Translatoric Spinal Manipulation For Physical Therapists, 2006

Companion DVD Included
Translatori c Spinal Manipul ati on

ISBN 978-1-59975-1 95-5
Written by - John R. Krauss PhD, PT, OCS, FAAOMPT, Ol af Evj enth, PT, OMT and Doug Creighton
OPT, OCS, FAAOMPT
Illustrated By - John R. Krauss
A Lakeview Medi a L. L.C. Publi cati on
This laboratory guide is intended to be used by li censed phys ical therapi sts or phys ical therapi st students
studyi ng under the supervision of an instructor skill ed in the appli cati on of TSM.
Other Kaltenborn- Evjenth based instructional materials are avail abl e through OPTP at www.optp.com.
These include:
Manual Mobili zati on of the Joints Volume I: The Extremiti es 6th Editi on by Freddy M.
Kaltenborn ISBN 82-7054-043-3.
Manual Mobili zati on of the Joints Volume II : The Spine 4th Editi on by Freddy M. Kaltenborn
ISB 82-7054-069-2.
Evjenth, O. and Hamberg, J. Muscle Stretching in Manual Therapy: A Clini cal
Manual, Volume I. Alfla Rehab Forl ag: Alfta, Sweden, 1998. ISB : 9 1-85934-02-X.
Evjenth, O. and Hamberg, J. Muscle Stretching in Manual Therapy: A Clini cal
Manual, Volume 2. Alfta Rehab Forl ag: Alfta, Sweden, 1998. ISBN: 9 1-85934-03-8.
Evjenth, O. and Hamberg, J. Auto Stretching. Alfta Rehab Forl ag: Alfta, Sweden,
1997. ISBN: 9 1-85934-05-4.
Copyright 2006 - rev 1.3
This manual is the copyright property of John R. Krauss.
Thi s manual is di stributed by OPTP. 800-367-7393 www.optp.com
Acknowledgements
The development of thi s book was an enormous undertaking, taking over three years to compl ete.
We would like to thank the indi viduals li sted below for volunteering their time as models, techni ca l
consultants and editors. Thi s proj ect could not have been compl eted without all of your generous
assistance.
Dawn Gilbert, PT, OMPT
Jill Marian, PT, OMPT
Chri stina Michajl yszyn, PT, OMPT
Jessica Wetzel, PT, OMPT
Melodi e Kondratek, DSc, PT, OMPT
Mari e- Eve Pepin, MS, PT, OMPT
Derek Chan, PT, OMPT
James Wold, MS, PT, OMPT
Dedicati on
For our wives,
Jennifer, Grella and Kristin
our children,
David, Kri stin, Ane, Karl eigh, Kati e and Cam
and our grandchildren,
Oli via and Vendela
Thanks for your love and support ...
Contents - An Overview
Chapter 1 - Introducing TSM - 3-6
Chapter 2 - Applying TSM - 7-24
Chapter 3 - Cervical Spine - 25-73
Chapter 4 - Thoracic Spine - 75-95
Chapter 5 - Lumbar Spine - 97-122
Chapter 6 - The SI Joint - 123-133
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Contents - In Detail
Acknowl edgements - II
Dedicat ion - iii
Introducing TSM
Background - 3
Joint moti on - 3
Indicati ons and contraindicati ons for TSM - 4
Goa ls ofTSM - 4
Research in TSM - 5
Mechanics ofTSM techniques - 5
Features of thi s text - 6
Applying TSM
Pati ent & therapi st positi oning for TSM 8
Locali zati on of the treatment segment - 8
Locking: an introducti on - 9
Locking the segment(s) above the treatment segment or j oint (l ocking above) - 10
Locking the segment(s) below the treatment segment or joint (locking below) - 10
Testing pri or to using locking during manipulation - \I
The amplitude of the translatori c mobili zati on & impul se - \I
Generating speed during high velocity translatori c manipulation - II
Us ing enough force with TSM: "As littl e as necessary, as much as needed" - 12
Integrating TSM into clinical practi ce - 12
Supporti ve and correcti ve interventi on techniques used in conjuncti on with TSM - 13
Clini cal conditi ons, examinati on findings and common sequencing ofTSM techniques - 14
Developing skill with TSM - 24
Cervical Spine
The Upper Cervical Spine - 26
Osseous anatoni y - 26
Upper cervical arti cul ati ons - 26
Li gamentous anatomy - 27
Vascul ar anatomy - 27
