appropriate skill
acquisition and methods to determine maintenance of these skills during practice life. It is the authors
opinion that teaching manual psychomotor skills should also include general fitness, proprioception
training, mental imagery and visualization methods to ensure that long-term acquisition is
accomplished. In the educational setting, we must keep in perspective that the graded application of a
manipulative preload and a high-velocity force are the most variable and difficult psychomotor skills
to learn and execute. It should also be fully appreciated that the application of a thrust is the last in a
series of skill sets performed during a manipulative procedure following a complex series of many
other preparatory skills. Additionally, there are a number of essential physical elements required for
developing manipulative skills, including speed, strength, coordination and balance; this is another
area of potential research investigation during manipulative skill acquisition.
Current evidence regarding manipulation indicates that chiropractors exhibit a wide range of
physical parameters during the delivery of an adjustment to the spine (Herzog 1996, 2000). For
example, forces measured during a side lying sacroiliac joint adjustment ranged from 0 to 300 N (0
32 kg) preload and 200 to 1200 N (20125 kg) for peak thrust forces (Herzog 1996, 2000). This
represents a considerable difference particularly when we currently dont know the therapeutic range
or threshold. This disparity may be the result of the level of experience or school of graduation, but
whatever the scenario this may in itself be a challenge for researchers and educationalists alike to
investigate and determine how one can narrow this gap and variability from a quantitative point of
view.
It is also a well-documented fact that patients tend to experience various side-effects to
manipulative intervention, ranging from more common local discomfort to more serious, but
extremely rare, adverse reactions. Are these mild reactions normal consequences of an adjustive
thrust, or are they proportionate to the amount of force applied or skill applied, or do they result from
the diagnostic palpation that occurs as a precursor to selecting a clinical target? There are a plethora
of questions that have never been addressed successfully and are, unfortunately, taken for granted. In
terms of serious adverse reactions, a causal link between cervical manipulation and stroke has never
been truly established despite a number of spurious articles designed to arouse public fears that have
appeared in the popular press internationally. Having said that, and considering the lack of valid and
reliable indicators to identify those at risk, clinicians have to become increasingly diligent and
skilled at recognizing the subtle signs and symptoms of an impending stroke. This particular subject
will be discussed in more detail in Chapter 11. This is a highly controversial area where facts and
research evidence must prevail. The post-manipulative stroke scenario has been the subject of many a
media headline generating significant inter-professional controversy and debate. Furthermore, there
are many that feel such clinically catastrophic events are already underway prior to visiting a
chiropractor and the challenge for the practitioner is to develop new investigative skills and
recognize those at risk in order to make the most appropriate decisions regarding the patients health
and welfare. In response the chiropractic profession (researchers and educators) must take a
responsible position and move towards formulating meaningful research and educational protocols to
ensure public safety and restore any loss of confidence.
Researchers are still pondering what delineates a good adjustment from a bad adjustment using
a psychomotor skill perspective, or how to predict what factors will determine that an adjustment
will most likely result in clinically meaningful outcomes. Dr Walter Herzog (University of Calgary)
has investigated this particular issue extensively. He and his co-workers have concluded from their
experimentation that there are at least two key psychomotor skills, force and speed, that are primarily
involved in the application of a manipulative thrust. Force and speed are measurable entities, which
provide for ideal research investigation and undergraduate assessment criteria. The amount of force
required may be a factor related to how much resistance is in the patient. These concepts will be
presented in more detail throughout the body of the text in the relevant chapters dealing with
manipulative skills. Other groups working in this area of investigation have identified rise time, rise
rate, peak force and fall time during the thrust application as key measurable skills that may provide
standards in educational development. Much work is needed within the educational environment to
identify key manipulative skill competencies, to standardize outcome assessment and to provide
meaningful feedback on progress. This will be addressed in more detail in Chapter 2, and throughout
the various chapters in the text dealing with manipulative skills.
The textbook
There is no doubt that chiropractic adjustive techniques are considered a complex interaction of
numerous structured psychomotor skills. They constitute the foundation of chiropractic clinical
therapeutics, and are an integral part of chiropractic management of musculoskeletal dysfunction. It
must be emphasized that chiropractic care is not simply synonymous with manipulation only, but it is
part of a package of care that is evidence based and adheres to many contemporary guidelines (such
as NICE and European Back Pain Guidelines).
Chiropractic manipulation is delivered with finesse. Manipulative/adjustive finesse is an
extremely important quality to engender in a protomanipulator, particularly at the undergraduate level.
Manual therapy, once dominated and practiced primarily by those who were perceived to have
sufficient muscular strength, is emerging as an elegant style characterized by smooth, controlled, and
purposeful movements adaptable for all physical derivations and capabilities. There is no room for
unskilled heavy-handedness within the manual arts, which may increase patient resistance and post
treatment reactions.
Furthermore, it should be reinforced that spinal manipulative therapy is a full-time vocation;
one which requires a great deal of time and energy for the acquisition, mastery and maintenance of the
necessary clinical skills (Cassidy et al. 1992). Skilled manipulation may appear quite simple to the
uninformed observer, however, control of the manipulative/adjustive thrust alone necessitates lengthy
practice sessions and skill development in order that the student/practitioner be exact with respect to
the magnitude, speed, and force of this thrust, or at least as exact as they can try to be. No acceptable
substitute exists for hard work and regular practice with a purpose to assimilate the wealth of
practical dexterity needed to perform skilled manipulation. The age-old proverb knowledge without
practice makes but half the artist goes without saying.
An undergraduate chiropractic curriculum must be an integrated and evidence-based approach to
skills learning, including a vast amount of basic science, diagnostic, therapeutic and clinical
knowledge to prepare the student for clinical training (Haynes et al. 2000, Manniche & Jordan 2001).
This intensive psychomotor development, which is strengthened by an in-depth functional and
biomechanical approach to the neuromusculoskeletal system, is the hallmark of chiropractic
manipulative sciences and forms the basis for an integrated clinical approach to patient care.
Furthermore, this process has forced educators to review and reflect on traditional methods and
curriculum content, which will be appropriate for primary care practitioners in a modern
contemporary healthcare system. Programme outcomes and problem-based education, which is
supported by science and clinical evidence, is developing as a dominant teaching strategy within
chiropractic institutions; it revolves around professional activities and prepares clinicians for the
realities of daily practice (Sefton 2005). Furthermore, enhancing critical thinking and problem
solving, in order to develop confidence and establish sound clinical judgement in the clinician, is of
the utmost importance in a patient-centred model (Eisenberg et al. 1998, Mootz et al. 2005, Murphy et
al. 2008, Myers et al. 2008). Skills should be taught with understanding and reasoning, not merely by
aimless repetition. Nonetheless, no one doubts that structured practice is the key ingredient toward the
learning of complex motor skills (Triano 2000). Furthermore, placing manipulative skills and
procedures in their intended clinical perspective should also enhance the learning and performance of
these skills. Continuity, consistency and positive reinforcement combined with a strong
neurobiomechanical rationale are prominent features of this formula. The rate and quality of skill
acquisition will no doubt be significantly affected by individual variables. Important diagnostic skills
and indicators plus an intelligent approach to the relative and absolute contraindications to spinal
manipulative therapy should be presented simultaneously. Clinical relevance, expectations of ability,
criteria for skill performance, and treatment outcome measures are all factors to be considered during
manipulative skills learning strategies.
What is the best strategy to accomplish these learning outcomes? Probably one in which clear
learning aims and performance objectives have been consolidated into a concise institutional plan,
underpinned by research evidence and best practice concepts and delivered by a professional team of
individuals within the higher education environment.
Typically, manipulative techniques are taught using visual demonstrations, initially, followed by
practice sessions with two or three partners. Direct personal feedback and individual/group
instruction are integral components of both the teaching and assessment methods, whilst ensuring an
appropriate student/tutor ratio. This may not provide an optimal environment for demonstration and
learning more complex skills, but learning is enhanced with clinical examples being combined with
relevant assessment criteria and feedback. This type of skill instruction requires attention to detail
and patience, as a number of performance subtleties may be overlooked and misinterpreted, which
could lead to habitual motor behaviour and substandard performance. Students should not be expected
to work backwards, but instead should work towards completing the entire sequence of smaller sub-
skills that make up the entire manipulative procedure. This particular concept will be discussed in
more detail in Chapter 4, which is concerned with the neurophysiology of skill performance and how
skills are learned and maintained. Moreover, this teaching method should exploit visualization and
conceptualization of the manual procedure, which should enhance skill acquisition (Stig et al. 1989).
Describing and illustrating the whole manipulative procedure, including a clinical example first, and
then breaking the procedure down into its component parts or individual skills and rebuilding the
whole, may represent a very potent teaching strategy. This constitutes the basic theme of this book and
the specific approach to skills learning. Mentally imaging the components of the spine and a positive
biomechanical/therapeutic outcome of a particular manipulative procedure has been shown to be a
very effective way of teaching new manipulative techniques (Josefowitz et al. 1986). Another study
established that mental practice and physical practice are equally effective methods used to acquire
complex manipulative skills (Stig et al. 1989). These studies indicate that there are more creative
strategies for learning complex psychomotor skills besides the traditional show and tell
demonstration method. A combination of many schemes appears promising, as therapeutic intent and
biomechanical rationale could also improve assimilation and performance. Developing an ability to
visualize specific aspects of the necessary functional anatomy would be advantageous. Therefore, the
role of the teaching staff is to create an environment in which communication is heightened and
learning may be facilitated as a direct result of the instructors own motivational characteristics, skill,
knowledge and enthusiasm, and presented in a clinical context.
The process of learning detailed psychomotor skills is both complex and difficult. Learning
psychomotor skills has been described as directly dependent on the environment in which the skill is
learned and the inherent skill learning capacity of the student (Good 1993). Knowledge of results and
internal proprioceptive feedback may be critical in the successful performance of psychomotor skills
(Good 1993). In terms of reinforcement, considerable uncertainty exists about which approach is
optimal in practical situations (Watts 1990). However, it does appear that the effectiveness of any
approach seems to depend upon the task itself, the conditions under which practice occurs, the present
level of skill of the student and a variety of student characteristics (Adamo & Dent 2005). Optimal
results are achieved through continuous reinforcement in the initial learning stages to less frequent
feedback as learning advances and skills are attained (Watts 1990). This may stimulate a complete
reconsideration of the number of instructors and other resource implications required during the peak
levels of skills learning. Chapter 2 of this book formulates key concepts of student learning derived
from contemporary educational research. This chapter presents several basic principles that may be
incorporated into more effective psychomotor skills learning, including appropriate clinical
examples, clearly identified tasks and step-by-step practice methods. This method of instruction is
taught in light of individual skill subcomponents as part of the clinical whole incorporating known
neurophysiological principles pertaining to skill acquisition. Therefore, the ultimate educational goal
is clinical competence driven by specific learning outcomes and a confident performance in a real
clinical setting revolving around problem-based and integrated learning principles (Prideaux 2005,
Sefton 2005).
The ability to learn the balance, control and coordination required during the preparation and
application of a dynamic therapeutic thrust plus all other aspects of several manipulative procedures
is an enormous task to undertake in such a relatively short period of undergraduate time. The students
impatience and sense of frustration confound this scenario when little progress is made. These
learning plateaus are considered a common phenomenon in the acquisition of complex psychomotor
skills. Inappropriate skills may result in an attempt to achieve the first joint crack before the
applicable neuromuscular reflexes have been proficiently achieved. The numerous preparatory steps
leading up to joint preload and patient comfort should be firmly established as well as placing the
clinical significance of the joint cavitation in the evidence-based perspective. Contrary to a
frequently misunderstood concept, a joint crack does not represent, according to some, a viable
means of performance feedback or of measuring treatment success, as discussed earlier (Herzog
1996, 2000). This is addressed in more detail in Chapter 3. There is good evidence that reflex
responses generated by the manipulative procedure or thrust occurs as a result of the speed of
application and force applied whether or not a joint crack or cavitation occurred (Herzog 1996). This
should be communicated to the patient and reinforced at the undergraduate level to dispel yet another
clinical myth and promote sound clinical advice and judgement based upon good research evidence
and best practice. Joint clicks and tissue sounds are considered to be a normal phenomenon (Nade
1992).
Therefore, it seems that it is the enthusiasm and creativity of the instructors investing time,
patience, encouragement and, above all, rational attitudes that will direct these eager hands through
these uncertain times. Chiropractic institutions have a duty to prepare their students to be flexible and
perform comfortably within the confines of clinical uncertainty (Cooperstein 1990). For those who do
not cope well with this incertitude, a career based upon the dogma and persuasion of the technique
and practice gurus is a likely and unfortunate conclusion that entraps many a potentially gifted
clinician (Cooperstein 1990). This needs to be addressed from an ethical perspective, debated and
wholly discouraged early in undergraduate education where focus should be re-directed to
professionalism and evidence-based mentality.
It is not the intent of this book to promote or endorse any specific chiropractic technique system.
However, it is the aim to address some very basic motor skills necessary to perform a selection of the
more common diversified manipulative procedures used today in chiropractic practice The
diversified approach attempts to apply the most ideal technique within the context of the reality of the
clinical picture and is based upon sound neurobiomechanicalorthopaedic principles (Gitelman &
Fligg 1992) and the foundation of the biomechanical model (Fligg 1985). Diversified techniques
provide immense clinical flexibility, adaptability and variety as each procedure can be employed as
either a mobilization or an adjustment/manipulation depending upon the specific biomechanical
indications. The diversified approach to the manipulative sciences is regarded as the core of
chiropractic (Cooperstein & Gleberzon 2004). This versatility and inherent variability begins to
prepare the student for the fundamental decision-making and problem-solving skills required for
clinical practice.
The chiropractic profession as a whole has contributed substantially to the peer-reviewed
literature describing these short- and long-lever diversified procedures (Bergmann 1993, Byfield
2005). There are a number of excellent manipulative technique texts available that document these
skills in descriptive detail. The author always recommends Chiropractic Technique by David
Peterson and Tom Bergmann as an excellent core and reference text (Bergmann & Peterson 2011).
Nevertheless, there is very little research evidence or other investigation that has attempted to
objectively chronicle these psychomotor skills. Moreover, as indicated earlier, work by Triano et al.
(2002, 2003) and McCarthy et al. (2002) has contributed a great deal to understanding the complexity
of teaching, assessing and measuring skill acquisition at both the undergraduate and postgraduate
levels. The extensive knowledge base and reputable body of research that has accumulated over the
last decade provides a favourable climate for the science of chiropractic to begin now, in earnest, to
investigate the art of chiropractic manipulative skill.
The foundation and principle nature of this textbook is simplicity. The aim is not to describe an
endless number of manipulative permutations, their diagnostic indicators or therapeutic outcomes.
The psychomotor skills required to perform numerous diagnostic and therapeutic actions are an
integral component of this task and should be given at least equal time. It is considered a natural
advantage to learn to crawl before one can walk and, similarly, attempting to perform a Mozart
concerto before mastering the basic scales would be ridiculous and futile.
This book is broken down into four main sections:

1. Background knowledge
2. Foundation manipulative skills
3. Basic manipulative skills for the spine and pelvis
4. Specialist manipulative skills.

The main objective of the text is to build a base for the purposeful balance and control necessary
for efficient execution of spinal adjustive skills. Specifically, this will include:

fundamental and concise movement of both long and short levers to isolate a specific spinal motion
segment or region
postural skills and weight distribution for both the practitioner and the patient
concepts of tissue slack, tissue tension sense, joint tension and joint preload
minimum force and energy expenditure
hand skills
basic side posture positional skills
accurate anatomical landmark location
basic high-velocity, low-amplitude thrusting practice skills.

These will be presented in the light of the current teaching and learning strategies most
applicable to the acquisition of complex psychomotor skills. Important background information,
including specific biomechanical issues relative to the spine and pelvis and a detailed description of
the neurophysiology of how a skill is actually performed, supplement the text. A list of the cardinal
or golden rules presented throughout the text (Appendix I) and a recommended learning sequence of
skills and manipulative procedures (Appendix II) complete the book.
The heart of the text is a detailed, step-by-step description of approximately 50
manipulative/adjustive procedures covering all regions of the spine and pelvis, which is expanded on
in a DVD format and additional skills are presented in the specialist chapters in section 4 of the text.
Assessment and manipulation of the major extremity joints are not the aims of this text are not the
aims of this text, but will be included in the video files. The main purpose of this exercise is to
establish a fundamental framework of specific motor skills and movement patterns associated with
spinal manipulative therapy. Each manipulative/adjustive procedure will constitute a sequence of
steps or building blocks made up of smaller reflex movement patterns which, when performed
together, will produce a smooth coordinated whole manipulative action. The ultimate aim is to
perform the manipulation in a graceful flowing action from beginning to end. Concise movements to
locate the point of counter-rotation (mechanical transition point), control leg drop, stabilize the upper
body, and shift and control body weight, in addition to essential pivoting procedures, are explained in
detail. Common mistakes and exaggerated movements encountered while learning these manipulative
procedures have also been included to deter unwanted habits from forming during the early stages.
This text also presents an area of clinical specialty covering some basic adjustive procedures when
dealing with the elderly and the pregnant patient. These chapters are far more general in approach as
the fundamental skills are covered earlier in the text.
The basic manipulative skills for the spine and pelvis chapters are presented on the whole in a
split page format (text on the left and figure on the right), to provide the reader with direct visual
reinforcement and feedback of each step or block described in the text. This type of layout is
designed to be user friendly, thereby saving valuable time often wasted searching laboriously
through several pages of text for the appropriate figure. This book also includes access to video clips
to accompany the written text and figures in more detail. This gives the reader a more in-depth
description and account of the adjustive skills and how they are built up prior to a pre-load. It is this
authors opinion that the single snapshot approach commonly used in a number of manipulative skills
texts is inadequate for early undergraduate clinical skill learning and is more appropriate in the
postgraduate environment.
We contend that the various skill sets in this book function as groundwork for more complex and
advanced treatment procedures that should be introduced later during professional development. Each
of the manipulative procedures is presented from the moment the patient is positioned on the table
through a series of steps, up to and including intersegmental isolation and the localization and
application of joint preload skills. All procedures process both long- and short-lever movement using
all ranges of joint motion followed by a light oscillatory mock thrust to begin to learn and
appreciate tissue tension and joint preload prior to the application of a manipulative thrust.
The application of a full specific thrust has been purposefully discouraged throughout the
manipulative procedures sections of the text. This strategy has been adopted because the skills
required to control thrust force, speed and depth are highly underdeveloped at this educational stage.
There are a number of ethical issues that need to be resolved within this context before full thrust
instructions are formulated. It is the authors view that a degree of competency must be achieved in
these core skills prior to adding the manipulative thrust or mobilization force. Consequently, the
specific movements and exercises to begin thrust skill development have been presented separately in
Chapter 6 and should be developed independently and subsequently integrated prior to clinical
training. From an educational perspective the point that a student should begin to deliver an adjustive
thrust and under what clinical conditions is still the subject of considerable debate. There are a
number of ethical considerations under these conditions including student safety and welfare. It is
also very important that undergraduates acknowledge that an adjustment/manipulation is a clinical
therapeutic intervention with side-effects and potential risks. Research efforts are currently under
way investigating this educational and clinical dilemma by providing a potential means of objective
assessment during manipulative skill development, particularly at the undergraduate level. Chapter 2
addresses this educational argument and presents some viable teaching options for consideration. Of
utmost importance is the fact that the student should begin to comprehend the number of intricate
movement patterns and numerous psychomotor skills that are required to prepare both patient and
practitioner alike for a manipulative procedure prior to thrust force application. Learning the
concepts of mechanical advantage, postural control, light touch, preload and minimal pressure are
essential features of early skills training and a basic requirement for developing/adjustive procedures
of the highest quality prior to the delivery of the dynamic thrust. This professional skill should not be
underestimated and encouraged prematurely without progressive training combined with assessment
protocols to ensure that outcomes and competencies have been successfully attained at the
appropriate level of learning.
The adjustive procedures in this book are identified by a specific anatomical land-mark on the
spine or pelvis (i.e. spinous process, transverse process, posterior superior iliac spine, etc.). This
represents the targeted lesion or the short lever through which the student/practitioner directs the
externally applied therapeutic leverage or thrust. This more descriptive method is a substantial step
towards unifying manual treatment procedures and eliminating the inherent confusion that underpins
the use of traditional terminology in chiropractic. Conventional diversified terms are used throughout
the text for cross-referencing and clarification.
This book does proclaim that reference to segmental specificity is required in the learning
process, even though many in the profession still question this assumption (Haas & Panzer 1995). As
a focus for discussion, the statement specificity of contact may not be necessary for specific
correction of the true subluxation (Haas 1992, Haas & Panzer 1995), implies that the biological
system and its complex multi-segmental neuroanatomical connections may tolerate segmental
inaccuracy. This may explain why poor manipulative skills achieve favourable clinical results. More
recent evidence suggests that chiropractors are not very accurate in cavitating targeted motion
segments in the lumbar and thoracic regions (Ross et al. 2004), nor are they capable of directing force
vectors to joints at specific angles (Bereznick et al. 2002). As a profession, we must revise our views
concerning manipulation and its physical parameters and bring them up to date. Hopefully, this does
not encourage or bolster an attitude of complacency and undermine the complexity and sophistication
of our diagnostic and therapeutic skills. It can be said that applying a manipulative force in one region
will undoubtedly cause some observable neurobiomechanical effects or consistent reflex responses
remote from the targeted spinal level. This may explain some of the beneficial effects of spinal
manipulative therapy, including reduction in pain and decrease in muscle hypertonicity (Herzog et al.
1999). Regardless of the outcome of this debate, therapeutic procedures should always be applied in
the best interest of the patients needs and their overall safety.
Summary
There are some who contend that texts of this nature simply function as aide-memoires and that
there is no substitute for observing and learning from a skilled and experienced practitioner,
preferably in a real clinical setting. The apprentice system definitely has its merits, but a one-to-one
teacher/student interaction is an unrealistic option in the higher education environment, because of
resource restraints, quality assurance regulations, accreditation criteria and assessment consistency
relative to the specified learning outcomes and clinical competencies. A sensible balance has to be
reached. This text goes beyond this view and fills a noticeable gap to provide a structured base from
which to begin the life-long undertaking of adjustive/manipulative skills training and enhancement.
This book is designed primarily for undergraduate education, but its importance for postgraduate
education should also be considered. The essence of this text is to recognize and appreciate the
amount of neuromuscular control and coordination required reproducing smooth deliberate
movements when administering spinal manipulative therapy as a chiropractor managing patient care.
This is a priority within the undergraduate domain. Observing the ease and efficiency of a top-ranked
tennis player or professional golfer is the end result of many hours and years of dedication and
repetition to master the skills: yet they still practise and continue to look for ways to perfect their
performance. More recently, Malcolm Gladwell (2009) has coined the 10,000 hour rule required by
professionals to master their skill. We have a professional responsibility and obligation to maintain a
very high standard of practice and patient care that includes skillfully applied spinal manipulation.

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Chapter 1

The importance of ethics and professionalism to


manual therapists

F. Stuart Kinsinger
Chapter contents

The basic premise


Becoming a health professional
Setting and maintaining boundaries
Positions of power
Boundary crossing and violation
Issues of touch
Summary
Further reading

All students learning the skills of a health discipline are taught the ethics of care and the principles of
professionalism. Even though the formal teaching of ethics is a relatively new part of the curriculum
at health profession educational institutions, the ethics and virtues of healthcare have always formed
an essential part of instruction that students must demonstrate competence in. Educators in all
professional disciplines are obligated to teach the principles of professionalism.
The academic foundation supporting the ethics of healthcare delivery is taken from two distinct
but co-dependent domains: bioethics, also termed biomedical ethics, and professional ethics. The
scholarly underpinning of bioethics academia has only been quantified and championed by scholars
since the early 1970s, many of whom are still active, principally Beauchamp, Childress, Pellegrino,
Engelhardt and Veach.
The other pillar, professional ethics, may be viewed as the application of the formal academic
concepts; though many of these concepts in our understanding of professional ethics were written long
before the 20th century. Hippocrates and the ancients took great care to instruct pupils on good and
proper healthcare behaviours as befits the role of the physician.
Why does any of this matter?
The basic premise
In the manual care domain, all assessment and therapeutic protocols are performed in the closest of
proximities to the patient. Anything less than a best practice interaction poses a legitimate risk of
breaching the therapeutic intent and subverting the healing encounter. It is, therefore, essential that the
learner demonstrates an understanding of the rights, roles and responsibilities that every professional
is obligated to advocate. This matters because our patients, and their loved ones, trust us to meet their
healthcare needs in a caring, competent and safe environment.
We do this for the greater good of society.
Becoming a health professional
Much has already been written on the defining tenets and characteristics of professionalism, and on
that which constitutes the work of a professional. While these concepts have evolved over centuries,
there has emerged a consensus on the values and attributes that characterize the primary tenets of
professionalism for the 21st century. This growing body of evidence dates from the ancient Greeks, on
through the Middle Ages and continues with the emergence of evidence-based and integrative health
care.
Manual therapy students need to demonstrate an understanding that the two most basic and
important features of every profession are control over a specialized body of knowledge and a
commitment to use this knowledge for good. The overriding construct governing professionals is that
our specialized work is service based and always, without exception, for the benefit of the client.
While it may be more easily accepted that the precise manual skills used in patient care are
difficult to learn and, hence, comprise a very specialized body of knowledge, and that the commitment
to use this specialized knowledge could only be a good thing, our present-day societal values and
ethics encourage serving oneself first before considering the welfare of others. This is antithetical to
the principles of professionalism. Some individual caregivers have engaged in inappropriate and
even illicit behaviours prompting disciplinary action. That this has happened in healthcare has had a
negative effect on the publics view, as the helping professions have been seen as helping themselves
to the detriment of the public, despite legislative regulatory controls.
Therefore, one constraint is that the need to teach professionalism and ethics is due to the
changing shift in values in Western society. Some of this shift is due to moral and ethical relativism,
which began with the baby boom generation, took off in the 1960s and 1970s, and continues to
influence modern society.
It is often the case that todays student has been raised in a climate of entitlement,
permissiveness and materialism. Entitlement is evident in aspects of leisure and achievement.
Permissiveness is seen in how Western society approaches discipline, entertainment and the arts.
Self-esteem became more important than self-control. Materialism has defined our culture as one of
the pivotal values that is characteristic of our modern society. We crave achievement and success to
the point of excess in everything we do, and are often considered a failure otherwise.
This has caused an enormous problem for the professions. Professional standards are always
held higher than those of the general public. This is the primary reason why all professions have
written codes of conduct, ethics and behaviours: to guard against societys changing standards. If the
changes in moral standards infiltrated the professions, there would be an erosion of the high standards
demanded of professionals. These standards protect the public by ensuring the highest level of trust.
While practising in an ethical manner is mandated and, therefore, not optional, the law, through
legislation and regulations, can only go so far in setting out what the minimum standards should be.
While the law does not establish precise optimal performance, professionalism demands that
professionals strive for and maintain excellence in all aspects of the clinical encounter.
As healthcare professionals and educators, we are faced with two unavoidable challenges. One
is that professionalism and ethics are key cornerstones predicating all other content for students
acquiring clinical competence. While all students must demonstrate competence in their clinical skills
before moving into patient care, clinical skills are to be performed in a setting of the highest
standards of ethics and professionalism. Furthermore, the public demands that health professionals
and educators advocate for the principles of professionalism, codes of conduct, behaviours and ethics
for the manual therapy professions. The public deserves this high level of care in order to ensure their
safety and protection.
Setting and maintaining boundaries
Anything other than an unequivocal understanding of the power that the professional holds, and why it
is essential to set and maintain a healthy boundary with each and every patient, can leave a
practitioner vulnerable to causing unintended harm. While this is essential for all professionals, for
those of us in manual healthcare, it is the highest priority, as the manual therapy disciplines are
recognized as being in a high-risk category for boundary violations leading to the potential for sexual
abuse of patients. This may be enabled by the situation that chiropractors often work alone, which
may increase this risk.
Boundaries serve to protect us in many ways by keeping us separate and distinct from each other.
A boundary is an unseen layer or invisible coating that all humans have, protecting us from potentially
harmful situations with other people. For the professional the boundary is the line that separates the
parties, keeping the relationship professional and not personal.
Boundaries regulate our interactions with others and give us our sense of personal control,
privacy, security and safety. We constantly monitor our boundary to allow some things in and to keep
other things out.
While boundaries are not visible, we can create a visual image for the patient. We can wear
clothing that reinforces our boundary. A professional uniform, clinic jacket or business attire serves
this purpose well. For this reason it is recommended that student learners and young professionals
always wear clinic attire when observing or treating patients, and wear clothing that reflects a
professional rather than a revealing presentation.
It is the party in the position of power, the professional, who is charged with setting and
maintaining a healthy interaction. Since inappropriate discussion and/or non-clinical touching form
the basis for most violations, it is the professional who controls what is said and what is done, thus
setting and maintaining the boundary.
Practitioners can resolve to care for patients only in the office or clinic, and not, for example, at
a social gathering or at a patients residence. Prudent professionals take care to avoid casual and
personal time with clients so that the interaction maintains the expected roles and customary power
differential.
During the clinical encounter, crossings and violations of the patients boundary can occur. In
reality a boundary violation can be generated by either party or by both parties together. What is not
negotiable is that the obligation to understand the mechanism of a crossing and potential boundary
violation rests exclusively with the healthcare professional, so that when a crossing is discerned, the
professional can react accordingly and appropriately by crossing back.
Positions of power
The responsibility of protecting the boundary of the weaker person always falls to the one who holds
the position of power. This is paramount. There are never exceptions to this, whether this is in a
professionalclient encounter, the employeremployee relationship in the workplace, the parentchild
relationship or that of the teacherstudent.
Stated another way, it is the exclusive responsibility of the practitioner to maintain and protect
the boundaries of both the professional and the patient when in the clinical setting. While most
patients have a keen awareness of a healthy patientpractitioner working relationship and do not pose
relational challenges, there are those who are a cause for concern.
To understand how problems may arise, we must gain an appreciation of how and why patients
are so vulnerable, and why professionals hold this position of power.
Patients are in a vulnerable position because they are needy. Patients present with problems that
they cannot handle on their own. The patients vulnerability can be described in terms of the basic
need of any patient. We alone as ordinary members of society simply cannot educate ourselves well
enough to survive every circumstance that we face in life. We further realize that we have finite limits
on both our time and ability to solve our own problems.
As patients we then are forced to accept our vulnerability and become dependent on someone,
the healthcare professional, who we then give ourselves over to in our time of need. This, then, is the
essence of vulnerability, in giving up personal power and control and asking for help. Furthermore,
the more urgent our need and the more distress we feel, the greater our vulnerability. We, therefore,
must trust our caregiver to be sensitive to our vulnerable position and to act only and always in our
best interest, whether we are able to appreciate it at those most vulnerable times or not. This
protection of our vulnerability nurtures the trustworthiness of the professional.
One key attribute of competent caregiving is the ability to communicate empathy. Empathy
exhibits sincerity, a caring attitude, tolerance and an understanding of the patients predicament.
Effective communication establishes good rapport using well-developed interpersonal skills,
attentive and focused listening skills, with the ability to communicate ideas and information
efficiently.
There is a delicate aspect to balancing the patients inherent rights as an autonomous individual,
who must be fully informed of their situation in order for them to consent to assessment and care, with
the specialized skills and professional power of the caregiver proposing such care. Because optimal
care is based on the patient partner being part of the decision-making process, it is incumbent on the
professional to not misuse or abuse this position of power for any intent other than in honoring the
patients best interests. Engaging the patient in this manner gives a real sense of control back to the
vulnerable party.
Whenever a boundary problem occurs, it is always predicated on the professionals failing to act
in the patients best interest, failing to protect the patient as an individual with dignity and integrity,
and failing to hold to a higher standard of thought, word and deed. This power differential renders it
not possible for a patient to consent to a romantic or sexual relationship. That is why all jurisdictions
forbid such severe personalizing of the therapeutic encounter. A romantic or sexual relationship with
a patient is never justified and is always disgraceful and unethical. This is the severest kind of ethical
violation and brings dishonour to ones profession.
Most jurisdictions set out protocols that the manual care professional must adhere to in the event
that the professional would entertain entering into a personal relationship with his or her patient.
Those protocols always mandate that the patient must be referred out to another practitioner for care
and that the parties then comply with a waiting period. Indeed, all practitioners have the option of
referring out any patient who is non-compliant, or acting in a flirtatious or otherwise inappropriate
manner.
Boundary crossing and violation
A boundary crossing occurs when something is said or an action is taken that compromises or may
potentially compromise the therapeutic relationship. A boundary violation is an extension of a
crossing and occurs when the boundary crossing becomes personal or abusive, causing harm to the
weaker party, the patient.
Boundary violations breach the core intent of the professionalpatient covenant to always, and
without exception, act only in the patients best interest, and instead demonstrate exploitive behaviour
that attempts to ameliorate the professionals personal needs. All of the boundaries in the
practitionerpatient relationship exist solely for the patients safety and protection.
In addition to this core intent in protecting the patient, the professional also derives enormous
benefit from the establishment and maintenance of mutual boundaries, as they safely provide the limits
on what is expected in the relationship with the patient. Altering these limits produces ambiguity,
uncertainty and confusion for the patient on what goes on in the professional encounter, creating a
scenario ripe for abuse.
Simply put, if the patient is protected, with the practitioner taking care to set and maintain a
healthy boundary, then the practitioner is protected.
Issues of touch
Physical contact with a patient is a privilege that requires the utmost integrity on the part of the
caregiver. For the student learning personal ethics and professionalism, many of their concerns centre
around the issue of touching the patient. Touch is a way of showing compassion and a deep form of
communication. These powerful qualities facilitate a closer connection in the doctorpatient
relationship when used in a careful and considerate way, but when touch is used inappropriately it
can cause harm in both physical and non-physical ways. There is good evidence that hands-on manual
care protocols enhance recovery and provide positive patient outcomes.
However, no one should be touched without first giving their consent, even in a clinical and an
educational environment. A patient needs to be fully informed regarding their care allowing them to
be an active partner with their caregiver in whatever assessment and therapeutic protocols are
undertaken on their behalf. The ability to communicate effectively and appropriately facilitates the
patient being able to give consent. Since any touch that is not consented to meets the legal definition
of assault, with non-consensual touching of a sensitive anatomical area possibly meeting the standard
for sexual assault, a practitioner cannot rely on good intentions, but must follow informed-consent
risk-management protocols which govern all jurisdictions.
Summary
Sociologist Coulter believes that an understanding of professionalization is a process and not an
automatic destination following the graduation from a professional school. Ultimately
professionalization is about acting professionally. It takes a long time to learn to be a professional
and it takes a lifetime to practise it. It takes no more than a few minutes to destroy it.
As you use this text to learn specific manual skills, take some time to reflect on the following:

1. When did your own journey of professionalization begin?


2. How much have you accomplished so far in your professionalization journey?
3. How much further do you need to go?

A professional professes. We profess to our community and society the promise of


trustworthiness, and profess not to use our specialized manual therapy skills for self-service and self-
reward, but always, and without exception, to use these skills for doing good to others for the
betterment of society.
There is no greater accolade or finer reward for professional work than to possess the rich
reputation of being found trustworthy. This is the heartbeat of the professionals professionalization
journey.

Further reading

eauchamp T., Childress J. Principles of biomedical ethics, sixth ed. Oxford: Oxford University Press;
2008.
enjamin B., Sohnen-Moe C. The Ethics of Touch. Tucson, Arizona: SMA Inc.; 2003.
oulter I. Professionalism versus professionalization. In: Kinsinger S., editor. Principles of
professionalism for manual therapists: a guide to building relationships of trust. Toronto, ON:
Canadian Memorial Chiropractic College, 2006.
ngelhardt T. The foundations of bioethics, second ed. Oxford: Oxford University Press; 1996.
ert B., Culver C., Clouser D. Bioethics: a systematic approach, second ed. Oxford: Oxford University
Press; 2006.
insinger S. Advancing the Philosophy of Chiropractic: advocating virtue. Journal of Chiropractic
Humanities. 2004;11:24-28.
insinger S. The Set and Setting: Professionalism defined. Journal of Chiropractic Humanities.
2005;12:33-37.
orszun A., Winterburn P., Sweetland H., Tapper-Jones L., Houston H. Assessment of professional
attitude and conduct in medical undergraduates. Med. Teach.. 2005;27(8):704-708.
cIntosh N. The educated heart; professional boundaries for massage therapists, bodyworkers and
movement teachers, second ed. Philadelphia: Lippincott Williams and Wilkins; 2005.
cPhedran M., Sutton W. Preventing sexual abuse of patients: a legal guide for health care
professionals. London: LexisNexis Butterworths; 2004.
ootz R., Coulter I., Shultz G. Professionalism and ethics in chiropractic. In Haldeman S., editor:
Principles and practice of chiropractic, third ed, New York: McGraw Hill, 2005.
urtillo R. Ethical dimensions in the health professions, fourth ed. London: Elsevier; 2005.
ahl M., Foreman S. Ethical Perspectives: sexual boundary issues and the chiropractic paradigm.
Philadelphia, PA: Lippincott Williams and Wilkins; 2004.
an Mook W., de Grave W., Wass V., OSullivan H., Zwaveling J.H., Schuwirth L.W., et al.
Professionalism: evolution of the concept. Eur. J. Intern. Med.. 2009;20(4):e81-e84. Epub 2008 Dec
4
an Mook W., van Luijk S., OSullivan H., Wass V., Harm Zwaveling J., Schuwirth L.W., et al. The
concepts of professionalism and professional behavior. Eur. J. Intern. Med.. 2009;20(4):e85-e89.
Epub 2008 Dec 5. Review
eloski J., Fields S Boex J.R., Blank L.L. Measuring Professionalism: a review of studies with
instruments reported in the literature between 1982 and 2002. Acad. Med.. 2005;80(4):366-370.
Chapter 2

The learning and performance of chiropractic


manipulative skills

B. Kim Humphreys
Chapter contents

Introduction
The context of learning
Elaborated learning and its facilitation
Acquisition, retention and transferability of motor skills
Skills acquisition
Motor imagery and mental practice
The effect of practice on skills acquisition
Gender and learning CM
Motor skills retention
Conclusions
References
Introduction
Life is a continuum of learning. The acquisition of knowledge and skills occurs continuously
throughout ones life by means of education, training and personal experiences. At institutions of
higher education, the raison detre of chiropractic programmes is to promote appropriate student
learning, particularly with regard to the diagnostic and clinical skills relevant to chiropractic practice
(Humphreys 1997).
Chiropractic education has undergone an exceptional evolution in terms of curriculum design
and development in the past four decades. The teaching and learning of clinical skills continue to
form a major part of the contemporary chiropractic curriculum. The clinical skills in chiropractic
education include both those of physical examination as well as manual treatment, most notably
chiropractic manipulation (CM). This chapter will concentrate on the educational aspects of the
teaching and learning of psychomotor skills related to CM.
The educational task of teaching chiropractic manipulative skills to novice students is
considerable. In a relatively short time, students must master the nuances of manipulative skills,
including decision-making on the most appropriate procedure to use and proficiency in the
performance of CM procedures that are safe and functionally beneficial. To practise chiropractic,
graduates will need to demonstrate a level of competence that is compatible with entry into
chiropractic practice. Over time, it is hoped that graduates, with continuing practical experience and
a conscious effort to improve their psychomotor skills, will evolve to the level of expert in order to
enhance the care of their patients (Triano et al. 2002, 2004).
Even though manipulative or adjustive skills in chiropractic institutions have been a major part
of the curricula since the beginning of chiropractic education, very little educational research has
been performed in this area. Over the past decade more research into the learning of spinal
manipulation has been carried out (Descarreaux et al. 2005, 2006, Descarreaux & Dugas 2010,
Triano et al. 2002, 2003, 2004, 2006). Considerably more work is needed, however, to understand
how students learn and retain the complex psychomotor skills of CM, and so how best to educate
these students to the level appropriate for entry into the profession.
Chiropractic manipulation is made up of complex motor skills (Cohen et al. 1995). It has been
described as a bimanual task requiring high levels of sensory and motor coordination involving the
upper and lower limbs (Descarreaux & Dugas 2010, Triano et al. 2006). To deliver therapeutically
safe and functionally effective manipulation, practitioners of CM must be able to control accurately a
number of biomechanical variables such as speed, preload, force production, peak force, time to peak
force, duration of peak force and direction of applied forces (Descarreaux et al. 2006, Descarreaux &
Dugas 2010). The goal of CM is to apply force and movement with specific parameters of direction,
amplitude and speed to joints and surrounding tissues that produce a neurological and biomechanical
effect on the affected tissues (Descarreaux et al. 2005, Evans 2002, Haldeman 2000, Kawchuk &
Herzog 1993). These factors need to be carefully controlled depending on the area of application, the
intended therapeutic outcome, and patient comfort and safety (Triano et al. 2006). Practitioners must
also learn appropriate body postures and sophisticated bimanual manoeuvres to produce a focused
and localized manipulative thrust. To learn the sophisticated and complex skills necessary to perform
a range of chiropractic manipulative techniques takes considerable time and effort on the part of
novice learners, as well as experienced and knowledgeable teachers (Descarreaux & Dugas 2010,
Humphreys 1997, Triano et al. 2006). Educational research into the most appropriate learning
approaches and teaching methodologies for students to learn the complex psychomotor skills of CM is
essential. Although research is increasing, too few chiropractic studies have been published. In light
of the paucity of educational research into chiropractic manipulative skills, research from motor
skills acquisition and behaviour continues to provide relevant insight into the teaching and learning of
CM.
The purpose of this chapter is to identify knowledge about psychomotor skills gleaned from
chiropractic and other research disciplines that may be applicable to the teaching and learning of
chiropractic manipulative techniques (CMT). Many chapters could possibly be written about
important ideas and theories extrapolated from other disciplines which may be relevant to
chiropractic psychomotor skills. The emphasis of this chapter will be on some key concepts of
student learning derived from contemporary research in medical and higher education, as well as
relevant constructs from work in the field of motor skills acquisition.
The first part of the chapter will briefly review the learning context within which CM is taught in
undergraduate chiropractic programmes. The rest of the chapter will identify selected research that
may be adapted to the teaching and learning of psychomotor skills relevant to CM.
The context of learning
The purpose of undergraduate chiropractic education is to prepare students for entrance into the
profession as primary-healthcare practitioners. The context of the curriculum, therefore, is designed
to provide students with a meaningful and clinically relevant education that closely resembles
modern-day chiropractic practice. In educational terms, the goal is to attain clinical competence,
defined as the mastery of a body of relevant knowledge and the acquisition of a range of relevant
skills, which would include interpersonal, clinical and technical components (Newble 1992, p. 504).
Mastery will of course differ between student and graduate and experienced clinician; it refers to an
expected level of achievement depending on training and experience.
The crucial point about the importance of the undergraduate learning context lies in the fact that
clinical competence is an integration and interrelation of knowledge and skills (Newble 1992,
Slotnick 2001). For chiropractic education, psychomotor skills, especially the teaching and learning
of manipulative techniques, form a considerable part of the whole, and it is the integration of these
skills with the relevant knowledge component that should be emphasized, demonstrated and practised
(Descarreaux et al. 2006, Descarreaux & Dugas 2010, Humphreys 1997). Recent evidence shows that
the safe and competent use of CMT requires a considerable amount of educational effort. This
includes the appropriate and timely delivery of knowledge, considerable practice, timely and
appropriate feedback, and the use of a variety of sequenced and paced educational formats (Scaringe
et al. 2002, Triano et al. 2003, 2006). The goal of chiropractic institutions is to produce graduates
who are clinically competent and comfortable with private practice, albeit with entry-level clinical
skills that are safe and, at a minimum, functionally adequate (Kovacs 1997, Triano et al. 2006).
Typically, students in technique classes are first taught the theoretical principles underpinning
CMT followed in the practical classes by instructors demonstrating the techniques followed by
students practising the techniques on fellow students (Descarreaux et al. 2005, 2006). However,
students in the early years typically start with the steps to position fellow students (set-up) for the
delivery of the adjustive thrust without delivering a manipulative thrust. In later years, students may
practise the various manipulative procedures from patient and practitioner positioning and other
skills to completion of the manipulative thrust. Little if any time, however, is spent on allowing
students to integrate these skills by practising the entire clinical procedure from history-taking,
physical examination, diagnosis, through to the appropriate selection and performance of the selected
adjustive skills. Time concerns are important, but even shortened versions equivalent to a regular
patient visit and treatment session are not regularly practised or rehearsed. It is expected that
students, upon entering the clinical attachment in their final years, will be able to make the
appropriate transition from technique learning in isolation to its appropriate integration as a
meaningful part of the whole clinical setting. The variety of possible clinical scenarios can make this
difficult.
Unfortunately, when the students or graduates find themselves in a clinical situation necessitating
recall of information, that situation may be distanced in time, space and nature from the original
situation in which the information was learned. Problems may arise for students trying to recall and
apply appropriately the previously learned information to a situation that is different from the setting
or context in which it was learned. Mayer (1979) coined the phrase far transfer of knowledge to
explain the ability to retrieve and apply information learned in one setting to another novel, but
related, situation. More recently, the term context dependence has been used to describe factors that
are associated with the learning task (Norman & Schmidt 2000). The context in which learning takes
place is important and recall and application of learning in different situations or contexts (far
transfer of knowledge) may be problematic. In terms of the teaching of psychomotor skills, techniques
taught in repetitious, non-clinical settings, contextually different to their eventual intended
application, may create both clinical and physical problems for students when they are required to
demonstrate clinical competencies.
For psychomotor skills educators, it is recommended that the knowledge for students to learn
should be presented in a manner that reflects the way in which it should be used. This again
reinforces the importance of the context of learning the clinical setting. How does this relate to the
learning of psychomotor skills? First, clinical competence is demonstrated by combining relevant
knowledge and skills with various attitudinal aspects (interpersonal, clinical and technical) to solve a
problem (Newble 1992). Second, there should be no reason to suggest that complex psychomotor
skills, such as CM, are simply acquired involuntarily without cognitive processes. This reinforces the
view that core knowledge in the basic and human sciences must be presented in tandem with the
introduction of complex psychomotor skills. Indeed motor skill studies suggest (support) this (Goode
et al. 1998, Singer & Chen 1994, Wulf & Shea 2002). Third, recent research into the learning,
transfer and retention of CM skills suggests that the context of learning such as knowing the desired
goals and receiving a visual or verbal feedback on performance reduced subsequent performance
error and enhanced retention (Descarreaux & Dugas 2010, Triano et al. 2006).
It would seem reasonable that a concerted effort should be made to teach manipulative/adjustive
skills in the context of their future clinical setting and centre the whole clinical process on an
appropriate knowledge base.
Elaborated learning and its facilitation
We have known for some time that effective learning for clinical practice is closely related to what
students actually do when confronted with their learning tasks and seems to be little influenced by any
generalized form of instruction on study skills (Coles 1990b). Much of this information comes from
studies seeking to identify differences between expert and novice clinicians as they approach similar
diagnostic conditions.
Diagnostic errors are not the result of a lack of medical knowledge, rather they indicate a failure
to access properly the relevant knowledge stored in memory (Allen & Bordage 1987, Bordage et al.
1984). The knowledge based model of clinical thinking arose from this work and suggests that the
major determinant of diagnostic thinking is the organization and availability of relevant knowledge in
memory (Bordage et al. 1990).
Expert clinicians are such because they have developed rich networks of knowledge that are
linked together by abstract relationships. The process of creating the rich cognitive network of
interconnecting information has been termed elaborated learning (Coles 1989, 1990a,b). Essentially,
it involves the relating of theory to practice. It is now known that exposing students to theory in the
early years of study does not necessarily result in its use or in a better understanding in the later or
clinical years. It is more important to look at the way in which students acquire their knowledge; in
particular helping students to see how one piece of knowledge relates to another and in turn linking
theory to the eventual realities of clinical practice.
A common analogy used to describe the elaborated learning process is to compare it to the
putting together of a jigsaw puzzle (Coles 1990b). On the puzzle box is a picture. This may represent
anything from concepts or process to clinical examples or practical situations and represents the
learning context. The puzzle pieces inside the box are the more theoretical or abstract ideas relating
to the concepts under study. The learning task of the student is to make the links between the different
theoretical pieces in the puzzle and to see how these relationships connect to form the overall picture.
By so doing, the student is able to develop cognitive structures, which not only relate small items of
information, but also, on a grander scale, create complex knowledge networks. The analogy may be
extended to a three- or multi-dimensional puzzle. Students who elaborate their knowledge in this way
are more likely to see the relevance of the information they are learning and to remember and apply it
more judiciously (Coles 1987, 1990a).
Instructors may help students to elaborate their knowledge when teaching the psychomotor skills
by applying a few basic principles. First, the student must be given an appropriate analogy or
example, or be put into the picture of how the skill to be learned is eventually to be used. It must be
remembered that students will at some time be expected to make the far transfer of knowledge, so a
few examples or scenarios or some variations to the original concept may be needed. I like to call the
method of teaching whereby relevant clinical examples introduce the practical material to be learned
clinical frameworking, and some studies have shown it to be helpful (Humphreys 1997).
Second, the background information relating to the new skills is offered. In this case, the student
must have clear access to all the necessary components of the skill such as a visual demonstration,
mental imagery, tutor supervision and step-by-step practice. These points find expression as a
common theme that will be elaborated throughout this book.
Third, students must set goals for themselves regarding their skill acquisition. This requires
students, with consultation, to set reasonable performance criteria in keeping with the overall goals of
the psychomotor skills class at each educational level, as well as addressing their particular strengths
and weaknesses. The performance criteria should be reasonably challenging, but attainable, and may
include items such as improvement in speed, force, posture, preload and patient set-up. Effective
methods of quantifying their progress, such as mechanical models, videos, in-depth performance
criteria as well as a host of other possible tools, are needed to give students accurate feedback as
well as to reinforce to students that their efforts to learn are matched by reliable assessment measures
(Descarreaux et al. 2005, 2006, Descarreaux & Dugas 2010, Scaringe et al. 2002;, Triano et al. 2002,
2003, 2006). Performance goals should be written down and ideally discussed with an instructor.
These performance competencies should be identified within the specific skills module that the
student is working towards achieving and they form the basis of the students assessment.
Performance goals may also be discussed and checked by fellow students who will act as the
students patient during practical classes. Valuable feedback should be given by the patient on the
receiving end, while the student is learning the new skill. This type of discussion and the writing
down of feedback helps to consolidate the gains and to identify areas still requiring improvement.
This type of on-site reflection may prove to be a valuable tool during skills acquisition.
Fourth, the learner must have a clear idea of his/her task. That task is to make sense of the whole
skill being taught in light of its sub-components (puzzle pieces/individual skill sets) and how they fit
into the overall performance of a manipulative procedure combined with a clinical example. In other
words, they are to relate theory to practice. Students may be given coursework or assignments such
as creating different case scenarios, alternative applications of the skill including indications and
contraindications. They should also be encouraged to look out for examples during their clinical
observations or treatment encounters with clinicians and fellow students.
Thus far, the chapter has centred on the importance of the clinical context in teaching
psychomotor skills in chiropractic undergraduate programmes. The most appropriate way for students
to go about acquiring their knowledge, elaborated learning, has also been presented because it forms
the foundation for developing clinical competence and becoming expert clinicians. Suggestions about
practical ways in which clinical frameworking may be incorporated into teaching to facilitate the
elaborated learning process have also been discussed.
The next part of the chapter will focus on research into motor skills derived from various fields
of study which provide useful information for teaching and learning manipulative psychomotor skills
that may act as a springboard for further research in chiropractic education. This section links with
Chapter 3 concerning the neurophysiology of skill performance.
Acquisition, retention and transferability of
motor skills
Over the past 30 years, motor learning research has investigated the factors affecting the learning and
performance of motor skills (Wulf & Shea 2002). In particular, considerable attention has been
directed towards the study of factors that may influence how motor skills are learned, stored in
kinaesthetic memory and generalized to other motor skills of similar characteristics. Unfortunately,
the teaching and learning of the complex skills of CMT in chiropractic institutions continues to ignore
the vast amount of motor learning research (Descarreaux et al. 2006, Descarreaux & Dugas 2010).
In motor skills research, the terms acquisition, retention and transferability are commonly used
to describe the fundamental features of learning skills that have been investigated. These need to be
related to learning complex manipulative psychomotor skills which also has a significant decision-
making component and is not just concerned with the pure movement component. A recent review by
Wulf et al. (2010) of the motor learning and performance literature that may have relevance to
medical training suggests four factors that have been shown to enhance motor skills learning, retention
and transferability. The four factors include: observational practice, focus of attention, feedback and
self-controlled practice.
Observational practice is the observation of others, such as experts or teachers, performing
motor skills, followed by the observer reproducing what they have observed. Although the notion of
observational practice has been questioned because it is typically not as effective as physical
practice, research has shown that it is better than no practice (McCullagh & Weiss 2001). Some
neuroimaging studies demonstrated that observation followed by physical practice activates a similar
core group of brain structures (Grezes & Decety 2001, Jeannerod 1994). This suggests that
observation followed by practice (observational practice) may be useful in the integration and
learning of motor skills.
Focus of attention relates to instructions or feedback given to the learner that may describe how
the movements of body parts should be coordinated to perform the motor skill (internal focus) or what
the desired target, goal or effects of the motor skill actually looks like (external focus). Movement
science research in sports such as golf, basketball, volleyball and soccer have shown that external
focus of attention is more effective than internal focus (Wulf et al. 2002, Wulf & Su 2007, Zachry et
al. 2005). Traditionally the teaching of CMT has used both internal and external focus of attention
strategies, although internal focus probably predominates. Unfortunately, currently no research into
this aspect of CM learning has been undertaken. It remains to be seen which approach or combination
of approaches would enhance the learning of CMT.
Feedback consists of information given to the learner about their performance of the motor task.
It can be given as information about the outcome of their performance (knowledge of results or KR)
or as feedback on the quality of the movement (knowledge of performance or KP). Typically KR is
used in the teaching and learning of CMT. Feedback will be discussed later in this chapter as a
number of chiropractic research studies have investigated this aspect of CM. However, it is now
known that motivational factors are also associated with feedback, but this has received much less
attention. Not surprisingly some research has shown that providing learners with positive feedback
after good performances resulted in better learning than negative feedback after poor performances
(Chiviacowsky & Wulf 2007).
Self-controlled practice describes the notion of the learning becoming more active in the
teaching and learning process. Traditionally medical and chiropractic curricula have been teacher-
centred, with the lecturer deciding on the content, pace and delivery of the material to be learned. Not
surprisingly, having the student more involved in making some of these decisions has been shown to
enhance educational learning (Humphreys 1997). In motor skills research, having learners decide
when they want to receive feedback on their performance and more control over practice sessions has
led to more involvement, interest and motivation to learn (Chiviacowsky & Wulf et al. 2002, Wulf et
al. 2010). Although this may provide some problems with how CMTs are taught, it might be of value
for instructors and curriculum planners to explore the concept of self-controlled practice in
chiropractic education.
Skills acquisition
Acquisition is the learning and practice phase where students first receive information about the new
skill. It may encompass a number of different teaching techniques, such as mental imagery, verbal
instructions, visual demonstration, information technology and practice (Al-Abood et al. 2001,
Descarreaux et al. 2005, 2006, Descarreaux & Dugas 2010, Liebermann et al. 2002, Triano et al.
2004, 2006). In chiropractic education, manual techniques usually involve the use of skilled models
(tutors) who introduce the tasks to be learned via demonstrations. The nature of the motor task to be
learned and the stage of the learner predicate the underlying processes that lead to the acquisition of
the skill. In addition, practice and feedback are two potent learning variables that enhance the
acquisition of new motor skills (Descarreaux & Dugas 2010, Scaringe et al. 2002, Triano et al. 2006,
Wulf & Shea 2002). The following discussion will concentrate on the more important features of
skills acquisition research and the possible implications for the teaching and learning of psychomotor
skills in chiropractic.

Motor imagery and mental practice


Motor imagery has been described as the mental representation of a movement with any body
movement (Dickstein & Deutsch 2007), whereas mental practice or motor imagery practice involves
practicing the mental imagery with the intent of improving motor performance (Malouin & Richards
2010). Traditionally, CMTs have been taught by visual demonstration and verbal instructions,
followed by practice under tutor supervision with feedback. Even though mental practice of a poem
or speech or a part in a play is commonly accepted, mental practice of motor skills is not, at least
until more recently (Dickstein & Deutsch 2007).
Neuroimaging research has shown that brain function shares similar areas whether the person is
performing common motor tasks, such as standing, walking, swimming, dancing or running, or
imagining doing these activities (Bakker et al. 2008, Ouchi et al. 1999, Szameitat et al. 2007). The
fact that mental practice and actual motor performance of the same activity activate, and are linked by,
common pathways suggests that motor imaging and mental practice should be a beneficial part of the
learning of motor skills (Malouin & Richards 2010, Szameitat et al. 2007).
Mental imagery applied in sports has been shown to increase speed, performance accuracy,
muscle strength, movement dynamics and motor skill performance (Boschker et al. 2000, Taktek
2004).
A number of studies have looked at mental imagery versus other forms of instruction, such as
video modelling of mental training, visual imaging and kinaesthetic imaging (Atienza et al. 1998, Fery
2003, Hall et al. 1997). Results suggest that when first learning a motor skill, visual imagery is better
for skills that emphasize form and position while kinaesthetic imagery is better for learning motor
skills that require more precise timing and sophistication of hand function and movement (Fery 2003).
There is also some evidence that video modelling may be just as effective as imagery training for
learning complex motor skills when both are combined with physical practice (Atienza et al. 1998).
There have been two studies on the use of mental practice in learning chiropractic psychomotor
skills. Josefowitz et al. (1986) compared two types of mental imagery using two groups. One group
rehearsed by imagining that they were performing CM while the second group mentally rehearsed by
concentrating on the spine and the positive effects of CM. The group who visually imaged the spine
and the effects of CM improved significantly more than the other group.
Stig et al. (1989) investigated the effectiveness of physical practice versus mental practice in
learning a specific CM skill using two groups. Over 1 day one group practised the CM skill while the
other group listened to an audiotape that described the skill. The groups were evaluated pre and
immediately post training. Both groups were found to be equally effective in learning the CM skill.
Further investigations comparing different practice protocols are necessary to elucidate better ways
of learning motor skills as well as maximizing the effects of actual practice and mental imagery.
However, when teaching chiropractic psychomotor skills, instructors may wish to use mental
imaging as an instructional technique for helping students to learn their complexities initially. From
the currently available research data, it may be wise to use a combination of visual and kinaesthetic
techniques.

The effect of practice on skills acquisition


Practice is fundamental to the development of expertise in any motor skill. Learning a psychomotor
skill, especially one as complex as manual manipulation, requires a considerable amount of practice.
However, the questions to be asked are: what types of practice and what practice schedules are most
beneficial in acquiring them?
Although little work has been carried out in this area with respect to learning CM, there has been
considerable work in the fields of physical education, sports studies and motor skills research
(Hebert et al. 1996, Pollatou et al. 1997, Soucy & Proteau 2001). Two common protocols for the
practice of motor or psychomotor skills are referred to in the literature as block and random practice.
Block practice involves the repetitive performance of a specific motor task. Random practice does
not imply chance; it is the performance of a number of different motor tasks during the same practice
session. Block practice, therefore, is the performance of one specific task; random practice schedules
rehearse a number of different motor tasks. Other common terms in the literature are massed practice
and distributed practice. Massed practice is essentially block practice and is defined as the
repetition of large numbers of trials of the same task within a particular practice session (Good
1993a). Distributed practice, on the other hand involves variations in time intervals for practising
learning tasks. The variations in time intervals are flexible and may encompass increased time
between practice trials within a session or the spreading out of practice trials to cover a number of
practice sessions (Good 1993a).
In chiropractic technique classes, the predominant form of practice is the block or repetitive
form (Josefowitz et al. 1986, Stig et al. 1989), and massed practice (Good 1993a). Earlier research
into the effect of practice schedules suggested that repetitive or block performance tended to inhibit
some of the cognitive processes (cognitive inhibition) that were important in both the learning and the
longer-term retention of the psychomotor skills (Bortoli et al. 1992). Unfortunately, most of this work
investigated the acquisition of simple and not complex motor skills. It is now clear that learning
principles gleaned from simple motor skill research is not necessarily generalizable to complex
motor skills (Wulf & Shea 2002).
Pringle (2004) investigated levels of feedback on chiropractic students learning a novel motor
skill (prone motion palpation spring testing in the thoracic spine) over a nine-session, 2-week period.
Feedback was given in varied schedules for study participants who were divided into four groups.
Group 1 received the least amount of verbal feedback, Groups 2 and 3 received more, but infrequent,
verbal feedback and Group 4 received constant verbal feedback. Pringle (2004) found that at the 2-
week retention trials Group 3 demonstrated the most targeted retention of the learned motor skill,
while Group 4, with 100% feedback, demonstrated the most accurate spring testing during the
acquisition trials, but not at the retention trials. Pringle concluded that constant KR feedback is
beneficial to reduce errors during CM learning, but it interferes with retention learning, while
intermittent KR is more beneficial for retention of learning.
Pringle (2005) investigated experience and practice organization in the learning of a simulated
high-velocity, low-amplitude prone thoracic spine manipulation using chiropractic students. Students
were given either visual or verbal feedback on their force-time histories during blocked and random
variable practice. Pringle (2005) concluded that experience and practice resulted in greater accuracy
of peak force production. Also, block practice resulted in lower error scores while in the short-term
accuracy in retention was enhanced with students who received random variable practice.
These results support earlier work by Hebert et al. (1996) who found that low-skilled students
assigned to block schedule classes performed better on a post-test than to those who were assigned to
an alternating or random schedule. For high-skilled students, no significant difference was found
between the block and alternating schedule groups. Hebert et al. (1996) suggested that high-
interference practice, such as is found in random practice schedules, should not be used in the early
stages of learning complex skills. Rather, novice learners should be allowed to perform repeated
practice under low-interference conditions (block practice). When learning chiropractic psychomotor
skills, it may be important to evaluate the skill level of students in a particular class. Not all students
have the same levels of coordination, skill and experience with learning psychomotor skills. Although
the vast majority will be novices in learning CM, some may be more adept, physically developed and
experienced as a result of sports or some physical or manual occupations.
Until more research on CM is forthcoming, it would seem prudent that for students learning a
novel motor skill, the guidance hypothesis should be used, namely constant KR, in the early phases of
acquisition and to reduce errors during practice. However, intermittent KR is more beneficial for
more experienced student learners and for retention of the motor skills.
Gender and learning CM
Currently there is no literature related to gender differences in learning CM, but undoubtedly there are
learning differences between males and females. Differences in gender and skill level are important
areas for psychomotor research in chiropractic education and need urgent attention. The Welsh
Institute of Chiropractic has introduced a physical fitness programme as a part of self-directed study
for the various skills modules in the degree. The aim of the programme is to target specific
components of overall fitness which impact on skill acquisition, including for example, balance,
coordination, upper body strength and aerobic fitness. It is also felt that participants in these
programmes will reap the benefits of regular exercise and cope better with the rigours of a
professional degree programme.
Educational pearl: from current evidence (Descarreaux & Dugas 2010, Wulf & Shea 2002), the
best recommendation for chiropractic instructors would be to start with more traditional block style
practice sessions, to enable students to develop the CM skills from repeated practice, and to utilize
random practice, which better promotes retention and transferability at a later, more appropriate
time.
Motor skills retention
How well a new skill has been learned is measured by assessing the learners retention after a
varying period of rest following the acquisition phase. In motor skills research, retention tests may be
given to the learner immediately following a practice session, or hours, days or even weeks later. In
chiropractic undergraduate programmes, similar to other institutions of higher learning, assessments
and examinations constitute the major form of evaluating students retention as a result of their
learning.
Chiropractic students, similar to others learning psychomotor skills, receive two important types
of information or feedback which aid them in their learning process. Intrinsic or internal feedback
describes the information that a learner receives from his/her body (visual, auditory, proprioceptive,
cutaneous) after performing a motor task while external or augmented feedback comes from external
sources, either qualitative or quantitative, that describe the outcome of the event (Triano et al. 2006).
External or augmented feedback can further be divided into two parts. Knowledge of performance
(KP) provides learners with information about the movement patterns used through verbal feedback,
video recording or biofeedback, while knowledge of results (KR) refers to the feedback on
performance given to students by tutors, instructors or devices (instrumented manikins, treatment
tables, simulators, etc.) (Schmidt 1982). In terms of motor skills acquisition and retention, KR is
thought to be one of the most important variables (Descarreaux et al. 2005, 2006, Descarreaux &
Dugas 2010, Magill 1993, Scaringe et al. 2002, Triano et al. 2002, 2003, 2006). KR can also be
divided into qualitative (direction of error) and quantitative feedback (direction and magnitude of
error) with quantitative feedback being more precise than qualitative feedback (Scaringe et al. 2002).
Two recent studies by Triano et al. (2002, 2003) using a mechanical training aid to provide
quantitative biomechanical feedback to students learning CM for the lumbar, thoracic and cervical
spine, demonstrated significant changes in performance by students who used the training device
compared to those who did not. Of particular interest was the fact that students were allowed to self-
administer the quantitative feedback by using the training aid. Unfortunately, because of mechanical
error, a logging of the frequency of KR was lost and not reported. In another recent study by Scaringe
et al. (2002), qualitative and quantitative augmented sensory feedback was investigated with students
simulating the application of a controlled CM procedure. This study also used a training aid (kinetic
simulator) for quantitative feedback. The authors concluded that both qualitative and quantitative
feedback groups produced accurate and consistent performance as a result of practice and that
training aids (kinetic simulators) as well as performance feedback, whether qualitative or
quantitative. This combination would, therefore, be useful in performing complex motor skills such as
CM.
It has been proposed by a number of authors that the performance of CM or spinal manipulation
and mobilization can be investigated using a variety of biomechanical parameters such as peak force,
preload force, time to peak force and rate of force production (Cohen et al. 1995, Descarreaux et al.
2005, Herzog et al. 2001, Kawchuk & Herzog 1993, Snodgrass et al. 2010a, b, c, Triano et al. 1997,
2006, van Zoest et al. 2007).
Descarreaux et al. (2004, 2006) have published research on the learning of CM skills using an
instrumented manikin to measure these biomechanical variables. A manikin used for cardiopulmonary
resuscitation was instrumented with a strain gain and other features to allow it to measure peak force,
peak force variability, preload, time to peak force and force production rate when students performed
a simulated thoracic spine manipulation. Participants also stood on a force platform in order to
measure the hand-body delay, which was the lag time between unloading of force plate and onset of
peak force production by the hands (timely weight transfer) producing the manipulation forces. In the
2004 study, Descarreaux et al. studied the biomechanical parameters of four groups of participants
with varying levels of experience and expertise (second and fourth year chiropractic students;
chiropractic interns and chiropractors with a minimum of 5-years clinical experience). Participants
were asked to produce ten consecutive thoracic spine manipulations. The results showed no
difference in peak force, peak force variability, and preload variables. However, important
differences were found for the time to peak force, time to peak force variability, rate of force
production, unloading time and handbody delay. In particular, the chiropractic interns and
chiropractors demonstrated significantly less time to peak force, less variability in time to peak force,
greater rate of force production, faster unloading times and less handbody delay. Overall, these
results showed differences in biomechanical parameters between participants with different levels of
expertise. In particular, more novice students are still learning to coordinate and control the execution
of the complex manoeuvre while the more experienced participants have mastered these skills, as
demonstrated by fast, coordinated and less variable results. Similar results have been found between
different levels of expertise in physiotherapy students performing cervical spine mobilizations such
as speed and force application (Snodgrass et al. 2010 b,c).
In 2006, Descarreaux et al. studied the effect of augmented feedback (KR) on fourth-year
chiropractic students using an instrumented manikin. One group of students received no augmented
feedback while the other group received feedback on the biomechanical parameters of their practice
thoracic spinal manipulations. After testing at the end of 5 weeks of training, the augmented feedback
group demonstrated significantly less variability in peak force, preload force and lower time to peak
force, although this did not reach statistical significance. There were no differences in the peak force,
or handbody delay measures. These results suggest that augmented feedback in the form of
biomechanical variables increases the speed as well as the retention of learning at least over a 5-
week period. It also indicates that practice, regardless of augmented feedback, also results in
learning, but to a lesser extent than augmented feedback. The global coordination index was a
measure of the ability of students to perform transfer of standing body weight from the lower limb and
thrusting of the upper limb in a coordinated fashion.
Triano et al. (2006) investigated the effect of visual feedback (KR) on the learning, performance
and retention of spinal manipulation as well as patient ratings. Using novice chiropractic student
volunteers, one group received instructions about a lumbar spine manipulation procedure (explicated
targeted outcome) as well as visual feedback on their time-load histories (forces and moments) while
practising the lumbar CM. The participants were permitted three trials and then were interrupted by a
10-minute distractive exercise (anatomy test). After the distractive test, they were asked to perform
the manipulation again without KR as a measure of non-KR retention. The other group received
instructions about the technique but did not receive any visual feedback in the form of time-load
histories. They also performed the non-KR retention trial. All participants who received the CM
were asked to rate the performance of the students who performed the manipulation in terms of
comfort, fast, force, precision and confidence.
At baseline, both groups produced similar results for the lumbar CM in terms of total force
(amplitude, speed and duration) as well a total moment (amplitude, speed and duration). Triano et al.
(2006) found the group that received augmented visual feedback (KR) demonstrated an improvement
in the biomechanical performance of the lumbar manipulation by a minimum of 14% to a maximum of
32% over the three trials. In addition, the patient ratings of performance were significantly better for
each of the indicators.
Triano et al. (2006) concluded that KR in terms of visual biomechanical parameters during the
learning of CM results in significant improvement in performance as well as retention of skills, at
least in the short term, for the biomechanical variables measured.
Snodgrass et al. (2010a) studied the effects of real-time augmented feedback to physiotherapy
students performing cervical spine mobilizations with (experimental group) or without (control) KR.
Using an instrumented table that could measure mobilization forces, Snodgrass et al. (2010a)
concluded that practice with real-time feedback (KR) enabled students to apply forces that were
similar to experts, even after a 1-week period.
Descarreaux and Dugas (2010) have provided us with a 5-year longitudinal cohort study of the
learning of CM in terms of biomechanical variables and as measured by an instrumented manikin,
which provided augmented visual feedback (KR). This is the first study of its kind that has attempted
to investigate the process and stages of learning the skills of CMT using augmented feedback KR.
Thirty-three chiropractic students participated in this 5-year study from the start of technique classes
in year 1 through year 5 using the same instrumented manikin.
The results of this study demonstrated two distinct phases of learning characterized by changes
in various CM biomechanical performance indicators. The emphasis for learning in the first stage
was on mastering the levels of force and reducing the time of force production. It appears that time for
force production can improve early in the learning process, but that variability in this parameter takes
a longer time to stabilize. In addition, the concept of preload seems to be ignored by novice learners,
especially when time to peak load is optimized. Interestingly, students at their first testing recorded
high preload values which were attributed to a lack of knowledge about CM.
Once the basic biomechanical variables have been mastered, the results of this study indicate
that students focus on reducing the variability or improving the consistency of their peak and preload
forces. In addition, global coordination (timely weight transfer and handbody coordination),
although it improved linearly throughout the 5 years, improved the most, approaching the skill level of
the experts, during the second phase of the educational programme. Similar results and effects have
been found by Snodgrass et al. (2010a, b, c) studying physiotherapy students performing
mobilizations of the cervical spine.
Descarreaux and Dugas (2010) recommend that chiropractic institutions and technique
instructors should be aware of the different phases of learners as they acquire CM skills. In
conjunction with established motor learning research, the curriculum could be enhanced to shorten the
time period between fundamental and specialized CM skills learning, so that more time could be
focused on learning specialized skills, particularly error-detection strategies, which is the ability of
an expert performer to detect that an error has occurred in their performance and to identify the
relevant and pertinent information necessary for correction. Error-detection is thought to be a high
level skill that is virtually unknown to the teaching and learning of CM.
In motor skills research, considerable work has been done to identify the effects of KR on the
retention of motor tasks. Del Rey and Shewokis (1993) looked at the interaction of summary KR on
the order of presentation of practice tasks. They found that the advantage of summary KR was
determined by the type of practice and when the feedback was given. In particular, for random
practice, KR is most effective if it is given in the later practice sessions, whereas KR was more
effective if given after each practice trial when using block practice schedules. The effectiveness for
each of the practice protocols was measured by tests of retention and transferability to other related
tasks. According to work by Swinnen et al. (1993) when students are learning complex psychomotor
skills such as CM, general kinematic feedback helps to promote long-term retention of learning and
performance. Although much is still to be learned with regard to the order of KR, there now seems to
be some evidence that, overall, KR given in a random fashion helps students to perform better on
retention tests than KR given on a regular block-like schedule (Good 1993b). It is thought that
students would have to concentrate more on their learning tasks because of the uncertainty of when the
next feedback would be given (Good 1993b).
The amount of feedback is also an important issue. Most likely there is a limit to which feedback
is useful even when using repetitive or block practice. Vander-Linden et al. (1993) studied three
groups of subjects learning a motor task. The groups received concurrent feedback (feedback during
and after each attempt), 100% feedback (after each attempt), and 50% feedback (after every second
attempt). The results indicated that on immediate and delayed (48 hours) retention tests, subjects in
the concurrent group demonstrated more error than either the 50% or 100% group and, in fact, the
50% group fared better than both the concurrent and 100% groups. Vander-Linden et al. (1993)
concluded that feedback to the learners about their learning task performance is best given after the
task is accomplished and most likely at a lower frequency than after each practice. The results
showed that too much feedback had a tendency to inhibit some learners from completing their tasks. It
is now generally accepted that augmented feedback (knowledge of results, knowledge of
performance) when given judiciously leads to more effective learning than giving feedback after
every single trial (Weeks & Kordus 1998, Wulf & Shea 2002).
The current literature suggests that feedback is useful, but only if given judiciously, and that
frequent feedback is probably best applied to the early phases of learning with the use of more
random and reduced feedback as students become more skilled and experienced. This concept now
finds some support in the CM literature from the 5-year longitudinal cohort research of Descarreaux
and Dugas (2010). Understanding the difference phases of learning as well as the most appropriate
KP and KR strategies and schedules to use would allow students the opportunity to explore more fully
their own intrinsic or internal feedback that should place them in a better position to take on board the
intermittent yet timely feedback from instructors. Finally, there are now a number of mechanical
training aids available that have been shown to be beneficial especially for timely feedback (KR) that
is essential for the effective teaching and learning of CMT.
Conclusions
The purpose of this chapter is to give the reader a flavour for current concepts in the teaching and
learning of psychomotor skills derived from research in the fields of chiropractic education, cognitive
psychology, movement and sport science.
A number of issues have been raised regarding the teaching and learning of psychomotor skills
by chiropractic students. I have tried to address some concerns regarding the importance of keeping
the end-goal, the clinical context, constantly in the minds of students as they are learning the skills. If
students have a better idea of what, when, how and where the skills are to be appropriately applied, it
seems logical that it would facilitate a greater integration of the motor skills with the cognitive skills.
To this end I have introduced the concept of clinical frameworking as an important goal towards
which both students and tutors should aim.
Presently, very little is known about the way in which skills should be presented to chiropractic
students to enhance their acquisition and mastery. Much needs to be done to see how different
approaches work, such as: presentation of skills, using mental imaging and practice, the best time to
give feedback, the types of practice schedules that reinforce skills better than others, to name just a
few. Currently, with little evidence to go on, caution might be the best approach. Students learn in
different ways and no single approach will be sufficient for all, although we now have some insight
into the different phases of CM skills acquisition in an undergraduate chiropractic programme.
Additionally, the wealth of research in motor skills learning should be adopted as appropriate,
particularly what has shown to be effective such as observational practice, focus of attention, various
aspects of feedback and self-controlled practice. Therefore a mix of approaches to teaching the skills
would, I suggest, be the way forward until more solid evidence is available on which to base some
conclusions.
It is hoped that the work presented here will serve as a basis for discussion and, possibly, the
motivation for some to investigate the many unresearched areas of the teaching and learning of
psychomotor skills relevant to chiropractic practice.

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Chapter 3

Biomechanics of the spinal adjustment and other


clinical biomechanical considerations in
manipulative skills training

an evidence-based investigation
J. Kim Ross, Michael Kondracki
Chapter contents

PART 1 The biomechanics of spinal Manipulation


Introduction
Forces associated with manipulation
Joint cavitation
Direction of applied forces
Motion (kinematics) associated with spinal manipulation
Proposed mode of action for spinal manipulation
Change of range of motion following spinal manipulation
Side-effects of spinal manipulation
Conclusion
PART 2 Clinical biomechanics
Introduction
Spinal forces
Intradiscal pressure
To lordose or not to lordose
Chiropractic in the neutral zone
Biomechanics and the art of motion palpation
Conclusion
References
Part 1 the biomechanics of spinal
manipulation
Introduction
Chiropractors use a large variety of diagnostic procedures and treatment protocols to address a large
variety of conditions. The treatment modality that is most commonly used by chiropractors, however,
is that of spinal manipulation (also known as a chiropractic adjustment) (Cramer et al. 2006).
Firstly we must describe what we mean by the term spinal manipulation. A recent paper by
Evans and Lucas (2010) suggests that five criteria must be met:

1. A force is applied to recipient.


2. The line of action of this force is perpendicular to the surfaces of the affected joint.
3. The applied force creates motion at a joint.
4. This joint motion includes articular surface separation.
5. Cavitation occurs within the affected joint.

Now that the criteria are described, we will attempt to describe the details of these criteria.
Despite its common usage over the past 100 years, the details of this treatment modality were
virtually unknown until recently. Only in the last 20 years have we been able to collect accurate and
reliable data that describe the characteristics of a spinal manipulative procedure. The major areas
that have been researched include force-time/moment-time profiles, force and moment magnitudes,
resulting gross kinematics, resulting segmental kinematics, and factors associated with cavitation and
specificity. It is interesting to note that the areas studied closely, correlate with the definition given
above. In terms of biomechanical outcome measures resulting from the manipulation, only range of
motion has been studied to any great degree.
Forces associated with manipulation
Conway et al. (1993) and Herzog et al. (1993) identified various phases of a manipulative thrust (Fig.
3.1). They described a preload force, a cavitation force and a peak force. As such there was also a
time to cavitation (defined as the point where force increased beyond preload until cavitation
occurred) and a time to peak (defined as the point where force increased beyond preload until the
peak force was reached). Kirstukas and Backman (1999) also termed this time period thrust
duration. Conway et al. (1993) also described three other parameters in attempt to characterize a
manipulative thrust. These were impulse to peak force (the area under the force-time curve during
time to peak) impulse to cavitation (the area under the force-time curve during time to cavitation)
and thrust rate (average slope of the force-time profile during time to peak). It is difficult to quantify
an entire force-time profile, so these parameters allowed one to quantify aspects of the curve that
were believed to be important as to whether or not one could consider the manipulation successful or
not. It is also very common for the clinician to gradually increase the preload force and then just prior
to the adjustive thrust, reduce the applied load (Fig. 3.2). This likely occurs as a result of attempting
to focus the muscular contraction over a very short time period.

Figure 3.1 Definition of parameters analysed; preload force (FL), peak force (FP), force of
cavitation (FC), time to peak force (TP ), time to cavitation (TC), amount of change from preload to
peak force (FP -FL), impulse to cavitation ( ), impulse peak force (sum of both shaded areas).
(From Conway et al 1993, with permission.)
Figure 3.2 Two force-time histories of SMT from the same patient separated by about 2 s (not
shown on graph). First treatment (---) did not produce cavitation whereas second (-) did. Arrow
indicates occurrence of cavitation.
(From Conway et al 1993, with permission.)

Regarding magnitude of force, for posterior to anterior thoracic manipulative procedures, peak
force varies generally between 200 and 600 Newtons (N), but could be as much as 800 N or greater.
In fact Herzog et al. (1993) found that chiropractors automatically seemed to scale the force of their
adjustment to the anthropometrics of the patient. Interestingly, in addition it was determined that the
preload force was directly proportional to the peak force. Peak forces for side-posture sacroiliac and
lumbar adjustments were of similar magnitude. Cervical peak forces were substantially different
however. Herzog et al. (1993) determined that peak forces ranged from 110 to 140 N and that preload
was essentially non-existent. Kawchuk et al. (1992) found similar ranges for peak force, but noted
preload forces in the 011 N range. In a subsequent study Kawchuk and Herzog (1993) determined
that these force characteristics were dependent on which cervical procedure was delivered. In this
study he compared a lateral break, a rotary, a Gonstead and toggle procedure as well as an Activator
(instrument assisted) procedure. Again the peak forces were around 100 N for most of the
procedures; however, activator and the rotary adjustment were around 40 N. As for preload forces,
there was a range from 1.9 N in the toggle procedure to 39.5 N for the lateral break. Regarding thrust
duration, most thoracic thrusts lasted approximately 100 ms while cervical procedures can be similar
or as low as half of that value. Thrust duration for lumbar and sacroiliac manipulation tends to be a
little longer getting up to 150200 ms (Herzog et al. 1993). This is probably reflective of the inertial
load that must be overcome to move the lower portion of the trunk in these side-lying procedures.
Does the gender of the clinician influence the magnitude of force in spinal manipulation? Forand
et al. (2004) sought the answer to this very question. Using seven female and seven male
practitioners, it was determined that the peak forces during thoracic spinal manipulation were not
significantly different between genders. Interestingly male clinicians applied significantly greater
preload forces compared to their female counter parts.
An approach to measuring manipulation forces, which even to this day is somewhat unique, is
that of Triano and Shultz (1997). In this study forces were determined from a force plate built into the
table, and then transmitted loads to the spine were calculated using an inverse dynamics approach.
Several side-lying lumbar and sacroiliac procedures were examined in this study and it was
determined that subtle differences in the procedure, produced significant alterations in the loads
actually transmitted to the spine.
Joint cavitation
The next question to address is the relationship between spinal manipulation mechanics and the
production of cavitation. First we need to define cavitation. In simple terms it is believed to be the
cause of the cracking or popping sound that occurs during manipulation. Evans (2002) describes
the sequence of events (Fig. 3.3) producing the cavitation as follows:

1. The curved surface of the articular surfaces become misshapen as one surface is pulled away from
the other. The central portion goes from a convex structure to concave. At the edges where the
concavity meets the original convexity, the surface becomes pointed in shape. The deformation
occurs because at such a high speed, the central region of the contact zone separated whereas the
outer region remains almost unmoved, creating a circular rim.
2. The surfaces snap back at the circular rim where the cavity initially forms.
3. Coalescence of small gas bubbles into a single cavity grows to reach maximum bubble size.
4. Because of its instability, the single bubble collapses into a cloud of smaller bubbles.

Figure 3.3 Cavitation. Schematic representation of surface geometry and shapes of growing
cavities at a high separation speed (v vc as is likely with HVLAT manipulation) where doughnut
(toroidal)-shaped cavities form around, rather than at the centre, of the contact zone. A, During
separation, the outer regions of the circular contact zone become pointed. This deformation occurs
because at this speed, the central region of the contact zone separates, whereas the outer region
remains almost unmoved, creating a circular rim. B, Surfaces snap back at the circular rim where the
cavity initially forms. C, Coalescence of toroid into single dendritic cavity that grows to reach a
maximum bubble size. D, The newly formed spherical bubble reaches its maximum size. E, Because
of its instability, the single bubble collapses to form a cloud of many smaller bubbles
(demonstrable by radiography as a radiolucent region), which later shrink as the gas and vapor
dissolve (see later). Adapted from Chen YL, Kuhl T, Israelachvili J 1992 Mechanism of cavitation
damage in thin liquid films: collapse damage vs. inception damage. Wear 153:3151.
Reproduced with permission
In the previous section, note that several of the parameters measured were with respect to the
cavitation. The goal was to determine if there was a threshold force, or moment, or rate of force
production that would produce a cavitation. However, studies have failed to demonstrate absolute
thresholds. Cavitations can be produced during very slow or very fast force onset, at low or high
forces or at low or high moments. It appears to be dependent on the patient, the position of the patient
at the time of thrust, the time of day and a variety of other factors. In fact during side-posture lumbar
manipulation, the presence of cavitation seems to be related to the amount of force delivered at the
spine relative to the force delivered at the posterior pelvis or thigh (Bereznick et al. 2006).
Paradoxically it was found in this study that if more than 25% of the total force was delivered to the
spine, cavitation did not occur. One other factor that has been well established is the time required to
produce a cavitation from a joint after a cavitation has already occurred (refractory period). It has
been noted in the metacarpal-phalangeal joints, that there is a refractory period of 20 minutes for a
cavitation to occur when one has previously occurred (Meal & Scott 1986). Until recently, it has been
assumed that the refractory period for spinal cavitation is the same. However, Bereznick et al. (2008)
challenged this assumption. They accomplished this by adjusting the lumbar spine until no further
cavitations could be generated during the procedure. At this point it was assumed that all the joints
had cavitated. They determined how many cavitations occurred during this process, and then
determined how much time was required to get the same number of cavitations to occur again. They
looked at three subjects and determined that the refractory period for lumbar side posture
manipulation varied from 40 to 95 minutes. A decidedly small sample size but the point is made that
the 20 minute refractory period rule does not apply to lumbar spine manipulation. Although the
presence of this refractory period implies that it is the synovial joints of the spine that produce the
cavitations, more evidence would be helpful. Cramer et al. (2008) examined the degree of gapping in
the facet joints of the lumbar spine following manipulation, and determined that the joints that showed
the greatest degree of gapping were the joints at which the cavitation occurred. The two technologies
that were needed to make this determination had previously answered two other questions about
spinal manipulation.
The first of these technologies came from Cramer et al. (2000). They were interested in
determining if there were changes in the facet joints following manipulation. We will re-visit this
concept later in the chapter, but it had been hypothesized that manipulative procedures separate the
joint surfaces and hence break up adhesions that restrict joint movement (Janse 1976). Therefore if
the one can show that the facet surfaces, indeed, separate as a result of manipulation, then the
aforementioned theory of how manipulation exerts its clinical effect is supported. Sandoz (1969) had
found that metatarsal phalangeal joints could be cavitated during manipulation and provided that
sufficient traction was applied afterward, one could identify an increase in the joint spacing and a
radiolucent region in the joint that was not present prior to the manipulative procedure. These
findings were later confirmed by Watson and Mollan (1990) and they were able to capture this during
the actual manipulation using cineradiography. As such Cramer et al. (2000) compared facet joint
gapping in subjects that had been manipulated with those that were not. Patients were placed in
neutral position for an initial MRI to measure the facet gapping. Then patients were either
manipulated or not manipulated and then placed back in the MRI in either a neutral position (supine)
or a side-lying position typically used for lumbar manipulation. The group that received spinal
manipulation and then were placed back into the MRI gantry in side-lying position, showed the
greatest increase in gapping compared to the original neutral position MRI. So in other words,
patients who received manipulation also showed more gapping following the procedure. Specifically
the joints on the up-side (if lying on the right side, the left side facets) showed this gapping
phenomenon. It was, therefore, expected that a similar phenomenon should also occur in the joints of
the cervical spine. Cascioli and Till (2003) looked for gapping, as well as the presence of a
radiolucency, in the cervical spine following manipulation. However, unexpectedly, they were unable
to show either of these. Since it seems unlikely that the cervical spine facet joints would be vastly
different from metatarsal phalangeal joints or the lumbar spine, the suggestion was made that the
failure to see such a phenomenon in the cervical spine was related to an error in methodology. The
suggestion was made that perhaps they did not apply sufficient traction to the cervical spine in order
to detect the difference imposed by the manipulation. However, since there was enough traction
applied to actually obliterate the cervical lordosis, this explanation seems unlikely. Therefore the
reason for conflict in results for the two regions of the spine remains unresolved.
Accelerometry was the second technology which allowed researchers to determine that it is the
gapped joints that cavitate during manipulation. Ross et al. (2004) were interested in the accuracy of
spinal manipulation. Specifically they asked the question Are the joints targeted prior to
manipulation actually the ones that cavitate? To answer this question they secured accelerometers to
either the lumbar or thoracic spine. The clinician would choose the segment which they were going to
manipulate (by whatever means they use to make this decision in practice). The targeted segment was
marked on the skin surface and then the manipulative procedure was performed. The distance
between accelerometers was known as was the location of the targeted segment relative to the
accelerometers. Based on the time required for the vibration created by the cavitation to reach each
accelerometer (the accelerometer would resonate when the cavitation reached it), the location of the
facets from which the cavitation emanated was calculated. For side-posture lumbar manipulation, the
average error from target was 5.29 cm. This distance is approximately the distance between lumbar
vertebra implying that the average error from target was one vertebral level. This doesnt sound too
bad except for the fact that the actual range of error was 014 cm. Thus some of the procedures were
perfectly accurate, while on the other hand, some were as far as threee vertebral levels from the
targeted level. Just less than half the total cavitations were accurate to target. However, it was found
that the more cavitations occurring in a single procedure, the greater the likelihood that one of them
will be accurate to the targeted level. In fact if there were four cavitations or more the procedure
almost always had one cavitation accurate to the target. In the thoracic prone adjustments, the average
error from target was 3.5 cm (still about one vertebral level away as thoracic vertebrae are smaller)
with a range of 09.5 cm. In this case just greater than half of the cavitations were accurate to target.
This was not the first study to look at the location of cavitations and compare it to the intended
target. Reggars and Pollard (1995) determined that in the cervical spine, counter to popular belief or
biomechanical reasoning, the cavitation emanated from the side opposite to that of the actual contact
with the neck. The exception to this rule occurred when the subject had undergone previous neck
trauma. Beffa and Matthews (2004), using microphones, compared the location of cavitation between
lumbar and sacroiliac adjustive procedures. They concluded that the location of the cavitation sounds
does not appear to have a relationship with the type of procedure used. In other words it was no more
likely to cavitate the lumbar spine during a lumbar procedure than it was during a sacroiliac
procedure. Herzog et al. (2001) determined that the centre of pressure during a thoracic procedure
shifted on average 1 cm away from the original target again suggesting that manipulation is not as
accurate as originally believed. To get an idea of how important chiropractors believe accuracy to be,
one needs to look a comment made by Meal and Scott (1986) in their paper on cavitation sounds.
They stated it goes without saying that one of the skills of manipulation is to be able to isolate the
effect only on the one joint that needs to be adjusted presupposing accurate diagnosis. The
aforementioned studies would suggest that this is not the case. Furthermore, one must also question
whether or not accuracy is even a desired effect. Haas et al. (2003) compared the clinical response to
cervical manipulation that was performed at a segment determined by a clinicians palpation, versus a
segment chosen randomly by a computer. Both groups exhibited clinically important improvement but
there was no difference between the groups. The results of this can be interpreted a couple of ways.
The authors concluded that pain modulation may not be related to manipulation of putative motion
restrictions. However, one should also consider the possibility that even though the clinicians chose a
particular vertebra to manipulate, another joint may have cavitated.
What has not been addressed as yet in this chapter is the clinical significance of the cavitation. Is
it necessary to produce a cavitation to acquire the desired clinical outcome? Flynn et al. (2003) were
one of the first to pose this question. The goal of this study was to determine the relationship between
an audible pop and symptomatic improvement with spinal manipulation in patients with low back
pain. The treatment consisted of a single high-velocity thrust procedure purported to have an effect on
the lumbopelvic region. The procedure is long lever in nature with a contact on the anterior superior
iliac spine and another through the arms of the patient that are linked behind the patients neck. During
the session, it was recorded as to whether or not the patient or clinician detected an audible pop. If a
cavitation occurred, the patient moved on to a range of motion exercise which was essentially a
supine positioned pelvic tilt. The patients were instructed to perform 10 repetitions of this exercise
three to four times per day. However, if a cavitation did not occur, the clinician would repeat the
manipulative procedure until a cavitation occurred or until four attempts at the manipulation had been
completed. The patient then proceeded to the exercise protocol as was followed for those patients
who did cavitate. Follow-up occurred between 2 and 4 days after the treatment using pain, disability
and range of motion as outcome measures. No differences were observed for any of the outcome
measures between those patients for which the audible pop occurred and those for whom it did not.
In a follow-up study Flynn et al. (2006) repeated the study but this time with the intent of looking
at the effects of multiple treatments over a 4-week period. Patients were given five treatments over
that period and the outcome measures were monitored over that period. However, again it was
concluded that the audible pop did not contribute to a change in outcomes despite the additional
treatments and time period. Regarding limitations of the study, the authors noted that without the use of
accelerometers they were unable to determine if the cavitations that occurred were at the site of the
intended target. Furthermore, they suggested that it was possible that cavitations did occur in some
instances, but were not reported by either the clinician or patient. Finally, one wonders if there was a
clinical effect of non-cavitators receiving up to four manipulations per session compared to the
single, double or triple manipulations of the cavitators.
Shortly after that study, the same group decided to investigate the influence of the audible pop on
the response of neck pain to manipulation. In this study (Cleland et al. 2007), three different
manipulative procedures were directed to the thoracic spine of each participant. Each procedure was
repeated such that a total of six manipulative procedures were experienced by each participant. Since
accelerometers were not used it was not possible to accurately determine how many pops occurred
during a single thrust and as such, single or multiple pops were recorded as a single pop for any
procedure. After this process, participants were then categorized as having experienced either 3
pops or >3 pops. Like their first study, follow-up occurred using pain, disability and range of motion
as outcome measures, but it additionally included a global rating of change measurement. Again the
results suggested that there was no clinical benefit to the participant experiencing a greater number of
pops.
In a similarly motivated study, Bialosky et al. (2010) sought to determine the relationship of the
audible pop associated with HVLA manipulation, to hypoalgesia. Participants in this study underwent
thermal pain sensitivity testing to their leg and low back. There were two protocols to determine this
sensitivity. The first is known as A fibre mediated pain. This was accomplished through the
application of heat impulses of 3 seconds duration. The second is known as temporal summation. It is
an increase in pain perception to an unchanging repetitive painful stimulation applied over a period of
less than 3 seconds. Following HVLA manipulation, the aforementioned sensitivity testing was
repeated and in addition patients were categorized as to whether or not an audible pop has been
perceived during the procedure. They then compared the before and after results in the two groups. It
was found that as A fibre mediated pain was reduced after manipulation as was temporal
summation. However, the presence of an audible pop only seemed to affect temporal summation. They
concluded that further work was required to determine the influence of the audible pop on
hypoalgesia.
So in summary, the evidence seems to suggest that the audible pop is not required to achieve the
desired clinical effect. Could the audible pop actually have an undesired effect? Watson et al.
(1989a), using accelerometry to capture the cavitation signals emitted from human
metatacarpophalangeal joints, concluded that the energy (expressed as a ratio of the articular cartilage
volume) contained in a typical crack, in many cases exceeded the level needed to produce articular
damage. The knowledge of what level of energy is required to produce articular damage came from
another paper written by that group. Watson et al. (1989b) directed ultrasound waves at bovine
articular cartilage for the purpose of inducing cavitation in the synovial fluid. They found distinctive
pits and craters, not present on control specimens. Similar surface anomalies were detected on the
surface of cartilage harvested during arthroplasty, from human osteoarthritic joint specimens. They
concluded that the mechanism of cavitation bubble collapse could be responsible for damage in vivo,
providing a degenerative pathway toward osteoarthritis. On the other hand, studies done on chronic
knuckle crackers have failed to show a correlation between this habit and the presence of
osteoarthritis in the metacarpalphalangeal joints (Swezey & Swezey, 1975).
Direction of applied forces
The next aspect of spinal manipulation that deserves investigation is the direction of the applied
forces. The papers described earlier in this chapter that determined the magnitudes of force for
various procedures were measuring force in a single direction (usually perpendicular to the patient
surface). Eventually technology permitted the determination of force components (two shear forces
and a perpendicular force). Triano and Shultz (1997) were first to record all of the components (3-D)
simultaneously. They recorded the 3-D forces at the table and then used inverse dynamics to calculate
the forces at the spinal level. As previously mentioned, such technology allowed investigators to see
subtle alterations in different adjustments. These differences were not usually seen in the standard
single dimension force profiles. van Zoest and Gosselin (2003) and van Zoest et al. (2002) measured
3-D forces at the doctor-patient interface (Fig. 3.4). They argued that 3-D provides a more accurate
description of the forces which could also be used for teaching the psychomotor skill to students.
Indeed, they did determine that in addition to the force applied perpendicular to the surface of the
patient, significant levels of force were also applied in the medial-lateral and anterior-posterior
shear directions. Of course the question arises as to which components of the force provide the
therapeutic effect of the manipulation. In other words clinicians may have developed the various
adjustive procedures without ever knowing what aspect of each caused the patient to respond.
Bereznick et al. (2002) questioned the idea that the vertebra would even be subjected directly to the
shear forces produced in manipulative procedures. This is based on the principle that if an interface
between two surfaces is frictionless, and a force is applied to one of these surfaces, only the
component of the force that is perpendicular to the surface will be transmitted to the surface on the
other side of the interface. If you move the skin on the back of your hand you will notice that it slides
very easily on the fascia below. If you push harder with your finger on the skin, you will note that the
skin still slides easily. No matter how much force you applied to the skin you cannot make it stick to
the tissue below. This would imply that the interface between the skin and the underlying fascia is
frictionless. If this is also true for the back, then forces applied in any direction other than
perpendicular to the surface will not be transmitted directly to the vertebra below. In this study, they
loaded the back with various weights and then recorded the force required to move the skin along the
fascia. It was determined that the force required to move the skin on the fascia was identical
regardless of the load applied and hence the interface is frictionless. The implication of this finding is
that only perpendicular forces during thoracic posterior to anterior manipulation will be transmitted
directly to the vertebra beneath. Hence, one should thrust perpendicular to the surface rather than
producing a vector consistent with the facet surfaces. Thrusting in a direction other than perpendicular
to the surface would result in some of the applied force being wasted insofar as moving the vertebra
was concerned. This waste of force was confirmed by the work of Kawchuk and Perle (2008). They
determined that when a thrust was applied perpendicular to the surface in porcine spines, vertebral
accelerations were maximized. Thrusting on angles that attempted to move the vertebra in a cephalad
or caudad direction did not increase the acceleration of the vertebra in that direction, but only served
to reduce the transmitted force. While large clinicians of manipulation can afford to waste some
transmitted force, smaller clinicians cannot and hence would benefit from thrusting perpendicular.

