Introduction to high velocity spinal manipulation in the cervical region - Dr. Donna Maitlen
- 1. Donna M. Maitlen, B.S., D.C., C.C.S.P.
- 2. Vertebral Subluxation Complex Mechanical Components *Joint Malposition and Hypo and hyper-mobility Neurobiologic Components *Nerve Root Compression (theory) *Visceral-Somatic dysfunction (autonomic) Inflammation *Vascular and soft-tissue responses
- 3. Most of the time, we are adjusting patients based on the functional evaluation of the spine, typically using motion palpation techniques. This means, most of our adjustments will be due to hypo- mobility as detected using our motion palpation with confirmatory static palpation findings. You may also use devices that detect and measure pain and temperature to determine spinal joint dysfunction.
- 4. The facets of the cervical spine angle upward from P-A at 45 degrees. Contact points for adjustments are typically the articular pillars, the postero-lateral border of the spinous process, or the transverse process.
- 5. Each joint has its own range Remember the segmental ranges of motion – these ranges help you define the subluxation complex. The occipito-atlantial joint (C0-C1) has the most flexion / extension in the upper c-spine. The atlantoaxial joint (C1-C2) has the most rotation in the upper c-spine.
- 6. DUE WITHIN 1 WEEK FROM TODAY Find out what the actual arch angle of a “Roman Arch” is – it is specific. Compare and contrast this to the cervical lordosis of a newborn and the effect of a shallower or greater lordotic angle on the resistance to injury.
- 7. Discovering contraindications to manipulation Ruling out dangerous pathology 1. Vertebral Artery Testing – integrity of the vertebral artery 2. Compression Testing – integrity of foramen and body 3. Distraction Testing – integrity of musculature and foramen 4. Percussion Testing – integrity of bony structures 5. Valsalva Maneuver – integrity of neural structures
- 8. Down’s Syndrome: possible lack of a transverse ligament Multiple risk factors of Osteoporosis Atherosclerotic Plaque – CVA History of sinus infection in conjunction with c-spine pain Remember that much of your pathology DX comes from the proper history of the patient - listen AND ask.
- 9. In George's test, we first measure the bilateral blood pressure, pulse rates, and auscultate the subclavian and carotid arteries. The patient is next asked to rotate the head right and left, and then rotate, laterally bend and extend in the seated position (Maigne's test) and in the supine position (DeKleijn's test). Look for : Nystagmus and fatigue, Ask: Do you feel anything different? (do not lead patient)
- 10. Seated • Observe active ROM (measure-especially before first adjustment) • Static Palpation • Motion Palpation with end range overpressure • Flexion, extension, lateral flexion / medial glide, rotation • Instrumentation Supine • Static Palpation – is anything different? • Motion Palpation • Flexion, lateral flexion / medial glide, rotation
- 11. Indication: restriction of rotation lateral flexion or extension of C1 Patient Position: relaxed, seated Doctor Position: behind patient toward side of contact Contact point: ventral surface of index finger (wrist straight as possible, forearm 90 degrees flex) Segmental Contact Point: Atlas transverse process (lateral or posterior) Indifferent hand: cradles patient’s head Vector: P-A with rotation, P-A with Extension, or M-L IMORTANT CONSIDERATIONS BEFORE ADJUSTING: *is patient relaxed? *have you maintained joint tension before thrust?
- 12. Indication: Restricted rotation, lateral flexion or extension Patient Position: Patient lies supine Doctor’s Position: Standing at head of table, 45 degrees to 90 degrees to patient Contact Point: Ventrolateral surface of index finger, thumb or thenar rests on patient’s cheek Segmental Contact Point: Posterior articular pillar Indifferent hand: Cradles patient’s head supporting occiput and cervical spine Vector: medial to lateral and superior to inferior IMORTANT CONSIDERATIONS BEFORE ADJUSTING: *is patient relaxed? *have you maintained joint tension before thrust?
- 13. The physical health of your body directly relates to and impacts your ability as a doctor to help people and to make a living. TAKE CARE OF YOURSELF!!!!!! Always consider your posture and core strength
- 14. Why is the subluxation or restriction present? o Evaluate cervical spine for strength o Biomechanics of neck curvature o Posture o Evaluate nutritional status, especially minerals o Sleeping considerations – of posture and pillows
- 15. Approach the patient with your questions in mind Do your seated assessment before the patient lies down • Observation, A-ROM, Orthopedics, R/O Pathology, vascular tests Do your supine assessment • P-ROM, Vascular tests… Pleasantries: assure the patient (before and after)
Editor's Notes
- #2: 1. Intro 2. Anatomy review 3. Physiology review 4. Ortho tests 5. George’s 6. ROM 7. MP 8. Technique set up