Kinemati cs - 28
Translatori c manipul ati on of the upper cervical Spine - 30
Selecting a contact for OA traction - 30
OA-Tracti on Side-lying - 31
OA-Traction Supine - 32
OA-Traction Seated - 33
OA glide techniques - 34
Occiput- Dorsal - 35
Atl as-Ventral - 36
Al ias-Dorsa l - 37
Selecting a contact for AA traction 38
Frequency of AA manipul ati on - 38
Translatoric Spinal Manipulation I v
AA-Traction Side-lying - 39
AA-Traction Supi ne - 40
The Lower Cervical Spine - 41
Osseous anatomy - 41
Lower cervica l articulations - 42
Ligamentous anatomy - 43
Kinematics - 43
Bi omechanics of Lower Cervica l TSM - 45
C2-7-Disc Traction Supine - 47
C2-Disc Traction Side-lying - 48
C2- Di sc Traction Supine - 49
C2-7-Disc Traction Seated - 50
C3-6-Disc Traction Side-lying - 51
C3-6-Disc Traction Supine - 52
C2-7-Facet Distraction Supine - 53
C2-6-Facet Distraction Seated - 54
C2-6-Facet Distraction Seated - 55
C2-6-Facet Distraction Supine - 56
C2-6-Facet Glide Supine - 57
C2-6-Facet Glide Seated - 58
C7-Disc Traction Side- lying - 59
C7-Facet Glide Supine - 60
C7-Facet Glide Side-lying - 61
C7-Facet Glide Supine - 62-65
C7-Facet Glide Prone - 66-68
C7-Facet Glide Seated - 69-70
C7-Facet Distraction - 71-73
Thoracic Spine
The Thoracic Spine - 76
The stable thoracic segments - 76
Osteological features of the thoracic spine - 76
Thoracic facet joints - 76
Biomechanics ofThoraciG Spine TSM - 78
Thoracic-Disc Traction Supine - 79
Thoracic-Facet Traction Bilateral Supine - 80-82
Thoracic- Facet Traction Unil atera l Supine - 83-84
Thoracic-Facet Traction Bilateral Prone - 85
Thoracic-Facet Traction Unilateral Prone - 86
Thoracic ribs - 87
First Rib-Distraction Supine - 89
First Rib-Distraction Seated Locking Above - 90
First Rib-Distraction Seated Locking Below - 91
.Ribs2-12-Distraction Supine - 92
Rib 2-12-Distraction Prone with Manual Stabilization - 93
Ribs2-12-Distraction Prone with Locking Above - 94
Ribs2-12-Distraction Seated - 95
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Lumbar Spine
The Lumbar Spine - 98
The intervertebral disc (lVD) - 99
Vascular anatomy - 99
Biomechanics of Lumbar Spine TSM 101
Lumbar-Traction Side-lying - 106-107
Lumbar-Traction Seated - 108-109
LI-4-Side Bending in Ventral Flexion - 110-112
LS-Side Bending in Ventral Flexion - 113
L 1-4-Side Bending in Dorsal Flexion - 114-116
LS-Side Bending in Dorsal Flexion - 117
L I-S-Facet Distraction Bilateral Prone - 118
L1-5-Facet Distraction Unilateral Prone - 119
L I-S-Facet Glide to Improve Dorsal Flexion Prone - 120
L1-S-Facet Glide Bilateral to Improve Ventral Flexion Prone - 121
LI-5-Facet Glide Unilateral to Improve Ventral Flexion Prone - 122
The SI Joint
SI Joint - 124
Muscular support of the SI joint - 12S
Kinematics of the SI Joint - 12S
The symphysis pubis - 125
Biomechanics ofSI joint TSM - 127
Sacrum Cranial Prone - 129
IIlium Caudal Prone - 130
Sacrum Cranial Side-lying - 131
IIlium Ventral Prone - 132
IIlium Dorsal Supine - 133
References - 134
TranslalOl'ic Spinal Manipulation I vii
TSM
Introducing TSM
Forward
The fo ll owing text is intended to be used by physica l the rapists and physica ll herapist students inte rested in developing their
thcorCli calundcrstanding and physical skill level in the of translatoric spinal mani pul ation (TSM). In keeping
consislenl wi lh Ihc slandard of pracli ce defi ned by Ihe Ameri can Physical Therapy Associal ion. Ihe aUlhors ha l e adopled Ihe
following definiti on of manipul ati on: '"A manual therapy technique compri sed of a conti nuum of ski ll ed passive movement s
to the j oint and/or related soil tissue that arc applied at vary ing speeds a nd a mplit udes. including a small amplitudclhigh
veloci ty therape uti c 1110 \ cme nt '".