Figure 3.4 Typical manual 3-D force-time profile of a chiropractic high-thoracic adjustment. Fz
represents the perpendicular force component; Fx and Fy represent the shear force components.
(From Van Zoest and Gosselin 2003., with permission.)
Motion (kinematics) associated with spinal manipulation
Now that we have described the forces applied during manipulation, we need to examine the motions
that result from the forces. The difficulty arises from the fact that firstly the motions are very small
and secondly the vertebrae are not readily accessible for us to measure these motions. Gal et al.
(1994) attempted to overcome these barriers. They took cadavers and threaded stainless steel bone
pins into the T10, T11 and T12 vertebrae. In addition surface markers and accelerometers were taped
to the skin over the spinous processes of these vertebrae. Using a reinforced hypothenar contact on the
right TVP of T11 vertebra, a clinician delivered a high-velocity low-amplitude thrust in a posterior to
anterior direction. Forces were measured using a pressure mat placed between the cadaver and the
contact of the clinician. The movements of the bone pins and surface markers were then used to
determine the absolute translation of the target vertebra during each thrust as well as the relative
movement of that vertebra compared to the neighbouring vertebrae. The accelerometers were also
used to determine translation through a double integration of the acceleration signal. So in other
words, three different measuring techniques were used to document vertebral movement. The hope
was that one of the non-invasive procedures (surface markers or accelerometers) would produce
similar results to the invasive procedure. If this were the case, there would be justification to use the
non-invasive procedure for future studies using live participants. Unfortunately it was determined that
the two non-invasive techniques underestimated the vertebral movement, compared to the gold
standard of bone pin movement. In any case the results of the study produced some interesting results.
Generally, a thrust on the T11 transverse process produced movements of equal magnitude in both
T10 and T12. This relates back to the idea of short lever manipulation being specific. If all three
vertebrae in this study translated or rotated to similar magnitudes, it is easy to see why the
aforementioned studies on the accuracy and specificity of manipulation, found that when a specific
contact is made, the average error from the targeted vertebra is about one vertebral level away. The
other interesting observation from this study is that the movements of the vertebrae as a result of the
manipulation are quite subject-specific. In other words the response of a vertebra to a thrust
procedure may be as dependent on the unique anatomy of the patient as it is on the procedure that was
performed on it. Another example of this principle relates to palpation. Ross et al. (1999) examined
the effect of C1-C2 facet asymmetry on the resistance provided by the C1 vertebra to a palpation
force. It was found that when the left and right facets were symmetrical in shape, similar forces were
required to translate the vertebra a given distance. On the other hand when facets were asymmetrical,
the forces required to move the vertebra during a palpation procedure were dissimilar. In other words
much of what we perceive during palpation or much of what happens to a vertebra when a clinician
applies a particular procedure is dependent on the anatomy of the joints rather than the presence of a
fixation or the intent of the manipulative procedure in terms of attempting to restore motion in a
particular direction. This idea is supported by the work of Nansel et al. (1989). They used a
rotational type adjustment and found that if it was applied to the lower cervical spine they detected an
increase in lateral flexion range of motion post-manipulation. However, if this rotational thrust was
applied to the upper cervical spine they did not get an increase in total cervical spine lateral flexion
range of motion. They argued that this is likely due to the fact that it is the lower cervical spine that
contributes to lateral flexion, not the upper cervical spine. In other words it is suggestive that a thrust
in any particular direction is likely to increase the range of motion that the portion of the spine
contributes to. We will examine this study in greater detail in the next section which explores the
biomechanical effects of manipulation.
The motion studies that we have discussed so far refer to the vertebral motion. We also have
some information on the gross movements of the body during manipulation. Triano and Schultz (1994)
looked at the motion of the head and thorax during direct break (lateral flexion) and a rotary break
(rotation) adjustment. They determined that preload positions for these adjustments approached
maximum voluntary ranges of motion for the upper cervical spine. In addition, it was found that SMT
procedures can be successfully modified to control amplitude and direction of body segment
displacements. Since the time of this study no further studies were done on other procedures. This is
unfortunate for a couple of reasons. Firstly, having accurate data on kinematics during a particular
adjustive technique would be very useful in the teaching of such procedures. Furthermore, when
clinical trials are done to assess the effect of manipulation on patient outcomes, being able to quantify
the movements associated with the procedure would help ensure that dose of manipulation could be
controlled, hence allowing a better comparison of studies.
Proposed mode of action for spinal manipulation
The exact mechanism by which spinal manipulation exerts its clinical effect remains elusive. Several
mechanisms have been proposed and it is possible that more than one of these is responsible for the
positive clinical effects seen following manipulation of the spine. According to Evans (2002), these
proposed mechanisms are as follows:

1. Release of entrapped synovial folds or plica


2. Relaxation of hypertonic muscle by stretching
3. Disruption of articular or perarticular adhesions
4. Unbuckling of motion segments that have undergone disproportionate displacements.

The details of these proposed mechanisms are beyond the scope of this chapter; however, they
have been derived in part from the observation that manipulation seems to have an effect on range of
motion. A desirable effect would be to increase range of motion that had been limited by perhaps a
trapped meniscoid or synovial tag, intra-articular adhesions or a hypertonic muscle. However, as we
will learn shortly, an increase in range of motion is not always the result of manipulation.
Change of range of motion following spinal manipulation
Nansel et al. (1989) was one of the first to study the effect of manipulation on spine range of motion
(ROM). If they were going to find an effect of manipulation on ROM, presumably they would need to
find individuals that had a restriction of motion amenable to manipulation. It is well established that
ROM varies considerably from one individual to another. Therefore if you find what you think is a
bilateral restriction, you dont know if you are just detecting that persons unique ROM.
As such, they chose to look at asymmetry of motion, reasoning that if the motion is reduced on
one side compared to its counterpart, perhaps the reduction is caused by a restriction amenable to
manipulation. With this approach they examined the effects of cervical manipulation on reducing the
asymmetry in lateral flexion movement. Asymptomatic participants were randomly assigned to one of
four groups. One group had no treatment between ROM testing. The second group would be put into
the position of an adjustment, but the adjustive thrust was not performed. The third group received a
rotary type adjustive procedure aimed at the most restricted side, while the fourth group received the
same, but to the least restricted side. Range of motion was tested pre-intervention and then tested a
second time 3045 minutes post-intervention. Figure 3.5 shows that the reduction in asymmetry of
movement was only notable for the group in which the adjustment was directed toward the most
restricted side. However, although the result was not nearly as dramatic, when the manipulative
procedure was directed to the side with the least restriction, statistically significant improvements in
symmetry were also observed. The study was repeated in a later study (Nansel et al. 1990), but this
time measuring ROM over a 48-hour period and comparing individuals with previous neck trauma to
those without. They determined that most of the individuals with previous neck trauma, despite
showing a temporary reduction in asymmetry of movement following manipulation, had regained the
asymmetries by 24 hours. This restoration of asymmetry in neck trauma subjects was even more
pronounced after 48 hours. Meanwhile the subjects without neck trauma continued to show the
reduced asymmetry even at 48 hours (Fig. 3.6). It was concluded that the subjects with previous neck
pain may have a pattern of movement that was dictated by the conditions that were present at the time
of the trauma. In fact, they suggest that the spinal cord may have learned this dysfunctional reflex
pattern and maintained this even in the presence of normal articular afferent input.
Figure 3.5 On pretest, all treatment groups exhibited mean cervical lateral-flexion end-range
asymmetries ( SEM) of approximately 14. As anticipated, No RX and Set-up no thrust groups had
not changed significantly on the post-test 30 min later. Even though adjustments delivered to the side
of lease end-range restriction (ADJ-LRS) cause a significant (P < 0.025) reduction in the mean
asymmetry exhibited by that group, the magnitude of the effect was only marginal compared to the
dramatic amelioration of asymmetry brought about when the adjustments were delivered to the side
of greatest end-range restriction (ADJ-MRS).
(From Nansel et al 1989, with permission.)
Figure 3.6 Graphic representation of the group goniometric data. Cervical adjustments induced
short-term amelioration of asymmetry magnitude in both groups of subjects. Although this effect was
slightly less robust in the group of subjects with previous neck trauma at 30 minutes and 4 hours
post-treatment, this difference did not meet 0.05 levels of significance. However, by 24 and 48
hours following cervical manipulation, a difference in the response of the two groups of subjects
had become readily apparent; most of the subjects with previous histories of neck trauma exhibited a
tendency to re-establish close to their original degrees of end-range asymmetry. By 48 hours, 12 of
16 subjects with prior neck trauma had regained asymmetry magnitudes of 10 or great, whereas
only 2 out of 16 subjects without previous history of neck trauma had regained asymmetries of
greater than 10 by that time. In fact by 48 hours following cervical manipulation, the mean
asymmetry magnitude of the group of subjects with prior neck trauma was no longer significantly
different from that initially exhibited by the group prior to manipulation.
(From Nansel et al 1990, with permission.)

Cassidy et al. (1992a) performed a study on ROM of the cervical spine following manipulation,
but included all planes of motion. They found a mean gain in range of motion of 3.05.2 as the result
of a single adjustment. The adjustment was of a rotary type and the greatest increase in ROM was in
fact rotation. In addition, this study also looked for the relationship between ROM and pain. It was
found that there was a significant relationship between a decrease in pain and an increase in cervical
rotation ROM. Cassidy et al. (1992b) went a little deeper to assess the relationship between ROM
and pain. This time the study was controlled by comparing the response to manipulation with the
response to mobilization. It was found that manipulation resulted in a significant improvement in pain
scores compared to mobilization, despite the fact that there was no significant difference in the range
of motion following the two procedures.
Whittingham and Nilsson (2001) performed an interesting study to show the effects of
manipulation on cervical spine ROM over a 12-week period. One group of subjects received
manipulation to the upper cervical spine for a 3-week period, followed by 3 weeks of no treatment,
followed by 3 weeks of sham treatment. The other group received 3 weeks of sham treatment,
followed by 3 weeks of upper cervical manipulation followed by 3 weeks of no treatment. Both
groups spent an initial 3-week period of pure observation to determine if the baseline was stable.
Figure 3.7 indicates that improvements for both groups only occurred during the periods in which the
spinal manipulation was performed. This study nicely demonstrates the relationship between when
the real manipulation was performed, and when actual improvements in ROM were demonstrated.

Figure 3.7 Developments in mean active right rotation during the 12-week trial period.
(From Whittingham and Nilsson 2001, with permission.)

Fernandez-de-la-Penas et al. (2007) sought to determine if cervical ROM can be increased when
the manipulation is directed at the thoracic spine. Their other outcome measure was neck pain. They
determined that there was a significant immediate improvement of neck pain following the
manipulation and 48 hours later. However regarding ROM, increases were found in flexion,
extension, lateral flexion, and rotation, but they failed to reach statistical significance. One might ask
why these investigators chose to use thoracic manipulation for the purposes of improving neck pain.
They argue that if thoracic manipulation can be used to treat neck pain, one can avoid the potential
risk that some suggest is associated with cervical manipulation. They are not the first to show that
neck pain is reduced with thoracic manipulation. Cleland et al. (2005) were also able to show the
clinical benefits of manipulating the thoracic spine in patients with neck pain. What would explain
this phenomenon? Fernandez-de-la-Penas et al. (2007) offered two possible explanations. One
possible mechanism could be that the thoracic procedure may induce a reflex inhibition of pain or
reflex muscle relaxation by modifying the discharge from proprioceptive group I and II afferents. The
second possibility is that the thoracic manipulation activates descending inhibitory mechanisms,
resulting in hypoalgesic effects distant to the site of treatment intervention. Regardless of the
mechanism, further investigation of such a phenomenon is warranted.
Has manipulation ever been shown to result in a decrease in ROM? Lehman and McGill (2001)
did a study looking at the electromyographic response to lumbar side-posture manipulation. Their
other outcome variable was ROM pre and post manipulation. Their data suggest that ROM decreased
following manipulation as often as it increased. One might ask what variables need to be present to
obtain the desired effect of increasing ROM and which ones should be avoided so that one does not
inadvertently decrease mobility when your goal was to achieve the opposite. Some research has been
done regarding inadvertently producing undesired effects as a result of manipulation. This will be the
topic of our next section.
Side-effects of spinal manipulation
The aforementioned study would suggest that sometimes undesirable effects occur as a result of spinal
manipulation. Cagnie et al. (2004) state that severe injuries may occur after spinal manipulation for
treatment of the neck (cerebrovascular accidents) as well as of the midback (rib fractures) and lumbar
spine (cauda equina lesions). However, the incidence of serious complications is low. They suggest
that minor side-effects of spinal manipulation are common in clinical practice. In this study they
surveyed the patients of 51 practitioners (chiropractors, physiotherapists and osteopaths) resulting in
465 completed questionnares. Of these patients, 60.9% reported at least one side-effect. The
following side-effects and their relative percentages were as follows:

1. Headaches (19.84%)
2. Stiffness (19.46%)
3. Aggravation of complaints (15.18%)
4. Radiating discomfort (12.08%)
5. Fatigue (12.06%)
6. Muscle spasm (5.84%)
7. Dizziness (4.28%)
8. Nausea (2.72%).

So if these side-effects of manipulation exist, are we able to predict who is most likely to suffer
from them? The investigators found that females are more likely to complain about stiffness, headache
and local discomfort. In fact gender was the only variable that was a significant factor for all types of
side-effects. They determined that females were 1.84 times more likely to report experiencing a side-
effect following manipulation. One must keep in mind, however, that females may simply be more
likely to report the side-effect than the male. In any case they also found that smokers complained
significantly more about headaches following manipulation than those who had never smoked.
Patients who used medication on a regular basis reported significantly more headache after treatment
than people who did not. People with a medical history of migraines experienced significantly more
headaches than those who did not.
Was treating one area of the spine more likely to result in side-effects? The investigators found
that cervical spine manipulation was followed by headache, fatigue, dizziness and nausea
significantly more frequently than when treatment was directed to the thoracic or lumbar spine. Does
it matter what region of the cervical spine is treated? It was also determined that headaches were
significantly more common when the treatment was directed at the upper versus the lower cervical
spine.
What about more serious complications such as disc herniation and cauda equina syndrome? Do
we have any evidence of these conditions and a causal relationship with manipulation? The data are
somewhat limited here, despite the fact that at least prior to 1997, disc herniation was the leading
cause of claims against chiropractors (Jagbandhansingh, 1997). Most studies describe a series of
cases in which records were obtained by searching for disc herniation cases in which the patient had
been subjected to spinal manipulation and the condition worsened. Murphy (2006) describes a single
case of cervical radiculopathy secondary to multiple level cervical disc herniations. It was stated that
these appeared to be related to cervical manipulation, although it was not certain if the herniations
had already been present and manipulation simply aggravated an existing condition. In any case the
patient responded well to conservative treatment, which included exercises and neural gliding (a
procedure designed to attempt to break adhesions in between the nerve root and neural foramina).
Oppenheim et al. (2005) describe 18 cases in which the patient experienced conditions such as
myelopathy, paraparesis, cauda equina syndrome and radiculopathy following manipulation. Of these
cases, 89% required surgery with, for the most part, good to excellent results. They were particularly
convinced of the causal relationship in three of those cases where the treatment was applied remote
from the area of original complaint, but post manipulation a condition developed at the manipulation
site. For example, in one case, the patient presented with neck pain and was given lumbar
manipulation and then it was subsequently discovered that there was a disc herniation at L4-5 and the
patient was now experiencing foot drop. So without further research we can only speculate on an
association between disc herniation and spinal manipulation. However, Oliphant (2004) estimate the
risk of manipulation causing a clinically worsened disc herniation or cauda equina syndrome, to be
less than 1 in 3.7 million.
Finally, lets examine the claims of an association between cervical spine manipulation and
stroke. Cassidy et al. (2009) cite the fact that there were two cases in Canada during the 1990s that
attracted a substantial amount of media attention. As a result of these cases, some neurologists called
for an avoidance of neck manipulation for acute neck pain. The question, however, is How certain
are we that there is a cause and effect relationship between cervical spine manipulation and stroke?
Did the adjustment cause the stroke? Did the symptoms associated with impending stroke prompt the
patient to visit the chiropractor? Was it simply a coincidence that the patient had a stroke after having
visited a chiropractor? Many authors have attempted to answer these questions. If stroke after
cervical manipulation was a common occurrence then it would be much easier to answer these
questions. However, its infrequency makes it difficult to make causal inferences.
In a systematic review, Ernst (2007) concludes in the abstract, that spinal manipulation can
result in serious complications such as vertebral artery dissection followed by stroke. However, in
the body of the discussion he concludes that there is an association between manipulation and serious
adverse effects. This observation should remind the reader that one should not rely on the abstract to
determine the actual results of a study. One should always look carefully at the methods and results
section before making any judgements. In a study by Rothwell et al. (2001) it is stated in the results
section of the abstract, In patients younger than 45 years, the odds of having a vertebrobasilar
accident (VBA) within one week of visiting a chiropractor were increased by a factor of five.
However, Rothwell et al. acknowledge in the discussion that The association could also arise from
confounding, in which some underlying pathology led to both the VBA and to symptoms such as neck
pain for which someone had sought chiropractic care in the first place. They go on to explain that in
some cases, neck pain is the only sign of vertebral artery dissection. The neck pain motivates the
patient to seek chiropractic care. In such a case, manipulation could trigger a dramatic brain stem
stroke. Smith et al. (2003) on the other hand concluded that spinal manipulative therapy is
independently associated with vertebral artery dissection, even after controlling for neck pain.
If the manipulation has something to do with these events, we should be able find factors unique
to these cases. Can we predict who will undergo a vertebrobasilar accident following manipulation?
Haldeman et al. (2002) looked at 64 medical legal cases of stroke temporarily associated with
manipulation. The goal was to search for common characteristics of treatment or presenting
complaints in these cases. Ninety-two percent of cases presented with a history of head and/or neck
pain and 25% presented with sudden onset of new or unusual headache or neck pain associated with
other neurological symptoms. The strokes occurred during any point during the course of treatment
and there was no apparent doseresponse relationship. The strokes were noted after any standard
form of cervical manipulation including rotation, lateral flexion, and extension. Furthermore, they
occurred following non-force and neutral position manipulations. They concluded that the results of
their study suggest that stroke (particularly vertebrobasilar) should be considered a random and
unpredictable complication of any neck movement. They suggest that the sudden onset of unusual head
and/or neck pain may represent a dissection in progress. Like Rothwell et al. (2001) they suggest that
this may be the reason the patient seeks spinal manipulation care, that then serves as the final insult
leading to stroke.
What is common in the aforementioned studies is the fact that the authors looked for a
relationship between the onset of a stroke and prior visits to a practitioner providing spinal
manipulation as a mode of therapy. Cassidy et al. (2009) also took this approach. However, in
addition they examined the association of stroke with visits to a primary healthcare physician.
Patients aged less than 45 years of age were about three times more likely to see a chiropractor or a
primary healthcare physician before their stroke than controls (patients that had not experienced a
stroke). Positive associations were found between visits to a primary healthcare physician and VBA
stroke in all age groups. Hence, the study concluded that the increased risk of VBA stroke associated
with chiropractic and primary health care physician visits is likely due to patients with headache and
neck pain from VBA dissection, seeking care from these individuals prior to their stroke.
Can the field of biomechanics (specifically tissue mechanics) provide any insight into the
problem. It has been suggested that rotational manipulation can cause intimal tearing as a result of
over-stretching the artery. Symons et al. (2002) tested this idea by testing the tissue tolerances of the
vertebral artery. The results of this study suggested that spinal manipulative therapy resulted in strains
to the vertebral artery that were almost an order of magnitude lower than the strains required to
mechanically disrupt it. As such they concluded that a single manipulative thrust to the cervical spine
was unlikely to damage the artery.
So the debate continues, but no causal relationship has been clearly defined in the literature. In
any case, Rothwell et al. (2001) conclude that caution on the part of the practitioner and patient is
justified and that patients should be made aware of the risks, however remote.
Conclusion
This chapter has examined the details of the chiropractic adjustment. We have used the terms
chiropractic adjustment and spinal manipulation synonymously. We have discussed the characteristics
of the intervention that must be present to consider it manipulation. One of those characteristics was
the presence of cavitation. The chapter showed how cavitation was used to determine that
manipulation is not necessarily accurate relative to the joints that were targeted. This was supported
by kinematic studies that showed when one vertebra was contacted the neighbouring vertebrae move
almost exactly the same magnitude. Regarding cavitation we also discussed the observation that the
presence of cavitation does not appear to be necessary to obtain the desired clinical effect of spinal
manipulation. In terms of characteristics of the force, it was found that force magnitudes for thoracic,
lumbar and sacroiliac procedures vary between 200 and 800 N, whereas in the cervical spine 100
140 N is more typical. Regarding direction of thrust, we discussed that even though the technology
exists to measure applied forces three dimensionally, it appears that it is primarily the forces applied
perpendicular to the spine that cause vertebra to move during manipulation. We discussed four
proposed mechanisms by which manipulation may exert its clinical effects and that most of them
referred to an increase in motion obtained by the manipulative force removing a restriction to motion.
As such we saw that manipulation seems to increase range of motion for the most part, but the
increase in motion occurs in the direction that that vertebral level is most involved in despite the
intended direction of the thrust. Finally, we have seen that spinal manipulation is associated with
undesirable side effects. Most are minor and more commonly associated with the cervical spine. In
addition, cervical manipulation has also been associated with more serious conditions such as stroke.
Studies indicate however that it is more likely the fact that the symptoms of a dissection of the
vertebral artery (neck pain and headache) cause the patient to seek chiropractic care for those
symptoms. Then the patient goes on to have a stroke because they were going to anyway, or
manipulation was the final insult leading to a stroke. Support for this comes from a study that found
that patients who have a stroke are also more likely to have visited a primary healthcare physician
prior to their stroke, than patients who have not had a stroke. In any case it is important to inform the
patient of the potential risks no matter how remote.
Part 2 clinical biomechanics
Introduction
The application of the laws of mechanics to the study of human systems and tissues is relatively new.
As with all new sciences biomechanics has entered a wunderkind phase and is now expected, quite
unrealistically, to provide the solution to all manner of complex biomedical problems. This is
certainly the case in most clinical sciences and is especially true regarding the study of the human
spine. Knowledge of the limitations of experimental methodologies and theoretical considerations is
a prerequisite for the interpretation of biomechanical data. Since there are a number of excellent texts
covering the fundamentals of biomechanics, this chapter will not attempt to introduce the basic
concepts of this science. For an introductory review of biomechanical knowledge the reader is
referred to the relevant chapters in Clinical Anatomy of the Lumbar Spine (Bogduk 1997) and
Clinical Biomechanics of the Spine (White & Panjabi 1990) and, most recently, The Biomechanics
of Back Pain (Adams et al. 2002). This chapter focuses on some topics in spinal biomechanics that I
feel are relevant to students of chiropractic, graduate and undergraduate alike. This will by no means
be an exhaustive appraisal of the state of spinal biomechanics, but rather a brief review of
controversial areas of research intended to stimulate thought and debate. The views expressed and the
topics covered here are, of course, a personal selection of issues the author regards as pertinent to the
study of spinal health and skills training.
Spinal forces
A useful illustration of research controversy is found among those attempting to model the forces
within the spine, in particular the lumbar spine. A very readable reassessment of spinal modelling is
provided by Richard Aspden in his review paper (Aspden 1992). The author first deals with the way
in which forces within the spine are traditionally estimated. As he points out, most models of the
spine assume that the bony skeleton is a simple lever with the muscles providing externally applied
forces. Since the spine is both curved and flexible and capable of changing shape during motion, thus
varying its response to applied forces with posture, this lever model, he argues, is a gross over-
simplification.
Traditionally, the sum of the forward bending moments created by the weight of the trunk, and
any weight being lifted, are balanced by the forces generated by the erector spinae. The compressive
force on the lumbosacral joint is then taken to be the sum of the erector force plus the compressive
components of the other loads. This, however, can result in unrealistic magnitudes of compression,
especially during lifting. These forces, as calculated using a simple lever model, can be in the order
of 10 kN. This seems paradoxical since vertebral failure strengths are usually between 5 and 8 kN
(Nordin & Frankel 2001), although others have reported compressive failure at 13 kN and even 14
kN (Porter et al. 1989, Yoganandan et al. 1994). A cadaveric study using lumbar functional spinal
units under compression demonstrated that one of the specimens was capable of resisting a force of
14.1 kN before damage occurred (Yoganandan et al. 1994). This exceptional specimen was an L3/4
functional spinal unit from a 21-year-old male and was comparable in strength to the L2/3 vertebral
body of a 25-year-old coal miner, which failed at 13.95 kN, as recorded by Porter et al. (1989).
Nicolai Bogduk, in a review paper on the lumbar disc (Bogduk 1991), also claimed that compression
forces greater than 10 kN could be attained during lifting. A study by Swedish workers on high-level
powerlifters using the lever model of Schultz and Andersson (1981) calculated a compressive load
on the L3 segments of eight male lifters that ranged between 18.4 and 36.2 kN (Granhed et al. 1987).
Although these loads seemed unfeasibly high, the authors felt that the biomechanical model used was
a reasonably accurate predictor of in vivo forces and could be explained by the athletes bone mineral
content. In a previous in vitro study the authors had found a linear relationship between the bone
mineral content and the ultimate compressive strength of vertebrae (Hansson et al. 1980). However,
the bone mineral content of the lifters involved in the in vivo study was extremely high and
contradicted the notion of a linear relationship, suggesting that after a threshold level, the mechanical
behaviour of these vertebrae would approach that of a solid block of bone and show an exponential
rise in compressive strength.
Nevertheless, considering the spine as an arch and not a lever will, Aspden maintains, help in
reconciling the contradictory data generated when modelling the spine (Aspden 1992). The principal
difference between an arch and a lever is that an arch is a curved structure which, if constructed
properly, is intrinsically stable, whereas a lever needs to be externally supported. Thus the forces
calculated for an arch are less than those for a lever since there is no requirement for an externally
applied balancing moment.
Major contributors to the axial compressive forces required to maintain stability in the spine are
the longitudinal ligaments. These ligaments pre-strain the spine throughout the whole range of flexion
and extension, reducing tensile forces that may damage the annular fibres. Unfortunately, this pre-
strain function comes at a cost and the cost is compression and thus an increase in intradiscal
pressure. Since the ligaments of the neural arch, the true ligaments, lie very close to the axis of
sagittal rotation in the intervertebral disc (Fig. 3.8), they act on a very short lever arm and hence
generate a high compressive load on the disc compared to more distant structures such as the lumbar
extensor muscles. These posterior ligaments come into play during flexion and since they are
viscoelastic structures, their resistance is not linear. Thus, although they do impose a compressive
force during flexion, this force is not excessive during the early phase of the movement but increases
substantially towards the end of the range (the neutral and elastic zone). In this way the disc is really
only exposed to damaging forces at the extremes of flexion (i.e. >95%) and this suggests that advice
to avoid hyperflexion, particularly in lifting, is sensible. In addition, their viscoelastic nature will
result in a disproportionate increase in stiffness when loaded rapidly. As the spine is curved the
ligaments will generate more force; additionally, the greater the curvature of an arch the less axial
force is required to produce equilibrium. The combination of these two effects will de-stress the
active muscle and reduce the energy required to maintain a certain posture.

Figure 3.8 Neural arch ligaments.

The observation noted by Goel et al. (1985) that extension of cadaveric whole lumbar spine
specimens produced the most stable loading mode, may, in part, be explained by the increase in
lumbar curvature. In the traditional lumbar spine model the closeness of the erector muscles to the
vertebral column has proved problematic. The perpendicular distance between the action line of the
muscles and the axis of the joint, in the posterior of the intervertebral disc, has been considered so
short that it has seemed almost impossible for the erectors to produce the extensor moment required
for equilibrium. Aspden (1992) reminds us, however, that the spine is not a simple lever and that
muscles do not contract in straight lines between their attachments. The curved nature of the spine,
and in particular the lumbar lordosis, will deflect the line of action of the erector spinae muscles and
will generate larger moments than previously estimated. In the late 1960s the moment arm of the
lumbar extensor muscles was estimated to be around 5 cm (Chaffin 1969), but today it is estimated to
be closer to 68 cm (McGill & Norman 1987). Attention has also focused, recently, on the erector
spinae aponeurosis. This connective tissue structure originates from the sacrum, ilia and lumbar
spinous processes and forms the tendons of the thoracic erector muscles. The erector spinae
aponeurosis is thought to have the longest lever arm for trunk extension and is a major contributor to
the extensor moment. In 1994 a magnetic resonance imaging (MRI) study on 11 healthy subjects
demonstrated an increase in the lever arm of the erector spinae and erector spinae aponeurosis, of
between 10 and 24%, in the lordosed position (Tveit et al. 1994). This study suggested that a lordotic
posture might be advantageous during lifting and might help to generate a greater extensor moment.
However, as this was an MRI study, the experimentation was confined to the supine, unloaded
position and the authors were cognisant of the limitation this placed on their study.
If, however, we accept that the curved nature of the lumbar spine is key to its function then
perhaps we should turn our attention to those structures most responsible for influencing lumbar
curvature? In terms of active elements, we cannot ignore the role of the lumbar multifidus muscles.
The principal action of these structures is in extending the lumbar segments and countering the large
flexion moments acting over the spine and particularly those over the lumbo-sacral joint (Macintosh
& Bogduk 1986). This is apparently achieved without any shear translation because of the near
perpendicular attachment to the spinous processes. Their fixture to the spinous process, which is so
posterior to the axis of sagittal rotation, also invests them with considerable mechanical advantage
(Fig. 3.9). The multifidus muscles, deep to the erector group, are also complex finely innervated
structures that are capable of precisely controlling the local curvature of the lumbar spine. In respect
of the factors mentioned above, this fine control of lumbar curvature can, it would seem, have very
profound effects on the gross function of the entire spine. This may help explain why some
chiropractors make great efforts to influence the multifidus muscle through adjustive procedures
(Grice 1979). The role of these muscles, their functional neurology and recent research will be
discussed in more depth later in this chapter.

Figure 3.9 Multifidus muscle and bioanatomical importance.

In the late 1950s, Bartelink (1957) alluded to the possibility that intra-abdominal pressure (IAP)
could help counteract spinal compression forces during lifting and other activities. Increases in IAP
were thought to cause upward forces on the diaphragm, producing a balloon-like resistance to spinal
flexion. Further studies, however, failed to unequivocally support this and in 1986 a group led by
Nachemson et al. (1986), showed that increasing IAP by a Valsalva manoeuvre increased rather than
decreased lumbar spine compression. By this time it became apparent that any mechanism for IAP to
result in a reduced flexion moment would have to be more complex than a simple balloon effect.
The thoracolumbar fascia (TLF) and the abdominal muscles together have been credited with the
ability to apply an extensor moment to the spinous processes and thus supplement the mechanically
disadvantaged erectors. It was proposed that an increase in IAP resulted in lateral tensile forces
being imparted to the TLF, which, because of the criss-cross fibre orientation of its posterior layer,
produces an extension moment on the lumbar spine via the spinous processes. The abdominal muscles
would, in effect, brace or even extend the spine during lifting. This phenomenon has been dubbed the
hydraulic amplifier by Gracovetsky et al. (1985). Aspden (1992), however, points out the work of
Tesh et al. (1987), which demonstrates that the ratio of axial to circumferential tension is a mere 0.4.
Aspden feels that the major function of the thoracolumbar fascia is in tightly constraining the erector
muscles. During contraction of these muscles their cross-sectional area will increase; if this
expansion is constrained by fascia the stiffness and strength of the muscle should increase by up to
30%, rendering the spine able to support a greater load. This enhanced stiffness will also increase the
resistance of the muscle to bending. In a similar way it is proposed that IAP will increase stiffness of
the lumbar spine to bending and thus provide additional stability during lifting. In 2001 an in vivo
study, involving five subjects, induced an increase in IAP by electrical stimulation of the phrenic
nerve with resultant contraction of the diaphragm (Hodges et al., 2001). These authors were able to
confirm that an increase in IAP could, indeed, generate a trunk extensor moment, but suggested that the
contribution was small compared to the potential moment produced by the back muscles. However,
Hodges and co-workers point out the limitations of their experimental method and remind us that, in
normal function, the increased IAP would be brought about by combined contraction of the
abdominal, pelvic floor and diaphragm muscles. In this way, the effect of raised IAP may be of more
value when the lumbar spine is involved in asymmetrical lifting, during axial rotation and lateral
bending, rather than in pure sagittal flexion/extension (Marras & Mirka 1996, McGill et al. 1994).
Most recently, however, investigators have revisited the biomechanical influence of the TLF and
suggested that earlier work may have been too focused on a single component of the TLF (Gatton et
al. 2010). The TLF comprises three layers, two of which, the middle and posterior, have been
credited with exerting an effect on the lumbar spine (Tesh et al. 1987). The posterior layer is divided
into deep and superficial laminae and, ultimately, attach to the spinous processes of the thoracic and
lumbar segments. It is this posterior layer, almost exclusively, that has occupied the attention of most
researchers to date (Barker et al. 2010, Gatton et al. 2010). The middle layer, however, attaches to
the tips of the lumbar transverse processes before blending with the aponeurosis of the transverse
abdominis and posterior part of the internal oblique muscles and, until recently, its influence has been
somewhat neglected. Gatton and colleagues (2010) developed a three-dimensional geometric model
of the posterior and middle layer in order to illustrate both the direction and maximum magnitude of
moments which the TLF is, potentially, capable of applying to the lumbar spine. Their results suggest
that, in the upright stance, the TLF exerts small flexion moments to the upper lumbar segments (L2-
L4), but provides larger extension moments to the lower lumbar region (L4-S1).
Almost all of these biomechanical models of lifting, however, choose to ignore the influence of
the pelvis. As chiropractors we are, of course, deeply interested in the mechanics of the pelvic ring
and in particular the sacroiliac joints. In 1993 Snijders et al. attempted to redress the balance and
focused their attention, almost exclusively, on the role of the sacroiliac joints and the pelvic ring in
the transfer of upper body loads to the legs. The first part of this publication looked at how the
sacroiliac joints resist the very large shear loads imposed upon them. The flat nature of these joints
makes them well suited to the transfer of large bending moments but susceptible to shear forces which
would tend to displace the sacrum inferiorly with respect to the iliac bones, bearing in mind that up to
60% of the body weight is supported by the sacrum. Although the flatness of the joint is evident in
the young, the sacroiliac joint becomes progressively more undulated with age. The opposing
surfaces of the joint develop projections and corresponding depressions that assist in withstanding
shear (form closure) (Vleeming et al. 1990). In a similar way to Aspdens analysis of the lumbar
spine, Snijders et al. (1993) view the pelvis as an arched structure. They describe a mechanism
whereby displacements of the sacrum are reduced to a minimum by a constant compressive force
across the sacroiliac joints. This mechanism is dependent not only on joint compression but also on
friction forces within the joint, sacral wedge angle and the influence of muscles and ligaments. The
extra muscle activity required to squeeze the sacrum between the ilia and thus resist shear through
increased frictional forces has become known as the self-bracing effect. Recently, the term force
closure has been used when a continuous force is required and form closure when no extra force is
necessary (Richardson et al. 2002). Snijders et al. (1993) also showed that if the pelvis is treated as
an arch, the intrinsic stability and mechanical function of the sacroiliac joints do not depend on an
intact pelvic ring. They go on to suggest that by far the greatest factor in sacroiliac joint stability is
the compressive forces acting across the joint surfaces (Fig. 3.10). These forces (force closure),
together with the propeller-like orientation of the sacral surfaces (form closure), will resist sacral
slipping. Almost any pelvic or abdominal muscle whose fibres have a transverse orientation with
respect to the sacroiliac joint can contribute to force closure. More specifically, however, the
transversus abdominus, piriformis, gluteus maximus, coccygeus and middle portion of the internal
oblique muscles have generated the most clinical interest. A recent collaboration between Snijders
and the Australian rehabilitative physiotherapy group, led by Carolyn Richardson, has focused on the
role of the transversus abdominus muscle on sacroiliac joint stability (Richardson et al. 2002). This
study used the transmission of externally evoked vibration across the sacroiliac joint to assess
laxity/stiffness of each sacroiliac joint in vivo. This measure of sacroiliac joint laxity was applied to
13 individuals with no history of lower back pain during a number of exercises designed to induce
specific muscle contractions. In all of the individuals studied, contractions of the transversus
abdominus had the greatest effect in reducing laxity of the sacroiliac joint. This effect was
significantly greater than that attributed to the bracing action of all of the lateral abdominal muscles
and suggests that specifically targeting individual muscles is more productive, in a clinical setting
than the general activation of the abdominal musculature. In terms of spinal rehabilitation, attempting
to isolate the transversus abdominus is accomplished via the so-called abdominal brace (McGill
2002).

Figure 3.10 The self-bracing effect as proposed by Snijders et al. (1993). Force F1 can be
increased by the action of certain muscles, ligaments and by the application of a trochanteric belt.
The self-bracing mechanism is reinforced with increasing friction between the surfaces, force Ff , by
enlarging the normal force Fn using muscle tension, the fibres of the gluteus maximus having the most
effective direction. Note also the propeller-like orientation of the sacral auricular surface
(adapted from Snijders et al. 1993 with permission.)

Sacroiliac joint stability is of great interest to chiropractors and particularly the balance
between, on one hand, restoring normal motion to a locked joint and, on the other hand, the
prevention of excessive laxity. In this regard, the notion that forces generated within certain pelvic
muscles, particularly the gluteus maximus and piriformis, can markedly increase the compressive
forces across the joint and thus improve stability is particularly attractive. It would seem logical that
to manipulate or adjust these joints one should exploit the influence these muscles have on their
related articulation. It is this authors opinion that the passive tension within these myofascial
structures is probably of greater importance to adjustive skills than the final thrust itself and,
therefore, a working knowledge of the mechanical properties and effects of muscular tissues is
essential to all manipulative clinicians. For example, Snijders et al. (1993) have hypothesized that,
through connections with the lumbodorsal fascia, other muscles, such as the latissimus dorsi, may
work in synergy with the gluteus maximus, under certain loading conditions, to support the sacroiliac
joints. More recent work by these authors has supported the notion that tension generated by these two
very large muscles can significantly contribute to force closure and hence the stability of this joint
(Vleeming et al. 1995, 1997). This hypothesis may help to identify activities that are likely to benefit
individuals in whom sacroiliac stability is compromised and to support rehabilitation programmes
incorporating the common lat pulldown exercise (Fig. 3.11). Perhaps the most natural activity in
which the coordinated contraction of the latissimus and contralateral gluteus maximus occurs would
be swimming. The front crawl may not intuitively spring to a patients mind as a rehabilitative
approach to sacroiliac disorders but knowledge of current biomechanics certainly supports it.

Figure 3.11 Latissimus dorsi pulldown exercise.

These biomechanical studies also support the use of trochanteric or pelvic belts for the treatment
of injured sacroiliac joints. The effect of the belt is thought to enhance the self-bracing forces
around the joints and the line of action of the belt is compared to that of the piriformis muscle. The
sacrotuberous ligament is also thought to play a central role in sacroiliac stability. In an earlier paper
Vleeming et al. (1989) suggest that, through connections with the long head of biceps femoris, the
straight leg raising test can directly affect the sacroiliac joint. Thus pain elicited by the straight leg
raising test may reflect sacroiliac dysfunction rather than nerve root tethering. They further suggest
that the stabilizing effect of the gluteus maximus may be partly mediated through tension in the
sacrotuberous ligament. This is hardly a surprising function of the ligament; however, the concept that
through attachments with the lumbodorsal fascia, gluteus maximus and biceps femoris muscles this
stabilizing function may be modified certainly provokes interest. The reductionist view that muscles
and ligaments subserve entirely separate functions may well be outdated. Indeed, Snijders and co-
workers have compared the sacroiliac joint to a multidirectional force transducer, presuming the
existence of mechanoreceptors in the surrounding ligaments. They point out the logic of having these
two sensors in the path of considerable force streams being transferred by the pelvis from the upper
body to the legs. This view is also shared by Panjabi (1992a) in his hypothesis of spinal stability.
Panjabi, on the other hand, suggests that spinal ligaments will act more like strain gauges than force
transducers. He submits that the large deformations that occur in these tissues around the neutral
position will better stimulate receptor cells than the forces (stress) generated as a consequence of
load. Panjabi sees the stability of the spine as a function of three subsystems (Fig. 3.12) with the
ligaments, disc and bony vertebrae as the passive subsystem: passive only in as much as they cannot
directly alter or modify the forces and moments placed upon them, but very much active as
transducers in the vicinity of the neutral position, or neutral zone. The information generated by these
sensors can then, Panjabi feels, be used via the neural subsystem to modify muscular responses to
imposed loading (the active subsystem) and restore mechanical stability if it has been compromised.

Figure 3.12 The spinal stability system as proposed by Panjabi. The passive subsystem
comprises the vertebrae, facet joints, discs, spinal ligaments, joint capsules and the passive
mechanical properties of skeletal muscle. The active subsystem includes all skeletal muscle and
tendons surrounding the spinal column. The neural subsystem includes the various force and motion
transducers found in ligaments, tendons and muscle together with the neural control centres. These
subsystems are considered functionally interdependent in maintaining spinal stability
(adapted from Panjabi 1992a, with permission.)
Whatever the details, it is clear that both these researchers see articular stability as an active
process rather than a passive or static resistance to imposed demands. Furthermore, it seems likely
that one can influence this mechanism externally through alterations to muscular tone and by indirect
stimulation of mechanoreceptors, a possible effect of manipulation. The neuromusculoskeletal system
and its ramifications are the natural domain of chiropractic and it behoves us to continually sharpen
our skills in light of new knowledge. Chiropractic, like the human condition it studies, should be a
dynamic science.
Intradiscal pressure
Of course, no discussion of spinal forces would be complete without some reference to the effects of
these forces and moments on the intervertebral disc. For some time now clinicians and scientists have
held changes within this structure to be responsible for the majority of patients presenting with low
back pain (Cavanaugh et al. 1997). Pioneering work by Nachemson and others in the 1960s and
1970s using live subjects (Nachemson 1965, 1981, Nachemson & Morris 1964) has provided those
working in the back pain field with data regarded, until very recently, as definitive and almost
sacrosanct in nature. Nachemsons early study involved inserting a pressure transducer (pressure-
sensitive polyethylene membrane) in the form of a modified needle into the L3/4 disc of 16 normal
subjects (Nachemson & Morris 1964). Since the focus of attention in these studies was the nucleus
pulposus, the term pressure is used rather than stress as the nucleus, in health, has the
biomechanical properties of a fluid (Adams et al. 2002). The subjects disc pressures were then
recorded under varying conditions and postures including sitting, standing, reclining, holding weights,
performing the Valsalva manoeuvre and wearing an inflatable corset. Using data from previous in
vitro studies of loaded cadaveric tissue, it was possible to establish a direct relationship between the
pressure within the nucleus and axial compression forces applied to the motion segment. The most
significant findings were that the magnitude of in vivo loads on lumbar discs are substantial, often
between 100 and 300% of total body weight, and that in all cases the loads were highest in the sitting
position, by around 3040% higher compared to relaxed standing. Based on these and subsequent
findings, advice to patients with low back pain, especially those considered discal in origin, has been
to avoid sitting and to stand or lie down in preference to a seated position. Further in vivo work by
Nachemson (1965) showed that leaning forward 20 (flexion) resulted in an average increase in
intradiscal pressure of 30%. As a result of ethical considerations few, if any, in vivo studies of this
kind have been carried out to validate and extend this area of research. In 1999, however, a German
group repeated Nachemsons work using a more sensitive and reliable pressure transducer (Wilke et
al. 1999). Owing to the risks involved in the procedure their study relied on a single subject and
single vertebral level (L4/5), but the transducer was in place and recorded pressure data at 200 Hz
(reduced to 1 Hz during sleeping) over a 24-hour period, allowing the effects of various activities of
daily living on disc pressures to be evaluated. In many respects the data correlated well with those of
Nachemson, but with some important exceptions. The most notable difference suggested by this study
was the effect of seated posture on intradiscal pressures. Nachemsons work identified an increase in
intradiscal pressure between relaxed standing and relaxed sitting, in contrast, Wilke et al. (1999)
found the intradiscal pressure to be lower in the seated posture. Only sitting with an erect, actively
straightened back (without a backrest), as often recommended to low back pain patients, resulted in
pressures greater than those found in the relaxed standing position. Interestingly, if the subject
slouched into a chair with a backrest, as patients are often advised against, the pressure dropped from
0.46 MPa to 0.27 MPa.
These findings, if representative, should prompt a radical reappraisal of the advice given to
patients suspected of symptomatic disc injury. It would seem that the restrictions on the activities of
daily living often placed on these patients, such as the avoidance of sitting at all times, may, in fact,
be unnecessary and unsupported by current knowledge.
Although the significance of this studys results are limited by the fact that all the data gathered
relate to a single subject, the positive correlation with the bulk of Nachemsons other findings only
serves to strengthen the veracity of the contradictory results. In addition, previous work has come to
light that may help to support these new findings. Since it is now well established that diurnal changes
in stature or height can be attributed to the fluid content and deformation of the intervertebral disc. In
addition, since this is directly related to spinal loading, then it can be assumed that differences in
height between postures may relate to alterations in disc pressure. A 1992 study that used precision
methods to measure such changes uncovered evidence that tends to corroborate the findings of the
Wilke study (Althoff et al. 1992). These authors examined the changes in stature of 20 individuals
with various postures in reference to standing. In all instances there was an increase in stature of
around 2 mm after relaxed sitting, suggesting a decrease in spinal loading. Furthermore, the greatest
increase in stature (4.2 mm) was associated with slouched, unsupported sitting which would appear
to mirror directly the findings of Wilke et al. (Wilke 1999). Another disparity between Nachemsons
and Wilkes studies was observed in the effect of supine versus side lying. Nachemsons work had
demonstrated an intradiscal pressure lying on the side three times that of lying on the back, whereas
Wilkes study showed essentially no difference in pressures between these positions. Again, if this
information is truly representative, current fears within the chiropractic profession regarding the use
of side-posture techniques in the management of discogenic symptoms may be groundless and
unfounded.
Of course, studies such as these give us information on the pressures within the nucleus only and
tell us very little about the stresses encountered throughout the whole intervertebral disc. Work by
McNally, Adams and others (Adams et al. 1996b, McNally et al. 1992, 1993, McNally & Adams
1992) has given us new insights into the effects of loading, posture and movements on the distribution
of stress across the disc. The technique of stress profilometry has been applied both in vitro and in
vivo and has provided valuable data on how the spine copes with the varying loads placed upon it.
For a more complete description of this fascinating area of biomechanics the reader is referred to the
excellent text The Biomechanics of Back Pain by Adams, Bogduk, Burton and Dolan (Adams et al.
2002). In essence, however, stress profilometry has shown that stresses across the disc are not
uniform and, for normal discs, the highest stresses are found within the annulus rather than the nucleus
(Edwards et al. 2001). More specifically, the region of highest stress appears to correspond to an
area of the posterolateral annulus close to the intervertebral foramen, an area clinically associated
with degeneration and prolapse (Adams et al. 1996a, Edwards et al. 2001). As the disc ages and
degenerates, its response to compression and bending becomes erratic, with higher peak stresses as it
passes from normal to mild degeneration, finally progressing to more irregular behaviour and an
overall reduction in the magnitude of stress as the disc narrows in severe degeneration. Stress
profilometry has also shown the way in which load is shared between the nucleus and the annulus
under differing conditions. The principal mechanism governing the distribution of compressive stress
across the disc is related to fluid balance within the nucleus (Adams et al. 1996b). As the nucleus
behaves in the manner of a sealed hydraulic system, small changes in fluid volume result in large
alterations in hydrostatic pressure. An experimental study to simulate the effects of erect standing on
the lumbar discs over time (Adams et al. 1996a) used stress profilometry to monitor how the disc
distributes sustained loading. Viscoelastic materials, by their very nature, deform in a non-linear way
over time and this time-dependent strain under constant loading is known as creep and in the disc is
associated, largely, with fluid loss. Adams and his team subjected a number of lumbar motion
segments to a constant compressive force for 23 hours in an attempt to simulate prolonged manual
labour in a flexed posture or the kinds of loads associated with driving. Their results demonstrated a
surprising loss of hydrostatic pressure within the nucleus of 1336%. A drop in nuclear pressure of
this magnitude will necessitate a transfer of the compressive stress to the annulus, and in particular
the posterior annulus. Adams and colleagues propose that this increase in regional stress occurs since
the posterior annulus is the narrowest part of the lumbar disc and has very little margin for
accommodating significant strain. The effect of creep loading, therefore, is to subject the annulus to
progressively greater stresses that, eventually, lead to an outward bulging of the outer annulus and
inward bulging of the inner annulus. Naturally, bulging of the annulus in the transverse plane will
cause an overall reduction in vertical height and narrowing of the disc space. This squashing effect
on the discs has been demonstrated in vivo by measuring changes in height. In 1994 a group led by
van Dieen et al. (1994) employed the same precision method as that used by Althoff et al. (1992) to
measure subtle changes in height during repetitive lifting. These authors examined two small groups
of subjects aged 20 years and 40 years, respectively. Before, during and after six 5-minute episodes
of lifting an 8 kg weight, any changes in stature were assessed. Their findings, a total stature loss
averaged at 3.9 mm (range 0.39.5 mm), suggest that creep loading can have a reasonably rapid effect
on reducing spinal dimensions, a phenomenon dubbed spinal shrinkage, and that approximately 30%
of this effect can be attributed to the lumbar spine. They also concluded that spinal shrinkage was
more marked in the older subjects and took effect over a shorter time period.
In any event, as disc space narrows and the vertebral bodies approach each other; compressive
loading can be shared, to some extent, by the zygapophysial or facet joints, although the mechanism by
which this takes place is dependent on posture. Moderate flexion allows the stresses to be evenly
distributed across these joints whilst extension reduces the area of contact and thus leads to an
increase in force concentration (Adams et al. 2002). Too much flexion, on the other hand, separates
the vertebral segments and exposes the disc to all of the compressive force. In this way, prolonged
lumbar flexion prevents the facet joints from shielding the disc and can lead to accelerated
degenerative changes or actual prolapse. This, Adams suggests, can help to explain the correlation
between prolonged driving, low back pain and prolapsed intervertebral discs (Adams et al. 1996a).
Stress profilometry has recently provided some very interesting data of great significance to the
chiropractic and allied professions. A Dutch group, using stress profilometry on cadaveric pig lumbar
spine specimens, have examined the effects of passive axial rotation (torsion) on the behaviour of the
disc (van Deursen et al. 2001a,b). Under a constant compressive force, the specimens were subjected
to small (<2) alternating axial rotations of rapid (<0.1 s) durations. In all cases there was an
immediate reduction in nuclear pressure and an increase in disc height. This effect has, it would
appear, never been demonstrated before and, because of the studys methodological approach,
provides a valuable insight into some of the possible changes associated with rotary manipulations of
the lumbar spine. Although the primary objective of the study was to simulate the small active rotary
movements occurring in daily life, during walking for example, the findings are likely to be valid for
passive rotational manipulation for two main reasons. Firstly, the study examined rapid rotations of
less than 0.1 s, as would be expected in an adjustive procedure such as the modified bonyun (double
hook/push) or lumbar roll manoeuvres, which are considered common diversified manipulative
procedures. Secondly, the authors demonstrated that creep loading the specimen in compression for 1
hour prior to testing, as might occur in the upright in vivo situation, produced similar results to the
specimens that were tested immediately after the vertical load was applied. This would suggest that
manipulation in the unloaded, side-posture position would produce comparable results. The authors
speculate that these small, segmental, alternating, axial rotations taking place throughout daily
activities help to redistribute stresses across the disc. The instantaneous increases in disc height and
nuclear depressurization associated with these movements might act as a kind of mechanical pump to
aid the fluid exchange between annulus and nucleus and assist in the nutritional supply of the central
disc. This is an attractive hypothesis, since the inner disc material is thought to rely exclusively on
diffusion to resource its metabolism. van Deursen et al. (2001a,b) further suggest that this alternating
torsion may have an immediate pain relieving effect as a result of the redistribution of stresses and,
through the increase in disc height, reduced contact forces across the facet joints and augmentation of
the foraminal space. If these small rotational movements are prevented or limited over time, because
of a segmental fixation for example, it is possible that long-term damage to the functional spinal unit
can occur as a result. Interestingly, another group in France have recently managed to record
intradiscal pressure changes during manipulation in two human cadavers (Maigne & Guillon 2000).
Using two different types of lumbar rotary manipulation, i.e. with the lumbar spine in flexion
(modified bonyun type) and extension (lumbar roll type), these researchers showed a similar drop
in intradiscal pressure associated with the passive rotation. In contrast to the van Deursen study
(2001b), however, the drop in intradiscal pressure was preceded by a transitory increase in the
pressure immediately following the thrust. The increased pressure coincided with an approximation
of the two vertebral segments, a maximum axial translation of around 1.1 mm. The findings of these
two studies would suggest that the manipulative thrust is associated with an immediate and brief
increase in intradiscal pressure and reduced disc height, whilst the resultant rotation produces a drop
in pressure together with an increase in disc height. It is likely, therefore, that the thrust induces a
brief compressive force before the rotational motion is initiated. Surprisingly, the French group,
whose work was published a year prior to that of van Deursens, attributed the rise in pressure to the
rotational movement and not the thrust! Maigne and Guillon (2000), however, shared the view that the
drop in intradiscal pressure could provide pain relief by redistribution of compressive stresses
across the disc. They also demonstrated significant differences in biomechanical behaviour between
the two types of manipulation, both in terms of the speed of onset of the pressure changes and the
directions of relative vertebral movement. For manipulations in flexion (modified bonyun type) the
intradiscal pressure changes occurred much faster, approximately twice as fast, compared to the
manipulation in extension (lumbar roll type). The flexion manipulation also showed similar
variations with regard to the direction of relative movement between vertebral segments suggesting
that movements in the vertical and horizontal axes were roughly equal. Manipulations in extension,
however, were associated with predominantly horizontal plane movements between vertebrae. This, I
would contend, supports the notion that the manipulative thrust is associated with an initial
compressive force likely to increase intradiscal pressure. The more rapid increase in pressure seen in
the flexion manipulation is not surprising given that a flexed spine will expose the disc to more direct
forces, unattenuated by the facet shielding or spinous approximation more likely in extension. This
would, however, bring into question the use of the rapid manipulation under certain clinical
conditions. This particular aspect requires further study and clinical investigation for more definitive
guidelines.
In view of the findings discussed above, it is not inconceivable that manipulative therapy can
have prophylactic consequences on the health of the disc. These possible positive effects on disc
mechanics have previously all been attributed to spinal manipulation and these recent studies may
help explain its benefits and support the active rehabilitation of low back pain.
In summary and in light of some of these recent findings, it may be helpful to review the advice
that is given to patients with suspected discal damage. It would appear that sitting per se is perhaps
not quite as deleterious to those with disc damage as previously thought. What is beginning to emerge,
however, is a consensus that excessive flexion, particularly if prolonged, of the lumbar spine is
certainly detrimental and places many spinal tissues at great risk of damage. More of which will be
discussed later in this chapter. Excessive extension, too, is liable to lead to long-term damage and so
moderation seems to be the key message in postural advice. In terms of adjusting skills, manipulating
the lumbar spine in excessive flexion should be avoided, especially for those patients with discogenic
symptoms. Cassidy et al. (1993) reported that any manipulation that flexes and compresses the spine
should be avoided, as their clinical studies seemed to suggest such procedures could aggravate
lumbar disk herniations. Notwithstanding, side-posture procedures in themselves may not represent
the risk to disc patients as was assumed earlier based upon the work of Nachemson and colleagues.
Indeed, small torsional movements would appear to have an immediate and beneficial effect on disc
behaviour, pain relief and possible long-term consequences on disc nutrition and health.
To lordose or not to lordose
For controversy, few topics of spinal mechanics can raise opinion more than spinal curvatures. The
function and requirement for lumbar and cervical lordoses in particular can provoke much debate
among bioengineers and clinicians, such as chiropractors, alike. The lumbar lordosis and its role in
load bearing is just one such issue. The view that preservation of the lumbar lordosis is necessary for
generating the forces required in lifting is not without its critics. This issue is particularly important
for those concerned with avoiding back pain in the workplace, where lifting tasks are demanded.
Since bending to pick up an object from the floor can be achieved by lumbar rotation, hip rotation or
any combination of both it has fallen to bioengineers to discover the most efficient and least injurious
method. Unfortunately, this has proved to be an onerous and controversial mission. In 1999 a Dutch
group undertook a literature review to assess the biomechanical consequences of using a stoop lift
(knees extended) or squat lift (knees bent) (van Dieen et al. 1999). In terms of compression and shear
forces acting on the spine, no significant differences could be attributed between the lifting
techniques. The conclusion, therefore, was that no clear recommendation could be made regarding the
efficacy of either method. Another group of researchers with extensive experience in lumbar spine
mechanics, and disc injury in particular, is that led by Mike Adams and Patricia Dolan (Adams &
Dolan 1995, Adams & Hutton 1982, 1985). These groups have endeavoured, amongst other topics, to
quantify the forces acting on the lumbar spine during lifting and bending in vivo so as to shed light on
the mechanisms of injury encountered by the lumbar discs and ligaments. In the early 1990s Dolan and
Adams (1993) examined the influence of hip and lumbar mobility on the generation of bending
moments and found that all subjects flattened or reversed their lumbar lordosis when lifting. Various
bending and lifting activities were performed from putting on a sock to lifting a large 10-kg box. In all
these activities all subjects flattened their lumbar spines even when lifting with knees flexed (Dolan
& Adams 1993). In a follow-up lifting study of 149 subjects, Dolan et al. (1994a) found that some of
these healthy, young subjects actually flexed up to 15% beyond their normal limit for static full
lumbar flexion. On average these subjects flexed their lumbar spines 8189% lifting 020 kg
respectively, despite being advised to keep the lumbar spine in lordosis (Dolan et al. 1994a). Another
group of researchers in Canada have also specifically investigated the changes in lumbar lordosis
during lifting (McGill et al. 2000). From their own studies, and review of others, they have outlined
the main disadvantages of lifting with a fully flexed, rather than neutral, lumbar spine. In the first
instance full flexion results in a reduced moment arm for the extensor muscles and hence increased
forces across the joint. Secondly, the fully flexed lumbar spine is less tolerant to compressive loading
than a spine in a more neutral posture. Finally, since the back muscles are essentially switched off
during extreme lumbar flexion, the flexionrelaxation phenomenon, the flexed spine relies much more
heavily on passive tissues such as the fascia and spinal ligaments, which can increase compressive
forces and expose the vulnerable intervertebral disc to injury. In addition to these changes, the
Canadian team found that the fully flexed posture also alters the line of action of the major lumbar
extensors such that they are less able to resist the anterior shear forces acting on the lumbar segments
(Fig. 3.13). Shear forces are among the most potentially hazardous encountered by the lumbar spine
and have been linked with increased occupational injury rates (Norman et al. 1998). Norman et al.
(1998) attempted to combine biomechanical and epidemiological methods to identify risk factors for
low back pain in the workplace. Their study has suggested that shear forces may play a more
important role in the development of work-related back pain than compression or torque. These
authors agree with McGill et al. (2000) that a lordotic posture indicates lumbar muscular activity and,
hence, an increased ability to counteract shear forces. In support of this notion a recent
electromyograph (EMG) study on lifting has demonstrated evidence of paravertebral muscle fatigue
during repetitive lifting (Bonato et al. 2003). Since the paravertebral muscles are largely responsible
for countering anterior shear forces, fatigue of these structures during cyclical activity is likely to
result in an increased risk of damage due to shear. In an earlier study modelling the changes in forces
acting on the lumbar spine, lumbar flexion had the most dramatic effect on the shear forces at the L5
vertebra; arguably the most clinically relevant segment of the entire spine (Macintosh et al. 1993).
Macintosh and colleagues used biplanar radiographs of nine healthy subjects to calculate the forces
generated by individual fascicles of the lumbar back muscles in the upright and fully flexed positions.
On flexion from standing the results of the study showed a marked reversal of shear force from
anterior to posterior. In other words, standing tends to create an anterior pushing force at L5 that, on
full flexion, is converted into a posterior pulling force. It is easy to speculate that these kinds of
opposing forces, acting on a prolonged and repetitive basis, might expose the L5 segment to an
increased risk of instability.

Figure 3.13 Fully flexed posture unable to resist shear.

Considering, therefore, the potential negative effects of excessive lumbar flexion it seems odd
that all subjects intuitively lift with a flattened back and some subjects lift with hyperflexion.
Lifting, as with most human activities, can be achieved by a wide variety of differing neuromuscular
strategies. Even when the same individual repeatedly lifts the same weight, the manner by which it is
accomplished is subject to great variability (Granata et al. 1999). The findings of Dolan et al.
(1994a) would suggest that there must be at least some advantages to lifting with a flexed spine. Since
muscle power is the single most important factor in lifting it is, perhaps, logical to examine how
differing postures of the lumbar spine might affect these structures. Chief amongst these factors is the
lengthtension relationship, which is how the contractile force and passive resistance within a muscle
combine to produce overall tension depending on how much initial stretch is placed on the fibres.
Skeletal muscle generates its maximum contractile force when it is at, or slightly beyond, its normal
resting length. Additionally, the non-contractile elastic components of a muscle can only develop
substantial tension as the muscle is stretched past its resting length. Dolan et al. (1994b) argue that a
lordotic posture prevents the lumbar extensor muscles from reaching their resting length and hence
generating sufficient contractile force to lift significant weights. These researchers contend that
moderate flexion is a necessity for generating the required extensor moment in lifting and should be
advocated in the context of manual handling in the workplace. Controversy, however, is never far
away and an earlier MRI study showed that the lever arm of the back extensor muscles is longer, at
all lumbar levels, in extension than in flexion (Tveit et al. 1994). These investigators, therefore,
concluded that it would be advantageous and advisable to adopt a lordotic posture when attempting to
lift. Tveit et al. (1994) were, however, aware of the limitations of their study, which restricted their
subjects to a confined space in a horizontal position and permitted only simulated lifting during the
experimentation. In addition, continued flexion allows the passive connective tissue elements within
the muscles to contribute to the development of tension. Their work has shown that after 80% of
forward flexion, tension within the lumbodorsal fascia is able to provide considerable assistance to
the active extensor muscles and, since the erector spinae are quiescent at this phase in the motion
sequence, due to the flexionrelaxation phenomenon, muscles (such as the gluteals and latissimus
dorsi) are likely to contribute via the lumbodorsal fascia. An EMG study in 1994 (McGill & Kippers
1994) suggested that what takes place during extreme flexion is a transition between generating
contractile force and elastic force within the muscle and that the activity simply shifts from electrical
to mechanical activity. The authors propose that the term flexionrelaxation is a misnomer and that
the relaxation in this context is solely electrical, since the passive tension generated ensures that the
stretched muscle is far from relaxed. In this study, although the lumbar extensors were electrically
silent, the thoracic extensors and abdominals remained active. Contraction of the abdominal muscles
could provide a minimal contribution to the passive extensor moment through their lateral attachment
to the lumbo-dorsal fascia and general stiffening effect, whilst the thoracic extensors would obviously
support the role of the erector spinae aponeurosis. Interestingly, another group of researchers in
Sweden have shown, using MRI and deep-wire EMG, that, although the superficial lumbar erector
spinae are silent at full flexion, the deep erectors and quadratus lumborum are very active at the
extremes of flexion (Andersson et al. 1996). Active contraction in these muscles would certainly be
of great assistance in countering any flexion moment and opposing distraction between the thorax and
pelvis.
Another aspect of interest in the Dolan and Adams study (Dolan & Adams 1993) was the effect
of individual flexibility or suppleness on the stresses encountered during lifting. The experimental
procedure used by Dolan and colleagues defines 0% flexion (neutral) as relaxed erect standing and
100% in vivo flexion as extreme toe touching. However, 100% flexion, in this sense, causes the
lumbar spine to bend only as much as 70% of the range permitted by the spinal ligaments, which
generates only 36% of the bending torque necessary to cause disruption or injury (Adams & Dolan
1991). Not surprisingly they found that a reduction in sagittal spinal mobility was indeed associated
with higher bending stresses and could result in a doubling of the bending torque compared with more
supple individuals. This is important since Adams has shown previously that compressive forces on
the lumbar discs can cause prolapse only when combined with bending moments (Adams & Hutton
1982). Nevertheless, Dolan and co-workers point out that the greatest influence on bending torque is
related to the diurnal changes in fluid content of the disc. Resistance to bending in the lumbar spine
can be increased by as much as 300% in the hours immediately following waking, since the discs are
at their most turgid (Dolan et al. 1994b). Previous work (Adams & Dolan 1991) had shown that over
much of its range the lumbar spine exhibits little resistance to bending, but towards the elastic limits
of flexion and extension the resistance rises rapidly. Adams observed that this region of low bending
moment formed a relatively constant proportion of the full range. This suggests that individuals with
good flexibility can perform a much greater range of flexion/extension before generating high bending
stresses within the spine. Similarly those individuals who possess stiff, inflexible musculoskeletal
structures will generate high bending moments over a very short range of flexion/extension. What
Adams alludes to here, I suspect, is what Manohar Panjabi refers to as the neutral and elastic zones.
That compression and excessive bending in the sagittal plane raises the risk of spinal damage as
a consequence of imposed stresses, then, seems reasonably well established. But what of the effects
of combining sagittal bending with forces in other planes? The potential for injury is also likely to be
increased when sagittal bending (flexion or extension) is coupled with axial rotations such as those
experienced by athletes engaged in, for example, cycling, rowing or fast bowling in cricket (Burnett et
al. 2004). That the repetitive coupling of sagittal bending and axial rotation might result in an
increased incidence of LBP has been recently investigated in female rowers (Perich et al. 2006). Out
of 356 adolescent, female rowers, Petrich and colleagues found a point prevalence of LBP close to
48% compared to a prevalence of 16% in age, height and sex matched non-rowing females. The
prevailing hypothesis that axial rotation in end-range (elastic zone) lumbar flexion or extension would
be greatly resisted by reduced compliance in osteo-ligamentous structures has, surprisingly, not been
confirmed in vivo until quite recently (Burnett et al. 2008). Burnett and colleagues used an
electromagnetic tracking device to measure axial rotation in eighteen adolescent, female rowers and
concluded that lower lumbar axial rotation is, indeed, reduced in flexion and extension in both sitting
and standing postures when compared to a neutral spine posture. Moreover, the greatest restriction to
axial rotation was found in flexion, most probably as result of the higher compression forces
associated with the flexed position. The comparison of ranges of motion in neutral with those at the
extremes represents further in vivo support of the neutral zone concept discussed below.
In summary the take-home message from these studies would seem to suggest, perhaps, a rethink
in terms of recommendations given to patients and others during lifting tasks. Moderate lumbar
flexion during lifting appears to be the soundest advice to give, together with the established practice
of keeping the motion uniplanar and the avoidance of combined rotational and bending movements. It
would seem that advocating a lordotic posture whilst lifting, although useful in tempering any
tendency towards hyperflexion, is unlikely to result in actual lumbar extension taking place.
Moderate flexion, or slight flattening of the lumbar curvature, also appears to produce the most
efficient contraction in the extensor muscles and protects the intervertebral discs from excessive
loading. The effect of fluid build-up in the disc during the sleeping hours is something patients with
back pain should be well aware of. Although the turgidity of the disc has the greatest influence on
bending torque the effect is transitory, lasting no more than 2030 minutes after adopting the erect
posture. Nevertheless, the disc is very vulnerable during this time and patients with discal symptoms,
particularly, should avoid excessive loading and/or bending until the fluid content has equilibrated.
Chiropractic in the neutral zone
In the early 1990s Panjabi (Panjabi 1992b) expressed concern over the methods employed in
cadaveric studies, in particular the practice of preconditioning or prestressing spinal specimens
before loaddeformation measurements. This procedure has been used to reduce the viscoelastic
effects and produce linear, or near-linear, results. In life, however, spinal tissues exhibit highly non-
linear behaviour. Indeed, this non-linearity in loaddeformation may well hold the key to the
understanding of spinal dysfunction and perhaps some of the mechanical effects of manipulative
therapy. Spinal, and many other, ligaments possess the ability to vary their stiffness throughout a range
of movement. This viscoelastic behaviour allows greater movement within and around the neutral
position but progressively limits motion towards the end of the range. The region of relative
ligamentous laxity around the neutral position has been termed the neutral zone (NZ) and that part of
the range of motion associated with increasing ligament stiffness the elastic zone (EZ) (Panjabi
1992b) (Fig. 3.14).

Figure 3.14 The loaddeformation curve of a soft tissue or body joint showing the highly non-
linear nature of these tissues. The region of high flexibility is the neutral zone and the region of high
stiffness is the elastic zone. The two zones together constitute the physiological range of motion of a
joint
(adapted from Panjabi 1992b, with permission.)

This biphasic nature of spinal motion allows minimum energy expenditure for movements around
the neutral position, but provides opposition to potentially damaging movements at the end of the
range. Using data from a previous study (Yamamoto et al. 1989), Panjabi (1992b) demonstrated a
method of measuring the NZ in vitro and proposed that it represents an index of clinical instability.
What Panjabi suggests is that, although an individuals over-all range of spinal motion may be within
normal limits, an increase in the NZ would indicate instability. As Dolan and Adams (1993) point
out, this region of low bending moment (Fig. 3.15), as they refer to it, is a fairly constant proportion
of the range and, therefore, should not be expected to change under normal circumstances. For
chiropractors, however, segmental instability is but one clinical entity that we may encounter. Closer
to home is the spinal fixation, restriction, dysarthrosis, or biomechanical dysfunction that we locate
and manipulate/adjust in almost all of our patients. Call it what you will, what it represents is a
perceived reduction in relative segmental motion in combination with some degree of pain and/or
tenderness. What I would like to suggest is that if segmental instability depicts one end of a spectrum
of spinal motion disorders then, perhaps, the restriction/fixation/dysfunction represents the other end.
Consequently, if an increase in the NZ characterizes instability, perhaps a reduction of this region of
low bending moment can characterize the spinal restriction/fixation. In practical terms, perhaps the
perceived tissue resistance that we detect on segmental motion palpation is simply the commencement
of the EZ sooner than anticipated, i.e. a fixation; in other words, a decrease in the NZ. This area of
clinical biomechanics has been discussed by many chiropractors, notably Sandoz (1976) who
proposed the passive range/elastic barrier concept of joint motion. Here he suggests that the
chiropractic adjustment takes the joint through the elastic barrier of resistance into the
paraphysiological space. After the adjustment takes place, Sandoz suggests that the range of
movement is slightly increased beyond the usual physiological limit. This concept is, I believe, in
concert with that of Panjabis NZ. The elastic barrier will be found shortly after the commencement of
the EZ. Thus the EZ contains both the elastic barrier and the paraphysiological space and ends with
the limit of anatomical integrity. An adjustment, therefore, should be followed by a slight increase
in the NZ. Until we can measure the NZ in vivo, however, the above statement remains a hypothesis,
but it nevertheless provides a reasonable explanation for this observed clinical phenomenon.
Research work, though, is underway to relate the model to real life. Recently, a group from Arizona
have attempted to redefine the NZ concept and discuss how this, as yet in vitro concept, may manifest
in vivo (Crawford et al. 1998). These researchers have hypothesized that a different parameter exists,
which they have termed the lax zone (LZ), and have stated that it more accurately describes the region
of ligamentous laxity than the NZ. Their contention is that the NZ is a smaller subset of the LZ
dependent on the frictional characteristics of the joint in question. Crawford et al. (1998) observed
that, using the experimental method for measuring the NZ in vitro described by Panjabi (1992b), the
resting position to which the spine returns after loading, was subject to extreme variation with small
changes in specimen posture. In other words, the upper border of the NZ, and hence the NZ itself, was
dependent on alterations in preload and posture and thus susceptible to error if these variables were
not controlled. Crawfords group hypothesized that the NZ actually represents a range of spinal
orientation where only frictional joint resistance occurs and that a different, less variable, parameter
exists: the LZ. This disparity occurs because the orientation of, and friction forces within, spinal
joints influence the neutral position of the spine and a true ligamentous neutral position differs slightly
from this. Their contention is that the LZ describes a range of orientations where only minimal
ligamentous resistance occurs, irrespective of slight changes in posture and loading. The complex
methodology devised by Crawfords team employed six cadaveric cervical spine specimens (C5/6),
the experimental results of which determined that the NZ was in all cases smaller than the LZ. This
finding supported their hypothesis that the NZ is a subset of the LZ and that both parameters should
increase with instability/injury. The authors suggest that the clearest advantage of using the LZ rather
than the NZ is that the LZ would be less sensitive to postural shifts. In this regard, any future in vivo
measurement of LZ, as yet undiscovered, is likely to be more clinically useful since it is impossible
to precisely control loading conditions in life.

Figure 3.15 The bending moment acting on the lumbar spine across the full range of flexion and
extension. Note how the bending moment increases rapidly towards the limits of motion, the elastic
zone, and the region of low bending moment around the mid or neutral position, in other words the
neutral zone
(adapted from Dolan and Adams 1993 with permission.)

In terms of manipulative skills the NZ can be useful in another respect. If we regard the NZ as
the slack that is taken up when we bring a joint to tension before an adjustive thrust, then knowledge
of the various NZs for each vertebral level might be valuable to us. For example (see Table 3.1) the
NZ for axial rotation of the C0C1 segment is some 22% of the movement, in other words the first
22% of axial rotation at that level will be required to bring that joint to tension before an adjustive
thrust can be gainfully applied. From a kinematic perspective this is a very small amount of movement
at best (<5). In contrast to that, the same manoeuvre at the C1C2 articulation will require the first
76% of axial rotation in approaching tension. This may have more clinical relevance particularly in
light of the fact that the C1C2 motion segment accounts for ~80% of cervical spine rotation. In the
lumbar spine the situation is somewhat similar. The NZ takes up 39% of axial rotation at the L1L2
segment compared with only 18% at the L4L5 level. The range of motion, however, between the two
spinal regions is very different. The range of motion at C1C2 for axial rotation is nearly 40, which
is in stark contrast with the 2.3 seen at L1L2 for the same movement. This, however, is a rather
simplistic interpretation of the data, extrapolated from values obtained under less than optimal
conditions, and life is rarely that simple. What Panjabi refers to in his papers are the NZs and EZs for
all intervening soft tissues at individual functional spinal units in pure axial rotation or
flexion/extension as determined by cadaveric experimentation. In manipulative procedures the
situation is somewhat different. If we take axial rotation at C1C2 as an example we note that the EZ
is reached only after some 30 of rotation between the segments. In the living subject, especially in
high-risk groups, this might represent some risk to related sensitive vascular structures. Thus
combined movements can be employed to bring the segment to tension at an earlier point for patient
safety considerations. Introducing lateral flexion will pre-stretch or pre-load the soft tissues before
axial rotation is applied and, in effect, reduce the NZ in one plane. One should also bear in mind the
sequential nature of the living spine. In life one can create stresses at certain segments of the spine by
causing movement at points distant from the desired level. These stresses can again be used to reduce
the NZ, bringing the EZ closer to home and allowing us to perform an adjustment in a safer loading
mode and with less force. One need only attempt a thumb-move at T1 without rotating the patients
head from neutral, to see what this means. These stresses are there by virtue of the sequential
attachment of soft tissues, both passive and active. This can be viewed for most diversified
manipulative procedures.

Table 3.1 Average neutral zones, in degrees, for the main rotatory motions for representative
functional spinal units at different regions of the spine

A fascinating update to the study of the NZ has recently been provided by a biomechanical study
of motion segments from sheep spines (Thompson et al. 2003). Sheep specimens were chosen
because the lumbar segments have similar dimensions, disc morphology and overall functional
anatomy to those in humans. The aim of the work was to define the NZ under physiological ranges of
motion, using a precision robotic arm, rather than the traditional method of applying pure moments to
the specimens. This had the effect of allowing reproducible movements to be applied to the motion
segments under differing conditions, i.e. intact or with the zygapophysial joints removed. The results
of this study confirmed the presence of the NZ for flexion/extension but, intriguingly, not for lateral
bending or axial rotation in the intact specimen. In specimens with the zygapophysial joints removed,
however, the NZ increased significantly for flexion/extension and it became possible to demonstrate a
NZ for axial rotation. This finding, the authors conclude, suggests that the zygapophysial joints act to
oppose motion before the intervertebral disc generates significant resistance and, not surprisingly, are
the most important factors in limiting axial rotation in the lumbar spine. Dysfunction or restriction of
one or both of these joints may distort this function and place the intervertebral disc under greater
mechanical loads. The presence of a NZ would, de facto, suggest that the intervertebral disc is likely
to provide substantial resistance to movement later in the motion sequence, particularly for axial
rotation, but permits a much greater degree of movement around the resting position. The stability of
the spine in this lax region is, therefore, dependent entirely on neuromuscular control, as the structural
restraining tissues are not capable of restraint. The authors suggest that when this neuromuscular
control is lost, even momentarily, the structural spinal tissues are at risk within the NZ and damage
may occur during normal loading. This may, the authors conclude, explain why many instances of
spinal injury occur as individuals carry out relatively undemanding activities of daily living. This
again shows the importance of skeletal muscle in spinal mechanics. If one ignores the role of these
tissues and simply adjusts ad infinitum, then one will inevitably encounter the law of diminishing
returns. If you truly wish to create change in the mechanical response of the spine then you must look
to the muscular tissues. The active elements can be strengthened and toned for improved stability or
the passive elements stretched and lengthened to restore optimal motion. Understanding of the
mechanical properties of the spine and the in vivo effects of loading and movement, knowledge of
which is only recently becoming available, will hopefully lead to the development of more thoughtful
practitioners and advancements in the science and art of chiropractic. The inclusion of sound
biomechanical and rehabilitative research strengthens our understanding of clinical phenomena.
It is also becoming clear that if you wish to fully understand the functions of the human spine,
you can no longer view the biomechanical aspects in isolation. Advances in the field of spinal
biomechanics are spilling over into the physiological disciplines and forcing researchers to examine
the complex interplay between the mechanical properties of the structures and their functional
responses to imposed loads. At the vanguard of this branch of biomechanics is Moshe Solomonow
and colleagues. In 1998 these researchers attempted to establish if a reflex arc exists between the
supraspinous ligaments and the multifidus muscle (Solomonow et al. 1998). The broad objective of
this study was to verify quantitatively the notion that spinal ligaments, although passive limiters of
motion, may have a greater role in the neuromuscular control of stability. They point to the now
established view that spinal ligaments are well endowed with sensory mechanoreceptors (Rhalmi et
al. 1993, Yahia et al. 1988, Yahia & Newman 1991). The study involved electrically stimulating
some of these receptors in the L2L4 supraspinous ligaments in three human patients undergoing
spinal surgery and recording any EMG changes from the multifidi over these levels. Twelve cats also
underwent the same procedure over the levels L1L7. The experiments did, indeed, show that such a
reflex exists and that mechanical deformation of the supraspinous ligaments led to activation of the
multifidus muscle at the involved level and at least one level above and/or below. The net effect of
this stimulation was, not surprisingly, to stiffen the motion segment and provide resistance to anterior
flexion and distraction moments or forces. Adams et al. (1980) have shown that the supraspinous
ligaments contribute little to the mechanical resistance to flexion, which is achieved mainly by the
facet capsules and the disc, and in fact are the first structures to be damaged immediately after the
limit of flexion is exceeded. This might suggest that their role is primarily that of a transducer or
strain gauge for fine control of the multifidus. In this way the multifidus muscle can act to strengthen
and stabilize the passive tissues such as the facet joint capsule and the intervertebral disc, when the
spinal unit is subjected to destabilizing forces. Additional experimental work involving a porcine
model supports this view and highlights the role of disc tissues (Indahl et al. 1997). In this simple but
elegant study, electrical stimulation of nerve fibres in the disc annulus was shown to elicit reflexes in
the multifidus and longissimus muscles. Furthermore, it was shown that injection of saline into the
facet joint capsule, simulating stretch of these tissues, reduced this muscular response. The authors
suggest that these reflexes form the basis of the flexionrelaxation response and demonstrate a
complex interaction between the neural components of the passive tissues and paraspinal muscles. As
Solomonow et al. (1998) argue In essence, if such is the case, the multifidus muscles could be
designated as active ligaments, capable of increasing and decreasing their tension on neural control,
as opposed to passive ligaments with fixed stressstrain relationships. Of particular interest, in the
Solomonow study was the finding that the load required to elicit a muscular response had a definite
and relatively high threshold. A result of this nature tends to support the neutral zone concept,
implying that muscle activity would not be triggered until the segment had moved beyond the neutral
zone. In an attempt to separate the effects of mechanoreceptors situated in other tissues and stimulated
by segmental movement, Solomonow loaded free segments in the cat lumbar spine before repeating
the trial in segments that were rendered immobile by external fixation. In the latter group this ensured
that no vertebral movement was possible and that any effect produced would be from isolated
supraspinous deformation only. These feline preparations required a load of around 1223% of body
weight in the freely mobile segments, but required approximately 2342% of body weight to initiate
muscle contraction in the immobilized segments. This would suggest that isolated sensory input will
require substantial loading to reach threshold, whereas combined mechanoreceptor stimuli from
various spinal tissues will converge to regulate joint stability at lower loads. What is becoming clear
from these studies is that a synergistic relationship exists between mechanoreceptors in the
viscoelastic structures, including the intervertebral disc (Roberts et al. 1995), and the multifidus and
possibly longissimus muscles (Gedalia et al. 1999). Deformation of the tissues of the intervertebral
disc and related ligaments leads to reflexive muscular activity aimed at stiffening spinal joints,
reducing strain in ligaments and preventing excessive motion. Where these physiological systems
break down, however, the potential for injury, pain and instability exist. Further work on cyclic
loading of the spine has suggested a possible mechanism for how these conditions might occur
(Gedalia et al. 1999, Solomonow et al. 1999, 2000). When viscoelastic spinal tissues are subjected
to cyclic, prolonged or vibratory loading, creep and laxity result (Adams & Dolan 1996, Kaigle et al.
1992, Leivseth & Drerup 1997). Compression of the disc and ligamentous strain is thought to lead to
an increase in neutral zone and laxity. This laxity appears to desensitize the afferent stimulation from
mechanoreceptors and results in a dampening of the reflexive muscle activity (Solomonow et al.
1999, 2000). The combination of reduced passive stiffness and the absence of protective muscle
contraction exposes the spine to an increased risk of injury and pain. Furthermore, the mutual
recovery process of both disc and ligament, two very different types of viscoelastic tissue, following
cyclic loading is complex and much longer in duration than previously thought. Solomonow et al.
(2000), however, demonstrated that less than 1 hour of cyclic loading required at least 7 hours of rest
before full recovery of all viscoelastic tissues occurred. Reflexive muscular activity measured by
EMG, however, was restored to normal levels after only 4 hours. In addition, following recovery of
reflex muscle activity, some muscles became hyperexcitable. These muscles then displayed a greater
magnitude of EMG response to viscoelastic deformation than witnessed before cyclic loading began.
Following on from this study, further experimentation has shown that prolonged flexion loading of the
cat lumbar spine, also produced waves of unpredictably timed contractions, or spasms, in the
multifidus (Williams et al. 2000). The authors speculate that this acute neuromuscular
hyperexcitability is initiated by pain following subacute damage to viscoelastic tissues, but were
unable to substantiate this hypothesis. An extension of this work, again using a feline model,
suggested that full recovery after prolonged static lumbar flexion, even within the physiological
range, might require up to 24 hours (Jackson et al. 2001). More recently, investigations have been
targeted at establishing the effects of rest periods during cyclic lumbar flexion (Hoops et al. 2007).
Hoops and colleagues, again using a feline model subjected to 10 minute loading cycles,
demonstrated that the acute neuromuscular disorder, comprising a precipitous reduction in EMG
during the loading periods coupled with random spasms of the multifidus and a delayed
hyperexcitability of the muscle over the course of the 7-hour recovery period, was prevented by 20
minutes of rest between cycles but not when the rest periods were 10 minutes or less. The authors
conclude that the reduction in EMG during loading is a reflection of developing laxity and creep in
the ligaments which dampens the mechanoreceptor responses to stretch leading, consequently, to
electrical silence in the muscles. The random multifidus spasms are considered to be evidence of a
protective response to the subacute damage in the viscoelastic tissues. Hoops and co-workers also
suggested that this acute neuromuscular disorder was more intense and severe with cyclic loading
when compared to the effects of static flexion even when the load magnitudes and durations are
identical. A recent extension of this work has established a link between the mechanical events taking
place during cyclic loading of the cat lumbar spine and the inflammatory response (King et al. 2009).
These authors subjected the feline specimens to a peak flexion load of 60 N at 0.25 Hz for 10
minutes, followed by 10 minutes rest, for cumulative load duration of 1 hour. Subsequent examination
of the ligaments showed a significant increase of cytokine expression in these tissues, together with a
total creep value of 57%. The authors noted that much of the total creep, 31%, was achieved during
the first loading cycle and despite 7 hours of rest the tissues possessed a residual creep of 25%. King
and colleagues hypothesize that micro-damage to the collagen fibres must undergo an immunological
response before full recovery of the tissues can take place. This work seems to support the findings of
Solomonow et al. (2000) which suggested 2472 hours of rest may be required to restore the normal,
resting length of ligaments following this kind of loading.
Naturally, conclusions of this kind extrapolated from animal studies must be applied with
caution when attempting to explain human phenomena. Nevertheless, human studies involving loads
applied to viscoelastic tissues have produced similar results (Olson et al. 2004, 2006). The
descriptions and sequencing also accord with clinical experience where repetitive lumbar flexion,
static or cyclic, are associated with low back pain, weakness, reduced range of motion and spasms in
the paraspinal musculature. Patients presenting with this, or a similar, clinical picture where the
injury is often work-related, can be grouped under the descriptive term cumulative trauma disorders
(CTD) (Melhorn 2003). These findings, this author believes, may have important ramifications for
practitioners of manipulative therapeutics. In particular, a patient whos occupational or sports
activities involve static or cyclic flexion of the lumbar spine with its associated residual strain, loss
of disc stiffness, reduced muscular stabilizing forces and spasms may be at higher risk of damage
from manipulative techniques during this 724 hour period. Under such circumstances, it is tempting,
in a clinical situation, to interpret the patients spasm as part of their segmental restriction and the
cause of their symptoms. As a chiropractor, the prime directive is to restore normal motion to areas of
limited movement and this is too often applied irrespective of the context under which it occurs. In the
instance described above, the spasm is a necessary mechanism to protect damaged spinal tissues
during their recovery period. Forceful manipulation, at any time throughout this 24-hour period, might
possibly lead to further damage and impede rather than assist the healing process. What this new
knowledge tells us is that we must be aware, not only of the history of the patients symptoms, but
also of the loading history of the spine, in the context of their chief complaint. Furthermore, this
improved understanding of spinal function and dysfunction should inform our therapeutic approach
and allow us to adapt our intervention where appropriate. In light of even newer developments, this
fascinating area of functional biomechanics will be revisited, in a little more detail, towards the end
of this chapter.
Studies, such as those described above, combining mechanical loading of spinal tissues and the
resulting neuromuscular effects are beginning to broaden our understanding of the neutral zone and its
role in spinal function. The NZ concept, as described earlier, is an in vitro phenomenon, currently
quantifiable only with respect to mechanical loading of passive tissues. These, perhaps, should be
referred to more correctly as structural or mechanical neutral zones (MNZ). However, since the
ligaments, capsule and disc offer little resistance within the NZ and since these structures play a key
role in the activation of muscles that biomechanically stabilize the respective joints, it is likely that an
in vivo neuromuscular neutral zone (NNZ) exists (Eversull et al. 2001, Solomonow et al. 2001).
These NNZs, or functional zones, are likely to coexist with the MNZs such that the reflex muscle
forces are absent or diminished within the MNZ and increasingly more active as the MNZ is
exceeded. This, you would imagine, could have important implications for high-amplitude spinal
manipulation under conditions where the integrity of the neuromuscular system is less than optimal.
The most obvious example of this, perhaps, is manipulation under anaesthesia (MUA). This particular
manipulative technique has come under some significant criticism in the past; however, the procedure
has been revisited by chiropractors and others with some reported success (Cremata et al. 2005,
Kohlbeck & Haldeman 2002, Morningstar & Strauchman 2010). Recent investigation of the NNZ has
identified two components of this functional phenomenon; the displacement NNZ (DNNZ) and the
tension NNZ (TNNZ) (Solomonow et al. 2008, Youssef et al. 2008). Passive intervertebral motion
that exceeds a certain displacement or load will result in reflex activity of spinal musculature aimed
at preserving stability. If the normal threshold for triggering this muscular activity is increased, either
for displacement or tension, this represents an increase in DNNZ or TNNZ and a consequent
impairment to stability, since greater motion or loading will occur without active muscle protection
(Solomonow et al. 2008). Solomonow and colleagues once again used a feline model and exposed
the specimens to passive cyclic flexion and extension loading (for a cumulative duration of 1 hour)
whilst recording reflexive EMG activity in the multifidii muscles. EMG activity, DNNZ and TNNZ
measurement was performed both during the loading phase and for 7 hours after cyclic loading. Their
results revealed three major findings. Firstly, following the cyclic loading phase, there was a
significant increase in the NNZ (DNNZ and TNNZ) and thus decreased stability, which lasted for a
period of 23 hours. Secondly, during the 23 hour post-loading phase the authors noted a marked
decrease in muscular activity which would obviously further compromise spinal stability. Finally,
Solomonows team identified a compensatory neural control mechanism that is triggered by the 3rd
hour post loading which allows the initiation of muscular activity at an earlier stage and at a greater
magnitude. This compensatory mechanism is thought to protect the segments while the ligamentous
creep (represented by the increase in DNNZ) and micro-damage recovers. The same group of
researchers conducted similar work focusing on the effects of static, rather than cyclic, loading which
revealed findings strongly supportive of those described above (Youssef et al. 2008). Using a
comparable methodology, Youssef and colleagues discovered the same 23 hour post loading period
of increased DNNZ and TNNZ, decreased EMG amplitude in multifidii activity and compromised
stability as seen in the cyclic loading study. Similarly, the static loading was also associated with a
neural compensatory mechanism that triggered earlier muscle activity and at increased amplitudes
some 3 hours after loading. During this compensatory period the DNNZ remains significantly
increased, reflecting viscoelastic creep, while the TNNZ decreases by up to 50% of its baseline
value and initiates muscular activity at levels around 60% higher than baseline amplitude. That these
changes represent an attempt to provide protective stiffness to the spine while allowing creep
recovery in the viscoelastic tissues seems clear, what are not so obvious are the mechanisms that
monitor and identify the need for such changes. Youssef and colleagues suggest that these complex
compensations are not activated by a simple ligamento-muscular reflex but by motor control
mechanisms in the spine responding to changes in the moments developed within the viscoelastic
tissues for any given movement. The role of reflex responses in preserving spinal stability in trunk
dynamics is thought, by some, to be greatly underestimated and that individuals with dysfunctional
reflex responses are at greater risk of injury and instability (Moorhouse & Granata 2007). Studies
such as these show us that mechanical loads and stresses applied to ligaments, although well within
the limits of physiological and anatomical integrity, can and do result in damage, inflammation and
impaired neuromuscular responses (Solomonow 2009).
Advances made in our understanding of intervertebral disc mechanics give another fascinating
example of how biomechanics overlaps with other disciplines. Traditionally, the biomechanical
responses of the disc to load have been considered separate from the metabolic processes taking
place at a cellular level. A growing body of evidence, however, is beginning to emerge linking
mechanical stresses with relatively rapid alterations in disc biochemistry. Studies in this area are
beginning to show how changes in spinal loading affect the metabolic health of the intervertebral
disc. Central to the function and mechanical properties of the disc is the interaction between water
and the macromolecules (chiefly proteoglycans and collagen) of the disc matrix (Guiot & Fessler
2000). The cellular components of the disc are responsible for the synthesis and hence maintenance of
the matrix that surrounds and supports them, and thus factors affecting the balance of matrix synthesis
and degradation will have a direct effect on the degeneration of these tissues. It has now been
established that changes in hydrostatic pressure have an inhibitory or stimulatory influence on
proteoglycan synthesis of lumbar discs depending on the magnitude of pressure applied (Handa et al.
1997, Liu et al. 2001). Pressures of greater than 30 atmospheres (3 MPa), equivalent to leaning
forward whilst lifting heavy weights, and pressures less than 1 atmosphere (0.1 MPa) significantly
depressed proteoglycan synthesis over 2 hours. In addition to the suppression of proteoglycan
synthesis by these extremes of hydrostatic pressures, there was also increased production of matrix-
degrading enzymes such as the matrix metalloproteinases (MMPs) at high pressures (30
atmospheres). MMPs are found in higher concentrations in degenerated disc specimens and are
thought to break down proteoglycan matrix directly in response to inflammatory mediators such as
interleukin-1, for example (Guiot & Fessler 2000). Thus excessive loading of the disc not only
reduces matrix synthesis, but also increases its degradation, a situation very likely to hasten the
development of disc degeneration. Interestingly, other researchers have noted that the cells most
active in the production of proteoglycans are situated in the region of the annulus associated with the
highest stress peaks during loading and, typically, the greatest evidence of degenerative change
(Adams et al. 1996b, Bayliss et al. 1988). The good news from these studies, however, is that
moderate pressures on the discs have an optimizing effect on disc metabolism. Hydrostatic pressures
of around 3 atmospheres (0.3 MPa) resulted in the highest levels of proteoglycan synthesis whilst
minimizing the production of MMPs. It also seems likely that the free radical nitric oxide plays a key
role in mediating the response of disc cells to mechanical stresses (Hashizume et al. 1997, Kang et al.
1996, Liu et al. 2001). A study of human discs obtained from scoliotic patients has found that the
density of cellular components was significantly lower in the apical discs (Urban et al. 2001). Since
intervertebral discs at the apex of a scoliotic curve suffer the greatest loading and demonstrate the
greatest deformity, the conclusion of this study is that the prolonged and excessive mechanical
stresses experienced at these levels actually lead to cell death. These observations are supported by a
cell culture study suggesting that mechanical loading can induce intervertebral disc cell apoptosis
through the production of NO (Kohyama et al. 2000). The outcome of these negative changes, in real
terms, is the development of disc degeneration, although, surprisingly, there is still little consenus on
the definition of degeneration in this context (Zhao et al. 2007). These degenerative changes are most
evident in the nucleus pulposus, where the concentrations of proteoglycans, water content and viable
cell numbers all decrease, in linear fashion, as time marches on (Boxberger et al. 2009, Sguin et al.
2006). Nuclear changes are predictable as this structure is the furthest away from the points of
nutrient supply which are mediated, largely, via the outer annulus and vertebral endplate (Shirazi-Adl
et al. 2010).
It would appear that, for some, clinical disc degeneration is regarded as simply an accelerated
form of the age-related changes evident in all of us (Sguin et al. 2006). Generally, however, this
approach is unhelpful in the healthcare domain when attempting to distinguish between purely
structural changes and the identification of pain producing tissues. In an effort to address this issue,
Adams and colleagues have recently reviewed the biomechanical and physiological literature with
respect to discogenic pain (Adams et al. 2010). These authors take the view that age-related
degeneration is an inside-out process and, as the central part of the disc is largely pain-insensitive,
is usually asymptomatic. Furthermore, the very low cell density and nutrient poor environment in this
region severely limits the potential for healing or reversal of changes here. Conversely, changes in the
vertebral endplate and outer annular region are most likely to be associated with pain production and
are, potentially, much more amenable to therapeutic intervention. Adams and colleagues have
synthesized an impressive body of evidence to support physical (and other) approaches aimed at
stimulating healing processes directed, specifically, at the endplate and disc periphery. These authors
draw parallels with manual interventions on other tissues suffering similar problems, such as tendons
and ligaments. Among other examples, they point to work carried out on the mouse spine that
demonstrates passive, static stretching of the annulus can inhibit degenerative changes following a
compressive overload insult (Lotz et al. 2008). Similarly, Adams and co-workers support the use of
cyclic, passive flexion in stimulating repair of the posterior annulus and longitudinal ligament.
Although this review confirms the difficulty of identifying discogenic pain with any certainty, the
authors have outlined some supporting evidence to help practitioners make informed choices
regarding the differentiation of likely pain producing tissues. For example, the endplate is a suspected
site of pain if the symptoms are provoked by compressive loading and relieved by spinal unloading.
An understanding of the metabolism of the disc and the effects of mechanical stress help us, as
practitioners, to have a more effective role in the prevention, as well as treatment, of spinal
disorders. The findings described above, together with those of van Deursen et al. (2001a,b),
discussed previously, help to support a possible mechanism of disc degeneration amenable to
chiropractic intervention. If small alternating rotational movements are necessary for an equitable
redistribution of stresses across the disc, as proposed by van Deursens team, then segmental
restrictions of axial torque will create regions of high and unequal stress. It is not inconceivable, then,
that if these conditions persist at any given spinal level over a prolonged period, long-term changes in
the structure and function of the disc may result? Healthy discs, it seems, require optimal loading and
optimal motion to remain healthy, resist injury and impede degeneration. An axiom that is equally
applicable, perhaps, to the musculoskeletal system in particular and the organism in general. Given
this interpretation of the data, then, chiropractic is well placed to provide a preventative role in
spinal disease, both in terms of manipulative therapeutics and neuromusculoskeletal rehabilitation.
This does provide some evidence for prophylactic intervention or at least providing exercise routines
and advice for patients to load their spines and maintain mobility. On the other hand it still challenges
the role of supportive care (therapeutically necessary) and maintenance care (elective care) in terms
of preventive strategies. This also suggests that ethical concerns such as patient dependency are still
paramount.
Biomechanics and the art of motion palpation
For students of chiropractic, some of the most difficult skills to master are those of motion palpation.
Here we attempt to feel segmental motion and determine if it is abnormal or not. This would imply
knowledge of what constitutes normal segmental motion and naturally one would turn to the science of
biomechanics for the answer. Which way should the spinous of L4 rotate on side-bending? Will it
change if the subject extends the lumbar spine at the same time? The answers to these types of
questions rely heavily on knowledge of the effects of coupling or combined movements within the
spine and have been the subject of much research. The coupling patterns of the cervical spine,
particularly the lower cervical spine, have been well-established (Lysell 1969, Moroney et al. 1988,
Panjabi et al. 1986). Coupling in the lumbar spine, however, remains controversial especially as
regards the association between axial rotation and lateral bending (Pope et al. 1977, Stokes et al.
1981). Some researchers report little or no such association in the lumbar spine (Rolander 1966,
Schultz et al. 1979). Coupling patterns may be clinically important and indicate spinal dysfunction
(Pearcy et al. 1985, Pearcy & Tibrewal 1984, Weitz 1981). On the other hand, coupling
characteristics may vary considerably within normal limits and might have a strong dependence on
posture and other variables. Without this fundamental knowledge observation of coupling patterns in
vivo has limited clinical significance. In an attempt to address this very question Panjabi and co-
workers (Yamamoto et al. 1989) applied axial torque and lateral bending moments, separately, to
cadaveric whole lumbar spine (L1S1) specimens. The three-dimensional intervertebral motions of
each segment were recorded by stereophotogrametry and the response to loading was studied in five
spinal postures (full extension and flexion, half extension and flexion and neutral positions). The
authors applied an axial compressive pre-load of 100 N, to simulate in vivo loads, and horizontal
forces, either anteriorly or posteriorly, to create the flexed or extended postures. To generate lateral
bending and axial rotation, only physiological pure moments were applied, through the body of L1,
along the relevant axes. This ensured that each intervertebral joint received the same magnitude of
moment. The components of the moment vector, however, will vary at each joint as a function of the
lumbar lordosis. The moments were applied in three load/unload cycles with a 30-second rest period
to allow for creep. Vertebral motion was recorded only after the third load cycle. In other words the
specimens were preconditioned in an effort to reduce their viscoelastic properties.
The findings of this study demonstrated that posture and intervertebral level are two very
important factors in determining the magnitude and characteristics of both the main and coupled
motions in the lumbar spine. This study again highlights the functional division between the lumbar
and lumbosacral spine. In the neutral position, for example, left axial torque brought about contrasting
effects between upper and lower lumbar levels. Upper lumbar segments were driven into right lateral
bending, that is bending to the opposite side of axial rotation. At lower lumbar levels, however, the
lateral bending was to the same side, with the L3/4 functional spinal unit acting as a transitional
segment. The authors also noted a distinct lack of mechanical reciprocity in lumbar coupling. In other
words, when left axial torque was applied to L4/5, for example, this produced left lateral bending.
However, when left lateral bending was applied the coupling was with right, and not left, axial
rotation. Although the distinction between lumbar and lumbosacral levels was not as clear, the
findings of this study were in uncommon agreement with the in vivo findings of Pearcy and Tibrewal
(1984). In their study the transitional segment for lateral bending direction appeared to be L4/5. The
magnitudes of main and coupled motions, however, were remarkably similar. The only other major
difference in findings between the two studies was in the associated sagittal plane coupling with axial
torque and lateral bending. In addition to lateral bending accompanying the main axial rotation and
vice versa, Panjabi and co-workers found a second coupling effect. They noted, in the neutral posture,
a sagittal plane rotation that tended towards flexion at all levels. Pearcy and Tibrewal (1984), on the
other hand, found the opposite. They noted extension as the predominant sagittal plane coupled
motion, with the exception of the lumbosacral segment, which showed an equivocal response. Panjabi
and colleagues suggested that this paradox could be explained if Pearcys subjects were standing in a
slightly flexed posture at the time of screening. This is, of course, speculation and the fundamental
differences in the two studies make the interpretation of contrasting results difficult. In the Panjabi
experiment the active or passive components of the spinal musculature could play no part in coupling
effects. With the in vivo work of Pearcy and Tibrewal (1984), however, muscle influences were
present but unquantifiable. Nevertheless, there was good agreement between findings, despite the
obviously dissimilar methodologies, and the complementary nature of the two papers remains quite
unique. It is interesting to note that in a later in vivo collaboration (Pearcy & Hindle 1989) Pearcys
findings support those of Panjabi and co-workers. Using an electromagnetic position sensor, the
3Space Isotrak, Pearcy and Hindle showed a strong coupling of flexion with lateral bending. A study
combining in vitro experimentation and biomechanical/mathematical modelling (Cholewicki et al.
1996) claims results in broad agreement with the in vivo work of Pearcy and Tibrewal (1984). The
authors attempted to distinguish between those coupling effects attributed simply to the degree of
lordosis and those arising from the intrinsic mechanical properties of the spine (McGill et al. 2000,
Shirazi-Adl & Parnianpour 1999). These studies disagree with the work of Adams and colleagues
(Adams & Hutton 1985, Dolan & Adams 1993, Dolan et al. 1994a), who recommended flattening or
moderate flexion of the lumbar spine during heavy lifting. Both of these studies, discussed previously
in the chapter, suggest that a mildly or slightly flattened spine tends to reduce maximum disc strain
and allow optimum function in the back extensor muscles in countering anterior shear forces. Larger
flexion angles, however, tend to reverse these changes and place the lumbar segments at risk. Their
results suggest that lordosis and mechanical properties had an approximately equal effect on
predicting coupling between axial rotation and lateral bending. The coupling of flexion associated
with lateral bending, however, was thought to be almost wholly a function of lumbar lordosis.
In terms of motion palpation, however, these coupling movements may be too small to detect via
human tactile means. This could very well explain the consistent lack of reliability between
examiners in most interexaminer studies to date. Thus knowledge of coupling behaviours in the spine
may deepen our understanding of spinal biomechanics and help us in the application of manipulative
skills but may be of little relevance in the interpretation of palpatory findings. As discussed
previously, palpatory appreciation of the quality and onset of the EZ may be more clinically relevant
particularly when accompanied by local pain and tissue tenderness.
It is interesting to note that, even currently, the effects of the lumbar lordosis, particularly on the
biomechanics of lifting, are still not fully understood. A consensus is, however, beginning to form that
extreme lumbar flexion should be avoided during loading. Some support for this notion has come
from a study, which suggests that those individuals who apply the most bending to their spines during
lifting are more likely to develop back pain following their efforts (Mannion et al. 2000). Indeed,
occupational activities requiring prolonged static spinal flexion, even without significant loading,
have identified this posture as a serious risk factor in the development of low back pain (Solomonow
et al. 2003a,b). Building upon the most recent experimentation and previous work, Solomonow and
colleagues have presented a neuromechanical model that attempts to explain the development of at
least one variant of low back disorder (Solomonow et al. 2003b). Using the same feline preparation
employed in prior experiments, Solomonows team subjected the lumbar spine segments to 20
minutes of static flexion under a constant load whilst recording the EMG activity of the multifidus
muscles and measurement of tissue creep. Static loads varied from 20 to 70 N and data recording was
continued through all loading cycles and for 7 hours after loading was terminated. Based on their
findings, Solomonow and colleagues propose a model of neuromuscular injury comprising four
distinct phases or components, each of which can be extrapolated to a common human experience of
low back injury frequently described by patients. The first component of the disorder produced by the
static flexion load is the decay in EMG activity over time. This shows that the reflex contraction in
multifidus, provoked by the flexion loading, decreases during the loading period such that, by the end
of the 20-minute cycle, muscular activity had reduced to between 30 and 70% of its initial level. The
consequence of this component suggests that, as a static flexion load persists, local muscular stiffness
and, hence, stability is compromised over a surprisingly short time frame. The second component
corresponds to the random spasms described in previous work (Williams et al. 2000). In the
Solomonow study (2003b), these spasms were evident throughout the 20-minute loading cycle and are
thought to relate to the damage caused by viscoelastic creep. After 20 minutes, the length of the
supraspinous ligament had stretched to between 6 and 22% of its resting value (well within the range
of 2540% considered physiological) and, furthermore, this creep did not fully recover even after 7
hours of rest. The authors hypothesize that the onset of tissue creep is interpreted as damage by the
nervous system and results in the initiation of random spasm of the lumbar muscles, superimposed on
the decreasing reflex activity of the multifidus. These two phases can be related to by anyone who has
engaged in work activity requiring prolonged, static flexion, such as gardening. These findings,
perhaps, may be extrapolated to sitting postures involving prolonged trunk flexion, an activity
undertaken by many on a daily basis. After a variable period of time in such a posture, the individual
will report lumbar pain and discomfort that is often ameliorated, intuitively, by extension.
Components 3 and 4 of this disorder occur after the load has been removed and are, therefore,
observed during the recovery period. The third component, a distinct hyperexcitability of the lumbar
muscles, was noted within 10 minutes of rest and is thought to represent a protective reflex following
microdamage of the tissues. This hyperexcitability was provoked by any tendency to further flexion of
the segments and seemed to last only for an hour or so following removal of the load. The authors
propose that this activity is mediated by pain receptors, sensitized by the sustained microdamage, in
an attempt to prevent any further stretch or damage by the generation of higher than normal muscle
forces. After an hour, they suggest, enough tissue recovery has occurred to allow mechanoreceptor
afferents to substitute the nociceptors and take control of reflex muscle activation. This component
may explain the pain and stiffness felt during bending activities immediately following gardening or
any flexion work.
The final component of this neuromechanical model of low back disorder, is characterized by a
delayed hyperexcitability, manifest as a significant increase in peak EMG amplitude, reaching its
zenith somewhere between 8 and 12 hours after the recovery period began. In some of the
preparations, the authors noted, the delayed hyperexcitability was marked by EMG activity that was
as much as two or three times greater than that recorded before the start of the loading cycle. The
delayed hyperexcitability was also estimated to decay to 5% of its peak value after 24 hours.
Solomonow and colleagues suggest that this phase marks the initiation of a delayed local
inflammatory reaction and its neuromuscular response, which they have dubbed the morning after
hyperexcitability. This too, is a common experience among those patients complaining of low back
pain associated with static bending work, where the pain, discomfort and stiffness are often reported
as worse the following day. This could also be a mechanism responsible for causing common
postmanipulative soft tissue reactions.
Perhaps the most surprising finding of this paper, however, was that none of the responses was
load dependent. All of the four components were present even with the 20 N applied load.
Solomonow et al. (2003b) chose to begin the experimentation with 20 N because they expected such a
small load would not be sufficient to initiate any significant creep, damage or inflammation. The fact
that the creep or strain was well within the physiological range and yet still provoked an
inflammatory and neuromuscular protective response strongly suggests that tissue damage took place.
These findings have important ramifications for chiropractors and anyone dealing with work-related
back problems. It would seem that even a very mild load in static flexion, over a period of only 20
minutes, is capable of producing tissue damage and altered neuromechanical behaviour that persists
for up to 24 hours. Chiropractors should, perhaps, review their therapeutic approach to such patients
within that 24-hour period and refrain from forceful mechanical intervention until tissue recovery is
complete, or near complete. Of even greater import, are the implications for those involved in daily,
prolonged and/or repetitive flexion loading? Solomonows team have shown that, although the creep
in the supraspinous ligament was load-dependent, the neuromuscular response was not, and that
residual creep after 7 hours rest is present regardless of load. Interestingly, the authors found that the
greater the load subjected, the greater the recovery after rest. However, even with a 20 N load the
residual ligament creep was still 4% over its initial length after 7 hours, compared to 7% for the
segments exposed to a 70 N load. These findings, the authors conclude, indicate that individuals
subjected to such daily loads accumulate microtrauma leading to tissue damage that cannot fully
recover between loading cycles. Residual creep is carried over into the next bout of flexion loading
and may, eventually, generate permanent changes in both structure and function. As the demand for
chiropractic services increases, particularly in the corporate domain, information of this nature will
become invaluable in influencing working practices in the interests of our patients. This may be of
particular importance from an occupational perspective as many of the protocols currently in place
have made little difference in the prevalence of workplace musculoskeletal pain.
This, and previous, work by Solomonow and others represents part of the cutting edge of spinal
biomechanical research in the way that it integrates methodologies from related disciplines and
generates clinically relevant data.
Conclusion
This chapter has demonstrated the immense complexity of the human spine and the deficits in current
knowledge. It is not, however, intended to be viewed in a negative way, but positively as an
indication of the common ground that researcher and clinician alike must share. This chapter also
demonstrates that what is known and verifiable concerning spinal function can be successfully
applied to patient assessment, manipulative therapeutics and other models of back pain management.
Better knowledge and understanding of spinal structure and function will not directly improve
manipulative skills. The skills of the early manipulator some 3000 years ago were probably as good
as, if not better than, those of manipulators today. What our predecessors lacked, however, was a
rational basis upon which to assess the appropriateness or non-appropriateness of the application of
their skills. Knowing when and when not to apply a manipulative intervention, perhaps above all
else, may be the most important facet of modern chiropractic. Knowledge and understanding allow
you to make the best use of your skills, to gain maximum efficacy from your therapeutic approach and,
in short, make you a better practitioner in the long run. It would appear that an understanding of both
traditional and contemporary bioengineering and bio-clinical concepts might combine to enhance and
reinforce the acquisition of basic manual skills during the early training years. This, no doubt, would
be strengthened by a knowledgeable and committed teaching team who are willing to step beyond
conservative restraints and integrate more innovative instructional methods into the curriculum.