Wilhin Ihi s lexl. bOlh hi gh (HV) and low velocilY (LV) Iranslatoric manipulalions arc presenled. some of whi ch are
appropri ale for enl ry- Iel el (EL) physical lherapi sl educat ion and olhers Ihal are more appropri ale fo r posl-professional ( PP)
physica llhcrapisl educati on. Thi s is due in part lO the ent ry- level student ' s lack o f experi ence in evaluating, mnnaging and
physicall y handling patient s who are ex peri encing spinalmovcmc nt impainnents. Thi s does not impl y that post-professional
students do not lack si milar skill s. however. they a re not faced wi th the daunting tas k of lea rning the wide range of skill s
necessary to become tI licensed physical the rapi st in additi on to the hi ghe r leve l cogniti ve and psychomolor skill s necessary
to develop a hi gh level o f profi ciency in all o f the techniques presented wit hin th is text.
To identify whether or not the a uthors feel a gi\ cn technique is a ppropriate for an ent ry- level or post-pro fessional
student and whether hi gh or low ve locit y is recomme nded, each technique page incl udes two boxes in the upper ri ght corne r.
nexllo Ihe lechnique lille (sec Ihe illuslralion below for fun her delai l).
C Z' 'J- Dlsc Traction
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2 I Chapter I : Inlroducing T5M
Examples
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Key
EL = Entry-level
PP = Post-professional
HV = This technique is appropriate for high vel ocity
LV = This technique is appropriate for low velocity
12' = This technique is not recommended for thi s student
group/population
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Background
TranslalOric Spi nal Manipulation (TSM) consists of a series of high and low velocity manipulative spinal techniques
do, eloped by Olar Evjenth PT, OMT in collaboration wi th Freddy Kaltenborn PT, OMT or Norway, Each or their careers has
spanned over 50 years or clinical practice, Early in their careers as educators and clinicians, Mr, Evjenth and Dr. Kaltenborn
realized that there were controversial issues regarding the safety of certain spinal manipulative techniques. They also noted
Ihal many commonly applied manipulati,e techniques failed to consistently decrease pain and restore motion in hYPolllobile
spinal segments. Following years of st udy and critical evaluali oll oftcchniqucs used by osteopat hs, chiropractors and
physical therapists they concluded that thesc issues and problems stemmed rrom the lack or spccific application of rorces to
\ ertebral segments and from the reliance on larger. angular and principally rotational forces during manipulation.
With these issues in mind. they endeavored to develop a method of manipulation that more specifi call y isolates
motion to a single spi nal segment. What they developed is now called '"Translatoric Spinal Manipulation" (TSM) and
consists ofa system of manipul ative techniques whi ch emphasize the use of small amplitude and straight line (Iranslatoric)
traction or gl iding impulses delivered parallel or at a right angle LO an individual vertebral joint or movement segment . To
further localize the effects of these lranslatoric techniques. TSM emphasizes the use of eit her direclmanual stabili zation or
the usc of spinal pre-positioning to restrict the amount or motion occurring al adjacent spinal segments during the translatoric
impulse. Deli\ erillg translatoric impulses (in the foml of disc traction. disc glides, facct traction and facet gl iding) to an
individual joilll or spi nal motion segment whil e using stabiliLation provides the malllial therapist with a manipulative tool that
has a predictable clrcct in terms of symptom reduction and motion rcstoration with minimal potcntial ri sk or patient inj ury.