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Chapter 4

The physiology underlying skill performance

Peter W. McCarthy

Chapter contents

Skilled movement the basic concepts


Muscle and associated tissues
Types of muscle fibre
Intrinsic properties and their association with joint movement
Ligaments and joints
Repetitive injury and skills training
Neuromuscular reflexes simple or complex
Higher motor centres
Sensory input
Motor output
Basal ganglia
Cerebral cortex
Brainstem
Cerebellum
Acquisition of new reflexes
Practical guidelines to skill acquisition
References
Further reading

In any discipline involving a specific manual skill, the development of that skill is one of the most
daunting prospects facing student and tutor alike. However, some of the problems can be better
appreciated, and even resolved, if one has a greater understanding of the underlying
neurophysiological mechanisms. The aim of the chapter is to describe the mechanisms underlying a
skilled movement and, hopefully, along the way give some insight into how skills are acquired and
possibly even facilitate the process of their acquisition. Since the original edition of this text, a
number of studies have been published that compare performance of psychomotor skill with training:
either assessed as years in clinical practice (e.g. Byfield et al. 1995, McCarthy et al. 2002) or as
years in educational training (Chandhok & Bagust 2002, Foster & Bagust 2004, Paulet & Fryer 2009).
These observations have been specific to either aspects of the manipulative thrust performance of
trained chiropractors or the changes in palpatory acuity of students of chiropractic with experience
and practice: i.e. years on the training course. In either case, it is highly likely that the performance of
these skills would not meet its full potential until the person has had significant (>5 years) full-time
(clinical) practice experience. This should be borne in mind as the reader continues through this
chapter.
Skilled movement the basic concepts
A skilled movement is essentially a smooth action. Skilled actions can be formed by combining a
group of simple, natural movements, even reflexes, to form a new or unusual one. Initially the
reflexes, or their individual components, are easy to resolve. Over time, the edges between each
component tend to become less distinct, until the final movement appears seamless, or smoothed-
out. A smooth movement could be said to become a skill as it is repeated to bring about a certain
degree of unconscious activation, easy adaptability and fine control: all characteristics suggestive of
hard wiring within the nervous system. Therefore, a skilled movement could also be considered a
reflex (a set response to a preprogrammed or predetermined stimulus). A reflex triggered by natural
stimulus is usually termed unconditioned. Those reflexes that underlie a skill require stimuli which
are not natural: often described as being conditioned refexes. The conditioning which links the
action to an unnatural stimulus (which will eventually act to initiate the skilled action) takes place
throughout the training period. In addition to learning the stimulus, the training period is also used by
the neuromuscular system to experiment in order to find the easiest, not necessarily the best, way of
performing the action. Simultaneously, those tissues whose rate of use has changed, adapt in response
to the changing load put upon them. Such changes would include both the strength (protein production
and neuromuscular coordination), flexibility (elastin and collagen) and even muscle length.
From the teaching perspective, it is important to note that one of the more appropriate ways of
teaching psychomotor skills is to adopt the same method that the body uses to learn them. This means
that a trained person who has achieved the required level of skilled performance needs to recognize
the necessary components of that skill. In addition, that individual is then required to deconstruct the
performance: isolating the naturally present unconditioned reflexes. The performance of these and
their appropriate sequencing is then taught to the students. The rate of repetition and progress is
necessarily slow at first to prevent so-called bad-habits creeping in and to consolidate the learning
process. Experience teaches that the more you know the greater your realization of how much you do
not know, which tempers your confidence! It is difficult to assess yourself in these matters, as your
level of ability and understanding will always affect your perception of your own ability!
An outline of the requirements for performance will be necessary to demonstrate adequately the
enormity of the problem associated with learning a new skill from the perspective of the body.
Simultaneously, this will illustrate why it takes time to develop a skill. Simply, coordination of
several joint movements is required to achieve a skilled smooth reflex with each joint movement
requiring a coordinated series of muscle actions involving contraction of some muscles and
relaxation of others. Additionally, consideration must also be given to the supporting structures and
tissues affected by the increased demand.
The next sections will outline those features of each component required for the performance of
any movement. Those tissues which produce the action, such as muscle and ligaments, will be
described first, followed by neuromuscular integration. This will lead into the role of higher centres
of the central nervous system in motor skill acquisition and performance.
Muscle and associated tissues
Types of muscle fibre
Striated (skeletal) muscle is otherwise known as voluntary muscle, which can be subdivided into
extra- and intra-fusal fibres. Contraction of these fibres is controlled by the activity of the two basic
types of motoneurone: for extrafusal and for intrafusal fibres. The -motoneurones have larger
diameter axons and conduct their information to the muscle faster than the -motoneurones. The -
motoneurones activate the extrafusal fibres, which are the active contractile units for the muscle
capable of directly changing muscle length and, thus, are the cause of muscle contraction. -
motoneurones control activation of intrafusal fibres, with their non-muscular component being
innervated by the receptive endings of muscle afferents (Ia, Ib and II stretch receptor afferents): they
are involved in feedback of information concerning length and rate of change of length in the muscle.
The activity of the -motoneurone sets the length of intrafusal fibres, determining both the sensitivity
and activity of the associated stretch receptor.
Extrafusal fibres can be subdivided into two groups based on speed of twitch (contraction
caused by a single action potential), development and cellular metabolic characteristics. Type I
extrafusal fibres have slower twitch characteristics and are fatigue resistant; these fibres are
important in posture maintenance. Type II fibres have faster twitch production and appear to have a
significant role to play in developing speed of movement, such as in a manipulative thrust.
The proportion of type I to type II fibres in any muscle tends to be related to intended function,
and genetic predisposition. Although training might have some effect, the amount tends to be
influenced primarily by the size of the muscle and effectiveness of those fibres already present. A
high proportion of type I fibres are found where prolonged contraction is necessary, for example
soleus. In contrast, a higher proportion of type II fibres are found where short bursts of rapid onset
contraction are required: examples being extensor digitorum longus and certain facial muscles, such
as orbicularis oris. Generally, the muscles with the highest proportion of type I fibres are those
responsible for maintenance of posture, e.g. the axial muscles. The muscles of the upper arm (biceps)
and some of the lower leg (gastrocnemius) have roughly equal proportions of type I and II fibres,
whereas more distal muscles involved in precise movements have a higher type II component. The
absolute proportion of each fibre type in any muscle appears to vary between individuals with some
degree of individuality, in that a person might have a general tendency towards dominance of either
type I or type II fibres consistently throughout the muscles of his/her body (Bellemare et al. 1983).
In any skill development, attention should be paid to the present use of the muscle, and therefore,
to some degree the predominant fibre type. Although it is commonly believed that the initial fibre type
proportions are important in the determination of final ability, there is little evidence to support this.
There may be a general link between muscle fibre type distribution and the ease with which a muscle
or skill may be developed; however, factors that appear to play a role include the individuals general
fitness and amount of previous skill training, especially when it involves similar movements and body
area.
Intrinsic properties and their association with joint movement
Everyone accepts that muscles can regulate motion, however it is less well recognized that they have
an important role in joint stabilization. Numerous problems can be associated with poorly developed
stabilizing elements especially when subjected to repetitive movements, e.g. inflammation of
ligaments/bursa, tendonopathy and nerve root irritation, i.e. in the wrist leading to carpal tunnel
syndrome. There are two main mechanisms through which muscles can stabilize joints and regulate
motion.
First, via the neuromuscular system including feedback loops and reflexes involving the spinal
cord and higher centres (see Figs 4.1 and 4.2). However, this can take between 50 and 100 ms to
affect the change and may produce unwanted oscillations in the movement. Secondly is a mixture of
intrinsic properties of muscle (the forcelength and forcevelocity relationships) including both the
contractile and non-contractile (resistive, elastic) elements of the muscle. Added to this is the effect
of the moment arm of the muscle across the joint (Young et al. 1992). The moment arms tend to
increase as the muscle is lengthened, which leads to an increase in its effective force and rate of onset
in the direction of the joints neutral point (balance point). If the agonist muscle lengthens, the
antagonist muscles will tend to shorten, thus exerting less force. The result is the stabilization of the
joint on co-activation of the agonist and antagonist muscles: this has been shown in the stabilization of
such complex joints as the ankle (da Fonseca et al. 2004, Young et al. 1992).
Figure 4.1 The components of a monosynaptic or stretch reflex. Action potentials are generated
by stretching the spindle in the intrafusal fibres. They travel along the Ia primary afferent neurone
into the spinal cord. The Ia fibre synapses (neuromuscular junction) onto an -motoneurone in the
ventral horn. Action potentials cause excitation by neurotransmitter (acetylcholine) release. Activity
of the motoneurone is suppressed soon after it is initiated, because it has a higher natural action
potential firing frequency, which is unnecessary and potentially damaging to the muscle if sustained.
Slightly delayed suppression is via the Renshaw cell (an inhibitory interneurone).
Figure 4.2 The components of a -loop reflex. Activity in the -motoneurones determines the
degree of activity in the intrafusal muscle fibres and thus the relative degree of stretch in the spindle
(stretch receptor). The -motoneurone is used to maintain the relative length of the intrafusal fibre in
proportion to the extrafusal fibres, so that any unexpected stretch on the muscle can be compensated
for rapidly. However, -motoneurone activity can also be affected by stimulation from descending,
contralateral, or cutaneous (skin afferent) axons.
Ligaments and joints
The core components of ligaments, tendons and joint capsules tend to be collagen and elastin.
Ligaments, which generally have much more collagen than elastin, tend to have a role of limiting
movement and can be found spanning joints or wrapping around tendons. Generally, tendons have a
higher proportion of elastin than ligaments, in their role of dampening and storing force generated by
the muscle (as with any generalized statement there are extreme exceptions: the ligamentum flavum is
so different, being almost totally composed of elastin, that it was felt worthy of mention here). All of
these tissues have a relatively poor blood supply, which is probably a major factor in their slow
adaptation and repair rates.
Synovial fluid is a proteoglycan/water mixture found inside joint spaces. It has many roles,
including nutrition, hydration, shock absorption and lubrication. The synovial fluid also has the
property of thixotropism; in other words if the solution was left undisturbed it would become a gel.
Other structures such as ligaments and tendons may have this property, albeit to a lesser extent.
Therefore, it follows that joints should be eased back into use after a period of immobility. This is
one factor that would support the use of warming-up before exercise. Stiffness also occurs in
recently traumatized muscles, tendons, ligaments and joints. However, this more than likely involves
a different mechanism, namely the inflammatory response. The effects are particularly apparent in the
morning when there is a general stiffness in the damaged tissues. As the stiffness tends to disappear
after a short period of movement or stretching, it again indicates the benefit of warming up. The
poorly coordinated use of the muscles during the initial stages of any complex skill acquisition can
also lead to trauma; as such, the benefits of preconditioning the muscle, warming up, may help
protect the muscle against trauma during this period.
Repetitive injury and skills training
An important aspect of skill performance is practice by repetition. A negative aspect of repetition
might be the potential for it to lead to damage. There are two periods in which such damage may
manifest. During the acquisition phase the neuromuscular system adapts to the altered demands
becoming more efficient (increase force by better coordination). Although tendons and ligaments also
adapt this takes longer, which predisposes them to trauma (fortunately, they are normally stronger than
necessary to start with). After learning the skill there is risk of repetitive strain injury or cumulative
microtrauma; more commonly found in those repeating a task on a daily basis, continually over years;
probably based on accumulation of microtears (Nakama et al. 2007) and exacerbated by an increasing
ability to override regulatory feedback mechanisms (Fig. 4.1). In normal use, the repair systems
would be given ample opportunities to recover from this trauma, however, the relative frequency of
continual use, does not allow for adequate repair or adaptation. Any type of trauma can reduce
efficiency and lead to adaptation and abnormal performance. Such effects are compounded by
relatively slow healing of the tendinous and ligamentous tissues coupled with an appreciable degree
of disuse atrophy potentially occurring in the associated muscles. As scar tissue is less elastic and
more collagenic than the original tissue, this changes the tissues properties and invariably imposes
limits on future use.
Therefore, care must be taken to incorporate acceptable training principles including adequate
rest, flexibility, and cross-training strategies when learning new skills.
Neuromuscular reflexes simple or complex
Prior to any discussion of how a skilled movement is constructed, we should consider the basic
building blocks, namely the components of a spinal reflex. Spinal reflexes come in many different
forms, from the simple knee-jerk (patella reflex) to more complex reflexes concerned with posture
control. To keep perspective each reflex will be considered as being a motor (efferent) response,
initiated by some form of sensory (afferent) input as best illustrated by the simple monosynaptic
stretch (myotactic) reflex (Fig. 4.1). Although an oversimplification, this reflex contains the important
elements from which a basic understanding can be gained, not only of the stretch reflex, but also the
basic mechanism for controlling muscle length using the -loop reflexes (activity in -motoneurones
altering sensitivity of the stretch receptors, which affect -motoneurone activity and therefore muscle
length). Activity in -motoneurones is used to set muscle length with the determination of the number
and size of motor units (-motoneurone and the pool of extrafusal muscle fibres it innervates)
required being delegated to the feedback system (intrafusal muscle receptor-motoneurone
extrafusal fibre), as illustrated in Figure 4.2.
An important concept requires introduction at this point, namely reciprocal inhibition.
Reciprocal inhibition is a way of preventing, or reducing, interference from the antagonist muscles,
e.g. the withdrawal reflexes outlined above. To perform this task, we have an important element of the
spinal reflex: the inhibitory interneurone (illustrated in Figs 4.1 and 4.3). Inhibitory interneurones are
a series of neurones found in the spinal cord grey matter which are involved with the integration,
dissemination and regulation of information from sensory input and upper motoneurones onto the
spinal motoneurone pool. A summary of the inputs onto a hypothetical inhibitory interneurone is
illustrated in Figure 4.3. For example, in the performance of a simple triceps flick, a recoil thrust
which forms the basis of many manipulative procedures, there is an extension driven by the triceps
activity. This transiently suppresses the antagonist muscle, biceps, via activation of the interneurones
which inactivate the -motoneurones to that muscle. A braking action by the biceps prevents
hyperextension of the elbow and associated risk of trauma. As the rate of movement increases along
with the degree of extension (both of which occur rapidly) the biceps activity also increases to
counter the inertia created by the triceps. The change in biceps activity is the result of many factors,
such as increasing activity in the biceps stretch receptors, as well as decay of the interneuronal
inhibitory drive onto the biceps motoneurone pool and cerebellar intervention.
Figure 4.3 Sources of input that affect inhibitory interneurone activity. There are two types of
inhibitory interneurone which have a direct output onto motoneurones: the la and the lb, represented
as a single entity in this figure. The activity in inhibitory interneurones can be increased or
decreased, the integrated sum of the input determining their activity, which in turn determines the
degree of suppression of the motoneurone. Ia-inhibitory interneurones have output onto -
motoneurones and take input from flexor afferents, cutaneous afferents, stretch receptors, Renshaw
cells and supraspinal centres. Ib-inhibitory interneurones have output onto -motoneurones and take
input from cutaneous afferents, Golgi tendon organs and supraspinal centres.

As intimated above, activity in the large -motoneurones can be affected in various ways: first,
direct stimulation by descending fibres (upper motoneurones); second, suppression of activity by the
inhibitory interneurones. These are, in turn, affected by input from higher centres or by local sensory
afferents (contralateral as well as ipsilateral, as can be seen in Fig. 4.3). The third type of modulation
comes from the Renshaw cells whose role, among others, is recurrent inhibition (regulation) of
motoneurone firing frequency (Fig. 4.1). An overview of the interactions within this system, and an
indication of the reflexes that may be evoked, are illustrated in Figures 4.2 and 4.3. It is clear that the
-motoneurones are not limited to involvement with ipsilateral afferent input.
A series of cross-spinal interactions form an important part of the coordination needed in
everyday movement such as the initiation of walking. In this case extension of one side is synchronous
with the flexion of the other. The hard-wired nature of this becomes apparent when one attempts to
walk without swinging the arms (or swinging them asynchronously with the leg movements). These
connections exist between the different levels of the spinal cord to facilitate coordination of limb
activity: this is probably of greater relevance to quadrupeds, but is still important for balance in
bipeds. An example of their use in humans can be seen in competitive running. Note the pumping
action of the arms to facilitate the leg muscle contractions: the greater the need, the more forceful the
arm movements. A further reflex activity that needs to be outlined is that related to activation of
specific joint receptors associated with ligaments. This activity is aimed at returning the joint back to
its neutral position following application of an uncontrollable displacement of the joint. The most
extensively studied joint structures in this respect are the cruciate ligaments of the knee. These
ligaments are ably assisted by a receptor which is similar in structure to the type Ib Golgi-tendon
organs in muscle. The major difference is in the action initiated by the ligament-based Golgi-tendon
organ-like receptors, which cause co-contraction of flexors and extensors alike around the joint. In
contrast, tendon-associated Golgi-tendon organs cause a reduction in the activity of their muscle. This
illustrates that shape of the receptor is not the main determinant of function, the tissue type and
placement are also important.
A key factor in any skilled motor performance lies in the ability of the system to predict or
anticipate an event and therefore prepare for it. Such anticipatory adjustments can be appreciated
when walking with your eyes closed (or even in the dark) where footfalls, which are usually of
minimal impact, become jarring collisions with the floor. The adjustments made in preparation for
change, especially of balance and posture, are issued from the cerebellarbrainstem nuclei, require
no conscious attention and can affect all muscles involved with maintenance of posture. The role of
the cerebellum in basic precision and prediction of motor requirements based on sensory feedback is
not necessarily unique. However, it has been suggested that the degree of temporal precision (timing)
is unequalled in the rest of the brain. It is this component that is considered the mark of a truly skilled
motor act (Nixon 2003).
The majority of reflexes described so far is used to move limbs, and is reliant on spinal reflexes.
However, following noxious stimulation, other reflexes, such as those involving verbal motor control,
become apparent. This gives an opportunity to illustrate reflexes based in higher centres! Such
reflexes might derive from the brainstemmidbrain, producing a sharp intake of breath as a result of
respiratory muscle activation, or the thalamuscerebral cortex to produce a simple word (expletive)
or other forms of relatively coherent prose.
Although not an obvious part of skill performance, there are many reflexes that do not have a
voluntary muscle component, but whose existence is worthy of mention. Such reflexes have their
motor response through the autonomic nervous system via changes in secretion (such as salivation) or
smooth muscle tone (e.g. pupil diameter). Similar pathways are used to those mediating voluntary
muscle reflexes; there also exists the tendency for all these reflexes to be initiated simultaneously:
however, autonomic reflexes use motoneurones whose fibres have much lower conduction velocities.
The speed of response to a stimulus does not necessarily indicate the level of importance of the reflex
to survival. However, speed probably relates more to functional significance, for example the need
for rapid conduction of messages in control of posture. As the conduction velocity of an axon is in
proportion to its diameter (even in myelinated axons) where speed is not required it is not used.
The existence of consciously driven movement is reliant upon reflexes. Such a hard-wired,
ready to use system reduces the amount of processing in the higher centres; which raises the next
question to be addressed: what is the role of the higher centres?.
Higher motor centres
Sensory input
Axons carrying discriminative information (light touch, vibration and position sense) tend to ascend
in the dorsal columns or lemniscal system (Fig. 4.4) with those carrying crude touch, skin
mechanoception, nociception (pain) and temperature ascending in the spinothalamic tracts.
Collaterals from these tracts enter the brainstem and midbrain, contributing to arousal and awareness.
Non-nociception generally accesses the cerebral cortex via the thalamus. Ascent via the
spinocerebellar tracts to the cerebellum can be used in the assessment of motor activity execution and
in the forward planning of new movements based on the knowledge of the bodys present position and
activity.

Figure 4.4 Location of some important components of the sensory (afferent) system. Details of
three possible pathways by which sensory information from somatic receptors may ascend to reach
the centres involved with conscious awareness. The faster conducted information concerned with
touch and pressure makes highly conserved synapses onto a second-order neurone with an axon
which terminates in the thalamus. The synapse may be in either the spinal cord at the level of entry
or the brainstem (nucleus cuneatus). Axons from the second-order neurones in the spinal cord ascend
in the ventral spinothalamic tracts. Those primary afferent axon collaterals to the nucleus cuneatus
travel in the lateral funiculus and from this region the second-order axons travel with those from
the ventral spinothalamic tracts. This final section is also known as the lemniscal system. The
slower conducted signals from receptors of nociception and temperature tend to be polysynaptic at
the level of entry into the spinal cord. As with the above pathways, the axon of the second-order
neurone crosses over prior to ascending to the thalamus in the lateral spinothalamic tracts. The
axons of this tract send collaterals into the reticular formation, an important factor in awareness and
functions such as onset of sleep: it is more difficult to sleep when you are in pain! Collaterals to the
Raphe nucleus in the brainstem are important for the activation of descending systems which
suppress transmission of nociceptive afferent information endogenous pain relief.
Motor output
The following text provides supplementary information to Figure 4.5, which outlines those areas that
have a role in the control over initiation, generation and performance of motor activity.

Figure 4.5 Location of the basic neurophysiological elements in the motor (efferent) system. This
illustration gives some indication of the approximate location of the principal components of the
motor system. Information descends from the motor cortex/basal ganglia complex through two main
pathways, the pyramidal and extrapyramidal tracts: these are not shown, to maintain clarity.
Pyramidal tracts contain axons which originate in the cerebral cortex and travel direct to spinal
motoneurones. Extrapyramidal tracts contain all those motor systems outside the pyramidal tracts.
This is an indirect system concerned with postural control output from the basal ganglia, brainstem
and cerebellum.
Basal ganglia
These are probably the most important areas with respect to the initiation and generation of pre-
programmed movement. The major components are the putamen and caudate nucleus (neostriatum)
and the globus pallidus. Other regions often associated with the basal ganglia are the subthalamic
nucleus, striatum and the substantia nigra; the latter being famous because of the link between its
degeneration and Parkinsons disease. Other diseases associated with damage (of a vascular nature)
or degeneration in this area are hemiballismus, or more commonly ballismus (associated with damage
to the globus pallidus/subthalamic nucleus) and choreiform movements, often referred to as chorea
(associated with degeneration of the intrastriatal and cortical cholinergic and -aminobutyric acid
(GABA)-ergic neurones). The presence of the GABAergic neurones has also made it a target for
many classes of pharmaceutical agent. The effects of alcohol and the benzodiazepines (such as
temazepam and diazepam) on motor activity are at least partly the result of their activity in this
region. The effects of generally activating GABAergic neurones in this region tend to include a
reduction in motor tone and a slowing of reactions and changes in motor activity.

Cerebral cortex
There are two main classes of cerebral cortex area involved with motor output. The first includes
those that form the primary motor cortices, usually lying in close proximity to the equivalent primary
sensory cortex. These areas are associated with precise movement; their outputs descend in the
pyramidal system via the corticospinal tracts. Second, the other class of motor areas are referred to
as the supplementary motor areas (such as the speech centres), which access the motor system via the
primary motor cortex. The patterning of a movement in both the spatial positioning and the timing of
individual contractions is thought to be derived from these centres.

Brainstem
The level of activity in this region tends to reflect the general state of awareness or arousal of the
body. Those nuclei which relay the motor signals down through the extrapyramidal tracts are found
in this area. The major nuclei involved are: (1) the red nuclei, descending down the rubrospinal
tracts; (2) the vestibular nuclei, descending in the vestibulospinal tracts to influence postural
mechanisms by inhibiting flexors and exciting extensors; and (3) the reticular formation, descending
via the reticulospinal tracts, which modifies and helps to coordinate reflexes at the spinal level.

Cerebellum
The role of the cerebellum pertains to control and learning (via an estimation of correctness or
comparison) of motor skills. By integrating information from proprioceptors, visual, auditory and
vestibular systems with that from the cerebral cortex and the basal ganglia, the cerebellum can output
corrections to all motor centres from the motor cortex down to the spinal cord. Without this system,
movements would be less smooth and controllable with noticeable over-shooting; resulting in the
classical pendular reflex activity. There would also be a reduction in accuracy of the anticipatory
changes required to maintain balance and posture control. As a consequence there would be an
increased tendency to bump into objects, appearing to be clumsy and falling over more frequently.
Acquisition of new reflexes
To reiterate from the start of this chapter, a skilled movement is essentially a smooth motor activity
which may have an unusual trigger and may be an unfamiliar combination of reflexes. The activity
can be simple combination of unconditioned reflexes; however, it may be necessary to temporarily
inhibit or override other reflexes, e.g. somersaults (forward rolls) and inhibition of the vestibular
(righting) reflex. Furthermore, the sensory trigger for the event tends to be a conditioned stimulus, so
learning to adapt reflexes to unfamiliar stimuli can also be a factor with performance in acquiring
skills appearing to be related to previous experience in learning similar skills (Kerr & Boucher
1992). These skills do not necessarily have to have been of the same type, illustrating the benefits of
training the brain, i.e. maintaining neuroplasticity (see Chapter 4). One of the really important
abilities of the cerebellum in motor learning is that it appears able to facilitate learning by imitation.
In this, it resolves and converts visual input (watching somebody else doing something) into a copy of
the motor activity (Petrosini et al. 2003). This ability is most noticeable in chimpanzees, children
and, of course, the inebriated!
It is apparent that a great deal of coordination of muscle activity is required to organize reflexes
into a final coherent action. Feedback control is also very important, initially visual being the
preferred method of assessing correctness. With time and practice the reliance on visual feedback
may be reduced and replaced by other forms of sensory feedback, e.g., in typing where the
replacement would be proprioceptive, as in the aptly named touch-typist. This also illustrates the
change in higher centre control, in that the areas of cortex involved in consciousness devolve some of
the direct control of the movement while retaining the driving force or direction. Conscious control is
apparent as an increased processing time which tends to slow down the performance. In addition,
there is usually an incorporation of extraneous movements that appears to serve no obvious purpose.
These extra movements may even interfere with the objective of the skill. This activity can now be
imaged using functional magnetic resonance imaging (fMRI) and appears to resolve itself into two
components: a reasonably rapid change (over days) in the striatum, cerebellum and numerous
supplementary motor areas, followed by a slowly evolving reorganization (over weeks) of the
primary motor cortex (Ungerleider et al. 2002). However, as the skill becomes more established, the
reflex pattern becomes more internal-feedback regulated and loses these aspects of conscious
intervention. The role of the cortex instead becomes one of strategy determination. At this point, it is
highly likely that little further reorganization of the cortical and sub-cortical body maps will occur,
unless the task is replaced, retired or lost. The final skilled movement is somehow stored in the
central nervous system and can be totally recalled by a simple trigger, which in some cases can be
simply conscious need or want.
The role of the cerebellum as a tutor of the motor cortex (Ito 1972, 2002) may not be important
for all types of motor learning. This hypothesis is supported by data from two studies of brain blood
flow, one of which showed no change in the cerebellum (Grafton et al. 1992) whereas the other, a
more automatic and less visual skill, showed changes in cerebellar blood flow which attenuated with
practice (Friston et al. 1991). It may be, therefore, that the cerebellum is more concerned with the
consolidation of some learned skills than with their acquisition; however, this is an area of research
that is growing quickly (Ito 2002: see Doyon et al. 2009 for review).
It was suggested many years ago that a strategy of construction and facilitation of previously
learned subskills is adopted during the early stages of practice for a new motor skill (Eysenck &
Frith 1977). Such strategies are said to account for the rapid increase in skill performance during the
early stages of acquisition. This is supported by experiments which showed parallel increases in
blood flow to the motor cortex and supplementary motor area with rapid increase in performance
during repeated trials. This effect was most noticeable during the first few attempts where the greatest
changes in performance were seen (Grafton et al. 1992).
Practical guidelines to skill acquisition
The acquisition of a new skill can be facilitated by following simple guidelines:

1. The final movements should be broken down into smaller and simpler reflexes and practised in
sequence.
2. Feedback should be given on the performance.
3. The feedback should be of a modality which is appropriate to the skill and its trigger (in other
words visuospatial, as in a visual image of the students performance with a superimposed image
of the tutor or expert performance).
4. It is important to be aware that mimicry forms the main way of teaching and learning physical
skills, your bad habits can become the basis for the students skill! Any unwanted or confounding
reflexes (bad habits) should be highlighted and discouraged from the outset.

As an important sequel to this, the reader should be aware that the same basic principals
outlined here for teaching and learning can also be of use for retraining and rehabilitation.
(Re)Education of the central nervous system is at the centre of successful adaptation (Nadeau 2002).
It is often said that the students experience in any training towards becoming a practitioner of
the manipulation is like learning to drive: it is only when on the road that the student really learns to
handle the car! This would appear to be the case based on the research available at present. It is
hoped that practice for the manual skills is taken seriously from the start, otherwise, as with driving,
it might take an otherwise avoidable accident to focus the mind!

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Further reading

lexander G.E., Delong M.R., Strick P.L. Parallel organisation of functionally segregated circuits linking
basal ganglia and cortex. Annu. Rev. Neurosci.. 1986;9:357-381.
Information on feedback loops..

ohen H. Neuroscience for rehabilitation, second ed. Philadelphia: J.B. Lippincott Williams & Wilkins,
1999.
An easy-to-read, extensive text with a valuable annotated bibliography at the end of each chapter..

ccles J.C. Evolution of the brain, creation of the self. London: Routledge, 1989.
o M. Historical review of the significance of the cerebellum and the role of Purkinje cells in motor
learning. Ann. N. Y. Acad. Sci.. 2002;978:273-288.
Both Eccles and Ito are interesting from the perspective of evolutionary significance of those areas of the nervous system
important in skill performance..

owitzke B.A., Milner M. Scientific bases of human movement, third ed. Baltimore: Williams and
Wilkins, 1988.
A detailed and easy-to-read study of the topic; the many pictures add a more appropriate demesne to the written description of
the topic..

osenbaum D.A. Human motor control. San Diego: Academic Press, 1991.
A useful text which delves into the psychology of movement and motor learning using various tasks as examples..

yed M. Bounce: how champions are made. London: Fourth Estate, 2010.
An entertaining and informative text which gives insight into the possible necessities for enhanced performance..
Section 2
Foundation skills for manipulative/adjustive
techniques
Chapter 5

Postural and positional considerations for the


practitioner

David Byfield
Chapter contents

PART 1 Posture
Introduction to posture the evidence
Occupational back pain and postural considerations
Occupational injury and the chiropractor
Summary
General postural considerations
Cervical spine and posture
Thoracic spine and posture
Lumbar/pelvic region and posture
Summary
PART 2 Hand-arm-shoulder skills
Introduction
The chiropractic manipulative contact hand
Hand postures and skills
The chiropractic arch
Chiropractic arch hand skills and variations
Digital or finger tip/goose-neck contact
Index/metacarpal/interphalangeal contact
Thumb contact
Metacarpal/hypothenar contact
Thenar contact
Summary
PART 3 Patient positioning skills
Introduction
Side posture
Side-posture skills patient positioning
Side-posture skills practitioner position
Supine posture skills patient
Prone posture skills patient
Recommended table height
Summary
References
PART 1 Posture
Introduction to posture the evidence
Posture is a state of dynamic muscular and skeletal balance that protects the supporting structures
against injury or progressive deformity irrespective of its position during the performance of
functional activities. It is a multifaceted interaction of a number of highly developed and complex
learned neuromusculoskeletal motor reflexes necessary to maintain upright stance and engage in the
complicated tasks associated with daily living (Byfield 2002, Peterson & Bergmann 2010). This
depiction denotes the inherent importance of overall postural control with respect to efficient
musculoskeletal function when engaging in activities of daily living. However, this extensive
definition clearly signifies posture as a collection of developmental reflex psychomotor skills sets
that are not easily defined, changed, modified or clinically assessed. Most spine specialists would
argue that good posture is an important component of spinal health, however there is very little
scientific agreement as to what constitutes good posture and scant epidemiological evidence that
there is a simple relationship between posture presentation and the prevalence of low back pain.
Currently there is a lack of clear evidence to support incorporating good posture implementation as
a prevention strategy. More importantly, it is more realistic to recommend a variety of functional
postures to patients relative to the diverse demands of human life, which equates to the fact that there
is no one single ideal posture. Methods to stabilize the spine during various complex activities
become a fundamental management strategy.
Notwithstanding, postural observation is still considered to be a traditional and routine
examination procedure in chiropractic practice (Peterson & Bergmann 2010, Vernon 1983) and is
still taught extensively at the undergraduate educational level as a learning and teaching tool (Byfield
2002). Moreover, in the educational setting postural analysis does provide a useful method of
introducing rudimentary assessment and observational skills as a foundation for the more complex
examination and case management procedures required during clinical training. These procedures
also afford students an early opportunity to appreciate normal anatomical landmark location and,
furthermore, to begin to understand the multidimensional nature of clinical decision making and case
complexity.
From a scientific perspective, however, the reliability and validity of multiplanar static or
dynamic postural analysis as an examination procedure is, at best, equivocal. There are very few
quality research studies that have established postural assessment as a compelling or, for that matter,
a sensitive treatment outcome measure. Moreover research has provided us with a few studies with
respect to the role of postural assessment. Vernon et al. (1999) found an association between faulty
head posture (forward head carriage) and a patient group suffering from chronic tension headaches.
This may provide some predictive value in identifying a sub-group of patients who may respond to
manipulative intervention with this type of headache presentation. This may also have some clinical
significance, particularly in those patients who present with upper back and neck pain with associated
headaches as a result of static occupational postures commonly associated with computer work.
Vasilyeva and Lewit (1996) describe an entire system of diagnosing muscular dysfunction by
postural inspection, albeit their systems have yet to be subjected to validation via rigorous
experimental investigation. The paucity of quality studies is not surprising considering the difficulties
associated with accurately assessing widespread postural variation within a complex musculoskeletal
pain population. Whats more, static and dynamic postural appreciation, the mainstay of postural
analysis, has limited association to daily life activities and correlates very poorly with specific job
requirements and those patients presenting with pain symptoms (Burton & Cassidy 1992). Evidence is
documented which dispels a number of longstanding myths concerning possible links between back
pain and so-called bad posture attributable to conditions such as obesity, height, lifestyle and leg-
length discrepancies (Burton & Cassidy 1992, Leboeuf-Yde 2000). These conditions demonstrate
poor correlation with clinical symptoms compared with a normal asymptomatic population.
Furthermore, attempting to incorporate accurate and reliable methods to measure various
postures may be impractical from a clinical perspective. Employing sophisticated, costly and
calibrated analysis equipment, which involves significant time restraints, only adds to this dilemma
and simply cannot recreate the work environment. A valid investigation of one aspect of a patients
posture, for example gait, would require advanced equipment under controlled conditions, which is
an unreasonable expectation in a private practice environment. The variability of the human form
alone and the vast array of posture types that exists within the population thwarts any attempt to
standardize what is regarded as ideal posture and subsequently establish postural analysis as a valid
outcome measure of treatment effectiveness (Byfield 2002, Vernon 1983). This is all confounded by
the fact that very little evidence exists that correlates poor posture with any increase in the incidence
of low back pain, particularly in the absence of a valid gold standard of good posture. A slightly
tilted head, a unilateral dropped or uneven shoulder, a protruding abdomen, a slanted pelvis or a
minor lateral spinal curvature may simply be normal variants of an upright posture, well tolerated and
totally unrelated to the symptom picture. Nonetheless, there have been several attempts to describe an
ideally aligned static posture and numerous assessment protocols have been developed to interpret
static and dynamic postural modes for both the normal and abnormal states (Byfield 2002, Panzer et
al. 1990, Peterson & Bergmann 2010, Sportelli & Tarola, 1992). As clinicians we must remain
mindful of the fact that the human body is extremely complex and adapts well to the various functional
demands encountered while performing normal daily activities. It may simply be that postural
symmetry is not the absolute rule by which we set our clinical goals and treatment objectives. Apart
from the purely observational exercise, these benchmarks have not been subjected to appropriate
scientific investigation nor tested as a valid outcome measure of treatment efficacy. The problem
seems to lie in establishing a valid gold standard and correlating this benchmark to everyday life
activities. More specifically, we should be focusing our clinical protocols on assessing the impact of
modern lifestyle contemporary sedentary work environments, and sedentary and repetitive
occupational activities on the musculoskeletal system, both from a physical and a psychosocial
perspective. Sophisticated systems are being developed to provide objective assessment of the
workplace that can reliably assess various job demands and mechanical loads and the workers
capability to meet these demands. More studies are necessary to catalogue these job tasks and
correlate them with individual occupational demands.
Similarly, static postural appreciation has only limited association to daily life activities.
Dynamic postural assessment in the coronal and sagittal planes, on the other hand, may provide
partial insight into functional patterns of movement, but it still lacks association with various
activities of daily living and subsequently any real clinical relevance (Byfield 2002). These patterns
may merely reflect normal movement variability. Dynamic evaluation may add another dimension to
the clinical assessment and aid in establishing appropriate management plans for patient care, but it
requires more extensive clinical investigation to determine its reliability and utility in terms of patient
outcomes. Regardless of the patients postural presentation, clinicians are required to make
appropriate decisions regarding those presenting with chronic mechanical back pain and their current
state of overall spinal stability. These assumptions have to revolve around intersegmental and global
spinal-core stability and the structures designed to ensure overall endurance during the performance
of the activities of daily living (Panjabi 1992). Panjabi (1992) described a model based upon sound
experimental research for spinal stability incorporating neural, active and passive subsystems all
functioning in harmony. Moreover, it is now well known that most occupational back injuries are not
the result of frank trauma, but are more likely to be as a result of trivial events and cumulative loading
with associated motor control errors causing inappropriate muscle activation and aberrant joint
motion (Jull & Richardson 2000, McGill 1998). It is with this clinical knowledge that the practitioner
can make appropriate decisions regarding restoration of function, irrespective of posture, by
providing appropriate exercise protocols to restore stability. In addition, the clinician can provide
sound evidence-based advice regarding postural control when performing a variety of complex
movements associated with most occupational activities. There is a plethora of research
investigations supporting the role of various functional stabilizers in overall core postural stability of
the lumbopelvic region (Byfield 2001, McGill 1998). This approach emphasizes muscle endurance,
motor control and the maintenance of sufficient spine stability in all expected tasks irrespective of
presenting posture (McGill 2002a). There are a number of excellent texts to supplement the readers
knowledge including Murphy (2000), McGill (2006), Leibenson (2007) and Morris (2006). The
component contractile soft tissues are integral to spinal stability to protect pain sensitive structures
during the execution of demanding occupational tasks, such as lifting or sitting for long periods.
Considerable functional demands are placed upon these stabilizing muscle groups during the
performance of common activities of daily living. Research data have indicated that the normal
strength ratio between the spinal extensors and flexors is 1.7:1 in the cervical spine and 1.4:1 in the
lumbar spine (Jordan et al. 1997, Manniche & Jordan 1995). From a clinical perspective, this ratio
appears to be only 1:1 in most chronic neck and back pain patients, which undoubtedly contributes to
a patients overall postural fatigue and chronic dysfunction (Biering-Sorensen 1984, Jordan &
Manniche 1996). This postural instability may contribute significantly to the high prevalence of both
conditions reported in various patient populations. It is well documented that strength and endurance
of the extensor muscle groups of the cervical and lumbar spine dominate partly because of the heavy
postural demands and their natural role in bipedal stance and gait. It is becoming more apparent that
muscle group recruitment patterns, reaction times and other aspects of the somatosensory system are
impaired in back pain patients compared with a healthy population (Byfield 2001). In addition to
postural extensor endurance and strength protocols, a comprehensive postural rehabilitation
programme should also include sensorimotor training (balance, reaction timing and position sense) to
address other aspects of postural regulation including the eyeheadneck coordination that is vital for
righting reflex control (Jull & Richardson 2000). This type of exercise programme may provide the
practising chiropractor with a functional strategy to manage the mechanical stresses associated with
their daily clinical activities.
Furthermore, recent research efforts have provided us with a greater degree of certainty with
respect to effective case management and postural/rehabilitation exercise programmes. McGill
(2002b) has identified strategic muscles including the quadratus lumborum, psoas major, multifidus,
iliocostalis lumborum and the longissimus thoracis as key postural and biomechanical stabilizers of
the thoracolumbar and lumbopelvic regions during complex tasks. Under these conditions it
becomes mandatory that self-management programmes must be developed with this in mind for
practising chiropractors. As a result, it is the authors opinion that clinicians should incorporate
dynamic postural analysis protocols to appreciate thoracolumbar and lumbopelvic movement
primarily throughout the sagittal and coronal planes. This would be to establish movement patterns
during and at the end of the flexion, extension and lateral flexion ranges (Byfield 2002). Ongoing
research by McGill (2002c) has identified the neutral spine posture (mid-range lordosis a posture
of minimal joint load, reduced shear forces and tissue strain) as a vital component for overall
postural stability and safety and this posture should be maintained during the execution of lifting
moments or sudden uncontrolled movements characteristic in manual skill intervention. Subsequently,
all postural exercise programmes or rehabilitation protocols must include routines that include neutral
spine training along with a range of additional exercises to enhance spinal extensor and stabilizer
endurance, strength and speed of contraction while performing various everyday tasks. Speed of
contraction is enhanced via proprioceptive skill training and is an essential component of a
comprehensive rehabilitation exercise programme for patients presenting with chronic recurrent
mechanical back pain and other related musculoskeletal pain syndromes. The neutral spine has been
challenged by a review which concluded that workers engaged in lifting and manual handling should
adopt a mildly flexed spinal posture, but both postures advocate strict avoidance of end-range
activity, which increases compressive and shear forces (Graveling et al. 2003). Modern spine
research supports the value of a variety of postures despite the benefits of the neutral spine (lordosis),
as there is good evidence for moderate flexion postures during normal activities (Adams et al.
2002b). These researchers have catalogued the biomechanical advantages of a moderately flexed
spine in both the sitting and standing positions. Adams et al. (2002b) outline quite specifically the
advantages of a flexed posture, and Scannell and McGill (2003) point out the mechanical advantages
offered by the moderately lordotic posture. Therefore, according to the research evidence, it would
seem that there may be advantages to a variety of postures including moderate flexion and moderate
lordosis while engaging in a number of common daily tasks involving standing, sitting, lifting,
walking or when manipulating patients as a chiropractor.
In summary, evidence suggests that functional stability during the performance of normal daily
occupational activities is governed by the complex interaction of various neuro-biomechanical
subsystems, which have been investigated and identified. It is with this in mind that clinicians should
adopt this methodology for practitioner safety and practice longevity. This approach to manipulative
skill performance must be developed at the undergraduate level when these skills are initialized and
then enhanced during post-graduate development.
Occupational back pain and postural considerations
Occupationally related musculoskeletal injuries represent a growing healthcare and socioeconomic
problem in current Western industrial societies (Waddell 2004, Waddell et al. 2002). Waddell (2004)
reports that there is strong evidence that no significant change has been observed in the self-reported
prevalence of back pain over the last two decades, even though there has been a major increase in the
number of people on long-term sickness absence and social security benefits for back pain on an
international level. According to this author, low back pain is occupational in the sense that it is
common in adults of working age, but questions are increasingly asked regarding the extent to which it
is actually caused by work. There is an abundance of literature and evidence that chronic low back
pain and related disability should be managed according to a biopsychosocial model and effective
therapeutic interventions including manipulation and rehabilitation exercises. There are now
considerable data supporting activity-based protocols for best recovery and less chronic disability.
Further discussion of this contentious topic is not the remit of this chapter but will be touched upon
later in this text.
With all the emphasis on occupational back pain, it is important to note that shoulder pain ranks
second only to low back and neck pain in clinical frequency and upper-limb disorders are clinically
challenging and responsible for considerable work loss and there is a need to determine effective
approaches for their treatment and management (Burton et al. 2009). With the large prevalence of
neck and shoulder pain it is surprising how few studies have previously been performed. This is
particularly of clinical importance for the chiropractor in terms of the movement and forces
transmitted by the shoulder girdle complex during the administration of various manipulative
interventions.
Moreover, occupation (e.g. dentist) and work posture have been identified as predisposing
factors for back, neck and shoulder pain (Rundcrantz et al. 1991b, Smith et al. 1997). Indeed, workers
with manual handling tasks are three times more likely to attain back injury or pain (Mior & Diakow
1987). Chiropractic might be expected to be one of those occupations that predispose the practitioner
to these problems. This results from the need for chiropractors to adopt complex postures and
movements during the performance of the various manual interventions (Byfield 1996, Mior &
Diakow 1987). These problems can be exacerbated by the practitioner adjusting their positioning to
meet the needs of the client, rather than adjusting the position of the client with respect to their own
needs (Sunell & Maschak 1996). Physical activity carried out at work, the physical conditions under
which work is conducted, the working environment or psychosocial aspects of work are all
independently related to the occurrence of shoulder symptoms and disability (McCluskey et al. 2006).
Another important consideration in relation to pain and clinical risk factors is the psychological
component. This is perhaps too frequently overlooked regarding physical pain. However, it has been
suggested that pain is a cognitive distracter and competing sensory stimulus, but deficits in
cognitive function have also been linked with depression and emotional distress (Lauren et al. 1997).
The perception of pain is altered when a person is emotionally affected, stressed, or depressed. Many
psychological factors have been associated with risk of injury and pain prevalence.
Body mass index and grip strength may be important factors in predicting neck and shoulder pain
(Huang et al. 1998, Van Poppel et al. 1998). Indeed, weakness in the hands has been recorded as a
strong predictor of neck and shoulder pain (Norlander & Nordgren 1998). In addition, lack of
coordination, strength and effective coupling of muscles may also potentially impair postural stability
(Lauren et al. 1997). As a consequence, chiropractors that are smaller in stature may be at greater risk
of damaging their shoulders and upper backs during execution of the more physically demanding
manipulative techniques. Indeed, with larger patients in side posture, for example, the smaller
chiropractor may have to reach around the patient, placing excessive strain on the thoracic spine and
shoulder girdle. Perhaps it was as a consequence of body size/differentials that Mior and Diakow
(1987) found a higher prevalence for thoracic spine pain amongst female practitioners and more low
back pain amongst male practitioners. Similarly, a higher prevalence of pain and discomfort in the
neck and shoulders of female dentists has been reported (Rundcrantz et al. 1991a).
Prolonged work in a stooped posture has been identified as a factor in the aetiology of back
pain. This posture has been found to place excessive loads on the passive stabilizing structures of the
lower back that over time may contribute to back pain symptoms (McGill 2002a,b). It can be
reasonably argued that these risk factors constitute a normal work day in a chiropractic office and,
therefore, it is not surprising that the type of job and the work environment have been closely linked
with back and neck pain.
Occupational injury and the chiropractor
Chiropractic daily practice involves the constant performance of various forms of manipulative
therapy and other manual tasks in a variety of different working postures which subject the
musculoskeletal system to potentially large repetitive mechanical loads. This says nothing about the
non-physical stress factors, such as financial concerns and patient demands, that may independently
contribute to the onset of occupationally related back pain. Moreover, many of the common
manipulative skills and techniques force practitioners to bend and twist the trunk (Figs 5.1 & 5.2),
generate pushing and pulling actions, and simultaneously reach and stretch around the patient (Fig.
5.3). The constant lifting of patients, readjusting their body weight and position on the table prior to
the thrust, represent professional physical risk factors for the chiropractor. The overall stress could
substantially increase during mobilization procedures, which require the clinician to adopt awkward
postures for extended periods of time. The majority of our manipulative techniques, particularly side
posture skills, combine a degree of forward flexion and lateral bending plus a rotational component,
potentially positioning the spinal joints at the end of their passive range. This could lead to injury
over a period of time as a result of fatigue or uncontrolled movements (McGill 2002c). It has been
stated that the cause of worker injury is heavily influenced by the way the worker moves and the next
leap toward zero injury rate may be fitting the person to the task, or retraining the way the worker
moves instead of fitting the task to the person (McGill 2009). This concept is explored in greater
detail in Chapter 3 dealing with the biomechanical considerations of spinal manipulative skills.

Figure 5.1
Figure 5.2

Figure 5.3

In addition, this twisting/torsion activity may be a physical risk factor and it has been
responsible for an increase in disc prolapse as awkward twisting movements are closely related to
these discal injuries and back pain (Adams et al. 2002a) (Fig. 5.4). The crucial aspect of these
movements is that the clinician is strongly advised to avoid the end of the passive range of movement
(McGill 1998) and awkward twisting as it is likely that the main movements of the lumbar spine are
forward and lateral bending (Adams et al. 2002a). The soft tissues of the upper back and shoulder
girdle are particularly vulnerable to injury because of the high loads encountered as a result of
repetitive tasks as a consequence of manual thrusting (Fig. 5.5). In addition, Marshall and McGill
(2010) have demonstrated that excessive twisting in combination with repetitive flexion extension
motion may cause radial delamination of the disc while repeated flexion caused more
posterior/posterolateral tracking of the nucleus giving guidance to prevention and rehabilitation
strategies.

Figure 5.4

Figure 5.5

A study that reported a high prevalence of neck and shoulder pain (50%) experienced by
chiropractors in the UK is of particular importance. Prevalence appears to be much higher than in
previously surveyed groups such as: other health professions, light industry and general population
studies. A significant correlation was found between the body mass index and grip strength, however
no apparent relationship was observed between gender, age, technique, stress, activity levels or the
other variables examined. However, it was apparent that many of the responders (68% of females and
48% of males) felt that their work aggravated their pain. Further research is warranted in respect of
this with a view to minimizing the variables assessed and determining the cause of this high
prevalence for neck and shoulder pain.
Issues, such as keeping the legs straight or bent during forward flexion, have different
mechanical effects upon the lumbosacral junction. Fortunately, the chiropractor is continually
changing postures to meet the demands of clinical practice and this regular change in posture has been
shown to be an important preventative strategy (McGill 2002b). Furthermore, a more mobile and
varied work posture has been correlated with a lower incidence of low back pain (Adams et al.
2002b) and probably reduces the cumulative mechanical effects of constant bending, twisting and
lifting. The constant manual thrusting and a combination of fatigue, poor technique, inadequate skills
and selection of inappropriate technique may contribute to an increased risk of musculoskeletal injury
in the office. These occupational injuries are not confined to the spine. The continual mechanical
stress applied to, for example, the shoulder girdle, elbow, and wrist joints during thrust delivery may
result in repetitive injuries to the supportive soft tissues.
Notwithstanding, evidence suggests that body weight should only be considered a possible weak
risk indicator as there are insufficient data to assess if it is a true cause of low back pain (Leboeuf-
Yde 2000). It does appear that, as a result of the rather inconclusive effects of individual risk factors,
the interaction of various occupational conditions that mechanically load the spine are of more
importance than the person performing them. How the various movements are performed could also
be a factor in this situation that could have significant training implications for the undergraduate.
Therefore, it is apparent that there are specific occupational hazards causing mechanical stress
to the musculoskeletal system of those engaged in spinal manipulative therapy, particularly
chiropractors. This has been confirmed by results reported in a study by Lorme and Naqvi (2003)
specifically investigating the mechanical loads on the spine with respect to the height of the
workstation (chiropractic table) when performing spinal manipulation. This particular study is
important with regard to identifying various loading patterns and then introducing clinical
modifications to reduce these loads and any long-term effects on the practitioner.
Furthermore, Triano has published an extensive piece of work entitled, The mechanics of spinal
manipulation, in Clinical Biomechanics of Spinal Manipulation (Herzog 2000) which stands as a
benchmark in this area of investigation and will be referred to in this and other chapters of this text.
As this research is ongoing and long term, other practical methods to minimize these inherent risks
need to be incorporated into undergraduate skills training. The procedure advocated by the author and
described in detail throughout this text includes a qualitative breakdown of many common diversified
techniques for each spinal region into a series of individual psychomotor skills presented in a
sequential pattern. This protocol is anecdotal at this stage and is described in detail in the
introduction to this text, but plans are in place to investigate this methodology under more rigorous
scientific conditions.
The constant use of the same manipulative techniques and procedures day after day and year
after year could contribute to developing chronic overuse syndromes as a result of poor
biomechanical performance by the practitioner. Clinicians should incorporate various techniques that
produce similar treatment outcomes, consolidating both manipulation and mobilization techniques in
the best interest of the patient. Furthermore, learning to execute all manipulative procedures
efficiently from both sides of the table and in a variety of postures (standing and sitting) could
possibly reduce the effects of musculoskeletal fatigue and the development of mechanical overload
and subsequent pain. Practitioners are creatures of routine and tend to use those few techniques that
produce consistent clinical results. However, it is clinically advantageous to master a wider range of
common manipulative skills that can be used interchangeably, producing similar clinical results.
Varying patient postures, including sitting and standing, will undoubtedly ease the accumulative
effects of mechanical overload. Further to this, maintaining full body fitness, preparing for the days
work, stretching during the day to relieve muscular tightness and maintain joint range of motion, plus
improving upper body strength to help stabilize the shoulder girdle, are other considerations.
Improving core stability muscles and learning and incorporating the abdominal brace technique
discussed above (McGill 2002a,b) prior to engaging in any manipulative procedure, particularly
positioning patients in side posture or delivering an adjustive thrust, may provide a protective quality
to the chiropractor. Incorporating an efficient functional posture (neutral spine or a slightly flexed
lumbar lordosis) as the most stable and efficient working posture of the lumbar spine for the
chiropractor is paramount (Adams et al. 2002b, McGill 1998, McGill 2002b), and may be a step
forward in the acquisition of manipulative skills. The abdominal brace technique enhances and
complements the neutral and slightly flexed posture and should become an automatic reflex skill for
all practitioners. This skill must be presented, learned and reinforced at the undergraduate level.
These practical skills are clearly supported by quality biomechanical research investigations;
however, more research needs to be conducted.
Another simple strategy would be to incorporate variable height chiropractic tables into
practice, which would provide flexibility and adaptability to the clinical environment (Lorme &
Naqvi 2003). These tables provide substantial comfort for both practitioner and patient alike and are
vertically adjustable, which provides great benefits for the practitioner who sees a range of patients
of various sizes and age. The use of a multifunctional table extends our armamentarium and permits
the use of many manipulative techniques and adjunct therapies suitable for patient care. Stationary
tables do not account for differences in patient girth and other anthropometric variations, which
means that the practitioner is continually working at different heights, which could compromise skill
delivery and place unnecessary mechanical stresses on the practitioner. This may upset postural
balance and important weight distribution over the targeted joint, compromising the efficiency of the
manipulative procedure and at the same time risking injury to both patient and practitioner.
Practitioners have a mandate at least to maintain their skills if not to continue to improve their
performance and manipulation repeatability under a number of quite different clinical situations and
patient types. Developing stable working positions and postural balance minimizes energy
expenditure and mechanical workloads. The use of adjustable height and motorized adjusting tables
must be a standard clinical feature. Improving postural awareness and overall physical fitness is
mandatory to reduce the effects of the high occupational risk factors associated with chiropractic
clinical practice. Furthermore, it is a chiropractors responsibility to maintain their core clinical
competencies from a diagnostic and therapeutic perspective to ensure high-quality care and patient
management at the primary contact level.

Summary
The purpose of this section was to present an overview of a few basic aspects of the practitioners
working posture. It is by no means inclusive, the details being covered in the appropriate chapters in
the text for each region of the spine and pelvis, including the specialty manipulative skills. Posture, in
the narrowest sense, may be considered to be the upright, well-balanced stance of the human subject
in a normal position; however, from a chiropractors perspective, functional posture (neutral and
slightly flexed lordosis), as discussed in more detail in the introduction to this chapter, is vitally
important in terms of efficient performance of complex manual psychomotor skills. The chain of
events leading up to the delivery of an effective manipulative or mobilization force is somewhat
dependent upon the practitioners control of his or her centre of gravity. The importance of
recognizing clinical risk factors early is equally as important as instituting appropriate preventive
measures to eliminate these hazards. Emphasis will be placed upon the position of the (supra)sternal
(jugular) notch as an anatomical reference point relative to the various hand contact positions used in
a variety of manipulative procedures. The alignment of the suprasternal notch over the contact is
regarded as the optimal position of the clinicians body weight for ideal control and efficiency of the
dynamic thrust. This will assist to essentially line everything up to improve weight transfer and force
distribution through the manipulator to the patient in the most efficient fashion. These specific skills
will be described in more detail in relevant chapters of the text.
General postural considerations
Cervical spine and posture
The manoeuvrability and skill of the practitioner play a key role in performing confident and safe
manipulation of both the upper and lower cervical spine. This ensures that the manual intervention is
skilful and that excessive forces are controlled to reduce the frequency and intensity of post-treatment
reactions. The following represents some basic aspects of practitioner posture and positioning with
respect to manipulative therapy directed to the cervical spine. Common errors will be presented and
suggestions of a more appropriate postural performance will be given. Please refer to Chapter 11 for
more detail with respect to specific diversified cervical procedures.

Thoracic spine and posture


Manipulation of the thoracic spine offers two main mechanical advantages. First, many of the more
common procedures are performed while the patient is in the prone position and second, the
mechanical stability of the rib cage helps to prevent excessive movement, improving specificity. The
prone position is an advantage to the patient in that the area being manipulated is virtually fixed and
the practitioner can use this relatively stationary position to control patient movement and maximize
the mechanical effects of the manipulative thrust via well-placed postural components. The following
represents some basic aspects of practitioner posture and positioning with respect to manipulative
therapy directed to the thoracic spine. Common errors will be presented along with more appropriate
postures and performance advice. Please refer to Chapter 10 for more detail with respect to specific
diversified thoracic spine procedures.

1) Standing at the head of the table with the legs straight and spine fully flexed stressing the passive
tissue end range of the thoracolumbar spine. The patients head is unsupported and held out in front
which increases the bending moment at the lumbosacral spine and could compromise the efficiency
and control of the dynamic impulse thrust and place considerable mechanical load on the lumbar
spine structures (Fig. 5.6). The longer levers acting on the head and neck may create more twisting
action and arm fatigue. There is increased flexion of the thoracic spine, placing more mechanical
loads on the cervical extensors.
2) Figure 5.7 illustrates good practitioner posture and patient comfort prior to the manipulative thrust.
The practitioner is using the mechanical advantage of the lower extremities, flexing the hips and
knees to effectively distribute the body weight across several joints. There is less flexion angle at
the lumbosacral (neutral/slightly flexed lordosis) and thoracic spines, taking the stress off the
spinal extensors reducing potential muscular fatigue and mechanical loading. The clinician is also
leaning against the head of the table supporting his own weight and is positioned at about 45
ipsilateral to the mechanical lesion, shortening the manipulating lever. The position of the
practitioners suprasternal notch is over the cervical spine, placing the centre of gravity very close
to the patient and maximizing the mechanical efficiency of the manipulator. The weight of the
patients head is supported by the headpiece to reduce the carrying load on the arms and upper
back and minimize muscular contraction by the patient prior to preload and mobilization/thrust.
This manual skill can also be performed in the sitting posture to reduce fatigue and loads on the
lumbosacral spine. Standing cervical manipulations are very useful clinically, but patient control is
compromised.
3) The sitting position for the practitioner reduces the load on the lumbar and thoracic spine by
modifying the flexion angle of both areas of the spine. Rocking the lumbopelvic region forward on
the ischial tuberosities maintains neutral/slightly flexed lordosis, thereby reducing unnecessary
mechanical spinal loading on the practitioner. Care has to be taken to ensure that the stool used is
mobile, can move from side to side and has an adjustable height to allow more flexibility with
different patient types. The ability to position the jugular notch (sternal notch) over the contact
point is difficult, reducing the efficiency of the manipulative thrust and increasing the stress on the
shoulders.
4) Sitting cervical manipulative techniques with the practitioner standing have an advantage in
limiting the loads on the spine by distributing forces through flexion of the hips, knees and ankles.
Care has to be taken to use a stool for the patient that has an adjustable height to maximize hand and
arm position for thrust delivery. Major disadvantages are reduced patient relaxation as a result of
weight-bearing posture of the head, and potential reflex muscle guarding prior to manipulative
thrust. If the patient is too high or low, the efficiency of the thrust is reduced. These skills need to
be applied where clinically appropriate. Neutral/slightly flexed postures can be easily adopted.
1) The practitioner is positioned at 45 to both the table and patient in a fencer stance posture (Fig.
5.8). The trunk, pelvis, hips and lower extremities are all positioned at 45 to eliminate any
potential torsional forces developing in any of the major joints of the body. Note that the arms are
also symmetrically placed to maximize the manipulative thrust and minimize the stress on the
practitioner relative to the jugular notch and the centre of gravity. The suprasternal notch is in line
with the contact hand position over the target joint. The practitioners shoulders are relaxed and
angled towards the table, keeping the elbows relatively extended (marginally flexed) but not
locked in full extension. The practitioner is leaning against the table to help support body weight
and reduce the mechanical load and postural stress. There is very little flexion of the trunk.
2) Figure 5.9 illustrates the overall effect of the body positioned at 45 low fencer stance from the
feet to the trunk and head with the suprasternal notch over the contact hands positions. The centre of
gravity is positioned for a weight distribution advantage. The hips and knees of the practitioner are
flexed to assist the impulse body drop. The body weight is forward over the front leg effectively
placing it over the patient and the table to maximize manipulative thrust/mobilization force. The
plantar flexion of the hind foot pushes the weight forward and adds spring to the lower extremities.
The legs are in contact with the table to help support body weight.
3) Figure 5.10 demonstrates the practitioner positioned back and away from the table losing the
support of the table and advantage created by the position of the centre of gravity. This
subsequently compromises the mechanical advantage of the practitioners body weight and body
drop thrust. This posture places greater demands on the practitioner in terms of overall work
demand. Flexion angles are increased and there is more stress on the shoulders. The jugular notch
and contact point have become uncoupled and all the mechanical levers are influenced,
compromising thrust efficiency and patient comfort.
4) Techniques that require the practitioner to reach around the patient (Fig. 5.11) require a great deal
of trunk flexion thereby stressing the lumbo-pelvic region of the spine. However, if the practitioner
maintains a 45 stance to the table, keeps the hips and knees flexed and leans over the patient
positioning the centre of gravity close to the patient, the effects of the mechanical overload may be
negated. Keeping the shoulders parallel to the table decreases the torque in the thoracolumbar
spine. This also controls the twist in the arm. Bending the contact arm elbow also reduces
mechanical loading on the shoulder girdle.
5) Manipulative techniques for the cervicothoracic spine illustrate the use of correct positioning of
the jugular notch and the targeted joint dysfunction (Fig. 5.12). Flexion of both hips and knees
while leaning against the table distributes the weight of the practitioner over the centre of the spine.
This reduces mechanical stress even though it appears that trunk flexion is excessive. The
shoulders are relaxed and level decreasing spinal twist and maximizing the thrust speed of the
shoulder girdle. Note the position of the shoulder relative to the trunk and the upper arm. There is
very little forward rotation which may compromise the anterior capsular region.

Figure 5.6
Figure 5.7

Figure 5.8
Figure 5.9

Figure 5.10
Figure 5.11

Figure 5.12

Lumbar/pelvic region and posture


The high incidence of low back pain in the general population would suggest that chiropractors spend
the majority of their clinical time treating low back pain. The high incidence of low back and
sacroiliac pain reported in chiropractors could be the result of the rigorous physical demands and
skill required to perform side-posture rotational diversified manipulative techniques. These
techniques place increased demands on the practitioner to control his/her weight plus the weight and
movement of the patient simultaneously. The patient is far less stable in the side-lying position
compared to the prone or supine postures. It is quite conceivable to suggest that improper skill
performance can cause repetitive asymmetrical mechanical loads on various soft tissues and joints of
the practitioner during the performance of side-posture spinal manipulation.
The following represents some basic aspects of practitioner posture and positioning with respect
to manipulative therapy directed to the lumbar/pelvic region. Common errors will be presented along
with more appropriate postures and performance advice. Please refer to Chapters 9 and 10 for more
detail with respect to specific diversified lumbar spine and sacroiliac joint procedures.

1) Figure 5.13 illustrates symmetrical positioning of the upper body during a side posture lumbar roll
rotational manipulation. Note the position of the suprasternal notch over the contact hand on the
spine and the square position of the shoulders. The contact hand arm and the arm supporting the
patients upper body are almost mirror images, reducing shoulder stress and torque in the upper
back. Also note that there is very little torque in the patients spine and the contact wrist
demonstrates very little extension. Some of the common mistakes encountered during performance
of this manipulation can include asymmetry of the shoulders, particularly the placing stress on both
soft tissues of the upper back and torquing the arm. This position also exaggerates the angle at both
the elbow and wrist, affecting the thrust efficiency and force localization. There is an increased
flexion angle at the trunk plus twist in both the lumbar and thoracic spines
2) Figure 5.14 illustrates a poorly executed side posture lumbar roll as described previously. Note
the twist in both the lumbar and thoracic spines and the exaggerated shoulder angle. There is also
an excessive twisting effect in the hips and lower extremities, increasing subsequent mechanical
loads on these joints. The ability to perform an effective body drop in this position is questionable.
3) Controlling the patients weight and movement on the table during side posture can be done by
gently squeezing the patients top leg between the practitioners legs, reducing excessive leg drop
and stress on the hip lever (Fig. 5.15). Stabilizing patient movement reduces the amount of effort
required by the practitioner to maintain overall control during the application of the manipulative
thrust. Also note the 45 position of the feet relative to the table and especially the left foot posture.
This helps to place the weight forward towards the patient and table, helping to support the
patients position. The practitioners feet should only be hip distance apart. The practitioner leans
against the edge of the table during this procedure to support body weight, reduce fatigue and
stabilize the patient.
4) Figure 5.16 illustrates a wide foot placement that causes a large gap between the practitioners
legs, compromising patient stability prior to the adjustive procedure. Patient movement is
increased and control is minimized. More effort is required to restrict patient movement, detracting
from the efficiency of the manipulation. The outward rotation of the right foot could place potential
stress on the knee during the body drop.
5) Other manipulative techniques utilize different contact and basic arm and hand positions. Figure
5.18 shows a sitting rotational manipulation that has advantages for the practitioner regarding body
posture but patient movements are increased, reducing control, which may outweigh the benefits.
This technique requires more work, does not localize thrust forces and may not be as clinically
specific. These techniques will be described in greater detail in Chapters 8, 9, 10 and 11.

Figure 5.13

Figure 5.14
Figure 5.15

Figure 5.16
Figure 5.18

Figure 5.17

Summary
The chapter, thus far, has also presented an introduction to some of the current thoughts concerning
work-related postures with more specific attention to more common postural and positional errors
associated with manipulative skills and techniques of the spine and pelvis. The overall aim was to
present alternative postures that could help minimize the mechanical effects to both the practitioner
and patient. The more efficient posture and use of body weight adopted prior to the delivery of the
dynamic thrust or mobilization force should enhance its efficiency and effects. This section also
attempted to acknowledge the importance of functional postural stability during the execution of
various manipulative procedures and the various evidence-based postures that provide inherent
lumbopelvic stability.
PART 2 Hand-arm-shoulder skills
Introduction
The application of spinal manipulative therapy is a hands-on affair, whereby forces are generated
and transmitted via the upper body and shoulder through the arm and hand. Manipulation requires
loads be transmitted to the patient by the hand up to 200 times per day, depending on patient
workload, which is a considerable mechanical demand on the upper extremity kinetic chain (Triano
2000).
From another perspective the handpatient interface represents that all important unwritten/non-
verbal communication between the practitioner and the patient. This chiropractorpatient interaction
has been described as the chiropractic healing encounter (Vernon 1991) and provides valuable
information for the practitioner during the delivery of a manipulative thrust. Moreover, this contact
interface also permits the patient to perceive or experience the skill, confidence and
professionalism of the practitioner, first hand. The hands should be placed gently and comfortably
over a tender and painful/symptomatic region, as heavy pressure may undermine the patients trust and
confidence in the practitioner, which may undermine therapeutic value and intent and bring into
question the appropriateness of the procedure. Demonstrating finesse under these circumstances is
very important. Furthermore, any patient apprehension should be regarded as a strong indicator for
modification or discontinuing and reassessing the clinical needs of the patient.
The hand is a highly sophisticated sensory device which not only probes the patients reaction
but also helps the practitioner ultimately to gauge the amount of force, depth and speed that will be
required to carry out a successful therapeutic event (mobilization or manipulation/adjustment).
Maintaining the proprioceptive feedback necessary to judge the point of passive physiological limits
of the tissue (elastic barrier or elastic zone) should not be interrupted or compromised. This is a
highly skilled procedure and methods to enhance this concept should be strongly developed
particularly at the undergraduate level and further enhanced in a postgraduate setting (McCarthy et al.
2002). In addition, any excessive tension or muscular stiffness in the clinicians hands will
automatically be perceived by the patient and may affect the therapeutic outcome and patient
compliance. The ability to communicate a sense of clinical skill and competence to the patient is a
major component of the art of chiropractic. It is the responsibility of those professionals employing
manipulative methods to develop and maintain the strength, flexibility, agility and dexterity of the
hands and fingers to meet all clinical demands associated with these clinical skills.
The hand is capable of great dexterity, accommodating various different shapes and postures that
are required in a number of clinical situations and with an assortment of patients. The hand also has
the capacity to distort and mould to conform to the more inaccessible anatomical contact points,
particularly those associated with, for example, the cervical spine. The hand is basically a
wonderfully engineered tool, particularly for chiropractors! To get the best out of that tool, one has to
learn to use it and understand its potential, thus making the task simpler and easier to carry out.
The first thing to learn is that the hand does not contribute to the force applied to the patient. It
acts as a transfer point only. Any excessive tension in the forearm or hand musculature will distort
this contact and the effective transmission of the thrust manipulation or mobilization. The hand is
magnificently designed, featuring small, padded areas that provide very effective buffers for the
contact and manipulative thrust. If the contact on the patient is smaller, less force will be dissipated
into surrounding tissue and subsequently less work will be required overall. A soft contact cushions
the transfer of the manual thrust or mobilization application making the event less painful for the
patient at this point of transfer. Furthermore, a much larger area of contact will ultimately stimulate
more muscle spindles and joint mechanoreceptors to produce a greater degree of neurological
afferentation for both pain control and functional change. Realizing these very basic concepts
combined with the fact that the thrust force is generated via the whole body, through the trunk, via the
shoulder, down the arm and across the hand through an anatomical kinetic chain, should put this
exercise into an important clinical perspective. This is particularly highlighted during the formative
undergraduate training period. The forces produced by the body during an impulse thrust are
substantial. The author would like to recommend Herzogs publication, Clinical Biomechanics of
Spinal Manipulation (Herzog 2000) as one important reference citation with respect to the
mechanics and physiological effects of manipulation. These citations have been meticulously
catalogued in the Introduction section and in many other chapters throughout this text for future
reference.
Moreover, the hand may be vulnerable to unnecessary injury if incorrectly positioned or
inflexible during a manipulative thrust placing additional mechanical stress on the soft tissues and
joints of the hand and fingers (Triano 2000). This is particularly important for first
metacarpophalangeal joint (thumb) and wrist articulations. The forces transferred to the patient may
be subsequently distorted and dissipated inefficiently into the neighbouring tissues that may influence
the efficiency of the manipulative procedure and contribute to post-manipulative soreness.
Undoubtedly, these forces could possibly account for and contribute to the high incidence of overuse
injuries associated with the lower back, neck and shoulder within the chiropractic profession and
others practising manual therapy, as discussed earlier in the chapter. Transferring forces and
mechanically loading joints along this anatomical chain at extreme ranges of motion may account for
this potentially higher incidence of reported pain by chiropractors. The incidence of shoulder pain in
repetitive work has been reported to be extremely high as a result of a number of biomechanical
restraints and psychological parameters (Leclerc et al. 2004).
Therefore, it goes without saying that physical fitness is an essential requirement when learning
complex psychomotor manipulative skills, particularly strength, endurance, flexibility and handeye
coordination. This will be discussed in more detail in this and other chapters of the book.
The hand is the most important short lever contact point used during the application of spinal
manipulative therapeutics. The development of good hand skills and dexterity is essential. The ability
to establish a firm and confident contact on the patients body without causing excessive pressure,
hand movement, or force is a considerable action to master, requiring many years of practice. The
hand is normally dextrous, flexible and capable of fine, intricate controlled movements when
properly trained. There is a tendency to contract the muscles of the hand too vigorously during
training. This inevitably makes the hand seem very hard over the contact, which will be felt by the
patient and will influence their ability to relax, particularly if the contact is positioned over a tender
region, compromising overall finesse.
The student, when initially introduced to manipulative skills, has the tendency to use the hand
contact like a hammer, pile driver or vice-like grip, inadvertently thinking that a hard bone on bone or
soft tissue contact is better: Ill find that mamillary or transverse process if its the last thing I do!
This can also be observed when students are examining soft tissue and other anatomical structures.
Moreover, students must learn to appreciate that a firm but gentle contact is less painful and more
comfortable for the patient. A tense, distressed and uncomfortable patient will naturally resist a
practitioners best efforts. The student should concentrate on the feedback from their practising
partner, actively visualize the structures and postures involved and learn to feel the sequence of
events and actively concentrate on producing a light but firm hand contact on the anatomical
landmark. This degree of sensitivity is frustrating to learn, but full awareness of the importance and
function of this feedback skill will guide many of the proceeding actions of the manipulative skill and
its eventual mastery.
The human handshake can be regarded as an excellent comparable analogy. A secure, firm,
steady contact communicates many things about the individual and their skill and ability. A handshake
has been known to make or break a business deal or, for that matter, to secure diplomatic detente. It
can express confidence and maturity, and can give the recipient a sense of reassurance that this
individual can be trusted. Such human interactions constitute a very important and basic aspect of
chiropractic clinical methods and of communication that may provide added clinical benefit. The
apparent success of chiropractic treatment for low back pain seems to be a combination of pain
reduction, improved function and, more interestingly, patient satisfaction (Cherkin et al. 1998,
Hertzmann-Miller et al. 2002, Hurwitz et al. 2002). Though the essence of this satisfaction has yet to
be identified, skilful manipulative techniques and confident patient handling may rank highly in this
scenario. The author is confident that future studies will investigate the contribution of these clinical
components and the role of the practitioner in the clinical encounter.
Patients react favourably when treated with consideration and basic courtesy. This approach
begins in a clinical context with an appreciation of the meaning of light touch. This section will
present the skills associated with developing the basic hand postures used in spinal manipulative
therapy. It is recommended that these skills be practised on a weekly basis to develop proficiency,
confidence and fine motor control of the hands. The angular relationship between the hand, arm and
shoulder through the wrist and elbow will also be presented.
The chiropractic manipulative contact hand
There are at least 12 areas on the hand that can be used to contact the skin surface and anatomical
levers of the patient (Peterson & Bergmann 2010, States 1968) (Fig. 5.19). These contact points are
used with varying degrees of frequency depending on the specific manipulative technique. The basic
hand postures for diversified techniques will be presented only in this chapter but there are
undoubtedly similar postures used in a number of other chiropractic techniques. Practitioners develop
a personal preference, but it is recommended that proficiency is accomplished in all hand skills as
one of the many key psychomotor skill components of spinal manipulation expertise.

Figure 5.19 The various common contact points of the manipulators hand: 1, pisiform; 2,
hypothenar; 3, metacarpal; 4, calcaneal (heel) ; 5, thenar; 6, thumb; 7, interphalangeal; 8, finger tip
(pad) or digital.
Hand postures and skills
The operative words for all undergraduate chiropractic students will be gentle, light and controlled,
but firm. The undergraduate should be able to perform the individual hand postures and contact points
competently before applying these skills on a practice partner when learning various manipulative
procedures. The flexibility and dexterity necessary for optimal use of the hand takes time and a great
deal of practice to develop clinical proficiency. Students are encouraged to engage in a number of
activities that improve the dexterity, flexibility and strength of the hand.
The chiropractic arch
The chiropractic arch is the most fundamental chiropractic hand posture employed during all
diversified skills. It is used in some fashion or modification during all manipulative skills presented
by the author in this text. The chiropractic arch is the hand posture of choice and provides a
traditional link during professional development. The arch places the hand in the most advantageous
position in such a way that it exposes most of the more common handpatient contact points or
regions necessary when learning and performing the basic manipulative techniques for each area of
the spine, pelvis and extremity articulations. Numerous variations of the chiropractic arch hand
posture are used in most if not all manipulative procedures of most chiropractic techniques,
particularly the diversified approach. The arched hand provides a buffer system between the
practitioner and patient. The chiropractic arch is a natural posture or configuration for the
articulations of the wrist/hand as a result of the anatomical and functional tendency of slight ulnar
deviation in the resting position. Ulnar deviation is another important hand posture variation
particularly employed in a number of cervical spine procedures that will be covered in Chapter 11.
The human wrist accommodates a wide range of positions to perform dextrous fine motor skills and
activities (Triano 2000). There are many different manipulative techniques and skills that place stress
on the wrist and hand during manipulative skills learning and practice. The mechanical loads acting
on the wrist while performing complex manipulative psychomotor skills has never been accurately
measured (Triano 2000). However, the preload and peak forces applied in a uniaxial fashion to the
thoracic spine as measured at the point of transfer have been recorded in detail by Walter Herzog and
his team (Herzog et al. 1993). Therefore, it is important to avoid extreme ranges of motion at the
wrist, particularly extension and radial deviation, which could potentially strain ligamentous
structures. Similarly, extreme flexion and ulnar deviation should be avoided. It is sufficient to say at
this point that avoiding extreme ranges and developing wrist strength and coordination are important
to ensure stability. Accordingly, it would appear that the most stable position when loading the wrist
is slight flexion and ulnar deviation which accommodates the natural posture of the hand, (Triano
2000). Hence, the safest procedure when administering manipulative forces is to minimize the
moment acting on the carpal structures. This can be physically achieved by applying loads along the
axis of the forearm through the neutral wrist. This is a learned skill and one that must be mastered as a
fundamental task.
There are a series of steps as the student slowly develops the dexterity and fine motor control
needed to acquire the necessary skills with his or her hands. The student must also learn to perform
these tasks with the hand and forearm musculature in a relaxed state to improve psychomotor skill
performance. At the same time the student must learn to introduce a degree of co-contraction of the
flexors and extensors across the wrist to stabilize the joint as high mechanical loads mechanical loads
are transferred. Flexibility of the joints of the hand and fingers will assist the learning of the
following skills. The student and graduate must develop control realize that developing control and
strength of the hand and finger and upper body muscles, particularly the shoulder girdle, is mandatory
and will enhance the learning of all skills. As an introduction to the basic manipulative hand skills,
the following flexibility, strength and balance exercises are presented in Figures 5.20 - 5.24C. It is
recommended that they be practised daily in combination with all other skills. A general exercise
programme covering full body flexibility, strength, endurance, balance and cardiovascular fitness is
advised to meet the new physical demands required during the acquisition of manipulative skills.
Improving muscular speed and coordination and at the same time increasing joint range of motion and
stability through strength training will cause adaptive changes in the neuromuscular system. Speed,
strength, coordination and finesse are the core elements for the development of foundation
manipulative psychomotor skills. The importance of developing bilateral strength, dexterity and
flexibility will give the student and graduate the confidence to learn these skills equally on both sides
of the body and expand these skills and procedures over a period of time at both the undergraduate
and postgraduate levels.

Figure 5.29
Chiropractic arch hand skills and variations
The basic V-arched bridge posture of the hand (Figs 5.25 - 5.26B) provides the foundation for a
number of other important hand configurations used during the application of a variety of regional
manipulative procedures common to the diversified approach to manipulative care. This hand posture
provides the flexibility and the versatility necessary for the transition of manipulative forces between
the practitioner and the patient. The following modifications describe a number of the most common
chiropractic arch derivatives.

Figure 5.33
Figure 5.34

1) The ability to separate the thumb and index finger is necessary to manoeuvre the contact fingers
around various anatomical locations. Therefore, the flexibility of the web of the hand should be
maximized. This can be extended to the other fingers as well. Figure 5.20 illustrates the position of
the fingers and thumb, and shows the required flexibility using a slow developmental stretch (SDS)
or proprioceptive neuromuscular facilitation (PNF) or post-isometric relaxation (PIR) procedures.
Remember that some people have natural flexibility and relatively looser ligamentous structures. If
you are tight jointed and less flexible, you have a great deal of work ahead of you, but with time
and regular stretching flexibility will improve. In either case the basic skills still prevail in terms
of light, gentle approach to patient contact and skill application.
2) The ability to gain both 90 of flexion and extension at the wrist is necessary for many of the
manipulative skills. Figure 5.21A demonstrates the flexibility required while Figure 5.21B
illustrate the position to introduce SDS, PNF and/or PIR to increase comfortably the soft tissue
extensibility and the range of motion of the wrist and forearm musculature. The elbow is kept
relatively straight during this exercise. This exercise may be better accomplished with the forearm
supported on a table or bench.
3) Strength training is an integral component of any fitness programme that will accelerate the
learning of these skills and reduce possible joint injury as a result of the demands placed upon the
upper extremity during manipulative skills. Stability during skill performance is necessary for
efficient execution but also to decrease uncontrolled movements and potential injury. Any number
of methods to gradually increase strength and stabilize the wrist and hand can be used. Balance the
exercise by using small hand weights for arms, forearm and finger strength for both flexor and
extensor mechanisms (Fig. 5.22). Begin with wrist curls in both flexion and extension and then
incorporate arm and shoulder repeats. A full upper body exercise programme to include push-ups
should be incorporated into the undergraduate teaching programme. Gradually increase training
repetitions on a very gradual basis to ensure neural adaptation and training response without any
overuse injuries.
4) Increasing the strength, flexibility and endurance of the shoulders and upper body would also be
advantageous, particularly with respect to thrust skills. Stretching the joints of the shoulder girdle
will improve the overall range of motion and efficiency of the shoulder mechanism when
performing complex manual skills requiring force and weight transfer (Fig. 5.23). The key is to
incorporate variety into the programme to control overuse and training injuries.
5) Simple push-ups (Fig. 5.24A) and the inclusion of a more structured fitness programme to improve
overall body fitness including a swimming programme would help to develop the strength and
endurance necessary to learn the manipulative skills presented in this and future chapters.
Improving the overall strength and endurance of the latissimus dorsi by front crawl swimming, aids
in stabilizing both the shoulder girdle and low back region. There are other components of an
overall exercise programme including handeye coordination and balance skills. Low back
flexibility is important for the student and practitioner and it is recommended that a daily flexibility
routine of the thoracolumbar spine is recommended incorporating the cat or camel stretch within
a neutral range to ensure safety (Fig. 5.24B). It is also recommended that students address postural
spinal stabilizers with respect to endurance with daily bird dog exercises (Fig. 5.24C).
1) The starting position is with the hand placed on a flat surface with the fingers and thumb spread
slightly (Fig. 5.25). There should be no tension in the hand while in this starting position. The hand
should be slightly ulna-deviated and marginally extended at the wrist for this position. This is a
natural posture for the hand otherwise allow the hand to find its own natural resting position.
2) The next step is to lift and flex the metacarpophalangeal joints up from the surface to form a bridge
or V shape with the hand so that the only areas in contact with the surface are the lateral aspects of
the thumb, the finger-tip pads and the calcaneal aspect of the palm. There should be no muscular
tension in the hand or forearm. Caution is advised not to incorporate hard contraction of the
intrinsic muscles of the hand. Too much tension increases the loads on the wrist/hand and forearm
which may affect psychomotor skill performance.
3) The hand is then slowly supinated at the wrist by lifting the thenar eminence while extending and
slightly adducting the thumb> (Fig. 5.26A). The hand and forearm are completely relaxed with no
muscle tension. The only contact with the surface of the table is the hypothenar eminence, the
pisiform and the four finger pads (Fig. 5.26B). The fingers are then spread a little wider apart to
stabilize the weight through the hand. This bridge is similar to the one used by the professional
snooker players when using the cue stick. Once this movement pattern has been rehearsed, it is
important to learn how to begin to use the fingers to tighten up the underlying soft tissues to
stabilize the contact point over the targeted dysfunctional joint complex (taking up the slack during
joint preload). This can be rehearsed by placing the hand on a small towel with the fingers spread
wider apart, and running through the steps described above. This time press the fingers gently into
a towel and draw it up under the fingers to simulate tissue pull and at the same time slowly
supinate the hand, drawing the towel in the opposite direction with the heel of the hand. The hand
should finish in the bridge posture with the hypothenar eminence and pisiform in contact with the
surface of the towel. There should be a mild amount of tension in the hand, mainly the flexors, to
stabilize the contact. Tension should be felt equally throughout the hand and fingers with no
excessive muscular tension in the forearm, upper arm, or shoulder region. This only creates a hard
contact which may aggravate symptoms and influence patient comfort and compliance.
4) The position of the arm and forearm in relation to the wrist and basic hand contact is important.
This will ensure better transfer of thrust force generated from muscle contraction in the shoulder
girdle and central body to the arm, wrist and hand through the contact point via a coordinated body
drop. With the hand in the basic bridge posture with a hypothenar contact, the angle between the
forearm and the hand should be about 100110 with the extensor muscle group in line with the
hand, the elbow locked but not hyperextended. The shoulder should be relaxed, lowered and
slightly adducted to the chest (Fig. 5.27). Move the arm further forward and back to get a feel for
the strain on the wrist and hand. Remember that stressing passive joint structures at their extreme
end range may compromise tissue integrity leading to injury. This needs to be acknowledged and
avoided, particularly at the undergraduate level where these skills are initialized.
5) There are three common errors encountered when learning hand posture skills.
i) The student often assumes that the only real contact is the pisiform. There is a tendency to lift
all the fingers up from the surface of the table, hyperextending the wrist (Fig. 5.28A). This
limits the stability of the arch and flexes the arm excessively. The pisiform is a bony contact
and could feel much harder to the patient when applied during potentially painful clinical
conditions (Fig. 5.28B).

Figure 5.20
Figure 5.21A

Figure 5.21B

Figure 5.22
Figure 5.23

Figure 5.24A

Figure 5.24B
Figure 5.24C

Figure 5.25

Figure 5.26A
Figure 5.26B

Figure 5.27
Figure 5.28A

Figure 5.28B

Hyperextending the wrist statically at the passive joint end range for a period of time combined
with increased tension in the extensor muscle group could contribute to an overuse injury scenario.
These unnecessary aspects of the skill need to be addressed early in skill learning.
It is recommended that the combination pisiform/hypothenar contact be adopted instead of a
pisiform alone.
It is also important that the practitioner maintain a relaxed shoulder posture as this may
compromise skill application and thrust depth. Any excess shoulder tension may compromise skill
performance and potentially increase forces delivered to the patient unnecessarily. Shoulders should
be relaxed and symmetrical during various contacts to ensure uniform force transfer and thrust depth.

Digital or finger tip/goose-neck contact


This particular contact hand/arm configuration is an important skill set for lumbopelvic manipulation
and mobilization procedures (Figs. 5.29 - 5.32).

ii) Students tend to develop excessive and unnecessary tension in the muscles of the hand, fingers and
forearm. This is a normal learning response that needs to be addressed. The fingers should be
relaxed sufficiently at all times in the arch posture so that they can be lifted with ease from the
surface of the table. This will ensure only slight muscle contraction of the flexor muscles of the
hand (Fig. 5.29).
1) With no supination or pronation of the hand or wrist, the hand is held over the edge of a table
supporting the forearm with the elbow positioned at 90. The wrist is then dropped over the edge
of the table maintaining the arch at the metacarpal joints (Fig. 5.30). The hand posture is held
firmly, but there is no excess tension in the muscles of the hand or arm. There is a very small
amount of ulnar deviation at the wrist.
2) The middle finger of the contact hand is reinforced by the index and ring fingers to stabilize and
strengthen the chiropractic arch. The middle finger and the wrist are flexed further, causing
moderate tension in the flexor muscle group of the forearm. The applicator should avoid forced
passive end-range motion of all joints involved in this procedure to reduce injury (Fig. 5.31). This
focuses the force through the middle finger. The fingers should still be flexible and movable,
indicating minimal tension in the hand to optimize contact and patient compliance. This
configuration is known as the goose-neck posture and is used as a standard contact for many
spinous process contact manipulative procedures in the lumbar spine. Note how the chiropractic
arch is still maintained and the thumb is extended clear of the hand. The finger pads provide a very
good small but padded contact point. The fifth digit pinky extension is optional. Wrist flexion
avoids a full passive range to minimize excessive mechanical loading.
3) There is one commonly encountered fault to be aware of when learning the goose-neck hand
posture. The wrist is not flexed to the relaxed 90, but still maintains the chiropractic arch (Fig.
5.32). This compromises the mechanical advantage of the arched hand and the efficiency of the
contact. The other problem is too little or too excessive tension in the forearm and hand that must
be avoided at all times, particularly during the skill acquisition period.
Figure 5.30

Figure 5.31

Figure 5.32

Index/metacarpal/interphalangeal contact
The finesse and control associated with this particular contact is one of the most difficult to learn.
This is in part the result of the delicate and sensitive nature of the soft tissues of the cervical spine
where this contact is most commonly used. The ability to maintain a firm, yet flexible and compliant
contact with the tissue is the learning objective. A great deal of practice is required to assimilate
these skills and a commitment must be undertaken by the student to realize that time and patience is
necessary to achieve a high level of learning.

1) The starting position is the elbow at 90, the wrist held in the neutral position with the hand totally
relaxed in ulnar deviation. There should be very slight flexion of the wrist. The wrist should feel
floppy. The hand is actively ulnar deviated, bringing the index finger almost perpendicular to the
line of the forearm. This action exposes the actual interphalangeal contact points on the medial
edge of the index finger. The thumb is simultaneously extended, making sure that the wrist remains
neutral (Fig. 5.33). The hand and fingers are still floppy and relaxed. There is slight flexion of the
wrist but the thumb and radius are in line to ensure that forces generated from the shoulder and arm
are transferred efficiently through the wrist to the contact point and across the targeted tissues.
2) There are two major faults to be aware of when learning this contact.
i) During ulnar deviation of the hand the wrist has a tendency to flex or extend excessively. The
wrist is susceptible to injury during an impulse thrust.
ii) The wrist is not ulna-deviated enough and consequently the metacarpal/interphalangeal
contact point does not reach the perpendicular finishing position.

Thumb contact
The thumb contact is used primarily in manipulative techniques associated with the cervicothoracic
spine using the head as a lever and for rotary manipulation of the cervical spine. The thumb provides
a particularly soft, fleshy contact for most spinous process contacts. As with the other contact skills,
there are specific hand and arm movements that need to be rehearsed and learned before they can be
applied in a clinical situation. Remember, it is the slow, controlled and relaxed movement patterns
that are important. Keep in mind that the first metacarpophalangeal joint is vulnerable to mechanical
loading and stress when used in this fashion, reinforcing the need to strengthen the hand muscles
overall and particularly the thenar eminence and forearm musculature. Learning to brace and stabilize
the hand appropriately during the acquisition of these skills will protect the soft tissues and joint
structures and ensure good transfer of manipulative forces during an adjustive thrust. This is
particularly relevant in this context as excessive flexion with ulnar deviation to compensate for lack
of strength and stability during the use of the thumb contact may create excessive loads at the wrist,
resulting in potential injury.

Metacarpal/hypothenar contact
The metacarpal/hypothenar contact is the fleshy lateral outside aspect of the hand which, although a
minor contact point in terms of manipulative skills, provides a delicate yet firm surface. Although
similar to other skills learned so far, the combination of these skills in various configurations is
important in training the hands to perform various fine and controlled movements consistently. This
particular contact is performed with the wrist in extension and radial deviation which may stress the
wrist structures (Figs 5.34 - 5.36). Caution is recommended during the acquisition and use of this
particular contact.

1) The basic hand bridge configuration is supinated perpendicular to the table from the prone position
until the extreme lateral edge of the hypothenar eminence and the metacarpal aspect of the hand is
in contact with the surface of the table (Fig. 5.34). The hand and forearm are relaxed at all times
during this procedure to learn the value of sustained light touch.
2) The wrist is then radially deviated slowly bringing the proximal aspect of the lateral edge of the
hypothenar eminence into contact with the table to make the actual contact point firm. The wrist
remains slightly flexed (Fig. 5.35A). There will be some muscular contraction of the flexors and
abductors of the hypothenar eminence so that the fifth digit remains flat on the contact and the
contact point is firm (Fig. 5.35B)).
3) There is only one minor error to be aware of during the learning of this hand skill.

Figure 5.35A

Figure 5.35B
There is a tendency to radially deviate the hand beyond the specified range causing excessive
muscular contraction in the hand and forearm musculature. This toughens the contact and causes
excessive muscle contraction in the forearm, stressing the wrist (Fig. 5.36) which also destabilizes
the contact point resulting in potential injury.

Figure 5.36

Thenar contact
This contact has considerable clinical use as an acceptable alternative to the hypothenar/pisiform
contact. The only problem is that the thenar contact is not as natural a hand position. It is also a
slightly larger muscle mass, which may dissipate some of the thrust force. However, because of its
muscle bulk, the thenar eminence offers considerable comfort for the patient and at the same time
provides a specific contact point. There are two types of thenar contact, prone and supine (Figs.
5.37A - 5.39C). The prone contact is generally used for lower thoracic manipulation, whereas the
supine thenar is most commonly used for the anterior thoracic and rib manipulative procedures which
will be described in more detail in Chapters 8, 9, 10 and 11.

1) The starting position is the elbow at 90, the wrist held in the neutral position with the hand totally
relaxed in ulnar deviation. There should be very slight flexion of the wrist. The wrist should feel
floppy. Tension is produced in the thenar muscles by adducting the thumb towards the index finger
and the fourth and fifth digits are slightly elevated (Fig. 5.37A). This ensures that the centre of the
thenar eminence is in full contact with the table or anatomical landmark (Fig. 5.37B). The thumb
and first two digits stabilize the hand.
2) There is one minor fault associated with learning this skill: namely over-pronating the contact
point which places internal torsional stress on the arm and shoulder. This is not a natural posture
for the upper extremity and any excessive movement may result in a number of overuse problems
associated with the shoulder and wrist in the future.
Figure 5.37A

Figure 5.37B

Supine thenar contact

1) Begin with the hand flat on the table with the palm side up, fingers together and the thumb adducted
close to the palm. Adduct the thumb fully bringing it in line with the index finger (Fig. 5.38). This
maximizes the contraction of the thenar musculature making the contact point firm yet comfortable
for the patient.
2) Flex the distal and proximal interphalangeal joints. This action gives the hand more depth making it
a better fulcrum for anatomical contact (Fig. 5.39A). The hand is relatively relaxed and the thenar
eminence is marginally contracted. Allow the thumb to extend into a vertically orientated posture
for another useful contact (Fig. 5.39B). Another useful posture for this procedure involves
extending the hand at the metacarpophalangeal joint and flexing the distal and proximal
interphalangeal joints (Fig. 5.39C). This requires a significant amount of skill acquisition to
assimilate these various configurations. These postures will be administered for the appropriate
clinical intervention.

Figure 5.38

Figure 5.39A

Figure 5.39B
Figure 5.39C

Summary
This chapter has presented a comprehensive description of the more common hand contact postures
associated with chiropractic manipulative therapeutic intervention. The importance of being able to
use ones hands skilfully and confidently during the application of spinal manipulative therapy has
been emphasized. These are considered first-order or basic skills, particularly at the undergraduate
level. The significance of maintaining moderately firm hand and arm musculature without excessive
muscle tension or joint ranges of motion at the wrist and elbow has also been highlighted to avoid
unnecessary injury and poor skill acquisition. The significance of avoiding extreme flexion/extension
and radial/ulnar deviated postures was reviewed in light of the excessive mechanical loads created
when transferring loads while performing manipulative procedures.
Careful attention and adherence to the sequential steps and fundamental movements adds to the
overall process of manipulative skills learning, development and long-term mastery. The interface
between the practitioners hands and the patient as an integral aspect of that special clinical
communication should not be casually overlooked.
PART 3 Patient positioning skills
Introduction
Patient compliance and comfort during spinal manipulation are paramount. This is simply part of the
overall skill and its mastery. There are many different postures within which manipulative therapy is
performed on a clinical level. These positions or postures are governed by clinical indications,
patient needs, individual tolerances and, most importantly, symptoms. Some positions are more
advantageous in terms of maximizing patient relaxation, thereby improving clinical efficiency and
outcomes, while others furnish the most mechanical advantage for regional isolation and reasonable
accuracy of manual force application. These represent a group of skills that are usually difficult to
learn but, once mastered, yield efficient manipulative procedures. The side posture procedure
provides biomechanical leverage and advantage for manipulative intervention for regions of the spine
and pelvis. This is in the light of the fact that chiropractors are not very accurate with respect to
producing a cavitation at a desired level (Ross et al. 2004). This study challenges the long held joint
specificity concept in the profession and the belief that chiropractors are capable of localizing
manipulative forces at one motion segment, where in reality segmental may be defined as one
segment at best. The side posture produces an essential leverage via the femur, pelvis and upper body
of the patient to produce a mechanical transition point (Peterson & Bergmann 2010, Triano 2000).
There are some drawbacks to this common procedure that may subject both the patient and the
clinician to excessive twisting actions and mechanical deformation of pain sensitive tissues. This may
produce some minor post-treatment reactions; these commonly occur and can be a source of repetitive
stress for the practitioner (Cagnie et al. 2004, Senstad et al. 1996). This later study presents data that
identify certain variables that predict how patients may react to manipulation. This has significant
clinical relevance in terms of education and patient selection. In terms of risk, it has been estimated
that 1 in 100 million manipulations may cause a disc herniation (Shekelle 1994), as the human spine
is biologically well suited and designed to accommodate the forces generated during these
manipulative procedures. The side posture is also far more difficult to learn from a manipulative skill
perspective for a number of reasons that will be discussed in this chapter and reviewed in greater
detail in Chapters 9 and 10.
The supine and prone positions, on the other hand, are far less demanding of both the practitioner
and the patient, because of the inherent patient control and stable positioning on the chiropractic table.
As a result of this fact alone, all the other factors, which determine the success of manipulative
procedures, are substantially improved. The sitting and standing positions are useful clinically, but
are limited because of the additional effects of weight-bearing and gravity on various postural
muscles and their influence on patient relaxation and cooperation in a clinical sense.
Correctly positioning the patient is a learned skill and forms an integral part of the overall
therapeutic encounter. This section will present the skills associated with the most common patient
positions. Emphasis is placed upon employing slow and methodical movements to appreciate the
complexity of the movements involved. Frequent practice is encouraged as part of the learning and
conditioning process particularly for side posture positioning.
Side posture
The side posture is one of the more traditional positions used by the chiropractic profession in the
treatment of the lumbar spine and pelvic girdle. This has been reported in a number of trials
comparing spinal manipulation with other modalities in the management of low back pain (Assendelt
et al. 2004, Bronfort et al. 2004, 2010). The side posture is by far the most difficult to learn.
Furthermore, it is difficult to gain clinical proficiency in the use of the side posture and it is a well
accepted fact that manipulation performed in this posture is infinitely more intricate than manipulation
performed in the prone, supine or even sitting positions. This is partly because the clinician has to
learn to balance both the patients and his or her weight simultaneously, since the patient is lying on
their side which in itself is an extremely unstable posture. Subsequently, there are numerous distinct
psychomotor skills contributing to the overall performance of the side-posture procedure. This
requires a great deal of time and effort on behalf of the student to learn and develop consistent
repeatability. The side posture provides optimal mechanical counter-rotation of the lumbar
intervertebral segments, which improves and the likelihood of safe application of the manipulative
forces and movement. This requires clinical expertise and skill delivered by professional clinicians
who engage in these activities on a full time basis and, as a result, develop expert skills. The side
posture is unique in that it incorporates both long and short levers to introduce both a
neurophysiological and biomechanical effect. The lumbar motion segments are biologically well
designed to withstand sustained compressive and torsional loads which occur during side posture
manual intervention (Adams et al. 2002a). The very nature of the tissue characteristics and their
biological properties ensures patient safety and that adverse reactions are minimized.
The essence of side posture skill is the ability to control the patient in order to apply controlled
manual forces transferred into the lumbar intervertebral and sacroiliac joints and related support
tissues. This is accomplished by manoeuvring the long levers of the patients shoulder and pelvic
girdles (including the hip/femur) and the short levers characteristic of the targeted spinal joint
complexes via a variety of hand and anatomical contact points. The palpatory skills and the ability to
process proprioceptive information regarding joint movement and soft tissue tension and resistance
are integral parts of the overall skill. Developing joint preload or joint tension at the precise
physiological barrier guarantees minimal force, patient movement and overall procedural efficiency.
This type of skilful positioning of the patient requires considerable balance and control on the part of
the practitioner before an adjustive thrust is considered. Both patient and practitioner should be
comfortable and balanced throughout the entire manipulative procedure. Ultimately, there is a
connection between the balance of the practitioner against the balance of the patient and it is this
balance which provides the minimum use of force and the maximum use of finesse. It is this important
balance of patient control and skill that will build effective clinical procedures, improve patient
compliance, enhance therapeutic outcome and, hopefully, reduce potential post-manipulative
reactions.
The following description will provide the basis for a sequential learning process for side
posture skills. Each of the steps represents an important building block for the acquisition and
patterning of these specific movements. These movements, or steps, are to be performed each and
every time a patient is placed in a side-lying posture. These skills will allow the practitioner to
establish clinical consistency, as well as clinical flexibility when dealing with a wide range of
patient types and presenting complaints. Learning the ability to reproduce skilful positioning
procedures should be the goal of the student of spinal manipulative sciences. Naturally, the student
should endeavour to attain the skill, coordination and dexterity required for handling patients in both
left and right side postures and under a number of clinical situations. This section is supported by
video clip material.

Side-posture skills patient positioning


1) The patient is instructed to lie on his or her right side from a sitting position facing the practitioner
with the head comfortably placed on the raised headpiece to support the upper back and cervical
spine. The patient folds his/her arms across the chest so that he/she is lying on the posterior aspect
of the shoulder and scapula on the down side. The patient then flexes both hips and knees to finish
in the semi-foetal position approximately in the middle of the table. Position the upper torso first.
Grasp the arm closest to the table by the wrist just above the radial and ulnar styli and by the
elbow just above the medial and lateral condyles with your thumb and index finger. Gently pull the
arm towards you and cephalad to take out the soft tissue slack in the upper back and shoulder girdle
(Fig. 5.40). This will essentially increase the tension in the upper back. Try not to pull any hairs or
skin. The arm is slowly pulled forward and down. There are a number of ways of accomplishing
this procedure depending on patient presentation.
2) Place the hand of the bottom arm on the anterior deltoid region of the opposite arm and ask the
patient to grasp the side of the table with the other hand for a sense of security (Fig. 5.41). Make
sure the patients elbows are not too high. Note that there are many ways to position the patients
hands and arms according to the preference of the practitioner. This arrangement represents a very
basic approach from which the student can build during the acquisition of more advanced
manipulative skills. This will be discussed and demonstrated later in the chapter.
3) Finally, the patient should be lying on the posterior aspect of the shoulder girdle with no excessive
torque in the full length of the spine (Fig. 5.42). It is good practice to ask the patient if he/she is
comfortable during these procedures. Note the support for the upper back and cervical spine from
the components of the table.
4) Position the lower legs next by flexing the upper leg at the hip and placing the dorsum of the foot
into the popliteal fossa of the bottom leg. This places the upper hip at about 90 of flexion. The
dorsum of the foot must be placed in this posture to ensure enough hip flexion for joint tension in
the lumbopelvic region. The bottom leg is flexed at the knee at about 2025 to reduce any tension
on the hamstrings if leg pain persists (Fig. 5.43). The other option is to place the medial malleolus
in the popliteal space, essentially reducing the amount of stress in the ankle mortice joint. How far
forward should the patient be positioned? This is important relative to patient balance and comfort,
and as a starting point it is suggested that the practitioner should use the anterior edge of the lower
leg thigh as a marker. The patient should be brought forward so that the lower thigh is just behind
the edge of the table and the pelvis is slightly supinated with the superior anterior superior iliac
spine just behind the centre line for better balance.
5) Bring the patient closer to the edge of the table from the initial central position. This will permit
better use of the practitioners body weight and also increase the leverage of the hip and femur and
lower leg structures which are crucial side posture levers. This should always be done facing the
patient. Never turn your backside toward the patient under any circumstances while performing any
manipulative skill! To accomplish this push the top knee down slightly with the right hand and
place the left hand under the iliac crest (Fig. 5.44). From this point scoop the pelvic girdle forward
towards the edge of the table. The amount of movement is minimal. Ask for the patients assistance
with a clear and concise command: Please, bring your body towards me.
6i) This completes patient side posture positioning so that the patient should be relaxed, comfortable
and stable on the table. If the patient is pushed on either the upper or lower part of the body, he or
she will not fall forward in an awkward and unstable fashion (Fig. 5.45A) . The shoulders and
pelvis should be lined up in a longitudinal fashion so that the shoulders are not too far back nor is
the pelvis too far forward. The patient should lie motionless and unassisted on the table without
feeling unsteady, establishing confidence. This control and balance is essential before other skills
are introduced.
6ii) There are a number of different arm postures for the patient in the side posture. For the purposes
of this text and for subsequent chapters (8 and 9) the author recommends the following variation.
With the patient in the relaxed posture as above bring both arms down onto the lateral chest wall in
the folded position (Fig. 5.45B). This takes the patients grip from the table and the other hand off
the shoulder region. This position helps to decrease the upper body leverage during a number of
side posture procedures which will be discussed in full in later chapters.
7) There are three commonly encountered errors to recognize during the learning of this part of the
skill.
i) Pulling the patients arm by the wrist only causes excessive skin pulling at both the wrist and
shoulder, and neck discomfort. This may contribute to patient resistance during the next steps
of the manipulative procedure. Forcing the arm out shows very little concern for the wellbeing
of the patient, compromising patient confidence. Also placing the headpiece too high or low is
uncomfortable for the patient.
ii) Not pulling the arm through enough and leaving the patient lying on the tip of the deltoid
region, cramping both the shoulder girdle and the cervical spine places the patients weight
forward instead of slightly posterior, reducing the balance that you want to achieve before the
next step can be effectively performed. Placing the patient too close to the edge of the table is
unbalanced and may compromise patient comfort and compliance.
iii) Do not lift the patient to the edge of the table unassisted. It is difficult and awkward. The
patient under most circumstances (except during extremely acute situations) is quite capable of
assisting the practitioner in shifting body weight. Think of your own back and potential spiral
injury.

Figure 5.40

Figure 5.41

Figure 5.42
Figure 5.43

Figure 5.44

Figure 5.45A
Figure 5.45B

Side-posture skills practitioner position


Once the patient is comfortable, secure and stable on the table the next step is to correctly position the
practitioners body weight over the patient. The next series of steps are important in balancing the
weight of both the practitioner and the patient during the manipulative procedure. One of the most
commonly observed mistakes by students is their rushing through this series of skills, thus mauling the
patient into submission. The movements should be slow and methodical. Repeat them in sequence as
often as required until the pattern becomes smoother. Focus on patient comfort and confidence.

1) The practitioner directly faces the patient at 90 to the table and places the cephalad hand over the
patients hand on the shoulder or over the crossed arms, keeping the arm relatively straight while
applying minimal pressure down and slightly cephalad to hold the patient on the table. This
maintains patient position and controls the patients upper body weight. Simultaneously, the
practitioner pushes the patients top leg down very slowly only a few inches with the fingertips to
be gently placed between the practitioners thighs just above the knees (Fig. 5.46A). This is the
thigh sandwich or thigh squeeze. This controls patient leg weight and position. The feet should be
about hip distance apart. The patients top leg should be flexed 90 at the hip to create some
tension in the posterior ligament system decreasing the lumbar lordosis, which is a key factor in
side posture manipulation. The patients leg should be clasped by the practitioner just above the
knee in the region of the vastus medialis. The patients arms can be folded lower on the chest wall
to maintain upper body stability (Fig. 5.46B). This keeps the practitioner upright and balanced with
the sternal notch positioned over the lumbar spine to allow maximum use of the practitioners own
body during this procedure.
2) There are four commonly encountered errors to note during this part of the skill.
i) The practitioner should not lie on the patient with the forearm when stabilizing the upper body. This
shifts the practitioners centre of gravity cephalad and has a tendency to drag the patient forward,
compromising the efficiency of the procedure.
ii) Do not push the patients upper body back with the support hand to counter the force being applied
to the pelvis. This creates unwanted torque in the spine and increases patient resistance. The
support hand should be used to maintain the patient on the table for a sense of security with the
pressure directed down towards the table. Using the patients upper torso to develop tension will
be described in more detail in Chapters 8 and 9 as this is an important skill in developing joint
preload and stabilizing other structures in the lower back and pelvic regions.
iii) Do not climb aboard or mount the patient and ram his or her knee into your groin when attempting
to secure and position the patients upper leg, while precariously balanced on the tips of the toes.
This is very clumsy and extremely unskilled and may simply require a table height change.
iv) Do not squeeze the patients knee and leg too tightly with your own legs during the thigh sandwich
manoeuvre. This compresses the knee, causing excessive flexion which may cause discomfort and
pain. This may disrupt comfort and compliance. Provide feedback for each other on this point
when working in pairs in the workshop or skills laboratory. The thigh sandwich or squeeze should
be very light for the best results and control. Try to ensure that the patients leg is not being jammed
into the table during this procedure and ensure that they are close enough to the edge of the table to
create some leverage. This is crucial for the next set of steps in developing preload and a
transitional point in the lumbopelvic region.
3) The next step is a critical transition for overall practitioner positioning and control. The
practitioner begins to shift and position body weight over the patient. The most advantageous
position is with the practitioner placed at a 45 angle to the table in a low fencer or lunge stance
position described in Chapter 6. The actual movement sequence will be called the 45 pivot shift.
This starts with the feet positioned hip distance apart. With the feet maintained in this position, the
clinician swivels on the metatarsal pads to face the table at a 45 angle. This has to be done very
slowly to maintain control of both the practitioner and the patient. Maintain a light thigh sandwich
throughout the pivot shift. The patient should not move during this procedure and movements have
to be light over the patient. The clinicians head, shoulders, pelvis, knees, and feet should all finish
at 45 to the table. The patients position is stable (S). The fencer posture reduces any torsional
stress to the practitioner and patient. Prior to transferring weight over the patient to develop
preload, the back leg must be repositioned to permit better use of the plantar flexion action to come
later. After the practitioner has shifted a thigh sandwich should be maintained with the back leg
perpendicular pushing towards the patients thigh. Then the lower leg is extended and the toe
placed on the ground. This is the duff move (Fig. 5.47).
4)i) With the back leg and foot in the duff posture and the back thigh perpendicular to the floor to
maintain patient leg flexion, transfer the practitioners body weight forward towards the patient and
over the front foot by plantar flexing the rear foot. Consciously maintain a light thigh squeeze
during the weight transfer to control leg weight and position. This action is extremely important for
all side posture manipulative procedures. Transferring the weight over the metatarsal heads gives
the clinician more spring and control of body weight and position. This shifts the weight towards
and down over the patient to position the practitioners centre of gravity as close to the target joint
as possible (Fig. 5.48). Additional support and spring come from flexion of the front knee. The
clinician also leans against the cushion of the table with the left knee for additional support. The
back foot is maintained in a plantar flexed posture. The patients flexed leg is stabilized in the same
position during the pivot shift to the fencer stance. There should be no muscular tension or excess
weight on the patient to maintain control and compliance. Learn to feel the play in the lumbar spine
and pelvis without creating too much tension from the position established in Figure 5.48. Pull the
pelvis towards the practitioner in succession several times to appreciate the give and play in the
spine while stabilizing the upper body. Do not push down on the pelvis or rib cage to maintain
patient stability and comfort.
5) There are four commonly encountered errors to be aware of during the performance of this
procedure.
i) Do not separate the feet more than hip distance. This effectively eliminates thigh sandwich control.
Loss of control of the patients leg subsequently jeopardizes control of the entire lower body of the
patient (Fig. 5.49). The practitioners back leg must remain perpendicular to the floor to maintain
the thigh sandwich and hip flexion.
ii) The angulation of the feet (optimally 45) has a tendency to drift into an exaggerated fencer stance
position with the front foot parallel to the table and the hind foot perpendicular and flat on the floor
with no plantar flexion (Fig. 5.50). A thigh sandwich is impossible to perform in this position when
the practitioners back leg is not perpendicular to the floor to maintain hip flexion and control.
Under these circumstances the patients leg drops through the practitioners legs offering no
stability and tension. This has to be observed and avoided. This reduces the spring on the feet,
keeps the clinicians body weight back from the table, compromising the overall efficiency of the
manipulative procedure. The back leg should not be straight.
iii) Do not over-rotate one part of the body during the pivot shift, producing unwanted torsion in the
spine and mechanical stress on the right anterior glenohumeral joint capsule which may lead to
injury (Fig. 5.51). This usually occurs because the sequence is performed too quickly. The lower
leg often compensates by kicking out to balance the trunk torsion. This could result in repetitive
torsional injuries to both the lumbar and thoracic spines and shoulder. The body moves as a single
unit.
iv) The practitioners body weight can be too far from the table and the patient. This will undermine
patient stability, increase the lever arms acting on the patient and affect the quality of the body drop
(Fig. 5.52). Note the distance between the practitioner and the targeted lumbar spinal region.
Optimal foot placement requires that the practitioners front foot should be positioned slightly
under the table. Practitioners should be able to view about two-thirds of their feet when looking
down. This gives practitioners enough room to apply a body drop but also brings their weight
closer to the table to ensure patient stability and efficiency of the manipulative procedure.
Figure 5.46A
Figure 5.46B

Figure 5.47

Figure 5.48
Figure 5.49

Figure 5.50
Figure 5.51

Figure 5.52

Supine posture skills patient


1) The patient lies with knees and hips flexed to relax the abdominal muscles and the hamstrings.
Flexion of the hips also slightly flattens the lumbar lordosis and relaxes the paraspinal musculature.
The hands are comfortably interlaced and placed across the lower part of the chest. This ensures
relaxed shoulders. The head is supported on a flexed and upright headpiece according to the
clinical needs of the patient (Fig. 5.53). There are many alternatives of this basic theme which are
tailored to the needs of the patient. All of the above cater to patient comfort and relaxation and will
be reviewed in the appropriate chapters.

Figure 5.53

Prone posture skills patient


1) The patient lies face down with the headpiece dropped slightly below the horizontal neutral
position to flex the upper thoracic lower cervical region to reduce any tension and control potential
symptoms. The feet are slightly elevated which takes the tension off the posterior leg musculature
using the adjustable rear foot rest (Fig. 5.54). The arms are placed over the table supports to
maintain shoulder relaxation and prevent the practitioner from stepping on the patients hands.
Cushion support is introduced under the lumbar and pelvic region on a case by case situation.
Some patients require more cushioning and support than others. See Chapters 12 and 14 for more
specific details for specialized patient populations.
Figure 5.54

Recommended table height


1) This is a personal preference in most instances. For the uninitiated, the ideal height is where the
top of the table lines up just at or above the level of the knee joint line in the fencer stance (Fig.
5.55). This allows the practitioner to lean comfortably against the table during side-posture skills,
thus supporting his or her weight and providing patient balance. This height will change according
to the size of the patient. The table height influences the efficiency of the manipulation will be
affected because of inappropriate weight distribution and patient control. A vertically adjustable
table is a clinical necessity to maintain this ideal height relative to the patient. This will be
discussed in more detail in subsequent chapters describing the individual manipulative procedures.

Figure 5.55

Summary
The overall effect of this step-by-step procedure is to produce an effortless process for patient
comfort and relaxation with a minimum amount of effort by the practitioner. Weight distribution of
both the patient and the practitioner are considered fundamental factors in maintaining overall
management and control. The above skills should be learned slowly, and practised until they become
a smooth series of movements in preparation for more advanced skills learning.
This chapter has presented a fairly comprehensive description of side-posture positioning skills
and, to a lesser extent, both supine and prone positions associated with chiropractic manipulative
therapeutics. These skills will form the foundation for all specific side-posture manipulative
techniques covering the spine and pelvis to be presented in subsequent chapters. Balance, control and
mutual comfort considerations have been emphasized.

References

dams M.A., Bogduk N., Burton K., Dolan P. The biomechanics of back pain. Edinburgh: Churchill
Livingstone, 2002;141.
dams M.A., Bogduk N., Burton K., Dolan P. The biomechanics of back pain. Edinburgh: Churchill
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Chapter 6

Adjustive and manipulative thrust skills, other


movements and related exercises

David Byfield
Chapter contents

Introduction
Definition
Thrust technique
Joint tension concepts
Objective feedback
General considerations of the thrust technique
Characteristics, localization, direction, speed and modifying factors
Amount of force application
Individual factors
Patient position
Anatomical lever
Postural stance
Summary
Educational relevance
Ski stance fencer or lunge stance
Ski stance to fencer stance (45 pivot shift)
Thrust skills
Triceps flick (unilateral)
Double triceps flick (preliminary toggle recoil)
Wrist flick (unilateral and bilateral)
Pectoralis thrust
Shoulder/arm pull thrust
Shoulder/arm thrust
Body drop
Combination body drop and shoulder thrust
Other movement skills
Shoulder flexibility protraction/retraction
Wrist supination/pronation
Thoracic compliance skills
Joint tension sense skills
Verbal skills
Thrust skills practise techniques
Summary
References
Further reading
Introduction
Spinal manipulative therapy is heralded as the most commonly used and effective therapeutic
intervention for low back pain, neck pain and headache (Bronfort et al. 2010, Meade et al. 1990,
Meeker & Haldeman 2002, Murphy et al. 2008). There is also good evidence that spinal manipulative
therapy is growing considerably in popularity and acceptance (Eisenberg et al. 1998, Lawrence &
Meeker 2007, Meeker 2000, Tindle et al. 2005, Wolsko et al. 2003). Of the vast number of
manipulative techniques within the field of manual medicine, it has been acknowledged that the high-
velocity, low-amplitude, single, impulse-based short-lever thrust technique is one of the oldest and
most widely practised (Bergmann 1992). Meade et al. (1990) have suggested that the high-velocity,
low-amplitude manipulation may be one of the specific components responsible for the effectiveness
of chiropractic management, however manipulation is only one component of a range of evidence-
based interventions offered by chiropractors in their package of care and skill toolbox (UK BEAM
Trial 2004).
Definition
There have been a multitude of definitions of manipulation or manual therapy published over the
years to describe this common intervention (Bronfort et al. 2012, Byfield 2004, Peterson & Bergmann
2010, Triano 2003). Spinal manipulation is a general term that encompasses different manual
techniques to restore and increase joint mobility, and it has been described as any passive physical
manoeuvre applied to the spine to increase either the regional or segmental range of motion and can
be subdivided into joint adjustment and joint mobilization (Byfield 1991). Joint manipulation has
been defined in two ways: a skilled passive movement to a joint or spinal segment either within or
beyond its active range of motion, or any manual operation or manoeuvre, specifically a skilled
therapeutic use of a passive movement designed to restore motion (Byfield 2005).
All manipulative procedures employ a high or low-velocity thrust of variable amplitude applied
through a long or short lever. High-velocity techniques may be referred to as an
adjustment/manipulation and all low-velocity techniques as mobilizations (Peterson & Bergmann
2010). High-velocity techniques which incorporate a dynamic thrust are characteristic of a
chiropractic adjustment/manipulation. Mobilizations are low-velocity, repetitive oscillations whereas
adjustments comprise a single, high-velocity graded amplitude thrust. Mobilization is a slower
technique in which the joint remains within its passive range under the control of the patient, whereas
manipulation is a faster technique which goes beyond the passive range without patient control.
The term spinal manipulative therapy has gained popularity to represent all manipulative
techniques applied to vertebral and non-vertebral articulations. It includes a very general and broad-
based definition which includes all procedures used to mobilize, adjust, massage and stimulate the
spine and paraspinal tissues. Mobilization was defined as a form of non-thrust manipulation within
the physiological passive range of joint motion, whereas adjustment is a carefully regulated thrust or
force manipulation delivered at the end of the passive range of joint motion (Byfield 2005).
From an historical perspective, Sandoz (1976) proposed a more precise definition of a spinal or
joint adjustment and expanded to include manipulation as a skilled passive manual manoeuvre during
which a synovial joint is suddenly carried beyond the normal physiological range of motion without
exceeding the boundaries of anatomical integrity (Cassidy et al. 1992). The dominant characteristic
is a thrust, which is a brief, sudden and carefully delivered impulsion given at the end of the normal
passive range of movement and often accompanied by a joint cracking noise or other physiological
responses.
It is the authors view that a great deal of emphasis is placed on the thrust, and more particularly
the cavitation event (cracking sound), despite recent research which suggests a physiological reflex
response can occur following a manipulative thrust without a cavitation (Herzog 1996). Under these
experimental conditions, it appeared that it was, in fact, the speed at which the manipulative thrust
was delivered that produced the reflex responses (EMG recordings), which did not seem to occur
with the cavitation. This suggests that the key manipulative psychomotor skills are the applied force
and the speed of thrust that predominate. If, in fact, manipulation is highly skill-driven, it may require
a clearer definition between spinal manipulative therapy (SMT) and spinal manipulative skill (SMS).
The former is the specific therapeutic type (high, low velocity) and the latter is the standard of
execution of the various psychomotor skills comprising the entire manipulative procedure. This, in
turn, may generate an alternative definition of SMT based on the complexity of various psychomotor
skills combined with the tissue type and biomechanical properties of the intended joint structures
(Triano 2003). The issue of cavitation and its therapeutic role needs to be put into perspective, as we
know that: (i) mobilization forces (low velocity) sometimes achieve cavitation; (ii) cavitation may
occur without movement into the paraphysiological space; (iii) high-velocity procedures may not
cavitate; and (iv) nerve function may or may not be altered by either a high-velocity (manipulation) or
low-velocity (mobilization) approach. This will be fully explored in Chapter 3. Under these
conditions the author proposes a new definition of spinal manipulation, which is based upon tissue
properties and their biomechanical response to mechanical loading and an appreciation of the
inherent complexity of the numerous psychomotor skills necessary to carry out a skilful procedure
(Byfield 2004, Triano 2003, Triano et al. 2004). Spinal manipulation by a revised definition is:

1. a bi-manual task involving high levels of sensorymotor coordination and significant training and
rehearsal (Triano 2003, Triano et al. 2004)
2. a complex set of learned psychotor movement patterns requiring years of training to develop a
level of consistency, competency and finesse to become masterful (Byfield 2004)
3. the controlled application of forces and moments in an effort to restore normal function, alter
tissue distribution and relieve local and/or referred (remote) symptoms (Triano 2003).

This definition is contemporary and developed in the light of the best available evidence, is
placed within a clinical context and matches the skill of the practitioner and the needs of the patient.
For the sake of clarity, the terms manipulation and adjustment will be considered to be the same
in terms of manual therapy, and used reciprocally throughout all chapters in this text. The common
denominator is the high-speed, low-amplitude dynamic impulse thrust delivered at a preloaded point
towards the end of the passive range of motion and tissue compliance.
Thrust technique
The thrust (or impulse) is the transmission of a controlled force very quickly through soft tissue and
through joint articulations using a combination of muscular power, posture and body weight. Speed is
one of the key psychomotor skills characteristic of the manipulative thrust (Herzog 1996, 2000,
Herzog et al. 1999). This is delivered towards the end of the passive range of motion, the limit of the
elastic properties (elastic zone) of the joint capsule and surrounding soft tissue elements, the elastic
barrier or the point of tissue tension. The speed at which the thrust force is delivered to the body,
with controlled force may be responsible for the reflex responses seen clinically and experimentally
(Herzog et al. 1999). Notwithstanding, neurophysiological afferentation could be more important than
the biomechanical effect of the manual thrust. Nevertheless, the thrust does not challenge or exceed
the anatomical integrity of the joint causing injury. This reflects the controlled amplitude or depth of
thrust which, by virtue of the skill, protects the tissues and joints. This particular skill is an art form
of refined balance and accuracy, and a great deal of practice is required to acquire the necessary
neuromuscular reflexes and competence to control and master it.
Manipulative or adjustive procedures are typically applied at the elastic resistance of a joint
which typically is the end of the passive range of motion. Movement beyond this point has been
recorded in the 35 mm range during axial distraction and cavitation of the
carpometacarpophalangeal joint (Sandoz 1976). These are extremely small distances, indicating that
the actual depth required for a physical change in joint mobility is indeed minute. Furthermore, it
could be argued that most of the forces and movement occurring during a manipulative procedure are
being dissipated into the surrounding tissues and joints (Herzog et al. 2001). Most studies to date
have measured predominantly global force (Herzog 2000, Herzog et al. 1993, 1999), however
Herzog et al. (2001) found that the effective loading at the target site was much smaller, which vastly
overestimates the local forces transmitted at the target site. Even though this is a limited study, it does
demonstrate that most of the forces applied by the clinician do not reach the intended target site and
are dissipated throughout local soft tissues, which may give rise to stimulation of a range of receptors
potentially enhancing the pain modulating effects of the manipulation/adjustment itself. Herzog et al.
(2001) also found that the manipulators point of contact on the skin moved an average of 10 mm
during the course of the manipulation, suggesting that peak forces transmitted are substantially less
over the target point than originally anticipated. This may further support the reflex
neurophysiological effects and safety of spinal manipulation.
Joint tension concepts
In addition to accomplishing control of the speed, force and depth components of the thrust, the
student must initially learn to appreciate the proprioceptive concept of joint or tissue prestress or
preload (Herzog 1996, 2000, Herzog et al. 1993) or the moment of joint locking tolerance (Schafer
& Faye 1989). This concept has also been referred to as preadjustive tension (Haas, 1990),
prethrust (Schafer & Faye, 1989), tension-set (Maigne 1985), or simply the joint tension. The
author prefers the term preload, which reflects controlled force application and tissue deformation
(Herzog 2000, McCarthy et al. 2002).
Preload is regarded as the application of pre-manipulative thrust load, which is perceived as a
feeling of a gradual development of the point of maximum physiological resistance of the joint-
holding elements of the targeted joint(s). The preload force is established just prior to the application
of the high-velocity thrust. This tissue feel is equally important during non-thrust mobilization
procedures. It is an appreciation of the amount and quality of stretch or tension during movement of a
muscle or joint (Grice et al. 1985). Joint tension has also been associated with a process of taking
up the slack during movement through both active and passive ranges of motion. Practice and
experience allow the operator to accurately gauge the amount of force that can be safely applied to
any tissue type or patient presentation. The tissue tension sense also permits the operator to identify
the point at which the thrust should be applied. This skill determines the amount of peak thrust force
(Herzog, 2000). Therefore, a student must learn to appreciate the concept of control and balance
before thrusting skills are introduced, as the technology to quantify these skills is yet to be fully
developed. In the meantime, to do otherwise may contribute to poor skill development and
performance. Learning to appreciate the viscoelastic properties of a joint requires solid core
functional and biomechanical knowledge of joint kinematics, motion segment morphology and the type
and nature of surrounding holding elements. Tissue tension sense helps the manipulator to prepare and
coordinate each component of the adjustive procedure into purposeful smooth rhythm. The contact
between the practitioner and the patient is a physical one that is sensitive to the pressure of the
practitioners hands. Patient compliance and relaxation are vital components for effective patient
management. Developing a refined tissue tension sense will at least guarantee that a minimum of force
will be applied which benefits all concerned, particularly the patient who should expect skilful
clinical interventions made as a result of appropriate decisions.
Objective feedback
The need for objective systems of measuring the performance of chiropractic psychomotor skills
during undergraduate training is becoming more apparent. This is of particular importance with
respect to the depth and speed of the dynamic thrust. Byfield et al. (1995) have shown that it is
possible to quantitatively measure the forces and displacement occurring during simulated joint play
palpation, which may provide valuable feedback during the learning process. The use of such models
and high-speed video facilities to record and monitor skill performance may provide more helpful
educational feedback systems. This work is ongoing, particularly at the undergraduate level where
researchers are investigating skill acquisition on a number of fronts including those associated with
palpation and manipulation (Byfield et al. 1995, Chandhok & Bagust 2002, Triano 2000, Triano et al.
2002, 2003). In particular, Chandhok and Bagust (2002) have demonstrated that the tactile acuity of
students in the later years of a chiropractic programme is greater than that of those students starting
the course, which is consistent with skill development and acquisition.
General considerations of the thrust technique
Characteristics, localization, direction, speed and modifying factors
The high-velocity thrust is only one aspect of the overall adjustive procedure. It is the skill that is
applied only after a series of practitioner and patient preparatory steps have been performed. A
combination of patient relaxation and posture should produce minimal thrust force. Absolute
concentration and attention to the learning task are mandatory. Even though the biomechanical and
neurological effects of manipulation are still largely unclear, there is a body of evidence accumulating
that documents the deleterious effects of spinal manipulative therapy as a result of inadequate skills
and poor technique selection. It is the responsibility of the practitioner to apply the appropriate
manipulative skill or technique at the most appropriate time. Not all patients either require or
respond favourably to high-velocity thrust manipulation. This is an important clinical issue within
the chiropractic community. For example, it has recently been shown that cervical spine manipulation
and mobilization may yield comparable clinical outcomes (Hurwitz et al. 2002). This study also
reported that benign mild adverse reactions are more likely to be reported following cervical spine
manipulation than mobilization (Hurwitz et al., 2004). This has significant educational and clinical
impact as it can be concluded that chiropractors may reduce iatrogenic reactions and at the same time
increase satisfaction and possibly clinical outcomes by incorporating mobilizing rather than
manipulating patients presenting with neck pain. These issues will be discussed in more detail in
Chapter 11 dealing with cervical spine manipulative/adjustive skills.
The speed, direction and force of a thrust are all specific and gaugeable characteristics that are
determined by the clinicians skill matched with the patients needs. The anatomical nature, position
and kinematic behaviour of the dysfunctional joint are significant determining factors. Another
characteristic of the thrust is its versatility. The thrust is introduced on a therapeutic basis throughout
the entire spine and pelvic girdle, and, just as effectively, in the treatment of dysfunction of the
extremities. Above all the most unique characteristics of the thrust are its speed and control of force
application for the intended pain modulation and functional improvement. It has been shown that
cavitation occurs with greater consistency, at a faster rate and with less force when a manipulative
thrust is applied at joint tension when compared to introducing a steady and gradually increasing
force (Conway et al. 1992).
High-velocity procedures are very close to physiological reaction times (Triano 1992, 2000). A
patients muscular response can modify the applied manipulative load, suggesting that a technically
slow manipulation will require more force to overcome the patients muscular reaction. It may be that
a high velocity manual thrust which is faster than normal reaction time is not compressing the tissues
for a long enough period to cause sufficient damage and a nociceptive response. A skilled
manipulative thrust lies within the protective physiological barrier of the joint (elastic barrier) as a
direct consequence of the controlled depth or amplitude required. It should also be pointed out that
the viscoelasticity of tissues is non-linear under load and the joint-stabilizing tissue becomes much
stiffer towards the end of the elastic zone (elastic barrier) which inherently protects the sensitive joint
structures during a manipulative procedure. This is discussed in detail in Chapter 3 dealing with the
biomechanical principles related to manipulative skills.
The duration and quickness of the thrust do not act independently (Haas 1990). A relatively
large-velocity or slow-impulse thrust will increase the depth and over-distend local tissue (Haas
1990). That brief, sharp pain occasionally reported by patients following a dynamic thrust may be
stimulating the rapidly conducting myelinated A-fibres, but not at a threshold sufficient to trigger the
unmyelinated C-fibre system responsible for deep, dull somatic pain. The brisk nature of the thrust
may cause a rapid contraction of the local muscles followed by a long, slow relaxation recovery
period, which could suggest reflex inhibition through activation and modulation by descending fibres.
This could be responsible for the immediate and observable changes in local tissue tone, pain
appreciation and increase in range of motion. Therefore, the dynamic impulse thrust has many built-in
safety features including rapid speed, low amplitude and reasonable localization. A more in-depth
analysis of these phenomena associated with spinal manipulative therapy can be found in the work of
Herzog and colleagues, which investigates electromyographic responses of the back and limb muscles
(Herzog et al. 1999). This is particularly relevant to this section of the chapter as the speed of thrust
and the force applied are significant (Herzog 1996, 2000).
The clinical objective is to minimize the effects of the mechanical load on sensitive joint
structures. Forces of between 20 and 100 N applied over the L3 spinous process during posterior
anterior mobilization have been shown to cause movement in the whole lumbar and lower thoracic
spine, indicating that these manual movements do not cause a local response (Lee & Svensson 1993).
Static loading caused less displacement than cyclic application. Triano (2000) describes this effect
from a tissue response perspective in his chapter Clinical Biomechanics of Spinal Manipulation,
which is essential reading. As educators and clinicians we have to view joint specificity in a full
biomechanical context and not just in terms of the effects on the bony contact.
Careful positioning of both patient and practitioner should increase the likelihood that the
direction of the thrust will:

1. be directed towards the intersegmental facets or spinal region


2. be in the direction of the loss of joint play/end play
3. be in the direction of the loss of active movement
4. be in the direction of pain-free movement
5. be in a direction which stretches the holding elements at the greatest point of resistance
6. stimulate the appropriate mechanoceptors for appropriate afferentation and pain control.
Amount of force application
Individual factors
The final stage of the manipulation or adjustment is the introduction of the dynamic thrust. There are
several factors which determine the amount of force to apply to the patient: age, sex, general health,
specific symptom presentation, stiffness, chronicity, patient compliance, manipulative position, size
of the patient and practitioner experience are only a few of the general modulating variables. It could
be argued that the skill of a therapist is inversely proportional to the amount of force utilized and the
majority of the clinical skill is in the preparation of the patient and the position of the
practitioner. Under these circumstances the amount of therapeutic force is reduced as there is very
little load applied to the patient during these preparatory steps.

Patient position
The amount of thrust force applied is also significantly influenced by the various patient positions.
The ability to control and stabilize patient movement is indirectly proportional to the energy used and
the applied thrust force skill. Non-weightbearing postures that naturally reduce muscular tension are
optimal. The side-posture technique displays less control and, consequently, more force overall, but
the long levers enable the practitioner/clinician to localize the point of counter-rotation (transition
point) in the lumbar spine. Consequently, more skills are incorporated during this procedure. The
prone position affords total patient control, but achieving adequate joint tension is more difficult,
potentially elevating preload forces and compromising specificity. Using the head as a lever in the
prone position for upper thoracic dysfunction improves the situation, but this significantly increases
leverage across a number of sensitive structures that may contribute to post-treatment reactions. Joint
tension in the thoracic spine in the supine position is accomplished mainly by trunk flexion; however,
patient control is marginal and large amounts of the thrust force are dissipated through the rib cage.
Supine cervical manipulation with head support has a high degree of control, specificity and low-
force thrust. It is crucial to minimize forces in the cervical spine for a number of clinical reasons,
many of which have been described in this chapter and later in Chapter 11.
Sitting and standing postures are naturally more difficult because of the potential lack of patient
control due to gravity which increases energy used, forces applied and possibly depth of thrust. These
are essentially secondary postures that are incorporated under specific clinical conditions requiring
additional skills. Nevertheless, a good clinician should develop skill to perform a variety of
manipulative procedures competently in several postures to meet the demands of the patient under a
number of clinical circumstances. Clinicians should also be realistic with respect to their own
abilities, strength and size. An experienced practitioner does develop bilateral dexterity, skill and
equality of thrust application with practice over time. This is an essential characteristic for consistent
and controlled thrust application. Moreover, it has been recently shown that a gender difference does
in fact not exist, as female chiropractors produce, from a mechanical point of view, similar manual
treatment as their male counterparts, at least in the thoracic spine, during posterior to anterior
manipulative procedures (Forand et al. 2004). This dispels the myth that female chiropractors are
unable to generate enough preload and peak forces in comparison to male practitioners, at least for
the thoracic spine. Side posture force comparison has yet to be investigated.

Anatomical lever
The choice of anatomical short-lever point at the practitionerpatient interface strongly influences the
amount of force the patient receives. Short levers provide some regional specificity, but their use
requires greater skill. Long-lever manipulation is considerably easier for the practitioner, but features
a lack of overall patient control and subsequent safety. The spinous and transverse processes, and the
posterior superior iliac spine are the most common contact points, yet laminar, mamillary, mastoid
and ischial contacts are frequently used as well as a multitude of extremity contact points. The
spinous process is probably the most ideal in terms of specificity compared to the mamillary and
transverse contacts. The combination of a pisiform/hypothenar contact on a mamillary process in the
lumbar spine equates to a greater amount of manipulative force dissipated compared to a fingertip
contact on the spinous process for the same clinical outcome. The ischial tuberosity is a common yet
poor contact point because of its size and the amount of overlying muscular tissue, requiring
considerable strength and force to achieve mechanical leverage of the sacroiliac joint. The broader
hand contact over the patient dissipates force over a larger area, needlessly involving otherwise
normal joints and soft tissues. This is not clinically advantageous when specificity is required,
however this may provide a certain inherent degree of safety for the patient. A degree of pressure is
maintained at the contact point to secure accuracy of thrust. This pressure should be minimal. The size
of the patient and the amount of subcutaneous fat also influence the choice of anatomical landmark. In
many cases specificity would have to be moderated at the expense of patient comfort.

Postural stance
Posture and balance will be addressed throughout this text as important skill parameters when
learning manipulative skills. Both patient and practitioner considerations will be presented in the
individual chapters. The use and position of the practitioners body weight, relative to the patient and
the gravity line, should reduce the amount of muscular effort and subsequently decrease the overall
forces applied to the patient. In the long term this should have beneficial effects in terms of less
mechanical stress on the practitioner and increased therapeutic compliance by the patient. Postural
balance is significantly improved when the feet are positioned about hip distance apart. This is a
recommended stance posture that will be presented in more detail during the skills section of this
chapter and relevant subsequent chapters.
Students will begin to learn that safe and effective manipulative procedures are accomplished by
applying slow and gentle forces with skilfully controlled amplitude. A common learning error
encountered by students is their preoccupation with attempting to contact the periosteum of the
pisiform with the periosteum of a transverse process or other anatomical lever.
Summary
The exercises and movements contained in this chapter and related video clips are designed to help
develop efficient dynamic adjustive/manipulative thrusting skills. Consideration should also be given
to the individual muscles that are primarily involved in each thrust skill, plus their relationship to full
body coordination. Active visualization of each muscle group and its action will help to facilitate
both learning and execution of the particular skill. Of primary importance in the upper body are the
triceps, pectoralis major and minor, biceps, anterior deltoid, serratus anterior, hip flexors and the
quadraceps of the lower extremity. This reinforces the full body effort necessary in delivering a
manipulative thrust. Therefore, knowing the origin and insertion, and understanding the action of these
muscles may assist the learning process. These specific muscle groups are very strong and capable of
accelerating body parts at great speed, causing high impact velocities. The thrust skills should be
introduced immediately as an essential part of the undergraduate psychomotor motor skills training.
Educational relevance
One may argue that developing thrusting skills without clinical relevance yields little benefit at the
preclinical level and may reinforce the notion that manipulative thrust has only one speed and one
depth. This may be the case, but by ranking the importance of these skills as part of a much larger
picture and by providing a rationale and clinical perspective, the credibility of these methods may be
enhanced. Demonstrating how and when these thrusting skills are actually applied and learning to
perform them in various real clinical postures may be laudable. Please refer to Chapter 2 in this text
by Professor Kim Humphreys (The learning and performance of chiropractic manipulative skills) for
thoughts and comment regarding clinical frameworking and the importance of a clinical context in
educational delivery. In addition, emphasizing the specific thrust skills at the same time as the
individual adjustments are being demonstrated may also be of value in the learning experience.
Practising active visualization of the individual tasks may also be of considerable benefit during
simulated skill acquisition. The process should introduce the student to the proprioceptive balance
and body weight control that will be required.
The primary objective is to learn to contract and isolate specific muscle groups while
maintaining core stability. The next objective is to learn to contract them very quickly against
resistance, and the last step is to gauge the depth of contraction in a simulated fashion. The muscular
power, overall postural control and stability of the body dictate the speed and depth of a manipulative
thrust. Speed is attained by practice. The student must realize that the amount of force actually
necessary to cavitate or overcome the elastic barrier is extremely small and that reflex responses
occur when tissue receptors are rapidly deformed whether you achieve cavitation or not (Herzog
1996). This is an important consideration, which was presented in some detail in the Introduction to
this text and earlier in this chapter. A number of these issues are also addressed in Chapter 2
concerning the educational and learning aspects of manipulative psychomotor skills.
Each of the following skills is to be practised daily, concentrating on isolating and contracting
the individual muscle first, depth second and speed last. To maximize each practice session, it
would be advisable to warm up the major muscle groups using light exercise and slow dynamic-
stretch techniques simulating the desired activity. Preparing muscle groups for explosive work is
advisable to reduce injuries. It is also recommended that students balance their upper body strength
and flexibility to develop bilateral dexterity and ensure that an equal force is applied with either the
left or right hand. A swimming programme complemented with light weights would be of great
benefit. A comprehensive fitness programme would be an advantage to all students improving
cardiovascular fitness, strength, flexibility and core stability to prevent injuries. The impact of
exercise on general health needs to be emphasized.
In addition, the practitioners posture is an important element during the learning and acquisition
of these thrust skills. The position of the centre of gravity and the alignment of body weight are major
contributions to enhance efficiency. Even though this is mainly carried out through simulation, it is
important that the exercises recreate the clinical context as closely as possible. Furthermore,
understanding that an efficient manual thrust is a total body commitment is an important consideration.
A keen sense of body position and awareness is an additional key factor. The importance of overall
good posture not only reduces mechanical overload, but also maximizes the efficiency and benefits of
the manipulative procedure.
This chapter presents an extensive series of common high-velocity, low-amplitude thrust skills.
Individual skills should be learned for each set of muscle groups responsible for a particular thrust
type. They should be practised in a variety of postures as the required skills are considered specific
for a certain movement pattern
Ski stance fencer or lunge stance
It is recommended that the following postural skills be learned as a basic first level skill prior to the
thrusting skills presented later in the chapter. The optimal starting position is similar to the ski stance
then turning to an angled 45 stance with the majority of the body weight supported by the front leg,
which adds symmetry and minimizes mechanical loading in the upper back and lumbopelvic regions.
This has been referred to as the fencer or lunge stance position (Byfield & Kinsinger 2002)(Figs.
6.1a - 6.4). The author prefers the fencer stance position as the standard. This position permits the
practitioner to lean over the patient, providing more efficient use of the arms and upper body weight
and helps to centre the upper torso for better weight distribution. The clinician can incorporate
valuable visual cues and it also prepares the lower body for an efficient drop thrust. Both the ski and
fencer stances are used exclusively during the delivery of chiropractic manual skills and for that
matter during the performance of many diagnostic examination procedures. Each stance should be
adopted with a neutral lumbar lordosis or slightly flexed lordosis with an abdominal brace to
stabilize the lumbopelvic region during the performance of these skills. Refer to Chapter 5 of this text
for further details regarding these stabilizing postures.
Figure 6.1A
Figure 6.1B
Figure 6.2A

Figure 6.2B
Figure 6.3
Figure 6.4
Ski stance to fencer stance (45 pivot shift)
This is a movement pattern that will be repeated thousands of times during the course of a clinical
career. It is a very simple yet effective movement for shifting and positioning body weight for many of
the side and prone posture adjustive procedures. Practise in both directions, developing
symmetrical movement patterns is essential. Next repeat the same movement patterns standing next
to a chiropractic table.
Practise this movement skill on a regular basis to become comfortable with the ease of
movement and the small amount of movement actually required during the turning process. Perform
the movement slowly and deliberately. It does appear easy but it has to be performed automatically
when subsequent skills are introduced. Leaning against the side of the table supports some of the body
weight but still allows flexibility for clinician movement and body drop thrust. Maintaining the
correct distance between the feet ensures that the practitioner is dynamic and in control of the patient
throughout the entire procedure. The student must get used to touching the side of the bench with the
legs. The feet should be placed slightly under the table so approximately one-third of the foot is
hidden by the edge of the table when looking down towards the floor (Fig. 6.3).
This posture and set of movement skills are integral and fundamental parts of the following thrust
skills. Before introduction to the thrust skills it is advisable that the ski and fencer stance movement
sequence is firmly set and reproducible. Learning the thrust skills in a common stance provides some
clinical relevance and enhances the learning and acquisition of these complex skills. The following
sequence of skills outlines the ski and fencer stance postures (Figs. 6.1 - 6.5).

1) Stand with the feet hip distance apart (about 1518 cm inside foot distance) and the knees bent
with the centre of the knee joint directly over the transverse metatarsal arch of each foot. The trunk
is inclined slightly with the head looking down and focusing on a point just ahead of the feet. This
is the ski stance (Fig. 6.1A). The shoulders and arms are relaxed and the majority of the body
weight is over the metatarsal joints. There should be a degree of spring in the practitioners legs.
The arms are held comfortably in front or behind the back. The body weight should be forward
over the forefoot and the lumbar lordosis should be neutral or slightly flexed (see Chapter 5 for
more details) with an abdominal brace/tuck to ensure stability in this posture and good skill
acquisition (Fig. 6.1B). The neutral or slightly flexed posture must be adopted for all manipulative
postures, particularly for the ski and fencer stances and their modifications. The pelvis must be
tilted forward and backwards through a full range and then fixed at the neutral point in the range
with an abdominal brace contraction to ensure core stability.
2) Push up on the metatarsal pads and slowly shift or twist 45 in either direction maintaining original
posture. The shoulders, hips, knees and feet are all facing 45 from the coronal plane of the body.
The movement associated with the pivot shift is minimal and should not be exaggerated. Pivot is
complete, plantar flex the rear foot of the trailing leg. This effectively pushes the body weight over
the front leg maintaining the neutral lordosis and abdominal brace (Fig. 6.2A). The front leg should
be springy, absorbing most of the body weight. The front foot is not completely flat as the weight is
borne mainly over the metatarsals. The effect is to transfer the body weight over the front leg to
simulate leaning over a patient. Figure 6.2B illustrates a good fencer stance with weight forward
over front foot, both knees slightly flexed and pushed forward by plantar flexing the rear foot
placing the body weight forward over the front leg to balance weight and maintain efficient
posture.
1) Now stand perpendicular to the table with the feet under the edge of the table but still in view from
just behind the metatarsal heads and the knees just away from the edge so that when the knees are
flexed the patellae just touch the edge of the table(Fig. 6.3). When looking down approximately
one-third of the feet are hidden under the table. Standing too far away from the table positions the
centre of gravity too far away from the patient, which will reduce the efficiency of the manipulative
procedure. The student must become comfortable and learn to stand very close to the table to
stabilize the patients weight and ensure safe positioning.
2) Pivot shift 45 to the left or right into a fencer stance posture by twisting on the metatarsal pads
(Figure 6.4). Keep shoulders, hips, knees, and feet at 45 to the table. Notice how this posture
brings the trunk and body weight over the table. The legs are just in contact with the table and the
front knee is just in contact with the lateral edge of the cushion of the table. Practise leaning against
the table to learn to feel the table close to the legs. This ensures proper weight positioning as a
result of plantar flexing the rear foot to bring the weight over the table. The rear leg (femur) must
be perpendicular to the floor.
3) The most common error encountered is adopting a very wide foot stance and an angle of greater
than 45 to the table (Fig. 6.5). This position affords little or no spring to the legs and body drop
techniques are difficult to perform from it. The trunk weight is also positioned too far back instead
of over the front leg. The wide foot posture does not permit the thigh sandwich skills for lever
control described in Chapters 5, 8 and 9.
Figure 6.5
Thrust skills
Triceps flick (unilateral)
This is the most basic of the upper extremity manipulative thrust skills (Figs. 6.6 - 6.8). It is meant to
isolate the triceps extensor group which is recruited in many of the common chiropractic manipulative
procedures including, most notably, the toggle recoil. It is also an entry level thrusting exercise for the
student to appreciate the whole concept of the manipulative thrust and muscle group contraction to
generate force. The triceps thrust can be used by itself or as part of an overall shoulder/arm thrust
through a hand contact. The objective of this introductory exercise is to isolate and contract the
triceps equally on left and right sides. Initially, concentrate and visualize isolation of the triceps only
and the desired movement. To increase the explosive nature of the skill, it may be effective for the
student to expel a small amount of air through either the mouth or the nostrils during triceps
contraction. This is the essence of the impulse thrust as described by Schafer and Faye (1989) as
coming from the diaphragm when coughing or spitting. This is only a brief expulsion of air
simultaneously with the muscle contraction. The expulsion of air is a skill itself and does assist speed
and concentration.
Figure 6.6
Figure 6.7
Figure 6.8

The triceps flick represents the most basic manipulative reflex thrust. It should be practiced
bilaterally for a period of time and in various postures until moving on to more advanced movements.
The ability to isolate this muscle group is an important step. Attention should also be given to
establishing good and effective posture. This is the time during which postural patterns are
reinforced. Initially, there may be an awkward feeling; however, with time the patterns will begin to
feel more natural. It is recommended that these skills be practised in both the ski and fencer stances to
simulate a clinical environment.

1) The practitioner stands with feet hip distance apart with slight flexion at both the hip and knee
joints (ski stance with neutral lordosis). The trunk is flexed forward about 20 with the right arm
hanging loosely out in front with the natural bend at the elbow. The head is slightly flexed forward.
The left arm is held behind the back (Fig. 6.6). The entire upper body is relaxed with most of the
body weight balanced over the centre of the knees. There is no excess tension in the arm, shoulder
or upper back region.
2) Contract the triceps slowly to cause extension of the forearm at the elbow only. The forearm should
swing like a pendulum. The upper arm, shoulder and the entire upper body including the head and
trunk remain completely still and relaxed (*) (Fig. 6.7). Repeat the contraction with a rest in
between. Do not lift the forearm or hand prior to contracting the triceps or forcefully hyperextend
the elbow or push the arm through the entire extension phase. After each contraction the forearm
should rebound or recoil in a bouncing fashion. The clinician expels a small amount of air through
the mouth prior to each thrust. Ensure that there is sufficient time between contractions for adequate
recovery. Contraction should be sharp creating a flicking action with an elastic rebound but no
rigid, stiff movements, which may indicate hyperextension action.
3) Repeat with the left arm and then with both arms simultaneously as per above (Fig. 6.8). The
practitioners posture should be relaxed at all times in the ski stance. There should be no tension in
the upper body during this skill. Ensure that the contraction does not cause a stiff hyperextension of
the elbows, which places considerable stress on the joints and transmits increased forces to the
joints. Keep a neutral lordosis and a relaxed upper body.
Double triceps flick (preliminary toggle recoil)
This skill should be practised in the same manner as the single triceps flick (Figs 6.9a - 6.10).
Practise slowly and methodically (Do not attempt to see how many contractions you can perform in
60 seconds!). The Guinness Book of World Records is not interested! Control each contraction,
concentrate, feel what is happening, check your posture (neutral/slightly flexed lordosis), including
bent knees and head position over the hands, and expel air through the mouth/nostrils. The key is to
take your time and to practise regularly. A few minutes at regular intervals until the skill is performed
efficiently is recommended. Intermittently or only during class time is not adequate to reinforce the
movement patterns. Many experienced chiropractors warm-up before they begin treating patients on a
daily basis and perform flexibility exercises as well as thrusting exercises to stimulate the reflex
movement patterns they will be using all day. Practise the skills in both the ski and fencer stance to
develop symmetry and variety. This is a form of dynamic stretching or movement simulation that is
seen in athletes preparing for a jump or a run.

1) Begin in the ski stance with both arms hanging freely with the thumbs interlaced. The hands are
positioned just below the suprasternal notch. The stance is relaxed at all times with the body
weight positioned over the metatarsal pads, upper trunk weight slightly forward and the shoulders
relaxed (Fig. 6.9A). The knees are bent with a certain amount of natural spring for body flexibility
and relaxation. Maintain a neutral lumbar lordosis with abdominal brace throughout this procedure.
Upper body relaxation and flexible spring in the lower legs are more efficient. Avoid flexing the
lumbar spine and thus placing passive end range stress on the sensitive structures (Fig. 6.9B).
2) Contract both triceps simultaneously in a slow and controlled fashion initially. There will be some
contraction of the pectoralis to assist. Expel air during each thrust contraction; do not lock out the
elbows and do not push the arms. The resultant action is a rebound or recoiling of the hands which
is the result of the natural elastic properties of the tissue. The hands and arms should bounce up and
down or recoil after each contraction (Fig. 6.10). There should be no stress placed upon the elbow
joint. The recoil is not an active or voluntary action. The head, trunk and upper arms are stable
during this exercise (*).
1) The arms are held close to the side of the body with the elbows flexed and positioned at 90. The
wrists are completely relaxed in a natural ulna-deviated posture. The practitioner is standing in a
ski stance posture with the suprasternal notch positioned over the hands (Fig. 6.11). There should
be spring in both hands and legs but the head and upper body should be completely relaxed and
motionless. The upper torso is positioned over the hands for thrust efficiency and there is a neutral
lordosis to maintain lumbar stability.
2) The wrists only are flicked rapidly into ulnar deviation by contraction of the flexor carpi ulnaris
alone from a neutral, relaxed posture. The body is totally relaxed especially the head and
shoulders. The trunk is also totally immobile (*). The position of the arms does not change. The
clinician expels a small amount of air during each contraction. This particular skill is important
during controlled rotary manipulation of the cervical spine. Perform the skill in the sitting posture
to increase stability and simulate a clinical situation (Fig. 6.12). Start very slowly and then
increase the speed gradually. Try to flick one wrist at a time followed by the two. Keep the head
over the hands at all times and the arms tucked in close to the body. Add a small forward
movement of one arm while flicking the wrists to simulate a rotary cervical manipulative
procedure.
Figure 6.9A

Figure 6.9B
Figure 6.10
Wrist flick (unilateral and bilateral)
The wrist flick is an important skill to learn and adapt as this represents the preferred skill for the
cervical spine manipulation (Figs. 6.11 & 6.12 shown on previous page). This has important
implications in terms of patient safety and post-treatment reactions. Learning to control head and neck
movement is paramount in developing fine psychomotor skills for the cervical spine.
Figure 6.11
Figure 6.12

This skill should be performed in a low crouched ski or fencer stance and should be practised
on both sides to develop symmetrical movement patterns. One of the key elements when learning this
skill is to keep the hands and wrists fully relaxed. Any tension in the arms or upper body will only
detract from the essence of the skill. Please refer to Chapter 11 for further details regarding the
clinical implications and safety regarding manipulation of the cervical spine.
Pectoralis thrust
A dynamic thrust of the pectoralis major muscle is incorporated into many manipulative procedures of
the spine and pelvis (Figs. 6.13 & 6.14). Its anatomical position as an integral part of the shoulder
girdle and its function, which includes adduction and flexion of the arm, provides an excellent lever
for a dynamic thrust. Many of the more common manipulative procedures thrust towards or across the
body with the arm in a position of flexion (e.g. the lumbar roll). For this reason it is vitally important
to learn to isolate and strengthen this muscle group, including both sternal and clavicular sections.
Start the exercise slowly to feel the isolation of the muscle group and then gradually increase the
speed and intensity. Do not rush or push this activity. The objective is to learn to contract each
pectoralis group individually and then simultaneously. The skills are to be learned in both the ski and
fencer stances to simulate clinical postures.

1) The practitioner is positioned in the ski stance. The arms are held out and flexed in front of the
body and interlaced at the elbows with the web of each hand (Fig. 6.13). The contact at the elbow
is extremely light but rapid. The arms are in a relaxed state, weight is borne on springy knees and
the trunk is totally stable and positioned in a neutral lordosis.
2) Rapidly adduct one pectoralis/arm first followed by the second after a small refractory period
(clavicular head). The head and trunk are completely motionless and stable (*). The movement will
be limited by isometric contraction of the opposite side. Do not pull back and push. As the ability
to isolate one muscle group improves, increase the speed and force gradually. Expel a small
amount of air with each contraction. Rest between each contraction. Use the breath cycle to gauge
the next thrust. Concentrate during the exercise and visualize each muscle group contracting.
Perform these in both the ski and fence stance postures with a stable neutral lordosis and brace for
efficient execution with the arms parallel to the floor. It may be useful to develop this specific
speed and strength using a pec deck apparatus common to most fitness studios. Performing push-
ups would also assist this development.
Figure 6.13
Figure 6.14

Adduct each arm individually, contracting the sternal head of the pectoralis major only in a
more neutral position (Fig. 6.14). The head and trunk remain completely motionless (*). Expel air
and concentrate on the motor action. Start slowly and increase both speed and force of contraction.
Do not pull back and push, causing a hitting or slapping effect. The effect is a short, sharp and crisp
thrust. The arms are perpendicular to the floor with the trunk flexed over the arms to shorten the
levers and compact the thrust procedures. Neutral lordosis and bracing are also included to
stabilize the practitioner.
Shoulder/arm pull thrust
This is a variation of the pectoralis thrust but is performed in the opposite direction (Figs. 6.15 -
6.17). It is incorporated in a variety of manipulative procedures of the extremities and manipulations
of both the cervical and lumbar spine, requiring a pulling-type action during the thrust. The muscles
used are primarily the shoulder extensors and abductors, namely the latissimus dorsi, teres major,
deltoid, triceps (long head) and supraspinatous. Broome (2000) describes a variation of this thrust.
This particular technique is used exclusively for extremity manipulation and controls thrust amplitude
via retraction of the scapulae via simultaneous contraction of the rhomboids to preload the target joint
thereby reducing thrust amplitude.

1) Start in the ski stance. Cross the arms close to the chest wall with the shoulders relaxed. The hands
are closed in a loose fist (Fig. 6.15) with the body relaxed but spring in the legs and arms. The
head and trunk are motionless.
2) Rapidly abduct and extend the arms individually and then simultaneously (Fig. 6.16A). Expel air
during each thrust to focus the energy (*). The arms are kept tight into the side of the chest wall
during the contraction. The distance is very small. A clean, sharp, rapid contraction is the goal. An
alternative posture would be to clasp the thumb, place the arms against the side of the body, retract
the scapulae simultaneously by contracting the rhomboids and then rapidly separate the hand
contacts (Fig. 6.16B). Keep the arms close to the body, preloading with the rhomboids and
producing a sharp crisp thrust causing rapid extension of both arms simultaneously with controlled
amplitude (Fig. 6.16C). Ensure that the shoulders do not rise up and that the arms are kept close to
the side of the body (Fig. 6.16D). This procedure has been described in detail by Broome (2000)
as the short lever pull technique.
3) The straight pull thrust using shoulder extensors is a common variation. This thrusting technique is
employed for a number of manipulative procedures in side posture for the lumbar spine (Chapter
10). The arms are close to the side of the body with the elbows flexed to 90. The thrust is a rapid
extension of the shoulder extensors (Fig. 6.17). The head and trunk are motionless (*). This should
be performed standing with a neutral lordosis and abdominal brace to ensure lumbopelvic stability
during execution.
Figure 6.15
Figure 6.16A
Figure 6.16B

Figure 6.16C
Figure 6.16D
Figure 6.17
Shoulder/arm thrust
The shoulder/arm thrust is used in many of the prone and side posture manipulative procedures
(Peterson & Bergmann 2010). The force is generated by the shoulder girdle, down the arm across the
hand and transferred onto a relatively short anatomical lever (i.e. TP or SP (Figs 6.18 - 6.20)).
Typically this thrust on a clinical note is combined with a body drop skill to generate more force. One
of the commonest mistakes encountered with students is a pushing or driving effect. They also lift the
arm and hand prior to the thrust, resulting in a pile-driving/thumping action. Part of this exercise is to
learn to thrust from a neutral position to avoid these common errors. The transition from preload to
thrust in a clinical sense must be continuous and transparent without any interruption. This will be
discussed later in the chapter when newly acquired thrusting skill exercises are introduced against
resistance initially introduced to simulate a patient encounter. The ability to isolate and rapidly
depress the shoulder girdle via muscle contraction and weight distribution will be introduced first.
The muscles used for this action are primarily the latissimus dorsi, pectoralis major and the serratus
anterior.

1) The practitioner is in the 45 fencer stance with the right arm placed in front of the body. The right
hand adopts a firm chiropractic arch and is positioned in line with the jugular notch (note the
position of the plumbline (*) and with the fingers pointing towards the lead foot. The upper part of
the arm is adducted and held in closely to the chest wall to shorten the levers (Fig. 6.18). Do not
forcefully hyperextend the elbow; it is comfortably extended. The left leg supports the majority of
the practitioners weight. The shoulders are relaxed at 45, the trunk is slightly inclined forward
and the head is stable looking down at the right hand. Neutral lordosis and brace are incorporated
and plantar flexing the rear foot shifts the practitioners weight forward. Standard operating
protocol.
2) The shoulder is marginally raised (a few inches). Slowly depress the shoulder girdle the same
distance to gauge the distance and depth of thrust required (Fig. 6.19). The shoulder girdle is the
only structure contracting and moving while the practitioner is in the fencer stance with neutral
lordosis and upper body stabilization. The head, upper body and lower limbs are motionless (*).
Do not assist with a triceps contraction. Expel air through the diaphragm with each contraction.
Repeat after a brief rest between each contraction. The contraction should gradually become
sharper and crisper in nature during the practice session. Keep the rest of the body stable and
relaxed and keep some spring in the legs. Practise this skill on both sides of the body to ensure a
balanced effect.
3) A variation of this is the shoulder push thrust. The arms are held relaxed but snug against the
lateral aspect of the rib cage with the elbows at 90. The shoulder is elevated marginally and the
thrust is a rapid depression of the shoulder girdle produced mainly by the action of the pectoralis
minor and the serratus anterior (Fig. 6.20). Each arm is contracted individually with a simultaneous
rapid extension or drop of the forearm in a pushing fashion. The practitioner is in both the ski and
fencer stance with the head and pelvis stable (*). The key is to expel air and impulse rapidly while
maintaining standard postural protocols.
Figure 6.18
Figure 6.19
Figure 6.20
Body drop
The body drop technique is commonly used to increase the force and the efficiency of the
manipulative thrust (Figs. 6.21 & 6.22). It is often used during side posture and prone manipulative
procedures when there is a greater mass to overcome. The body drop increases the use of the trunk
weight in a controlled fashion and is a particularly good use of available levers to distribute the
overall workload and mechanical leverage. The body drop is usually incorporated with the shoulder
thrust, which is seldom used alone. The body drop requires control of the practitioners body weight
during a rapid and assisted delivery. The body drop is an important fundamental skill and is learned
in conjunction with other manipulative skills and is incorporated into a number of common
manipulative procedures to improve overall efficiency.
Figure 6.21
Figure 6.22

Begin the skill in the ski stance and pivot into the fencer stance posture. This helps to prepare the
clinician for the initial sequencing required during body weight shift, a basic movement for many of
the manipulative procedures described later in this book.

1) Start in the ski stance posture and pivot through 45 into the basic fencer or lunge stance position.
Slowly push the body weight forward by plantar flexing the back foot. This essentially raises the
centre of gravity slightly for the body drop (Fig. 6.21). Ensure that there is some spring in the front
leg, which can be measured by bouncing the weight over the front foot. Notice the position of the
plumbline, an indication of body weight alignment over the front knee and the metatarsals of the
foot. Standard postural protocols prevail with respect to lumbar spine stability.
2) Initially raise up and essentially straighten the front leg and let the body drop through the front
knee, slowly at first and then increase the speed to the point that the action is similar to a free body
fall or impulse drop (Fig. 6.22). The body is motionless apart from the vertical drop. The body
drop is a controlled movement. Control of the free fall is stopped by the braking action of the
quadriceps. The entire distance dropped is approximately 23 inches (57.5 cm) vertically. Repeat
with a short rest to appreciate the movement and appropriate feedback. Do not let the body and leg
bounce. This has to be a rapid drop/catch sequence to transfer the weight vertically. There should
be no movement in the upper body or head, both of which should be relaxed during the execution of
this skill.
Combination body drop and shoulder thrust
Both skills are combined to produce one action (Fig. 6.23). This should be attempted only after each
individual skill is performed with confidence and proficiency. Do not attempt to chew gum at the
same time! Many of the manipulative procedures incorporate a variety and combination of thrusting
skills depending upon the biomechanical indications and the needs and the size of the patient. This
scenario also depends upon the ability of the practitioner and their particular skill development. The
practitioner can increase the speed and force of the manipulative thrust by using the whole body as a
mechanical lever. The workload is distributed throughout the system, which places less strain on any
one of the individual anatomical structures. The body drop and the shoulder thrust constitute a
common method for this purpose.

1) Move from the ski to the fencer stance. Prepare the shoulder girdle and push the body weight
forward over the metatarsals of the front foot by plantar flexing the back foot as described in
Figure 6.18. Simultaneously and slowly engage a body drop and depress the shoulder girdle at the
same time, initially to feel the overall movement and then increase the speed gradually (Fig. 6.23).
Do not develop a pushing or pounding action with the shoulder. The body drop is to be a crisp,
short movement and not a floating action. The depth of the body drop and shoulder thrust are equal.
Expel air during each thrust movement.
Figure 6.23

2) The combination of body drop and shoulder pull and push variations can also be
introduced and practised at this stage. Keep the arms in tight against the rib cage and expel air
during each thrust, producing a rapid impulse type movement.
Other movement skills
Shoulder flexibility protraction/retraction
The ability to retract and protract the scapula actively and passively adds to the overall efficiency of
the shoulder girdle during the development of thrusting skills (Fig. 6.24). Flexible scapulothoracic
movement gives a cushioning effect that effectively reduces the potential rigidity of the shoulder/arm
thrust when combined with a torso or body drop. This makes for better force transmission across the
shoulder region and less stress on the upper back.

1) Stand in a ski stance with both arms hanging freely in front of the body clasped together by the
thumbs. Actively retract both scapulae while keeping the torso and head completely stable (*) (Fig.
6.24). Protract the scapulae slowly and eccentrically. The exercise is to actively isolate the
scapulothoracic/shoulder girdle movement. The shoulder girdles move around the torso, which is
commonly used to generate force during a number of common thrusting procedures via the shoulder
region.
Figure 6.24
Wrist supination/pronation
The ability to supinate and pronate both wrists and forearms simultaneously is a clinical asset,
particularly during skilful and safe manipulation of the cervical spine. The amount of rotation has to
be controlled, as well as other potential extreme ranges of motion. The cervical spine exhibits
considerable range of motion under normal conditions and this feature should not be abused during
therapeutic manipulation at the expense of achieving joint cavitation. Control of movement can be
accomplished by subjecting the head and neck to the short-lever action provided by the wrists only.
The following is a simulation exercise to develop the motor skills to control any excessive movement
of the cervical spine.

1) Stand in a low fencer stance, shoulders relaxed, elbows flexed at 90 and the arms tucked in close
to the side of the body in a neutral lumbar lordosis. Both wrists are relaxed, naturally ulnar
deviated and holding a small ball between the index finger and thumb. The ball represents the
patients head as illustrated in Figure 6.25. Simultaneously and slowly pronate and supinate the
wrists and forearms only, balancing the ball between the fingers. The pronated hand is the contact
and the supinated hand is the support hand usually cupping the occipital rim in a typical clinical
combination. The head, shoulders and arms remain completely stable and motionless during the
exercise (*). Repeat the motion in the opposite direction. Do not allow the arms to drift from the
body as this produces unwanted shoulder motion which effectively increases the size of levers
acting on the head. Practise this skill with the ball on the headpiece of the table once the
pattern is learned. Do not lift the ball; move the ball while the hands are still in contact with the
table.
Figure 6.25
Thoracic compliance skills
The ability to control the compliance of the patients rib cage is another acquired skill that has to be
learned during actual manipulation exercises. This is particularly important when dealing with
manipulation of the thoracic spine in any position. The flexibility and expandability of the thoracic
cavity and the rib cage permit a great deal of mobility and this skill has to be learned to be able to
realise this compliance and develop safe and effective preload at the same time. Students need to
understand and develop an appreciation for the viscoelastic properties of tissues and stiffness that
develops near end-range motion (Figs. 6.26 & 6.27). This is related to a stability issue and is
discussed in more detail in Chapter 3. Therefore, to achieve joint tension/preload without distress or
lack of cooperation and without any impairment of the patients respiration, it is important to consider
the breathing cycle and thoracic cage compliance/flexibility. The untimely application of a dynamic
adjustive/manipulative thrust to the thoracic spine may lead to potential injury and patient
dissatisfaction.
Figure 6.26
Figure 6.27

It is advisable to introduce and practise these skills during a simulation exercise using a small
beach ball or reasonable facsimile. This is the students first exposure to the concepts of joint preload
or prestress (joint tension). Progressing to the real patient quickly in this process is important and
advisable. Care must be taken to accommodate patient breathing and at the same time appreciate the
flexibility in the thoracic region. This will be covered in more detail in Chapter 10, which deals
specifically with manipulative skills relating to the thoracic spine and covers some of the
contradictions concerning manipulation of this region. It must always be kept in mind that acute
thoracic pain is a red flag in the first instance.

1) Stand at the table in a fencer stance posture with a beach ball stabilized by reinforced double-hand
contact. The suprasternal notch is directly above the hand position (Fig. 6.26). Note the position of
the plumbline in the middle of the table and ball for more effective use of the practitioners torso
weight and body drop through the centre of gravity. The rear foot plantar flexes to push the weight
forward. The practitioner is in contact with the side of the table to help support body weight.
Normal postural protocols are in effect.
2) Push the body weight up and forward over the centre of the ball by plantar flexing the rear foot.
Keeping the head, shoulders and arms completely stable, compress the ball very slowly (Fig.
6.27). Feel the gradual development of the resistance under the contact and the spring in the ball as
the weight and compression are increased. This should be done only during the expiratory stage of
respiration in a real clinical setting. Try to visualize the same series of steps on an actual patient
and the activity within the rib cage. Practise on both sides of the table. Perform this activity very
slowly, simulating the speed of patient exhalation. These skills will eventually be introduced
during the introduction of the many manipulative skills related to this region. As the student begins
this aspect of their development it is important to address these treatment options. Normal postural
protocols in effect including neutral lordosis, abdominal brace and head position are also
incorporated.
Joint tension sense skills
The ability to sense when joints are approaching the elastic barrier limit during joint preload is
another learned skill (tissue tension sense). This is the point at which the dynamic
manipulative/adjustive thrust or mobilization force is applied. Tissue tension describes the
viscoelastic properties of the soft tissues through a passive range of motion. There are numerous
descriptive terms which are used to delineate the condition of the joint and surrounding tissues, such
as springy, hard, muscular, bony, etc. From an educational point of view, simulation provides some
realism for the student to begin to build a base of experience for eventual clinical use. The ability to
recognize normal joint give or spring provides the student with an early appreciation of this important
proprioceptive sense.
Learning to appreciate and isolate the natural joint tension or spring, from either a diagnostic or
therapeutic perspective, should be performed slowly and purposefully. This ensures that the natural
tensile properties of the soft tissues will gradually create inherent resistance, and time for feedback is
accomplished to enhance patient comfort and safety.
Verbal skills
Patient cooperation depends upon, among other factors, effective communication. This is of utmost
importance if the patient is demonstrating signs of distress or apprehension. The patients must know
what is going to happen to them and what is expected of them while undergoing care. This is a
fundamental component of professional practice and patient focused care. This requires that the
practitioner expresses clear, concise and very simple commands to the patient. The practitioner has to
speak slowly and clearly during a therapeutic encounter. Patient relaxation is a necessary component
for successful and efficient manual care. A lengthy technical explanation just prior to a manipulative
thrust to the cervical spine is certainly neither good patient management nor in the patients best
interest. These skills begin at the undergraduate level to prepare graduates fully for public service.
Read the following aloud slowly and do not mumble or feel embarrassed:

Lie face (tummy) down on the table, please.


Lie on your right side, please [tap the shoulder of the side in question].
Take a deep breath in, please.
Slowly breathe out and let your head and shoulders relax.
Do you feel comfortable in that position?
Do you feel any discomfort or pain?
Close your eyes and just relax, please [useful during cervical manipulation].
Would you hold and interlock your wrists, please [always demonstrate].
Place your hands on top of your tummy, please.
Would you mind getting up slowly.
Roll on to your left side [tap the anatomical region].

Once patients have been with you for a while they will respond to your instructions more
readily. These are just a few examples of some very simple and short commands. Learning to
communicate with other students before clinical training is highly recommended. The practitioner is
the director/facilitator and you simply cannot expect patients to fall into place like your colleagues do
in a classroom situation where everyone knows what is expected of them. Providing a patient with an
open and relaxed style of effective communication reduces a great deal of frustration and promotes
cooperation and good healthcare. This is an ideal situation to apply the KISS principle of keep it
simple, stupid.
It would be pointless to develop the complex psychomotor skills of manipulative therapy only to
be unable to communicate your expertise in a clinical setting for the sake of poor and non-assertive
verbal communication. Developing good communication skills requires time and experience. The
author suggests that this should start early in the undergraduate training.
Thrust skills practise techniques
Many of the more common types of dynamic thrust skills have now been introduced; learned in
principle and practised in terms of muscle groups used and specific motor action required. These
have been simulation exercises only, with little or no resistance against which to receive feedback
about the force and nature of the thrust. It is more important initially to isolate and develop the reflex
motor patterns required. If resistance is introduced at the same time, there may be a tendency to push
or thump the targeted object, which may contribute to and reinforce poor motor skills. Learning thrust
skills in a simulation has its shortcomings, but provided this is kept in perspective with both
psychomotor and clinical relevance, the procedure has not been futile. Even though the classroom is
unable to supply realism, rudimentary proprioceptive and psychomotor training is provided through
these methods. Once the various thrust skills are performed proficiently in a clean, sharp and
controlled fashion, it is recommended that some form of resistance be established. Research is
ongoing to develop quantitative feedback systems to measure objectively the development of these
skills at the undergraduate level. Students of manipulative sciences in a hurry to achieve a joint crack
often lose sight of the fact that these procedures consist of complex psychomotor skills requiring time
and practice.
The following thrust skills are somewhat repeated (Figs. 6.28 - 6.32b); however this time
thrusting against some resistance and in various clinical combinations. The same postural and
performance rules apply as previously described in this chapter. Perform all skills bilaterally using a
chiropractic table. Keep the body weight positioned close to the table and a neutral spine posture at
all times during each exercise. This guarantees optimal weight distribution over the patient and
contact point. The legs should be touching the table; but still freely movable. The amplitude of each
thrust is very small. Concentrate on the rapidity, explosiveness and quickness of each impulse thrust.
Do not just pound the table, practise with a purpose and do not lift the hand contact off the surface as
this may lead to erroneous skill development.
Figure 6.28
Figure 6.29
Figure 6.30A

Figure 6.30B
Figure 6.30C
Figure 6.31

Figure 6.32A
Figure 6.32B

These are just a few of the ways in which the elastic bands can be incorporated into learning
joint and tissue tension sense prior to the delivery of an impulse thrust. Practise these skills regularly
in association with the other important skills presented in this chapter. For experienced chiropractors,
this may help to review and improve existing speed and thrust efficiency. Therabands can also be
incorporated into any strength programme to improve overall fitness.

1) Shoulder thrust High, firm chiropractic arch placed on a cushion positioned just below the
suprasternal notch reinforced with the opposite hand; fencer stance posture. Depress the cushion in
a preload simulation by lowering the body towards the table through the front leg. Apply a
relatively straight arm impulse thrust straight down along the line of the arm (Fig. 6.28). The torso
and pelvis are completely stable (*). The triceps comes into play to add a little elbow extension.
The main thrust is from the shoulder girdle with slight assistance via a body drop. Expel air during
each thrust, try not to pound or lift up from the cushion prior to each thrust. Take a rest period
between each impulse thrust. This skill may also be performed with single arm thrust with
reinforced contact hand.
2) Shoulder thrust and body drop Same as above but combine the body drop thrust. The body weight
is positioned and lifted over the contact point via plantar flexion of the rear foot (standard
protocol). This action extends/straightens the front leg, bringing the knee away from the table to
allow a dropping action. The contact arm is relatively stable as the force is generated through the
shoulder (Fig. 6.29). There are degrees of shoulder and body drop depending on the clinical
situation. This skill set can be adapted to include a single arm reinforced contact with body drop
and a cross bilateral contact shoulder thrust with body drop. The student must learn to adapt a
number of different combinations of shoulder and body drop with different hand postures and a
variety of thrust forces.
3a) Recoil (toggle) thrust Stand in a ski stance with a reinforced contact hand and the jugular notch
directly over the hands. The arms and shoulders are relaxed and motionless during the whole
procedure (*). There is no preload applied. The thrust is a sudden and sharp triceps contraction
followed by a biceps recoil (Fig. 6.30A). The body remains stable during the impulse thrust. The
same breathing rules apply. Rest between each contraction. The use of a speeder board at different
tensions can also be used to develop the psychomotor skills in either a ski or fencer stance (Fig.
6.30B). The use of the drop mechanisms within the chiropractic table can also be used to develop
these reflex recoil skills (Fig. 6.30C). These drop skills are used clinically as part of the
diversified biomechanical approach to many dysfunction/pain syndromes.
3b) Recoil thumb thrust This is a variation of Figure 6.31. Reinforced thumb contact over the
cushion replaces the hand/pisiform contact.
4) Pectoralis thrust Crouch down in a low fencer stance at the head of the table. Contact the table
using the web of the left contact hand. The contact arm is at 90 to the edge of the table. Sudden
short sharp pectoralis/biceps thrust straight across the cushion of the table (Fig. 6.32A). The head
and upper body are stable and motionless (*). Practise both ipsilateral and contralateral thrusts
(Fig. 6.32B). Expel air with each contraction and rest adequately between each contraction.
Summary
This chapter has presented a variety of commonly used dynamic thrust techniques associated with
many diversified adjustive procedures used in the chiropractic profession. It has been the purpose of
this chapter to present these skills from very simple movements to more complex ones emphasizing
key muscle groups and clinical purpose. The key element of the exercise is to learn to isolate and
contract specific muscle groups in a sudden and rapid fashion with controlled amplitude of limb or
lever movement. Basic concepts of joint tension or preload and the impulse thrust have also been
presented. Pounding and pushing movements have been highlighted as a potential learning error and
discouraged in an attempt to promote control and muscle isolation. The importance of daily practice
to reinforce and develop competent skills has been addressed. The dynamic thrust is only one aspect
of the overall manipulative skill learning. Learning to appreciate tissue tension and the
proprioceptive sense of joint movement and resistance has also been covered as an important
associated skill.
Control of the force of mobilization and the manipulative or adjustive thrust demands discipline
and skill as many hours of practice are needed to attain a competent level of performance. The
accuracy and precision of application is the clinical objective. This chapter has presented simulation
only. Nonetheless, the importance of introducing these skills to develop an awareness of their
existence and potential application may offer a potentially useful teaching strategy. The importance of
learning rudimentary movements that can be improved with experience and time has been
emphasized. The need for further research development in this area has been highlighted.

References

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Further reading

assidy J.D., Thiel H.W., Kirkaldy-Willis W.H. Side posture manipulation for lumbar intervertebral disc
herniation. J. Manipulative Physiol. Ther.. 1993;16:96-103.
urtis P. Spinal manipulation: does it work? Occup. Med.. 1988;3:31-44.
yberg R. Role of physical therapists in spinal manipulation. In: Basmajian J.V., editor. Manipulation,
traction and massage. third ed. London: Williams and Wilkins; 1985:22-46.
Chapter 7

Identification of important spinal landmarks

B. Kim Humphreys

Chapter contents

Surface anatomical landmarks


Occiput and cervical spine
Thoracolumbar spine
Some important spinal relationships
Summary
Further reading

The accurate location of spinal landmarks is important in facilitating both a musculoskeletal diagnosis
as well as the appropriate application of spinal manipulative therapy.
The most accurate way to identify a vertebral structure and its level is by careful spinal
palpation. Non-spinal bony structures such as the scapula and pelvic girdle are useful surface
landmarks with which to compare the approximate location of important vertebral structures.
Although anatomical variations do occur, general rules regarding the relationships of non-spinal
landmarks to vertebral structures will allow the clinician to approximate the location of the spinal
structure. Following this, the spinal palpation need only be applied to a much smaller area, reducing
time and effort but sacrificing little in the way of accuracy.
Surface anatomical landmarks
Occiput and cervical spine
As a number of mechanical pain syndromes including headaches and neck pain commonly affect this
area, location of painful structure by palpation is important.
In the sitting or the lying prone position, the mastoid process, transverse process of the first
cervical vertebra (C1) and the mandible of the jaw can all be found in an anterior-inferior line of
approximately 45. The C1 transverse process can be found anterior and inferior to the mastoid
process in the depression at the angle of the jaw (see Fig. 7.1).
Figure 7.1 Anatomical relationship of top of C1 (black *) to mastoid process (white *) and angle
of mandible (>).

The bony occipital rim can be palpated medially from the mastoid process, deep to the overlying
muscles trapezius, rectus capitus posterior major and rectus capitus posterior minor. The bony
external occipital protuberance (EOP) is found by moving in a cephalad direction and serves as one
of the attachment points for the trapezius muscle, an important postural muscle.
Moving inferiorly in the midline from the EOP, the palpator will come across a soft tissue
depression followed by the first bony prominence, which is the spinous process of the second
cervical vertebra (C2) (see Fig. 7.2). The spinous process of C2 is large and bulbous and generally
bifid, although this may not be palpable because of the overlying ligamentum nuchae. The posterior
tubercle of C1 is between the occipital rim and the spinous process of C2, but is generally not
palpable. Palpation of this area is aided by flexing the head in the seated position or by lowering the
headpiece in the prone position.
Figure 7.2 Location of the important anatomical landmarks on the posterior aspect of the
cervical spine.

Continuing inferiorly in the midline with the head slightly flexed, the next spinous process to be
found is C3 spinous process which is small, pointed and hides underneath the large spinous process
of C2. The spinous processes of C4, C5 and C6 are generally palpable as they are larger than the
spinous process of C3 (see Fig. 7.2).
The spinous process of C7 or vertebra prominens, is the most prominent in the cervical spine.
Sometimes however, the spinous process of C6 may be large and difficult to distinguish from that of
C7. Therefore, place the index finger on the uppermost spinous process and the middle finger on the
adjacent spinous process inferiorly. Next slowly extend the head and neck several times. The spinous
process of C6 will move during extension while that of C7 will remain stationary, thereby providing
a distinction between the two (see Fig. 7.3).

Figure 7.3 Procedure to locate the spinous process of C7 (vertebra prominens).


The zygapophyseal or facet joints are important pain-generating structures in the spine. Affected
facet joints are generally tender to palpation and may be described as boggy or puffy because of
inflammation. The facet joints are generally 1.5 and 2 fingers lateral to the spinous processes and at
the level of the interspinous space. Palpation of the facet joints and adjacent articular pillars is
usually done using the index and thumb of one hand while the other hand stabilizes the patients head
(see Fig. 7.4).
Figure 7.4 Palpitation of cervical spine facet joints.
Thoracolumbar spine
Various landmarks from the shoulder girdle are useful in identifying the approximate level of spinous
processes in the upper and middle thoracic spine. When patients are in the prone lying position they
tend to elevate their shoulders. Therefore, gently pull down their shoulders to the normal standing or
sitting position.
In this position, the acromioclavicular (AC) joint of the shoulder is level with the spinous
process of T1. For the scapula, the superior angle overlies the second rib while the medial angle or
the root of spine of the scapula is at the level of the spinous process of T3 and the inferior angle is
level with the spinous process of either T7 or T8. Generally, the scapula overlies ribs 27 or 28
(see Fig. 7.5).

Figure 7.5 Anatomical relationship of bony landmarks to spinal levels. AC, acromioclavicular;
PSIS, posterior superior iliac spine.

The pelvic girdle also provides important landmarks for identifying the position and level of
various spinal segments (see Fig. 7.5). The posterior superior iliac spine is very subcutaneous, lying
just beneath the dimples of Venus. The posterior superior iliac spine (PSIS), as well as the
posterior inferior iliac spine, identify the longitudinal extent of the sacroiliac joint with the sacral
tubercle of S2 approximating the joints midpoint.
The top of the iliac crest is useful in identifying the approximate location of the spinous process
of L4, although variation exists and it may also be level with the L4L5 space or the L5 vertebral
body. Palpation of the lumbosacral junction inferiorly should help to clarify any variation of this
landmark (see Fig. 7.6).

Figure 7.6 Location of L4 spinal level in prone position. PSIS, posterior superior iliac spine.

This procedure may be used in both the prone and side-lying positions. With the palm open and
fingers fully extended, thumb abducted, simply roll the index finger over the skin from the inferior to
superior position. The thumb will point towards the midline and correspond to a particular spinal
level, typically L4 (see Fig. 7.6). Figure 7.7 illustrates the side-lying position.
Figure 7.7 Location of L4 spinal level in side-lying position.

Additionally, halfway between the inferior angle of the scapula and the superior aspect of the
iliac crest is useful in identifying the approximate level of T12L1 (see Fig. 7.5). Palpation of the
spinous processes of T12 and L1 usually identifies this level because of the distinct differences
between the shapes of the two spinous processes.
Some important spinal relationships
In addition to the surface, non-spinal landmarks, manual therapists should be aware of useful
relationships between the different vertebral structures.
The thoracic spine transverse processes are important structures to locate as their short levers
are used in spinal mobilization or manipulative therapy. From the upper to lower thoracic spine, the
relationship between spinous to transverse processes change due to the change in shape and direction
of the spinous processes. For T1T4, the corresponding transverse process is located at the level of
one spinous process above. For T5T8, the corresponding transverse process is located
approximately two interspinous spaces above while the transverse processes of T9T12 again
correspond to one spinous process above (see Fig. 7.8).
Figure 7.8 Anatomical relationship of transverse to spinous process in the thoracic spine.

In the lumbar spine, specific hand contacts for manipulations are made over the facet joints
making their location important. As a rule, the lumbar facet joints are located at the level of the
interspinous space of adjacent vertebrae and approximately 1.5 to 2 fingers lateral to the spinous
processes. The upper lumbar facet joints are closer to the spinous processes than the lower lumbar
vertebrae as the width of the lumbar vertebral segments increases inferiorly.
Figure 7.9 illustrates the approximate location of the left facet joint of L4L5 in the right lateral
decubitus position. The side-lying position is a common position for lumbar spine manipulations.

Figure 7.9 Location of left L4L5 facet joint in sidelying position.


Summary
A good knowledge of the general anatomical relationships of non-spinal structures to the spine as
well as of the relationships of different vertebral landmarks is important to chiropractors and other
manual therapists who wish to be accurate and effective, especially in the application of spinal
manipulative therapy.