Joint motion
All joint motion is comprised of two types of arthrokinematic motion. joint rolling and glidi ng (aka translation).
The dircction and amount of joint rol ling and gliding differs within and bet\\een joints depending on the specific functional
requirements and osseous configuration of the joint. Changes in the normal proportion of rolling and gliding in the joint
due to pathological or age related changes in the joint and its surrounding sofl ti ssues may lead to excessive rolling or
gliding between joint surraees. Excessive joint gliding is defined as h.lper/llobilil)' and decreased joint gliding is defined as
I-Iypennobility is managed through phy ical therapy inten entions that assist in restricting motion. such as
stabilization exercises, mQ\cmcnt re-education techniques. cervical collars. lumbar braces corsets and taping. Hypomobility
is managed through physical therapy interventions such as manual muscle stretching. fl.lllclionalmassage and low and hi gh
velocity TSM.
Table I - R'llings of joint motion. theral)ist I) Crcept ions joint end feels
Rating of Joint Motion (6 point
Resistance Perceived During Testing Endfeel
scale)
6 Unstable Little force required to move segment. little Least firm, if non-guarded
resistance to movement perceived. Finn. if significant guarding
present
5 = Moderately increased Illotion Moderately decreased resistancc to spinal Ill otion Less firm. soficr and later endrecl
4 = Mildly increased mot ion Mildly decreased resistance to passive spinal Firm and later end feel
motion.
3 - Normal Motion Anticipated resistance. similar in quality LO Firm
adjaccnt spinal segment (assuming no regional
hypermobil ity)
2 Mildly decreased motion Mildly increased resistance to spinal Illotion. Firm. endreel pcrccived mildl y
Increased force required to move spinal segment earlier in range of motion
I - Moderately decreased motion Moderately increased resistance to spinal mot ion. Finllcr cndfeel percci\ cd
Moderate force rcquired to move spinal segment modcrntel y earlier in the rangc of
motion
0 - No perccivable motion Segment resistant to mOlion. even when l'lard endreel perceived
signifi cant force is used immediately upon initiation of
passive motion
Translaloric Spinal Manipulation I 3
The di agnosis of segmental or regional spinal hyper or hYPOlnobility is deteml ined through the careful analysis
of the patient hi story. observation of acti ve moti ons and passive angul ar and translatori c motion testing. For exampl e. if
a patient/cli ent: ( I) reports that he/she feels worse wiLh stati c posi ti oning of hi s/her lumbar spine and bctter during and
foll owing movcment , (2) demonstrates earl y excessi ve moti on in the lumbar spine upon backwa rd bending, (3) demonstrates
increased lumbar spinal motion upon passive segmental motion testing and (4) reports tenderness upon pa lpation of the
interspinous space at the corresponding spinal segment(s) then he/she would be cat egori zed as hypennobile in the involved
lumbar spinal segmenl (s). The amount of spinal moti on can be categori zed by the therapi st by using a six point sca le (see
Tabl e I). When performing passive segmental moti on testing, the therapi st will percei ve less resistance to movement and
a larger range of avail abl e motion in hypermobile spinal segments (assuming there is no muscl e guarding due to segmental
irritability). Conversel y, the therapist will percei ve increased resistance to movement and a decreased range of avail abl e
motion in hypomobil c spinal segments (i.e. an earl y endfee l). Lastl y, the therapist may perceive a difference in the resistance
rell at the end or pass ive moti on testing. Abnormal/ pathological endl'eels may be perccived as either ( I) less finn, as may
be the case wi th hypermobil ity, (2) more firm as may be the case with hypomobility or (3) more firm over a region of spina l
segments when the patient is using hi s/her muscl es to resist movement due to pain or apprehension.