Further reading

ergmann T.F., Peterson D.H., editors. Chiropractic technique, third ed, London: Elsevier, 2011.
yfield D., Kinsinger S. A manual therapists guide to surface anatomy and palpation skills. Oxford:
Butterworth Heinemann; 2002.
agee D.J. Orthopedic physical assessment, fifth ed. St Louis: Saunders; 2006.
Section 3
Basic manipulative/adjustive techniques for
the spine and pelvis
Chapter 8

Pelvic/sacroiliac adjustive and manipulative skills

David Byfield

Chapter contents

Introduction
Biomechanical and functional considerations of the sacroiliac joint
Functional stability model
Sacroiliac joint manipulation clinical considerations
Lifting and the sacroiliac joint
Force of manipulation
Sacroiliac manipulative skills
Posterior superior iliac spine (PSIS) contact
Ischial tuberosity (IT) contact
Sacral base (SB) contact
Summary
References
Further reading
Introduction
The sacroiliac joint complex or lumbopelvic region (sacroiliac and lumbosacral facet joints
combined) has been the subject of great debate and contention over the past decades. This is
primarily due to the complex neuro-biomechanical function and pain-generating properties (Bernard
& Cassidy 1991, Cassidy 1992, Mierau et al. 1999, Quon et al. 1999, Waddell 2004). It is the least
understood region of the spine and the most controversial with respect to overall function, complexity
and role in low back pain (Pool-Goudzwaard et al. 1998; Vleeming & Stoeckart 2007). There is
some speculation at present regarding the true function of these structures, but as for their exact role in
the pathogenesis of non-specific mechanical low back pain syndromes, though not absolutely clear,
there is evidence that about 20% of patients complaining of chronic back pain can be traced to the
sacroiliac joints (Maigne et al. 1996, Schwarzer et al. 1995). However, others suggest that the
sacroiliac joint accounts for approximately 1630% of cases of chronic mechanical low back pain
(Cohen 2005, Vanelderen et al. 2010). It has also been reported that more than 70% of chronic back
pain is due to pain originating from the zygapophyseal and sacroiliac joints and internal disc
disruption (Bogduk & Aprill 2007, Liebenson 1992). Nonetheless, the chiropractic profession has
always championed the fundamental role of the sacroiliac joint in the production of low back and leg
pain, a supposition linked by a clinical understanding of the functional anatomy and biomechanics of
the sacroiliac and interaction with the pelvis and lumbar spine which has provided a clinical rational
basis for manipulative intervention (Bernard 1997). Bernard (1997) also states that the sacroiliac
joint is a frequently overlooked source of primary low back pain as it shares similarities with other
synovial joints even though there is substantial emperical evidence from treating patients. Further
research in this area is of considerable clinical interest and may yet shed some light on this matter.
Ongoing research efforts have recently been made investigating the role of both the lumbar
zygapophyseal and sacroiliac joints in the genesis of low back pain (Bogduk & Aprill 2007, Daum
1995, Schwarzer 1995, van Kleef et al. 2010). This has clinical implications for those health
professionals using spinal manipulative therapy as part of a package of care for the management of
low back pain that is based on reputable evidence. This vital information is also of great value to
undergraduates, underpinning their psychomotor skill learning. The various biomechanical models we
use to rationalize clinical phenomena have a profound effect upon psychomotor skill acquisition. This
is outlined in detail in the Introduction and Chapter 3 of this book.
Biomechanical and functional considerations of
the sacroiliac joint
Even though attempts have been made to describe and measure sacroiliac motion, discussions
regarding joint biomechanics have until more recently been predominantly theoretical and its
biomechanical function has been regarded as variable and uncertain (Cassidy 1992, Cassidy &
Mierau 1992, McGregor & Cassidy 1983). However, a model describing lumbopelvic stability has
been proposed which incorporates a comprehensive interplay between the various structures of the
thoracolumbar and lumbopelvic regions (Pool-Goudzwaard et al. 1998, Vleeming & Stoeckart 2007).
This model is based primarily upon the anatomical and biomechanical properties of several vital
structures within the lumbopelvic region, which provide both form and force stability via their
anatomical structure and compressive friction properties.
From a simple functional perspective, the sacroiliac joints play an important role in the dynamic
challenges encountered during upright stance and other posturally demanding tasks. The sacroiliac
joints also provide support for the trunk and guide overall movements. They also function to provide
elasticity to the pelvic ring, serve as a buffer between the lower limbs and spine, and contribute to
both the proprioceptive and nociceptive output of the joint capsule. They also transfer large loads
during weight-bearing and locomotion. More recently, Indahl and Holm (2007) have postulated that
the sacroiliac joints function as the bodys bathroom scale, measuring joint loading during various
tasks and controlling the switching on of various key muscles that control movement. Studies have
demonstrated that, contrary to previous ideas, the sacroiliac joint has little proprioceptive function,
suggesting that the mechanosensitive receptors in the capsule are, in effect, nociceptive in nature
(Sakamoto et al. 2001). One could argue that in all tissues there is probably a greater potential for
nociception than proprioception based upon the proportions of each neurone type present. This
reinforces the fact that the sacroiliac joint may be a potent source of mechanical pain in humans. The
results of another study investigating double anaesthetic block techniques and the value of sacroiliac
pain provocation tests concluded that the sacroiliac is an uncommon but real source of low back pain
and that the accuracy of common provocation tests is highly questionable (Maigne et al. 1996). They
did, however, go on to say that the sacroiliac joint should be included in a differential diagnosis when
managing mechanical non-specific low back pain, despite the fact that to isolate a distinct sacroiliac
syndrome, based upon the evidence, was currently untenable.
In terms of mechanics, evidence suggests that sacroiliac joint mobility is small, which may be
influenced by increasing age and gender (Sturesson 2007, Vleeming et al. 1992). Movement has been
found to be greatest around the transverse (X) axis in the order of 2.5 with a mean translation of 0.7
mm (Sturesson 2007, Sturesson et al. 1989). Sturesson (2007) summarized the following regarding
the sacroiliac joint:
1. Sacroiliac joint mobility is 3040% less in men than in women.
2. Small differences in sacroiliac joint movement occur in patients with unilateral v bilateral pain.
3. Studies reveal no indications of hypo- or hypermobility.
4. No significant differences occur in mobility between symptomatic and asymptomatic joints in
patients with unilateral symptoms.
5. Manipulation does not alter the position of the joint.
6. Muscular forces and increased loads reduce movement of the sacroiliac joint.
Functional stability model
Current scientific models describing the sacroiliac joint complex favour the functional stability
model as a paramount necessity for efficient movement (McGill 1998, Panjabi 1992, Pool-
Goudzwaard et al. 1998). This model is underpinned by a shear-prevention system defined by
anatomical form and dynamic force closure components which create a self-locking mechanism for
sacroiliac joint stability (Pool-Goudzwaard et al. 1998). The wedge-shaped sacrum, rough articular
cartilage and the multiple articular grooves and ridges are all designed to reduce the effect of shear
forces up to 1750 N, while the lumbosacral ligaments, thoracolumbar fascia and related musculature
(multifidus, piriformis, gluteus maximus and iliopsoas) via ligamentous attachments increase joint
compressive forces and overall stability (Bergmann & Peterson 2011, DonTigny 1985, Harrison et al.
1997, Pool-Goudzwaard et al. 1998). These authors have suggested that insufficient self-locking may
result from ligament laxity, muscle weakness and inadequate coordination between various key
muscle structures (force closure concept). It would appear that active rehabilitation aimed at
restoring functional capacity to these structures would be an appropriate therapeutic methodology,
particularly in light of the underlying rationale for the instability and the outcomes of a specific and
graded exercise programme (Byfield 2001). Furthermore, there is promising evidence regarding the
importance of both strength and endurance characteristics of soft tissues required for spinal stability
and optimal function (McGill 2002a, McGill 2006). This concept fits well with Panjabis spinal
stability model and its various components, which theoretically could be extrapolated to encompass a
number of related joint complexes in the spine and pelvic regions (Panjabi 1992). This supports the
fact that most back injuries are not the result of frank trauma, but are more likely to be the result of
trivial events, unstable movements and associated motor control errors causing inappropriate muscle
activation and aberrant joint motion (Jull & Richardson 2000, McGill 1998). This in turn could
potentially stimulate local nociceptors, thus producing the typical diffuse, dull ache associated with
the sacroiliac syndrome (Bernard & Cassidy 1991). McGill (1999) suggests that the stiffness and
subsequent stability of a spinal motion segment is the result of both muscle stiffness and inherent
passive stiffness of non-contractile soft tissues structures. Therefore, the cornerstone of lumbopelvic
rehabilitation is trunk muscular endurance (extensor/flexor/lateral flexor) and sensorimotor training
(Jull & Richardson 2000, McGill 1998). Such an approach provides patients with the skills
necessary to sustain a variety of trunk postures over a period of time and improve reaction times
appropriately to sudden shifts in movement as a result of changes in terrain and environment (Jull &
Richardson 2000, McGill 1998). Furthermore, these programmes are considered safe and effective
for all age groups as a prevention strategy for mechanical back pain (Byfield 2002).
The mechanical influence of musculoligamentous interplay has been closely associated with
various kinematic chains influencing sacroiliac joint mobility (Pool-Goudzwaard et al. 1998,
Vleeming et al. 1989). It is their contention that contraction of the gluteus maximus, for example,
could strongly affect the nature of sacroiliac joint motion via its attachment to the sacrotuberous
ligament. This could shed some light on the aetiology of mechanical irritation of the sacroiliac joint
by way of asymmetrical contraction of these large stabilizing muscles or other contractile structures
during the performance of common activities such as walking or running. More recently researchers
have reported that contraction of the transversus abdominis significantly decreases the laxity of the
sacroiliac joint, improving the overall stability of this structure, as has been shown within the lumbar
spine for the treatment of low back pain (Richardson et al. 2002). Other reseach groups have
demonstrated the functional integration and role of various structures related to the lumbosacral
region and the links between the legs, spine and arms during the performance of various activities of
daily living (Vleeming et al. 1996).
It has come to light that the function of the long dorsal sacroiliac ligament has anatomical
connections with the erector spinae muscles, the posterior layer of the thoracolumbar fascia and the
sacrotuberous ligament. These structures provide a mechanical connector transferring loads
efficiently between the upper and lower body (Vleeming et al. 1995, 1996). This may have significant
clinical implications with respect to patients with non-specific mechanical low back pain as a result
of dysfunction of the sacroiliac joints. In fact there has been some suggestion that posterior pelvic
pain in pregnant women may occur as a result of disturbed muscle function in a response to
nociceptive stimulation during gait (Hungerford & Gilleard 2007, Sturesson et al. 1997). Hungerford
and Gilleard (2007) have demonstrated altered patterns of intrapelvic motion and delayed onset of
various muscles including internal oblique, multifidus and gluteus maximus on the side of single leg
support when compared with controls. This could imply an impairment of the stability cycle at the
lumbopelvic level due in part to the reported pain (Panjabi 1992). Some of these concepts are
expanded in Chapter 13 dealing with basic manual skills in the pregnant patient. The concept of
functional stability and biomechanical integration is extremely important clinically in understanding
the complexity of low back pain syndrome presentation and the recognition of the influence of other
related joint complex dysfunctions (Cibulka et al. 1998). Furthermore, the functional stability
scenario has clinical implications, particularly when specific segmental muscle stabilizer atrophy
(i.e. multifidus) persists without recovery after the acute pain has resolved leaving the individual
susceptible to recurrent episodes (Hides et al. 1996). This may have an indirect influence on
sacroiliac joint function because of the origin and insertion characteristics of these muscles. In
addition, a recent clinical trial found a significant decrease in recurrent low back pain episodes in the
exercise group specifically targeting the multifidus via transversus abdominis co-contraction
compared with the control group employing advice and medication (Hides et al. 2001). This
particular situation demonstrates the need to instigate a rehabilitation programme immediately in
order to restore functional stability to control recurrent pain episodes (Byfield 2002). The fact that
the multifidus extends throughout the lumbar spine and caudally to cross the sacroiliac joints and
related aponeuroses indicates its role in posterior joint stability. In addition, it has recently been
demonstrated that asymmetric laxity of the sacroiliac joints in pregnancy-related pelvic pain has been
identified as a possible predictive indicator for those who may suffer moderate to severe postpartum
back pain (Damen et al. 2002). The role of these stabilizing structures and the responsibility of
clinicians to introduce effective management strategies become more apparent as more sound
evidence continues to emerge.
McGill (2002a, 2002b) has postulated that the extremely high mechanical loads characteristic of
this region (lumbosacral and sacroiliac joints) could potentially lead to microfailure of the tendo-
periosteal attachment of these soft tissues and corresponding extensor aponeurosis resulting in a local
pain response. This may explain the local tenderness associated with the tissues of this region during
examination, which may be totally unrelated to joint dysfunction (McGill 2002a). Since the sacroiliac
joint displays extremely small movements, it is unlikely that the response to manual therapy is simply
a reduction of a medical subluxation or dislocation (Bernard & Cassidy 1991, Tullberg et al. 1998).
These workers imply that the role of a high-velocity, low-amplitude manipulation lies in restoring the
balance between joint kinematics and associated muscle function, which subsequently normalizes the
arthrokinetic reflex and breaks the pain cycle. It could well be that active stimulation and stretch of
these large pelvic muscle structures creates a reflex myofascial relaxation and pain inhibition, thus
overriding nociceptive stimulation. These concepts would certainly support the notion that assessment
and skilled manipulation by a fully qualified professional is mandatory to discriminate the complex
interaction of so many influential and pain-sensitive structures.
Sacroiliac joint manipulation clinical
considerations
One of the postulated goals of manipulation is to restore normal motion to the joint. Joints, by their
inherent viscoelasticity, are stiff and increasing the motion via manipulation may mean more motion
but less joint stiffness and stability. Therefore overmanipulation may produce excessive motion
which compromises stability, leaving the patient vulnerable to future episodes of back pain (McGill
1999). This is another professional debate but the key in this situation is to enhance stability via
appropriate exercise and manipulate according to symptom/mobility needs. This is an essential
clinical management issue.
Lifting and the sacroiliac joint
There are numerous biomechanical models to quantify lifting and they include the influence of the
pelvic mechanism and lower limb kinetic/kinematic chains as part of an integrated regional system
that functions in harmony, transferring and distributing loads safely and at the same time providing
efficient movement patterns. The debate surrounding the merits and utility of various lifting techniques
continues and there is still doubt as to which particular skill provides an advantage for those involved
in different types of lifting. This is particularly relevant for the chiropractic student learning various
manipulative psychomotor skills that involve a degree of lifting, transferring body weight in addition
to advising patients and others in industry about such important issues. The authors draw your
attention to work by Vleeming and Stoeckart (2007) and Adams and Dolan (2007) for a very
comprehensive description of the functional biomechanics of the lumbopelvic region and the use of
the spine, legs and pelvis during lifting.
Force of manipulation
The magnitude of the thrust force recorded during prone manipulation of the sacroiliac joints was in
the range of 220550 N (50 lb (23 kg) to 120 lb (55 kg)), which equates to roughly one-third to three-
quarters of the body weight of an average 150 lb (68 kg) man (Hessell et al. 1990). Height, weight
and grip strength may be physical characteristics that play a role in a clinicians ability to generate
efficient manipulative forces. Since height and weight do not fluctuate greatly, improving strength
generally may improve the ability of the practitioner and, especially, the student to deliver a range of
manipulative thrust forces required for each clinical situation and patient type. This research
indicates the variability of forces delivered by chiropractors. Speed of thrust appears to be
reasonably consistent but the applied force varies considerably. This is consistently so throughout the
spine. Innovative research is currently being conducted at various centres throughout the international
chiropractic community and has been reported in the introduction to this text. It goes without saying
that these efforts should be translated into undergraduate training to provide useful, objective and
pragmatic methods to ensure high standards of manual skill acquisition.
Sacroiliac manipulative skills
It has been postulated that asymmetrical tension across these joints may provide a clinical model
explaining a number of clinical observations pertaining to this region. It would seem feasible to
suggest that the forces applied during pelvic manipulation are gradually dissipated through several
layers of soft tissue before actually affecting the joint surfaces, if they reach them at all. It is difficult
to visualize absolute joint isolation during manipulation of the lumbopelvic articulations, especially
considering the complex arrangements of supporting soft tissue that are common to both regions.
Therefore, an adjustive/manipulative thrust directed towards the sacroiliac joint may influence the
lumbosacral articulation and vice versa.
There are many different techniques available to manipulate the sacroiliac joints in a variety of
postures including the supine, prone and side positions. Several different techniques have been
described by the various professionals, including physiotherapy, osteopathy and chiropractic
(Bernard & Cassidy 1991, Blackman & Prip 1988, Bourdillon & Day 1987, Byfield 2005, Cassidy &
Mierau 1992, Cassidy et al. 1992, 1993, Gitelman 1980, Gitelman & Fligg 1992, Greenman 1989,
Grice 1983, McGregor & Cassidy 1983, Nwuga 1976, Peterson & Bergmann 2002, Schafer & Faye
1989, States 1968, Szaraz 1984).
A clinician should become proficient in a number of different mobilization and manipulative
styles, depending upon the clinical presentation of the patient. Many of these techniques are only
variations of a common theme, which is based upon a neurobiomechanical model of reciprocal
movement of the innominates and nutation/counter-nutation of the sacrum (Bernard & Cassidy 1991,
Grice & Fligg 1980, McGregor & Cassidy 1983, Sturesson 2007). This model includes the
mechanical influence of the stabilizing ligaments and the contractile elements of the pelvis, which
form an influential kinematic chain.
The student should begin at a point that will also provide the basis for the introduction of other
manipulative methods used for treatment of the sacroiliac joint. This hinges on a fundamental
understanding of the anatomy, biomechanics, pathogenesis and diagnosis of sacroiliac dysfunction. It
has been reported that the side posture method is the most effective method for treating sacroiliac
dysfunction (Bernard & Kirkaldy-Willis 1987, Bourdillon & Day 1987, Cassidy & Mierau 1992,
Cassidy et al. 1985, Kirkaldy-Willis & Cassidy 1985, Mierau et al. 1984). It is for this reason that a
description of side posture skills for the sacroiliac joint will be presented. Reference will be made to
the anatomical landmark and not the therapeutic indications for pelvic correction. Three anatomical
contact points will be presented:

1. Posterior superior iliac spine (PSIS), (Figs. 8.1A -8.17)


2. Ischial tuberosity (IT), (Figs 8.18 - 8.22)
3. Sacral base (SB), (Figs 8.23 - 8.26).
Posterior superior iliac spine (PSIS) contact
This anatomical landmark contact point is frequently used for adjustments/manipulations for clinically
identified sacroiliac joint mechanical dysfunction. This adjustment is primarily driven by symptoms,
and standing and prone sacroiliac joint palpation, and provocation tests (Byfield 2002) (Figs. 8.1A -
8.7B).

1) Follow and complete the basic side posture procedural skills as described in Chapter 5 to the
point where the practitioner is directly facing the patient and supporting the upper leg (thigh
sandwich) with minimum of 90 of hip flexion. With the index and middle finger of the contact
(left) hand, the clinician palpates the space just medial to the PSIS (sacroiliac joint line) to
appreciate the tissue tension around the sacroiliac joint during increased hip flexion (Fig. 8.1A).
Increased hip flexion is achieved by moving the clinicians hips and thigh sandwich in a cephalad
direction (Fig. 8.1B). At the point of perceived tissue tension (tension in posterior sacroiliac
ligamentous capsule) further hip flexion is unnecessary. The patients hip should be stabilized to
prevent loss of flexion and laxity within the joint elements. The clinicians firm foot placement and
stance maintain this position. The lumbar spine will be flattened and there should be no excess
tension placed on the patients hip. The table and the patient support some of the clinicians weight
for stability. The patients pelvis is perpendicular or slightly supinated relative to the table as
indicated by the superior ASIS (*). The indifferent/support arm stabilizes the patients upper body
on the table.
2) Once appropriate hip flexion and medial joint tissue tension have been accomplished, the hip is
stabilized. Additional or excess tissue slack is drawn cephalad from just medial to the PSIS
directly towards the practitioner using the index and middle fingers of the indifferent hand (right)
prior to the application of the contact hand (Fig. 8.2).
3) A chiropractic bridge arch formed by the contact hand and the hypothenar/pisiform contact point is
placed lightly over the most medial aspect of the PSIS and drawn up in the same direction as the
tissue slack hand to tighten and increase the specificity of the contact hand. The contact arm is
relaxed and positioned parallel to the patients body (*) (Fig. 8.3). The shoulders should be in a
relaxed position with no muscular tension in either the contact or indifferent hands. There is
minimal wrist extension (*). The practitioner is still directly facing the table in a relative ski
stance.
4) The contact arm is brought in line with the joint by pivoting the arm around the wrist not the
shoulder, bringing the arm almost perpendicular to the contact point until the angle at the wrist is
comfortably placed, with no muscular tension in the arm or shoulder girdle (Fig. 8.4A). The arm is
not positioned at 90 to the patient as this places considerable stress on the shoulder and wrist. The
contact is firm but very light and not hard and forceful. The wrist is kept straight with no radial or
ulnar deviation. The clinician must not pivot from the shoulder, disturbing the symmetry and
balance already established (*). The practitioner is still positioned perpendicular to the patient and
the table, standing firmly in place. Note that the shoulder posture does not change before or after
the pivot shift. Note the lack of upper back torsion during this procedure (Fig. 8.4B). The clinician
can lean towards the table and patient to support body weight and reduce postural fatigue.
5) The clinician begins the 45 pivot shift into a fencer stance while at the same time maintaining
joint tissue tension hip flexion and patient comfort. The pivot procedure, which is described in
Chapters 4 and 6, is a full body 45 turn. This brings the contact hand and arm into position without
excess shoulder torsion. The fencer stance position places the body weight slightly forward on the
front leg and the heel of the back leg is slightly raised with both legs flexed (Fig. 8.5). The
suprasternal notch should be slightly ahead of the PSIS (*). There should be absolutely no force on
the PSIS or muscular tension in the clinicians upper body. Minimal tension and effort should be
expended to support the patient on the table. Note the shoulder posture does not change. The
patient is relaxed with no twist or tension in the body. Compare position in Figure 8.4. The
patients pelvis remains perpendicular to the table with little movement for stability.
6) The next step is to shift the practitioners body weight forward and onto the patient to further
stabilize the patient on the table and position the body weight over the joint prior to the preload and
application of the manipulative thrust. The practitioner/student very slowly pushes his/her weight
forward by plantar flexing the foot of the back leg, which will project the body forward towards
the patient so that the front leg assumes a majority of the practitioners body weight (Fig. 8.6). This
is done while all other previous skills remain intact to maintain patient control, stability and
comfort. A gentle thigh squeeze is essential at this point to maintain hip flexion and control of the
anatomical levers. The clinician/student slides the rear leg over the patients tibia to control the
amount of leg drop (*). As the clinician/student moves forward, the rear foot will elevate off the
floor as the front leg supports the majority of the body weight.
7) The practitioner/student continues to move up and forward until the patients tibia ridge falls into
the suprapatellar fossa (*). The patients leg is not forced towards the table. This controls leg drop
and excess twist in the hip and lumbosacral region. The hip is maintained at a minimum of 90
during this entire procedure via the thigh sandwich. The contact arm and shoulder should not
change. In addition there should be no tension or excess weight felt by the patient. The patient
should be relaxed and cooperative. Do not squeeze the patients leg and do not let it drop. The
amount of leg drop and hip flexion assists sacroiliac joint isolation and tension prior to joint
preload and preparation for either mobilization or manipulative thrust.
8) Once body weight is over the patient, the clinician/student brings the rear foot down to the floor
with a plantar flexed posture to maintain the duff position, which permits flexibility in the
clinicians stance. This action will bring the patients leg down towards the table to increase the
tension in the sacroiliac joint via the various levers (innominate and femur) (Fig. 8.7A). Note the
position of the patients knee in Figure 8.7A to get an appreciation of the amount of drop involved.
Notice that the clinician/student has dropped his weight down over the patient and the rear leg is
slightly flexed supporting under the patients leg with a thigh sandwich. The practitioner gently
squeezes his legs together to hold the leg in place without compressing the patients knee and at the
same time maintaining appropriate hip flexion and sacroiliac joint tension. The practitioners feet
are still only hip distance apart and 45 to the table. Note that the back leg is perpendicular to the
floor to assist in maintaining appropriate hip flexion and joint tension prior to preload. There are
many other methods of stabilizing the patients leg. The practitioner maintains counter-rotation by
holding the upper body back to create the transition point at the appropriate sacroiliac joint (Fig.
8.7B). The patient is prevented from rolling off the table, which is a common error.
9) There are many errors to be aware of during this sequence of skills, (Figs 8.8 - 8.12).
i) The contact arm pivoting at the shoulder instead of the wrist will produce unwanted torque
and tissue stress at the shoulder (Fig. 8.8). This can also be produced by over-pivoting the
lower body. Note the amount of internal rotation of the contact (right) shoulder. A dynamic
thrust applied through this joint may cause injury to the practitioner and patient. The excess
twisting action may stress the lower back, upper back and shoulder girdle regions.
ii) The feet and legs can drift apart during the pivot to a low fencer stance. This will contribute
to loss of control of the patients leg and body weight (Fig. 8.9). Some find this stance
clinically useful, but they have developed other patient control skills to compensate. This
should be discouraged at undergraduate level. Control is vital and learning to minimize effort
to control the patient in the side posture as well as deliver an effective manipulative thrust is
an important undergraduate learning outcome.
iii) There is also a tendency to push the upper body backwards or posteriorally in an attempt to
gain joint tension (Fig. 8.10).
iv) The practitioner/clinician may tend to lean on the patients upper body instead of elevating
the torso and centre of gravity above the target joint to maximize the use of body weight to
develop joint tension prior to the dynamic manipulative thrust or mobilization procedure (Fig.
8.11).
v) Positioning the torso too high, whereby the angle of the contact arm could create a piledriver
or pushing effect over the contact point, is another common error. This increases the length of
the lever arm which amplifies the amount of force applied (Fig. 8.12). The balance of torso
weight is somewhere between (iv) and (v). Care must be taken to ensure that the clinicians
sternal notch is above the level of the target joint to ensure appropriate weight distribution and
ease of manual intervention.
10) From the sequence of movements described in Figures 8.1 to 8.7, the student/clinicians body
weight moves forward and down by slightly flexing the legs at the knees. At the same time the
patients pelvis is slowly rolled forward from a perpendicular position (*) (Fig. 8.13A) to a
position that is slightly angled towards the table (Fig. 8.13B). This is controlled by the
practitioners leg position and body weight. The indifferent hand maintains upper body position
and stability by pressing down and not backwards, but allowing the upper torso to roll very slightly
forward to eliminate excess upper body torque.
11) The suprasternal notch and the body weight should be located just posterior to the PSIS as a result
of the forward movement of the student/clinicians weight and after the pelvis has been moved
forward. This should still align the centre of gravity and weight distribution optimally for the
dynamic manipulative thrust following preload or via joint mobilization (Fig. 8.14). The indifferent
arm (right) is brought in to the side of the practitioners body to make a more compact manipulative
thrust or mobilization application. The indifferent contact is placed over the patients folded arms
to stabilize them on the table when preload is eventually applied. The patient is aligned in a
straight longitudinal fashion along the table, reducing overall torque and spinal stress (Fig. 8.14).
12) The contact arm/hand begins to apply force gradually to the contact point using, primarily, the
shoulder adductors (Fig. 8.15A). This is likened to a squeezing action between the contact hand
and the practitioners body to isolate, localize and develop preload or tension in one specific
region. The pelvis is virtually stationary at this point as the practitioners body weight is placed to
block further forward movement. This is the point at which the short levers are introduced and
controlled by very slow application until a resistance is appreciated at the point of contact while
the patient is in breathing out cycle. The student should consider this a mock thrust, a repetitive
oscillation at joint tension to feel the point of maximum joint give. This is the only time that any
significant muscular tension is produced by either the contact or indifferent hand and arm at a
contact point. There are a number of variables for this skill. One of the most common is the use of
the forearm contact which offers a fleshy contact point just lateral to the PSIS and short levers (Fig.
8.15B).
Figure 8.1A

Figure 8.1B
Figure 8.2
Figure 8.3
Figure 8.4A
Figure 8.4B
Figure 8.5
Figure 8.6
Figure 8.7A

Figure 8.7B
Figure 8.8

Figure 8.9
Figure 8.10
Figure 8.11
Figure 8.12
Figure 8.13A
Figure 8.13B
Figure 8.14
Figure 8.15A

Figure 8.15B

A dynamic manipulative thrust should not be applied at this stage, only mock preloads (mini-
midi thrust) to learn to appreciate joint resistance and the tightening of the targeted joint and
surrounding tissue. Care must be taken not to stress the tissue over a period of time, which may
cause unwanted reactions during practice sessions and erroneous joint movement.
13) There are a few errors to be aware of during this last section.
i) Over-rotating the pelvis forward and too quickly causes excessive twist in the thoracic spine
and thoracocolumbar region and loss of control of the patient before the manipulative thrust or
end-range mobilization procedures. The upper back is pushed too far back and the pelvis too
far forward (Fig. 8.16). Also note the tension in the shoulder girdle (*). It is difficult for the
patient to relax under this excessive tension. The practitioner is also pushing down on the
patients shoulders to maintain some stability.
ii) The most common mistake encountered occurs during transferring of body weight. The
tendency is to push up and then straight down instead of forward and then down over the
patient to centre the body weight. In this instance the body weight is over the front of the table
(Fig. 8.17). This movement brings the patient too far forward on the table and the clinicians
suprasternal notch and weight are not centred over the sacroiliac joint. Further movement will
compromise the patients stability on the table and the patient may automatically roll
uncontrollably forward, resulting in emergency evasive action by the clinician/student to keep
the patient on the table. Note the stress on the contact arm (*). Application of a mobilization or
manipulative force at this point will only bring the patient precariously close to the edge of the
table.
iii) Students have a tendency to focus on the PSIS contact point. Unnecessary muscular forces
may cause fatigue and possible patient distress if the contact is also painful. Patients will
typically resist this type of approach, which decreases the efficiency and smooth performance
of the skill. This is not good technique.
Figure 8.16
Figure 8.17

One of the most common errors at this stage is the excessive use of muscular force and overall
workload by the student while attempting to develop tension at the specific sacroiliac joint via the
PSIS contact. It is a natural tendency to work harder than is necessary. The awkward movements
trying to control patient motion often result in an increase in pressure over the patient. The firmer the
contact the better the manipulative technique is not valid. The procedure revolves around positioning
and patient comfort. Keep things light at all times with no excessive movements. The important
considerations for students at this stage are:

minimize effort
minimize pressure over the patient
minimize positional movements, including pivot shift and weight transfer
do not rush the preload
remember leverage system and transitional point (joint localization).

Up to this point there should be no excessive tension across the lumbosacral joint complex. The
transition point for maximum biomechanical effect must be directed towards the sacroiliac joint. This
is the essence of the skill and will be the basis for a number of other procedures presented in this and
other chapters dealing specifically with side-posture skills. The skills have been introduced to
position the patient and isolate the joint movement effectively using both long and short levers to their
maximum efficiency.
The next series of steps will bring the sequence to the point of maximum joint tension or preload
appreciation, concentrating on incorporating the short levers. The ability to appreciate these subtle
movements and joint tension components takes time and development through years of practice and
application of accepted scientific models and physiological behaviour.
Move slowly and methodically. The movement sequence should not be hurried. There is a
natural tendency to rush the process and attempt an adjustive thrust. This may reinforce unwanted
habits which are sometimes difficult to modify in the long term.
At this point:

the patient should be relaxed, comfortable and stable in the side posture
the practitioner should be positioned with body weight forward
the centre of gravity should be close vertically to the sacroiliac joint (suprasternal notch)
the contact shoulder, arm and hand are relaxed with no compressive force placed over the PSIS
there should be no muscular tension in any part of the practitioners body apart from the front leg.

It is recommended that students must not proceed past this point until the sequence of skills thus
far is efficiently performed. The movements of both the practitioner and the patient are very small in
relation to the whole manipulative skill. This is the essence of control limit the amount of movement
and control the patient.
The following steps of this manipulative skill will function to introduce the short levers to
develop joint tension and apply preload prior to the adjustive thrust. During this final step, it is
recommended that the patients breathing pattern be incorporated as part of the overall skill sequence.
The patient will be requested to breathe in and then slowly out as tension and joint preload are
applied across the sacroiliac joint and surrounding soft tissues. This action may help to focus the
patients attention and assist overall relaxation. It is recommended that the practitioner also
coordinate his/her breathing pattern with that of the patient, which may help to focus the effort
required for the eventual dynamic thrust. This breathing pattern may quite simply distract the patients
attention from the impending manipulation by reducing muscular tension, maintaining trunk flexibility
and patient control.
Tension in the contact arm/shoulder girdle should take place only during the final stages of the
manipulative skill towards the end of the breathing cycle. This tension should be applied gradually.
All aspects of the sequence are equally important.

Ischial tuberosity (IT) contact


This anatomical landmark contact point is commonly used for adjustments/manipulations for
sacroiliac joint flare dysfunction. This adjustive procedure is driven by modified standing and prone
sacroiliac joint palpation and provocation tests (Byfield 2002).
This manipulative procedure involves the same sequential steps previously described for the
PSIS contact above and side posture skills in Chapter 5 up to where the contact hand is applied to the
IT anatomical landmark. It should also be pointed out that the IT represents a very large and broad
contact that has a tendency to distribute the manipulative forces over a wider area, (Figs 8.18 -
18.22). With this in mind, the muscular power required for this set of skills may seem to exceed the
students capabilities. Keep this in perspective and concentrate on the slow movement and gradually
develop the necessary strength to perform an efficient overall manipulative procedure. The majority
of the muscular power is used only at the end of the sequence, just as the preload is applied, and
during the manipulative thrust itself. On a clinical note, this particular manipulation is not
recommended during the treatment of suspected lumbar intervertebral disc herniation (Cassidy et al.
1993). This is a clinical observation but recent evidence would suggest that this
adjustive/manipulative procedure tends to cause flexion of the lumbar spine or flattening of the
lordosis which stresses the posterior passive structures, thus jeopardizing spinal stability at the end
range of full flexion. This could potentially place the disc under excessive compressive loads,
contraindicating this particular procedure.

1) To develop tension in the surrounding soft tissues, three simultaneous actions are required.
i) The contact hand is pulled caudad and around the IT drawing tissue and at the same time the
contact arm is brought in toward the body in a slow controlled scooping movement (arm is
extended and adducted across the chest wall) (Fig. 8.18). This causes dorsiflexion (extension)
of the wrist during this movement (*).
ii) The student/clinician assists the innominate flexion by pivoting and moving the hips cephalad
with the knees bent and feet planted hip distance apart at the same time, thereby keeping the
torso in the same position, which is now positioned behind the contact point. There is only a
minimal pivot shift into a semi-fencer stance (not 45 to table) (Fig. 8.19). If additional
tension/leverage is required, the patients leg is allowed to drop towards the floor marginally
via the thigh sandwich control.
iii) As the hips pivot forward, the practitioners torso becomes positioned closer and behind the
contact hand and arm for additional support, shortening the levers (Fig. 8.20). The contact arm
is positioned close to the body to reduce any torsional effects. This is a very large and stable
structure that cannot be moved by the arm only. Effective use of the shoulder girdle and the
body weight will minimize any excessive mechanical effects. The torsion in the lumbar region
is minimal (*). Appreciation of both joint and soft tissue tension and the muscular force
required for joint preload should be introduced gradually.
2) The indifferent hand (right) adds slight traction and downward pressure in a cephalad direction.
The indifferent arm is kept close to the practitioners body (Fig. 8.20).
3) An alternative forearm contact may be used and is just as effective. The flexor region of the contact
forearm contacts the IT in the same way as the pisiform/hypothenar contact (Fig. 8.21). The arm is
pulled toward the body in a similar scooping action to cause flexion of the innominate. The use of
this contact does not subject the shoulder girdle to the same physical demands. Note the lack of
torsion in the lumbar spine (*). The arm is adducted towards the body to assist the appropriate
tension.
4) There is one major error to be aware of while learning this particular set of manipulative skills
combined with those already presented in the section on PSIS contact (above).
Figure 8.18
Figure 8.19

Figure 8.20
Figure 8.21

The practitioners torso drifts ahead of the contact point, increasing the mechanical stress on
the arm and shoulder (Fig. 8.22). This places the centre of gravity at a disadvantage. The whole
body moves forward during the hip pivot action in the cephalad direction, causing unnecessary
torque of the student/clinicians shoulder. As a result of the lack of an efficient scooping action of
the contact arm and hand to assist flexion of the innominate, the student attempts to push the IT
cephalad against considerable resistance (Fig. 8.22).
Figure 8.22

Sacral base (SB) contact


This anatomical landmark contact point is often used for adjustments/manipulations to correct
sacroiliac dysfunction. The sacrum represents a smaller anatomical landmark and lever compared to
the larger PSIS and IT, which may provide additional biomechanical advantage to both the patient and
the manipulator. Nonetheless, a substantial amount of control is necessary to manoeuvre the small
levers prior to the dynamic thrust. The biomechanical effects upon the joint should be almost
identical. This particular contact point may have more direct biomechanical effect upon the
lumbosacral joint merely from its proximity and anatomical location.
This particular manipulative skill is almost self-explanatory. The anatomical contact point is on
the sacral base just superior and lateral to the second sacral tubercle, (Figs. 8.23 - 8.26). The
sequence of skills is exactly the same as that described and practised for the PSIS contact, except for
some minor modifications related to the contact hand and arm and the position of the practitioner. The
angle of the sacroiliac joint to the vertical or y-axis will have an influence on the direction of the
preload and manipulative thrust. The joint is angled laterally from the vertical line. This will be
described in the next sequence of adjustive skills. The side posture positional skills have previously
been described. Position the patient accordingly.

1) The hypothenar or thenar contact points are used for the sacral base/sacroiliac joint contacts. The
hypothenar is the easiest adaptation already described above for the PSIS; however, the thenar
provides an excellent contact point for this configuration. Everything is the same for this base
contact, already described for the PSIS sacroiliac procedure, except that after the tissue has been
drawn, the contact hand is placed just lateral to the first sacral segment or just superior and medial
to the PSIS on the base of the sacrum (Fig. 8.23). Then proceed with the other steps as described
above. Remember, the bridged hand posture is essential. Note the symmetry in the shoulder girdle,
the position of the body weight over the contact point and the lack of torque in the shoulder. The
elbow has to drop slightly to accommodate the angulation of the sacroiliac joint.
2) The thenar eminence contact is slightly more difficult to perform as the wrist is pronated, which
may cause some torque at the shoulder joint (*) (Fig. 8.24). Note the symmetry of the shoulders.
The practitioner slowly rotates the pelvis forward as the body weight drops to develop preload
prior to the dynamic body drop thrust or mobilization procedure. Note the angle of the contact arm
accommodating the specific anatomical line of the sacroiliac joint.
3) As a result of the movement of the arm to position the thenar contact, the shoulder has to rotate
forward. To reduce this effect upon the shoulder girdle structures the practitioners torso has to
move their centre of gravity cephalad (Fig. 8.25). This is not the most advantageous posture for the
optimal use of the practitioners body weight and the efficiency of the overall manipulative skill.
The thenar eminence offers advantages in terms of comfort and ease of localization. Contacting the
sacral base on the side in contact with the table (contralateral joint/lesion down) offers stability for
the patient and may accommodate symptoms. During this procedure the arm is angled toward the
table to come in line with the sacroiliac joint to improve the efficiency of the procedure either as a
manipulative thrust or mobilization (Fig. 8.25).
4) As described previously, there are similar errors to be aware of while learning this set of
manipulative skills.
Figure 8.23
Figure 8.24
Figure 8.25

The most common one encountered for both the hypothenar/pisiform and thenar contacts is the
excess torque of the shoulder when the hand contact is made (Fig. 8.26). The shift of the body
weight forward reduces the efficiency of the manipulative response. Care must also be taken to
accommodate the angle of the sacroiliac joint for both lesion up and lesion down skills.

Figure 8.26
Summary
This chapter has presented three of the most common anatomical landmarks used for manipulative
procedures associated with dysfunction of the sacroiliac joint. The presentation has been careful not
to overemphasize the dynamic thrust but has, more importantly, stressed the sequence of skills for
both patient and practitioner up to the point of joint/tissue tension and the application of joint preload.
The dynamic thrust is a highly skilled manoeuvre that should be introduced only after proficiency
in all other aspects has been demonstrated. Finesse, control and balance have been highlighted.

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Further reading

ogduk N., Twomey L.T. The lumbar muscles and their fascia. In: Bogduk N., Twomey L.T., editors.
Clinical anatomy of the lumbar spine. second ed. Edinburgh: Churchill Livingstone; 1991:83-105.
earcy M. Biomechanics of the spine. Curr. Orthop.. 1989;3:96-100.
Chapter 9

Lumbar spine adjustive and manipulative skills

David Byfield

Chapter contents

Introduction
Low back pain prevalence
Source of low back pain
Lumbar biomechanical and stability considerations
Role of manipulation for low back pain
Manipulative considerations
Summary
Manipulative skills
Double spinous process (DSP)
Single spinous process (SPP)
Spinous hook/pull
Spinous push
Mamillary process/interspinous space
Summary
References
Further reading
Introduction
The quantity of information, research and clinical evidence concerning all aspects of the lumbar spine
and its link with low back pain continues to grow exponentially. It is certainly not the intent of this
chapter to present this subject matter in its entirety, as there are simply just too many reputable
databases, textbooks and journals that cover this area of musculoskeletal medicine. As far as these
publications are concerned, they were developed, written and researched by some of the most
contemporary authors worldwide who have increased our understanding and appreciation of such a
complex subject matter. The author will refer, where applicable, to these works throughout the
chapter.
Therefore, the main objective of this part of the chapter is to provide an overview of current
views and evidence regarding the lumbar spine and its relationship to lumbar manipulative skill
acquisition particularly at the undergraduate level.
Low back pain prevalence
The social impact of low back pain has been described as enormous and extremely costly in terms of
treatment and lost productivity (Dagenais & Haldeman 2012, Epker & Block 2006, Waddell 2002,
2004, Waddell et al. 2002). There is little doubt that low back pain affects the quality of life for a
substantial number of people in contemporary Western society (Waddell 2002, 2004). It has also been
suggested that modern societies are currently facing an epidemic of lower back disability that, until
recently, was rising exponentially and the magnitude of this problem is clearly indicated by the
statistic that 6080% of the general population will suffer low back pain at some time during their
life (Waddell 2004).
It goes without saying that chronic back pain represents the most rapidly growing form of
disability (Waddell 1996, 2002, Waddell et al. 2002). More alarming is the fact that there appears to
be no evidence of any major change in the nature, severity, or knowledge of the biological basis of
back pain (Waddell et al. 2002, 2004). However, there is some evidence that this trend may be
changing, particularly in the United Kingdom, not as the result of any biological changes but more
likely because of social, cultural and social security shifts (Waddell & Aylward 2001).
Musculoskeletal pain is both multidimensional and multifactorial in nature, therefore the potential
aetiological parameters associated with low back pain are wide ranging. There have been repeated
attempts by the back pain community to redirect and focus the attention of the healthcare providers
towards the view that the problem is more of a comprehensive psychosocial dilemma rather than a
single identifiable lesion (Waddell 2002, Waddell & Aylward 2001, Waddell et al. 2002, Waddell
2004).
The aetiology of most spinal pain remains obscure. In many cases the cause is unknown,
primarily as a result of the complexity of the pathophysiology which remains a poorly understood
chain of events. Even though there is little agreement upon the nature of the aetiology of low back
pain, a range of clinical models, management strategies and clinical guidelines have recently been
developed in a number of countries based upon the available best evidence regarding natural history,
biomechanical characteristics and therapeutic effectiveness (Bigos et al. 1994, European Back Pain
Guidelines 2005, Kirkaldy-Willis et al. 1978, NICE Guidelines 2009, Waddell & Burton 2001,
RCGP 2001). There is no doubt that a sedentary lifestyle, escalating socioeconomic tensions and a
limited understanding of the pathomechanical aetiology of back pain have contributed to the problem
in the industrialized world. Biomedical treatment and management of back pain have apparently
failed due in part to the passive role and a sustained focus on single structural disorders. This
seemingly limited approach has been supplanted by more clinically relevant functional, psychosocial
and environmental factors (biopsychosocial model). This contemporary management strategy is based
upon current best research evidence, clinical experience and patient needs; it is far more
comprehensive and patient focused (Engel 1982, Waddell 2004). A complete review of the approach
to back pain management has produced sensible, evidence-based national clinical guidelines which
promote:

differential diagnosis of serious pathology (12%)


early intervention
effective therapeutic interventions (manipulation/analgesics)
the value of patient reassurance/education
continuing daily activities/exercise/rehabilitation
cognitivebehavioural strategies
prevention of long-term chronicity and disability.

To participate in such an interdisciplinary integrated approach, the chiropractic community must


sanction contemporary principles of evidence-based care in the treatment and management of various
musculoskeletal conditions, such as back pain, and include:

diagnostic triage
early diagnosis/early intervention
skilled manipulative/manual care
rehabilitation expertise/exercise therapy
sound advice/reassurance
biopsychosocial factors
prevention of chronicity
patient-focused care.

These clinical activities are all vital components of most national clinical guidelines for back
pain, as mentioned above. In fact, it is this very exercise that will define chiropractic in the future,
specifically the participation and co-management of common musculoskeletal conditions and the
shared research with a wide range of other professionals. As participants in this area of healthcare,
the chiropractic profession must modernize and lead the way in terms of patient care and promote its
unique, safe, cost-effective, effective and skilful therapeutic methods (Hartvigsen et al. 2011). The
authors direct the readers to many fine published works dedicated to this particular subject, including
The Back Pain Revolution by Waddell (2004), Managing Low Back Pain (4th edn) by Kirkaldy-
Willis and Bernard (1999), Low Back Disorders Evidence-based Prevention and Rehabilitation
by McGill (2002) and Low Back Syndromes Integrated Clinical Management by Morris (2006),
Evidence-based Management of Low Back Pain by Dagenais and Haldeman (2012). These texts will
set the stage and provide valuable background to this area of healthcare for both student and
practitioner.
Source of low back pain
The posterior lumbar spinal joints and the sacroiliac joints have been identified as a source of
uncomplicated, mechanical and referred low back pain syndromes (Bogduk 1995, Maigne et al. 1996,
Quon et al. 1999, Schwarzer et al. 1995). It stands to reason that understanding the role of the
posterior joints (intervertebral facet or zygapophyseal joints) and sacroiliac joints is integral in
interpreting the complex issues surrounding low back pain syndromes and effective management
(Dreyfuss et al. 1995, Dudler & Balague 2002, Schwarzer et al. 1995).
It is only by developing a greater understanding of the pathophysiology that a more accurate
diagnosis and, therefore, appropriate management, is possible. Resolving the actual cause of the
problem from within, such a multiplicity of pain-producing structures, requires highly developed
clinical and diagnostic skills.
Despite such a vast number of available technological and other clinical procedures, the
scientific literature has not significantly changed its conclusion that in up to 85% of all low back pain
episodes the exact cause remains unclear (Dudler & Balague 2002).
The terms non-specific or simple mechanical low back pain or syndrome are clinically
sound for the majority of patients because they reflect the fact that the nociceptive source and precise
pathophysiology are primarily unclear. A syndrome is simply a collection of signs and symptoms that
do not necessarily reflect the true pathogenesis. Moreover, it must be taken into consideration that
most of these terms enjoy only limited acceptance by the scientific community and are viewed with
scepticism by the medical community. In reality, clinicians have an obligation to their patients to make
an attempt to resolve this dilemma and employ all aspects of their knowledge and clinical experience
to develop a diagnostic profile. Is a precise diagnosis really necessary when a number of modalities
have shown general success without an exact identification of the tissue source? It is these sorts of
questions that require an in-depth analysis based upon basic research and clinical investigation.
Future endeavours will hopefully provide some necessary solutions.
Lumbar biomechanical and stability
considerations
This is a very broad and complex topic. The author refers you to Chapter 3 for an excellent
presentation regarding some of the pertinent biomechanical properties and characteristics related to
both the lumbar spine and sacroiliac regions and related issues concerning the biomechanics of
manipulation. In addition, there are excellent textbooks highlighting in detail the biomechanics of the
lumbopelvic region (Adams et al. 2002, McGill 2002). These publications provide essential
supplemental reading regarding back pain and the functional rationale concerning the intervertebral
disc and facet joints that extends well beyond the scope of this particular chapter. The intricate
biomechanical interaction of these various posterior joint complexes makes this an intriguing clinical
dilemma and challenge from both a diagnostic as well as a functional management perspective
(McGill 1999, 2000).
This biphasic nature of spinal motion allows minimum energy expenditure for movements around
the neutral position, but provides opposition to potentially damaging movements at the end of the
range and is vital in understanding the concept of spinal and pelvic stability during the normal
activities of daily living, which is covered in Chapter 3 of this text. This suggests that, although an
individuals overall range of spinal motion may be within normal limits, an increase in the NZ would
indicate instability. This region of low bending moment is a fairly constant proportion of the range
and, therefore, should not be expected to change under normal circumstances (Adams & Dolan 1991,
Dolan & Adams 1993). For clinicians who use manual techniques, such as manipulation, segmental
instability is one entity that ought to be recognized clinically, particularly with todays understanding
of spinal function and stability concepts.
This certainly has clinical implications in terms of joint stability and the role of the various
functional components in this particular scheme. Panjabi (1992) proposed a spinal stability model
comprised of three interdependent components, including neural, muscle and ligamentous elements
that function to maintain overall spinal stability when carrying out basic movements. This particular
model highlights the basis for understanding lumbopelvic stability, case management, rehabilitation
and injury prevention. It also emphasizes a more global mechanical view of these pain syndromes and
a more global view of case management that incorporates a wide range of interventions.
McGill (1998) suggests that most back injury occurs due to trivial movements as a result of
functional instability rather than of frank trauma. This view concurs with Panjabis multidimensional
stability model which has active, passive and neural control elements (Panjabi 1992). All these
features must, therefore, be addressed during case management to ensure restoration of stability to the
lumbar spine and to control the number of future episodes, thereby preventing recurrent buckling
events (McGill 2002). In its simplest form, motion segment buckling behaviour represents a local,
uncontrolled mechanical response to spine load environment that manifests clinically as a set of
symptoms (Triano 2000). Empirically, this phenomenon has been observed to occur in the lumbar
spine regions with critical loads as low as 20 N and as high as 18,000 N measured during activities
of daily living (Cholewicki & McGill 1996).
Chiropractic management of lumbar pain syndromes typically involves manipulation of various
joints (restrictions), which is meant to increase the range of motion of the segment. More motion
means less joint stiffness and stability. This may be a clinical paradox as it would appear that
manipulation alone is incapable of restoring spinal segmental stability, particularly since patients
with chronic low back pain demonstrate segment-specific multifidus atrophy that does not recover as
the symptoms subside (Hides et al. 1996, 2001). It has also been shown that chronic back pain
patients who exercise to improve lower back stability, strength and endurance have fewer recurrent
episodes (Richardson et al. 2002). Therefore, chiropractic management takes on a multi-purpose role
implementing appropriate tools to help restore and maintain overall stability.
The structures of the lumbar spine are biologically and biomechanically well designed and more
than capable of withstanding and transferring significant mechanical loads while performing normal
tasks of daily living. Torsional loads that would normally damage the facet joints have been shown to
have no effect on the integrity of the disc (Adams et al, 2002). Under normal conditions within the
physiological range of movement, there is minimal strain on the disc. Excessive torsional strain will
be resisted by the intact facet joint (Stokes 1988), which, if applied repetitively, may disrupt the axis
of motion, increasing the lateral shear across the plane of the disc, causing torsional failure and
peripheral tears in the annulus (Bogduk & Twomey 1991, Kirdaldy-Willis & Mierau 1999).
Clearly, the intervertebral disc is not totally exempt from injury. It has also been reported that the
intervertebral disc is under substantial compressive stress during full flexion range only (McGill
2002). This reinforces the recommendation of avoiding repetitive lifting at full end-range flexion. The
disc has also been demonstrated to prolapse gradually over a period of time as a result of cumulative
microtrauma from repetitive compression and flexion loads. These mechanisms, sudden or insidious,
are common aetiological processes seen clinically with patients presenting with both acute and
chronic low back pain. The lumbar spine in a neutral lordotic posture can sustain very large forces as
a result of the tension developed in the posterior ligamentous and muscular systems, which includes
the joint capsules and the interspinous and supraspinous ligaments (Adams & Hutton 1986). On the
other hand, McGill (2002) has emphasized the need to maintain a neutral spine or lordosis (that
position between extreme flexion and extension as determined by pelvic forward and backward tilt)
during the performance of a number of common tasks, which provides more inherent stability. The
neutral or slightly flexed spine or lordosis concept is defined as a lordotic lumbar spine which
typically avoids extreme end-range motion in either flexion or extension, thereby avoiding excessive
compressive and shear loads at the discal and facet levels (McGill 1998). This has been thoroughly
described in Chapter 5 dealing specifically with postural considerations for the practitioner. This
concept will be introduced later in the chapter when specific manipulative skills are presented for the
lumbar spine.
In terms of side-posture rotational manipulation, the lumbar spine is normally flexed, which
increases the tension in the posterior ligamentous system. One of the more important manipulative
skills is the ability to isolate a specific group of motion segments and concentrate the thrust force by
selectively using the posterior elements to stabilize the segments above and below the targeted
region, minimizing force dissipation and injury to neighbouring tissues.
Unfortunately, this view has been challenged recently by investigators who assessed the
accuracy and specificity of manipulation in the thoracic and lumbar spine (Ross et al. 2004). Their
data suggest that spinal manipulation is not as accurate as once thought, which will undoubtedly have
some impact on undergraduate training and clinical expectations.
Maintaining a passive lordotic spine of the patient during side posture may impair the protective
effects of the posterior ligamentous system, leaving the posterior joints and contractile tissue
susceptible to injury during rotational manipulation which, it may be argued, will need to be more
forceful combined with greater amplitude as a result of the lack of posterior element tension. These
mechanical properties may provide a rationale for safe and controlled manipulative procedures. The
fact that the patient is in the non-weight-bearing posture could minimize the mechanical effects of the
posterior ligamentous system. This will be addressed in greater detail later in the chapter when
dealing specifically with various manipulative psychomotor skills.
Role of manipulation for low back pain
Meade et al. (1990) concluded that chiropractic manipulative management was highly successful in
the long-term management of chronic and severe forms of low back pain compared with outpatient
hospital care. A follow-up study conducted 3 years later demonstrated that chiropractic management
conferred worthwhile, long-term benefit, mainly with chronic or severe pain compared with
outpatient hospital care (Meade et al. 1995). More recently, Bronfort et al. (2010), in a systematic
review of the manual therapy literature, found that the evidence of the effectiveness of
manipulation/mobilization for chronic low back pain was very positive and of high quality when
compared with other modalities. The publication by Bronfort et al. (2010) is accompanied by
supportive commentaries by two very prominent researchers, Professor Scott Haldeman and
Professor Martin Underwood (2010). The UK BEAM trial investigating low back pain care across a
number of professions (chiropractic, osteopathy, physiotherapy) developed common terminology and
procedures related to manipulative intervention for a consistent methodological approach (Harvey et
al. 2003). This demonstrates that the three primary manipulative providers share far more similarities
than differences with respect to manual procedures, which may benefit the public and policymakers in
the long term.
Therefore, the effectiveness and safety of spinal manipulation for the treatment of low-back pain
can no longer be justifiably called into question, as reported in a number of high-quality systematic
reviews of randomized clinical trials and meta-analyses (Assendelft et al. 2003, 2004, Bronfort et al.
1996, 2004, Koes et al. 1996, Rubinstein et al. 2011, Shekelle et al. 1992, van Tulder et al. 1997,
1998, Waddell 1998, 2002) and most recently by Bronfort et al. (2010). A number of high-quality
studies have also demonstrated that the efficacy of spinal manipulation is enhanced when combined
with other proven modalities, such as a rehabilitation exercise programme (Bronfort et al. 1996,
Skargren et al. 1998). This combined therapeutic effect of manipulation/mobilization plus exercise
has also been demonstrated in the management of patients with mechanical neck disorders (Gross et
al. 2004). The author feel that manipulation/mobilization provides an effective therapeutic option for
a range of patients, particularly those presenting clinically with non-specific mechanical back pain.
The healthcare community will have to accept the fact that back pain is a complex clinical condition
requiring interprofessional cooperation and expertise. This does have considerable resource
implications, yet any strategy to stem the development of chronicity and long-term disability should
be worth investigating considering the current overall cost to society.
The issue of safety is always of great concern with any therapeutic intervention and the
chiropractic profession as a whole is acutely aware of this important clinical issue. This is
predominantly relevant in an evidence-based healthcare model where public safety and patient needs
are paramount. We know that there are common side-effects following spinal manipulation that are
generally benign and self-limiting in nature (Leboeuf-Yde et al. 1997). With respect to side-posture
manipulation of the lumbar spine there are very few case reports alleging lumbar disc herniations
either caused or aggravated by the intervention (Slater & Spencer 1992). Furthermore, there have
only been 14 cases of cauda equina syndrome reported in the literature from 1911 to 1989 following
lumbar spinal manipulation (Haldeman & Rubinstein 1992b). The true number of cases of severe
side-effects following lumbar spinal manipulation has been, according to Shekelle (1994), probably
under-reported in the literature. Nevertheless, he estimates the risk as being as low as 1 case per 100
million manipulations, suggesting that the risk is extremely rare. The issue of postmanipulative
fractures is also of great concern since a larger number of elderly patients with osteoporosis currently
seek chiropractic care (Haldeman & Rubinstein, 1992a). This is discussed in great detail in Chapter
14, which deals specifically with manipulative skills for the elderly population. Therefore, it would
be safe to assume under these conditions that spinal manipulation provided by skilled practitioners is
a viable therapeutic option in the comprehensive management of common musculoskeletal conditions
such as low back pain (Vautravers & Maigne 2003). Practitioners also have an obligation to manage
any potential risks associated with manipulative intervention and weigh these against the benefits to
the patient, which are formulated via an informed consent protocol.
With respect to practitioner skill, several factors have been identified as being at least partially
responsible for the complications of manipulation of the lumbar spine, including inadequate history
taking, insufficient patient assessment, lack of diagnostic knowledge, diagnostic errors, incompetent
technical skills and inappropriate technique selection (Kleynhans 1980, Terrett & Kleynhans 1992).
Finesse, correct positioning of the patient and technique, manipulation of the relevant area of the
spine, as well as standardized patient assessment, are all factors that may reduce the number of
complications. It becomes clearer that the clinical efficiency and consistency of spinal manipulative
therapy depends not only upon the use of clever skills, but also on the combination of these skills with
an in-depth knowledge base, upon which meaningful decisions can be made concerning patient care.
This will be discussed in more detail later in the chapter.
Manipulative considerations
Manipulation is a physical therapeutic process involving the transfer of large loads, which introduces
a potential health risk to the provider (applicator) and, possibly, the recipient. The potential risk to
patients has been discussed in respective chapters dealing with specific regions of the spine.
Nonetheless, when performed by highly skilled practitioners these procedures are very safe and
highly effective (Triano 2000). This is essentially the overall message of this text, which describes
many common diversified manipulative procedures in a step-by-step sequence focusing on precise
movement skills, posture and control. The book also emphasizes the importance of patient control,
weight distribution and apparent loading on the patient. Moreover, Triano (2000) states that very little
consideration has been given to the effect these procedures may have on the applicator, particularly
over time with respect to potential overuse injuries. The chiropractor is at risk of injury in several
regions, including the wrist/hand, shoulder girdle and lower back, as a direct result of the nature of
the application of therapeutic loads delivered via a dynamic manipulative thrust. This has been
discussed in detail in Chapter 5 of this text, but it would be appropriate to reiterate that chiropractors
are vulnerable to the mechanical effects of prolonged static postures and sudden overloads during
patient preparation. More work is required to develop training protocols to measure loads and
determine optimum positioning during undergraduate training to ensure that psychomotor skill
acquisition is optimal.
Triano (2000) has identified patient transfer as the most precarious task in patient care with
respect to risks to the provider. He identifies a number of transfer tasks including pushing, pulling and
lifting actions to assist the patient in preparation for the delivery of the manipulative procedure.
These specific psychomotor skills have been described in detail in most chapters in this text,
particularly with regards to the side posture depicted in detail in this chapter. It should be pointed out
that these skills are highlighted as part of a number of foundational skills included in the entire
manipulative procedure that are of equal importance to the overall performance. This text provides a
number of strategies that address many specific psychomotor skills related to manipulative
performance. Naturally, more work is required to determine more quantifiable data dealing with the
acquisition of these skills.
Many researchers have measured the various forces both generated by manipulation through the
applicator and those absorbed by the patient (Herzog 1996, 2000, Herzog et al. 1993, 1999, Triano
2000). These forces have been found to be well within mechanical tolerance thresholds for the tissues
of the lumbar spine with respect to those transferred to the patient by the practitioner. Triano (2000)
has written the most comprehensive work concerning the biomechanics of spinal manipulation
relative to tisssue behaviour, forces involved and clinical scenarios. This is well beyond the scope of
this textbook, but is within the remit for all those who embark on manipulative skills training. For this
readership Triano (2000) is essential, as there is an intelligent attempt to combine known
biomechanial principles with manipulative skills delivered in a clinical setting and with the
management of complex spinal syndromes. Triano (2000) goes on to say that lesions of the spine may
have aetiologies, complications and treatments that are mechanical in nature and subject to
mechanical laws. The buckling concept from a biomechanical perspective seems to provide an
understanding of manipulation strategies to assist in patient recovery. Triano (2000) unites various
observations and hypotheses underlying manipulation and transforms these thoughts into a systematic
approach based upon sound biomechanical principles that will generate innovative research and new
ideas. This will enhance both educational development and research initiatives. In fact, Triano (2000)
goes on to affirm that, professional competence comes from training followed by regular practice
and spinal manipulation has survived the challenges of time and has withstood scientific inquiry.
Manipulation performed in the side-posture subjects the lumbar spine to both long and short
levers in order to achieve joint preload at the biomechanical transition point (Bergmann & Peterson
2011, Triano 2000). This is an inherent feature of side posture as both the upper torso and lower
pelvis/limbs are involved in the procedure. Therefore, methods to control and minimize long-lever
action and emphasize short-lever action would clearly be clinically advantageous. Patient comfort is
also a primary consideration, particularly with the fact that most patients present in pain and low back
pain is one of the most common conditions seen by the chiropractic profession. The point of counter-
rotation or maximum mechanical twist is achieved by flexing the lower leg towards the chest, thereby
flattening the lumbar lordosis, creating tension in the posterior ligamentous system and protecting the
segments below (Bergmann & Peterson 2011, Cassidy et al. 1992a). This procedure has been
described in great detail in Chapter 5. Gently pushing the patients torso slightly posterior from the
midline and lightly down towards the table produces tension in the posterior ligamentous system
above the point of counter-rotation, which essentially focuses the manipulative forces to theoretically
one intervertebral level (if possible) or region of dysfunctional motion segments (at best). Directing
the patient to breathe in and then out just prior to the manipulative thrust introduces the small, but
stabilizing effect of increasing the intraabdominal pressure (Byfield 1991). This procedure also
assists the patient to relax and stiffens the thoracic spine and rib cage to protect these structures. Any
increase in the intrathoracic tension would provide a more solid base of support for the practitioners
indifferent (support) hand and body weight. Therefore, the concept that the disc is susceptible to
excessive rotational strain is no longer justified in view of the biomechanical and clinical evidence
available as per the known biomechanical behaviour discussed above and referenced throughout this
chapter. This is also an extremely safe procedure in light of the biomechanics of the lumbar spine
tissue properties, and the fact that there is a noticeable void in the literature regarding any adverse
side-effects.
Summary
Those in the chiropractic profession are capable of playing a key role in the future management and
rehabilitation of musculoskeletal syndromes, particularly chronic back pain, neck pain and headaches
(Mierau 2000). Chiropractic professionals possess all the elements to fully accept this responsibility
with understanding and clinical expertise. This chapter has briefly reviewed the literature concerning
low back pain and manipulative intervention. The literature clearly demonstrates that low back pain
is still a major consideration for all modern societies, in terms of long-term disability and overall
cost. The literature also supports manipulative intervention as a safe and effective therapeutic option
for acute and chronic low back pain. This chapter also indicates that the chiropractic profession is
developing training programmes and innovative research protocols to investigate the learning and
acquisition of complex manipulative psychomotor skills.
Manipulative skills
The following manipulative skills represent the basic and fundamental movements required to
perform safe and efficient side-posture manipulation, the most common position for manipulation of
the lumbar spine. The skills section will concentrate on the introduction and use of both long and
short levers, plus a sample of the more common errors encountered during the acquisition of these
complex psychomotor skills. The sequence of skills represents a series of building blocks which form
the basis of diversified side-posture manipulation. These skills are a continuation of the patient
positioning skills presented in Chapter 5 of this text. There are other postures, most commonly the
sitting and prone positions which, although frequently used, are generally considered more advanced
clinical skills that should be introduced later in the students undergraduate and postgraduate
technique development.
The skills presented should be learned as a sequence and executed slowly and methodically up
to the point of joint tension/preload prior to a mobilization or manipulative event. Each manipulative
procedure will incorporate several planes of movement to illustrate the concept of attempting joint
specificity and segmental isolation for focusing manipulative mobilization or manipulative thrust
forces at the biomechanical transition point (Bergmann & Peterson 2011). The key element is to
maintain patient control and relaxation at all times. This will enhance palpatory skills and provide
essential proprioceptive feedback information for the student. Deliberate movements and courteous
positioning of the patient will be stressed at all times throughout the procedure.
The manipulative skills in this text will concentrate on targeting the spinous and spinous lamina
junction of the L3/L4 intervertebral motion segment (functional spinal unit) as the anatomical/soft
tissue hand contact points. Specific reference to the posterior facet on the ipsilateral uppermost side
with respect to the position of the clinician during the description of the skills will be presented. The
following three specific anatomical landmarks will represent the specific contact points for the
manipulative skills discussed in this chapter:

1. double spinous process (DSP)


2. single spinous process (SSP)
3. mamillary process (MP) (interspinous space).

Additional psychomotor skills and specific manipulative procedures will be presented


throughout the chapter.
Double spinous process (DSP)
The manipulative procedure using this anatomical contact combination is often referred to as: (i) a
zygapophyseal rotatory adjustment (Paris 1983, Schafer & Faye 1989), (ii) modified Bonyun, (iii)
Bonyuns discal techniques (Bonyun & Brunner 1976), (iv) the double spinous rotary adjustment, and
(v) the double spinous hook/push technique (Gitelman 1980, Gitelman & Fligg 1992) otherwise
classified as a combined short-long lever specific contact procedure (Grice & Vernon 1992). It has
also been described as THE technique of side-posture manipulation (Cassidy et al. 1985, 1992a,
1993). The double spinous procedure is presented initially as it provides the basic hand, arm and
body skills that will be required for many other lumbar side-posture manipulative procedures
illustrated in this chapter. (Figs 9.1 - 9.10)

1) Place the patient in the side posture as described previously in Chapter 5, with no torso rotation.
The patient should be positioned in a stable fashion and secure on the table. The
practitioner/student is positioned at 90 to the patient with the patients top leg flexed to 90 and
secured between the practitioners legs (thigh sandwich) (*) (Fig. 9.1). The practitioners body
weight is forward over the patient and the upper body is stabilized with the clinicians indifferent
hand. The patient should be positioned in a line along the central axis of the table to decrease
excess twist in the trunk. The patients thigh of the lower leg should be parallel to the edge of the
table and slightly flexed at the knee to provide more stability.
2) With the practitioner in this position (Fig. 9.1) the patient is requested to interlock the hands
around the mid-forearm region (Fig. 9.2A). This is the average position of the hands. If the patient
has particularly long or short arms then adjust the position accordingly. Make sure the patient is
secure on the table before attempting this procedure. This is mandatory because if the patient is too
far forward they will start to roll off the table. To improve this stability, ensure that the patients
lower shoulder is brought forward and that they are lying on the back of the scapula as opposed to
the point of the shoulder (Fig. 9.2B).
3) The clinician/student then brings the cephalad arm under and through the patients interlocked arms
up to the cubital fossa. The forearm of the caudad arm is placed with the flexor side down over the
fleshy part of the buttock just below the pelvic crest (*). Care is taken not to place the caudad arm
over the sciatic nerve at the postero-medial third of the pelvis. Both hands adopt a reinforced
fingertip contact posture (Fig. 9.3). Notice the position of the plumbline. Do not push down on the
patient at this point as this may cause some distress especially if they are in pain, particularly in the
rib-cage region.
4) Segmental/regional localization and intersegmental tension are accomplished by flexing the
patients hip beyond 90 (Fig. 9.4A), until the point at which the contact fingers begin to feel slight
tension or stretching in the L3/4 interspinous space (*). This is the point at which counter-rotation
is reached and no further hip flexion is required (Fig. 9.4B). This is a difficult skill, but an absolute
requirement for segmental specificity and isolation. Locating anatomical landmarks is the first step
to accomplishing this goal. There should be no pressure over the patient.
5) Once interspinous tension has been determined, double finger/spinous contact is made. Try to
stabilize hip flexion with a gentle thigh squeeze. L3 ipsilateral lateral spinous contact is made first
with the cephalad hand. The thumb of the caudad hand draws tissue slack down towards the table
followed by the reinforced finger pad contact of the cephalad contact hand. The DIP joints are firm
and extended (Fig. 9.5). The wrist and hand are in a goose-neck posture that is fully described in
Chapter 5.
6) The caudad hand hooks the contralateral lateral border of the L4 spinous by pulling excess skin
slack towards the practitioner. The finger pad contact follows by flexing the DIP joint of the middle
finger in the hooking process with the wrist and hand in a goose-neck posture (Fig. 9.6). The
contact points should be light and the hand postures should be relaxed at all times with no
tension or pressure over the spinous processes. Body weight should be directly over the contact
hands and the practitioner should still be facing the patient. Note the flat lumbar curve and the
relaxed upper back (*). Both contact hands are in the same goose-neck posture angled at 90 to
each other with a firm yet light contact on the osseous landmark. The thumbs are extended and out
of the way so as not to interfere with the overall hand position.
7) Pivot shift 45 to the low fencer stance bringing body weight slightly forward. Maintain patient hip
flexion with the thigh sandwich to secure segmental isolation and finger contact on each spinous
process (Fig. 9.7). Absolutely no force or pressure is to be applied to the contact hand or the
patients arms at this point. Patient comfort and cooperation are essential. The clinicians front leg
should lean against the edge of the table for added stability and control during this move.
8) Control patient leg drop to regulate the amount of tension in both the hip joint and lumbar spine
using the legs (*) (Fig. 9.8). The clinician must maintain a thigh sandwich by keeping the rear leg
perpendicular to the floor. The rear foot is plantar flexed (duff procedure) ready to shift the weight
forward and maintain the foot to hip distance ratio. Note the relaxed and symmetrical posture of the
practitioner.
9) Prior to the weight transfer, politely ask the patient gently to squeeze the cephalad arm against their
own rib cage to stabilize the upper body. Transfer the weight up and forward by plantar flexing the
rear foot. This brings the body weight over the targeted joint. The practitioners trail leg slides up
and over the patients tibia until it reaches the suprapatellar fossa while maintaining a thigh
squeeze (*) (Fig. 9.9A). The rear foot re-plants with the leg flexed at the knee and the foot plantar
flexed and the weight forward over the front leg (Fig. 9.9B).
10) As the weight drops slowly towards the table, the practitioner simultaneously and slowly pulls
the pelvis with the caudad arm towards the edge of the table and the cephalad arm resists the
patients forward movement by pressing down and slightly cephalad by flexing the shoulder
essentially pushing the torso cephalad and slightly posterior (Fig. 9.10). This maintains upper body
in a neutral position with very little torque (*). Be careful not to push down on the patients rib
cage and push back too far creating excessive twist in the lumbar spine which may cause more
distress for the patient. Remember to ask the patient to take a breath in as the clinicians weight is
transferred and breathe out slowly as the weight is brought down over the spine in time with the
various lever movements to create joint preload. The hand postures remain firm over the spinous
contact points to detect spinous and soft tissue movement. As the weight comes down and the arms
separate, tension/joint preload should be developing at the L3/L4 segment. Remember to breathe
and do not thrust. Feel the joint tension developing.
11) There are several errors to be aware of during the development of this manipulative procedure.
i) The standard over-rotation during weight shift causes excessive twist in the practitioners
upper and lower back; improper hand posture and contact affects force localization and
specificity; pushing the patients upper body back too far produces twist in the patients spine;
lifting the caudad arm off the pelvic contact completely changes the lever system.
ii) Applying excessive compressive or pushing force to both the upper body and the pelvic crest
of the patient.
Figure 9.1
Figure 9.2A
Figure 9.2B
Figure 9.3
Figure 9.4A

Figure 9.4B
Figure 9.5
Figure 9.6
Figure 9.7
Figure 9.8

Figure 9.9A
Figure 9.9B
Figure 9.10

The soft tissues of the pelvic crest region are very sensitive to pressure, especially when dealing
with painful mechanical syndromes of the lumbopelvic spine. The student/clinician may also risk
compressing the sciatic nerve if the arm placement is too low over the buttock, which could elicit a
painful response and a protective reaction by the patient. Additionally, compressing and leaning too
heavily on the rib cage will have a similar effect and may compromise patient breathing. Both will
potentially distress the patient and jeopardize the performance of the manipulative procedure. Other
faults to consider have been presented in Chapter 8 covering the sacroiliac joint. Foot spread, hip
flexion, posture and lumbar lordosis are all factors to consider in the area of potential errors.
The aim is to begin to appreciate the concept of joint resistance or tension prior to applying a
dynamic thrust. This should be seen as a gradual process throughout undergraduate training as with all
other psychomotor skills.
Single spinous process (SPP)
There are several manipulative procedures that use a single spinous process as an anatomical lever
point. These manipulations use the upper body, lower limb and pelvic structures as long levers to
produce a counter-rotation/transition at a specific segmental level. These manipulative procedures
are commonly referred to as the spinous hook or pull (Cassidy et al. 1993, Gitelman 1980, Gitelman
& Fligg 1992, States 1968, Szaraz 1984,) and the spinous push (Fligg 1984, Gitelman 1980, Gitelman
& Fligg 1992, Grice 1983, Szaraz 1984) adjustments and are classified as a combined shortlong
lever specific contact procedure (Byfield 2005, Grice & Vernon 1992). These manipulations are
performed in the side posture and present skills which are both common and unique, such as those
presented above. The skills presented in this section of the chapter are a continuation of the common
building skills already presented in Chapters 5 and 8 and this chapter (Figs 9.11A - 9.12). These
manipulative procedures use all the planes/axes of motion of a typical lumbar motor unit. A sensible
approach to segmental isolation and specificity is considered.
Figure 9.11A
Figure 9.11B
Figure 9.12

1) Place the patient in the side posture as described previously (Chapter 5) with the patients arms
folded with the hand placed on the anterior deltoid area and no torso rotation (Fig. 9.1). An
alternative arm configuration can be incorporated at this point and learned by the student which
includes bringing the arms lower and closer to the practitioner to reduce leverage (Fig. 9.2A). The
practitioner is in the starting posture perpendicular to the patient with hip flexed to 90 and parallel
to the table. The practitioners cephalad hand supports the patients upper body and the caudad arm
is resting on the lateral pelvic crest region just above the greater trochanter. The patients pelvis
should be at right angles to the table or just slightly supinated.
2) The L3/L4 intersegmental location and isolation is secured as described in Figures 9.1 and 9.2A
except that the interspinous space is palpated with the fingers of the caudad hand only (Fig. 9.11A).
Hip flexion is secured once tension and separation in the interspinous soft tissue of L3/L4 is
perceived (Fig. 9.11B). The practitioner is positioned in a ski stance at this stage with the patients
thigh secured in a thigh sandwich.
3) A reinforced fingertip goose-neck hand posture is formed with the caudad hand. The middle finger
is flexed at both the proximal and distal interphalangeal joints in a cup-like fashion and is placed
on the contralateral, lateral edge (down side) of the spinous process of L4 providing a hooking
action of the fingers. The middle finger of the cephalad hand can be used to pull any excess tissue
towards the clinician to make a more secure contact for the reinforced finger. The flexor aspect of
the forearm (fleshy part) is simultaneously and very gently placed over the posterior gluteus medius
portion of the pelvis just below the region of the pelvic crest and just above the greater trochanter,
forming a 90 angle. There should be no downward pressure of the arm on the pelvic musculature
or sciatic notch as this can be very painful for a patient already presenting with back and leg pain.
The arm and hand are basically placed in position with little or no tension. Monitor patient
relaxation and reactions at all times. Prior to the pivot shift and weight transfer, the practitioner
should be in a relaxed position with both cephalad and caudad arms and hands in position, with the
patients weight balanced on the table. Note the placement of the cephalad arm close to the
practitioners body (*) to shorten that lever and ensure control of the counter-rotation of the upper
body (Fig. 9.12). The patient is in line on the table. There is no downward pressure over the iliac
crest soft tissues or spinous process contact.
4) Pivot 45 maintaining patient control and hand contact position. Transfer weight by lifting and
flexing the plantar flexors of the back leg (this has been described in Chapter 8 (Fig. 9.13A).
During this action the contact arm is rolled slightly forward on the pelvic position, increasing the
angle at the wrist to increase the leverage and also ensure that the forearm contact is not placed
over the sensitive lateral hip soft tissues (gluteus medius) (Fig. 9.13B).
5) With the weight positioned over the contact hand, the practitioner slowly lowers body weight
towards the patient and simultaneously slowly pulls the contact arm back towards the body pulling
the pelvis anterior at the same time, using the thigh sandwich to facilitate this action (Fig. 9.14A).
The support arm/hand maintains the upper body in place on the table being careful not to push
posterior. This provides the mechanism for counter-rotation to develop the transition point. The
main component of counter-rotation and tissue/joint elimination is a direct result of the anterior
movement of the patients pelvis towards the table (Fig. 9.14B). The cephalad hand holds the upper
torso down on the table with minimal superior and posterior traction. The purpose of the support
hand is to secure the patient on the table and help to stabilize the clinicians weight. The support
arm blocks forward movement of the patient. The hand posture is maintained throughout the entire
procedure. The patients leg lever is supported by the thigh sandwich and is slowly brought down
towards the table/floor to increase leverage at the transition point (Fig. 9.14C).
6) With the practitioners weight forward over the front leg and coming down through the patients
leg, the contact arm very slowly continues to pull the pelvis forward by keeping the arm close and
tucked into the body. This ensures that all the tissue slack is taken out (end of the passive range of
motion near the elastic barrier) and the segments below the L3/L4 are stabilized (Fig. 9.15A). The
pelvis continues to roll anterior to increase counter-rotation (Fig. 9.15B). The cephalad arm is also
kept in close to the body to make the practitioner more compact during preload and subsequently
prior to the delivery of a mock thrust at the end of the passive range of motion. At this point only
appreciate the tension. As the weight is coming down on the patient instruct him to breathe out to
assist the weight transfer, maintaining appropriate hip flexion, thigh sandwich and leg leverage to
assist in developing the transition point. Note the position of the plumbline, indicating the position
of the body mass. Compare the subtle movements between Figure 9.14 and Figure 9.15. The hand
posture is maintained throughout the entire procedure. There should be no pressure down on the
pelvis. The action is purely a pulling one.
7) There are several common errors to be aware of during the learning of this manipulative
procedure. The errors associated with this manipulative skill are the same as those encountered
with the double spinous skills and other side-posture procedures thus far including: (i) over-
rotating and twisting the spinal elements at the wrong level; (ii) poor hand skills and goose-neck
hand posture; (iii) excessive body weight and compression over the sensitive tissue of the buttock
region; and (iv) permitting the patients leg to drop below the 90 threshold of hip flexion which
may compromise segmental specificity.
Figure 9.13A
Figure 9.14A
Figure 9.14B

Figure 9.14C
Figure 9.15A
Figure 9.15B

Figure 9.16 illustrates several errors listed above including:


i) over-rotating the practitioners upper back
ii) pushing the patients upper body too far back excessively twisting the spine
iii) applying downward pressure on the sensitive iliac crest instead of pulling
iv) loss of hand posture on the spinal segment (*).
Figure 9.16

1) A reinforced middle finger in a goose-neck hand posture is placed on the ipsilateral lateral edge or
spinous lamina juction of L3. The skin slack is initially removed by pulling the skin with the
support hand thumb towards the table. The interphalangeal joints are positioned at 90 with slight
ulnar deviation of the wrist. The flexor portion of the forearm is gently placed upon the lateral
aspect of the buttock just below the pelvic crest lateral to the posterior superior iliac spine with
both arms held relaxed and close into the body (Fig. 9.17). Note the position of the plumbline
relative to the hand. There should be no downward pressure over the iliac crest and no excess
cephalad push with the indifferent arm.
2) The practitioner transfers body weight forward by plantar flexing the rear foot from the duff
position (Fig. 9.18A). Note the 45 position of the practitioner and the bend in the legs to add
spring and to control the patients leg drop (thigh sandwich) (*). Also note that the practitioner is
leaning the front leg against the chiropractic table for additional support. At the same time the
contact arm is also brought slightly forward on the pelvic contact, exaggerating the hand posture to
bring the forearm just slightly lateral to the posterior superior iliac spine, well away from the
sensitive lateral hip musculature (Fig. 9.18B). This will provide the practitioner with more
leverage across the pelvis to reach joint tension and apply preload.
3) Very slowly
i) Pull the pelvic contact towards the body, tucking the contact arm into the body to the point
when movement of the L3 spinous process is perceived and tissue resistance between the
contact finger pads and the pelvic contact is increasing. This should occur at a point when the
contact arm is at a 90 angle at the elbow (Fig. 9.19). At this point the pulling action is stopped
(as opposed to the spinous pull described above).
ii) The practitioner simultaneously pushes gently down on both contact points on the spinous
process of L3 and the pelvic contact with the arm (Fig. 9.19). The natural movement of the
practitioners weight assists this down through the long levers of the patients leg. The pull-
push action needs to be equally balanced. This overall movement increases the tissue tension
below the L3 contact point, thereby stabilizing the other local segments and ensuring that the
transition point occurs at the L3/4 motion segment.
4) There are several potential learning errors to be aware of during this set of
manipulative skills. These are very similar to those associated with any of the side-posture
skills learned thus far. This is particularly applicable to the double spinous and the single
spinous processes described above. The spinous push provides a very safe and efficient
procedure for side-posture lumbar spine manipulation, but there are some very specific and
subtle skills that must be adhered to for successful performance of these procedures. There are
a number of spurious skills associated with this procedure including: (i) a tendency to over
pull the pelvis and push down with too much force on the sensitive pelvic musculature; (ii) the
pulling-pushing action is not equivalent; (iii) the practitioner is too far back and the weight is
not over the appropriate spinal level increasing the overall workload; (iv) performing the
sequence of skills too quickly; and (v) a tendency to just pull the pelvis similar to the spinous
pull skills and not incorporate a push component.
Figure 9.17
Figure 9.18A
Figure 9.18B
Figure 9.19
Spinous hook/pull
Spinous push
This manipulative procedure is far more complex than the spinous pull in terms of performance and
overall psychomotor skills. It is essentially the same as the single spinousspinous pull except for the
following subtle differences: (1) segmental localization and specific facet contact stabilization take
place from above the contact on the spinous instead of from below (i.e. finger pad contact is on L3);
(2) reinforced fingertip contact is placed on the ipsilateral side of the spinous process of the upper
segment of the motion segment being isolated; and (3) the short levers are controlled by a pullpush
action on the pelvis rather than just a pulling action with leverage via the innominate and femur
(Byfield 2005).
Therefore, the patient is placed in the side posture as described above in Figure 9.12 and
following in Figures 9.13A and 9.13B, including the pivot shift into a fencer stance with the
appropriate amount of body weight transfer up and towards the patient. To this point the only
significant difference is the placement of the contact hand and finger pad, which is described
previously in Figure 9.5 and below in Figures 9.14 and 9.15.

Figure 9.13B
Mamillary process/interspinous space
The manipulative procedures which use this anatomical landmark are often referred to as the lumbar
roll adjustment (States 1968, Szaraz 1984), mamillary process rotary adjustment (Gitelman 1980,
Gitelman & Fligg 1992) or the extension move (Cassidy et al. 1993). It represents one of the more
traditional and most widely used manipulative procedures in the chiropractic profession to correct
inter-segmental rotation restrictions (Barrale et al. 1989) and is one of the more difficult to learn and
perform. Breen (1988) describes a specific derivative of this manipulative procedure using a
mamillary contact for the treatment of lateral recess encroachment. Although reported to be an
effective alternative, it is a very difficult and strenuous manipulation to perform as a result of the lack
of effective levers that would assist to preload the spinal joints. The forces and energy consumed are
substantial, which places additional strain on the practitioners own back and shoulder girdle. This
must be recognized throughout the entire range of manipulative procedures and skills with respect to
clinican/student welfare. This has been covered in detail in Chapter 5 of this text dealing specifically
with practitioner posture.
The manipulative skills are different from those presented previously in this chapter mainly
because the contact arm is positioned much further away from the body. This essentially makes the
contact arm a longer lever. This could compromise both the stability of the patient and the overall
proficiency of the skill. This has been presented in detail in Chapter 8 concerning manipulative skills
for the sacroiliac region. The longer lever of the contact arm could place the upper back and
shoulders under greater mechanical load and result in potential overuse injuries. The point of contact
is the mamillary process of the superior articulating process. This contact point is much more difficult
to control because it is not a superficial one such as the spinous process. Therefore, this could also
compromise segmental specificity and increase the forces applied, which are subsequently dissipated
in the surrounding tissues. This reduces its clinical efficiency and increases the amount of work
required.
To begin this manipulative skill, execute the same sequential steps and skills as described above
and in Chapter 5 covering side posture and positioning skills. This procedure is also similar to the
posterior superior iliac spine pelvic manoeuvre described in Chapter 8. Therefore, the basic skills
and rationale have already been presented.
To review:

1. The patient is placed in the posture recumbent position.


2. The hip is flexed to 90.
3. The leg is placed gently between the practitioners thighs (thigh sandwich) to stabilize the position
of the lower body.

The upper torso is supported by the cephalad hand with no excessive torque to place any
excessive strain on the spine. The practitioner is perpendicular to the patient and the table. The
patients hip is flexed and the L3/L4 interspinous movement is monitored by the index and middle
finger of the caudad contact hand. Once tension in the L3/L4 interspinous space is perceived, further
hip flexion is unnecessary and the segment is stabilized by dropping the patients leg down slightly
towards the table, but still controlled by the practitioners thigh sandwich or squeeze. This step is
necessary for patient comfort and stability. The patient will begin to roll off the table if the leg is
allowed to drop too close to the table. The cephalad arm is kept close to the body to reduce fatigue
and maintain upper body control.

1) Interspinous movement and tension are monitored by the caudad hand during hip flexion (*) and
excess tissue slack is drawn laterally towards the practitioner by the index and middle finger pads
of the cephalad hand (Fig. 9.20). This procedure is a very common starting point and has been
described above in great detail. Note the relative flatness of the patients spine. The patient should
be relaxed at all times.
2) Replace the palpating fingers with the pisiform/hypothenar eminence fleshy contact point of the
caudad hand, at the same time assisting tissue tension by rolling off the spinous processes of L3 and
L4 to a position just lateral to the edge of the spinous process. It is assumed that the mamillary
process of the superior articulating process of L4 is anatomically located in this region (Fig. 9.21).
The contact hand should be arched and the fingers should be pointing cephalad and slightly towards
the table with the hypothenar eminence and the fifth digit parallel to or slightly overlapping the
spinal column. The lateral border of the contact hand should be in contact with the ipsilateral
border of the spinous process. This at least ensures some degree of accuracy in segmental location
but keep in mind that the thenar eminence is relatively large compared with the much smaller
contact point.
3) The cephalad or indifferent hand is placed on the shoulder to support the upper torso with gentle
downward pressure and no backward rotation. The arms can be brought down as described above
to decrease the overall leverage. The caudad contact arm is held parallel to the spine and the
practitioner is still positioned 90 to the patient (Fig. 9.22). Note the position of the patient on the
table and the relaxed configuration of the spine. Also note the position of the practitioners sternal
notch relative to the contact point and targeted spinal segment.
4) Pivot shift 45 into fencer stance maintaining hip flexion (thigh sandwich), upper torso and hand
contact control. This is performed very slowly to maintain position and control. The contact arm
pivots with the rest of the body at the wrist and not the shoulder (Fig. 9.23). This protects the
shoulder from excess torsion (*) and strain on the soft tissues. The caudad arm is positioned
comfortably at about 45 to the patients spine. The thigh of the back leg should be perpendicular to
the ground to maintain the thigh leverage and the lower leg should be in a duff position to control
this action and maintain tension and segmental location. Note the position of the contact elbow, the
shoulder and upper back alignment to decrease undue stress on the shoulder girdle.
5) With the arm angled away from the body the practitioner has to lean forward and over the patient to
a much greater degree when compared to the spinous contacts described above (Fig. 9.24). The
practitioner is not as upright or in control of body weight to the same degree. This places
potentially greater loads over the whole spine and shoulder even before tension and mock thrust
are applied (*). The patients leg is controlled very effectively by the clamping action of the thigh
sandwich (*). Note that the practitioner leans the front leg against the edge of the table cushion to
stabilize the weight and improve posture efficiency.
6) Transfer the body weight forward and over the patient by plantar flexing the rear foot in the same
way as described previously (Fig. 9.25). Care has to be taken to watch the torsion in the shoulders
and the flexion strain on the lower back. Keep the legs flexed and springy to absorb some of the
load (*). Patient leg control is described in Chapter 8. There are other methods to secure the leg
and transfer weight, for example by pinning the patients leg to the table. The practitioners weight
is transferred up and over the patient by plantar flexing the rear foot and then down over the patient
to place the centre of gravity in the appropriate place.
7) The final sequence is the weight distribution and the patient roll. The sequence starts with Figure
9.26A where the weight is positioned over the contact, with comfortable arms and no pressure
over a relaxed patient. As the weight comes down slowly over the L3/L4 segment and contact
point, the practitioner allows the patient to begin to roll slightly forward towards the edge of the
table from a 90 position (Fig. 9.26B). The patient is instructed to breathe in and out slowly at this
point and the practitioner moves in unison with the breathing cycle. This roll continues to about 45
to the table, applying pressure to the contact point at the same rate as the weight is being dropped
(Fig. 9.26C). There should be no excessive tension on the contact point, no twist in the spine (both
the upper body and pelvis roll forward). The roll is performed slowly so that the patient does not
react, feel unsteady and tense up. When the roll is complete the practitioner can begin to preload
the long levers, initially resisting upper body forward movement by holding the patient back and
then the short lever of specific segment (L3/L4). The cephalad hand pushes down, cephalad and
only slightly posterior to avoid twisting the spine. The practitioner locks in against the patients
leg and stops any further forward pelvic movement (Fig. 9.26C).
8) An additional clinical procedure is a similar push type of technique that can be accomplished using
the hypothenar contact on the ipsilateral side of the spinous process of the targeted joint. All side-
posture skills are incorporated in this procedure as described previously. The practitioner contacts
the spinous process of the L3 segmental level and positions the arm towards the table (Fig. 9.27).
9) There are a number of mobilization procedures that provide a useful alternative from a clinical
perspective for the undergraduate chiropractic clinician. This has significant importance to the
undergraduate in terms of appreciating a multitude of manual techniques that are readily available
to apply to any clinical encounter. Procedures performed in the prone posture provide clinical
advantages in terms of symptom presentation and mechanical leverage available. Counter-rotation
of the lumbopelvic spine can be accomplished using the pelvis and lumbar spines (Fig. 9.28A and
B). This skill uses an ipsilateral lumbar spinous contact at the dysfunctional segmental level to
create a transition point. Placing the patients hand over the anterior superior iliac spine (ASIS)
may assist this procedure if the patient is sensitive (Fig. 9.28B). This particular skill can be
extended to the thoracic spine and can include both mid to lower thoracic facet mobilization and
costo-transverse joint mobilization using the pelvis and specific thoracic or rib angle as the
specific anatomical contacts for the manual procedure. Another useful skill is a long-axis
traction/distraction mobilization procedure for the lumbopelvic joint and soft tissue structures
incorporating dysfunction at the thoracolumbar region (Fig. 9.28C).
10) Flexion distraction is a very common technique within the chiropractic profession. This technique
is performed using a specifically designed table to provide a mechanical loading effect at a
specific region of the lumbar spine in a particular plane and around a specific axis of motion. This
is characteristically driven by patient symptoms and clinical findings whereby very conservative
methods are initially incorporated to control pain and begin to improve function. This particular
technique is supported by the use of a sophisticated piece of equipment that can be adapted for the
specific clinical purpose (Fig. 9.24).
Figure 9.20

Figure 9.21
Figure 9.22
Figure 9.23
Figure 9.24
Figure 9.25
Figure 9.26A
Figure 9.26B
Figure 9.26C

Figure 9.27
Figure 9.28A

Figure 9.28B
Figure 9.28C

There are several potential errors associated with learning these side-posture skills:

1. The most common is rolling the patient too fast and too far, thus losing complete control.
2. Excessively twisting or rotating the contact arm placing it 90 to the spine to get more push on the
short lever contact, produces a pile-driver effect. This can introduce mechanical compression to
already irritated soft tissues and compromise patient comfort and cooperation during the
procedure.
3. Excessively pushing the upper body backwards instead of maintaining upper body position subjects
the thoracolumbar spine to increased torsional stress which may aggravate thoracolumbar
symptoms.
Summary
This chapter has presented the basic skills necessary for a variety of side-posture manipulative
procedures that are used within chiropractic practice. Supine procedures have been avoided as they
represent procedures that are specifically selected under special clinical circumstances and are
essentially skills to be incorporated at the postgraduate level. Prone mobilization and other skills in
this posture have been presented to increase skill selection at the clinical level. Problem solving and
appropriate manual skill selection have been covered to some degree in this chapter as one of the
advanced clinical activities incorporated during patient care. Moreover, the side posture is more
difficult to learn in terms of skill acquisition, because the clinician has to learn to control both his/her
movement/weight and the patients unstable position simultaneously. Supine and prone skills are
simply easier to learn, not used as often and do not generate the same amount of tension and leverage
characteristic of side-posture manipulative procedures. However, a number of prone mobilization
skills are useful procedures for the undergraduate to assimilate from a mixed collection of cases.
Managing an acute low back episode or an osteoporotic patient requires judicious selection of
manual intervention. There are other procedures which are driven by the type of equipment that
permits a practitioner with a good understanding of the
Figure 9.29

pathophysiology to manage various spinal conditions. The use of flexion/distraction or tables that
permit lateral flexion and rotation around the long axis of the table increase the variability open to a
chiropractor. This was covered briefly in this chapter as well as in Chapter 14, which deals with the
elderly patient. This approach permits the practitioner to intervene in a particular case from the outset
and gradually change the manual input commensurate with the patients symptoms and tolerance. This
is particularly applicable during the management of acute discogenic pain and low back pain with
neurological deficit. Another example would be the use of an articulated or motorized adjusting table:
though requiring specific skills, the overall procedure is dictated by the quality of the instrument
being used. This is not to detract from the use of such tables and the skills necessary, but once the
mechanics of the table are conquered it could be reasoned that most patients will fit the manipulative
therapy. There are advantages for the use of these tools for both patient and practitioner alike.
Certain biomechanical properties of the tissues of the lumbar spine act harmoniously to protect
and stabilize the structure during specific tasks and movements. During side-posture rotational
manipulation the spinal elements are subjected to compressive and torsional loads. These forces
could be similar to those generated during the performance of a lift, for instance. The author feels that
these loads are within the range typically produced during activities of daily living which are well
tolerated by the inherent properties of the spinal tissues. The clinical skill is being able to determine
the nature of the pathophysiology and then intervene safely with an appropriate manual intervention
where indicated. The author also feels that even though side posture is a non-weight-bearing position,
mechanical advantage can be maintained. This will promote integrity of the soft tissues of the motion
segment, as long as specific technique skills and biomechanical principles are used to accomplish
segmental isolation, patient comfort and motion segment stability.
This chapter has presented the most common manipulative skills and procedures associated with
mechanical dysfunction of the lumbar spine. It illustrates how a group of common psychomotor skills
can be repeatedly incorporated to develop specific manipulative procedures for a distinctive region
of the spine. The objective has been to develop and organize these skills slowly in context with the
designated joint. The presentation has been careful not to overemphasize the dynamic thrust
component of the overall manipulation, but has more importantly defined the sequence of events for
both the practitioner and the patient leading up to joint tension. The dynamic manipulative thrust is
only one aspect of the overall skill that is learned after the basic skills are perfected. The chapter also
attempted to demonstrate the clinical importance of case management and selection of the appropriate
tool for the patient. Manipulative and mobilization procedures were both presented and it was
pointed out that a manipulative procedure is essentially the next step up from a mobilization technique
in terms of skill with the application of the adjustive/manipulative thrust. This transition is probably
the most skilful aspect of the procedure that takes many years to master.

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Further reading

hapman-Smith D. Manipulation professional standards of training and practice. The Chiropractic


Report. 1987;1:4.
hapman-Smith D. Manipulation for chronic back pain strong new evidence of long term results. The
Chiropractic Report. 1992;6:4.
hapman-Smith D. The chiropractic world major current developments. The Chiropractic Report.
1992;6:6.
hapman-Smith D. The chiropractic profession. The Chiropractic Report. 1993;7:3.
hapman-Smith D. Cost-effectiveness the Manga report. The Chiropractic Report. 1993;7:1.
erzog W., Conway P.J.W., Kawchuk G.N., et al. Comparison of the forces exerted during spinal
manipulative therapy on the sacroiliac joint, the thoracic spine and the cervical spine. In: Haldeman
S., editor. Proceedings of the Scientific Symposium World Chiropractic Congress (Toronto, 1991).
Toronto: World Federation of Chiropractic; 1991:37-41.
essell B.W., Herzog W., Conway P.J.W., et al. Experimental measurement of the force exerted during
spinal manipulation using the Thompson technique. J. Manipulative Physiol. Ther.. 1990;13:448-
453.
cGill S.M. Estimation of force and extensor moment contributions of the disc and ligaments at L4L5.
Spine. 1988;13:1395-1402.
earcy M. Biomechanics of the spine. Curr. Orthop.. 1989;3:96-100.
Chapter 10

Thoracic spine adjustive and manipulative skills

David Byfield

Chapter contents

Introduction
Thoracic pain
Biomechanical considerations
Thoracolumbar junction
Manipulative considerations and technique
Manipulative forces
Manipulative skills
The mid-thoracic spine manipulative skills
Single transverse process prone
Thoracic preload and compliance skills respiration cycle
Double transverse process prone
Upper thoracic spine manipulative skills head as a lever
Single transverse process
Single spinous contact head as a lever
Mid-thoracic spine manipulative skills
Single spinous supine
Lower thoracic spine
Additional thoracic procedures
Summary
References
Introduction
The thoracic spine is arguably the most neglected region of the spine and interest is often
overshadowed by the more dramatic presentations of low back and cervical spine pain even though
thoracic pain is probably just as common as the cervical and lumbar pain. The role of the thoracic
spine within the vertebral column has been viewed as enigmatic a similar view to that of the
clinical perspective (Singer & Edmondston 2000). Disc herniations and nerve root compression is
simply less common partly due to the restricted movement and stability created by the rib cage and
related myofascial structures. Moreover, the structural anatomy of the thoracic spine and thorax has
been well documented and described in detail (Singer 1997, Singer & Goh 2000). The functional
anatomy of the thoracolumbar spine has also been acknowledged as an intergral part of the overall
stability of this region of the spine (McGill 2000). The most comprehensive description of the
thoracic spine, including anatomy, biomechanics, pain syndromes and management has been written
by Giles and Singer (2000). This particular text is a recommended read, as the range of topics and
clinical perspective is geared towards primary care and particularly chiropractic management of
disorders of the thoracic spine.
However, the natural history of pain and dysfunction of the thoracic region of the human spine is
poorly understood when compared with the cervical and lumbar spine regions (Singer 1997). This
may be because so much attention and research efforts have been directed towards the cervical and
lumbar spines, mainly as a result of the higher prevalence of related conditions such as headaches,
neck pain and low back pain in the population. It is difficult to extrapolate or generalize function or
biomechanics of either the lumbar or cervical spine as the mechanical role of the thoracic spine is
one of stability/rigidity rather than mobility (Singer 1997). The unique anatomical features that
underpin its functional and protective contribution to overall spinal function are still undergoing
investigation and debate. Nevertheless, McGill (2000, 2002, 2004) has provided the professional
community with a comprehensive review of the functional relationship between the lumbar and
thoracic spine providing an evidence-based, clinical insight into this region. McGill (2000, 2004) is
essential reading for both undergraduates and postgraduate students.
Pain in the thoracic region is a common complaint, being described in a number of chronic
recurrent pain syndromes, implicating a number of pain-sensitive structures such as the posterior facet
joints and the intervertebral discs (Horton 2002). Moreover, since the thoracic spine is a potential
target for referred pain from both the cervical and upper lumbar spine regions a diagnostic triage must
be administered prior to any therapeutic intervention and management. Acute thoracic pain is a
potential red flag until systematically ruled out prior to any recommended therapeutic intervention.
In addition, the presence of multiple areas of tenderness found on digital palpation are often confused
by clinicians and interpreted as manipulable lesions of either the posterior joints or costotransverse
articulations. Further investigation may reveal only a tender myofascial structure which may or may
not be clinically significant or simply a target for referred pain from other more common and proven
nociceptive structures (Bogduk 1995). This scenario requires strict adherence to a systematic,
evidence-based, clinical approach to intersegmental dysfunction, identification of which involves
multiple clinical indicators, including pain, topical asymmetry, tenderness, and temperature, tone and
texture characteristics, to determine the need for manipulative intervention at levels of primary
dysfunction (Bergmann & Peterson 2011).
Thoracic pain
There are very few original data pertaining to thoracic pain. The neurological basis of pain emanating
from the thoracic spine has been previously described, including the nature and distribution of the
pain receptor nerve endings and the mechanisms by which thoracic spine pain may be produced
(Erwin et al. 2000, Wyke 1967). The fibrous capsules of the posterior joints, the longitudinal, flaval
and interspinous ligaments, the periosteum and the vascular structures are all richly innervated by
pain-sensitive, unmyelinated nerve fibres (Wyke 1967). Bogduk and Valencia (1988) reviewed the
innervation and pain patterns of the thoracic spine in an attempt to establish a foundation for the
differential diagnosis of idiopathic thoracic pain. Their approach was based upon the principle that
any structure receiving a nerve supply is a possible source of pain. Consequently, the fact that most
tissues are innervated only adds more complexity and additional confusion to an already
misunderstood concept (Bogduk & Valencia 1988). Groen and Stolker (2000) have comprehensively
reviewed the neuroanatomy of the thoracic spine and thorax in significant detail and have described
this as the most segmentally organized area of the human body. The regional differences in adjacent
structures and internal organs make the functional implications of thoracic pain extremely variable
(Groen & Stolker 2000). This particular topic is a complete chapter in its own right and therefore the
author directs the reader to the appropriate references for additional reading to supplement their
knowledge base.
It should also be highlighted that the costovertebral and costotransverse joints have been
described as important, yet they are routinely overlooked sources of atypical chest/thoracic spine
pain (Triano et al, 1999). These authors confirm that there is very little information in the literature
regarding the clinical biomechanics and diagnostic features of these joint complexes. Furthermore,
they conclude that the costovertebral joint complex is a potential source of thoracic pain along with a
number of other clinical presentations producing similar symptoms (Triano et al. 1999). In addition
Erwin et al. (2000) have also reported that the costovertebral joints are a candidate for producing
thoracic pain and pseudo-angina that may be successfully treated by spinal manipulation. They go on
to say that the costovertebral joints are innervated by structures similar to other joints of the spinal
column (Erwin et al. 2000). Naturally, this has important clinical implications for those who suffer
chronic thoracic as well as referred pain on to the anterior chest wall. Christensen et al. (2003) have
reported significant variations between experienced chiropractors palpating for intercostal tenderness
or tenderness in anterior chest wall muscles in patients with and without chest pain. This may hamper
clinicians ability to differentiate between chest wall pain of mechanical origin and that referred from
crucial structures. As a result this scenario may initiate costly and unnecessary investigations,
inappropriate treatment and delay appropriate care, contributing to potential chronicity and all of the
associated social and psychological ramifications.
The thoracic spine takes on additional importance from a neurological perspective, with its
relationship to the sympathetic ganglionic chain located on the anterior border of the costotransverse
articulations (Groen & Stolker 2000, Greenman 1989). Joint dysfunction of the thoracic motion
segments may be a direct cause of mechanical irritation, resulting in both local and referred
phenomena, as demonstrated by such conditions as the so-called T4 syndrome (DeFranca & Levine
1995) or chest pain (pseudo-angina) (Erwin et al. 2000). From a postural and biomechanical point of
view, the primary curve of the thoracic spine provides balance and a base of support during many
common activities. The thoracic spine also provides stability to the axial skeleton via the rib cage,
which in itself may contribute to a number of clinical pain syndromes (Bland 2000). There are also a
number of postural syndromes such as scoliosis and degenerative kyphosis that may present as
comorbidity with, or even be the cause of, mechanical pain (Byfield 2003). It is also very important
for the primary care chiropractor to be cognisant of the growing public-health concern regarding
osteoporosis of the spine, particularly with an aging and under-exercised population, regarding
appropriate triage and relative contraindications for manual intervention (Byfield 2002). This is
covered in much greater detail in Chapter 14, as these types of chronic presentations require
additional specialist management strategies. The authors would also like to refer the reader to
Chapter 5 for more information regarding the clinical implications of posture and current views
regarding postural stability during the performance of common daily activities with respect to the
thoracic spine. The clinical application of these implications takes on important relevance,
particularly at the undergraduate level.
Biomechanical considerations
Probably the most comprehensive work relating the biomechanics of the spine to the mechanics of
spinal manipulation has been written by John Triano (2000) and it is a must read for all students and
practitioners of the manual arts. In addition, evidence is emerging regarding manipulation of the
thoracic spine for the management of neck pain. This is thoroughly covered in Chapter 3 of the text. In
addition, there is also good biomechanical data that suggests that manipulative forces applied
perpendicular to the spine are more effective in reaching the intended area, thereby reducing the
wastage and improving the efficiency of the manipulative procedure. Factors such as spinal contour
and patient presentation will have an influence on this approach to thoracic spinal manipulation. Once
again reference to Chapter 3 will enlighten the reader.
From a kinematic perspective, the upper thoracic spine behaves similarly to the cervical region
and the lower thoracic spine is similar to that of the lumbar region (Bergmann & Peterson 2011, Blunt
et al. 1995, Stokes 2000). This has clinical management implications, particularly with respect to the
biomechanical contributions from these regions. The shared muscular influence by structures that
cross several regions may also provide a clinical challenge for the chiropractor. This is particularly
evident at the cervicothoracic and thoracolumbar junctions, where erector spinae groups support
movement across several regions. Axial rotation is greatest in the upper thoracic spine, whereas
flexion/extension predominates in the lower thoracic motion segments (White & Panjabi 1990). This
has meaningful clinical implications for the use of diagnostic techniques and specific manipulative
skills and procedures designed to restore function to the thoracic spine. This is the scenario, even
though the exact pathophysiology of these mechanical disorders has yet to be determined. It is most
likely that the zygapophyseal and costotransverse joints are the most common and potent sources of
thoracic pain (Erwin et al. 2000, Kellgren 1977). The uniqueness of the biomechanics of the thoracic
spine is dominated not only by the characteristic morphology of each region, but also by the influence
of the rib cage. As mentioned earlier in the chapter, the rib cage not only offers significant stability to
this spinal region, but also provides a more complicated clinical picture particularly with respect to
determining the origin of thoracic pain, i.e. determining whether the pain is local or referred. An
additional clinical complication arises from the fact that the thoracic spine is also a common target
for spinal metastases (Singer 2000). This is particularly important for primary tumours related to the
breast, prostate and lungs, presenting the primary care practitioner with the need for further
exploration and investigation prior to establishing appropriate care or immediate referral. Other
metabolic conditions and infective diseases, such as osteomyelitis, are frequently encountered in this
region and must be differentiated prior to providing any care (Singer 2000). This is the responsibility
of the practitioner in keeping the patients best interest in mind as with any therapeutic intervention.
Thoracolumbar junction
The thoracolumbar junction represents a transitional region of considerable clinical and
biomechanical importance. Maignes syndrome (Kirkaldy-Willis & Bernard Jr 1999, Quon et al.
1999) or the thoracolumbar syndrome has been well described (Maigne 2000, Proctor et al. 1985).
This syndrome, which shows all the hallmarks of a posterior joint syndrome involving dysfunction of
the T12L1 articulations and referred pain over the iliac crest, has been reported to respond well to
manipulative management combined with stretching of the local musculature (Proctor et al. 1985).
The influence of the psoas major on the thoracolumbar spine has also been the topic of
considerable debate. It has been described as one of the most complex muscles in the body and acts
primarily as a hip flexor only and as such is not a major stabiliser of the lumbar spine (McGill,
2004). However, Bogduk et al. (1992) have dispelled these misconceptions by stating that the psoas
major is designed to act on the hip and has no substantial role as a flexor or extensor of the lumbar
spine, but can exert considerable compression and shear loads on the lumbar joints. This would
appear to have important clinical significance as a possible aetiological factor in the production of
mechanical back pain requiring prompt recognition and immediate therapeutic intervention to reduce
the tensile stress and contracture of the psoas muscle. In addition, the numerous postural changes that
occur during the last trimester of pregnancy have also been reported to affect the mechanics of the
thoracolumbar junction and place additional stress upon the psoas muscle. Please refer to Chapter 13
for more detail pertaining to the clinical implications related to pregnancy. Manual intervention
during this stage may provide some relief, particularly if the intervention is segment specific.
Moreover, the concept of segmental specificity has been seriously questioned and supported by
quality science (Ross et al. 2004).
Biomechanically, the facet joints of the twelfth thoracic vertebra are oriented intermediately
between the coronal plane of the thoracic motion segments and the sagittal plane of the lumbar units,
which potentially places additional stress upon this motor segment (Singer & Goh 2000). Singer
(1989) investigated the variety and frequency of the types of thoracolumbar mortice joint. He
concluded that this mortice configuration functions to limit axial rotation during normal activities and,
therefore, may be a focal point for additional injury during forced torsional movements. For this
reason, Singer and Giles (1990) have advocated the strict limitation of manipulative or mobilization
procedures that utilize excessive rotation and extension. They adamantly challenge the use of
exaggerated shoulder and pelvis counter-rotation as a method of isolating and developing joint
tension in the posterior joints of the thoracolumbar complex. They warn that vigorous counter-
rotational techniques could cause injury and aggravate presenting symptoms. Consequently, employing
techniques that push the shoulder back and cephalad as a traction component and that pull the pelvis
forward at the same time should be strongly cautioned against. This is covered in great detail in
Chapters 8 and 9, dealing specifically with side posture skills. Manipulative techniques for the
thoracolumbar junction will be introduced in the skills section of this chapter.
Consequently, the use of non-torsional manipulative techniques in either the supine, prone, or
kneeling positions may be more appropriate in light of this evidence. The use of non-torsional side-
posture skills (Byfield 1991, Fligg 1984, 1986), traction/distraction techniques (Cox 1992) and
placing the drop centrepiece in the open position (Schafer & Faye 1989) have been suggested as
viable alternatives for manual intervention of the thoracolumbar junction. A low thoracolumbar
kyphosis, often seen in association with recurrent low back pain (Pedersen & Nielsen 1993), may
have important clinical significance with respect to the type and nature of the manipulative
procedures selected for the management of such cases. The key issue under any of these clinical
scenarios is selecting the most appropriate therapeutic intervention in terms of the clinical symptoms,
the underlying pathomechanics and the patients needs.
Manipulative considerations and technique
Manipulative procedures in the thoracic spine tend to be more general and less specific than in other
areas of the spine (Grice 1980). However, attempts have been made to examine and describe in detail
the rationale and the skills associated with common diversified manipulative procedures of the
thoracic spine (Bergmann & Peterson 2011, Gatterman 2003, Good 1992, Fligg 1984, 1986b; Nelson
1992, Zachman et al. 1989). Nelson (1992) states that the conventional indications and mechanical
rationale for the anterior thoracic are riddled with error. It is his contention that the actual dynamics
and forces transmitted during the anteriorposterior anterior thoracic adjustment are quite similar to a
posterioranterior adjustment (transverse process contact crossed bilateral type procedure). He
estimated that the total compressive forces acting on the thoracic cage are similar for both
procedures. Even though his rationale has some clinical merit, the quantification system limits any
substantial conclusions as empirical only. Nonetheless, any attempt to discuss and challenge the
traditional use of popular manipulative procedures deserves attention.
Zachman et al. (1989) propose that the anterior thoracic lesion is a sectional (regional)
dysfunction rather than a segmental one. This same clinical issue has been raised by Haas and Panzer
(1995). They contend that segmental specificity is simply an unproven clinical assumption that to date
has not been fully validated. They go on to say that since contact specificity is not valid, then
practitioners would not have to agree on a specific segment, but rather a specific region to have the
same clinical outcome (Haas & Panzer 1995). This regional rather than segmental concordance
may be sufficient enough to satisfy an acceptable level of inter-examiner reliability. In fact it has been
shown that chiropractors are simply not as accurate as we think in terms of cavitating specific joints
in the lumbar or thoracic spines (Ross et al. 2004). It would be nave to think that in such a complex
mechanical region, absolute joint isolation and specificity of dynamic thrust would be possible. The
application of a manipulative thrust in either the prone or supine position will undoubtedly influence
multiple synovial joints and multiple local receptors (Herzog et al. 1999). This may be partly because
of the anatomical proximity of the joints and the density of joint/soft tissue receptors and the physical
coverage of the clinicians contact hand over a very small anatomical lever point buried in layers of
muscle tissue and other structures. Multiple joint cracks are not the therapeutic aim but do occur
(Ross et al. 2004), as opposed to a consistent and systematic stimulation of appropriate receptors
which may be responsible for the changes noted clinically in pain levels and local muscle
hypertonicity (Herzog et al. 1999).
From a technique perspective, with respect to the thoracic spine and common manipulative
procedures such as the anterior (supine) thoracic, one of the most precarious tasks is related to the
risks associated with transferring and stabilizing patient weight (Triano 2000). These skills require
patient control, postural stability, clear instructions and cooperation between the patient and the
practitioner. Making use of the practitioner as a counterweight is both biomechanically sound and
good practice, particularly when the practitioner combines co-contraction of the leg, pelvic,
abdominal and back stabilizing muscles during the procedure to reduce the compressive forces
sustained on his or her self, particularly if a patient suddenly shifts their weight when the practitioner
is off balance (McGill 1998, 2002, Triano 2000). These strategies have been discussed in detail in
Chapter 5, addressing practitioner posture and the importance of the neutral spine slight flexion
posture and overall stability during the execution of manipulative procedures. Twisting, lateral
bending and sagittal bending moments acting on the spine are considered to be those risk factors that
lead to injury. Good technique, such as described above, using appropriate posture and bracing
reduces disc compression loads at the L5/S1 motion segment (Triano 2000). Even though the peak
loads are momentary, it is potentially the repetitive accumulation that may be injurious to the
practitioner in the long term. More basic research is required to answer these specific questions,
which will have added value, particularly at the undergraduate level, when these skills are
initialized. Some of these concepts will be mentioned in the section presenting the applicable thoracic
manipulative psychomotor skills.
Manipulative forces
The magnitudes of the forces generated during a unilateral reinforced prone manipulation of the
thoracic spine have been determined experimentally (Conway et al. 1993, Herzog et al. 1991a,b). In
these studies, an experienced chiropractor applied a rapid manipulative thrust to the transverse
process of T4 using a hypothenar contact in a posterior to anterior plane perpendicular to the thoracic
spine after the recording of a preliminary preload or prestress load. The preload force was
approximately 145 N (15 kg). The peak forces recorded were in the region of 400 N (41 kg) and
cavitation occurred just prior to peak force in about 116 ms with an average overall thrust time of 285
ms. Herzog et al. (2001) have shown that most of these treatment forces are taken up by non-target-
specific tissues owing to the nature of the contact point, which increases in surface area as the
preload force increases. They also demonstrated that the peak pressure point moved about 1 cm
during the course of the manipulating procedure, which again challenges the joint specificity concept.
The preload, peak forces, and speed of thrust recorded in the thoracic spine were greater than those
reported for both the sacroiliac joint and cervical spine (Herzog et al. 1991a). As a comparison,
forces in the order of 200 N (20 kg) have been measured during the application of graded oscillatory
mobilization of the spine, a technique that is commonly used by physiotherapists (Matyas & Bach
1985). Even though they demonstrated a wide variation, the magnitude of these forces compares with
the preload forces measured during chiropractic manipulation (Conway et al. 1993). Triano (1992)
reports that experimental peak pressures of 50 PSI (lb/inch2) are distributed to the thorax during an
anteroposterior procedure, creating tissue stresses well below the structural limits. This may have
significant clinical implications particularly for those patients who present with various systemic
conditions that may represent a relative contraindication to spinal manipulative intervention. More
recently, Bereznick et al. (2002) concluded that, owing to the negligible friction exhibited at the skin
fascia interface of the thoracic spine, it is not possible to direct a manipulative force at an oblique
angle and most efficiency was achieved when the forces are applied perpendicular to the spine
creating little wastage. These investigations also concluded that the ability to contact (hook) a
thoracic spinous or transverse process is over-rated. These results have both educational and clinical
implications that will be addressed throughout this text.
From a manipulable skills point of view, specific gender differences related to the ability to
generate sufficient mechanical forces have been investigated (Forand et al. 2004). The experimental
protocol required an adjustive procedure that included a transverse process contact with a posterior
to anterior mechanical thrust through the T4 and T9 segments. These researchers established that
female chiropractors produced similar manual effects from a mechanical perspective when compared
with a male cohort. The only difference between the groups was that the male chiropractors produced
significantly greater preload forces for lower thoracic manipulations than the female group, with no
difference recorded for the upper thoracic manipulations (Forand et al. 2004). These data confirm the
importance of psychomotor skill acquisition and force production which appears to be independent of
the practitioners overall mass, particularly under these experimental conditions. This line of
investigation needs to be expanded to determine how male and female practitioners compare with
respect to mechanical forces generated during more complex side-posture manipulations. This would
provide valuable information from an educational perspective both in terms of presentation and
assessment.
Manipulative skills
Manipulative skills of the thoracic spine are performed in all positions, including prone, supine,
lateral recumbent, sitting and standing postures. This is a unique situation. Other areas of the spine
and pelvis do not permit this versatility. The purpose of this chapter is to present the basic skills
performed in the more common prone and supine positions. It is unreasonable to expect proficiency in
all the various combinations in early undergraduate training, but it is envisaged that the skills learned
at this level will provide the foundation for manipulative skill development during the postgraduate
phase. Each manipulative procedure is not a separate entity to be learned in isolation, but forms part
of a series of fundamental building blocks. The type and speed of thrust may differ, but many of the
basic practitioner and patient movements are similar and repeatable across a variety of manipulative
techniques.
This chapter will be divided into three sections: the upper, mid- and lower thoracic spine. The
thoracic spine is divided in this fashion to accommodate the significant differences in the functional
anatomy and the specific mechanics of the region which will dictate the type of skills necessary. The
prone position will be presented first. Patient movement here is minimal so efforts can be directed
towards learning the necessary skills without having to control patient movement. The prone or
supine posture places greater emphasis upon the manipulative skills, particularly practitioner posture
and weight distribution rather than patient stability.
This chapter deals strictly with spinal inter- segmental manipulative skills. It is very difficult not
to include skills concerning the costotransverse articulations. However, this represents more
advanced training that should be undertaken once the basics of this chapter have been accomplished.
Many of the skills for the intervertebral joints can be easily extrapolated to the costotransverse
articulations with minor changes in hand contact position, depending upon the clinical indications.
The mid-thoracic spine manipulative skills
The following skills will be covered by this section:

1. Single transverse process prone (Figs 10.1 - 10.7)


2. Double transverse process prone (Figs 10.8A - 10.10)
3. Single spinous process head as lever prone (Figs 10.11 - 10.22)
4. Single spinous process (Figs 10.23A - 10.30C).
Figure 10.1
Figure 10.2
Figure 10.3
Figure 10.4A

Figure 10.4B
Figure 10.5A
Figure 10.5B
Figure 10.6
Figure 10.7

Figure 10.8A

Figure 10.8B
Figure 10.9A

Figure 10.9B
Figure 10.10
Figure 10.11
Figure 10.12
Figure 10.13
Figure 10.14A
Figure 10.14B

Figure 10.15
Figure 10.16
Figure 10.17
Figure 10.18

Figure 10.19
Figure 10.20
Figure 10.21
Figure 10.22
Figure 10.23A

Figure 10.23B
Figure 10.24

Figure 10.25
Figure 10.26
Figure 10.27A
Figure 10.27B
Figure 10.28
Figure 10.29
Figure 10.30A

Figure 10.30B
Figure 10.30C

Single transverse process prone


This manipulative procedure is also known as reinforced unilateral (Byfield 1996) and hypothenar
transverse rotational adjustment (Bergmann & Peterson 2011). This particular sequence of skills
probably represents the fundamental positioning for many of the prone manipulative procedures (Figs
10.1 - 10.7). With the patient lying passively prone, the student can concentrate on important
individual posture and positioning skills. The patient is positioned so that the head-piece is dropped
down slightly from a neutral horizontal position to relax the upper back region and the feet are
elevated only minimally to flex the knees and relax the hamstrings. If the patient experiences any low
back pain whilst in this position, then a roll can be placed under the abdomen for the period of the
procedure. Lying in the prone position with the lumbar spine in a flexed posture for extended periods
of time compresses the intervertebral disc anteriorly and could potentially aggravate discogenic pain.
Conversely, lying with the spine slightly extended could cause facet irritation or increase the pressure
on the posterior aspect of the intervertebral disc and create a consequent difficulty in rising from the
table into the upright posture. One of the most potentially difficult activities to appreciate with respect
to patients in the prone posture involves the patient rising from the table without placing the spinal
facets under any undue mechanical load, which may result in the aggravation of an existing pain-
producing condition. This can be avoided by instructing the patient to avoid leading with extending
the spine, but by rather bracing the lower back and pelvis via co-contracting the trunk stabilizers and
pushing themselves up on all fours to avoid any sudden uncontrolled movements that may result in
acute mechanical (nociceptive) pain (McGill 2002). Alternatively, the practitioner assists in turning
the patient into a side-laying posture, before asking the patient to move, again with assistance, as a
unit into the seated position. This must be reinforced through a training process and we must not take
these activities for granted with our patients and it would be advisable to begin learning to instruct
these methods at the undergraduate level.
The skills for this section will focus on the T5/T6 motion segment. It should be emphasized that
skills should be practised on both sides of the spine to develop dexterity and clinical flexibility.
Please refer to Chapter 7, which deals with the location of anatomical landmarks. Reasonably
accurate landmark identification encourages segmental isolation and manipulative specificity. This is
of particular importance in the thoracic spine because of its anatomical complexity. The transverse
and spinous processes are very small landmarks in comparison with the size of the treating hands.
Anatomical proximity and overlap of the hand contact could easily influence several thoracic
articulations when mechanical leverage is applied during a manipulative procedure, which may
compromise segmental specificity. This concept has been discussed previously in the Introduction
section of this book and above in this chapter. Segmental specificity within the constraints of the
system within which we operate is a very stringent standard, yet very difficult to ensure. The
objective under these circumstances is approximate localization and manual application where
appropriate, preferably within one segment above and below the target articulation (Gal et al. 1994).
This challenges the specificity concept and it may very well be that, particularly in the thoracic spine,
the manipulative lesion is in fact a regional phenomenon as opposed to dysfunction of a single
articulation. This has been observed clinically and reported by Panzer and Haas (1995) and Byfield
et al. (2002) and challenged by a number of investigations (Bereznick et al. 2002, Gal et al. 1994,
Herzog et al. 2001, Ross et al. 2004). As educators we must take a more realistic approach to the
instruction and rationale underpinning these skills in light of this evidence. This certainly places some
doubt on various claims purported by certain technique systems that are supported by weak evidence
at best (Cooperstein & Gleberzon 2004).
The ability to locate the transverse process of the desired motion segment, in this case the
transverse process of T5, is a formidable task, even for the experienced practitioner, and the evidence
suggests is it really necessary! We rarely see the models that appear in the anatomy books; the ones
with about 3% body fat and such well-defined musculature and bony landmarks that are ideal for
accurate landmark identification. The process is, in most instances, difficult and frustrating.
Therefore, visualization of the anatomical landmarks and use of the procedures outlined in Chapter 7
to identify important landmarks, which is also depicted in great detail in Byfield and Kinsinger
(2002), are critical to minimize this problem.

1) With the patient lying in the prone position the practitioner should pivot from 90 to a 45 angle to
the patient directly in line with the T5/T6 motion segment. The feet should be placed about hip
distance apart. The practitioner is leaning against the table with both thighs, primarily the front leg.
This helps to support the practitioners body weight reducing fatigue yet, more importantly, adding
to practitioner stability and reducing the transfer of excessive weight into the patients spine. The
majority of the body weight is over the flexed front leg. This allows the practitioner to lean over
the patient and position the centre of gravity for efficient weight distribution and thrust (*). The
practitioner should feel comfortable in this stance with relaxed shoulders and arms. The back is
reasonably straight (neutral lordosis) and there is no torsion in the body. The head is slightly flexed
forward to accommodate visual cues and the front leg is positioned ahead of the patients
arm/shoulder (Fig. 10.1).
2) After locating the transverse process of T5 (two interspinous spaces above the T5/T6 interspace)
(Chapter 7; Byfield & Kinsinger 2002), use the middle finger or the thumb of the cephalad (left)
hand to draw or pull the tissue slack cephalad and laterally, simultaneously. The skin over the
transverse process should be tight, which allows for a firmer and more accurate contact (Fig.
10.2). Tissue slack movement should be firm and direct, not pinching or hard. Patient relaxation is
important and continuously encouraged. The clinician is required to maintain an appropriate
posture at all times, this constitutes an important part of the learned skill set. Note the position of
the clinician relative to the patient and the contact point. The practitioner hugs the table to position
the body weight over the target motion segment.
3) With the excess tissue slack removed, the contact hand follows immediately to ensure reasonable
transverse process location. The contact hand forms a firm chiropractic arch which is placed over
the spinous processes of the T3/T4 motion segment. The padded hypothenar/pisiform contact is
moved laterally, drawing additional skin slack during this movement to finish (ideally) over the
transverse process of T5 (but more likely T4, T5 & T6), with the fingers pointing cephalad and the
little finger placed against the spinous processes (Fig. 10.3). The lateral aspect of the contact hand
should be directly placed against the lateral aspect of the spinous processes, which would place
the middle of the hypothenar eminence over the T5 transverse process. The finger pads of the
contact hand are comfortably placed over the paraspinal muscles and used to secure the contact
hand by drawing tissue toward the arch. The contact is light yet firm, to give a stable contact and
reassure the patient. The practitioner leans against the table for additional support and stability.
4) The position of the practitioners arm and chest promotes efficiency of the manipulative procedure.
The shoulder of the contact arm is relaxed and level. The elbow is not fully extended, which spares
the joint unnecessary strain (*) and the shoulder girdle is not elevated. The wrist is also in a
relaxed position (*). The suprasternal notch is positioned slightly behind the hypothenar/pisiform
contact point on the transverse process to position the practitioners body weight prior to joint
preload and mock thrust. The extensor muscle group of the forearm should be pointing in the
direction of the fingers to reduce any torsional stress at the elbow (Fig. 10.4A). The hand is
relaxed but firm over the tissue. The fingers assist in supporting the hand by drawing in excess soft
tissue (Fig. 10.4B). This gives some idea of the actual size and spread of the hypothenar contact
over the transverse processes of a number of segments (*). This in essence cushions the contact and
dissipates the manipulative thrust forces over a larger area providing comfort for the patient and
stimulating more receptors for potential pain relief.
5) From this very basic position, the practitioner transfers body weight forward over the patient by
initially plantar flexing the rear foot, which brings the trunk forward. This movement is slow and
controlled (Fig. 10.5A). Place the indifferent hand (left) over the contact hand to help stabilize the
hypothenar/pisiform contact position for more efficient force transfer and less movement of the
hand during the thrust. The hand accommodates a firm chiropractic arch over the contact hand (*)
(Fig. 10.5B). The practitioner is positioned 45 and leaning against the table. The weight of the
trunk is brought down over the contact point of the patient by allowing the front leg to flex to
cushion the weight. The feet are maintained no more than hip distance apart during this whole
procedure. There should be no compression or force down over the patients thoracic cage at this
point. The contact must be light and comfortable for the patient. There is a tendency when learning
these skills to place excessive force down over the contact point. This must be avoided in the best
interests of the patient and for a skilled procedure. The weight shift should align the suprasternal
notch just slightly ahead of the anatomical contact point. This places the majority of the clinicians
body weight over the left T5/T6 posterior facet joint which will concentrate the majority of the
preload and peak thrust forces through this area. The head is slightly flexed forward looking down
over the contact configuration. Shoulders and arms are relatively relaxed with no muscular tension.
Note the extension of both elbows which are firmly locked, but not hyperextended. It is very
important during the acquisition and reinforcement of these skills to maintain a neutral or slightly
flexed lumbar posture to ensure lumbopelvic stability and efficiency of the practitioner to avoid
any excessive mechanical loading and fatigue.

Thoracic preload and compliance skills respiration cycle


Up to this point in the chapter all the skills have been performed to locate and stabilize the T5/T6
motion segment and correctly place the practitioner in the most advantageous posture without
discomfort to the patient. Joint tension/preload (elastic barrier) is accomplished by eliminating the
compliance in the thoracic rib cage. This is a fundamental procedure for many manipulative skills in
the thoracic spine and rib cage. Learning the basic skills at this stage will provide the foundation for
the introduction of a number of manipulative skill variations for the thoracic spine. The compliance or
natural give characteristic of the rib cage must be considered during all manipulative procedures of
this region of the spine in a slow and controlled fashion. To accomplish this, the patient is asked to
slowly take a small breath or half breath prior to preload/joint tension and mock thrust depending on
the actual position in the thoracic spine or the patient/symptom presentation. The practitioner moves
with the rhythm of the patients rib cage during the inspiration stage. There should be absolutely no
impedance to this action, i.e. excessive pressure placed upon the patients thoracic spine or rib cage.
Following these steps ask the patient to breathe out slowly, after which the practitioner/clinician
follows the expiration phase equally slowly with their trunk weight. This should be accomplished via
a combination of upper and lower body weight distribution. As the patient reaches the final stages of
expiration, the practitioner/clinician continues to apply compression over the contact point with the
trunk weight until that point at which resistance/stiffness (viscoelastic deformation property of all
joints) is perceived, predominantly through the hands and arms. This will ensure that the joint to be
manipulated/mobilized has been preloaded. It is absolutely mandatory that the student learns to
perform this slowly and gradually within the rhythm of the patients breathing cycle, tissue
characteristics and pain tolerance. The student must avoid rapidly pushing with the arms straight
down like a pile-driver with no concern for patient comfort or safety. The force down should be a
combination of shoulder depression and downward movement of the pelvic girdle via flexion of the
weight-bearing lead knee. This, initially, is a particularly difficult skill to coordinate. Perform the
movements slowly and with purpose, keeping the entire procedure in mind. The compliance of the rib
cage has to be judged on an individual basis for each patient and considered in the context of any
absolute or relative contraindications to spinal manipulative therapy. This is particularly relevant for
the thoracic spine from a clinical perspective as this is a region of referred pain as well as a target
for serious pathology. In addition, there is no standard force or threshold that has yet to be identified.
The student must learn to appreciate the compliance and elasticity in the rib cage with each individual
patient to develop and isolate joint preload at a reasonably precise segmental/regional level.
Developing a slow and controlled method from the initialization of these skills allows the
appropriate receptors to adapt to the resistance, instead of rushing the process and applying an
inappropriate amount of force to a patient, which may contribute to lack of compliance, poor
satisfaction and a limited therapeutic outcome. Thoracic compliance skills are presented in Figure
10.7 and throughout the remainder of this chapter. Thoracic compliance and the respiratory cycle
concepts have been presented in other chapters dealing with pelvic and lumbar manipulative skills.

Double transverse process prone


This manipulative skill is a modification of the single transverse process contact set of skills. It is
commonly referred to as the rotational crossed bilateral (Bergmann & Peterson 2011, Gitelman &
Fligg 1992, Szaraz 1984), double transverse (Grecco 1953, Schafer & Faye 1989), or crossed
bilateral transverse pisiform (States 1968). The manipulation is generally incorporated to correct
apparent rotation dysfunction of either the posterior facets or the costotransverse joints.
The skills are exactly the same as for the preparation of the single transverse manipulative skills
(Figs 10.8A - 10.10). The significant difference is using the indifferent hand to stabilize the opposing
joints above and below the target joint. It also helps to centre the practitioners body at a 45 angle to
the patient as the support arm crosses over the contact arm.
The errors encountered during this manipulative skill are similar to those described for the
single spinous process (Figs. 10.6 & 10.7). Please note that over-twisting of the contact hands and
forcing the expiration phase could cause unnecessary patient distress. Please note the position of the
sternal notch and the bilateral extended arm posture just prior to preload development.
Upper thoracic spine manipulative skills head as a lever
The preceding section dealt with skills associated with manipulative procedures in the mid-thoracic
spine in the prone posture. The next stage will be to introduce common skills employed in the upper
thoracic spine at the cervicothoracic junction in the prone position using the transverse and spinous
processes as anatomical contact points (Figs 10.11 - 10.22).

6) The final action during weight transfer and compliance is to add a small amount of twist to the
contact hand which tightens the tissue over the contact to stabilize the contact position over the
targeted motion segment. This skill assists in removing additional tissue laxity to aid in developing
joint tension/preload. There is considerable soft tissue in the thoracic paraspinal region which
inhibits a firm contact point. The twist takes place during the latter stages of patient exhalation and
it is accomplished by slight radial deviation of the contact hand towards the practitioners body by
internally rotating the contact arm. The fifth digit remains in line with the spine to ensure
maintenance and accuracy of the contact (Fig. 10.6). Do not thrust at this point; appreciate the
tension developing in a mock fashion. Repeat this several times within the tolerance of your
patient. Ask for feedback from the patient regarding pressure points and degree of comfort.
7) There are errors that are commonly encountered during the learning of the initial skills.
i) The practitioners legs may be too far apart with the feet angled improperly, positioned too far
from the table causing the clinician to lean towards the table and placing additional postural
stress on the back. This will also place the suprasternal notch and the centre of gravity/body
weight too far forward, compromising the efficiency of the manipulative procedure (Fig. 10.7).
ii) Poor hand posture skills both for the chiropractic arch and the removal of tissue slack will
compromise the overall performance of the manipulative skill (*). Segmental specificity and
patient comfort are of utmost importance when initializing these skills in preparation for
clinical training. Rough handling of the patient may influence therapeutic compliance and
patient satisfaction.
iii) There is a tendency to rush the breathing sequence and compress the patients rib cage
prior to the joint tension and preload at this early stage of skill acquisition. This can cause
significant patient distress, especially in an acute presentation, which could increase the
likelihood of poor compliance and post-treatment reactions. The development of the tissue
tension/joint preload is slow and gradual and must be in coordination with the expiration
phase. Concentrate on appreciating the patients breathing cycle as air is exhaled and when the
rib cage and other tissues start to stiffen. This is a natural response of viscoelastic tissue which
has been discussed in previous chapters.

1) With the clinicians contact hand positioned as for a single transverse process contact (see Figs
10.1-10.5A for detail) the indifferent hand (left) crosses over in front of the contact hand to the
other side of the spine (Fig. 10.8A) and adopts a firm bridge arch (Fig. 10.8B). The clinician uses
the dorsum of the contact hand to guide the indifferent hand into position. The clinician is still at
45 to the table, the front leg is flexed for comfort and leaning against the side of the table. There is
no muscular force or pressure applied to the spinal elements at this point. The plumbline should be
over the middle of both hand positions.
2) The heel of the indifferent hand (left) rolls off the dorsum of the contact hand and then the heel of
the indifferent hand should be placed directly against the lateral edge of the ipsilateral aspect of the
spinous processes. The thenar and hypothenar eminences of the indifferent hand should be
positioned over the contralateral transverse processes of the segments above and below the
targeted region, with the hand in a high chiropractic arch (Fig. 10.9A). The thenar eminence is
placed over the transverse process of the vertebral segment below (T6) and the hypothenar
eminence is over the transverse process of the segment above (T4). Tissue slack is taken from the
midline spinous laterally over the contact points. The hands are basically at right angles to each
other. Figure 10.9B illustrates the relative hand relationship for this set of skills and the size of the
contact area over the transverse processes demonstrating that the forces applied are dissipated
over a large surface area. This provides an inherent safety mechanism as the soft tissues absorb a
great deal of the high-velocity thrust. Note that there are many variations of this manipulative skill,
particularly the hand placement combinations depending on the biomechanical correction, fixation
pattern and clinical symptoms. The skills presented here are the foundation for all additional
diversified skills.
3) To bring the body weight over the contact hands the clinician moves forward and over the
patient/contact point by plantar flexing the rear foot. The patient is asked to breathe in. The
practitioner follows this movement without losing the contact over the target segment(s). As the
patient breathes out the clinician gently follows the movement downward precisely until the
thoracic compliance has been eliminated and there is a perception of resistance under the contact
hand. This is the feeling of overall joint and tissue tension completing joint preload (Fig. 10.10).
Note the position of the sternal notch and plumbline to provide feedback regarding the clinicians
optimal posture. Simultaneously, as the body weight moves down slowly and the thoracic
compliance is diminishing, both contact arms and hands slightly twist producing internal rotation
and radial deviation, respectively, as the patient is breathing out to eliminate as much excess tissue
slack as possible. This is particularly necessary in the mid-thoracic spine because of the excessive
soft tissue in the region. The efficiency and skill of this procedure requires a stable contact point
over the targeted segment(s) so that manipulative force is not unnecessarily dissipated to
neighbouring joint/tissues.

Single transverse process


Using the head and cervical spine as a long lever to manipulate the upper thoracic
spine/cervicothoracic junction offers several advantages. The head is a relatively short lever in
comparison to the leg or the shoulder girdle. There are several myofascial structures which are
common to both the upper thoracic region and the cervical spine. This has important clinical
implications in terms of presenting symptoms, referred pain and subsequent treatment strategies and
rehabilitative protocols. Passive movement of the head implies that the practitioner can control upper
thoracic spine movement to attain reasonable joint specificity and tension, which improves the
efficiency of the manipulative procedure. However, the head and neck are sensitive structures and
must be handled with care to reduce the possibility of any post-treatment reactions.
This sequence of manipulative skills uses a single transverse process contact (Figs 10.11 -
10.16). For the purpose of this next series of skills, reference will be the T3/T4 segment. As before,
the authors encourage you to learn these skills equally and proficiently on both sides of the spine.
This particular manipulative skill is often referred to as the combination upper thoracic
adjustment (Grice 1980, Szaraz 1984), the single temporal-transverse adjustment for the upper
dorsals (Grecco 1953), correction for upper thoracic rotation fixation patient prone (Schafer &
Faye 1989), combination movement (States 1968), or hypothenar transverse push (combination move
or modified combination move) (Bergmann & Peterson 2011). This particular manipulative
procedure uses relatively short levers (transverse process) which are anatomically close together and
embedded within layers of myofascial structures and other soft tissue. The use of the head to
anatomically isolate movement in the upper thoracic spine has both anatomical and biomechanical
advantages. The muscles which stabilize and initiate head posture and movement are common to both
cervical and thoracic regions. It is therefore important to understand and visualize the direction of the
individual muscle groups (origin and insertion) during this specific set of manipulative skills to better
appreciate the skill acquisition.

1) The patient is prone, with the headpiece positioned slightly lower than the mid-thoracic spine to
ease the mechanical stress at the cervicothoracic junction and provide some joint tension to the
region to assist preload. The patients arms are placed comfortably alongside the table with the
hands positioned well under the table away from wandering feet. The clinician must check this
each time to ensure that the patients fingers are not stepped on (this could be a bit embarrassing).
The practitioner is positioned 45 to the table and patient, the feet are hip distance apart and the
front leg placed ahead of the patients left arm. The practitioner locates and contacts the transverse
process of T4 using the skills described above. There is considerable tissue bulk in this area which
makes segmental localization and accuracy more arduous. This is why it is important for the patient
to relax the upper body as much as possible to avoid any excess muscle hypertonicity. Keep in
mind that the fingers of the contact hand are recruited to stabilize the contact hand and thus ensure
specificity and patient comfort. The contact should be firm but light in a fairly high chiropractic
arch (Fig. 10.11). Tissue slack is taken cephalad and laterally to accommodate preload and thrust
directions. The clinician remains in contact with the table at all times to support body weight and
keep the trunk weight over the contact region.
2) Using the head as a lever will create movement above the contact but stabilize below. The head as
a medium lever takes considerable finesse to move skilfully. Without losing contact over the target
segment transverse process, the web of the indifferent hand (left) is cupped around the ear of the
patient being careful not to pinch the earlobe. The hand is extended and radially deviated when
performing this task. The thumb comfortably cups the occipital rim (*) and the pads of the index
and middle fingers contact the parietal/temple region of the skull just above the ear (*). There is a
slight arch in the hand. This is to protect the earlobe from being compressed against the skull with
the hand and allows the patient to hear the practitioners dialogue during this procedure. The arm
crosses in front of the contact arm and there is no movement of the head at this stage (Fig. 10.12).
Please remove any jewellery before proceeding to avoid any risk to the patient particularly
pierced earrings which can be compressed into the mastoid region.
3) The head is then gently teased out of the middle of the headpiece no more than 2040 of head
rotation or until movement or rotation is felt under the contact point through the soft tissue contact.
This is done by slowly flexing the wrist and moving the arm across the body in front of the contact
arm. Discourage patient assistance. As a result of this step the head is positioned in slight flexion,
lateral flexion and rotation using all ranges of segmental motion to develop preload and avoiding
end-range motion in one plane/axis. The nose is clear of the head cushions and there should be no
tension in the patients upper back or neck regions (Fig. 10.13). The support arm is resting on the
practitioners thigh (*). The clinician must concentrate on maintaining their contact on the target
joint without any excessive pressure and lightly move the head at the same time.
4) The clinician now shifts the weight forward by plantar flexing the rear foot. This brings the body
weight forward over the headpiece in preparation for joint preload/tension. The contact arm is
almost straight and the indifferent arm is tucked into the side of the body to keep the levers as short
as possible (Fig. 10.14A). Care is taken not to place any weight on either anatomical landmark or
produce any excess tension between the two contact points. The distance between the points should
not change. The body weight is supported by the front leg and is over the centre of the patient and
the table (Fig. 10.14B). The clinician leans against the side of the table for support; note the
midline position of the plumbline/body weight (see dashed arrow).
5) The patient is asked to breathe in and out and at the same time the clinician develops joint preload
by simultaneously moving the hands in combination away from each other. This is accomplished by
rotating the head with the indifferent hand and lowering the body weight by slowly flexing the front
leg as the patient slowly breathes out (Fig. 10.15). This action causes the two contact points to
separate slowly, increasing tissue tension between the contact and indifferent hands. Cephalad
traction is maintained by the indifferent hand contact. The practitioner should begin to feel
maximum tension across the tissue as the patient completes the breathing cycle. The clinician leans
against the table during the whole procedure, keeping the upper torso only slightly flexed with the
majority of the trunk weight over the legs.
6) There are several potential errors associated with the learning of this skill. Apart from a
heavy forceful contact, a commonly observed error to note is the clinician positioned parallel to
the table with a flexed contact arm with the body weight located well behind the transverse process
contact and the upper torso and shoulder in cramped elevated position (*) (Fig. 10.16). This will
place the shoulder girdle under increased mechanical loading particularly the glenohumeral joint.
Single spinous contact head as a lever
This next series of skills is combined to influence mechanical spinal dysfunction, mainly related to
rotation and lateral flexion of the cervicothoracic spinal junction (Figs 10.17 - 10.22). This
manipulative procedure is commonly referred to as the thumb move (Szaraz 1984), thumb movement
of bench TM (States 1968) or a thumb spinous push in the prone position (Bergmann & Peterson
2011). The steps are once again a continuation of the previously learned skills. The sequence will
focus on the T1/T2 segment and assumes that movement takes place above the contact point as a result
of head-assisted rotation (Bergmann & Peterson 2011).

1) The patient is positioned in the prone position with the headpiece slightly dropped down from a
horizontal position and the arms and hands in a relaxed state hanging to the side of the table out of
reach of the practitioners feet. The practitioner is positioned with the front leg ahead of the
patients arm, 45 to the table, feet hip distance apart, slight trunk flexion (neutral lordosis) and
leaning against the table for weight and postural support (Fig. 10.17).
2) After locating the spinous of T2 the skin slack is pulled by the thumb or the index finger of the right
hand or support hand (S) starting from the ipsilateral side of the spinous process, taking it straight
across to the contralateral side until tension is felt over the spinous process. The thumb pad of the
contact hand (C) follows in behind this tissue pull to contact the spinous lamina junction of the
spinous process of T2. The contact is light but firm and comfortable to the patient. The thumb pad
takes up additional skin slack. The fingers and web of the hand are draped over the ipsilateral
trapezius muscle in a stable and relaxed chiropractic arch (Fig. 10.18). The fingers lightly cup the
bulk of the trapezius muscle. Note the practitioner is leaning against the table at all times (*). The
contact hand wrist is straight (very slightly flexed) and in line with the thumb contact. Also note the
low position of the clinician relative to the contact hand.
3) The clinician lowers himself to bring the contact arm almost horizontal and at right angles to both
the table and the patient. The wrist is straight (very slightly flexed), ulna-deviated and the elbow is
flexed to approximately 90. The arm, hand and shoulder are relaxed (Fig. 10.19). The patient
should feel no more than mild pressure against the spinous process of T2. The contact arm rests on
the front thigh for support (*). Note the position of the practitioners sternal notch relative to the
contact point. This ensures a compact position which is centred over the target joint.
4) Rotate the head in the opposite direction (right rotation) until movement is perceived at the thumb
contact point at T2 (no more than 2040). This assures that the joints below the contact are
stabilized and the force during the manipulative thrust will be localized at the targeted segmental
level. The arms are kept close to the body to avoid spurious movement and excessively long
levers. The suprasternal notch is directly over the midline of the spine to centre the practitioners
upper body weight (Fig. 10.20). Note: discourage any assistance from the patient when turning the
head. This may need verbal reinforcement. There should be no tension or compressive force
perceived by the patient at this stage. This ensures patient cooperation and reduces any protective
muscular resistance if the patient is in pain.
5) Once the head is rotated pause, ensure patient comfort and request the patient to breathe in and then
out. Simultaneously introduce additional rotation, slight lateral and cephalad traction to the rim of
the occiput with the support hand. At the same time move the thumb contact gradually towards the
spinous lamina junction along the line of the wrist and forearm perpendicular to the spine (Fig.
10.21). Feel the preload/joint tension developing gradually between the two lever points. Visualize
the soft tissues involved and the effect on the joint structures under tension. Attempt a mock
repetitive mobilization thrust only to appreciate the elastic barrier and joint resistance. Maintain
contact with the patient at all times during this procedure for feedback. Keep in mind these are
relatively long levers that traverse a very sensitive region of the spine.
6) There are potential errors when learning this set of psychomotor skills.
The errors are similar to those already described above using the head as a lever. The most
common error is the position of the practitioner and the orientation of the wrist and forearm
relative to the spine and target joint. Positioning too far behind the patient causes the wrist to flex,
which may cause mechanical stress on the soft tissues of the forearm. This situation is impaired
even further with the clinician standing too far back or forward from the optimal cervicothoracic
junction position. Note the position of the plumbline and the orientation of the contact wrist.
NB. A variation of this ipsilateral manipulative skill is the contralateral procedure which has
certain mechanical advantages in terms of the position of the practitioners upper body weight over
the contact point and the direction of the pectoralis thrust required to provide a safe and skilful
manipulative thrust at this clinically important junction. The contact skills are similar to those
described above but in this set the skin slack is drawn towards the practitioner after locating the
target spinous process (Fig. 10.22). The clinician is leaning against the table for support bringing
the body weight over the midline. Roll the head out of the headpiece as described above (in left
rotation) until movement is felt at the T2 spinous process. Ask the patient to breathe in and out
slowly while simultaneously rotating the head and applying pressure against the spinous lamina
junction at ~90. This does not represent an advanced set of manipulative skills only a variation on
previously learned movements.
Mid-thoracic spine manipulative skills
Single spinous supine
This is one of the most commonly employed manipulative procedures (Figs 10.23A - 10.30C). It is
commonly referred to as the anterior thoracic adjustment (Fligg 1986b, Gitelman & Fligg 1992,
Nelson 1992, States 1968), the manipulative procedure for interspinous fixations (Gatterman &
Panzer 1990, Schafer & Faye 1989), or the supine thoracic adjustments (Bergmann & Peterson 2011).
There are many variations of this technique depending on the area of the thoracic spine and the
biomechanical indications (Bergmann & Peterson 2011). However, there is a common thread which
when mastered, like so many of the manipulative procedures already described, makes advancing to a
more complex skill easier for the student or experienced practitioner to learn. It needs to be
reinforced at this juncture that transferability of skills is not perfect in that any new specific and
unique skills must be learned in proper sequence to develop competency. Each set of skills is unique
and needs to be practised to develop the appropriate expertise.
For this set of skills the patient will be lying supine in a comfortable and relaxed state with the
headpiece flexed for cervical spine support/stability and the knees drawn up into flexion to reduce the
stress on the hamstrings and reduce the lumbar lordosis to ease any mechanical loading of the lumbar
facets. The practitioner will be standing on the patients right side. Once again the student will be
instructed to learn skills from both sides of the table to enhance clinical flexibility and practicality.
For the purpose of the description of this next set of skills spinal anatomical landmark reference will
be the T6/T7 motion segment. Refer to Chapter 7 or Byfield and Kinsinger (2002) for the appropriate
location skills.

1) The patient is lying supine as described above with the arms folded across the chest and the
practitioner facing at right angles to the patient just below the T6/T7 vertebral level feet separated,
with the cephalad foot at the level of the patients shoulder and the caudad foot at the level of the
hip (Fig. 10.23A). The clinician is leaning against the table with flexed knees to support body
weight and provide stability for the patient. The arms are crossed specifically with the patients
left arm folded over on top of the right with the hands reaching around the body (*). This
configuration maximizes tension in the interscapular region which reduces thoracic cage
compliance (Fig. 10.23B). It may be advisable to begin by using a thoracic board at this point
which will provide a firmer base and maintain comfort for the patient and practitioners contact
hand. The headpiece is raised slightly to provide comfort for the patient and support the
cervicothoracic spine in slight flexion.
2) To make a specific segmental contact the spine and related structures must be visualized. To
accomplish this procedure the patient is rolled towards the practitioner by simultaneously rotating
both the chest and pelvis until the patient is supported by the clinicians thighs (Fig. 10.24). The
patient must feel secure when rolled to the edge of the table. In addition to this skill set,
communicate very clearly to the patient that you are going to roll them towards you and that they
will not fall. To ensure safety the clinicians knees act to prevent the patient from rolling
uncontrollably off the table onto an unsuspecting novice (Fig. 10.24). This stabilizes the patient and
allows the practitioner to see and locate the dysfunctional motion segment. Note the position of the
clinicians arm and hands over the pelvic and shoulder region to help to roll the patient towards the
practitioner.
3) The thenar eminence is the contact point of choice at this level of skill learning. Refer to Chapter 5
for details of the two most common hand contacts. Each of these is selected depending on the needs
and size of the patient and practitioner. For each posture the thumb is adducted across the palm
with the thumb in line with the index finger. For the sake of consistency the open hand posture will
be demonstrated for ease of demonstration. With the index finger of the contact hand (right) the
T6/T7 interspinous space is located and simultaneously tissue slack is drawn cephalad from that
point with the middle finger of the indifferent hand (left). Once the excess skin slack is removed,
the middle of the thenar eminence is placed directly over the spinous process of T7 with the
inferior aspect of the spinous process of T6 positioned at the superior border of the thenar
eminence (interspinous space) (Fig. 10.25). The practitioners arms and knee/thigh contact safely
hold the patient in the side lying position (*).
4) The patient is rolled back very slowly onto the table with the practitioners contact hand making
sure that contact remains securely in place and does not cause the patient any discomfort. If the
patient shows any signs of distress, it is recommended that the contact hand is repositioned
immediately after rolling the patient off the hand. The next step at this stage is to lock the indifferent
arm (left) across the patients folded arms. The contact arm is positioned at right angles to the
patients torso and the elbow is dropped low towards the top of the table (Fig. 10.26). The
clinician is leaning against the table and over the patient, with absolutely no body weight
compressing the rib cage allowing the patient to breathe normally. Remember the patient could be
in some discomfort so this must be monitored at all times. Therefore, ensure that the patient is
comfortable by effective communication. Note the patients head is flexed to assist contact tension
(*). Gently pull/move the patients arms parallel to the patients body by flexing the indifferent arm
towards the practitioner. Do not push down towards the chest wall as this may distress the patient.
This action is a very short action which assists in flexing the trunk to the segmental level and
creating some tension in the upper body. There is to be no downward pressure on the patients
chest at this stage. The patient should be able to breathe comfortably and normally. There is a
tendency to push down at this level of undergraduate development. Take note and avoid as much as
possible. Give each other feedback during practice sessions as this is a measure of skill and
finesse.
5) The next step governs patient cooperation, compliance and control. The clinician plantar flexes the
rear foot, which brings their weight up and over the patients elbows, tucking them under/below
their axilla (Fig. 10.27A). The patient is then asked to breathe in very slowly, after which he or she
is requested to breathe slowly outward. Once again there should be no excess weight applied to
the rib cage during the breathing cycle. As the compliance of the rib cage is being removed the
clinician simultaneously applies downward and cephalad pressure at exactly the same rate as the
patient is breathing out (Fig. 10.27B). The clinician/student pulls up on the contact hand into the
spine to increase tension by contracting the biceps of the contact arm causing slight flexion. To
accomplish this, the forearm of the contact arm is almost parallel to the table with the elbow low
(*). Once rib compliance has been eliminated, the final aspect of the skill is the application of joint
preload/tension. Appreciate the joint tension and apply mock preload only.
6) Maximum flexion of the thoracic spine at the specific segmental level is an important aspect of this
manipulative procedure. Flexion of the headpiece may not be enough to reach the desired
segmental tension. Other appropriate modifications to maximize this are:
i) Asking the patient to lift his or her head actively off the table during the breathing out stage of
the sequence of skills for the midthoracic spine just prior to achieving joint resistance (Fig.
10.28).
ii) Using a clasped, interlaced hand contact by the patient behind his/her neck or head (*) will
increase upper back flexion and the appropriate joint tension and isolation. This position
provides long lever function to achieve the desired amount of flexion (Fig. 10.29). Consider
contraindications, as this technique may place excess stress on the cervical spine in a patient
presenting with concomitant mechanical neck pain.
iii) The TL junction is a clinical challenge from a manipulative skill perspective particularly
since there are numerous mechanical pain syndromes associated with this region. Refer to the
appropriate section in this chapter for more detail. The anterior thoracic cradle procedure is
a very useful clinical procedure that requires additional skills particularly during patient
transfer and weight distribution (Triano 2000). Triano (2000) has described patient transfer as
a potentially injurious event. The key to this procedure is bracing and counter-weight transfer
control. Begin the procedure as per the anterior thoracic as described above. Ask the patient to
lift their head off the headpiece of the table and the practitioner wraps their arm around the
neck and head for support and introducing flexion. The clinicians weight is predominantly
over the front foot at this stage, this being positioned at or slightly behind the contact point.
Note the position of the arm supporting the head for maximum stability (Fig. 10.30A). The
patient is lifted by the practitioner by pushing their weight back with the front leg essentially
transferring the weight from the front to the rear leg. The practitioner leans against the table for
stability and keeping the body weight over the patient. At this stage the clinician adopts the
most appropriate hand contact posture over the target motion segment. The patient is requested
to breathe in and out slowly and as this occurs the patient is slowly lowered over the contact
hand by transferring the weight from the rear to front foot to carefully control patient
movement. The key at this stage is not to go beyond the contact hand, transfer too quickly or
lose the flexion of the trunk which must be maintained to achieve reasonable joint tension. As
the patient is lowered over the contact hand the clinician ensures that their body weight is over
the centre of the patient to maximize joint tension and reduce overall manipulative forces.
Lifting and cradling the patient to the desired level in the mid-thoracic to lower thoracic
spine allows the practitioner to control the patients weight and movement. This is performed
by extending the front leg pushing the clinician back and simultaneously lifting the patient off
the table. The head and neck are supported by the clinicians arm, which is placed behind the
head to assist moderate trunk flexion and the body weight is supported by the clinicians back
leg (Fig. 10.30A). The student/clinician must communicate each and every step with the patient
to receive cooperation and relaxation. The patient is slowly lowered down onto the table/hand
contact at the appropriate segmental level after breathing in and out by transferring the patients
weight from the clinicians back leg to front support leg (Fig. 10.30B). The practitioner/student
must maintain trunk flexion while lowering the patient until they reach the point of maximum
tension at the desired segmental level.
iii) This is achieved by keeping the patients trunk flexed and not permitting the trunk to roll
cephalad above the contact (Fig. 10.30C). This particular variation requires considerable
control of patients body weight as it is lowered down over the contact. This is accomplished
by positioning the practitioners front leg well forward to control and support the weight as it
comes down. This is a more advanced skill.
Lower thoracic spine
Manipulative skills for the lower thoracic spine present a more arduous task to the practitioner for a
variety of reasons, among them the changing nature of the spinal curvature, the orientation of the
facets, a sensitive rib cage, the patients body weight and the impact of many of the spinal stabilizing
muscles crossing this region from the pelvis and lumbar spine regions. Mechanical dysfunction
syndromes, such as Maignes syndrome (thoracolumbar syndrome) (Bernard & Kirkaldy-Willis
1999), respond well to manipulation, therefore practitioners need to be confident and skilled to
introduce a manipulative thrust confidently and safely into the region to restore intervertebral
function. This is also a common region for various spinal pathologies (compression fractures,
metastases) that challenge the clinician when contemplating manipulative intervention.
There are a multitude of manipulative procedures commonly employed to correct dysfunction of
the lower thoracic spine. The thenar and hypothenar/metacarpal hand contact points are routinely
selected for this purpose. They are often referred to as the bilateral thenar or the bilateral hypothenar
(Carver Bridge) (Szaraz 1984), bilateral thenar push (Bergmann & Peterson 2011) and the
phalangeometacarpal (States 1968). The transverse processes are the preferred anatomical
lever/contact point because of the changing morphology of the spinous processes and the angulation of
the posterior facets. The problem with this contact lever is the presence of the thick thoracolumbar
paraspinal musculature that can challenge hand contact point. This is overcome by introducing
comprehensive tissue slack movement in the cephalad direction to improve contact specificity. Tissue
pull is taken in the cephalad direction in the line of the preload and thrust. On the other hand, the
spinous process is an effective anatomical lever for this region depending on the nature of the spinal
curve and the overlying soft tissues. However, in these instances the spinous process assists in
segmental location and hand positioning. Other manipulative procedures including the knife-edge
(Schafer & Faye 1989, Szaraz 1984) employ the edge of the hypothenar eminence to contact the
inferior tip of the spinous process, but it is employed mainly in the mid- to upper thoracic spine
where the spinous process is more prominent. These manipulative skills will not be presented, as the
author feels that they are not appropriate at undergraduate level. The following is an introduction to
the skills in this region of the spine (Figs 10.31A - 10.32). Refer to Chapter 5 regarding hand
configuration skills for these two specific hand contacts.

1) The most important aspect of these manipulative skills (double hypothenar and double thenar) is
keeping the shoulders, hands and arms symmetrical throughout preload and the mock thrust
exercises. It is also important to note that the contact points for both procedures are broad, thus
dispersing preload and thrust forces over a significantly large area. This unique practitioner
posture ensures equal mechanical loads and stresses on the soft tissue and a balanced thrust across
the joints. For the double hypothenar procedure the practitioner leans against the table to support
their weight thereby reducing weight bearing and moment stress on the spine (Fig. 10.31A). Note
the symmetry of the arms and the position of the elbows, which are close to the body. The body
weight is pushed forward to help develop preload over such a broad contact covering regional
dysfunction in the lower thoracic spine. As the patient is breathing out the practitioner brings their
upper body forward and down towards the contact hands to assist joint preload and position the
body weight as close to the perpendicular as possible (Fig. 10.31B,C). For the double thenar
contact, note the position of the plumbline and the sternal notch, indicating that the weight of the
practitioners body is centred over the patients spine in the midline for a more efficient procedure
and preload/thrust. The midline position of the practitioner is paramount to equalize preload and
thrust forces across the regional dysfunction. Ask the patient to breathe out while plantar flexing the
rear foot to drive the body weight forward to assist joint tension. The practitioner starts very low
(Fig. 10.31D) and rises up slightly as the patient breathes out to position the body weight
perpendicular as possible to maximize the force transfer (Fig. 10.31E).
2) The angle of the arm is determined by the level of the spine and the practitioner attempts to transfer
forces perpendicular to the spine to ensure efficient load transfer to the spinal structures (Fig.
10.32). The lower the dysfunctional facets are located in the thoracic spine the greater the
horizontal angle at preload prior to manual thrust/mobilization procedure. For patient comfort,
forces are directed more vertically in the mid to upper thoracic spine.
3) This particular skill is a variation of the thumb move procedure described earlier (Figs 10.17-
10.22 ) taking a spinous process contact at the cervicothoracic junction. This set of skills takes a
cephalad approach by the practitioner to the cervicothoracic junction using a hypothenar spinous
process contact and the head as an important additional lever. The practitioner draws the skin slack
towards the opposite inferior scapular pole to stabilize the contact position. A fleshy hypothenar
contact on the ipsilateral spinous process of T2 is taken with the right hand in a chiropractic arch.
The practitioner is positioned with the left knee braced up against the headpiece of the table in a
fencer stance (Fig. 10.33A). The indifferent hand stabilizes the head lever and rotates the head as a
lever by wrapping the web of the hand around the ear until some movement at the cervicothoracic
junction is perceived by the contact hand (Fig. 10.33B). There is no attempt to create joint
tension/preload at this stage.
4) In the next step ask the patient to breathe in and out during which the practitioner begins to rotate
the head further and at the same time applies preload force to the contact hand by plantar flexing the
rear foot to push the weight forward (Fig. 10.33C). Note the position of the practitioners lead knee
braced against the headpiece for stability and the flexion in the contact arm. The process of preload
is continued until maximum tension is perceived by the practitioner at which point no further
movement is warranted. At this point the practitioner is lined up directly towards the inferior pole
of the opposite scapula and the sternal notch is almost over the target joint just prior to
mobilization or dynamic thrust (Fig. 10.33D).
5) One useful procedural variation for the cervicothoracic region is the contralateral hypothenar
spinous process contact for the cervicothoracic junction (Fig. 10.34). See Figures 10.17-10.22
above for the basic procedural skills to supplement this variation. This variation may provide an
alternative for those clinicians/practitioners who have particularly flexible thumb articulations
which may impair their ability to acquire these skills. The contact is the contralateral side of the
spinous lamina junction with a fleshy hypothenar contact (Fig. 10.34). Note the position of the
sternal notch and the practitioner leaning against the table for stability and postural assistance.
6) The first rib is often involved in a number of cervicothoracic junction mechanical pain syndromes,
particularly combined with the fact that the biomechanical linking between the first rib and the
posterior facets all of which are potential pain generators. The association of a number of
important myofascial structures, particularly those that cross both regions of the spine, have
clinical significance, for example the scalene group and their role in respiration. There are a
number of clinical variations to manually influence the costotransverse articulation of the first rib.
The key to this set of skills is the metacarpophalangeal contact of the soft tissues overlying the
costotransverse articulation without compromising the lower cervical spine facet joints. In the
prone posture the skin slack is taken down towards the table at the junction of the trapezius and the
cervical spine both for the ipsilateral and contralateral procedure. The majority of the skills are
similar to those presented in Figures 10.17-10.22. The thumb contacts the spinous lamina junction
of the corresponding segmental unit (usually T1) (Figs 10.35A,B). Joint tension/preload is
developed as above and as well as the head roll. The contact arm is angled towards the inferior
pole of the opposite scapula to target the costotransverse articulation and protect the sensitive
lower cervical spine facet joints. Care must be taken not to twist the shoulder and mechanically
load the glenohumeral joint capsule.
7) The first rib articulation can also be approached from the cephalad position, as well as the caudad
posture as described above. This is generally a practitioner preference. In both postures the
headpiece is always positioned just below the horizontal to provide tissue tension at the
cervicothoracic junction. The cephalad first rib prone is depicted in Figure 10.35C. The tissue
slack is taken down towards the table to help cushion the contact point. The clinician stands on the
side of the lesion positioned at about 45 to the contact arm which is directly in line with the
inferior pole of the opposite scapula. All other skills are consistent with the above descriptions.
The thumb pad of the contact hand is stabilized against the spinous lamina junction of T1. The
supine first rib procedure is simply the reverse of the prone with the headpiece raised to support
the head and create some tissue tension at the cervicothoracic junction. The tissue slack is brought
from posterior to anterior to cushion the contact point (Fig. 10.35D). The head is laterally flexed
towards the contact hand and slightly rotated in the opposite direction. The thumb of the contact
hand is stabilized by either contact on the mandible or, in this case, over the clavicle (Fig.
10.35D). As with all of these manipulative skill procedures the patient is asked to breathe in and
out to assist the manoeuvre and the preload is developed by increasing joint tension towards the
inferior pole of the opposite rib.
Figure 10.31A

Figure 10.31B
Figure 10.31C

Figure 10.31D

Figure 10.31E
Figure 10.32
Figure 10.34
Additional thoracic procedures
There are a number of additional manipulative skills for the thoracic spine, particularly those
commonly incorporated clinically for dysfunction syndromes related to the cervicothoracic and
thoracolumbar junctions (Figs 10.33A-10.35D). These regions, as mentioned earlier in the chapter,
offer a clinical challenge for the clinician and a variety of skills are available to address this common
source of local and referred mechanical pain. This is by no means exhaustive, but will provide the
undergraduate with a number of additional psychomotor skills and manual procedures for a number of
clinical scenarios. It should be emphasized that the previous skills must be assimilated before going
on to this next series.

Figure 10.33A
Figure 10.33B

Figure 10.33C
Figure 10.33D

Figure 10.35A
Figure 10.35B
Figure 10.35C

Figure 10.35D
Summary
This chapter has presented a detailed description of the more commonly used diversified
manipulative procedures for the thoracic spine including the cervicothoracic and thoracolumbar
junctions. The theme has been the demonstratation of each manipulation as a set of individual
complex motor skills and movements in a sequential fashion. These skills represent the basis or
foundation for more advanced manipulative procedures that may be learned once these basics have
reached a level of proficiency. This endeavour requires a commitment of many hours of practise in
the pursuit of excellence. These skills must be practised on a regular basis to engrain the sequence
and develop the finesse required to enhance the overall performance. Students are reminded that
active visualization and mental imagery skills will enhance this process. Reference to case study
material and workshop discussions will support the learning process. A thorough in-depth knowledge
of the functional anatomy and relevant biomechanics of this complex region and their role in spinal
integration will also enhance high quality and high standards of manual skill acquisition.

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Chapter 11

Cervical spine adjustive and manipulative skills

David Byfield

Chapter contents

Introduction
Vertebrobasilar insufficiency and the cervical manipulation issue
Summary of relevant research and clinical management
Common post-manipulative reactions
Biomechanical evidence
Suggested mechanisms or pathophysiology of vertebral artery injury
Educational issues clinical and manipulative skills
Manipulative thrust forces and technique considerations of the cervical spine
Manipulative skill and performance
Common cervical manipulative considerations
Midlower cervical spine manipulative skills
Articular process (AP) supine
Spinous-lamina (SL) supine
Transverse process (TP) supine
Additional cervical manipulative skills
Summary
Thumb rotary skills
Sitting cervical skills
Upper cervical spine manipulative skills: an introduction
Occiput atlas manipulative and important mobilization skills
Mastoid process (MP)
Occipital rim (OC)
Summary
References
Further reading
Introduction
There is substantial body of clinical evidence that supports manipulation/mobilisation as a safe and
effective intervention for the management of neck pain and associated disorders including common
types of headache (Bronfort et al. 2001a,b, 2004a,b,Bronfort et al. 2010, Carroll et al. 2009, DSylva
et al. 2010, Gross et al. 2010, Haldeman et al. 2009, 2010, Hurwitz et al. 2009, Miller et al. 2010,
Rubinstein et al. 2007, van der Velde et al. 2009). Spinal manipulative therapy appears to provide a
better effect than massage for cervicogenic headache and also seems to function in a comparable
action as commonly used first-line prophylactic prescription medications for tension-type and
migraine headaches (Bronfort et al. 2001a, Vernon, 2003). Furthermore, Bronfort et al. (2004a) has
reviewed the literature and reported the sum of the evidence available with respect to manipulative
intervention for common headaches in the prestigious Cochrane Collaboration Database. These
investigators indicate that chiropractors and other practitioners of spinal manipulation can effectively
manage migraine and cervicogenic headaches with predictably good to excellent clinical outcomes
when compared with other common treatments. These findings provide an important clinical
intervention/option for headache sufferers particularly in light of the incidence of headache in the
population. From a clinical perspective, we are now at a point where we can predict patients who
will have a favourable outcome when treated for neck pain by a chiropractor (Rubinstein et al.
2008a) and even, to some degree those who may have an adverse reaction (Cagnie et al. 2004,
Rubinstein et al. 2008b). It is not the intention of this chapter to present an in-depth presentation
concerning the epidemiology, aetiology, mechanisms and treatment of chronic headache; however,
there are a number of excellent publications and textbooks written by very accomplished researchers
that accomplish this particular task. It is the intention of this chapter to provide some background
information and knowledge that supports spinal manipulative therapy as a safe, effective and viable
therapeutic option for the treatment of mechanical dysfunction of the cervical spine. The main thrust of
the chapter is to present relevant information to support the introduction and acquisition of common
psychomotor skills assocated with manipulative procedures of the cervical spine from an educational
perspective. Therefore, this chapter will describe and illustrate many essential
mobilization/manipulative/adjustive psychomotor skills, commonly employed in the cervical spine. In
addition, the authors will present some views on the controversial issues concerning safety of
manipulation of the cervical spine and rare adverse reactions, in an attempt to place the discussion in
clinically applicable and educational perspective. This will be presented in light of (1) the outcome
of the Lana Dale Lewis Inquest concluded in Canada (2004); (2) published incidence of adverse
reactions following neck manipulation; and (3) clinical trial evidence comparing cervical spine
mobilization and manipulation outcomes for neck pain. For example, recent clinical evidence
indicates that patients with neck pain who are mobilized rather than manipulated experience fewer
mild adverse reactions to treatment (Hurwitz et al. 2004) and there is also good evidence that
manipulation of the thoracic spine has resulted in good clinical outcomes with respect to neck pain
(Cleland et al. 2005, 2007, Fernandez-de-la-Penas et al. 2007), which is thoroughly reviewed in
Chapter 3 of this text.. This does give the clinician further options to safely treat patients with neck
pain and manage the post-treatment reactions that commonly occur. This could have quite a significant
impact on the way we address manipulative psychomotor skills from an educational perspective for
both clinical training and skill acquisition. Current research and reliable evidence must drive our
educational programmes, particularly when it may impact on patient care and safety. Therefore,
the following will focus on these issues and present current evidence and expert opinion with respect
to this extremely contentious issue.
Vertebrobasilar insufficiency and the cervical
manipulation issue
The role of spinal manipulation for mechanical neck pain and many headaches has been firmly
established; however critics of manual therapy, specifically chiropractic, seem to emphasize the
possibility of serious injury and downplay the benefits of the intervention (Rubinstein et al. 2007).
These authors demonstrated that adverse reactions are common and the majority of these reactions
fully recover in a very short period of time. Their study concludes that the benefits of cervical spine
manipulation outweigh the risks (Rubinstein et al. 2007). A more recent study investigated the
potential variables that could predict adverse events in subjects undergoing chiropractic care for neck
pain (Rubinstein et al. 2008b). These authors found:

1. use of rotation manipulation by the chiropractor and work status were weakly to moderately
predictive of adverse events
2. longer duration with neck pain in the previous year and increased neck pain after the first treatment
session was moderately associated with headache
3. patients who visited the GP in 6 months prior to treatment were less likely to have an adverse
reaction.

A recent study by Cassidy et al. (2009) reported that vertebrobasilar artery (VBA) strokes are
rare in the population and that patients were no more at risk of suffering a stroke when receiving
chiropractic care compared with visits to a primary care practioner when seeking care for neck pain
and headache. These are symptoms typically associated with those seeking care and who may be
experiencing a stroke.
There are numerous case reports concerning serious post cervical manipulative complications,
including a range of neurovascular events, e.g. cerebrovascular strokes. The case reports indicate that
these events do happen, but they are extremely rare and represent a very small percentage of those
patients receiving cervical manipulation. Most of the case reports are retrospective in nature and
cannot be incorporated to establish a causal relationship between manual therapy and the onset of
serious complications (Bergmann & Peterson 2011a, Chapman-Smith 1999).
In terms of prevalence it has been determined that slight neurological complications have been
observed in one in 40 000 manipulations and one significant complication in 400 000 cervical
manipulations (Rosner 2004a), whereas others have reported that severe cerebrovascular accidents
(CVA) will follow in one out of 500 0001000 000 upper cervical manipulations and minor, often
temporary, cerebrovascular problems will occur following one in 50 000100 000 upper cervical
manipulations (Martienssen & Nilsson 1989). However, the most quoted incidence and potential risk
of CVA as a result of vertebral artery dissection following manipulation of the cervical spine is
approximately 1 in 1.3 million treatment sessions (Haldeman et al. 1999). In addition, CVA from
vertebrobasilar artery dissection has been calculated to be extremely rare, giving rise to only 1.3 per
1000 cases of stroke. It has also been reported that a major medical centre cannot expect to see more
than 0.53 cases in a year, which are numbers that are simply insufficient for detailed analysis of risk
factors and other precipitating events (Chapman-Smith 1999). It has been documented that the
likelihood of a Canadian chiropractor being made aware of a vertebral arterial dissection following
cervical manipulation will occur in approximately 1 per 8.06 million office visits, 1 per 5.85 million
cervical manipulations, 1 per 1430 chiropractic practice years and 1 per 48 chiropractic practice
careers making this a very rare event (Haldeman et al. 2001). This perspective has been expressed by
Licht et al. (2003) who conclude that if there are sound clinical indications for cervical manipulation
the risk is acceptably low and the fear of serious complications is greatly exaggerated. This view is
reinforced by the results of a review of the evidence which suggest that the exact figures for the risk
of severe adverse events following cervical manipulation are not yet available and that overreliance
on one type of study design is misleading (Thiel 2003). This is also overshadowed by the fact that
very little is known about the mechanisms of vertebrobasilar damage following cervical manipulation
and useful risk management strategies have not as yet been satisfactorily developed and implemented
(McDermaid 2001).
A less biased, population-based, casecontrol study has estimated that the risk of stroke
secondary to chiropractic manipulation for individuals under the age of 45 is about 1.3 per 100 000
chiropractic visits (Rothwell et al. 2001). The current incidence, whatever the true number, is
particularly relevant when one considers, for example, that approximately 134.5 million cervical
manipulations were performed by Canadian chiropractors between 1988 and 1997 (Haldeman et al.
2001). This is comparable to the estimated 1838 million cervical manipulations performed by US
chiropractors for neck pain and headaches (Shekelle & Coulter 1997). In the final analysis, the true
risk of cervical artery dissection and stroke following cervical manipulation continues to remain
unknown at this time. Cervical artery dissection is a multifactorial disease with multiple risk factors
including genetic, environmental, trivial trauma and the risks related to atherolsclerosis (Rubinstein et
al. 2005). The existing data just does not provide a definitive answer to this question calling for more
quality research. A review by Haldeman et al. (1999) stated that until there is more evidence and
knowledge regarding post-cervical spinal manipulation reactions and complications:

1. No manipulative technique can be said to have more associated risk except rotation.
2. No patient can be seen to be at a higher risk as a result of unidentifiable risk factors.
3. CVAs after any neck movement, trauma, or manipulation should simply be seen as a rare, random
and unpredictable complication (Haldeman et al. 1999).

In another publication, Chapman-Smith (1999) concludes that:

1. rotation is a very common and repetitive movement of the neck during a multitude of normal daily
activities
2. premanipulative provocation testing is unreliable at best (should be discontinued)
3. informed consent prior to neck manipulation is a definite clinical necessity. The reality is that
CVAs can be associated with a number of mundane common daily activities (e.g. wall papering,
turning the head while driving, or other sustained rotational activities).

To date, most manipulative accidents have been associated with pure rotational neck
manipulation predominantly directed towards the upper cervical spine articulations. This is the
region in which the vertebral artery may be more vulnerable to direct trauma because of its
anatomical relationships. Rotational types of manipulation are the most common spinal manipulation
procedure for the cervical spine in use in chiropractic practice (Byfield 1996) and would, therefore,
most likely be associated with the greatest number of serious vertebral artery cases attributed to
chiropractors. It also stands to reason that since neck and head pain are common clinical symptom
presentations, it is more likely that chiropractors and other healthcare professionals are going to see
patients who may potentially be at risk, and, as a result, encounter more patients with signs and
symptoms of a CVA in progress. However, the evidence suggests that patients are no more at risk of
experiencing a stroke if they consult a chiropractor or a primary care practitioner (GP), which may
shed some important light on this issue (Cassidy et al. 2009). Notwithstanding, clinicians must
develop the appropriate skills to identify those patients at risk and manage accordingly. It has been
reported that the possible indication of the prodrome to a stroke may lie in the case history rather than
the examination findings and provocation testing procedures (Kier & McCarthy 2006).
Kawchuk and Herzog (1993) investigated peak force magnitudes associated with a number of
common cervical spine manipulative procedures. Their results illustrated that the cervical rotary and
lateral break flexion adjustments were delivered very quickly but imparted much lower forces
compared with the toggle recoil or Gonstead type of procedure. Symons et al. (2002) and Herzog
(2001) have investigated the internal forces experienced by the vertebral artery during spinal
manipulation. Even though the studies are in vitro, the investigators found that it was impossible to
mechanically disrupt or injure the vertebral artery during cervical spinal manipulative therapy. It also
appears highly unlikely that the vertebral artery might be damaged mechanically by a single
manipulative thrust intervention. Symons et al. (2002) have estimated that it would take
approximately 10 times the force generated during a lateral flexion manipulation to damage the
vertebral artery under these in vitro experimental conditions. Future experimentation should
investigate the behaviour of arteries that have undergone pathological changes associated with known
vascular disorders, including atherosclerosis and the effect of repeated manipulations on these
arteries.
Terrett (2001) has reviewed the literature regarding post-manipulative CVA events. He reports
that patients who suffer vertebrobasilar stroke or stroke-like symptoms after neck manipulation
generally:
are young healthy adults
have a previously uneventful medical history
have none, or only a few, of the known stroke risk factors
cannot be identified by clinical or radiographic examination.

Women do not appear to be at a greater risk.


Terrett (2001) also documents that the most important vertebrobasilar stroke risk factors to
identify in the history and clinical assessment are:

dizziness, unsteadiness, giddiness, vertigo


sudden severe pain in the side of the head and/or neck, which is different from any pain the patient
has had before.

It has been reported that vertebral and carotid artery dissections are the most frequent causes of
stroke in young adults and are usually associated with mild to severe trauma, but it has been also
reported that they can arise spontaneously (Gallerani et al. 2001). The authors reported that the most
frequent and inaugural symptoms of vertebrobasilar artery dissection in 80% of cases are posterior
neck or occipital pain (symptoms commonly reported by headache and post-whiplash patients who
present to a chiropractor). These same patients also present with diffuse headache and cervical
stiffness plus signs and symptoms of transient or persistent brain ischaemia (vomiting, vertigo,
nausea, nystagmus, diplopia and ataxia). Stahmer et al. (1997) reported that dissections of the
vertebral arteries are a common cause of stroke in young adults, but may typically be missed because
the characteristic signs and symptoms are easily confused with other commonly encountered clinical
entities. Haldeman et al. (1999) established in their study of 367 cases of CVA that 43% were
spontaneous and an additional 16% were the result of minor trauma, thus accounting for
approximately 60% of the overall total. Mokri et al. (1988) reported the clinical and angiographic
features and outcome of 25 patients who sustained spontaneous vertebral artery dissections. They
reported that most of the patients studied were in their fourth or fifth decade and were predominantly
women. This raises the possibility of an underlying arteriopathy that predisposes the vessel to
dissection. Of the 367 CVA cases reported by Haldeman et al. (1999) only 31% were attributed to
manipulation by a range of different practitioners not just chiropractors.
Terrett (2001) documented the major signs and symptoms of vertebrobasilar insufficiency that
appear to occur immediately after or during the spinal manipulation in 63% of the cases. These were
modified by Kier and McCarthy (2006) and they are now known as The 5Ds And 3 Ns:

Tinnitus
Dizziness/vertigo/giddiness/light headedness
Drop attacks/loss of consciousness
Dysarthria (speech difficulties)
Dysphagia
Ataxia of gait (walking difficulties/incoordination)
Nausea (with possible vomiting)
Numbness on one side of the face or body
Nystagmus.

These represent clinical features suggestive of brainstem ischaemia, as a result of vertebral


artery insufficiency and it requires the talents of a trained clinician to attribute these signs to those of
a medical emergency. Failure to do so could be detrimental to the patient and deny them appropriate
emergency care
Terrett (2001) has identified dizziness and atypical severe pain in the side of the head or neck as
the most important risk factors for vertebrobasilar insufficiency. This information is gathered in the
case history and is regarded as a potential red flag (Kier & McCarthy 2006). Furthermore, it is
extremely difficult, or next to impossible, for the practitioner to differentiate if this pain is of
labyrynthine, vascular, or musculoskeletal origin, particularly if there are no other brainstem
symptoms using current clinical testing procedures. These testing procedures have been shown to be
extremely variable, lacking validity, reliability and specificity in a clinical setting (Haldeman et al.
1999), and the clinical test procedures used routinely to detect individuals susceptible to vertebral
artery compromise have been shown to be unreliable and of little diagnostic value (Chapman-Smith
1999, Haldeman et al. 1999, Terrett 2001). Furthermore, evidence suggests that vertebral artery blood
flow is not impeded during the most commonly used vertebral artery functional test (known variously
as the Wallenburg Test, de Kleyns Test or Georges Test) of sustained head and neck rotation with
extension (Thiel et al. 1994). Additionally, Licht et al. (1999, 2000) reported that there are virtually
no changes in blood flow during these premanipulative testing procedures for the vertebral artery.
This research implies that more complex neurophysiological mechanisms are involved besides the
more obvious mechanical stresses on the vascular structures. Therefore, there doesnt appear to be
any accurate clinical procedure to detect those patients at risk. Most victims are young, without
osseous or vascular pathology and do not present with overt vertebrobasilar symptoms. This presents
a clinical challenge, yet with careful history taking and full clinical testing, the likelihood of a
vascular accident is said to be significantly reduced (Terrett 1987b, 2001). This clinical scenario
regarding varying blood flow, poor predictive values and low force measurements clearly impairs the
clinicians attempt to conduct appropriate and sensitive risk management at a clinical level, basing
the majority of their decisions on accurate history taking and clinical observation. Notwithstanding,
Thiel and Rix (2004) have provided an excellent commentary regarding the utility of functional
premanipulative testing of the cervical spine with respect to the available evidence and the quality of
the methodology of these studies. They suggest that the significant disparity of the results of various
studies on vertebral artery blood flow during premanipulative provocation testing is dependent upon
a number of methodological flaws. Under these conditions the weight of the evidence seems to
strongly suggest that these screening tests lack diagnostic sensitivity in order to be a valid and
dependable predictor of risk following cervical manipulation. There is still a belief that performing
these screening tests offers the practitioner some medico-legal or clinical negligence protection
and may afford the patient a lesser risk of post-manipulative stroke. This is simply not the case,
which may lead the practitioner into a false sense of security regarding patient safety and legal
protection.
One of the recommendations from the Lewis Inquest (2004) advocates that certain vertebral
artery provocation tests should neither be used clinically nor continued to be taught at the
undergraduate level. These provocation tests may have another clinical purpose, but there is some
evidence that the testing procedures may be putting vulnerable patients at risk as the test position
appears to place high forces on the vertebral artery (Symons et al. 2002).
Thiel and Rix (2004) have collated information regarding the clinical features of vertebral artery
dissection and brainstem ischaemia arising from vertebral artery insufficiency. They have listed a
number of these clinical features, specifically:

pain in the head and neck, often unilateral and sub-occipital (90% of reported cases)
patient reports never having experienced a similar pain previously
onset is most often acute details need to be established via case history
pain is severe, distinct and sharp
patient reports neck stiffness, but there is no limitation of neck range of motion
time delay of symptom onset and clinical features of brainstem ischaemia can range from just a few
hours up to 14 days.

In conclusion, Thiel and Rix (2004) have made the following observations and recommendations
in this area of clinical uncertainty:

1. Practitioners must assess patients thoroughly, including a detailed case history and physical
examination. Practitioners must keep in mind that dissection of the vertebral artery may present as
pain only, which is particularly severe and reported by the patient to be the worst pain they have
ever experienced. Practitioners should also record if there has been a change in the nature and
character of the presentation. This combined with distinct occipital or sub-occipital location
should be regarded as potentially serious and managed appropriately.
2. If vertebral artery dissection is suspected, provocation testing should not be introduced and the
patient should be referred immediately.
3. If the patient presents with non-dissecting stenotic vertebral artery disease provocation testing will
not provide additional information. This comes down to the practitioners clinical acumen and
diagnostic skill.
4. Practitioners on the whole have to consider whether provocative testing provides any real clinical
benefit for this patient population. This must be placed in clinical context, particularly with regard
to the risks and ethical considerations of provocative testing. Symons et al. (2002) have shown that
the vertebral artery is under more strain during the provocation position. Whatever the outcome,
practitioners must maintain a clear focus on the needs of the patient and the best available evidence
to establish any conclusions and recommendations for future clinical activity in this region of
clinical debate and controversy.
5. Chiropractors must develop the skills and ability to recognize patients at risk of and those currently
experiencing signs and symptoms of brainstem ischaemia as a result of a number of possible
aetiological factors. Chiropractors must always err on the side of caution under these conditions
and establish professional links to ensure appropriate referral and patient welfare at all costs.
Summary of relevant research and clinical
management
1. There is good evidence from quality research and systematic reviews that manipulation is a safe
and effective therapeutic option for headaches (cervicogenic and migraine) and neck pain.
2. Post-cervical spine manipulative vertebrobasilar artery dissection is an exceedingly rare and
idiosyncratic event (Haldeman et al. 2002).
3. Patients at risk of developing a post-manipulative CVA are extremely difficult to identify. There are
a number of crucial historical and examination details with this type of clinical presentation that
may identify those patients at risk.
4. No one particular chiropractic manipulative technique places a patient at any greater risk. Rotation
alone does not appear to be singularly responsible for all recorded post-manipulative events, but
pure rotational manipulative techniques should be avoided and clinicians should use multiplanar
techniques.
5. Those patients most likely to suffer a post-manipulative vertebrobasilar stroke or insufficiency are
often young with an unremarkable medical history and few, if any, stroke risk factors.
6. Dizziness, unsteadiness, giddiness, vertigo and a sudden severe pain in the head
(occipital/suboccipital) or neck, which is significantly different to any previously reported by the
patient, are the most important vertebrobasilar stroke risk factors to date.
7. It is particularly difficult to clinically differentiate pain of vascular and musculoskeletal origin.
Specific aspects of the clinical presentation of pain of vascular origin are important clues for the
clinician to identify those potentially at risk, particularly intense occipital or suboccipital pain.
8. Premanipulative vertebral artery functional provocation testing is unreliable, does not occlude the
blood supply, does not differentiate normal from abnormal artery function and is not predictive in
terms of those at risk of developing such a vascular accident. These tests demonstrate low
sensitivity as a screening procedure and low specificity as a diagnostic test.
9. Emergency care procedures for a suspected vertebral artery dissection have been suggested and
documented.
10. A causeeffect relationship with respect to vertebral artery dissection may be inappropriate as the
pathogenesis of such an event is complex and may evolve over a long period of time prior to any
therapeutic intervention. Family medical history may provide valuable clinical information in these
circumstances.
11. It is a well-documented fact that most vertebral artery dissections are apparently spontaneous in
origin or occur as a result of common daily activities.
12. Most post-manipulative reactions of the cervical spine are not adverse but are predominantly
benign and self-limiting.

As indicated previously, there are various clinical indicators that should function as red flags
to the clinician, which would initiate further investigation prior to any therapeutic intervention,
including:

1. sudden-onset severe occipital or suboccipital pain and/or headache


2. a distinct change in character, frequency and nature of the headache that is frequently described as
the worst pain ever experienced
3. presence of any objective neurological signs or symptoms taken in a clinical context.

Other historical data, including age, cardiovascular complications, family history and trauma, all
provide valuable information regarding the health status of the patient presenting with head and neck
pain, so that the clinician may proceed safely. Furthermore, this must be presented in conjunction with
the various psychomotor and manipulative skills associated with management of the cervical spine.
Common post-manipulative reactions
There are a number of key studies describing common post-manipulative reactions (Cagnie et al.
2004,Leboeuf-Yde et al. 1997, Senstad et al. 1996, 1997). All these studies are practice-based and
indicate that post-manipulative reactions are very common, but are generally benign and subside
within 24 hours. Most patients in this study described one or more of the following:

1. local discomfort
2. headache
3. fatigue as a result of chiropractic manipulative care.

More recent work investigating common side-effects after manipulation is consistent with this
early work (Cagnie et al. 2004). Cagnie et al. (2004) have looked at reactions associated with
chiropractic, osteopathic and physiotherapy practitioners. They found no difference between different
professions and that most reactions were common (61%) and subsided within 2448 hours. Their
work identified certain predictors of post-manipulative reactions: gender, age, smoking, medication
and region of the spine. Manipulation of the upper cervical spine was three times more likely to cause
a reaction in a female patient.
These reactions appear to be a common response to manipulative intervention, but they are not
adverse nor are they associated with any neurological complications. The authors would like to refer
the readership to the excellent work by Sidney Rubinstein in this very area and his groups
conclusions regarding predictive risk factors and benign adverse reactions (Rubinstein et al. 2005,
2008b).
Biomechanical evidence
Kinematic research has provided evidence that up to 80% of all axial rotation in the cervical spine
takes place between C1 and C2 (Iai et al. 1993, Panjabi et al. 1988). The researchers in the latter
study also detected a unique paradoxical contralateral motion at the occiput-C1 motion segment of 4
of counter-rotation during cervical axial rotation. This was interpreted as being a buffer of the atlas
during head rotation or, more importantly, it may serve to decrease the overall mechanical torsion
inflicted upon the vertebral artery at this level during extreme head movements. This may represent a
natural mechanism both to protect the vertebral artery on the contralateral side of rotation and to
reduce excess axial load on the joints below C1C2.
The C1C2 segmental level is the region where the vertebral artery is reputedly most
susceptible to injury. The artery emerges from the transverse foramen of the atlas and travels
posteriorly and medially around the lateral mass of the atlas and passes anteriorly to enter the
foramen magnum (Terrett 1987b, 2001). The vertebral arteries are virtually unprotected when
traversing from C1 to C2 with a considerable amount of laxity that allows the arteries to move freely
with the movement of the head and neck. Furthermore, there are a number of important vascular
structures (internal carotid artery) and soft tissues in this region which are also at risk during normal
activities and/or during spinal manipulation. Mechanically, the vertebral artery can be deranged and
potentially injured by stretching, shearing, or crushing at no less than eight potential sites along its
path in the cervical spine (Terrett & Kleynhans 1992). Even though these movements may have some
mechanical effect upon the vertebral artery, there is evidence that demonstrates that there is no
interruption to the arterial flow. There is alsoevidence to suggest that the vertebral artery elongates
during normal activities (Herzog 2001, Symons et al. 2002).
The cervicothoracic spine is a complex biomechanical region with a number of characteristic
properties, which are important for those learning undergraduate manipulative skills. There are a
number of excellent textbooks that have been published that describe in great detail the relevant
biomechanics of the upper and lower cervical spine for those engaged in spinal manipulative
therapeutics. Murphy (2000) and Vernon (2001) have authored and edited specific textbooks devoted
to the basic science and clinical aspects related to the cervical spine region that are highly
recommended by the authors. These texts thoroughly review the biomechanics of the entire
cervicothoracic spine, providing a foundation for manipulative skills training.
Suggested mechanisms or pathophysiology of
vertebral artery injury
Terrett (1987b, 2001) has reported that the most common mechanism of injury to the nervous system
from a vertebrobasilar accident is brainstem ischaemia, as a result of damage to the arterial wall.The
authors would like to recommend reading Terretts (2001) publication, Current Concepts in
Vertebrobasilar Complications following Spinal Manipulation, for a thorough account of many
aspects of this clinical event. Martienssen and Nilsson (1989) have concluded that cerebrovascular
accidents may be expected in an age group, which is slightly younger than that of the average
manipulative patient. Cerebrovascular accidents are not the sole domain of the old. As the spine ages,
it naturally becomes stiffer, which limits extreme ranges of motion, thus resulting in less mechanical
stress on the vertebral artery. The younger spine is simply capable of greater ranges of motion with
increased flexibility. However, this does not mean to say that care and caution to protect sensitive
vascular structures and joint integrity should be irresponsibly overlooked for the purpose of
achieving joint cavitation only.
Evidence is emerging, particularly in those young patients who have suffered a spontaneous or
post-manipulative vertebral artery dissection, that there appears to be a number of predisposing
genetic connective tissue abnormalities (e.g. Marfans syndrome, EhlersDanlos syndrome,
fibromuscular dysplasia) (Haldeman et al. 1999, Saeed et al. 2000, Schievink 1994). This may
predispose an individual to arterial wall breakdown, making them susceptible to a CVA. In addition,
elevated levels of the amino acid homocysteine have been linked with post-traumatic and spontaneous
vertebral artery dissection (Pezzini et al. 2002). In this regard, homocysteine determinations currently
appear to be the most plausible means of assessing patients who are at most risk of experiencing a
CVA from routine activities, let alone cervical spine manipulation. Therefore, extreme caution is
advised under these circumstances and appropriate therapeutic options are suggested for patients with
these disorders. Counselling and current advice would prevail in this instance, particularly for those
at potential risk, while at the same time maintaining a balance with regard to benefits of care. The fact
still remains that most CVAs are:

1. spontaneous,
2. cumulative
3. caused by factors other than spinal manipulation.