Indications and contraindications for TSM
In simple and brief teml s, TSM is indi cated when pati ent/cli ents are di agnosed with decreased j oint moti on. Thi s
corresponds with the moti on ratings of grade 2 and grade I li sted in Tabl e I. Typi cally. pati ents experiencing moti on
restricti ons or a grade 2 will demonstrate the qui ckest and best response to TSM. Pati ents with grade I moti on restri cti ons
Illay sti ll respond to tracti on TSMs, however, improvement in segmental range of moti on typi call y requires a longer time
peri od and lower velocity TSMs in additi on to mallualmuscle sLretching procedures.
Factors that the authors have found to be associated with good manipUl ati ve out comes include: ( I) recent onset
or impaired moti on. (2) lower level or j oint or segmental irritati on. (3) endleel s that are firm and arri ve sli ghtl y earl y in the
passive range or moti on, (4) good pati ent and therapi st rapport and (5) good compli ance with selrmanagement programs.
Factors that the authors have found to be associated wi th poor manipul ative outcomes include: ( I) constant unremitting pain,
(2) pain that is pul satile and wavel ike in quality. (3) pain that awakens thc pati ent from s leep and is unrelated to positi on
or changcs in position. (4) pain and associated sensory di sturbanccs that are experi enced more peripherally than centrall y.
(5) pa in that is provoked by all spina l movements, (6) signifi cant skeletal de rormity. (7) poor response to prior spinal
manipUlati ve interventi on, (8) patients who are apprehensive about moving their spi ne and (9) pati ent s who are unwilling!
unable to relax enough during TSM. Additi onal factors associated with poor outcomes from TSM are li sted in Tabl e 2.
Table 2 - Reasons for poor outcomes with TSM
Therapist Related Reasons Patient Related e ~ l s o n s
Pathological and Structural
Related Reasons
Inadequate diagnosti c skill s Emoti onal li abi lity Connective ti ssue laxity/weakness
Inadequate experi ence recogni zi ng
Psychologica l involvement
Worsening of an infl ammatory
and managing spinal pathology episode
Reliance on a positi onal vs. Too much pai n in too many Multipl e medica l comorbiditi es
movement related diagnos is directi ons. (e.g. circul atory compromi se)
Inadequate manipul ati ve skill s Signifi cant j oint restri cti on Signifi cant osteophytosis
Casua l use of manipulati on without 1-1 istory of Illulti ple manipulati ons Central cord signs
adequat e physical exa minati on with onl y transient benefit. Long track signs
Goals ofTSM
The overall goal or TSM is the restorati on or moti on in hypomobi le spinal segments and the reducti on orpai n in
symptomati c spinal segments. The exact mechani sms behind thc effect of all spinallll anipulati on techniques. including
TSM. have been di scllssed amongst practiti oners for many years. Proposed mechanisms include: ( I) mechani cal. (2)
ncurologic. (3) hydrauli c. (4) circulalOry and (5) psychologiGal. Mechanical e nects include the breaking of connective
ti ssue adhesions. stretching of li gaments and j oi nt capsul es and restorati on of gliding within fascial pl anes. In additi on.
intra-art icular meniscoids that are trapped or impinged between joint surfaces may be freed. Neurological effects include
those effects generated by stimul ati on of the mechanoreceptor system and include changes in resting musc le tone and pain
percepti on. Hydrauli c e fTects incl ude changes in synovial fluid distri bution within the j oint as well as synovial flu id viscosity.
Circul atory elfects include a reducti on of circul atory congestion and are postul ated to occur secondary to reducti on in
prcssure in the intervert ebral foramen and muscle ti ssues. Psychologica l. e ffects include those that result rrom thc patient's
belief that manipulati on will be effecti ve, their trust in the physica lthcrapi st's compctence and the benefit s associated with
human touch.
Whil e the authors do not claim to have any parti cul arl y un ique insight int o the specifi c mcchani sm(s) behind
4 I Chapter I : tntroducing T5M
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the effect of manipulation. we have seen benefits from TSM that would likely indi cate that more than one of the above
mechani sm are involved. For example, changes in quality and quantity of overall spinal motion and specific segmental
function have been seen with TSMs delivered using Kaltenborn's grade II and II I at both hi gh and low velocity. For a review
of these grades, see Table 3 bel ow. Logica ll y, these movement changes would seem to be related to non-mechanical effects.