In summary, there is an increasing body of knowledge supporting manual therapy of the cervical
spine as a treatment option neck pain and headaches (Bronfort et al. 2001a,b, 2004a, Bronfort et al.
2010,McCrory et al. 2001). Cervical spine posterior facet joints have been implicated as a source of
pain via controlled studies (Bogduk 1995) and a neuroanatomical basis for cervicogenic headaches
has been identified as a mechanism for pain referral from the upper cervical spine joints (C1C3) to
the head and facial regions (Bogduk 1992, 2001a,b, 2002, Humphreys et al. 2003, Mitchell et al.
1998). The mechanism and pain pattern of the upper cervical spine has been described in detail to
support this view (Bogduk 2001b). This material is maatory reading for all practitioners of spinal
manipulative therapy.
Educational issues clinical and manipulative
skills
There is good evidence that under appropriate conditions cervical spine manipulation is a very safe
procedure, when applied by trained and skilled practitioners. Patients presenting with mechanical
pain and normal neurological findings are considered good candidates for spinal manipulative
intervention (Shekelle & Coulter 1997). Kleynhans (1980) and Kleynhans and Terrett (1985) cite the
lack of practitioner skill as a common cause of practitioner-related accidents leading to adverse
reactions following manipulation of the upper cervical spine. They also allude to technique selection,
particularly the excessive use of manipulative procedures, as causative agents. Forceful and non-
specific manipulation has also been described as a potentially hazardous procedure (Gatterman 1991)
and, more importantly, those improperly trained in related diagnostic procedures and therapeutic
techniques. Therefore, developing clinical expertise and skill to reduce the possibility of such an
accident and to determine when not to manipulate and refer to the appropriate health professional
becomes clinically significant. Developing appropriate clinical skills to identify those at high risk of
potentially experiencing a CVA is a clinical priority (Kier & McCarthy 2006).
From a clinical perspective, for manipulative skills intervention, the most sensible approach
would be to avoid any excessive range of motion in the upper cervical spine, as this may have a
deleterious effect on pain and mechanically sensitive tissues and joint structures. This may be
particularly relevant for extreme rotation in this region (Thiel 1991, Thiel et al. 1994) and possibly
responsible for increased afferent bombardment. Lateral flexion, on the other hand, appears to have
little effect upon vertebral artery blood flow and should be considered as part of the clinical rationale
for all manipulative procedures introduced to the upper and lower cervical spine (Terrett &
Kleynhans 1992). Grice (1988) recommends that during rotation manipulation of C1C2, the
practitioner should rotate the spine no more than 30 and include a small lateral flexion component
of up to 5. This would ensure both optimal biomechanical correction and less loading of vital soft
tissue structures during full cervical rotation. The use of passive mobilization techniques as a
premanipulative procedure or tolerance test has also been promoted in questionable cases. Therefore,
it is clear that the cervical spine is capable of considerable axial rotation with varying amounts of
coupled movements. Subsequently, it becomes imperative to control and limit the amount of
rotation/other extreme ranges of motion in the cervical spine and the upper cervical spine specifically
during a manipulation with a high-velocity thrust, in contrast to elimination of rotation, as suggested
by Terrett (1987b) and Martienssen and Nilsson (1989). There are many alternative methods or
techniques for dysfunction of cervical spine including mobilization, traction and mechanical adjusting
devices that characteristically avoid extreme ranges of tissue and joint tolerance. Terrett and
Kleynhans (1992) do suggest that upper cervical techniques should be restricted to togglerecoil,
Gonstead, or supine lateral flexion procedures. This view has never been subjected to research
scrutiny, but to the best of the authors collective knowledge, there has been only one respectable
study investigating the clinical effectiveness of a specific chiropractic technique, togglerecoil
(Whittingham et al. 1994). This particular study demonstrated the effectiveness of togglerecoil in the
management of migraine headaches. A mechanical adjusting instrument has also been proposed as a
safe alternative method for treating spinal dysfunction (Byfield 1991). The instrument delivers a
consistent and predetermined force with extreme speed without the potential dangers of introducing
extreme ranges of motion. Symons et al. (2000) have thoroughly studied this mechanical adjusting
device in comparison to a manipulative thrust and their findings confirm that the reflex effects of an
activator are far less than those of a high-velocity procedure, particularly in the thoracic spine.
Herzogs work categorically demonstrates that the activator is less effective from a
neurophysiological afferentation perspective. The use of this type of instrumentation is an acceptable
clinical method under a number of clinical circumstances.
Therefore, it would appear that manipulative intervention for the cervical spine, and primarily
the upper segments, should be delivered with caution and in ways that minimize mechanical
deformation of tissues and reduce the amount of rotation of the region. Full rotation, although not
unequivocally associated with any increase in CVAs, should be avoided and coupled with other
planes of motion to produce preload without any undue distress on the local soft tissues. Mobilization
should be considered an excellent choice over full manipulation, according to more recent research,
where it is clinically applicable (Hurwitz et al. 2003, 2004). Specific techniques (mobilization or
manipulation) should always be considered in the best interest of the patient. Therefore, chiropractors
need to develop additional manual skills and competencies with respect to treating spinal dysfunction
within the upper cervical spine.
Manipulative thrust forces and technique
considerations of the cervical spine
The forces generated on the cervical spine during spinal manipulative therapy are generally less and
executed faster than those on the thoracic spine and sacroiliac joint (Herzog et al. 1991). There is
also good evidence that cervical manipulations are performed three times as fast as thoracic
manipulation (Conway et al. 1993, Kawchuk et al. 1992) and approximately four times faster than
manipulation of the sacroiliac joint (Hessell et al. 1990). This appears consistent with the
physiological and kinematic properties of the individual regions. The manipulative procedures
selected for these investigations seemed to be tailored more to the force measurement system than to
quantifying more commonly practised side-posture and supine cervical procedures involving a
preload. It would be logical to assume that direct force measurements are infinitely more difficult to
quantify the more complex the manipulative procedure, particularly the effects of preloading the joint,
the patients reaction and force dissipation into surrounding soft tissues.
The loads transmitted through the cervical spine seem to be a cumulative effect of the forces
applied by the manipulators hands, the inertia caused by the head accelerating during the thrust and
forces generated by the internal muscular forces (Triano & Schultz 1990). A common habit that
develops is the art of whipping the head through the entire physiological range to achieve a
cavitation or joint crackevent which may be contraindicated and not in the patients best interest.
Triano (1992) calculated that the speed of a C2 lateral break adjustment was in the 0.135 second
range. This is very close to normal reaction times, suggesting that the biological effects of the
adjustment may take place before any protective muscular splinting. This has recently been confirmed
by (Herzog 2000), who has demonstrated in a number of well conducted studies concerning the
physical parameters of spinal manipulation that the peak force of an adjustive procedure has been
reached prior to the development of sufficient muscular force to offer any clinically significant
resistance. However, large cervical muscular activity has been measured during a C2 lateral (flexion)
break, indicating that the mechanical effects of the applied manipulation may be influenced by the
patients muscular reaction (Triano & Schultz 1990). Reactions as high as 51% of maximum voluntary
contraction have been recorded in the semispinalis capitus (Triano 1992). Large muscular reactions
such as this may be responsible for increasing the risk of normal post-treatment reactions and
possibly any adverse complications. Patient compliance and apprehension, in response to the
intensity of the manipulation, may significantly influence this situation. Methods to reduce these
seemingly important modulating factors may be advantageous during overall patient management. It
appears that the investigators in this study inadvertently lifted the patients head prior to the adjustive
thrust. This manoeuvre could increase muscular activity in the surrounding cervical musculature
(particularly the deep cervical flexors) due to patient assistance, influence the feel for the critical
moment of joint tension and increase the amount of thrust force necessary. Keeping the patients head
supported on a raised headpiece may contribute to less premanipulative muscular activity and
internal muscular forces because of a non-weight-bearing position supporting the head. Therefore,
this may decrease the forces required and reduce patient apprehension, but at the same time
improve control, speed, compliance and finesse of the psychomotor skill. Herzog (2000) has
demonstrated that, under normal conditions, muscular activity does not take place until well after the
peak force; thus dispelling the age-old myth that muscle guarding occurs during a manipulative thrust.
The author refer the readership to Chapter 3 of this text for more detail concerning the biomechanics
of spinal manipulation and many important clinical considerations.
Finally, a number of early manipulative techniques directed towards the occiputatlas (OccC1)
and atlas-axis (C1C2) articulations employed, for example, a great deal of rotation (States 1968,
Szaraz 1984). The author of this chapter regard this as unnecessary, particularly in light of the
kinematic characteristics of these joint complexes, the size of the neutral zone (area of laxity
measured around the neutral axis of the joint) and the potential risks to patient safety. Kinematically,
rotation is a minor movement at the OccC1 joint complex, in contrast to the dominant sagittal plane
movement of flexion/extension (Panjabi et al. 1988). Therefore, restoration of occiputatlas articular
function could be accomplished by manipulative procedures that incorporate no forced rotation with
movement primarily directed via the x-axis. This would protect vital structures and control the risk of
post-manipulative tissue reactions but, at the same time, maintain the principles of the biomechanical
model and clinical rationale for the manipulative intervention in this region. This is in contrast to the
C1C2 articulation, which demonstrates substantial y-axis rotational movement and has an inherently
larger neutral zone (Kondracki 1996; and Chapter 3 in this book). These issues will be presented and
discussed later in this chapter dealing with specific manipulative skills for the cervical spine.
Manipulative skill and performance
The question arises: how can passive mid-end-range motion loading and preloading be applied
during cervical manipulation in all ranges of motion, thereby protecting non-symptomatic, pain-
sensitive and other vulnerable structures and produce a functional and/or neurophysiological change?
This can be addressed by learning and incorporating a specific set of manipulative skills outlined
below and consolidating the concept of high-quality psychomotor skill performance (finesse). These
skills should be performed following a full history and thorough examination using reliable testing to
screen those patients at risk.
The literature is reasonably clear on issues of the mechanism of vascular injury, but somewhat
unclear regarding the incidence of vertebral artery dissection in relation to manipulation. A
significant number of myths have been dispelled in the last decade since the first edition of this
textbook was written, mainly regarding the potential risks of upper cervical spine rotational
manipulation. These are ongoing concerns and the profession needs to remain focused on
participating in research endeavours to learn more about those at risk and develop clear clinical
protocols to identify these patients. This should be emphasized at both educational and clinical
levels. Risk versus benefit must always be of paramount concern for the clinician to proceed safely
and effectively, and there is good evidence that the benefits of manual intervention outweigh the risks
(Rubinstein et al. 2007). Therefore, extreme ranges of motion, especially rotation, have to be
reduced throughout all aspects of manipulation of the cervical spine, regardless of the diagnostic
indications, fixation pattern, or symptom picture. The primary clinical goal is the protection of the
patients overall welfare and safety by introducing the most appropriate clinical procedures
available, delivered with expert skill in light of the symptom presentation.
Common cervical manipulative considerations
The following specific list of manipulative skills will underpin the common manipulative procedures
to be incorporated in learning safe and skilful manipulative procedures of cervical spine promulgated
within this text:

1. An absolute maximum of 3040 of head and neck rotation is performed. Keeping within this safe
margin reduces any excess transverse shear and stretch of the vertebral artery at the C1C2
articulation and lower segments and, more importantly, minimizes joint capsule and other local soft
tissue loading. Reducing these loads could theoretically also depress nociceptive stimulation and
thereby potentially reduce common post-treatment reactions.
2. Using multiple planes of motion to develop joint tension (preload). The introduction of mainly
rotation/lateral flexion coupled with varying degrees of flexion components while completely
avoiding extension and excessive rotation, can incorporate normal mechanical coupling and
loading, thereby developing tissue tension or preload without exceeding joint capacity in any one
plane. Flexion theoretically produces more of a longitudinal stretch of the vertebral artery, which
may be tolerated to a greater degree than a transverse shearing during extreme rotation. Flexion
may also increase the intervertebral foraminal space necessary in certain clinical presentations.
3. Using the headpiece of the adjusting table to completely support the weight of the head instead of
lifting the entire weight with the arms and hands. The headpiece is of little use when dropped down
and not supporting the patients head. This position may increase the leverage sustained by the
cervical joints during a rotational movement of the head and local muscle contraction forces. The
overall finesse including regional joint specificity and thrust application becomes difficult while
holding a 56 kg (1113 lb) weight. The head should remain on the headpiece during all aspects
of supine motion palpation and manipulation.
4. The headpiece should be positioned at 010 from the horizontal for the upper cervical spine, 10
20 from the horizontal for the mid-cervical spine and 2030 from the horizontal for the lower
cervical spine. This will enable the practitioner to develop some tension in the posterior elements
during flexion, help to isolate a specific segmental level (Szaraz 1984) and, most importantly,
support the weight of the patients head in a non-weight-bearing and anti-gravity posture.
5. The clinician should be positioned on the side of the dysfunctional facet(s). This places the
clinician closer to the patient and shortens the levers for more effective joint tension, preload and
impulse/mobilization thrust. Positioning of the clinician at the head of the table tends to lengthen the
lever action on the head and neck, which may affect speed, depth, control and safety of the
procedure.
6. Place the patient in a preload/pre-tension position for 23 seconds prior to manipulative thrust
to ensure that he or she can tolerate this position and that there is no exacerbation of symptoms
or any distress (provocation testing position). If this does occur, the procedure should be
stopped immediately and the patient should be reassured and assessed if necessary.
7. Use an impulse-based, short, sharp and extremely brief thrust without scissoring the hands or arms
at preload. It is not necessary to ask the patient to breathe in or out during the performance of
all forms of cervical spine manipulation. As mobilization is an effective manual skill for the
cervical spine, undergraduates must learn to move the head and neck in a skilful fashion to
mechanically load the joints and soft-tissue structures sufficiently for a physiological response.

These suggested modifications may allow the clinician to use more traditional manipulative
skills, which include rotation to minimize the risk of vascular and/or neurological irritation, yet at the
same time maintain patient comfort, tolerance and reduce potential post-treatment reactions.
The following presentation will concentrate upon basic manipulative skills for the cervical
spine. This is by no means an exhaustive review of all the procedures used within the chiropractic
profession, but it does represent a number of primary diversified skills. The aim is to focus on those
skills that form the infrastructure and pattern of skills for many of the manipulative procedures that are
used to manage cervical mechanical dysfunction. The more advanced manipulative procedures should
be introduced only when the basics are fully mastered. It would be pointless to expect students to
assimilate all the major diversified skills if they are unable to locate an articular process, take up
tissue slack, preload a joint, or adequately judge the amount of passive rotation of the patients head.
A number of mobilization skills will also be suggested for practical and evidence-based reasons.
These skills, like most complex psychomotor skills, need to be practised in a structured fashion and
on a regular basis.
These skills require a more delicate, dedicated and structured approach as compared to the more
robust thoracic and lumbopelvic regions. It is recommended that these procedures be introduced later
in a students undergraduate skill and psychomotor development, particularly when he or she has
demonstrated proficiency in performing some of the basic movements outlined for the cervical spine
in Chapter 6 (thrust skills and other movements). The art of judging the degree of cervical rotation
and articular tension is an acquired skill of significant clinical importance with respect to clinical
effectiveness and patient safety. It is preferable that these skills be developed at a suitable pace
commensurate with present psychomotor development. It seems reasonable to assume that a hasty
approach will cause only frustration and poor skill acquisition.
The skills section for this chapter will focus primarily on the mid-cervical region (C4C5
motion segment). Naturally, the student will develop skills to include both sides of the body and,
eventually, to include all regions of the cervical spine. The occiputatlasaxis region will be
addressed at the end of the chapter, once the basic skills have been mastered. The skills will be
presented in accordance with the kinematic and biomechanical characteristics of the mid-cervical
spine and then introduce more complex manipulative skills associated with clinical practice for both
the upper and lower cervical spine regions. The chapter will present skills up to the appreciation of
specific joint isolation and elastic barrier tension or joint tension with a minimidi (mock) thrust
(gentle repeated testing of the elastic resistance of the joint), but not including the delivery of a high-
velocity, low-amplitude dynamic thrust. It is simply too early to venture beyond this point. Students
will be repeatedly applying considerable stretch across sensitive joint structures to acknowledge,
recognize and define the end play/preload is an important aspect of manual skills learning. Care must
be taken at all times to recognize any signs or symptoms that may cause the student any potential harm.
The dynamic manipulative thrust remains only one aspect of the overall procedure, which is made
up of several complex psychomotor skills. The manipulative thrust should be introduced when control
and joint tension/preload are fully appreciated and within the context of a controlled clinic
environment. The joint assessmentmobilizationmanipulation/adjustment continuum principles
will be incorporated in this as well as other sections of the text. This will allow students to
appreciate the continuity required at a clinical level early during skill development.
One of the key elements of performing manipulation of the cervical spine is the ability to use
both hands, essentially producing simultaneously the same movement patterns. This movement pattern
is covered in Chapter 6 and should be practised regularly to learn to control the amount of rotation of
the hands. This action will also function to determine the overall leverage on the head and neck.
These skills will be presented with the patient in the supine position for ease of instruction. There are
various other postures, which are equally effective from a clinical standpoint, including sitting and
prone postures. Even though the basic skills for the spine itself are essentially the same,
manipulations in other postures such as sitting require an additional set of patient control skills.
Midlower cervical spine manipulative skills
Articular process (AP) supine, (Figs 11.1 - 11.15)
Spinous-lamina (SL) supine, (Figs. 11.16 - 11.21)
Transverse process (TP) supine, (Figs 11.22 - 11.26)

Figure 11.1
Figure 11.2
Figure 11.3
Figure 11.4
Figure 11.5C
Figure 11.6

Figure 11.7B
Figure 11.8B

Figure 11.9B
Figure 11.9C
Figure 11.9D
Figure 11.10
Figure 11.11
Figure 11.12
Figure 11.13
Articular process (AP) supine
This particular manipulative procedure is often referred to as the cervical rotary or modified
cervical rotary (Bergmann & Peterson 2011a, Byfield 1991, Fligg 1984, States 1968, Szaraz 1984, )
or specifically used to correct midlower cervical posterior rotation fixations (Schafer & Faye 1989)
(Figs 11.1 - 11.15). It is considered to be the most frequently used manipulative technique (Gitelman
& Fligg 1992). For the purpose of this set of manipulative skills, the contact is made on the articular
process of C4. The motion segments are stabilized above and below the C4/C5; motion will therefore
occur below C4.

1) The patient is lying comfortably in the supine position with the headpiece of the table flexed up
1020 from the horizontal supporting the head. The patients knees are flexed to relax the
hamstrings and flatten the lumbar curve and his or her hands are interlocked and placed over the
abdomen to relax the shoulders and arms. The practitioner, initially, is standing crouched at the
head of the table in a low ski stance with the knees bent and in contact with the table for support (*)
(Fig. 11.1). This crouched position is an important component of the overall skill as it assists in
generating part of the impulse thrust and allows the practitioner to be mobile to adapt to any
emergency that may arise. The body weight is centred over the patients neck. The practitioner must
adopt a neutral or slightly flexed lumbar lordosis with abdominal brace to stabilize lumbopelvic
region for skill efficiency while in this posture (Fig. 11.1).
2) The practitioners hands are then simultaneously placed around the cervical spine with the
hypothenar and thenar regions of the hands cupping and supporting the occipital region (*) and the
fingers along the paraspinal region. The hands and arms are exact mirror images (Fig. 11.2).
Palpation and segmental location takes place from this position as demonstrated. The palpating
fingers assess joint play alternately and bilaterally. The patients head is not lifted during these
procedures but remains in contact and supported by the headpiece to stabilize the head and reduce
muscle guarding. This gives the patient a feeling of security. The practitioners hands are also in
contact and supported by the headpiece to take the weight off the arms and shoulders.
3) The practitioner locates the articular process of C4 with the palpating and locating middle finger
of the left hand and rotates the right by ulnar deviating the wrists for ease of palpation (Fig. 11.3).
Care is taken not to rotate the head excessively at this point and keep it firmly in place on the
headpiece (*).
4) To maintain contact on the C4/5 motion segment, tissue slack is removed by bringing the middle
finger of the opposite hand behind the contact finger as far around as the spinous process of C4 and
then slowly pulling the tissue around and upwards in the direction of rotation. This is done gently
but with a firm movement (Fig. 11.4). There should be no discomfort to the patient as the tissue pull
is performed slowly, with very little pressure on the tissues overlying the articular processes.
Ensure that the patient is positioned with the border of their upper trapezius muscles about 34 cm
away from the lower edge of the headpiece. This allows the practitioner to palpate and locate
posterior structures without any impedence.
5) The flat contact hand is turned palm up and positioned just behind the segment locating finger
(tissue slack finger) (Fig. 11.5A). The contact hand is then drawn laterally, pronated at the forearm
and ulnar deviated as it comes into position on the contact segment. This is done in one smooth
movement and additional tissue is drawn around at the same time to cushion the contact. Do not
push the hand inwards into the spinal tissues as this can be very tender. The lateral side of the first
digit slides around drawing more tissue slack. This action is done by ulnar deviating the contact
hand at the wrist as the fingers are drawn around, until the medial side of the PIP or DIP joints are
approximately resting on the articular process of C4 (Fig. 11.5B). The wrist is kept straight and
care is taken not to push inward against the sensitive soft tissues. The hand and fingers are only
slightly arched in order to give the contact some flexibility. The third, fourth and fifth digital pads
provide support for the contact point by contacting the occiput/mastoid region and there should be a
space between the web of the hand and the patients mandible. This ensures that the hand is flexible
and relaxed and permits for a better adjustive thrust. The thumb is gently placed on the mandibular
region in front of the ear (*). This is done to support and stabilize the contact hand (Fig. 11.5C).
6) Once the contact is secured the indifferent hand (right) or tissue slack hand reaches around and
supports the inferior aspect of the occipital rim with the palmar aspect of the middle finger. The
support hand is also ulnar deviated at the wrist. The fourth and fifth digits cup and support the base
of the occiput (*), the first finger wraps around the cervical musculature and the thumb is placed
gently over the face just in front of the ear (Fig. 11.6). The contact should be light, but firm and the
head should not be rotated more than a few degrees to maintain comfort and patient confidence.
7) The practitioner moves very slowly to the side of the lesion or contact side so that he is positioned
at 45 to the table. The practitioner maintains a ski-crouch position, neutral lordosis, knees bent,
trunk flexed, arms relaxed and close to the body and leaning against the head of the table with the
suprasternal notch over the contact hands. At this stage the patients head is in a neutral position
with no rotation of the head. The practitioner is in a tight and compact posture close to both the
patient and table. There should be no movement of the patients head up to this point and the weight
of the head should be totally supported by the headpiece of the table (Fig. 11.7A). It is important at
this stage that the indifferent arm is dropped down towards the headpiece in order that unwanted
movements are not introduced (Fig. 11.7B). This position of the indifferent arm is very important
during preload and thrust delivery.
8) Perform the next series very slowly. The hands are moved simultaneously. The contact hand (left)
slightly pronates and ulnar deviates at the wrist and the support hand (right) supinates at the
wrist. The amount of movement is exactly the same on both sides. The patients head is rotated 30
40maximum (Fig. 11.8A). This is the safe zone and the patients nose should end up at
approximately half way between the sternal notch and the shoulder. Only the wrists are moving, not
the arms or shoulders. This ensures control of the head and neck. The head is not lifted off the
headpiece during this procedure. The rotation takes place along the long axis of the spine to
eliminate torsion or twist developing in the spine. The head should always be lined up with the
middle of the sternum. The hands and wrists are mirror images (Fig. 11.8B). Care is also taken not
to push or press the contact finger in towards the spine that may cause the patient some pain and
possible muscular tension, reducing the efficiency of the manipulation. Both contact hands are light
but firm.
9) The next four steps are very small movements to establish joint tension and preload the C4/C5
segment just prior to application of the manipulative thrust.
i) Rotate the head and neck into the safe zone (3040) (Fig. 11.9A) as described for Figure
11.8A. Ensure the space between the web space of the hand is intact and that the hands are
relaxed with no excessive tension. Do not push the contact point into the soft tissues over the
spine. The contact wrist must be straight with slight flexion only.
ii) Lateral flexion is added to avoid over-rotation by bringing the support hand towards the body
over the contact hand. The amount of lateral flexion is minimal and care should be taken not to
lock the joints but maintain some degree of free play at the contact point. The movement is very
small and the degree of movement is directly related to the amount of tension perceived under
the practitioners contact finger (Fig. 11.9B). The contact hand does not move. Its position is
stable, not being pushed into the contact. The practitioner monitors the patients response to
these movements. Any signs of distress which can be monitored by facial expressions or
increase in muscle tension should not be ignored. If this does happen it may signal that the
contact or movement is excessive.
In some clinical circumstances lateral flexion should take place in the opposite direction to
avoid facet encroachment and permit facet gliding. This would be determined by the patients
tolerance at preload or symptom provocation during the procedural steps.
iii) Joint tension is achieved by the contact hand only. The contact hand is pulled up and in
towards the spine and ulnar deviated very slowly, monitoring the amount of resistance against
the medial border of the contact finger.
iv) The last step is an optional degree of traction to the cervical spine which may have some
effect upon the muscle receptors (Gitelman & Fligg 1992). The practitioner simply pulls in a
cephalad direction with both arms. The action can be supplemented by a further cephalad lean
of the practitioners trunk (Fig. 11.9D). The arms are tucked in close to the body at all times to
shorten the levers controlling the movement and the practitioner adopts a very low ski/fencer
stance with body weight close to and over the patient.
Figure 11.5A
Figure 11.5B
Figure 11.7A
Figure 11.8A
Figure 11.9A

Steps iiv have been separated and should be practised in sequence until they are performed
with a degree of confidence and skill. This section should not be rushed and the importance of the
slow controlled movements at the wrist should be emphasized. Care should be taken not to
maintain joint tension for too long and there is no dynamic thrust at this point. All movements
are small in all planes and controlled for skill learning and patient comfort.
10) There are a number of potential learning errors associated with the acquisition of these
manipulative skills.
i) Failing to move to the side of the lesion or anatomical contact point may increase cervical
rotation and force the practitioners arms out from the body producing much longer levers
acting on sensitive structures of the cervical spine. This causes the practitioner to assume an
inefficient posture which places increased mechanical loads on the lumbar spine and twists the
shoulder (*) (Fig. 11.10). Note the excess rotation of the head and neck.
ii) The most common mistake is rotating the head and neck too far when attempting to establish
joint tension prior to preloading (Fig. 11.11). Additional movement at the elbows and
shoulders and a failure to keep the arms in close to the body usually causes this situation (*).
This has to be carefully monitored by the student to eliminate potential mechanical stress to the
sensitive structures at risk in the cervical spine. Note the excessive angulation of the right
wrist that over time could produce an overuse strain/sprain of the wrist structures which must
be avoided.
iii) Pushing the medial side of the contact finger forcibly into the sensitive spinal structures
instead of rolling the contact hand by ulnar deviating the wrist in an attempt to achieve a bony
contact. This is often caused by keeping the hand too rigid and stiff and not using a relaxed
semi-arched posture (*) (Fig. 11.12). Note the fact that there is no space between the web of
the contact hand and the mandible (*). Watch for patients reaction! Care must always be made
to maintain a middle finger wrap around the rim of the occiput with ulnar deviation of the
indifferent/support hand to ensure symmetry of activity. The hand can drift up over the occiput
that is not optimal.
iv) Introducing excessive secondary lateral bending combined with surplus rotation will stress
the soft tissues of the cervical spine. These are exaggerated movements that are not well
tolerated, particularly when the patient is presenting with neck pain. This may also pull the
head away from the central axis of the body (Fig. 11.13). The practitioner shifts more than 45
to the side of the lesion. These exaggerated movements should be avoided at all costs.
v) Do not lift the head off the headpiece and support the weight of the head in the hands (Fig.
11.14). It is very difficult for the practitioner to control head and neck rotation and lateral
bending, plus develop the feel of joint tension when he is holding a 12 lb (5.6 kg) weight in the
hands. This will automatically produce longer levers, which may influence the dynamic thrust
and compromise control of the excess movements. Failure to pivot shift to side of the lesion
will complicate the situation. Loss of lumbar lordosis with flexion up to the full passive end
range places the practitioner at risk of potential injury over a period of time.
vi) Do not bend the wrist of the contact arm. This is not stable. Keep it straight or only slightly
flexed in its most mechanically advantaged posture (Fig. 11.15).

Figure 11.14
Figure 11.15
Spinous-lamina (SL) supine
This particular manipulative procedure provides another opportunity to minimize rotational forces in
the cervical spine, but at the same time adhere to biomechanical principles concerning myofascial
dynamics, joint kinematic properties and safety (Bergmann & Peterson 2011, Byfield 1991, Gitelman
& Fligg 1992). The fingertip contact on the spinous process generates the rotary force through the
facets with minimal rotation. The manipulative procedure is often referred to as the cervical push
(Fligg 1984) or finger-push adjustment (Gitelman & Fligg 1992) and is primarily suited to correct
rotary fixations in both the upper and mid-lower cervical spine. For the sake of ease of
demonstration, this particular sequence of manipulative skills will concentrate on the C4/C5 motion
segment. Specific anatomical contact is made on the SL of C5 as the motion segments below are
stabilized and movement is occurring above this point (Figs. 11.16 - 11.21).
The patient is positioned in a supine and relaxed comfortable posture as described above. The
practitioner is similarly standing in a crouched posture at the head of the table cupping the patients
occiput and supporting the cervical spine. The headpiece is flexed at approximately 1020 and the
patients head remains in contact with the headpiece during the entire manoeuvre. The space between
the two headpiece cushions and the give in the headpiece foam itself permit arms and hands to be
neatly hidden without obstructing free head and neck movement

1) Start this set of skills with the head on the headpiece with the palpating fingers of both hands
assessing the C4/C5 motion segment (Fig. 11.16). With the middle palpating finger of the contact
hand (left) on the SL junction of C5, the middle finger of the support hand (right) reaches around
and pulls excess skin slack from underneath this contact towards the right side. The patients head
is in a neutral position resting comfortably on the headpiece during this procedure. Note: the head
has been lifted to demonstrate hand/finger position only.
2) As the skin slack is drawn towards the right side, a reinforced middle finger follows the direction
of the tissue slack and firmly contacts the SL junction of C5. The contact hand (left) is in a
moderately high chiropractic arch posture with the hand moderately extended at the wrist and the
thumb adducted across the hand and thumb pad placed over the mandible. The hand, wrist and arm
of the practitioner should be angled at 45 to the patients cervical spine and the thumb is gently
placed on the mandible to help to secure the contact hand. The lateral aspect of the hypothenar
eminence is placed over the base of the occiput and the musculature of the cervical spine (*). Both
hands should be relaxed yet making a firm and painless contact. The patients head is still in a
relatively neutral position.
3) With a firm contact, the support hand (right) is positioned around the occiput with the palmar
surface of the middle finger supported under the occipital rim. The wrist is also ulnar deviated.
The fourth and fifth digits are placed over the base of the occiput (*) and the index finger along the
cervical spine (*). The thumb is placed just ahead of the earlobe to help to secure the hand. The
hand is slightly arched in order to avoid crushing the patients earlobe (Fig. 11.18).
Figure 11.16
Figure 11.18
Figure 11.17

4) The practitioner moves 45 to the ipsilateral side of the SL contact and simultaneously rotates the
head about 30 in the safe zone to the contralateral side using the support hand. Care is taken not
to lose contact on the SL during this rotation, and try not to dig your fingers into the soft tissue (Fig.
11.19). The contact fingers actually move in the same direction as the head to maintain the soft
tissue contact over the SL of C5 or other contact depending on the clinical indications. It is
important that as the head rotates away the finger pad contact perceives and resists spinous
movement at C5 towards the contact. Keep both arms close to the body during all phases of this
procedure (*).
5) Joint tension without over-rotation up to preload is achieved by marginally laterally flexing the
head and neck towards the contact finger by simultaneously pulling the head towards the contact
hand and pushing gently along the SL contact in the line of the forearm to create joint tension (Fig.
11.20). This action can be aided by dipping the upper body down which keeps the arms close to the
body, maintaining short lever action. The head and neck should not stay in this position for
extended periods to avoid possible joint or muscular reflex reactions. Please avoid the temptation
to thrust or push too hard along the contact point.
6) A traction component can be added to assist additional joint tension at the C4/C5 motion segment.
This is performed by slowly tractioning the support hand around the rim of the occiput in a
cephalad direction. The fingertip contact will resist this movement.
7) There are at least two major errors associated with the learning of this particular sequence of
skills.
i) Do not permit the arms to drift out from the body (Fig. 11.21). This reduces the mechanical
advantage of the contact points, increases the movement about the cervical spine and
compromises the efficiency of the dynamic thrust.
ii) A straight contact hand instead of a chiropractic arch posture will not stabilize the contact
point and eliminate the flexibility and firmness of the procedure. The position of the thumb
does not stabilize the contact hand. Over-rotating the head and standing at the head of the table
are additional errors to be aware of. Pulling the contact fingers off the SL as the head is rotated
is another movement pattern to avoid.
Figure 11.19
Figure 11.20
Figure 11.21
Transverse process (TP) supine
This particular anatomical landmark is often used for a group of manipulations referred to as the
cervical break (States 1968), lateral flexion adjustment (Grice 1980), supine lateral break (Szaraz
1984), lateral cervical (Fligg 1984), lateral cervical fixations (Schafer & Faye 1989), and adjustive
procedure for cervical lateral flexion joint dysfunction (Bergmann & Zachman 1989). For the sake of
clarity the authors will refer to this procedure as a lateral flexion manipulation/adjustment (Figs
11.22 - 11.26).
This manipulative procedure is considered biomechanically sound, taking into consideration the
arc of motion through the joints of von Luschka, an integral component of the three-joint complex and
a common site of degenerative changes (Grice 1980). More importantly, it accommodates lateral
flexion of the cervical spine which has been reported to have less influence on vital soft tissue
structures (Terrett & Kleynhans 1992). There is little to no rotation associated with this particular set
of skills which has many clinical advantages, yet still functions to correct cervical segment mechanics
and restore the appropriate motion. This is another example of coupled motions and multiplanar
movements within a region of the spine and how they are incorporated into various manipulative
procedures.
The target for this next set of skills is the C4/C5 motion segment. Contact takes place on C4 and
movement is assumed to take place below the primary contact point. This manipulative procedure is a
combination of the skills described above for both the articular process landmark or cervical rotary
and the SL landmark or finger-push adjustment. There are elements of each particular manipulation
that will be duplicated here, to develop an additional versatile manipulation that can be used in
various clinical situations best suited for both the practitioner and the patient. Each manipulation is
not a completely separate entity, but provides for skill overlap.
The patient is comfortable in a supine position as described above with the headpiece flexed
upward at 1020. The practitioner is standing at the head of the table in a crouched palpating posture
with the patients head cupped and stabilized by the hypothenar eminences of both hands with the
remaining digits free to locate the necessary anatomical landmarks as described in Figures 11.1 and
11.2. The crouched posture (ski stance) places the practitioners weight over the cervical spine which
centres and focuses the dynamic thrust and helps to ensure that the levers acting on the neck remain
short. The student performs steps 1 to 7 as outlined above for the AP skills, up to the point where the
practitioner has moved 45 to the side of patient with the patients head in a neutral position, before
any movement takes place. The only significant difference at this point is the actual contact on the
spine.
The finger contact is by convention supposed to contact the TP of C4. However, the TPs are
small, very sensitive and painful structures at clinical presentation. My recommendation is to contact
the posterior aspect of the TP and the anterior aspect of the AP with the medial aspect of the middle
phalanx of the first digit, which is a softer fleshy contact point. This affords a reasonably large target
plus it offers a certain amount of soft tissue cushioning effect through the paraspinal musculature. This
will avoid prodding the TPs and guarantees a greater degree of patient comfort and compliance. The
contact is extremely light yet firm and if the patient is at any time showing signs of distress or pain
please do not ignore this vital, clinical feedback. Under these conditions the practitioner/student
should re-adjust their contact and decrease applied pressure.

1) Complete steps 17 above (Figs 11.1-11.9) for the AP skills but change the anatomical contact
point slightly (*). Both the support and contact hands are virtually mirror images with the contact
hand and wrist positioned at 45 to the cervical spine and straight. The head and neck are in a
neutral position at this starting point (Fig. 11.22). The skills required are exactly the same in terms
of ski/fencer stance and other body posture recommendations.
2) The support arm and hand slowly laterally flex the head and neck in a controlled fashion using the
anatomical contact as a pivot point. There is no rotation. The amount of lateral flexion is
determined when the practitioner starts to feel some resistance (tissue tension sense) on the medial
aspect of the proximal or middle phalanx of the index finger and hand at the specific segmental
level (Fig. 11.23). The contact point does not push into the sensitive structures. The head and neck
are laterally flexed over the contact point. The head stays on the headpiece and the contact arm,
wrist and hand are completely stationary in contact with the side of the body. The practitioner
crouches low over the patient. Note the ski-stance posture and the position of practitioner over the
patient.
3) The practitioner moves the contact arm towards the lateral aspect of the cervical spine to gain
additional tension. Flexing the shoulder flexors very slowly produces this movement. The arm is
kept in close contact with the body (Fig. 11.24). Movement of the contact hand towards the spine is
cushioned by the wrist (ulnar deviation joint play). This makes contact with the spine less rigid and
uncomfortable for the patient. A slight traction component may be added at this point, if joint
tension or muscular stretch is required. This is done primarily by the support hand through the
occiput. There is no dynamic thrust. Care is taken not to push too hard and always keep an eye on
the patient for any signs of distress during the setup and preload.
4) There is always a small degree of rotation (1020) with this procedure to accommodate
multiplanar activity and symptom presentation (Fig. 11.25). Rotation is normally added as a last
step depending on patient needs and is often symptom driven. This takes advantage of the coupling
action of the cervical motion segments to gain joint isolation and specificity.
5) There are two faults encountered during the learning of this manipulative skill.
i) The most common is using the contact hand like a sharp blade, pushing into the side of the
sensitive TPs laterally flexing too quickly without stabilizing the hand position with the thumb
or other digits. As these are sensitive structures it is advisable to observe the patients reaction
during the procedure for vital feedback.
ii) Laterally flexing and extending the head and neck too far (Fig. 11.26). Joint tension is
possible without extreme ranges of motion being introduced. Care must be taken by the
practitioner to ensure at all times patient comfort. The cervical spine and head regions are
typically sensitive areas and any movements are amplified. Therefore movements must be
slow and controlled at all times, particularly if the patient is symptomatic or anxious.
Figure 11.22
Figure 11.23
Figure 11.24
Figure 11.25
Figure 11.26
Additional cervical manipulative skills
Summary
The previous section has presented a few selected and common manipulative procedures which form
the basis of many of the diversified cervical spine techniques. The presentation has concentrated on
the mid-cervical spine for the obvious reasons of safety and student appreciation. Mastering these
skills is advisable before introducing more advanced and selective skills for the upper and lower
cervical spine motion segments. However, it should be noted that the previous skills could be
adapted to the upper (occiputatlasaxis complex) and lower (C5C7) cervical spine with some
very simple modifications of these foundation skills. Two additional adjustive skills are presented
below helping to build on newly acquired psychomotor skills.

Thumb rotary skills (Figs 11.27 A-C)


1) The thumb pad represents a very useful alternative to the metacarpalphalangeal joint during
various manipulative procedures of the cervical spine known as the rotary thumb move. The
starting position is similar to the other procedures described above with the patient in the supine
posture and the headpiece with the middle palpating finger identifying the specific target joint (Fig.
11.27A).
2) The middle finger on the AP is replaced with the posterior lateral aspect of the palmar surface of
the thumb (anatomical position) of the same hand by way of a pronation action of the contact wrist
to bring the thumb pad around to contact the SL junction (Fig. 11.27B). The index and middle finger
pads fingers are placed over the mandible to stabilize the contact. The fourth and fifth digits are
extended out of the way of the sensitive throat and mouth structures.
3) The indifferent contact is exactly the same as above, with the middle finger gripping the rim of the
occiput with the wrist ulnar deviated. The head is rotated within the safe zone by rolling and
flexing the wrist (Fig. 11.27C). The head/neck is also laterally flexed to gain some joint tension via
the indifferent forearm towards the midline. Note that the elbow of the contact hand is below the
level of the wrist to ensure efficient preload. Do not let the contact arm drift away from the body,
which will automatically increase the lever arm and subsequent rotation applied to the cervical
spine in general (Fig. 11.27C). This is a natural tendency due in part to the orientation of the thumb
pad. Therefore, the contact on the SL must be with the lateral aspect of the thumb to ensure that the
arm aligns up behind the contact point.
Figure 11.27A

Figure 11.27B
Figure 11.27C

Sitting cervical skills (Figs 11.28A-E)


1) The sitting position can be an effective clinical alternative, particularly if the patient is unable to
lie supine. However, the effects of gravity acting on the head will cause some degree of muscle
activity and possible reflex resistance by the patient. This may compromise control of the
manipulative skills. The key is to learn to regulate actively the amount of rotation, lateral bending
and flexion, plus manage the weight of the patients head, all at the same time. The starting position
is with the practitioner standing perpendicular (right angles) to the patient assessing the
contralateral cervical spine facet joints with the middle finger acting as a segmental locator (Fig.
11.28A). The practitioner assumes a modified ski stance to ensure good balance. This requires that
the height of the patient is compatible with that of the practitioner. This may require that the table is
raised or lowered appropriately.
2) Once the segment has been located on the contralateral side the opposite hand reaches around and
replaces the localizing finger pad with a middle finger contact over the SL and AP region of the
targeted motion segment (Fig. 11.28B). The thumb of the contact hand is placed just ahead of the
ear of the patient and the other fingers drape over the soft tissues of the cervical spine to add
support.
3) The indifferent hand contact is crucial in this manipulative procedure to support the weight of the
head. The middle finger wraps around the inferior aspect of the occipital rim and the thumb is
placed in exactly the same position as the contact configuration. The remaining fingers support the
weight of the head (Fig. 11.28C). Ensure that the arms are tucked in close to the side of the body to
shorten overall leverage.
4) The next sequence is to bring the target joint to tension. Flexion is initiated first, followed by
rotation and then lateral flexion at the desired level. All movements must be small and controlled
within patient and joint tolerance (Fig. 11.28D). The key here is to flex the head and neck forward
in the sagittal plane first followed by the other ranges.
5) Preload is an essential psychomotor skill with this particular procedure. Maintain stability of the
indifferent hand and slowly pull the contact arm/hand through in rotation in the direction of
eventual dynamic thrust impulse (Fig. 11.28E). This particular procedure is not the most common
clinical skill, but from a training perspective it provides the undergraduate with an opportunity to
learn patient stability and segmental localization skills. Keep close to the patient to reduce the
levers. The practitioner maintains the ski stance during the entire procedure to ensure good
leverage and positioning. Do not let the head drop forward too far, stressing the soft tissues and
articular elements. This is often as a direct result of standing to the side or slightly behind the
patient instead of right angles. This tends to over-rotate and laterally flex the cervical spine

Figure 11.28A
Figure 11.28B

Figure 11.28C
Figure 11.28D
Figure 11.28E

Upper cervical spine manipulative skills: an introduction


It would be appropriate to include some of the basic skills associated with the upper cervical
techniques. These techniques are taught in many institutions throughout the world integrated into an
overall diversified biomechanical model. This section will include a small section addressing some
of the basic skills related to the upper cervical spine, particularly those related to the recoil thrust
technique.
The upper cervical region constitutes a challenge to the practitioner of manipulative therapy,
particularly in light of the greater potential for side-effects and adverse reactions following
manipulation of the upper cervical spine than for any other spinal location. This may be partly the
result of the extent of the innervation of this region and the neuroanatomical connections via the
cervical trigeminal nucleus (Bogduk 1992, 2001a, 2002, 2003, Humphreys et al. 2003, Vernon 2001).
Nonetheless, togglerecoil and other upper cervical techniques incorporate absolutely no forced
rotation or other extreme range of motion, which inherently reduces joint and tissue stress. This, in
theory, should automatically present added clinical value as an additional method potentially
minimizing possible post-treatment reactions. This area of the head and neck is extremely sensitive to
movement via connections with the middle ear and cerebellum. The head and neck are neutral
throughout the entire procedure, the patient is in a relaxed position and there is no prestress or
preload force applied to the contact articulation. The technique provides a very useful method for
those patients in whom the introduction of a dynamic thrust has been relatively contraindicated. In
addition, the togglerecoil is the only unique chiropractic technique that has demonstrated clinical
effectiveness in a clinical trial investigating migraine headaches (Whittingham & Nilsson 2001,
Whittingham et al. 1994). The downside to the technique is the fact that it appears to introduce higher
forces to the spine when compared with other manipulative techniques, such as rotary and lateral
flexion procedures (Kawchuk & Herzog 1993).
The togglerecoil is classified as a neutral posture, short lever thrust (Grice & Vernon 1992),
given in a specific direction with a designated depth and rapid speed (refer to the specific section in
Chapter 6). The thrust is characterized by a fast release, rapid and sudden contraction of both triceps
and pectoralis muscles simultaneously, creating leverage with both arms to apply the manipulative
force directed to a specific point through the hands. The force of the adjustment will be delivered
equally with both arms as a result of this arrangement. The recoil component is generated mainly by
the stretch response in the biceps before full extension of the elbows takes place. The contact hands
are also actively lifted away from the patients spine as part of the recoil procedure. This is usually
where individual style is developed. The elbow joints are subsequently protected from repetitive
impact trauma and the patient is spared full thrust forces. The trunk and shoulders are stable to
maximize the rapid delivery of the dynamic recoil impulse thrust. A joint crack or pop associated
with cavitation is not characteristic of this technique procedure and should not be the therapeutic
goal.
To perform the togglerecoil technique for the upper cervical spine, a free-fall headpiece and
drop mechanism is most commonly incorporated with a set spring reset/release apparatus to take up
part of the force and assist in force application. This technique requires a specially designed table,
similar to the model illustrated throughout the text with the appropriate mechanical drop devices.
Such a design minimizes potential injury to the patient and allows for some counter-resistance of the
fixed vertebrae. The movable headpiece has a fixed and constant depth of approximately half a
centimetre with a variable resistance control depending on the size of the patient and the force
required. This maintains a certain amount of control throughout the procedure combined with a
standard and repeatable application in most instances. Upper cervical recoil manipulative procedures
are delivered primarily to the atlas and, to a lesser degree, the axis. From a mechanical perspective,
it would seem difficult to isolate a single articulation during such a generalized thrust combined with
a rather broad-based contact. Typically, the hand contact is either the reinforced hypothenar/pisi-form
or double thumb combination. The thumb contact may provide a more realistic and accurate point of
hand contact, considering the size of the transverse process or lateral mass of the atlas and the
anatomical proximity of the atlas and axis.
The recoil thrust is characteristically performed with the patient in the side posture for
correction of upper cervical dysfunction. The thrust skills can be applied to other areas of the spine
and the extremities in various postures using prop/drop mechanisms to facilitate the therapeutic thrust.
The following section describes some of the basic skills associated with preparation of the
upper cervical spine for application of a togglerecoil thrust(Figs. 11.29 - 11.32). This is by no
means exhaustive, considering all the diagnostic and therapeutic indications for this particular
manipulative intervention. The skills are once again basic in nature, to provide an introduction to this
traditional chiropractic manipulative approach. Special attention to the finesse, speed and control that
are required for this recoil technique will be acknowledged. Only one contact, the posterior aspect of
the transverse process of the atlas, will be included (if you can find it!!). This section will describe
only patient preparation skills. Establishing a firm and accurate contact with the spine will improve
the successful delivery of the toggle thrust and the outcome of the manipulative procedure. There will
be no delivery of a dynamic togglerecoil thrust at the undergraduate level. The patient is lying in the
right-side posture recumbent position, as described in Chapter 5, with both knees flexed.

1) The patient is lying in the right side posture with the head supported by the headpiece which is
elevated to accommodate the width of the patients shoulder. The head is placed in a neutral
positon and is slightly flexed to open the suboccipital region. The practitioner stands in front of the
patient at a 45 angle to the head in a crouched ski posture. The thumb of the left hand, after the TP
of Cl has been located with either finger, draws the tissue slack away from the practitioner being
careful not to drag too much hair (Fig. 11.29).
2) The hypothenar/pisiform aspect of the right hand (the contact hand) follows the locating/tissue
slack thumb drawing more tissue if necessary in the same direction (Fig. 11.30). The contact is
light with no excess pressure over this naturally sensitive and tender area. The contact hand forms
a firm but relaxed chiropractic arch over the anatomical contact. The other fingers support the
placement by lightly gripping the cervical musculature.
3) The support hand reinforces the contact hand position (Fig. 11.31). Both hands are in a high
relaxed arch posture to maintain a high degree of hand skill and anatomical specificity. Both arms
are flexed equally. There should be no pressure over the contact point and the arms should be
totally relaxed.
4) The practitioner completes the series of skills by positioning the suprasternal notch directly over
the contact hand. The practitioner is in a relaxed ski crouch stance, with the arms equally flexed at
the elbows and the shoulders are level to maintain symmetry required for the dynamic thrust (Fig.
11.32). There should be no noticeable pressure over the contact point and no dynamic impulse
should be rendered.
Figure 11.29
Figure 11.30
Figure 11.31
Figure 11.32

The following section will present the basic skills associated with upper cervical togglerecoil
techniques and some of the specialized therapeutic interventions common to the upper cervical spine.
These need to be elaborated and developed in conjunction with the diagnostic and therapeutic
rationale associated with this particular technique. Variations of torque and lines of drive in specific
directions will slightly modify the information presented above. Keep in mind that a number of these
complex skills are transferable to other manipulative procedures.
There are several errors that may occur during the learning of these skills and should be
rectified, including:

a hard and forceful contact point


excessive flexion at the elbows
asymmetry of the shoulders
hyperextension of the elbows during thrust
pushing the shoulders during the thrust
misalignment/asymmetry of the episternal notch relative to the target joint.
Occiput atlas manipulative and important
mobilization skills
It was not the intent of this chapter to present manipulative skills dealing with the occiput as an
anatomical contact. However, it may be appropriate to convey a few guidelines. It would be
important to introduce these skills early in undergraduate training, particularly in light of the
controversy surrounding upper cervical spine manipulation which has been dealt with in great detail
in this chapter. Clinically, this region has been implicated as a source of referred pain projecting over
the head and being responsible for various headache presentations (Bogduk 1991, 1995, Bronfort et
al. 2004a, Nilsson 1995 Vernon 2001). Therefore, learning to mobilize the cervical spine becomes
just as important in light of this important clinical information for safe and effective case management
for a wide range of patient presentations.
Traditionally, excess leverage has been applied to the occiput at extreme ranges of rotation by
way of the zygoma or mastoid. Subsequently, under the present state of knowledge regarding rotation
and its potential dangers, it would be wise to reconsider this approach. Besides, there is very little
kinematic y-axis rotation between the occiputatlas articulation (Panjabi et al. 1988). Under these
biomechanical conditions, it is quite conceivable that a dynamic rotational thrust would most likely
influence the C1C2 motor unit or other distant articulations which is not the intended therapeutic
segmental level. The clinical goal is to restore function where patient safety is paramount.
Many chiropractic authors have described both mobilization and manipulative procedures that
influence the occiputatlas articulation (Bergmann & Peterson 2011, Byfield 1991, Fligg 1985b,
Gitelman & Fligg 1992, Grice 1980). These procedures are based upon a sound kinematic and
applied anatomical rationale. They incorporate the concept of coupled motion and the significance of
the large postural extensors acting on the occiput. There is a dominant traction component that affects
these myofascial structures and, therefore, there is no need for forced rotation during the thrust, which
may cause unwanted torsional stress. This is a very important aspect when learning these
psychomotor skills. The levers are meant to be short, which adds to the efficiency of the manipulative
procedure.
There are two important anatomical landmarks, the mastoid process and the occipital rim. The
following description will provide the basic manipulative skills associated with these landmarks,
incorporating the other psychomotor skills already introduced earlier in the chapter (Figs. 11.33 -
11.38C).
Mastoid process (MP)
1) The practitioner is in a crouched posture perpendicular to the table at the level of the MP. The
patients head is lifted and rotated away from the practitioner and supported by the flexor surface
of the right forearm (support arm) (Fig. 11.33). The fingers of the support hand cup the chin and
introduce flexion of the occiput. Rotation is not forced but relaxed within the patients tolerance.
The headpiece is positioned 010 from the horizontal. If there are any signs of distress
discontinue the procedure. The patient should be in the appropriate supine position.
2) The hypothenar/pisiform arched contact hand (right) is secured along the inferior aspect of the
mastoid process on the ipsilateral side. The contact is broad based cupping the ear in an arch
posture (*) (Fig. 11.34). Both arms are kept very close to the body to control the action at this
point. The patient should not feel any excess tension or pressure on the MP. The practitioner is
crouched very low and leaning up against the table and tractioning in a cephalad direction.
3) Traction is applied by moving both contact points cephalad simultaneously to attain joint tension.
This action can be assisted by moving the trunk at the same time through the legs in the crouch
posture (Fig. 11.35). At no time is there to be any forced rotation. Patient comfort is paramount.
4) It is from this basic position that various combinations can be applied to the occiputatlas
articulation depending upon the diagnostic indications. For example, by laterally bending and
flexing the head over support arm a traction impulse thrust can be applied to directly influence a
single joint (in this case on the up side) and its surrounding myofascial structures without any
excess or forced rotation (Fig. 11.35). Application of an impulse thrust should be avoided at this
point.
1) The palmar surface of the middle finger of each hand grasps the rim of the occiput. The fourth
and fifth digits support the occiput and the index finger supports the musculature of the cervical
spine. Both hands are ulnar-deviated for this position. Cephalad traction and flexion are
applied together by slowly extending the arms at the shoulders and ulnar-deviating the hands at
the wrists, respectively (Fig. 11.36). The practitioner can lean back, adding more traction in
the process. The headpiece is flexed about 010. Feel for the give in the tissue at the base of
the occiput.
2) This illustrates the contact for upper cervical spine procedures. The contact hand just drops
off the occipital rim on to the region of the C1 (Fig. 11.37). All other preparatory skills are the
same as described above in order to achieve joint preload.
2) Mobilization of the cervical spine is an important skill to learn early in the undergraduate
education particularly in light of current research which indicates that mobilization provides
equally good clinical outcomes. The skill requires that the clinician carefully move the general
cervical spine or specific segment through a series of repeated movements within the passive
range of motion for that joint structure. In the cervical spine this can be via lateral flexion,
rotation (Fig. 11.38A) and reproducing a figure of eight movement in both the horizontal and
vertical planes. This passive movement can be performed with a certain amount of traction
depending upon the patients tolerance and symptom presentation.
Figure 11.33
Figure 11.34
Figure 11.35
Figure 11.36
Figure 11.37

Figure 11.38A
Occipital rim (OC)
With the patient in the supine posture, the practitioner can apply a cephalad traction component along
the entire rim of the occiput (Figs. 11.38B & 11.38C). This can be done as a reflex traction skill or
combined with a dynamic impulse thrust. At this stage it is recommended that the impulse thrust be
avoided to allow the other essential skills to develop. The purpose of this skill is to stretch the upper
cervical joint capsules and, to a lesser degree, the posterior musculature, without subjecting the area
to excessive mechanical stress. Applying traction to the occiput is a skill on its own.

Figure 11.38B
Figure 11.38C
Summary
This chapter has provided an account of the current thinking, clinical evidence and controversial
debate regarding spinal manipulative therapy (SMT) of the cervical spine.
This chapter has also presented some of the basic manipulative psychomotor skills required to
develop efficient manipulative procedures to treat dysfunction of the cervical spine. Emphasis has
been placed upon mastering a number of skills that reduce any excessive rotational movements,
thereby ensuring some degree of protection of vital structures. Patient comfort, safety and welfare are
paramount in this particular approach. The objective has been to present the individual movements
and skills in an organized and detailed fashion. The presentation has been careful to avoid the
dynamic thrust, which is only one specific component of the overall manipulative procedure, and
replace it with a mock thrust with emphasis placed on the preparatory skills. The midcervical region
was selected for various safety reasons and patient comfort. Once the skills have been mastered for
this region, modification and adaptation for the upper and lower cervical areas can be taken in due
course. It is felt that these skills should be introduced in the senior years of chiropractic education
prior to the start of clinical training. At this stage the skills are maturing and a better understanding of
their clinical implications will evolve. Keep practising!

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Whittingham W., Ellis W.B., Molyneux T.P. The effect of manipulation (toggle recoil technique) for
headaches with upper cervical joint dysfunction: a pilot study. J. Manipulative Physiol. Ther..
1994;17:369-375.
Whittingham W., Nilsson N. Active range of motion in the cervical spine increases after spinal
manipulation (toggle recoil). J. Manipulative Physiol. Ther.. 2001;24:552-555.

Further reading

aldeman S., Kohlbeck F.J., McGregor M. Stroke: cerebral artery dissection, and cervical spine
manipulative therapy. J. Neurol.. 2002;249:1098-1104.
ierau D., Cassidy J.D., Bowen V., et al. Manipulation and mobilization of the third
metacarpophalangeal joint: a quantitative radiographic and range of motion study. Manual Medicine.
1988;3:135-140.
mith W.S., Johnson S.C., Skalabrin E.J., Weaver M., Azari P., Albers G.W., et al. Spinal manipulative
therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60:1424-1428.
errett A.G.J. Vertebrobasilar stroke following spinal manipulation. In: Murphy D.R., editor.
Conservative management of cervical spine syndrome. London: McGraw-Hill; 2000:553-557.
Section 4
Specialist adjustive and manipulative skills
Chapter 12

Basic paediatric manual skills

Steve Williams

Chapter contents

Introduction
KISS syndrome
KISS I
KISS II
Examination and treatment
Examination techniques for infants

Assessment of trunk flexibility


Method
Correction
Assessment of the cervical spine
Examination of the thoracic and lumbar spine
Sacroiliac joint examination
Manipulative treatment
Cervical spine
Digital cervical
Cervical bridge
Thoracic and lumbar spine
Prone corrections
Vertical lift adjustments
Side posture lumbar spine
Pelvic corrections
Side posture
Prone corrections
Supine corrections
Summary
References

SECTION CONTENTS

12. Basic paediatric manual skills 327


13. Basic manual techniques for the pregnant patient 341
14. Spinal adjusting and clinical management of the older adult 359
Introduction
Manual treatment of children including manipulation has been practiced for thousands of years by
many cultures within their folk medicine traditions. Since the 19th century allopathic medicine has
shown a relative disinterest in manipulation (Livingston 1981), which has largely been provided by
chiropractors and osteopaths. Manipulation by chiropractors and osteopaths was the most commonly
used provider-based complementary and alternative therapy among U.S children in 2007 (Barnes et
al. 2008).
Musculoskeletal pain is the commonest primary complaint in children aged between 2 and 17
years. For those children who are under 2 years of age, the commonest primary complaint reported is
excessive crying/infant colic (Hestbaek et al. 2009).
The literature shows that the prevalence of spinal pain in children is high; it has been estimated
to be near 60% in a recent study (Trevelyan & Legg 2010). A study of 1446 1114 year olds found the
1 month prevalence for low back pain was 24% (Watson et al. 2002). The lifetime prevalence for
low back pain in children is between 30 and 40% (Louw et al. 2007, Sato 2010, Sato et al. 2008).
Recurrent low back pain appears to be a significant health issue; (Jones & MacFarlane 2009) found
that more than 25% of children aged between 11 and 14 years experiencing low back pain were still
reporting symptoms 4 years later. Risk factors include male gender, greater age, increased weight,
increased height and a parental history of back pain (Kaspiris et al. 2010). Health-related quality of
life is considerably impaired in children with chronic low back pain (Petersen et al. 2009).
While 510% of chiropractic patients are children or adolescents mostly complaining of spinal
pain, there is a paucity of studies showing benefit from chiropractic care (Hestbaek & Stochkendahl
2010). There is, however, good opportunity for chiropractors to take responsibility and engage in a
determined effort to bring forward evidence-based strategies for prevention of spinal pain and other
musculoskeletal problems (Hartvigsen & Hestbaek 2009).
There have been a number of papers looking at the efficacy of chiropractic for various non-
musculoskeletal disorders in children such as colic (Miller & Phillips 2009, Olafsdottir et al. 2001,
Wiberg & Wiberg 2010, Wiberg et al. 1999), asthma (Alcantara et al. 2010, Balon & Mior 2004,
Bronfort et al. 2001, Hondras et al. 2005, Kaminskyj et al. 2010), otitis media (Fallon & Edelman
1998, Fysh 1996, Froehle 1996, Sawyer et al. 1999), nocturnal enuresis (Keating 1995, van Poecke
& Cunliffe 2009), attention deficit (Alcantara & Davis 2010, Karpouzis et al. 2009, 2010) and
developmental delay (Cuthbert & Barras 2009). Gotlib and Rupert in a 2008 systematic review of
chiropractic care for paediatric health conditions found that while chiropractors treat a range of non-
musculoskeletal conditions in children and infants, the rationale for treatment rests primarily with
clinical experience, descriptive case reports and very few observational and experimental
studies. Ferrance and Miller (2010) also note the lack of higher level evidence for chiropractic care
of non-musculoskeletal conditions and suggest the burden of proof rests with the chiropractic
profession.
Bronfort et al. (2010) in a well-publicized systematic review conclude that spinal manipulation
is not effective for infantile colic and asthma when compared to sham manipulation. They also state
that the evidence for chiropractic care is inconclusive for otitis media and enuresis. However, in a
systematic review encompassing the wider evidence base, Hawk et al. (2007) state that the evidence
supports chiropractic care (the entire clinical encounter) as providing benefit to patients with
asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of
manual procedures for children with otitis media
A difficulty for the chiropractic profession with regard to the evidence base is that much of the
current evidence does not make a distinction between chiropractic spinal manipulation as a mono
therapy and chiropractic care that incorporates multiple non-manipulative therapies as a package
(Hawk et al. 2009).
There is a relative lack of higher level evidence (randomized controlled trials and systematic
reviews) for chiropractic care for both musculoskeletal and non-musculoskeletal conditions.
Manchikanti et al. 2007 suggest that when there is a lack of such evidence, expert consensus is the
form of evidence which must be relied on.
Safety of chiropractic care and manipulation in particular, is an issue that has been in focus
recently. Vohra et al. (2007) and Humphreys (2010) suggest that further study is necessary to assess
the safety of spinal manipulation in children. Miller and Benfield (2008) published a 3 year
retrospective analysis of adverse events associated with paediatric spinal manipulative therapy at the
Anglo European College of Chiropractic. Based on 697 children attending for 5242 patient visits they
reported a minor adverse reaction (excessive crying; as reported by parents) per 100 children or one
reaction reported every 749 treatments. Alcantara et al. (2009) in a practice-based survey found three
minor adverse events in 5438 treatment visits from the treatment of 577 children. While significant
adverse effects due to SMT in children appear to be very rare, caution does need to be employed
with the use of high velocity or forceful upper cervical manipulation in infants. Koch et al. (2002) in
a study of 695 infants between 1 and 12 months of age found that the application of an impulse type
manipulation to the upper cervical spine produced a change in heart rate in over 40% of the infants.
Infants in the first 3 months of life responded more vigorously, some exhibiting a severe bradycardia
(1585% decrease in heart rate). In the authors opinion there should be great caution employed when
dealing with the upper cervical spine in infants and preference given to lower force techniques for
infants in the first few months of life. However, according to Biedermann (2005) the upper cervical
spine is the source of many infantile ailments and as such often needs to be addressed.
Kiss syndrome
The field of manual medicine is particularly strong on the continent of Europe, especially in countries
such as Germany, Holland and Belgium, and has provided some interesting insights and research for
the manual care of infants. Biedermann (1992) used the term KISS (Kinematic Imbalances due to Sub-
occipital Strain) to encompass a variety of symptoms that have their origin in the upper cervical
spine.
Biedermann (2005) has more recently refined and subdivided KISS syndrome into KISS I and
KISS II, reflecting the different parameters he has observed.
Kiss I
The major marker these children exhibit is fixed lateral flexion/rotation of the head. This may be
accompanied by unilateral microsmia, asymmetry of the skull, scoliosis of the neck and trunk, gluteal
area asymmetry, asymmetric limb movements and retardation of motor development on one side.
Kiss II
The major marker these children exhibit is fixed cervical hyperextension during sleep. This may be
accompanied by asymmetric occipital flattening, shoulders pulled up, fixed supination of arms,
difficulty in lifting their trunk when prone, orofacial muscle hypotonia and difficulty breast feeding
from one side.
Biedermann (1992, 2005) qualifies his KISS theories by stating that the symptoms cover a wide
range of pathological conditions and cannot always be attributable to the upper cervical spine, but
when encountered in combination of motor asymmetries, sleep disorders and cranial asymmetry, it is
worthwhile to look at the upper cervical spine.

Examination and treatment


It is important to realize that examination treatment techniques within the paediatric realm vary
greatly according to age. Examination and treatment of the infant and young child demands particular
skill sets and techniques, while for older children (greater than 5 years of age) a chiropractor can
adapt manipulative techniques in standard use for adults by simply changing the force and depth of
thrust. Indeed, the main adaptation necessary for treating children is to decrease the force and the
depth of the thrust used in high-velocity manoeuvres and to make it relative to the age and size of the
patient. This skill set requires practice and the novice is always advised to err on the side of caution.
Another key point is the importance of preloading the joint to be adjusted and not backing off from the
preload before the adjustive thrust is given, as this can feel somewhat traumatic and unpleasant for the
child. The chiropractors ability to preload the joint and to feel for the ideal point of tension to
deliver the trust is something gained with experience and is one of the key skills that enables good
paediatric adjusting technique. Pre-thrust tension can best be described as the point at which gentle
ligament tension is achieved after the muscular barrier has been overcome. In infants there is little
muscular barrier so the pressure used is very light and the direction needs to be specific.
The manner of the clinician also needs to alter somewhat from that used when managing adults.
Infants and young children need to be approached with a gentle, calm and non-invasive attitude and
persuaded gently or distracted so the adjustment can take place with as little trauma as possible. This
also ensures that future treatment sessions can occur without the infant or child getting fractious when
the encounter begins and so the chiropractor does not dread seeing the child again: a screaming child
is stressful for all concerned parents, the clinician, staff and other patients. It is worth stating at this
point that with very uncooperative toddlers and young children (who may have previously
experienced an unpleasant interaction with other medical professionals) it may be worth spending
much of the first encounter with a fractious toddler or young child simply history taking from the
parent and playing with the child to gain trust and to allow future encounters to be more productive.
Treatment tables do not make the best surfaces for adjusting infants; beanbags can be useful as they
cradle the infant and appear to be well tolerated. The authors preference is for a memory foam
wedge angled at about 10 (Fig. 12.1). This helps decrease gastro-oesophageal reflux during
treatment, which may make the infant uncomfortable whilst supine and the soft distortable nature of
the memory foam is comfortable for infants who may have undergone head and neck trauma during the
birth process. In order to facilitate the infant being comfortable with the attention of the chiropractor,
the mother (parent) should stay in close attendance within the infants view, holding their hand and
comforting them. This is generally only helpful if the parent is relaxed and comfortable with the
situation, so detailed explanations of the chiropractors intentions and actions as the
examination/treatment happens is vital. The chiropractor should also reassure the parents and
emphasize the non-traumatic nature of the interventions.

Figure 12.1 Angled memory foam wedge

Examination techniques for infants

Inverted hang
The inverted hang (DeJarnette 1979) is a test that is used extensively in the chiropractic profession
and can give some very useful results, but it needs to be used with caution. It is absolutely
contraindicated in haemorrhagic disease of the newborn or any other condition involving
bleeding or haemorrhage. Inversion should also be avoided if there is hydrocephalus, hip
instability or any neurological symptoms, (i.e. epilepsy). The inverted hang should be avoided in
the first month of life, as up to one-quarter of infants that have experienced normal vaginal delivery
have an asymptomatic intracranial hemorrhage (Huang & Robertson 2004, Looney et al. 2007, Roland
et al. 1990). That said, the test provides, in not too severely compromised babies older than 4 weeks,
definitive indications of where a lesion is located and where to focus treatment.

Method
The baby should lie supine on the chiropractors lap, with the soles of the feet facing the
chiropractors body. The lower limbs (not just the ankles) are gripped so that the feet can be
dorsiflexed (using a pistol grip with the forefinger performing the dorsiflexion) (Fig. 12.2). The
chiropractor, sitting on the edge of the bench, gradually lowers his/her knees so the baby angles down
towards the floor without being startled. Slowly, the chiropractor lifts the baby up by the legs so he or
she hangs in inversion over the chiropractors lap (if the baby is small enough) or over the bench or
floor (Fig.12.3). The baby is then gently returned to the chiropractors lap, the chiropractors knees
being used as the fulcrum to lie the head back down. This can be a little tricky if the infant goes into
hyperextension, so the parent may need to guide and support the infants head.
Figure 12.2 Inverted hang stage 1
Figure 12.3 Inverted hang stage 2

The chiropractor should explain the procedure and reassure the parents (particularly first-time
parents) prior to performing the inversion: the author will never forget having a mother burst into
tears when she saw her beloved baby inverted.

Results

The head rotates in one direction: fixation of C1C2 (change the babys position first to make sure
that he or she is not looking at Mum)
The head is held in lateral flexion: occipital condyle or cervical facet fixation (possible KISS I
syndrome)
The neck is in extension: bilateral occipital condylar compression (possible KISS II syndrome)
The neck is held in flexion: cranial dural restriction
The babys trunk adopts a laterally flexed or twisted posture: thoracic/rib fixation and/or body
fascial restriction
The leg lengths are uneven: sacro-iliac ligamentous injury/instability (Williams 2005).

Most babies, certainly those below 6 months of age, should enjoy being hung upside down; if
this distresses them, this is another sign of a spinal or cranial restriction or compression.
Assessment of trunk flexibility
This procedure (which can be used up to 3 months of age) is a very useful method of finding and
correcting fascial restrictions occasioned by intrauterine constraint.
Method
The baby is held by the chiropractor, one hand under the pelvis and the other hand under the
shoulders, neck and occiput. The baby is gently flexed and extended, ease of motion and restriction
being ascertained. The baby is then laterally flexed at the trunk to the left and right, the trunk is then
twisted to the left and right. Restriction in any direction is noted (Fig. 12.4).

Figure 12.4 Assessment of lateral flexion


Correction
If, for example, the baby is restricted in left lateral flexion, the baby should be taken gently into right
lateral flexion (the direction of freedom) as far as possible until a release is felt in that direction. The
infant should then move more easily into the previously restricted direction. This principle is applied
to all directions of restriction: go into the opposite free direction until it releases or unwinds and then
recheck the areas of previous restriction.
Assessment of the cervical spine
In those older children who can sit still, conventional static and motion palpation procedures can be
employed, but in infants this is not the case. With younger babies, the easiest method is for the
chiropractor to cross his/her leg over, ankle onto thigh in a figure 4, and sit the baby in the recess
formed. The babys head is held over the fronto-parietal area, while the other hand presses the
infants transverse processes individually from T1 to C1, posterior to anterior, feeling for pliability.
Any rotation, bilateral fixation or restriction is then easily palpated (Fig.12.5).

Figure 12.5 Assessment of the cervical spine

Cervical spine examination can also be performed supine, with the examiner laterally flexing the
infants neck and feeling for restriction of the cervical facet joints (Fig.12.6).

Figure 12.6 Spine cervical palpation


Examination of the thoracic and lumbar spine
Thoracic and lumbar spine examination in infants who cannot sit unsupported (before aged 6 months)
can be performed a number of ways; firstly static palpation and gentle segmental springing can be
undertaken with the infant supine on the adjusting table or on the memory foam wedge. For the more
stressed infant, examination of all spinal regions may have to be carried out while being held by a
parent over their shoulder (Fig.12.7) or lying prone on the parents stomach with the parent in turn
lying on the adjusting table. Static palpation and segmental springing are performed in a very similar
way to the adult, but with obviously much decreased force; this activity, therefore, requires more
refined palpation skills.
Figure 12.7 Spinal palpation

Motion palpation of the thoracic and lumbar spine in infants can be problematic requiring the
application of specialized techniques.
The easiest method for motion palpating the ribs and thoracic and lumbar spine in an infant is
with the infant lying prone over the chiropractors lap (it is advisable to use a towel or other covering
to protect the chiropractors clothing). The infants head and face hang over the lateral edge of one
thigh, facing the floor. The doctors legs are then slowly opened and closed by a few centimetres; this
creates some extension in the spine and ribs and allows motion and any restrictions present to be
assessed (Fig. 12.8). This is useful as far up the spine as T1 and as low as L5.

Figure 12.8 Motion palpation prone

This is also a good position for static palpation and to look for any static spinal rotations or
vertebral malpositions.
Sacroiliac joint examination
Sacroiliac joint assessment is also easily performed with the infant prone on the examiners lap. The
relative position of the posterior superior iliac spine (PSIS) should be noted. The chiropractor can
then extend the infants thigh and, as the leg is extended, the ability of the PSIS to rotate to the anterior
is palpated (Fig. 12.9). Sacroiliac joint end play can be evaluated and any flexion/extension lesions
of the SI joints noted. An indicator the author has found to be reasonably reliable for indicating sacral
position is the buttock squeeze. The method is to remove or pull down the nappy and squeeze the
buttocks together and observe the gluteal cleft (Fig. 12.10). Deviation of the cleft to either side
indicates an anterior sacrum on that side. There will often also be poor lower body flexibility and
sometimes an unwillingness to abduct the knees with the hip and knees flexed.
Figure 12.9 Sacroiliac palpation

Figure 12.10 Gluteal squeeze

Often asymmetric fat creases are apparent on the thighs or over the sacrum in the presence of hip
pathology. This can also be due to a lesion of the sacrum. Sacroiliac pliability can be assessed with
the infant supine. One ileum is grasped over the PSIS by one hand and the sacrum on that side is
sheared against it by the other hand. This is then repeated on the opposite side; the pliability of each
joint is assessed and compared for restriction.
Manipulative treatment
There are numerous manipulative techniques in chiropractic many of which can be adapted for
paediatric use. The purpose of this chapter is not to give the reader a detailed how to of chiropractic
technique, but some guidance of manipulative strategies and adaptions for paediatric use.
Cervical spine
Great care needs to be taken when adjusting the cervical spine of young children and infants in
particular. It should be remembered that the infants cervical spine has poor neuromuscular control,
which leaves it vulnerable to trauma, for example from just being picked up without supporting the
head.
The frontal angle of C0C1 is increased (Biedermann 2005) in infants. The facet joint angles in
the cervical spine are less oblique in young babies and children, and the uncinate processes are
horizontal (Pauc 1980). This allows considerable motion of the cervical spine in flexion and
extension, but increases vulnerability to damage with careless handling. Weinstein (2001) stated that
the paediatric spine is between 5 and 10 times less stiff than the adults spine; meaning that the depth
and force of manipulative procedures in children should be much less.
Strong rotary manipulation of the cervical spine is, in the authors opinion, inappropriate in
young infants and the achievement of an audible osseous release is not necessary. It should be
remembered that the parents may be very nervous about their child undergoing any manipulation, and
loud noises and rapid movements of the infants head and neck can increase the parental stress,
making case management more difficult.

Digital cervical
The fingertip is an excellent contact point for corrections in the infants spine; the spinous, lamina and
transverse processes are the main vertebral contact points used. Which vertebral contact point is
chosen depends on the desired line of drive, i.e. whether the chiropractor is trying to establish motion
in rotation, the posterior-anterior (anterior-posterior) or inferior-superior (superior-inferior)
directions.
When adjusting the atlas the transverse processes and posterior arch are the main contact points,
the indifferent hand stabilizes and supports the infants head and neck on the contralateral side, a
small amount of lateral flexion and rotation of the infants spine may be needed to gain sufficient joint
tension. The infants neck can be very mobile in lateral flexion and rotation, therefore attention should
be given to trying to establish lateral flexion and rotation at the segmental level to gain the necessary
joint tension, rather than laterally flexing and rotating the whole of the cervical spine. It is very
important for the chiropractor to think clearly about the line of drive of the correction bearing in mind
the angulations of the facet joints to be corrected. This is best accomplished by lining up the forearm
of the contact hand in the same plane as that of the impulse or adjustive thrust (Fig. 12.11). The thrust
used is a low amplitude fast impulse; the depth varies according to the size of the child. One
illustration of the amplitude of this thrust is that on newborns and young infants it is only of the depth
of thrust that would be tolerable on ones eyeball.
Figure 12.11 Digital cervical adjustment

Cervical bridge
The previously described cervical bridge examination technique can be easily adapted for correction
of cervical restrictions. The examiners forefinger and thumb bridge around the infants cervical spine
while the infant is stabilized in the chiropractors lap with the front of the infants skull stabilized by
the indifferent hand. Contact points are the laminapedicle junction or the transverse processes. The
side of posterior rotation of the transverse process (lack of anterior glide on that side) is identified. A
direct but gentle pressure is exerted in that direction, after a few seconds a soft tissue give is felt;
this is then set with a fast flick (a rapid contraction of either the wrist extensors or the wrist flexors
on the side of correction) in the direction of correction. The author equates this to the soft tissue
give of the muscular contraction at the vertebral level releasing and then the fast stretch set is
applied at the ligamentous barrier. The infant will tend to wriggle against the pressure, which instead
of being disruptive often facilitates the adjustment. If no soft tissue give is felt, the opposite side
should be taken gently to the anterior for a few seconds and held in the opposite direction (using the
rusty hinge principle). A fast stretch is not used on that side. The original direction of the adjustment
is then repeated and the soft tissue give is then usually achieved and the high-velocity flick is
applied (Fig. 12.12).
Figure 12.12 Cervical bridge adjustment
Thoracic and lumbar spine
Prone corrections
Prone adjustments of the thoracic spine are easily accomplished for young infants in the same position
that palpation takes place; across the chiropractors lap using finger-tip contacts. The contact points
can be bilateral transverse processes, unilateral transverse process, bilateral/unilateral rib angles or
a spinous process.
The chiropractor can use bilateral finger contacts to the infants transverse processes (Fig.
12.13). This would be the most common contact for segmental restriction in the thoracic spine. If
significant unilateral vertebral restriction or rotation is present, the contact can be a unilateral
transverse process (Fig. 12.14). These contacts can be reinforced by the other hand, if required, to
stabilize the contact and the thrust.

Figure 12.13 Bilateral TVP adjustment stabilized with indifferent hand


Figure 12.14 Unilateral TVP contact

Spinous process contacts are less commonly used but are also very effective for treating
extension restrictions of the thoracic and lumbar spine, and for correcting static vertebral posteriority.
The contact point is usually the tip of the spinous process with the tip of the first or second finger
(Fig. 12.15). The lateral aspect of the spinous may be contacted if there is a static rotation or a
restriction joint play in rotation. Spinous contacts can be supported by the other hand if desired, but
due to the contact area being very small it is often easier not to. The direction of the thrust is of great
import and is generally performed in the plane of the facet joints, i.e. posterior to anterior and inferior
to superior when adjusting the spine. The direction of rib angles is mainly posterior to anterior,
although some accommodation should be made if one of the ribs sits in a more superior or inferior
direction. The thrust is a gentle set and may or may not be accompanied by joint cavitation. The
depth of the thrust depends on the age of the infant/child, but is never at a level to cause discomfort to
the infant/child.
Figure 12.15 Spinous contact

Vertical lift adjustments


The thoracic spine (below T2) and the upper lumbar spine is most easily adjusted once the infant has
gained adequate head control, by using the weight of the infant to assist with the correction. The
chiropractor picks up the infant with both hands around the thorax, fingers to the spinal segments/ribs
to be adjusted and extends the infant over his or her hip or thigh a few degrees; this allows tension to
be introduced into the involved segment (Fig. 12.16). The area of fixation spine or ribs is
contacted with two fingers on either side (rotation can be corrected by primarily contacting only one
side). A flexion flick of the wrists performs the adjustment, usually with a joint cavitation, but this is
not necessary as long as motion is improved.
Figure 12.16 Vertical lift adjustment

With slightly older infants who need less stabilization and have more body weight, the
chiropractor can lift the infant up in front of him or her and adjust the involved vertebral level with
the flexor wrist-flick. This can also be performed with the baby facing away from the chiropractor,
who then uses the thumbs to contact the involved vertebra. A wrist extension flick is then used to
complete the adjustment (Fig. 12.17).

Figure 12.17 Vertical left thumb contacts


Side posture lumbar spine
Rotational fixations of the lumbar spine can be addressed in young infants by a side-posture
correction. This is accomplished with small infants side-lying in the chiropractors lap on the side of
spinous rotation or anterior sacrum, with the babys inferior arm stabilized and held between the
chiropractors thighs (Fig. 12.18). The upper shoulder is held with one hand, the infants upper leg
being flexed and the pelvis stabilized with the practitioners wrist. Contact is made with the
mamillary process using the first two fingers of the chiropractors inferior hand. Tension is taken up
and a gentle flick adjustment is given, usually with an audible osseous release.

Figure 12.18 Side-posture correction on lap

Older infants are better adjusted on an adjusting table. The infants leg can be stabilized by the
chiropractors thigh; keeping the infants knee straight and flexing the hip will help gain tension (Fig.
12.19).
Figure 12.19 Side posture toddler
Pelvic corrections
Side posture
Side posture adjustments to the pelvis can be used for infants and young children as detailed above
for the lumbar spine. The contact points are obviously different and depend on what the chiropractor
is trying to achieve. The main contact points are the PSIS, ischium, and the upper and lower sacrum.
Excessive trunk rotation of the infant/child should be avoided and the thrust should be shallow and
fast.

Prone corrections
Prone pelvic adjustments are commonly used on infants and young children. The application often
involves the application of a high-velocity impulse at the point of the range of motion the chiropractor
has palpated a restriction. For example with the infant prone, the chiropractor extends the infants
thigh and palpates the anterior rotation of the PSIS at the point of restriction a very shallow high-
velocity impulse is then applied (see Fig. 12.9). The sacrum can also be the contact point, especially
on the posterior side (the side opposite gluteal cleft deviation). Drop piece techniques can be used on
the pelvis for older children, but this is not recommended for infants, as it often stimulates a Moro
type stress response and can cause the infant to become distressed.

Supine corrections
Correction of an infant sacrum supine takes place with the hands in the same position as for the
assessment detailed earlier in the chapter. The side of posterior restriction is held in posterior to
anterior stress and this is continued until a soft tissue give is felt; with this a fast stretch impulse (via
the wrist flexors) is given to set the adjustment (Fig. 12.20). In an infant it is also advantageous to
ensure the sacrum is able to rotate about the axis of the second sacral tubercle. To facilitate this it is
necessary to open the posterior aspect of the sacroiliac joints and encourage the flexion-extension
motion of the sacrum. The chiropractors hand contacts the supine infants anterior superior iliac
spines and squeezes them gently together, opening the sacroiliac joints. The doctors other hand cups
the sacrum (with a nappy in situ!); this hand gently flexes and extends (rocks) the sacrum to encourage
the motion (Fig. 12.21).
Figure 12.20 Supine sacroiliac adjustment
Figure 12.21 Sacral mobilization supine
Summary
The skills necessary for competent paediatric spinal adjusting have been outlined in this chapter. The
principles of learning psychomotor skills have already been clearly presented in earlier chapters;
these principles also apply when attempting to gain competence in paediatric adjusting. The novice is
urged to gain experience adjusting older children before proceeding on to infants. They would be
well advised to observe those experienced in paediatric adjusting to progressively build confidence
and expertise.

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Williams S.P. Pregnancy and paediatrics: a chiropractic approach. Privately published; 2005.
Chapter 13

Basic manual techniques for the pregnant patient

Mark Webster, Steve Williams

Chapter contents

Introduction
Biomechanical considerations
Flexibility
Risk of spontaneous abortion (miscarriage)
Informed consent
Monitoring the patient
Manual care considerations
Patient comfort
Manipulative/mobilization modifications
First trimester
Second trimester
Third trimester
Side posture modifications
Prone modifications
Supine modifications
Sitting techniques
Kneeling techniques
Mechanical pelvic blocking
Mechanical prone pelvic blocking techniques
Mechanical supine pelvic blocking techniques
Mechanical drop techniques
Prone pelvic mechanical drop techniques
Supine pelvic mechanical drop techniques
Points to remember when using the drop mechanism
Pelvic (trochanteric) belts
Summary
Acknowledgements
References
Introduction
Pregnancy-related low back pain (PLBP) and pelvic girdle pain (PGP) are common complaints
affecting between 45 and 72% of all pregancies (Skaggs et al. 2007, Wu et al. 2004). It would appear
that these are two distinct forms of pain with different aetiologies that can occur separately or in
combination with each other. In a systematic review, Wu et al. (2004) found PGP to be more common
affecting 50% of symptomatic patients with PLBP affecting 33% and the remaining 17% having
features of both complaints. The onset of PLBP/PGP can occur at any point, though most commonly
starts around weeks 20 to 28, with the most intense pain being experienced around week 30 (Fast et
al. 1987; stgaard 1999). Pain levels can adversely impact on the quality of life, interfering with
normal daily activities and resulting in sleep disturbance (Skaggs et al. 2004, Wang et al. 2004).
There is also evidence of socioeconomic detriment mainly as a consequence of absenteeism from
work (Darwich & Diwan 2009). In the majority of pregnancies pain levels are reported to be
moderate, however 15 to 21% of women complain of severe pain (Skaggs et al. 2007, Wang et al.
2004;). With women with two or more pain sites suffering from more severe pain (Skaggs et al.
2007).
Risk factors for the developing PLBP/PGP include strenuous work, previous low back pain,
previous history of PGP or PLBP, and multiparae (Wu et al. 2004). There is speculation that these
factors are related to local tissue damage which results in a predisposition to develop subsequent
symptoms. Psychosocial factors such as high levels of stress and low job satisfaction have also been
reported (Borg-Stein & Dugan 2007). Factors that do not affect the risk include time interval since
last pregnancy, height, weight, smoking, age and the use of epidural/spinal anaesthetic techniques
(Vermani et al. 2010).
The majority of women do not report PLPB/PGP to prenatal providers or receive care (Skaggs
et al. 2007). In most cases the pain is self-limiting with over 60% resolving within 1 month of
childbirth (Albert 2001). Recently, however, Skaggs et al. (2007) reported that up to 40% of women
still experience pain 18 months post partum. The exact aetiology of PLBP/PGP is unknown, although
it is thought to be multifactorial in origin (Darwich & Diwan 2009). Some of these factors are related
to the normal changes seen in pregnancy, which include mechanical strain secondary to the enlarging
gravid uterus and accompanying postural changes. Stretching, weakness and separation of the
abdominal muscles, which impede spinal stabilization and increases paraspinal muscle strain. In
addition hormonally related pelvic joint laxity may affect the normal force closure mechanism of the
sacroiliac joints (Mens et al. 2001).
Risk factors associated with long-term PLBP and/or PGP include pre-pregnancy back pain,
prolonged labour, a high number of positive pain provocation tests, a low mobility index, the onset of
severe pain at early gestation, inability to lose weight following delivery to the pre-pregnancy level,
and combined PLBP with PGP (Gutke et al. 2008). Furthermore, it has been suggested that it is
important to distinguish between PLBP and PGP, as the management and prognosis of the two
conditions may differ (Vermani et al. 2010). Useful prevocational tests for PGP include Patricks
Faber (Figure 4 Test), posterior pain provocation (thigh thrust), long dorsal ligament palpation, side-
lying sacroiliac compression, active straight leg raise and modified Trendelenburgs test (Vermani et
al. 2010, Vleeming et al. 2008).
Pregnant women may also seek chiropractic care for issues regarding foetal position and
intrauterine constraint. Evidence is limited however; 6992% success rates have been claimed for
correcting breech presentation using the Webster Breech Technique (Pistolese 2002, Alcantara &
Ohm 2008). Chiropractors and others involved in manual therapy may well have a role to play in the
management of intrauterine constraint by decreasing torque and tension in the transverse fascial
planes (pelvic floor and thoracic diaphragm) and therefore the mechanical stress on the foetus
The relief of pain and discomfort as well as the maintenance of activities of daily living should
be the primary goals in the manual treatment of the pregnant patient. Treatment should be
individualized to the patients particular presentation and needs to facilitate the patients adaptation to
the increasing and changing demands placed on the body and musculoskeletal system during
pregnancy. Understanding the changes that take place during pregnancy is of paramount importance in
allowing the chiropractor to determine how to treat a pregnant patient, what technique modifications
may need to be made and which cases need referral to another healthcare provider.
Biomechanical considerations
The overall postural effect of pregnancy by the final month substantially increases the biomechanical
stress placed upon the body (Fig. 13.1), these include:

anterior pelvic tilt with hyperextended knees


accentuated lumbar lordosis with a short radius curve
anterior gravity line
hyperkyphosis of the upper thoracic spine
protracted shoulders
forward head carriage
extension of the occiput on atlas.
Figure 13.1 Plumb line posture in the third trimester of pregnancy.

The postural changes place increased mechanical loads on the sacroiliac joints, lumbosacral
region, L1T12, 10th12th ribs, T6T8, C6T2 and C0C2 regions (Fligg 1986). Additionally the
abdominal muscles stretch to the extent that they no longer contract adequately and hence do not
function in the normal role of increasing intra-abdominal pressure so helping to stabilize the
lumbopelvic region (McIntyre & Broadhurst 1996). The glutei muscles also lose some of their
abduction function resulting in the characteristic gait seen in late pregnancy (Abitbol 1999).
Flexibility
During pregnancy, joint flexibility increases due to hormones such as relaxin causing connective
tissues (e.g. ligaments, tendons, capsular fibres) to lose some of their viscous qualities and become
more elastic (Willow & Carrington 1987). As a result the symphysis pubis widens, which starts
during 10th to 12th week of pregnancy and can be associated with tenderness and pain over the joint
(Borg-Stein & Dugan 2007). The sacroiliac joints and pubic symphysis also exhibit increased
mobility, which starts around the 4th month of pregnancy and continues until approximately the 7th
month, after which only a slight increase occurs (Lee 1999). In women with PGP this mobility is
exaggerated, with 32 to 68% extra movement compared to asymptomatic pregnant controls (Mens et
al. 2009). This decreased ligamentous tension may affect the force closure mechanism of the
sacroiliac joint which is reliant on muscular (the longitudinal, posterior and anterior oblique muscle
slings), ligamentous (sacrotuberous and long dorsal sacroiliac) and fascial (thoracolumbar) integrity
(Pool-Goudzwaard et al. 1998). So the efficiency of load transmission is diminished and the shear
forces within the pelvic joints are increased, potentially resulting in pain. Normally, the pelvic girdle
returns to its pre-pregnant state between the 3rd and 6th months postpartum. Although, recently, it has
been demonstrated that asymmetric laxity of the sacroiliac joints in PGP is a possible predictive
indicator for those who may suffer moderate to severe postpartum pain (Damen et al. 2002a).
The spinal stabilization system as conceptualized by Panjabi (1992a,b) consists of three
subsystems: the passive musculoskeletal system, consisting of the vertebrae, facet joints,
intervertebral discs, spinal ligaments and joint capsules; the active musculoskeletal system,
comprised of the muscles surrounding the spinal column and pelvic region; and the control neural
system, consisting of the various force and motion transducers located within the ligaments, tendons
and muscles combined with the neural control centres. These subsystems are functionally
interdependent upon each other for the overall goal of spinal stability. Dysfunction in any one part of
the system may result in the loss of optimum stability and the possible development of pain and
disability. Pregnancy-related increased ligament laxity may potentially cause joint instability.
Musculoskeletal dysfunction in load-bearing joints may be associated with these hormonally driven
ligamentous changes, along with strain as a result of weight gain, postural alterations and associated
muscle dysfunction. Together these factors are probably the primary cause of PLBP.
The authors would also like to draw your attention to Chapters 3 and 8 of this book for
additional information regarding the clinical biomechanics of the sacroiliac region.
Risk of spontaneous abortion (miscarriage)
Chiropractors must be aware that spontaneous abortion (SAb) is a common complication of early
pregnancy, the frequency of which decreases with increasing gestational age. Eight to 20% of
clinically recognized pregnancies under 20 weeks undergo SAb; 80% occurring within the first 3
months (Kalra et al. 2003, Wang et al. 2003). The loss of unrecognized pregnancies is greater,
occurring in 1326%. After 15 weeks the overall risk is low (approximately 0.6%) for chromosomal
and structurally normal fetuses (Wyatt et al. 2005).
In the majority of SAb the aetiology is unknown (Kalra et al. 2003). Identified risk factors,
however, include previous miscarriages, previous pregnancies, increased maternal age, high body
mass index and lifestyle factors such as imbibing 5 or more units of alcohol per week or 375 mg or
more caffeine a day (El-Metwalli et al. 2001, Metwally et al. 2008, Rasch 2003). Prenatal use of
non-steroidal anti-inflammatories and aspirin have been reported to increase the risk of miscarriage
by 80%; paracetamol use, however, would not appear to be associated with increased risk,
regardless of timing and duration of use (Li et al. 2003). Occupational physical activity and
pregnancy outcome found that women with SAb scored significantly higher work intensity and work
fatigue scores. They also had significantly higher housekeeping working hours per day and larger
family size than the control group (El-Metwalli et al. 2001). The influence of psychological stress on
the risk of SAb is unclear (Nelson et al. 2003).
No adverse effects have been reported in the literature from manipulative/mobilization treatment
during pregnancy (Diakow et al. 1991). It has also been stated that chiropractic treatment during
pregnancy does not result in an increased use of obstetric procedures during labour and, therefore,
should not be a concern in the treatment of pregnancy-related disorders (Phillips & Meyer 1995).
Chiropractic management during pregnancy may actually shorten labour time in primigravid and also
multigravid women and decrease pain in labour (Diakow et al. 1991).
Chiropractic management and spinal manipulative/mobilization therapy may not be an
aetiological factor in SAb, but a temporal relationship may occur while a patient is under care. This
may result in a distressed patient looking to attribute blame. This potential stressful and unpleasant
situation may be prevented by a frank discussion at initial consultation of the risk (or lack of it) of
care during pregnancy and of the risk of SAb, particularly if there is a history with the individual or
within the family.
In addition to those mentioned above, there are numerous recognized risk factors for potential
complications during pregnancy in which clinicians managing a pregnant patient should be fully
versed in order that appropriate clinical judgements can be made.
Risk factors present at the onset of pregnancy that may result in complications included (Holst &
Hilden 1989):
primiparae 30 years
younger than 17 years
multiparae pregnant >8 years after latest delivery
previous toxaemia
previous haemorrhage
previous hydramnios
previous infant <2500 g or >4500 g
previous Caesarean section
previous vacuum or forceps extraction
previous still-born infant
previous infant with physical malformation
previous complications in the placental period
previous primary or secondary infertility
3 abortions
heart disease
lung disease
hypertension
kidney disease
recurrent cystitis
liver disease
endocrine disorders
neurological disorders
psychiatric disorders
haematological disease
height <150 cm
history of genetic disorders
poor housing conditions
drug or other type of abuse
Rhesus-immunized women.

Risk factors occurring during pregnancy included that may result in complications (Holst &
Hilden 1989):

hyperemesis
severe infections
anaemia
toxaemia with two or more of the following signs: high blood pressure (140 mmHg systolic or 90
mmHg diastolic), albuminuria, edemata, weight increase >1 kg per week
haemorrhage requiring hospitalization
hydramnios
uncertain term
gestational age >42 weeks
intrauterine growth retardation
Rhesus immunization recognized during pregnancy
imminent preterm delivery
not attending antenatal service
diabetes recognized during pregnancy.
Informed consent
Prior to care the clinician must obtain informed consent from the patient. Sensitive, clear
communication with any patient is important. However, the pregnant patient is likely to have a
heightened sense of concern about any potential harmful effects of care to both themselves as well as
to the unborn child. It is, therefore, paramount to respect the patients concerns and to explain all
aspects of care and answer any questions honestly and openly prior to intervention.
Monitoring the patient
It is important that the patient is assessed for complications at each clinic visit, and possible
contraindications to the prescribed care. Keep in mind the identified risk factors to pregnancy
described above. The patient should be asked how the pregnancy is progressing and whether they
have noted any changes related to the pregnancy. In addition, specific questions should be asked
throughout the course of the pregnancy to help you monitor for potential problems:

Is the baby growing/moving?


When was your last prenatal visit?
Were there any problems/concerns as a result of this visit?
Is your blood pressure being monitored?
When is your next appointment?
Are you having any cramping, contractions, or episodes of increased (sometimes-painless) tightness
of the abdomen?
Have you noticed any leaking of fluid or bleeding?
Are you having pain in the legs (if there are signs of swelling, inflammation, severe pain or redness,
consider thrombophlebitis).
Do you have any urinary tract infection symptoms; flank pain, dysuria, sudden change in
frequency/urgency, fever?

The blood pressure should also be monitored for signs of pre-eclampsia.


Any question the patient has directly related to the pregnancy should be referred to the obstetrics
provider or general clinician. This should be done immediately in cases where preterm labour or
other complications are suspected.
Manual care considerations
Patient comfort
An important aspect of treatment is patient comfort. A patient who is comfortable will relax, allowing
less forceful manipulation/mobilization to be applied. From the 12th week of pregnancy many patients
may not be comfortable lying prone or may not tolerate standard side-posture techniques.
Consequently supine or sitting techniques can be used or modifications to side posture or prone
techniques can be applied (Bartol 1997, Fligg 1986).
Manipulative/mobilization modifications
Pelvic and lumbar techniques should be limited to low force procedures during which the patient
should not experience abdominal pressure. The thrust can be a single high-velocity, low-amplitude
thrust in the open pack position, or six to eight repetitive mobilizations utilizing a low-velocity and
low-amplitude type of force (Bartol 1997, Fligg 1986).

First trimester
The risk of spontaneous abortion is highest during the first trimester of pregnancy. As a consequence,
clinicians should be cautious and enquire about previous miscarriages or spotting and only apply low
force procedure if at all in the lumbar pelvic region (Fligg 1986).
At 6 weeks the breasts start to enlarge, exerting strain on the thoracic spine. Nausea and
vomiting of morning sickness may also start at this time, and the constant physical stress involved
will also place additional stress on the spine and thoracic cage (Parsons 1994a). Thus, gentle
manipulation/mobilization of the thoracic spine and ribs would be beneficial during this time if
indicated. Gentle stretching techniques for the rhomboid, trapezius, pectoral and intercostal muscles
may also be beneficial.

Second trimester
As the uterus rises out of the pelvis, abdominal enlargement becomes progressively apparent
(Parsons 1994b). At this stage, the posture begins to alter and the musculoskeletal system adapts to
the changing centre of gravity, with increased weight-bearing to the heels (Howe 1993). The
development of an increased lumbar lordosis is compensated for by an increased thoracic kyphosis
(Parsons 1994b). These developments place additional mechanical forces on pain-sensitive
structures. A variety of manipulative/mobilization and soft-tissue techniques can be utilized in helping
the patient adapt to these changes.

Third trimester
As pregnancy nears term, abdominal enlargement becomes rapid. The weight of the enlarging uterus
is borne by the rectus abdominis muscles, the perineum, the muscles of the pelvic floor and the
symphysis pubis.
The size of the abdomen places certain restrictions on the patient positioning, and only gentle
manipulation/mobilization to areas below the level of T5 are desired (Esch & Zachman 1991). The
body drop during the thrust phase should be avoided (Howe 1993). A special bench is not necessary
as long as the patient can be positioned to avoid pressure on the abdomen (Esch & Zachman 1991).
In the last trimester, especially in the last month, when the likelihood of difficulties and
discomforts is greatest, frequency of treatment may need to be increased where indicated (Fligg 1986,
Howe 1993). Maintaining good pelvic function is important during this stage in preparation for
childbirth (Fligg 1986, Tyler 1983).
Side-posture modifications
Flex the hips less than usual to reduce adverse pressure being placed on the abdomen by the flexed
upper thigh. Position the patient further away from the clinician, so as to provide more support for the
abdominal region on the table. If the patient complains of stretching or pressure in the groin, abdomen
or ribs consider whether there is too much rotation, torque or hip flexion (Bartol 1997, Esch &
Zachman 1991, Fligg, 1986). It is advisable to assist your patient on and off the bench and help
support the abdomen when moving the patient into position (Fig. 13.2). If needed, place a pillow or
folded towel between the abdomen and the table to support the weight of the fetus.

Figure 13.2 Support the abdomen when moving the patient into position.
Prone modifications
Certain tables have an abdominal/thoracic section that can be dropped away, and a lumbar/pelvic
section that can be raised to reduce pressure onto the abdomen (Fig. 13.3). In tables with spring-
supported drop pieces, the tension should not offer much resistance (Esch & Zachman 1991). In
addition commercially made pregnancy pillows can be used to allow the patient to lie prone more
comfortably by reducing abdominal pressure and pressure on enlarged and tender breast tissue (Figs
13.4 & 13.5).

Figure 13.3 Bench modification showing abdominal/thoracic section dropped away, and a
lumbar/pelvic section raised to reduce pressure onto the abdomen.
Figure 13.4 Commercially made pregnancy pillow allows a pregnant patient to lay prone more
comfortably by reducing pressure on the breast tissue and abdomen.
Figure 13.5 Pregnant patient lying prone on a commercial pregnancy pillow.

The use of pillows may allow prone positioning on a flat bench. The pillows should be
sufficiently high to take pressure off the abdomen. The knees should be flexed to take stress off the
lower back, and the feet should be elevated with a pillow or roll (Fig. 13.6).
Figure 13.6 Bench modification with pillows to reduce abdominal and breast pressure in a
prone pregnant patient.
Supine modifications
After the first trimester the length of time the patient is supine may need to be limited as pressure can
be exerted on the aorta and superior vena cava, possibly decreasing the fetal circulation or reducing
the maternal cardiac output. The clinician must be vigilant for warning signs such as shortness of
breath, and increased breathing.
When positioning the patient supine, the head and shoulders should be elevated enough to avoid
cardiovascular stress and the knees should be supported in a flexed position. Triangular wedge
pillows are available commercially and work well for these purposes; alternatively normal pillows
can be used (Fig. 13.7).

Figure 13.7 The use of pillows to elevate the neck and upper thoracic region of a pregnant
patient to allow for more comfort in the supine position.

Anterior thoracic adjustments may be beneficial in the thoracic spine in pregnancy, but may need
modification. Breast tenderness may make this technique uncomfortable for the patient. This can be
reduced by the use of a rolled up towel being placed just below the breasts and the patient crossing
their arms over it so reducing pressure directly over the breast tissue (Fig. 13.8). In late pregnancy
because of an increase in size and weight, the patient may be more difficult to elevate and lower than
a non-pregnant patient. To overcome this, the patient can be rolled to the side, allowing the contact
hand to be placed appropriately and then gently rolled back over your contact and a thrust delivered
though the arms.