While scicntific theory regarding the proposed efTects of manipulation remai n important, our focus over the past few years
has shifted to outcome analysis ofTSM. The author 's pos iti on regarding this research is di scussed below.
Research in TSM
The authors strongly encourage further research into the effectiveness of TSM. A number of case studies and case
seri es performed at Oakland Uni\ ersily are in various stages of publication. It is the hope of the authors that these studies
will providc a fo undation for continued development of controlled case series and randomi zed controlled tria ls in order to
assess the efficacy of TSM in terms of moti on restoration and symptom reduction. The authors also recommend that studies
in spina l manipulative therapy should not just address manipulati ng through the symptomatic segment but should also assess
the outcomes of joint manipulati on of hypo mobil e segments that are adjacent to symptomatic hypermobi le segment s.
Table 3 ~ Ka ltcnborn 's three treatment gr ades
Defined Trentment Use
A very small traction force used
to nullify the normal compress ive
lorces acting in a joint. No
Grade I appreciable joint eparation or
movement occurs. No ti ssue
resistance is perceived by the
therapist.
Grade I and II are used to reduce
Movement from grade I to the end pain/symptoms and restore qua lity
orthe slack in ti sslles surrounding of motion within the joint.
the joint. Little resistance is
Grade II
percei ved in the beginning of grade
II while a great deal of resistance is
relt at the end or grade II . A greater
amount of moti on is relt by the
therapi st.
Stretching of the ti ssue surrounding
the joint occurs. Little to
Grade II I is used to stretch tight
Grade II I 110 movement is felt by the
practitioner, however a great deal
structures crossing the joint.
of resistance is perceived.
Mechanics ofTSM techniques
There are three primary types ofTSM techniques: di sc traction. facet di stracti on and face t gliding. Di sc tractions
are applied at a ri ght angle to the S U r f ~ l orthe di sc joinl and are intended La unload/decompress the di sc and intervertebral
foramen. During disc tracti on techniques, the pati ent is positioned in hi s/her actual resting positi on (the position of greatest
comfort or ymptol11 relief). Irthe patient is mosl comfortabl e with hi s/her spine in a mid-positi on, then care is taken to
assure the patient's spine ends in a midline position during the TSM. If the therapi st is usi ng a bilateral contact and force 10
generate the spinal traction. then the patient may start in a mid-posi tion. If
a unil ateral force or contact is being used. the patient will be placed in sli ght
side bending towards the si de orthe impulse pri or to the manipulation. The
resultant manipulative force generated during the techni que wili return the
spinal segment to a mid-positi on.
Facet joint di stracti ons are generall y performed with the spinal
segment posi ti oned in side bending and rotati on in opposi te directions. These
techniques use facet joint compression on one side of the spinal segment to
create facet joint distraction on the other. While the patient's spinal segment is
only placed in thi s position for a short time, two factors should be considered.
One. the articulations undergoing compress ion must tolerate the compressive
lorces and two. the position and movement used during facet di straction may
cause narrowing to occur in the intervertebral lora men.
Cervical disc traction example
TrclI1slalOric Spinal Maniplllalion I 5
...
Facet joint glide techniques arc pcrfonncd with the spinal segment in a coupled position (see Chapter 2 for a
description of coupl ed patterns in the various spinal regions). The TSM impulse is directed parallel to the articular surface
during facet gliding techniques. Stabilization of adjacent spinal segments is achieved through direct manual contact or
through spinal locking (see Chapter 2 for further details).
Cervical facet distraction example
Ventrally. medially and
...... 'V caudally directed impulse
Features of this text
Cervical facet glide example
A ventral cranial
directed impulse on the
left.
Caudal stabilization
A dorsal caudal
directed impulse on
the right
The technique pages of thi s text have been designed to reduce the I11cntalload imposed on the learner when studying TSM.