Figure 13.8 Towel placement to optimize comfort in performing a cross-armed anterior thoracic
adjustment.
When the patient is ready to stand up from a supine position following treatment, she should be
instructed to first turn onto her side. From this position she should lower her feet/legs over the side of
the table and push herself up onto her arms. This avoids the hazard of possible abdominal muscle
strain from a sit-up in late pregnancy, which can complicate labour (Esch & Zachman 1991). The
clinician should be at hand to assist the patient if needed.
Sitting techniques
If the patient is uncomfortable in side posture, supine or prone positioning, sitting techniques can be
used. Sitting manipulative/mobilization can be performed in the cervical, lower thoracic and lumbar
regions. A single, high-velocity short-amplitude thrust can be applied either through the spinous
process for the lumbar spine (Fig. 13.9), transverse process for the thoracic spine (Fig. 13.10), or the
rib angle for the lower ribs. By applying repetitive low-velocity low-amplitude thrusts using the
above contacts, this position can also be used for mobilization.

Figure 13.9 A lumbar sitting adjustment showing a mamillary process contact.


Figure 13.10 A sitting rib adjustment showing an angle of the rib contact.

Caution however is needed when applying these techniques to the thoracic and lumbar spine to
avoid rotation which may cause transverse fascial plane torque creating foetal stress and maternal
discomfort. Sitting cervical techniques can be performed as usual throughout pregnancy as described
in Chapter 11 of this text.
Kneeling techniques
The kneechest table is designed to allow for less restriction of the torso when performing a
posterior to anterior lumbar or thoracic manipulation. This patient position with no compression of
the abdomen is useful for treating pregnant patients who cannot lay prone or in the side posture
(Plaugher & Lopes 1990).
Commercial kneechest tables are available, but they may not be economically viable.
Alternatively, some chiropractic benches can be modified to allow the clinician to make use of
kneeling techniques. For this type of procedure the patient is positioned at the cephalic end of the
bench with a flat pillow or folded blanket on the floor for the patient to kneel upon. The headpiece is
positioned so that the thoracic spine is level with or slightly higher than the lumbar spine. The knees
should be positioned so that the femurs are almost perpendicular to the floor and the hands should rest
on the armrests (Fig. 13.11). The patient should be relaxed and not supporting the chest with the upper
extremities. A number of different lumbar and thoracic spine techniques can be carried out in this
position, dependent on the hand contact position. This position is rarely used for adjusting the
sacroiliac joints with the exception of the sacrum.

Figure 13.11 Bench modification to allow the clinician to make use of kneeling techniques.
Since the torso is unsupported in this position it can move more freely in a posterior to anterior
direction during manipulation. The magnitude of the force needed for most kneeling techniques is,
therefore, less than that required for side-posture and prone manipulation. The clinician also has a
greater mechanical advantage with the patient in this position, so care must be taken to limit the
amount of force used (Plaugher & Lopes 1990).
Preload is applied by contacting the appropriate short lever arm (spinous process, mamillary
process (Fig. 13.12), transverse process (Fig. 13.13), rib angle) and translating the joint involved to
pretension. Care must be taken to translate the involved segment along the line of the facet joint
orientation while minimizing unnecessary extension of the spine. Once preload has been reached a
high-velocity short-amplitude thrust can be applied. At the end of the thrust the hand contact and
pressure are maintained for 12 s, allowing the viscoelastic tissues time to adapt. This is followed by
a gradual release of pressure. The togglerecoil thrust is contraindicated when performing kneeling
manipulations (Howe 1993).
Figure 13.12 A kneeling lumbar adjustment using a bilateral mamillary body contact.
Figure 13.13 A kneeling thoracic adjustment using a reinforced unilateral contact.
Mechanical pelvic blocking
Low force such as pelvic blocking can be used in clinical situations where a less forceful approach is
indicated. Though it must be remembered that lying prone is contraindicated after the first trimester,
due to abdominal compression. Dr DeJarnette developed blocking techniques as part of the diagnostic
and treatment system known as sacro-occipital technique (SOT) (DeJarnette 1984). Pelvic blocks,
however, can also be used based on mechanical principles where the patients body weight is used to
relax soft tissue structures, thereby releasing muscular and fascial influences on the sacroiliac joints
and lumbar motion segments. This approach can theoretically aid in stabilizing sacroiliac joint
separation and help control hypermobility.
Mechanical prone pelvic blocking techniques
Mechanical indicators for prone blocking are based on functional leg length analysis and pelvic
torsion patterns. To help determine leg length the patient can be assessed in the prone position by
comparing the relative levels of the medial malleolli. With a true functional short leg it is usual to
find a high iliac crest with a posterior inferior posterior superior iliac spine (PSIS) and an anterior
inferior sacral base on static palpation on the side of the short leg. This pattern is usually associated
with sacral nutation on sacroiliac motion palpation or prone springing. It is worth noting that
sacroiliac instability may well be made worse by prone blocking and should therefore be avoided in
such cases and supine blocking used instead.
Lay the patient prone, with a pelvic-board under their pelvis. Place the short leg block under the
thigh at the level of the greater trochanter, inserting it sufficiently to support approximately 60% of the
weight of the pelvis. The block should be angled 45 cephalad, with the centre of the block being
under the hip joint. The long leg block is angled 45 caudad at the level of the ASIS, with the centre
of the block being under the spine of the ilium. The blocks are angled to face each other but when in
position can be adjusted if needed for patient comfort (Fig. 13.14). If there is any increase in patient
discomfort, remove the blocks and reassess the patients condition and treatment options.
Figure 13.14 Mechanical prone blocking for a sacroiliac extension restriction on the left.

When in position, the patient should be monitored at all times. The short leg should be
approaching level in comparison with the long leg, or in some cases even longer, and there should be
a reduction in hypertonicity of the spinal musculature and/or a reduction in symptoms. If this is not
found remove the blocks and reassess. In the case of an anatomical short leg, the leg will still
lengthen, but will usually not become equal to the long leg. The duration of blocking will vary from
patient to patient, but usually 410 minutes is sufficient. While on the blocks the clinician can do soft
tissue work to aid muscle relaxation, such as myofascial trigger point therapy and fascial release
techniques. It is worth remembering that too long on the blocks may be more detrimental than a too
shorter time. The blocks should be removed at the same time by pulling them smoothly and slowly
outward in the same direction they are laying.
Mechanical supine pelvic blocking techniques
Supine blocking is often useful in the treatment of sacroiliac joints laxity where the aim is to use the
patients body weight to approximate the affected joint and de-stress the non-contractile supporting
elements and guarding musculature. According to Forrester & Anrig (1998) sacroiliac laxity will
often allow pelvic torque that can create stress on the uterine ligaments and pelvic soft tissues and
therefore the fetus itself. The clinical diagnosis of a sacroiliac laxity should be based upon indicators
from both the case history and physical examination, including the active straight leg raise test
described by Mens et al. (2001), as motion palpation is unreliable. Hochman (1999) also advocates
the use of a standing stress test, whereby the patient stands with both arms extended out in front of
them with their feet about 20 cm apart. The practitioner applies a downward pressure onto both arms
and any relative strength or weakness is noted. The patients then shifts their weight, first onto one leg
and then the other, with the practitioner testing the arm strength in both positions. Arm weakness found
on the side of increased weight bearing may indicate sacroiliac laxity. The validity of this test
however has not been investigated. For those experienced in SOT, this can supplement the arm fossa
test.
Position the patient supine, with a pelvic-board under the pelvis. Place the first block
horizontally, perpendicular to the spine under the functional short leg side, with the top of the patients
iliac crest located in the middle of the block. The second block is placed under the greater trochanter
contralaterally and angled 45 cephalad, with the centre of the block under the acetabulum. The pelvis
should be level from side to side and from inferior to superior, if not the blocks can be positioned
further in or out to achieve this balance (Fig. 13.15). When correct placement is obtained the patient
often feels comfortable with less pain if there is residual discomfort elevate the feet a few inches to
take the stress off the lumbo-sacral junction. The blocking duration will vary based on the individual
however should not take more than a couple of minutes. If discomfort develops, remove the blocks
and reassess the patient.
Figure 13.15 Mechanical supine blocking for a pelvic instability with a right sided functional
short leg

Trochanteric belts can be useful in the management of this condition (see the section on support
belts later in this chapter) and treatment should include exercises to enhance the force closure
mechanism of the sacroiliac joints.
Mechanical drop techniques
Most chiropractic benches come with optional cervical, thoracic, lumbar and pelvic drop-pieces,
which can be used with a number of techniques to reduce the amount of applied force needed. The
drop-piece tension should be set with minimal resistance. The patients body weight is stabilized
over the drop-piece until an adjustive thrust is applied. The thrust imparts motion to the contacted
anatomical structure that remains in motion until the conclusion of the drop completing the
manipulation/mobilization.

Prone pelvic mechanical drop techniques

Sacroiliac prone thrust (extension restriction) (Fig. 13.16)


Position the patient prone so that the anterior superior iliac spines (ASISs). Bilaterally are just
superior to the edge of the pelvic drop-piece, which is then cocked. The clinician takes a fencers
stance on the ipsilateral side of the bench at the level of the pelvis. Contact is made by the hypothenar
eminence of the caudate hand that is in a chiropractic arch, being placed onto the inferior medial
aspect of the patients PSIS. The indifferent hand is placed over the contralateral PSIS. The thrust is a
body-drop combined with a shoulder thrust with the line of drive being posterior to anterior and
inferior to superior.
Figure 13.16 Sacroiliac prone drop technique for an extension restriction with posterior
superior iliac spine contact.

Sacroiliac prone leg thrust (extension restriction) (Fig. 13.17)


Position the patient prone so that the ASISs are just superior to the edge of the pelvic drop-piece,
which is then cocked. The clinician takes a fencers stance on the ipsilateral side of the bench slightly
cephalad to the pelvis. Using the caudal hand the clinician flexes the patients knee to 90 on the
ipsilateral side and asks the patient to hold this position while the clinician now places the caudate
hand under the knee on the medial aspect so cupping it. The lower leg can now be relaxed and
supported by the clinicians arm. The cephalad hand forms a chiropractic arch and is placed on the
ipsilateral PSIS. The leg is then lifted, extending the hip until movement is felt at the pelvis. A
shoulder thrust is then given, (with or without a body-drop), by the cephalic hand in a posterior to
anterior line of drive.
Figure 13.17 Sacroiliac prone drop technique for an extension restriction with posterior
superior iliac spine contact and hip extension.

Sacroiliac prone ischial thrust (flexion restriction) (Fig. 13.18)


Position the patient prone so that the ASISs are just superior to the edge of the pelvic drop-piece,
which is then cocked. The clinician takes a fencers stance on the ipsilateral side of the bench at the
level of the pelvis. The cephalad hand is made in to a chiropractic arch and the hypothenar eminence
is placed on to the patients ipsilateral ischial tuberosity. The caudad hand also forms a chiropractic
arch and is placed over the dorsum of the contact hand to reinforce the contact. The thrust is from a
body-drop combined with a shoulder thrust, with the line of drive inferior to superior and posterior to
anterior.
Figure 13.18 Sacroiliac prone drop technique for a flexion restriction with reinforced ischial
tuberosity contact.

Sacroiliac prone sacral and ASIS thrust (flexion restriction) (Fig. 13.19)
Position the patient prone so that the ASISs are just superior to the edge of the pelvic drop-piece,
which is then cocked. The clinician takes a fencers stance on the ipsilateral side at the level of the
pelvis. The cephalad hand contacts the patients ipsilateral ASIS. The caudad hand forms a
chiropractic arch and the hypothenar eminence contacts the ipsilateral sacral base. The cephalad
contact impulses anterior to posterior, while the caudad contact thrusts posterior to anterior with
enough thrust to release the drop mechanism.
Figure 13.19 Sacroiliac prone drop technique for a flexion restriction with anterior superior
iliac spine contact and sacral base contact.

Sacroiliac prone ischial and PSIS thrust (flexion and/or extension restriction)
(Fig. 13.20)
Position the patient prone so that the ASISs are just superior to the edge of the pelvic drop-piece. The
pelvic and lumbar drop-pieces are then cocked so that they will drop together. The clinician takes a
fencers stance on the side of the extension restriction at the pelvic level. The clinicians caudad hand
is in a chiropractic arch and contacts the ipsilateral PSIS with the hypothenar eminence. The cephalad
hand, also in a chiropractic arch, is positioned so that the hypothenar contacts the contralateral
ischium.
Figure 13.20 Sacroiliac prone drop technique for a reciprocal flexion and extension restriction
with anterior superior iliac spine and ischial tuberosity contact.

Supine pelvic mechanical drop techniques

Sacroiliac supine pubic rami contact (extension restriction) (Fig. 13.21)


Position the patient supine so that the PSISs are just superior to the edge of the pelvic drop-piece. The
pelvic and lumbar drop-pieces are then cocked so that they will drop together. On the side of the
extension restriction the patient slightly flexes the knee so the foot comes to rest on the footpad of the
bench. The clinician takes a fencers stance on the involved side at the level of the pelvis. The
cephalad hand is placed so that the web of the hand contacts the patients pubic rami on the ipsilateral
side with the thumb facing interiorly (the clinician must use their judgement regarding any instability
present of the symphysis pubis when using this contact). The caudad hand stabilizes the lower limb by
contacting the ipsilateral knee. An impulse is given from the cephalad contact from anterior to
posterior and superior to inferior. This thrust must be sufficient to drop the pelvic-drop mechanism.
An impulse from the caudad contact is given simultaneously in an anterior to posterior direction.
Figure 13.21 Sacroiliac supine drop technique for an extension restriction with a pubic rami
contact.

Sacroiliac supine knee high, ASIS thrust (flexion restriction) (Fig. 13.22)
Position the patient supine so that the PSISs are just superior to the edge of the pelvic drop-piece,
which is then cocked. The clinician is positioned in a fencers stance at the level of the pelvis on the
ipsilateral side. The patient flexes the ipsilateral hip to 90 and bends the knee. The cephalad hand
contacts the ipsilateral ASIS, while the caudad hand cups the patients flexed knee. The cephalad
hand thrusts anterior to posterior while the caudad hand stabilizes the knee and leg.
Figure 13.22 Sacroiliac supine drop technique for a flexion restriction with an anterior superior
iliac spine contact.

Points to remember when using the drop mechanism


The correct drop-piece tension should be set to the individual patient. This tension should be strong
enough to support the patients weight, without dropping but light enough so only minimal force is
needed to overcome the resistance. This is achieved by setting the tension so that the drop-piece only
just fails to support the patient weight then increasing the tension by three half turns of the tension
control dial to the right. Pre-tension especially posterior to anterior is not necessary, as this will tend
to release the drop-piece before the impulse is applied. Care must be taken to make the patient fully
aware of what to expect when the drop mechanism collapses, especially the sound that the table
makes.
Pelvic (trochanteric) belts
The use of pelvic belts in the treatment of PPGP and postpartum patients has been reported to be
beneficial (Mens et al. 1996, Penna 1989, Vleeming et al., 1992). Mens et al. (2006) has determined
that a pelvic belt placed high on the pelvis, just caudal to the ASIS (Fig. 13.23) reduces laxity within
the sacroiliac joint more so than a belt positioned at the level of the pubic symphysis in women with
PPGP. It has also been demonstrated that this higher position is more important at reducing laxity than
the tension in the belt (Damen et al. 2002b). This may contribute to a better understanding of the
management of PPGP, as the effect of the belt is thought to enhance the forces closure mechanism
around the joints. The higher position may stimulate the action of the transversus abdominis by
anterior compression on ASIS, which forms part of the anterior oblique sling and the action of the
multifidus by posterior compression on the PSIS which is part of the longitudinal sling. While the low
position at the pubic symphysis may simulate the action of the pelvis floor (Mens et al. 2006).
Figure 13.23 Lateral view showing the position of a trochanteric belt just below the anterior
superior iliac spine.
Summary
This chapter has presented an overview of the physiological and biomechanical changes that may
contribute to the development of low back/pelvic pain in pregnancy, to allow for a better
understanding of the management of pregnant patients. Although manipulative and mobilization
procedures can be used throughout pregnancy most require some modification to allow greater
comfort to the patient and reduce the risk of harm to the mother and unborn child. These modifications
have been highlighted together with the rationale behind the adaptations. It should be emphasized that
mastery of the basic manipulative skills presented in the early chapters of this book must be
accomplished prior to embarking on developing more advanced skills and modifications presented in
this chapter. It is also a professional responsibility of the chiropractor to develop an excellent
working knowledge of the three stages of pregnancy along with the biomechanical and physiological
changes seen and complications that can arise in order to ensure patient safety when considering
therapeutic interventions.
Acknowledgements
The authors would like to thank Louise Sasse, Melanie Clark Nicola Dilly, Julianya Jay and Claire
David for kindly assisting as models in the photographs, and Vincenzo Cascioli for his contribution to
the chapter in the previous edition.

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Chapter 14

Spinal adjusting and clinical management of the


older adult

Brian J. Gleberzon, David Byfield


Chapter contents

Introduction
The ageing population
The older patient and spinal manipulative therapy
Spinal adjusting for older patients: managing the five Is
Intellectual impairment
Neurological impairments
Instability
Immobility
Osteoarthritis (OA)
Osteoporosis (OP)
Non-musculoskeletal (non-MSK) conditions: hypertension, pulmonary disorders,
gastrointestinal disorders and urinary incontinence
Spinal and extremity joint pain
Musculoskeletal pain and physical activity
Spinal adjusting for older patients: suggestions and modifications
The use of non-manipulative chiropractic techniques for older patients
Manual care considerations
Final thoughts and summary
References
Introduction
Imagine you enter your office on the proverbial Monday morning and are told by your receptionist you
have a new patient already waiting for you in your new patient room. You quickly scan her intake
form and notice she is experiencing chronic headaches and neck pain. She is in relatively good health,
with only mild hypertension and some occasional bouts of knee stiffness (something she attributes to
arthritis). You conduct a thorough history and physical assessment, including postural analysis,
palpation and orthopaedic tests. You diagnose her with moderate chronic cervical joint dysfunction
and suggest she would most likely benefit from manual therapies including spinal manipulative
therapy (SMT)/adjustments directed to her neck. Prior to administering the adjustment, however, you
notice her year of birth. It is approximately 85 years ago. The question posed to you now is: Does her
age affect your clinical management decision to the extent that you no longer think cervical SMT
(cSMT) is a viable therapeutic option for her, due to her advanced age? If youre like many
chiropractors especially newer graduates the answer is most likely yes. But is that a fair
characterization of our state of knowledge? Should chronological age be the definitive factor in
deciding whether or not a chiropractor administers cSMT and, more importantly, should older
patients seek out chiropractic care only when all else fails them or when medicine simply no longer
has anything to offer? The authors would argue no. Based on clinical experience, combined with a
burgeoning and impressive body of scientific knowledge, a cogent argument can be made that
chiropractors are well suited to manage many clinical conditions that commonly afflict older persons
and should be the option of first resort rather than the last.
The ageing population
Since the focus of this chapter is on spinal adjusting for the older person, a very cursory review of the
broader issues germane to geriatric chiropractic care will be provided; that said, there exists a
number of high-quality publications that explore these topics in greater depth, and these are cited
throughout this chapter. One article in particular that details Best Practices for older chiropractic
patients is worth reviewing (Hawk et al. 2010).
People the world-over are living much longer due to a complex interaction of economic
development, social progress and advances in medicine. As a result of this global shift in the
population demographics, elderly patients present a clinical challenge for the chiropractor for many
reasons, particularly in terms of manual intervention and overall functional management. It has been
estimated that approximately 25% of the global population will be over the age of 65 by 2050
(Jenkins & Cooper 1993) and in the UK alone 16.8 million people will be over the age of 65 by 2051
and a staggering 4 million will be over 85 by the same date (Joseph Rowntree Foundation 2004). In
addition, the 85+ group, considered to be the fastest growing population subset, will necessitate that
clinicians modify and adapt their clinical management skills to successfully cope with their
healthcare requirements (Gleberzon 2001a, Killinger 2006, Killinger & Dougherty 2011). This
demographic shift has been referred to as the silver tsunami and is occurring in most nations and is
considered a significant public health issue that will require new clinical skills and research
(Killinger & Dougherty 2011). Furthermore, the number of seniors in this group is expected to triple
by the year 2030 (Ory & Cox 1994) and the number over the age of 100 years is predicted to increase
by 11-fold by the year 2050, when, for example, the number of American centenarians is expected to
exceed 800K (Brown 2000). With these predictions in the forecast, it is vital that maintaining function
and quality of life is paramount as the decline in key biological systems with age accounts for much of
the disability seen in the elderly, most notably the cardiovascular and neuromusculoskeletal systems.
Decrease in maximal heart rate, widespread loss of muscular strength and selective atrophy and
decrease in nerve conduction velocities are only a few of the effects of biological ageing and
functional decline these may be preserved with strategies to keep physically active to delay disability
and premature death. The needless burden on national health systems to manage the magnitude of
preventable chronic musculoskeletal disease in the elderly is not sustainable. The massive strain on
dwindling public resources is enormous and clinical strategies need to be implemented to manage this
situation. Therefore, front-line practitioners, such as chiropractors, need to become highly skilled and
aware of the needs of this expanding patient base.
In addition, populations pyramids are becoming rectangularized and feminized due to the
dramatic increase in life expectancy in developed nations seen over the past 50 years and in
developing nations over the past 20 years (Gleberzen 2001c, Turchotte & Schellenberg 2007). This
increase in life expectancy is due to a confluence of factors (Myers 1997) (see Box 14.1) and the
concomitant feminization of population pyramids (due to the fact women outlive men) uniquely
impacts healthcare costs (Borowski & Hugo 1997, Gleberzon 2001c, Myers 1997, Turchotte &
Schellenberg 2007). This impacts healthcare economics since certain diseases are more prevalent
among women, notably breast cancer and osteoporosis (often resulting in hip fracture subsequent to a
fall). In addition, since women in this cohort were less likely to have worked outside their homes,
they have accrued less social security, pension and retirement savings, resulting in a larger economic
burden among women who often live below the poverty line. Over the past decade, the characteristics
of older chiropractic patients have been well described (Christensen et al. 2005, Coulter et al. 1996,
Gleberzon 2011, Hawk et al. 2000, Wolinsky et al. 2007) (Box 14.2) and, although these patients
most commonly seek out care for spinal pain, a recent narrative review of the literature has described
the plethora of other clinical conditions that older patients seek out chiropractors as well (Gleberzon
2011).

Box 14.1 Factors leading to increase in human life expectancy (Gleberzen


2001c)
Precipitous declines in infant mortality rates
Improvements in sanitation and nutrition
Strides made in emergency and crisis care
Advances in successfully managing chronic illnesses (i.e. diabetes, heart disease and cancer)
Ageing of the baby boomers

Box 14.2 Characteristics of older chiropractic patients (Coulter et al. 1996,


Gleberzon 2011, Hawk et al. 2000, Wolinsky et al. 2007)
Female
Caucasians
Married
Retired
Higher education
Higher income
More likely to visit physicians
Alcohol users
Able to drive
More spiritual
The field of geriatrics was an early adopter of the biopsychosocial approach first advocated by
Engel in the 1970s (Engel 1977), and Rowe and Kahn (Rowe & Kahn 1987) used that concept as the
basis to differentiate between what they referred to as successful versus usual ageing. Successful
ageing is characterized by a low probability of disease and disease related disability, high cognitive
and physical functional capacity and an active engagement with life (Rowe & Kahn 1987). In
contrast, usual ageing would be the downward spiral of senescence experienced by sedentary seniors
with poor lifestyles (Rowe & Kahn 1987). This concept of successful ageing resonates well with the
2002 World Health Organizations definition of Active Ageing, which is the process of optimizing
opportunities for health, participating and security in order to enhance quality of life as people
age (Kalache & Gatti 2003) and Killinger has maintained that the most important outcome measure
of all to older patients is the ability to live independently (Killinger 1998).
A number of articles have chronicled the challenges facing a clinician during a clinical
encounter with an older patient along with strategies to overcome these (Bowers 1996, Gleberzon
2001g) (Box 14.3). Many of these hurdles specifically impact spinal adjusting/manipulation for older
patients. Principle among these is that variability between patients increases with age in terms of
condition presentation, time to recovery, improvement quality and range of safety with respect to
tolerating manual therapies (Bowers 1996, Gleberzon 2001g). Comorbidity also presents a challenge
to clinicians since it complicates the ability of a practitioner to both reach a definitive diagnosis and
to judge the successful resolution of therapy. This is further complicated by the fact that many clinical
conditions present either atypically or with no signs or symptoms at all. Another significant challenge
facing clinicians is polypharmacy and the drug-related symptoms they can cause (Bowers 1996). This
problem is so endemic among older patients that the authors recommend that any sign or symptom
mentioned by an older patient ought to be considered an adverse drug reaction (ADR) until it is
excluded from the list of differential diagnoses (Bowers 1996, Gleberzon 2001g, Gleberzon 2002).
Lastly, ageism presents a significant problem when managing older patients since management
decisions are often (erroneously) based solely on the patients chronological age and not them as a
person (Butler 1969, Gleberzon 2002, Palmore 1999, Sarkisian et al. 2002).

Box 14.3 Challenges of managing older patients (Bowers 1996, Gleberzon


2001)
Increase in variability between patients
Comorbidity
Atypical presentation
Polypharmacy
Under-reporting of certain diseases (i.e. incontinence)
Over-estimation of cognitive functions (i.e. dementia)
Ageism
The older patient and spinal manipulative
therapy
Studies that investigate the characteristics of older chiropractic patients consistently report that they
are most commonly provided with SMT (Christensen et al. 2005, Coulter et al. 1996, Gleberzon
2011, Hawk et al. 2000, Wolinsky et al. 2007). However, if SMT is contraindicated (Table 14.1)
chiropractors commonly use other chiropractic manual methods and techniques, the most common of
which are discussed towards the end of this chapter. After successfully managing the patients chief
presenting complaint, many chiropractors recommend chiropractic maintenance care (CMC) (Axen
et al. 2009, Jamieson & Rupert 2001, Leboeuf-Yde & Hestbaek 2008, Rupert 2000, Rupert et al.
2000 ) for their older patients and the vast majority of patients report that they find that schedule of
care to be either beneficial or extremely beneficial for their health (Rupert 2000). Chiropractors have
ascribed a number of theoretical health benefits positive to CMC (Axen et al. 2009, Jamieson &
Rupert 2001, Leboeuf-Yde & Hestbaek 2008, Rupert 2000, Rupert et al. 2000) (Box 14.4) and
studies have demonstrated that older patients under CMC report requiring less medication and less
need for hospitalization; Coulter reported very similar findings, whereby older chiropractic patients
were less likely to be hospitalized or to have used nursing care facilities, more likely to report better
health status and more likely to exercise and to be mobile in their communities (Coulter et al. 1996).

Table 14.1 Contraindications to SMT


Box 14.4 Purported benefits of Chiropractic Maintenance Care (CMC)
(Axen et al. 2009, Descarreaux et al. 2004, Jamieson & Rupert 2001,
Leboeuf-Yde & Hestbaek 2008, Rupert 2000, Rupert et al. 2000, Sarkisian et
al. 2002)
Optimize a patients health
Identify clinical conditions in their infancy
Provide palliative care
Prevent reccurrences or exacerbations
Promote an increase in quality of life

Authors note: Even though it is tempting to ascribe the observed benefits manifested by older
chiropractic patients exclusively to the chiropractic care they receive, it must be stated that these
are only observations and thus do not necessarily indicate a causal relationship. It is unknown if the
health benefits realized by older chiropractic benefits are purely due to the chiropractic care they
received or if it is a reflection of the subgroup of people who attend for chiropractic services in the
first place. That said, a recent study by Descarreaux et al (2004) reported that only a test group of
patients receiving SMT maintenance chiropractic care exhibited continued improvements for their
chronic back pain, as compared to a group of patients who only received acute or crisis care.

Cooperstein and Killinger, in what is widely heralded as one of the most comprehensive
reviews of the literature on chiropractic techniques for older patients, listed the following
management goals to be set for older patients (2001):

Reduced pain, thus reducing reliance on medications and minimizing likelihood of iatrogenic drug
reactions
Increased joint mobility
Improved neurological function
Increased patients quality of life
Promoted wellness
Compressed morbidity
Maintained positive patient attitude
Avoidance of surgery.

To this list, we can add championing healthy lifestyle choices in order to age successfully, live
independently, age actively, and retain activities of daily living (ADLs) and instrumental activities of
daily living (IADLs) as long as possible (Bowers 1996, Gleberzon 2001a, Gleberzon 2001g). On a
final note, rather than simply focusing on an increase in life expectancy, modern geriatricians now
focus on an increase in health expectancy (Ministry of Health, New Zealand). That is, the length of
time a person lives in good health is viewed by many seniors as more important than simply living
longer.
Spinal adjusting for older patients: managing
the five Is
The study of healthy ageing is characterized by focusing on those clinical conditions that
preferentially affect older persons. Referred to as both the geriatric giants (Allen 1999) or the Is
of geriatric care (Lonergan 1996), these clinical conditions are: Intellectual impairments, Instability,
Immobility, Incontinence, Iatrogenic drug reactions and social Isolation. This chapter will now
review the emerging evidence that patients with these clinical conditions and other conditions
common to this age group can be co-managed using spinal manipulative/adjustive interventions.
Intellectual impairment
Depression, dementia and delirium have been labelled as the three Ds of geriatric mental health
challenges (Conn 2001). To date, there is a paucity of studies chronicling the successful management
with these conditions by chiropractors. In perhaps the only case study retrievable in the chiropractic
literature at the time of this writing, Rowell et al. (2006) described a case of a 72-year-old man with
chronic low back pain and depression who responded favourably to flexion-distraction technique,
moist heat packs and interferential current (Rowell et al. 2006).
Although not a direct treatment for delirium, since chiropractic is a non-pharmaceutical
approach to healthcare, and bearing in mind that delirium often is the result of polypharmacy, the
preference towards chiropractic care for conditions such as spinal pain may lower the risk that an
older person will demonstrate a drug-related episode of acute confusion (Gleberzon 2001d, Rowell
et al. 2006.
Williams and his colleagues (2007) conducted a systematic review of those randomized clinical
trials that monitored psychological response to spinal manipulation (PRISM). They reported that
there was some evidence that spinal manipulation improved psychological outcomes compared to
verbal interventions alone.

Authors note: If a practitioner suspects that a patient may be experiencing cognitive declines
(dementia) this requires special considerations in obtaining informed consent and referral for
appropriate co-management. In much the same way, suicidal ideation expressed by a patient
mandates immediate referral to a mental healthcare specialist. Lastly, delirium also mandates
immediate referral (Conn 2001).
Neurological impairments
Elster published a case study of a person with Parkinsons disease (PD) who demonstrated
improvement in symptoms (both subjectively and objectively) following treatment with a Kale
adjustment (toggle-recoil type upper cervical adjustment with a knee chest table) (Elster 2000).
Dougherty and Lawrence reviewed the literature pertaining to the chiropractic management of patients
with multiple sclerosis (Dougherty & Lawrence 2005). In the six publications reviewed (four case
studies and two case series) all patients reportedly experienced symptom relief following the use of
SMT and there were two reported cases of patients demonstrating increases in strength as well
(Dougherty & Lawrence 2005).
Although the prevalence of diabetes has reached almost pandemic proportions, very little has
been written in the chiropractic literature about it (Gleberzon 2001b). An article by Wyatt and
Ferrance reviewed the musculoskeletal effects of diabetes, reminding practitioners that presenting
chief complaints such as muscle cramps, carpal tunnel syndrome, tenosynovitis, adhesive capsulitis,
hydroxyapatite deposition disease, muscle infarction and complex regional pain syndromes may all
be the result of diabetes (39).
Instability
Dizziness is a significant problem among older patients, with 5060% of seniors living at home and
8090% of patients reporting to outpatient clinics reporting episodes of dizziness annually
(Gleberzon 2001f). Dizziness is an umbrella term encompassing lightheadedness, vertigo, tinnitus and
disequilibrium. Causes of dizziness include adverse drug reactions, diabetes, diseases of the visual
or labyrinthine system and dysfunctions of the cervical spinal joints (Gleberzon 2001f).
Kessinger and Boneva described a case study of a 75-year-old woman with a long-standing
history of vertigo, tinnitus and hearing loss who responded favourably to upper cervical adjusting
(Kessinger & Boneva 2000). Bracher et al. (2000) conducted a small practice-based study involving
15 patients who were diagnosed with cervicogenic vertigo. Patients were treated with a combination
of passive and active therapies, including SMT directed to the cervical and thoracic spine. Of the 15
patients, nine reported complete remission of their symptoms and an addition three patients reported
consistent improvement.
In 2009, Hawk et al. reported the results of a larger practice-based clinical trial investigating the
effects of two different schedules of care (symptomatic care or symptomatic care followed by
maintenance care) compared to a schedule of no care, for a group of older patients with dizziness,
balance difficulties and spinal pain using SMT or instrumented adjusting (Hawk et al. 2009).
Improvement in pain scores and balance as assessed by the Berg Balance Scale was demonstrated
among patients in the intervention groups only. There were no treatment-related adverse effects
reported.
Immobility
A number of clinical conditions that target seniors can lead to immobility. From a general
perspective, spinal pain, muscle weakness, dizziness, a plethora of neurological conditions (see
above) and various arthridites often result in a person purposefully limiting their ADLs and becoming
more and more sedentary (Gleberzon 2001f).
Fibromyalgia (FM) is characterized by diffuse musculoskeletal pain of 3 months duration,
distributed bilaterally through the spine and peripheral joints manifesting as morning stiffness (Wolfe
et al. 1990). Often affecting older woman, FM is characterized by tender spots in 11 of 18
characteristic locations on a persons body, non-restorative sleep, and fatigue and exhaustion,
resulting in a state often termed a fibro-fog (Schneider & Brady 2001, Schneider et al. 2006, Wolfe
et al. 1990). In addition, newer diagnostic criteria emphasize that patients suspected of having FM
display allodynia, pronounced tenderness to mild palpation or physical touch (Forbes 2004).
Blunt et al. reported the results of an RCT wherein only FM patients under active care (who
received SMT, soft tissue techniques and patient education) demonstrated improvement in pain levels,
cervical and lumbar ranges of motion and straight leg raise (Blunt et al. 1997). A practice-based
clinical trial involving 15 women with FM monitored their response to 30 chiropractic treatments
consisting of spinal manipulative therapy and ischaemic compression (Hains & Hains 2000). Nine of
the 15 women reported a 50% decline in their pain intensity and a corresponding improvement in
their quality of sleep and fatigue levels.
A more recent observational prospective study involving 20 women with FM receiving
connective tissue manipulation and ultrasound demonstrated improvements in their reported pain
levels, problems of non-restorative sleep and functional activities (Hains & Hains 2000).
Osteoarthritis (OA)
As there is no known cure for OA that exists, clinical management focuses on minimizing symptoms,
preventing progression of the disease, preserving joint function and optimizing a persons ADLs and
QOL (Gleberzon 2001e).
Conventional chiropractic thinking has traditionally posited that, as spinal joints become
progressively hypomobile degenerative changes ensue, resulting in osteoarthritis (Cramer et al.
2004). As a method of cure, chiropractors posit that spinal adjusting gap these hypomobile segments,
breaking up any inherent adhesions, reestablishing normal joint motion and either remit or reverse
degenerative changes (Cramer et al. 2004). A recent study added evidence to this theory when it
reported that white rats, when they had their lumbar vertebrae externally fused, demonstrated
degenerative changes in their facet joints compared to a control (non-fixated) group of rats and that
these degenerative changes were reversible if fixation was removed early (Cramer et al. 2004).
There have been a few case studies published in the peer-reviewed literature documenting the
successful management of patients with OA using manual therapies. Vaux (1998) reported the
successful management of two patients with OA of the hip using muscular relaxation techniques, drop
table techniques and prone pelvic blocking. Law (2001) reported on her success in the management of
a patient with OA of the knee using nutritional support, home-exercises, passive therapies
(interferential current and ultrasound) and active therapies (mobilizations, long-axis distraction and
SMT directed to affected spinal joints) over a 6-month period.
A practice-based study involving 83 patients with OA of the knee reported only those patients
who received manual therapy experienced clinically and statistically significant improvements in
their self-perception of pain, even at 1-year follow-up (Deyle et al. 2000). Another prospective,
randomized clinical trial of 60 patients with OA of the knee compared the effects of Meloxicam (and
NSAID) to manipulation (Tucker et al. 2003). Using both subjective (pain, patient-specific functional
scale) and objective (goniometer and pressure algometer) outcome measures, both groups of patients
demonstrated similar improvements. However, given the favourable safety record of manipulation
compared to pharmaceuticals, the researchers argued that preference should be given to the manual,
non-pharmacological approach (Tucker et al. 2003).
Pollard et al. 2008 published the results of a randomized clinical trial involving older patients
with OA of the knee. At the end of the clinical trial, members of the intervention (manual therapy)
group reported significant decreases in their knee pain and this group of patients felt that the
intervention had helped them, they felt it had decreased their knee symptoms (such as crepitus), had
improved their knee mobility and their ability to perform general activities. There were no adverse
reactions reported during the duration of the study (Pollard et al. 2008). A more recent study reported
that a group of patients (n = 124) with OA of the lumbar spine responded better to a combination of
SMT, flexion-distraction and moist head than a group of similarly afflicted patients (n = 93) who
received moist heat alone (Beyerman et al. 2006).
Osteoporosis (OP)
The appellation of the silent thief is often given to osteoporosis since it typically develops in the
absence of any observable signs or symptoms (Gleberzon 2001e). OP is clinically silent until
fracture, which is the only important manifestation of OP. OP is the cause of 700 000 vertebral
fractures, 300 000 hip fractures and 250 000 distal forearms and other anatomic structures among
Americans, with a lifetime prevalence of 40% (Anderson & Weinstein 1997, Coxam 2004, Gleberzon
& Killinger 2001, Huijbregts 2001, Melton 1997). Looked at another way, 90% of all pelvic, wrist
and forearm fracture is the result of OP and only one-third of individuals who sustain a hip fracture
regain their pre-injury independence and one-third are institutionalized (Anderson & Weinstein 1997,
Coxam 2004, Gleberzon & Killinger 2001, Huijbregts 2001). Osteoporosis management is best
achieved by preventive strategies, including weight-bearing exercise, vitamin D supplementation,
early detection and pharmacotherapy (Gleberzon & Killinger 2001). Modifications to manual therapy
that can be used for patients with OA will be discussed below.
Non-musculoskeletal (non-MSK) conditions: hypertension,
pulmonary disorders, gastrointestinal disorders and urinary
incontinence
Noll et al. (2000) published the clinical outcomes involving the application of osteopathic
manipulation, mobilization and soft tissue therapies, including myofascial release technique, for 58
hospitalized elderly patients. The most significant findings from this clinical trial were that older
patients receiving osteopathic manual care required shorter hospital stays and shorter duration of IV
antibiotics.
Dougherty reported a case series involving seven frail older women, ages 6889 years old, all
of whom had chronic obstructive lung disease (COLD) and were treated using SMT, mobilizations or
instrumented adjusting for spinal pain (Dougherty 2006). On average, the women reported significant
improvements in their pain scores. Only minor adverse effects were reported.
In a recent publication, Bakris et al. (2007) chronicled a group of 50 hypertensive older patient
who received National Upper Cervical Chiropractic Association (NUCCA) adjusting (a type of low
force upper cervical adjustment), and found there were measurable differences in both systolic and
diastolic blood pressure, along with improvement in atlas positioning in the intervention group. There
were no adverse reactions reported. The authors reported that the results obtained by NUCCA
adjustments of the atlas were similar to results obtained by using a two drug combination therapy
(Bakris et al. 2007). More research in this area is warranted.
Redley described the case of a 64-year-old woman who was relieved of her symptoms of
chronic constipation and experienced an enhanced quality of health using side posture lumbar
manipulation (SPLM) (Redley 2001) and, more recently, Hains and Hains (2007a) conducted a
prospective practice-based clinical trial with cross-over involving 62 adults with gastroesophogeal
reflux disorder (GERD), a common problem among the elderly. The group receiving SMT and
ischaemic compression reported the most favourable results with respect to their GERD symptoms,
and these improvements were maintained at 6-month follow-up (Hains & Hains 2007a).
Hains et al. also conducted a prospective randomized clinical trial involving 33 patients with
urinary incontinence (UI), ranging in ages from 33 to 62 years (Hains & Hains 2007b). Patients in the
treatment group reported statistically significant outcomes with respect to their symptoms after 15
treatments and these improvements were maintained as long as 6 months after the clinical trial (Hains
& Hains 2007b).
Spinal and extremity joint pain
Pain has been called the fifth vital sign in old age and spinal pain seems to plague people up until
the time of death (Weiner 2002). Pain in the elderly has also been associated with poorer self-rated
health and higher morbidity and mortality (Hartvigsen 2006, Weiner 2002). Back pain and neck pain
are common, intermittent symptoms in the elderly, widely underestimated and associated with general
poor physical health in old age (Edmond & Felson 2000, Hartvigsen & Christensen 2008, Hartvigsen
et al. 2004). The peak prevalence of low back pain occurs in the fifth decade of life, and estimates
place the prevalence of back pain among the elderly between 13% and 49% (Bressler 1999). A
recent Danish study established that 26% of those aged 70102 reported back pain and 22% reported
neck pain (Hartvigsen et al. 2003a,b). It would appear that neck and back pain continue to be common
and bothersome complaints even into extreme old age suggesting that primary prevention is an
illusionary goal and concentrate more on secondary prevention including pain behaviour, fears and
chronicity (i.e. biopsychosocial principles) (Hartvigsen & Christensen 2008). Nevertheless, neck
pain and back pain of longer duration were associated with significantly lower physical performance
(Hartvigsen et al. 2006). More significant is the fact that strenuous physical activity for at least one
session a week (i.e. heavy gardening, long walks (>1 h), bike rides (>1 h), dancing), appeared to
provide a protective effect for developing low back pain in seniors and is consistent with the health
benefits of physical activity with age. This has substantial social implications in terms of quality of
life and independence as those patients with poor initial physical function experienced the strongest
protective effect of strenuous physical activity (Hartvigsen & Christensen 2007). This is consistent
with the available evidence that indicates exercise therapy is a widely used and justified intervention
in chronic non-specific low back pain showing greater improvements in pain and function when
combined with other conservative treatments such as spinal manipulation and medication (Hayden et
al. 2005). It is simply insufficient to recommend to elderly patients that they should go and exercise
and get physically active without providing guidance and adequate supervision. Regardless of the
age, exercise programmes or physical activity recommendations should be tailored specifically to the
individual considering overall health, starting point, specified objectives and resource availability.
Practitioners need to consider indicators for exercise, type, dose, frequency, potential side-effects,
alternative protocols and interaction with other physical activity when prescribing programmes for
the elderly as well as issues around motivation and support. In addition, physical activity
programmes should be comprehensive and include the basic types of exercises to cover strength,
endurance, flexibility and balance training tailored to the individuals activities of daily living and
specified requirements (Byfield 2001, Gleberzon et al. 2007).
In addition, pain of the peripheral joints is very common among older persons, and the incidence
increases as they age, even among centenarians (Hartvigsen 2008). The benefits of SMT for spinal
pain are well documented and the author refers the reader elsewhere in this textbook for a more
comprehensive review of that literature, as well as the comprehensive review by Bronfort et al. who
concluded moderate quality evidence that spinal manipulation/mobilization is an effective
treatment option for subacute and chronic LBP in older adults (2010, p. 17).
A non-surgical manual approach was used by Murphy et al. in a study involving older patients
with lumbar spinal stenosis (LSS) (2006). Using a prospective practice-based design, 57 consecutive
pains with LSS were treated using distraction manipulation. There was improvement in disability and
pain. No adverse effects to treatment were noted during the duration of this study (Murphy et al.
2006).
Another randomized clinical trial compared two types of SMT to minimal conservative care for
older adults 55 years and older with low back pain was conducted by Hondras et al. (2009). In this
study involving 240 participants (average age 63 years) sub-acute or chronic low back pain sufferers
received either HVLA side-posture Diversified-style spinal manipulation or Cox-Flexion distraction
technique. Patient responses from both intervention groups was compared to a group of patients who
received minimal conservative care (control group). At the end of the treatment sessions, the study
team reported that patients receiving both forms of spinal manipulation experienced improvements in
their functional status compared to the control group, although there was no statistical difference
measured between the intervention groups. Because both forms of SMT resulted in clinical
improvements, the authors concluded that patient preference as well as clinical experience should
drive how clinicians and patients determine which form of spinal manipulation to use for older
patients with back pain. No adverse reactions were reporting during this study (Hondras et al. 2009).
Musculoskeletal pain and physical activity
If the chiropractic profession believes itself to be part and parcel of healthcare, then the profession,
ipso facto, are concerned with health. Without question, the single most important contributor to
achieving and maintaining optimal health is physical activity or exercise. The evidence pertaining to
physical activity and its relationship to health is both strong and unequivocal. The benefits of exercise
are legion and include, for example, improved general health, functional capacity, reduced intraocular
pressure, improvements in cognitive brain function and memory, and extending longevity (Blair &
Morris 2009, Gale et al. 2009, Vainionp et al. 2009, van Praag, 2009). The data in support of
exercise benefits are not weak, equivocal or contentious; rather, supportive evidence is robust and
irrefutable and these benefits are experienced in older and younger person alike. A wealth of studies
now show the effect extends to those already stricken with a variety of illnesses including chronic
obstructive pulmonary disease, rheumatoid arthritis, multiple sclerosis, hypertension, heart failure,
diabetes, Parkinsons and the age-related illnesses and the improvements that can be achieved by
regular activity (Dibble et al., 2009, Lin et al. 2009, Liu & Latham 2009, Woods et al. 2009).
The barriers to increasing an individuals activity level and hence enjoying the health gains are
both physical and psychological. The physical barriers have a great deal to do with musculoskeletal
pain (MSP) and dysfunction, and the psychological barriers are mostly a result of irrational thoughts
or assumptions leading to negative feelings, catastrophizing, fear-avoidance and de-motivation.
Managing MSP is an enormous challenge for all professions and is thought to be the most common
source of serious long-term pain and physical disability. It is a well-documented fact that the most
widespread cause of persistent pain and functional compromise in the elderly is pain of
musculoskeletal origin and older patients with long-lasting pain are four times more likely to suffer
from anxiety and depression and report poor health status, which will impact on independence and
quality of living (Weiner 2002). Individuals with musculoskeletal pain concerns are regularly
ignored, their complaints often misunderstood by healthcare providers, and, accordingly, they do not
receive timely or effective treatment (Gleberzon 2002).
Even though rehabilitation is not the focus of this chapter, it would be appropriate at this point to
emphasize the importance of the functional approach to pain management of the elderly (Byfield
2001, Gleberzon et al. 2007). Within this model, manual care and other clinical strategies should be
viewed as a multi-dimensional regime to maximize preservation of structural bone mass and, on a
larger scale, to maximize both social and functional independence. Regardless of the risks associated
with ageing and osteoporosis, the benefits of exercise, especially regular and consistent exercise to
all body systems, appear to be greater than any deleterious effects (Byfield 2001). The overriding
consideration for treating spinal problems among the elderly is preventing functional decline and
activity avoidance. Fears of recurrent injury and persistent pain may reinforce an already sedentary
lifestyle, thus perpetuating both functional and metabolic decline. Furthermore, patients with more
serious cardiovascular conditions such as arteriosclerosis and hypertension will, as a consequence,
restrict their activities. It has been shown that those who remain functional and active have the best
opportunity for more productive living in their later years (Sarkisian et al. 2000). It is a well-known
fact that physical inactivity is one of the biggest public health problems of the 21st century. There is
overwhelming evidence that regular physical activity provides significant and wide-ranging health
benefits, including reduced risk of chronic disease such as heart disease, type 2 diabetes and some
cancers, and enhanced function and preservation of function with age (Blair 2009). Despite these data
large segments of the population remain insufficiently active resulting in a very high proportion of the
population at risk of developing chronic disease during their lifetime (Haskell et al. 2009). This vast
evidence base also indicates that sustained activity slows cognitive decline providing benefits for a
healthy brain and the positive impact on the rest of the body are well documented (Blair 2009, Dwyer
et al. 2009, Martin et al. 2009, Ruiz et al. 2008, Sui et al. 2007). There are several important health
issues facing society, such as healthy eating and smoking prevention, but the evidence is very clear
that low cardiorespiratory fitness (CRF) accounts for about 16% of all deaths in both men and women
and this is substantially more than any other risk factors apart from hypertension in men (Blair 2009).
Researchers have established that both physical activity and CRF are associated with a lower risk of
developing hypertension, which provides a basis for health professionals to emphasize the
importance of engaging in physical activity to improve fitness to prevent hypertension in men (Chase
et al. 2009). CRF has been reported to be an important independent predictor of death in older adults,
which adds to the existing evidence that promoting physical activity in older adults provides
substantial health benefits (Sui et al. 2007). CRF in both men and women declines in a non-linear rate
that accelerates after 45 years of age. Therefore, maintaining a low body mass index (BMI), being
physically active and not smoking is associated with higher CRF across the adult life span (Jackson et
al. 2009). A recent study investigated 23 657 men aged 3079 and demonstrated that men with a
normal waist girth, who were physically fit and not smoking had a 59% lower risk of events
associated with coronary heart disease, a 77% lower risk of cardiovascular disease and a 69% lower
risk of all-cause mortality in men (Lee et al. 2009).
It is becoming clear that more attention needs to be given to physical activity in both clinical and
public health settings for all age groups considering the impact on health and quality of life,
particularly the older age groups (Blair 2009) and fitness through physical activity and exercise is
critically important for the health and wellbeing of people of all ages (Gatterman & Kirk 2011). As a
result of this advice, it is recommended that clinicians begin to take a physical activity history and
put physical activity on the agenda of all patients of all ages with a clear message that the impact of
low activity will be highly detrimental to overall health and wellbeing (Blair 2009). Regular physical
activity of 150 min per week of moderate intensity physical exercise, as recommended by the
American College of Sports Medicine (30 min of moderate exercise per day), reduces the risk of
many chronic diseases, preserves health and function (both physical and mental) into old age and
extends longevity (Blair & Morris 2009). People who engage in physical activity are simply at less
risk than those who choose a sedentary lifestyle, irrespective of their age. Muscular strength which
constitutes another important aspect of overall fitness has been shown to be inversely and
independently associated with death from all causes and cancer in men (Ruiz et al. 2008). All health
professionals should develop the knowledge and skills to engage in this important public health issue.
Although there is still no evidence that exercise prevents falls and fractures in the elderly,
epidemiological studies consistently demonstrate that both past and current physical activity does
protect against hip fracture, reducing the risk by up to 50% (Kannus 1999). Issues of endurance,
strength, flexibility, balance, coordination and posture would be similar, but tailored to normal
activities of daily living. It has been reported that there is a progressive degenerative loss of
mechano-afferent systems, which may significantly impair postural and kinaesthetic sensations
leading to imbalance and an increased likelihood of falls (Bergmann & Larson 1996). Therefore,
some consideration of the influence of the cervical articular mechanoreceptors should be included in
designing a rehabilitation programme, but emphasis should also be placed on the potential role and
influence of manipulative care on these systems. We would like to direct the readership to the work
by Don Murphy on cervical spine rehabilitation and functional restoration of all components systems
(Murphy 2000).
Spinal adjusting for older patients: suggestions
and modifications
The most comprehensive contribution to date has been compiled by Cooperstein and Killinger
(2001), in a textbook dedicated entirely to the chiropractic management of the geriatric. We
recommend this text to all those currently managing the geriatric patient as the editor has been very
comprehensive in collating a number of relevant topics. Cooperstein and Killinger (2001)
specifically introduce their work by saying, we must make a full range of chiropractic care
available, albeit cautiously, to the ageing population. The elderly patient is most deserving of, and
perhaps most in need of, alternatives to the traditional pharmaceutical and surgical options
offered through allopathic providers. In a more recent publication, (Killinger & Doughterty 2011)
review the public health implications with respect to ageing and the value of chiropractic care.
Many practitioners may purposefully avoid the use of SMT for their older patients for fear of
injuring them. However, a review of the literature suggests that these concerns may be misplaced. In
the seminal studies characterizing the injuries sustained by patients under care, Senstead et al. (1996)
reported the incidence of injuries was considerably lower among older patients compared to younger
patients (49% compared to 60%). Cooperstein and Killinger posited that older patients may not suffer
more adverse reactions to SMT compared to younger patients and may even suffer fewer
(Cooperstein & Killinger 2001). They attribute this to (i) a number of patient-related variables
(greater joint stiffness among older patients, for example), (ii) doctor-related variables (reliance on
low force techniques and more prudence overall) or a combination of the two (Cooperstein &
Killinger 2001).
To further enhance the margin of safety for older patients receiving SMT, Cooperstein and
Killinger put forward the issue of risk may be more one of pressure rather than of force (Cooperstein
& Killinger 2001). Specifically, these authors argue that practitioners may be able to apply the same
level of force to a spinal segment so long as they direct such force over a larger surface area, thus
decreasing the amount of pressure overall. Although this may result in a concomitant decrease in
segmental specificity, Cooperstein and Killinger assert that the 40N of force generated by
instrumented adjusting directed to a specific target (such as transverse or spinous process) may be
more threatening to a patient than the 120N of force generated by manual HVLA thrusts spread over a
broad area. Lastly, they write that leverage must also be taken into account, especially in the
thoracolumbar region during side-posture lumbopelvic manipulation (SPLM), since excessive
pretension applied to this region of the spine during the premanipulative set-up may result in sprain or
even fracture of costorovertebral joints (Cooperstein & Killinger 2001).
If a practitioner is confronted with a patient with mid back pain who is severely osteoporotic,
but could benefit from SMT, there are several strategies available to him or her. For example, rather
than attempt to manipulate the patient in either the supine or prone position, during which a fracture
could occur due to the compressive forces generated through the patients body, the clinician can
choose to position the patient in either a side-lying or seated position (Gleberzon & Ross 2008). In
that manner, the clinician could still provide a HVLA thrust on the clinical target with a greatly
reduced fear of causing harm.
Moreover, the use of the terms mobilization and manipulation will become very important
clinically, particularly when describing manual care of the elderly, as there are significant differences
with respect to the preload (prestress) and peak forces applied, speed of thrust, amplitude and
leverage, and proposed effects on joint function. Research has confirmed that though chiropractors
demonstrate similar manipulative thrust speed times, the magnitude of the recorded forces (both
preload and peak force measurements) differs considerably for all regions of the spine and pelvis
(Herzog et al. 1993). For the geriatric population, it may be safer to achieve maximum preload (joint
tension) to fully appreciate and assess the amount of resistance likely to be encountered (Cooperstein
& Killinger 2001). This may have significant relevance particularly when assessing age-related
degenerative joints that are inherently stiffer and exhibit a harder end-feel characteristic than in
younger age groups (Bergmann & Peterson 2002).
Whatever the technique or definition used, the clinical objectives for this age group should
remain essentially the same as with other chiropractic patients. This should primarily be: (1) pain
control and (2) the restoration of joint function. The key focus of care of the elderly should be to
assist in maintaining independence and functional status and sustaining the ability to carry out
activities of daily living.
There are a number of contraindications to spinal manipulative therapy that must be considered
Lastly, with respect to regional consideration, Cooperstein and Killinger suggest that
practitioners, when confronted with a patient presenting with neck, shoulder or scapula pain consider
the interconnectedness of these regions and examine and direct treatment to all of them, even if a
patient only expresses pain in only one (Cooperstein & Killinger 2001).
The use of non-manipulative chiropractic
techniques for older patients
For any number of reasons chiropractors often use non-manipulative (HVLA) forms of spinal
adjusting for the management of older patients. One of the most commonly used non-manipulative
procedures for older patients is instrumented adjusting using a hand-held, manually manipulatable
device capable of providing a HVLA thrust (Cooperstein & Gleberzon 2004a). Percussive styluses
such as the Activator provide several benefits, including: variable force application; highly
accelerated thrust (which some advocates theorize obviates the need to overpower the patients
muscle tension); ability to increase segmental specificity; physical ease for the doctor and ability to
overcome anthropomorphic differences between a larger patient and diminutive doctor. There are a
number of instrumented upper cervical techniques as well, chief among them Atlas Orthogonal
technique (Cooperstein & Gleberzon 2004f).
Another non-manipulative procedure used by chiropractors for their older patients is the use of
padded wedges or block (Cooperstein & Gleberzon 2004d). Padded wedges or blocks provide many
advantages, including: use of gravity to enhance the procedure (which may be especially
advantageous if a heavy patient is osteoporotic); enhancement of patient stability; provision of an
alternative if patient is fearful of manipulation or has absolute or relative contraindication to HVLA
thrusting procedures; ease of use by doctor and, similar to instrumented-assisted adjusting, the
avoidance of injury to the practitioner if confronted with a larger patient.
The use of specialized tables for care planning exists both inside and outside of the chiropractic
profession. Commonly used specialized tables include tables that provide long axis distractions that
are either manual or mechanized (i.e. Leander table or Cox-Flexion distraction technique)
(Cooperstein & Gleberzon 2004c). A new generation of specialized distraction tables uses computer
programs to enhance their procedures. Other specialized tables incorporate a drop-piece to
theoretically enhance patient safety; this is most often associated with Thompson Terminal Point
Technique (Cooperstein & Gleberzon 2004e).

Authors note: Many practitioners may use the instrumentation, padded wedges or specialized
tables as a substitute to SMT or they follow the protocols of the Technique System associated with
these modalities (Activator Methods Chiropractic, Sacro-Occipital and Thompson Terminal Point
Technique, respectively).

There are a plethora of low-force techniques that can be used for older patients. Low-force
techniques include BEST, Toftness, Logan Basic, Network Spinal Analysis and a large number of
upper cervical techniques. That said, to the best of this authors collective knowledge, only BEST has
published a study that specifically included older patients. The reader is referred to respective
chapters in Technique Systems in Chiropractic by Cooperstein and Gleberzon for a more
comprehensive description of each of these techniques (Cooperstein & Gleberzon 2004af).
Manual care considerations
Chiropractic clinical considerations with respect to the geriatric patient should include:

1. adequate clinical assessment


2. objective data regarding bone mineral density and integrity
3. risk management (risk v benefit)
4. review any precautions red flags and/or yellow flags
5. establish five diagnostic criteria for spinal (joint) dysfunction and conditions for manipulative
intervention (i.e. PARTS (Bergmann and Larson, 1996; Kannus, 1999)). Three of the following
five criteria are necessary in order to determine a primary region of joint dysfunction:
P pain/tenderness periarticular soft tissues (two postures)
A asymmetry osseous or soft tissue
R joint range of motion abnormality loss of passive end range play and neutral joint play
assessed in two different postures (i.e. sitting and prone)
T tissue tone, texture, temperature abnormality
S special tests (orthopaedic, neurological, imaging)
6. manual care modifications and options.

There are a number of technique modifications that may enhance manipulative skill performance
and overall spinal manipulative interventions in the geriatric population (Bergmann & Larson 1996,
Byfield 1996, Bartol 1997, Cooperstein & Killinger 2001). This is certainly not an exhaustive or
conclusive list but provides practical clinical recommendations to follow when dealing with the
elderly patient including, for example:

1. use of broader hand contacts, such as the hypothenar eminence, thenar eminence and forearm
(flexor region) over a large area of soft tissue to disperse manual forces
2. appropriate case-specific patient positioning (sitting, supine, prone) to decrease unnecessary
leverage encountered in side posture
3. varied preload (joint prestress/tension) to suit individual patient needs
4. multiple lighter (less force) thrusts or oscillations (mobilizations)
5. sustained slowly applied pressure rather than rapid thrust techniques
6. use of specific active/passive motion-assisted procedures (long lever) with specific contacts
7. use of accessory equipment.

There are many forms of manual therapy at the practitioners disposal when considering the care
of the elderly. Various techniques and procedures may be selected from the following as defined
above to achieve the desired therapeutic result including:

1. joint specific manipulation (adjustment)


2. regional/multisegmental joint mobilization
3. flexion distraction and traction methods
4. mechanical instrument assistance (handheld percussion (activator), drop-piece mechanism tables,
pelvic blocks, lumbar cushion rolls, pillows)
5. manual soft tissue techniques (muscle energy techniques, active release, strain/counterstrain, cross
friction, Graston technique) functional therapy
6. specific soft tissue massage (ischaemic compression, general massage, trigger point therapy)
7. assisted exercise protocols (post-isometric relaxation, post facilitation stretch) functional therapy
8. somotosensory exercises (cervical and lumbopelvic)
9. active exercise therapy core stability, general exercise, posture, strengthening, general aerobic,
performance based).

Moreover, there are a number of key psychomotor skill determinants for the practitioner to
consider when introducing modifications of diversified skills. These factors may influence the skill,
delivery and performance of spinal manipulative therapy when managing the elderly patient and
include:

1. postural control and balance


2. weight distribution and coordination
3. tissue tension appreciation (preload force)
4. clinical rationale
5. clinical model (neuro-biomechanical) principles
6. patient need and expectations
7. specific technique choice
8. evidence available.

The authors place considerable importance on the preload or joint tension appreciation (taking
up the slack) particularly with regards to the elderly patient, as this patient group tends to be
somewhat less flexible and stiffer overall. This places additional importance on recognizing changes
in end-play/capsular integrity. In addition, this also affirms the importance of specific psychomotor
skills this older age group, including:

depth of thrust/mobilization (amplitude)


number of repetitive oscillations
Figure 14.1
Figure 14.2
Figure 14.3
Figure 14.4
Figure 14.5
Figure 14.6
Figure 14.7

Figure 14.8

Figure 14.9
Figure 14.10
Figure 14.11
Figure 14.12

Figure 14.13
Figure 14.14

Figure 14.15

Figure 14.16
Figure 14.17

Figure 14.18
Figure 14.19
Figure 14.20

Figure 14.21
Figure 14.22
Figure 14.23
Figure 14.24
Figure 14.25
Figure 14.26

Figure 14.27

Figure 14.28
Figure 14.29

Figure 14.30
Figure 14.31
Figure 14.32

Figure 14.33
Figure 14.34

amount of force applied or necessary depending on the clinical implications


speed of thrust/mobilization force.

All procedures must at all times be performed within the patients tolerance and consideration of
any underlying conditions should drive the decision to implement manual care in light of the scope of
chiropractic practice. The following series of illustrations represent the authors preferred
manipulative skills and procedures for the various regions of the spine, pelvis and major extremity
joints (hip and shoulder) of the elderly patient. This is by no means a complete list, but it provides the
reader with a guide to the therapeutic approach to this expanding patient population. Refer back to the
relevant chapters for additional instruction on specific manual skills for various areas of the spine
and pelvis.
Final thoughts and summary
This chapter has presented an overview of manual/adjustive care of the elderly with particular
emphasis on the osteoporotic patient. This clinical scenario presents the chiropractic profession with
a new challenge to develop a set of unique manipulative skills to deal with the needs of this
expanding and ageing cohort. Chiropractors are well trained in the management of
neuromusculoskeletal disorders and, therefore, should be considered an essential part of the geriatric
management team (Killinger 1998).
There is absolutely no doubt that successful ageing and quality of life for the elderly is closely
linked with a routine of regular physical activity to prevent functional decline. There is an abundance
of evidence supporting physical activity in this age group and the importance of CRF for better health
and wellbeing. Therefore, it is up to all clinicians to promote and encourage patients of all ages to
maintain and sustain levels of activity to avoid the detrimental health effects of a sedentary lifestyle.
As a result, clinical management of the older age group requires an understanding of the common
degenerative disease processes (heart disease, osteoporosis, sedentary lifestyle, nutritional issues)
and other important psychosocial needs associated with the aging process and impact on quality of
life. Clinicians will continue to provide a conservative approach to common musculoskeletal pain
syndromes and functional disability seen in this age group, but they will need to assume a critical role
in managing and advising on levels of physical activity to help contain the functional deterioration
that accompanies increasing age. With this in mind, it is our task to incorporate new knowledge,
master innovative clinical skills, integrate physical activity history and assume the responsibility for
dealing with the healthcare needs of this expanding age group. As a profession, our role will be to
meet this challenge and engage fully in this important public health concern.
It is hoped that further discussion and presentation of a variety of manual skills will be reviewed
at a later date. The authors encourage the reader to incorporate a number of principles discussed in
other chapters pertaining to manual intervention and joint specificity, joint cavitation,
manipulation/mobilization and functional stability.
Evidence-based medicine (Sackett 1999) care has not been kind to the elderly, since it often
excludes older patients from clinical trials by design (Cooperstein & Killinger 2001). Not only that,
but experts such as Goodwin have observed that the most important resources required in caring
for the old sufficient time and empathy are not included in the critical pathways of managed
care (1999, p. 1285). In response, conventional healthcare has moved towards patient-centred
healthcare, which equally considers research evidence, clinical expertise and patient preferences
(Haynes et al. 2002, Triano 2008), outcomes that are contextually important to patients (Mootz 1995)
and is measured by both quantitative and qualitative outcome measures (Bolton 2001) that places the
patients best interest ahead of the practitioners pecuniary interests.
Let us now return to the hypothetical patient introduced at the beginning of this chapter. She was
85 years old and was experiencing recurrent headaches that you diagnosed with joint
dysfunction/subluxations of the cervical spine. In all likelihood, your knee-jerk reaction prior to
reading this chapter was to avoid cSMT in favour of other forms of therapy. While that decision is
still valid and defensible, hopefully the reader will now no longer automatically cross cSMT off
their mental pull-down option list of therapeutic interventions for this patient. Not only that, hopefully
the next time an older patient presents with any clinical conditions that commonly afflicts them, the
reader will consider spinal adjusting a viable treatment option, along with appropriate referral to
other healthcare professionals, as may be required.

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Appendix I

Summary of cardinal rules

David Byfield
Chapter contents

Mental tasks
Contact tasks
Positioning skills
Thrust skills
General considerations and fitness
Mental tasks
1. Concentrate while performing each individual task.
2. Visualize and mentally rehearse all movements and skills.
3. Visualize anatomical landmarks, local joint biomechanics (transition point), tissue (biomaterial)
properties and response (transition point).
4. Always think BALANCE, CONTROL and SAFETY.
5. Frustration and lack of confidence are normal student anxieties encountered when learning complex
psychomotor skills. These feelings are partially overcome with understanding, appropriate
feedback, constructive assistance by the professional teaching staff and loads of focused practice
sessions.
6. Accept the fact that learning to perform competent manipulative skills and procedures takes
commitment and professional dedication. This equates to hours of practice over a period of several
years to achieve a competent level of psychomotor skill.
7. Learn to accept clinical uncertainty as a professional challenge and part of being a health care
professional.
Contact tasks
1. A light, yet firm hand contact is mandatory.
2. The interface between the doctors hand and the patient should never be painful and distressing.
3. Apply as little force and expend as little energy as possible at all times.
4. Avoid developing excess tension in the hand, arm, or shoulder regions while performing
manipulative procedures to ensure patient comfort and avoid overuse injuries.
5. Avoid heavy-handedness and rough treatment of fellow students and patients and encourage respect
and a caring attitude.
6. Hand control, dexterity and flexibility are vital to attain proficiency at all levels of skills training.
7. The hands are the tools of the trade and should be groomed and cared for accordingly.
8. Anatomical specificity is questionable when learning manipulative skills and we should be
thinking about regional contacts (plus or minus one segment).
Positioning skills
1. Movements of both the patient and the practitioner during each step-by-step procedure should
always be controlled, slow, deliberate, methodical and minimal.
2. Postural control and weight distribution of the practitioner are fundamental considerations.
3. The ski stance and fencer stance are basic dynamic postures that are fundamental to all aspects of
learning diagnostic palpatory and manipulative skills.
4. The 45 pivot shift into a fencer stance including weight distribution is essential and prerequisite
psychomotor skills.
5. Never exaggerate patient movement; all movements are performed within a very small range of
patient movement to develop confidence and trust.
6. Patient preparation and comfort are extremely important considerations for control and
effectiveness.
7. Most manipulative procedures operate at 45 or 90 to the patient and table. This may vary under
specified circumstances.
8. Stand close to and lean on the chiropractic table and patient for added weight support.
9. Avoid any excessive postural torsion or strain on both yourself and the patient.
10. The patient should rarely feel any tension or compression over the contact point or through the
long levers until just prior to and during the application of the joint preload and/or mock, mini,
or maxi thrusts.
11. Patient confidence and compliance are established through considerate handling and careful
attention to detail.
12. Long levers function to isolate and control segmental (regional) specificity and constitute a major
aspect of manipulative skill learning.
Thrust skills
1. Each individual step of each manipulative procedure has equal importance and ranking, including
the preload and manipulative thrust or mobilization forces.
2. The dynamic manipulative thrust is the last applied skill in a chain of several complex procedures.
3. Mobilization skills are equally important to learn and appreciate from a clinical perspective.
4. Do not be preoccupied with the thrust; it is an important skill, but only one in a chain of other
movements and skills that prepare the clinician for an efficient and controlled thrust.
5. During thrust development and practice, THINK clear, short, crisp, explosive, lightning, impulse.
6. Appreciating and feeling tissue tension and the point of pretension and joint preload are
mandatory before attempting to apply a dynamic thrust in a clinical setting.
7. Do not skip steps to apply a thrust prematurely; make sure that all steps are sequential, purposeful
and mastered.
8. Assessmentmobilizationmanipulative/adjustive continuum principles underpin clinical
management.
General considerations and fitness
1. Practise with a purpose by setting realistic goals.
2. Bad habits do occur, but a review of the prescribed sequence should help to identify and correct
the faulty movement behaviour.
3. Always practise and engage in a variety of different skills during a practice session to broaden the
overall skills and avoid boredom.
4. Good physical fitness, including endurance, flexibility and overall strength, will complement and
enhance manipulative skills learning and are beneficial for your overall health and wellbeing.
5. Engage in a variety of different physical activities to maximize neuromuscular development
including balance and coordination.
6. Identify your weaknesses and devote the necessary practice and review them.
7. Constructive feedback from a practice partner should be actively encouraged.
8. Review previously learned skills regularly to maintain sharpness and variety.
9. Maintaining basic spinal anatomical and biomechanical knowledge will enhance psychomotor skill
learning, understanding and retention for clinical purposes.
10. The patients needs are always of paramount importance. Practise! Practise! Practise!
Appendix II

Recommended sequence of manipulative skills and


other considerations

David Byfield
Index

Note: Page numbers followed by b indicate boxes, f indicate figures and t indicate tables.
A
abdominal brace technique, 102
abdominal muscles, 5051, 5960
abortion, risk of spontaneous, 343345
accelerometry, 39
acromioclavicular (AC) joint, 179, 180f
adjustment, 142
adverse drug reactions (ADRs), 361
ageing population See older adults
-motoneurones, 82, 8586
anatomical landmarks, surface, 177180
anatomical lever, thrust technique, 146147
annulus fibrosus, 5556
anterior thoracic adjustment, 263
arteriopathy, 282
articular pillars palpation, 179
asthma, 328
atlas, manipulation, 315318, 315f, 316f, 317f, 318f
augmented feedback, 2829, 30, 31
autonomic reflexes, 87
axis, 312
B
back pain
in elderly patients, 366367
occupational, 9899 See also low back pain
ballismus, 8789
basal ganglia, 8789
biceps femoris, 5354
long head of, 5354
bioethics, 15
biomechanics
cervical spine, 285286
clinical, 4872
intervertebral discs, 212
intradiscal pressure, 5458
lordosis, 5861
lumbar spine, 211213
motion palpation, 6972
neutral zone, 6169
pregnancy, 342, 343f
sacroiliac joints, 186
spinal forces, 4854
spinal manipulation, 3548
thoracic spine, 243244
biopsychosocial model, 210
bird dog exercises, 306f
block practice, 27
body drop, 163, 163f, 164f
and shoulder thrust, 164, 165f, 171f
body mass index (BMI), 99, 101, 367368
bone mineral content, 49
Bonyuns discal techniques (modified Bonyun), 216
boundaries
crossing and violation, 18
setting and maintaining, 1618
brainstem, 90
ischaemia, 286
breathing cycle, thoracic compliance, 167, 248252
buckling concept, lumbar spine, 212, 214215
C
cardiorespiratory fitness, 367368
carotid artery dissection, 282
cauda equina syndrome, 46
caudate nucleus, 8789
cavitation, 48
cervical spine, 39
force, 36, 36f
learning, 8
significance of, 34
spinal manipulation, 3741, 37f
cerebellum, 90
cerebral cortex, 8990
cerebrovascular accident (CVA) See stroke
cervical articular mechanoreceptors, 368369
cervical push, 301
cervical rotary procedure, 291
cervical spine, 279323
articular process - supine, 291300, 291f, 292f, 293f, 294f, 295f, 296f, 297f, 298f, 299f, 300f
assessment in children, 331332, 332f
biomechanics, 285286
cavitation, 39
landmarks, 177179, 178f
lateral flexion, 287
lordosis, 5859
manipulation
adverse reactions, 6
in children, 333335
cervical bridge, 334335, 335f
digital cervical, 334, 334f
considerations, 289291
educational issues, 287288
and headaches, 279280
mid-lower region, 291314
neck pain, 280
in older adults, 359360
performance, 289
post-manipulative reactions, 285
research, 284285
side-effects, 46
skills, 287288
stroke risk, 4647
thrust forces, 288291
upper region, 312314
and vertebrobasilar insufficiency, 280284
mastoid process, 177, 178f, 315318, 315f, 316f, 317f, 318f
and posture, 103
range of motion, 45
rotation, 287
seated procedures, 308309, 310f, 311f
spinous-lamina - supine, 301303, 301f, 302f, 303f, 304f
spinous processes, 178179, 178f, 179f
thumb pad rotary, 308309, 308f, 309f
toggle-recoil, 287, 312, 313f, 314f
transverse process, 177
supine, 303f, 304307, 305f, 306f, 307f
cervicothoracic junction, 252, 257f, 262f, 271f, 273f, 274f, 275f
cervicothoracic spine, 286
chest wall pain, 242243
children See paediatric patients
chiropractic arch, 113114
skills, 114127
variations, 113127
chiropractic healing encounter, 111
chiropractic maintenance care (CMC), 361362, 362b
Chiropractic Technique, 9
chorea, 8789
chronic obstructive Lung disease (COLD), 365366
clinical frameworking, 24
coccygeus, 5153
colic, 328
collagen, 84
communication skills, 169
compression forces, 5051, 5455
conditioned reflexes, 8182
consent, 18, 281 See also informed consent
constipation, 366
context dependence, 23
control neural system, 343
costotransverse joints, 242243
costovertebral joints, 242243
coupling patterns, 6970
creep, 5556, 6667
cross-spinal interactions, 8687
cumulative trauma disorders (CTD), 66
D
de Kleyns Test, 283
delirium, 363
dementia, 363
depression, 363
diabetes mellitus, 364
diagnostic errors, 24
digital contact, 121126, 121f, 122f
discs See intervertebral discs
displacement neuromuscular neutral zone (NNZ), 6667
distributed practice, 27
diversified techniques, 9
dizziness, 364
double spinous procedure, 216221, 216f, 217f, 218f, 219f, 220f, 221f
double triceps flick, 154156, 155f, 156f
drop techniques, mechanical, 351354
elderly patients, 365
points to remember, 354
prone, 351354, 351f, 352f, 353f
supine, 352354, 353f, 354f
duff move, 133f
E
education, 46 See also learning
elaborated learning, 2325
elastic barrier, 6163
elastic resistance, 143
elastic zone, 4950, 6063, 62f
elastin, 84
elderly patients See older adults
empathy, 1718
entitlement, 16
erector spinae, 50
lumbar, 50
and sacroiliac joint dysfunction, 187188
erector spinae aponeurosis, 50
ethics, 1519
exercise
elderly patients, 367369
programme for practitioners, 116f, 117f
extension move, 229
extensor muscles
lumbar, 50
and posture, 9798
external feedback, 2829, 30, 31
external occipital protuberance (EOP), 178
F
facet joints
cervical spine, 179, 179f
gapping after manipulation, 3839
and intradiscal pressure, 56 See also under cervical spine See also lumbar spine See also
thoracic spine
far transfer of knowledge, 23, 24
feedback, 2526
amount of, 31
augmented/external, 2829, 30, 31
intrinsic/internal, 2829
objective, 144
qualitative, 2829
quantitative, 2829
usefulness of, 31
visual, 2930
fencer stance, 148151, 149f, 150f, 151f, 152f
fibromyalgia, 364
finesse, 6
finger-push adjustment, 301
finger tip/goose-neck contact, 121126, 121f, 122f
flexion-relaxation phenomenon, 5860
flexor muscles and posture, 9798
focus of attention, 25
force, 56
direction of applied, 4142, 41f
shear, 5859
spinal, 4854
spinal manipulation, 3637, 36f
force closure, 5153, 187
form closure, 5153, 187
fractures
osteoporotic, 365
post manipulative, 213214
vertebral, 362t
functional stability model, sacroiliac joint, 187188
G
GABAergic neurones, 8789
-loop reflexes, 8384, 84f, 85
-motoneurones, 82, 85
gastroesophageal reflux disorder (GERD), 366
gastrointestinal disorders, 365366
gender
effect on force, 37
and learning, 28
and side-effects, 46
Georges Test, 283
geriatric patients See older adults
globus pallidus, 8789
gluteal squeeze, 333, 333f
gluteus maximus, 5154
sacroiliac joint motion, 187
goal setting, 24
Golgi-tendon organ-like receptors, 8687
Golgi-tendon organs, 8687
Gonstead procedure, 3637, 282, 287
goose-neck contact, 121126, 121f, 122f
grip strength, 99
H
hand-body delay, 29
hands
chiropractic arch, 113114
skills, 114127
variations, 113127
contact points, 113, 113f
digital contact, 121126, 121f, 122f
exercise programme, 114, 115f
finger tip/goose-neck contact, 121126, 121f, 122f
hypothenar contact See hypothenar contact
importance of, 111112
index/metacarpal/interphalangeal contact, 122, 122f
injuries to, 112
metacarpal/hypothenar contact, 123124, 123f, 124f
postures, 113
skills, 113, 118f, 119f, 120f
students, 112
thenar contact See thenar contact
thumb contact, 123
handshake, 112113
headache
after manipulation, 46
cervical spine manipulation, 279280
cervicogenic, 279280
and posture, 96
hemiballismus, 8789
higher motor centres, 8791
acquisition of new reflexes, 9091
motor output, 8790
sensory input, 87
high-velocity low-amplitude (HVLA) thrust, 4
in elderly patients, 370
high-velocity techniques, 142, 145
homocysteine, 286
hydraulic amplifier, 5051
hypertension, 365366
hypothenar contact, 123124, 123f, 124f
cervical spine, 304305, 314f, 316f
lumbar spine, 230f, 234f
sacroiliac joint, 191f, 202f, 203f, 204f
thoracic spine, 249f, 250f, 251f, 255f, 269f, 271f, 273f
I
iliac crest, 179, 244
immobility, elderly people, 364
impulse to cavitation, 36, 36f
impulse to peak force, 36, 36f
index/metacarpal/interphalangeal contact, 122, 122f
infants
examination techniques, 330331
inverted hang, 330331, 330f, 331f
informed consent, 213214
in pregnancy, 345
inhibitory interneurones, 8586, 86f
innominate flexion, 201f
instability, elderly people, 364
intellectual impairment, 363
interleukin-1, 6768
internal feedback, 2829
internal oblique muscles, 5153
interneurones, inhibitory, 8586, 86f
interspinous space, 229235, 230f, 231f, 232f, 233f, 234f, 235f, 236f
intervertebral discs
degeneration, 6768
herniation, after manipulation, 46
intradiscal pressure See intradiscal pressure
lumbar spine biomechanics, 212
metabolism, 6869
intra-abdominal pressure (IAP), 5051
intradiscal pressure, 5458
extension, 5658
flexion, 5658
passive rotation, 5658
intrinsic feedback, 2829
inverted hang, 330331, 330f, 331f
ischial tuberosity contact, 146147, 200202
J
joint crack See cavitation
joint(s), 84
extremity pain, elderly patients, 366367
flexibility in pregnancy, 342343
manipulation, 142
movement, intrinsic muscle properties, 8384
stiffness, 188
joint tension
concepts, 143144
sense skills, 169
K
kinaesthetic imagery, 26, 27
kinematics See motion
KISS principle, 169
KISS syndrome, 328331
examination and treatment, 329
infants examination techniques, 330331, 330f
KISS I, 329
KISS II, 329331
knee-chest tables, 348349
knee-jerk, 85
knowledge
of performance, 2829
of results, 2830
kyphosis, 243, 244
L
lateral recess encroachment, 229
latissimus dorsi, 53, 53f
lax zone, 6163
learning, 2134
context of, 2223
elaborated, 2325
gender and, 28
lemniscal system, 87, 88f
length-tension relationship, 5960
life expectancy, 360361, 360b
lifting
biomechanical models of, 5153
lumbar lordosis, 5860, 61, 7071
sacroiliac joint and, 188204
stresses during, 60
ligaments, 84
ligamentum flavum, 84
light touch, 113
longissimus muscle, 6466
long-lever manipulation, 146147
lordosis, 212
lumbar, 5859, 7071, 212
mechanics, 5861
low back pain
in children, 327
in elderly patients, 366
from lifting, 7071
manipulation, 213215
neuromechanical model, 7071
occupational, 9899
and posture, 9596
in pregnancy, 341342
prevalence, 209211
and sacroiliac joint complex, 185186, 187188
shear forces, 5859
source of, 211
terminology, 211
low-velocity techniques, 142
lumbar muscles hyperexcitability, 7071
lumbar roll adjustment, 229
lumbar spine, 209240
biomechanics, 211213
buckling concept, 212, 214215
cavitation, 39
coupling, 6970
curvature, 50
double spinous process, 216221, 216f, 217f, 218f, 219f, 220f, 221f
erector muscles, 50
examination in children, 332, 332f, 333f
extensor muscles, 50
facet joints, 3839, 180181, 181f
flexion, 5860
landmarks, 179180
lordosis, 5859, 7071, 212
mamillary process/interspinous space, 229235, 230f, 231f, 232f, 233f, 234f, 235f, 236f
manipulation
in children, 335337, 336f, 337f
considerations, 214215
skills, 215235
and posture, 104f, 107110
side posture, 212, 215
cavitation, 38
in elderly patients, 366
safety, 213214
single spinous process, 221228, 222f, 223f, 224f, 225f, 226f, 227f, 228f, 229f
spinous processes, 179, 180
stability, 211213
stenosis, 367 See also low back pain
lumbodorsal fascia, 5354
lumbopelvic region, 185186
lumbosacral junction, 179
lunge stance See fencer stance
lying down, intradiscal pressure, 5455
M
Maignes syndrome, 244, 268
mamillary process, 229235, 230f, 231f, 232f, 233f, 234f, 235f, 236f
mandible, 177
manipulation under anaesthesia (MUA), 6667
massed practice, 27
mastoid process, cervical spine, 177, 178f, 315318, 315f, 316f, 317f, 318f
materialism, 16
matrix metalloproteinases (MMPs), 6768
mechanical adjusting device, 287
mechanical neutral zone (MNZ), 6667
mechanoreceptors, cervical articular, 368369
memory foam wedges, 329, 330f
mental imagery, 26, 27
mental practice, 78, 2627
metacarpal/hypothenar contact, 123124, 123f, 124f
metacarpal-phalangeal joints, 38
metatarsal-phalangeal joints, 3839
migraine, 279280
miscarriage risk, 343345
mobilization, 142
monosynaptic reflex, 8384
morning after hyperexcitability, 71
motion
palpation, 6972
spinal manipulation, 4243
motoneurones, 82
motor cortex, 8990, 89f
motor imagery, 2627
motor output, 8790, 89f
motor performance, 26, 87
motor skills
acquisition, 22, 2531
research, 3031
retention, 2531
transferability, 2531
movement patterns, 2829
multifidus muscle, 6466, 7071
lumbar, 50, 50f
and sacroiliac joint dysfunction, 187188
multiple sclerosis, 363364
muscles, 8285
fibre types, 8283
intrinsic properties, 8384
length-tension relationship, 5960
musculoligamentous interplay, 187
musculoskeletal pain
elderly patients, 367369
paediatric patients, 327
N
neck pain
cavitation, 40
cervical spine manipulation, 280
in elderly patients, 366
occupational, 99, 101
thoracic manipulation for, 45
vertebral artery dissection, 47
neural arch ligaments, 4950, 49f
neural system, control, 343
neurological impairments, 363364
neuromuscular neutral zone (NNZ), 6667
displacement, 6667
tension, 6667
neuromuscular reflexes, 8587
neutral spine posture, 98, 212
neutral zone, 4950, 5354, 6169, 61f, 62f, 63t
mechanical, 6667
neuromuscular, 6667
nitric oxide, 6768
nocturnal enuresis, 328
nucleus pulposus, 5556
O
objective feedback, 144
oblique muscles, 5153
observational practice, 25
occipital rim, 178, 319
occiput
landmarks, 177179
manipulation, 315318, 315f, 316f, 317f, 318f
occiput atlas manipulation, 315318
occupational injuries
back pain, 9899
chiropractors, 99103, 100f, 101f
older adults, 359387
ageing population, 360361
challenges of managing, 361, 361b
characteristics, 361b
chiropractic maintenance care, 361362, 362b
extremity joint pain, 366367
immobility, 364
instability, 364
intellectual impairment, 363
manipulation, 361363
contraindications, 362t
modifications, 369370
suggestions, 369370
manual care, 370380
musculoskeletal pain, 367369
neurological impairments, 363364
non-manipulative techniques, 370
non-musculoskeletal conditions, 365366
osteoarthritis, 364365
physical activity, 367369
spinal pain, 366367
osteoarthritis, 364365
osteomyelitis, 243244
osteoporosis, 365
otitis media, 328
overmanipulation, 188
P
padded wedges/blocks
for elderly patients, 370
for infants, 329, 330f
paediatric patients, 325339
cervical bridge technique, 334335, 335f
cervical spine assessment, 331332, 332f
digital cervical adjustment, 334, 334f
KISS syndrome, 328331
KISS syndrome, 328331
examination and treatment, 329
infants examination techniques, 330331, 330f
KISS I, 329
KISS II, 329331
lumbar spine examination, 332, 332f, 333f
manipulation, 333337
cervical spine, 333335
lumbar spine, 335337, 336f, 337f
safety, 328
thoracic spine, 335337, 335f, 336f
musculoskeletal pain, 327
non-musculoskeletal disorders, 328
pelvic corrections, 337, 337f
prone corrections
pelvis, 337
thoracic spine, 335337, 335f
sacroiliac joint examination, 333, 333f
side posture
lumbar spine, 336337, 336f, 337f
pelvic corrections, 337
spinal pain, 327, 328
supine corrections, pelvis, 337, 337f
thoracic spine examination, 332, 332f, 333f
trunk flexibility, 331, 331f
vertical lift adjustments, 336, 336f
palpation
force, 42
motion, 6972
paraphysiological space, 6163
paravertebral muscles, 5859
Parkinsons disease, 363364
PARTS acronym, 371
patella reflex, 85
patient positioning
prone position, 127, 136, 136f
side posture, 127, 129130, 129f, 130f, 131f
skills, 127137
supine position, 127, 136, 136f
thrust technique, 146
peak force, 3637, 36f
pectoralis thrust, 157, 157f, 158f, 173f
pelvic belts, 5354
in pregnancy, 342, 354f
pelvic blocking, mechanical
elderly patients, 365
in pregnancy, 349351, 350f, 351f
prone, 349350, 350f
supine, 350351, 351f
pelvic crest region, 221
pelvic girdle/pelvis, 5153
landmarks, 179
manipulation in children, 337, 337f
pain, in pregnancy, 341342
and posture, 107110
pelvic ring, 5153
permissiveness, 16
physical activity See exercise
physical practice, 78
piriformis, 5154
pisiform contact, 113f, 120f, 125, 191f, 202f, 204f, 314f, 316f
pivot shift, 133f, 148151, 150f, 151f, 193f, 219f, 231f
positions of power, 1718
posterior inferior iliac spine, 179
posterior superior iliac spine (PSIS), 179, 180f
contact, 190200, 190f, 191f, 192f, 193f, 194f, 195f, 196f, 197f, 198f, 199f, 201f, 202f
posture, 95111
analysis, 9697
cervical spine and, 103
dynamic assessment, 9798
evidence, 9598
exercise programmes, 98
general considerations, 103111
good, 9597
instability, 9798
and intradiscal pressure, 55
lumbar spine and, 104f, 107110
occupational back pain, 9899
pelvic region and, 107110
poor, 9697
practitioner injury, 99103
in pregnancy, 342, 343f
sacral spine and, 104f
symmetry, 9697
thoracic spine and, 103106, 104f
working, 102
power, positions of, 1718
practice
block, 27
distributed, 27
effect on skills acquisition, 2728
massed, 27
mental, 78, 2627
observational, 25
physical, 78
random, 27
self-controlled, 26
practitioner position, 131135, 132f, 133f, 134f, 135f
pregnancy, 341357
biomechanics, 342, 343f
comfort of patients, 345
first trimester, 345
flexibility, 342343
informed consent, 345
kneeling techniques, 348349, 349f
manipulative/mobilization modifications, 345346
mechanical drop techniques, 351354
points to remember, 354
prone, 351354, 351f, 352f, 353f
supine, 352354, 353f, 354f
mechanical pelvic blocking, 349
prone, 349350, 350f
supine, 350351, 351f
miscarriage risk, 343345
patient monitoring, 345
pelvic (trochanteric) belts, 354355, 354f
prone modifications, 346f, 347f
sacroiliac joint dysfunction, 187188
second trimester, 346
side posture modifications, 346, 346f
sitting techniques, 348, 348f
supine modifications, 347348, 347f, 348f
third trimester, 346
preload, 143144
appreciation, 200
force, 3637, 36f
professional ethics, 15
professionalism, 1519
basic premise, 1516
becoming a health professional, 16
issues of touch, 18
positions of power, 1718
setting and maintaining boundaries, 1618
proteoglycans, 6768
provocation testing, 281, 283, 284
pseudo-angina, 242243
psoas major, 244
psychological response to spinal manipulation (PRISM), 363
psychomotor skills, 6, 78
educators, 23
pubic symphysis, 342343
pulmonary disorders, 365366
putamen, 8789
Q
quadratus lumborum, 5960
qualitative feedback, 2829
quantitative feedback, 2829
quickness, 145
R
random practice, 27
range of motion, 4345, 44f, 45f
reciprocal inhibition, 85
recoil thumb thrust, 173f
recoil (toggle) thrust, 172f
red nuclei, 90
reflexes, 8182, 87
acquisition of new, 9091
neuromuscular, 8587
Renshaw cells, 8586
repetitive injury, 8485
respiration cycle, 248252
reticular formation, 90
rib cage compliance, 167
rowing, 6061
S
sacral base contact, 203204, 203f
sacral spine, 104f
sacroiliac joint, 5153, 183208
biomechanics, 186
dysfunction, 187188
examination in children, 333, 333f
flare dysfunction, 200
functional considerations, 186
functional stability model, 187188
ischial tuberosity contact, 200202
lifting and, 188204
and low back pain, 185186, 187188, 211
manipulation, 188
force of, 189
skills, 189204
mechanical drop techniques in pregnancy, 351353, 351f, 352f, 353f, 354f
mechanical dysfunction, 190
mobility, 186187
posterior superior iliac spine contact, 190200, 190f, 191f, 192f, 193f, 194f, 195f, 196f, 197f,
198f, 199f, 201f, 202f
in pregnancy, 342343
sacral base contact, 203204, 203f, 204f
stability, 53
treatment of injured, 5354
sacroiliac joint complex, 185186
sacroiliac ligament, long dorsal, 187188
sacroiliac syndrome, 186, 187
sacro-occipital technique, 349
sacrotuberous ligament, 5354
sacroiliac joint dysfunction, 187188
sacroiliac joint motion, 187
sacrum, 203
scapula, 165, 166f, 179
landmarks, 177, 179
pain, 370
scapulothoracic movement, 165, 166f
scoliosis, 243
self-bracing effect, 5153, 52f
self-controlled practice, 26
semispinalis capitus, 288
sensorimotor training, 187
sensory input, 87, 88f
shear forces, 5859
short-lever manipulation, 146147
short lever pull technique, 159f
shoulder/arm pull thrust, 158160, 159f, 160f
shoulder/arm thrust, 161162, 161f, 162f, 170f
shoulder/shoulder girdle
flexibility, 165, 166f
landmarks, 179
occupational pain, 99, 101
side-effects, 6, 4548
side posture, 128137
difficulties in learning, 128
lumbar spine, 212, 215
in children, 336337, 336f, 337f
double spinous process, 216f, 217f, 218f, 219f, 220f, 221f
in elderly patients, 366, 369
mamillary process/interspinous space, 230f, 231f, 232f, 233f, 234f
safety, 213214
single spinous process, 222f, 223f, 224f, 225f, 226f, 227f, 228f, 229f
patient positioning, 127, 129130, 129f, 130f, 131f
pelvic corrections in children, 337
practitioner position, 131135, 132f, 133f, 134f, 135f
pregnancy, 346, 346f
sacroiliac joint, 190f, 191f, 192f, 193f, 194f, 195f, 196f, 197f, 198f, 199f, 201f, 202f
skill, 128
single snapshot approach, 10
single spinous process (SPP), 221228
spinous hook/pull, 222, 222f, 223f
spinous push, 223228, 223f, 224f, 225f, 226f, 227f, 228f, 229f
sitting, intradiscal pressure, 5455
skilled movement, 8182
skills
acquisition, 5, 8, 2628
effect of practice on, 2728
gender and, 28
goal setting, 24
motor imagery and mental practice, 2627
core, 5
psychomotor See psychomotor skills
training, 8485
ski stance, 148151, 149f, 150f, 151f, 152f
smoking and cardiorespiratory fitness, 367368
smooth reflexes, 82
speed, 6
spinal ligaments, 5354, 54f, 60, 6466
spinal manipulation, 4
biomechanics of, 3548
change of range of motion following, 4345, 44f, 45f
definition, 142143
direction of applied forces, 4142, 41f
forces associated with, 3637, 36f
joint cavitation, 3741, 37f
learning, 29
motion (kinematics) associated with, 4243
proposed mode of action for, 43
psychological response to, 363
side-effects, 4548
spinal manipulative skill (SMS), 142143
spinal manipulative therapy (SMT), 142143
spine
forces, 4854
important relationships, 180181, 181f
landmarks, 177181
neutral, 98
pain See back pain See also low back pain
reflexes, 85
shrinkage, 5556
stability, 5354, 54f, 6466, 343
models, 211212
spinocerebellar tracts, 87
spinothalamic tracts, 87
spinous hook/pull, 222, 222f, 223f
spontaneous abortion risk, 343345
standing, intradiscal pressure, 5455
stiffness after manipulation, 46
straight leg raising test, 5354
stress
intradiscal pressure, 5556
profilometry, 5558
stretch reflex, 8384, 83f
striatum, 8789
stroke
causes, 282
post-manipulative, 286
risk, cervical spine manipulation, 6, 4647, 280281
substantia nigra, 8789
subthalamic nucleus, 8789
supraspinous ligaments, 6466, 7071
suprasternal notch, 103
surface anatomical landmarks, 177180
swimming, 53
sympathetic ganglionic chain, 243
synovial fluid, 84
T
T4 syndrome, 243
tables
for elderly patients, 370
height of, 102103, 137
knee-chest, 348349
tendons, 84
tension neuromuscular neutral zone (NNZ), 6667
thenar contact, 125126, 125f, 126f
sacroiliac joint, 203f
supine, 126, 126f
thermal pain sensitivity testing, 40
thigh sandwich manoeuvre, 132, 190f, 220f, 228f, 230, 231f
Thompson Terminal Point Technique, 370
thoracic spine, 241278
biomechanics, 243244
compliance, 248252
skills, 167168, 168f
contralateral hypothenar spinous process, 273f
double transverse process, prone, 252, 254f, 255f, 256f
examination in children, 332, 332f, 333f
facet joints, 39, 244
landmarks, 179180
manipulation
in children, 335337, 335f, 336f
considerations, 245
forces, 245246
lower region, 268270, 269f, 270f, 271f, 272f, 273f, 274f, 275f
mid-region, 247252, 263267
for neck pain, 45
skills, 246275
technique, 245
upper region, 252262
non-torsional techniques, 244
pain, 242243
and posture, 103106, 104f
preload, 248252
single spinous contact
head as a lever, 260262, 260f, 261f, 262f, 263f
supine, 263267, 264f, 265f, 266f, 267f, 268f
single transverse process
mid region, 247248, 248f, 249f, 250f, 251f, 253f
upper region, 256259, 257f, 258f, 259f
spinous processes, 180
transverse processes, 180, 181f
thoracolumbar fascia (TLF), 5051, 187188
thoracolumbar junction, 244
thoracolumbar syndrome, 244, 268
thrust duration, 36
thrust rate, 36
thrust technique, 144147
body drop, 163, 163f, 164f
and shoulder thrust, 164, 165f, 171f
characteristics, 144145
definition, 142143
direction, 144145
double triceps flick, 154156, 155f, 156f
force application, 146147
anatomical lever, 146147
individual factors, 146
patient position, 146
postural stamps, 147
localization, 144145
modifying factors, 144145
pectoralis thrust, 157, 157f, 158f, 173f
recoil thumb thrust, 173f
recoil (toggle) thrust, 172f
shoulder/arm pull thrust, 158160, 159f, 160f
shoulder/arm thrust, 161162, 161f, 162f, 170f
skills, 152164
practise techniques, 168f, 169173, 170f, 171f, 172f, 173f
speed, 144145
triceps flick
double, 154156, 155f
triceps flick (unilateral), 152153, 153f, 154f
versatility, 145
wrist flick, 156f, 157
thumb contact, 123
thumb move, 260
time to cavitation, 36, 36f
time to peak force, 36, 36f
tissue creep See creep
tissue tension sense, 143144, 169
toggle-recoil, 4
cervical spine, 287, 312, 313f, 314f
contraindications, 349
toggle thrust, 172f
touch
issues of, 18
light, 113
transversus abdominis, 5153, 187
trapezius muscle, 178, 261f
triceps flick, 152153, 153f, 154f
double, 154156, 155f, 156f
trochanteric belts, 5354
in pregnancy, 342, 354f
trunk
flexibility in children, 331, 331f
muscular endurance, 187
U
UK BEAM trial, 213
ulnar deviation, 113114, 122, 123, 156f, 306f
unconditioned reflexes, 8182
urinary incontinence, 365366
V
verbal skills, 169
vertebral arteries
cervical spine biomechanics, 285
dissection, 47, 281
injury, 285, 286287
mechanisms of injury, 286287
pathophysiology of injury, 286287
susceptibility to injury, 285286
vertebral artery functional test, 283
vertebral fracture, 362t
vertebrobasilar accident (VBA), 47
vertebrobasilar insufficiency, 280284
vertigo, 364
vestibular nuclei, 90
video modelling, 26
visual feedback, 2930
visual imagery, 26
vulnerability of patients, 17
W
walking, 8687
Wallenburg Test, 283
working posture, 102
wrist
positions, 113114
supination/pronation, 166, 167f
wrist flick, 156f, 157
Z
zygapophyseal joints See facet joints
zygapophyseal rotatory adjustment, 216
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