The author's recommendation regarding how to best approach the study of these materials is described below. The authors
do not recommend that first time learners attempt to read and process all infomlation on each page at the same time. Rather
we recommend that the technique and its description boxes be studied first. followed by the other sections as appropriate.
C2-7-Disc Traction
Indication : To improve movement in all directions
Position: Supine
Start by reading and studying the
technique illustration thoroughly.
The details needed to understand
and perform the technique are
integrated into the illustration to
eliminate the need for student
integration of separate pictures
and technique descriptors.
The next section, titled "trouble-
shooting your
provides the author's insight into
common mistakes made by the
learner when learning TSM. It is
intended to serve as a guide to
instructors who are trying to
determine the source of a
student' s error and for students

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The last section includes clinical

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6 I Chapter I : tntroduclng TSM
TSM
Applying TSM
Translatori c thrust technique consists of a series of manipulati ve maneuvers which arc quite complex and present a learning
challenge to even the Illost experienced clini cian. The following secti on provides a detailed description of techlliquc
parameters such as patient and therapi st positioning. loca li zati on of movcmcnt within the spine and the generati on of speed,
force and appropriate amplitude ofmovcmcnt when performing TSM. Finally, suggestions regarding training arc di scussed.
Patient & therapist positioning for TSM
As with all physica l examinati on and treatment techniques, proper positioni ng is essential for both the patient and
therapi st. When posi ti oning a pati ent for translatori c manipulation,
it is cnlciai that he/she is comfortabl e and able to relax hi s/ her
whole body, especially the region of the body that wi ll be treated. In
addition to selecting a positi on that promotes patient relaxation, the
therapi st must also consider patient posi ti ons where they are most
effective in achieving a success fu l manipUlation. Thi s text includes
a number of different positions the therapi st may use to achieve
the same manipulati ve effect. Therapi sts studying these various
positional options are encouraged to practice all variations to achieve
the same cflectiveness regardless of patient position. The therapist
should always posit ion themselves with: ( I) a stabl e (wide) base of
support, (2) good spinal alignment/position and (3) a relaxed upper
body. This will assist in the process of correct patient positioning and
promote more precise control of the patient's body part during the
manipulative technique.
Finally, the skillful appli cati on ofTSM requires thc
therapi st to be in close proxi mity to hi s!her patient. Regarding th is,
the therapi st should be aware of all physical contacts that occur
when positioning the patient. These contacts. in addition to the
specific pre-posi tioning, manual stabili zati on and pre-stressing ofa
vertebral segment , should at the minimum, be non-painful and should
also allow the pat iel1l to relax. Patient relaxation is facilitated by
providing adequate and skillful suppon of all body pans supponed
by the therapist ' s hands. In addition, the movement used to posi ti on
the pati ent for the translatori c thrust technique should be preCise and
purpose/ul. Therapists should avoid repetitive pre-positioning. The
considerati on of our physical presence and the use of precise and
purposeful movement enhances pati ent confidence in Ollr abil iti es
as experienced and professional practitioners of manual therapy.
Ultimatel y, both patient relaxation and patient confidence in our
abilities will further improve the outcome ofTSM.
Localization of the treatment segment
TSM emphasizes the locali zed appli cati on of joint specific
and segment specific manipulat ion. This is achi eved by manua l
contacts directly on the joint or segment to be moved. The use of
stabi li zat ion techniques such as locking or direct manual stabilizati on
of the adjacent vertebra further enhances treatment specificity. This
Therapist & patient positioning
i
i with his/her
spi ne in good alignment
avoiding excessive
ventral. dorsal and
lateral flexion.
To achieve this the
patient is positioned
dose to the edge of the
table, the table is
adjusted to an
appropriate height and
the therapist uses a
wide base of support.
Localization of the treatment segment
is in contrast to some commonl y applied methods of manipulative
treatment that lISC contacts whi ch may be far away from the intended
treatment segment , such as the pelvis or the head. Typically, these
techniques are combined with larger rotational moti ons that move
mUltiple spinal segments. These nonspecific rotational techniques not
only produce multiple cavitati ons in an unpredictable pallem bUlmay
also unnecessarily stress weakened and sensit ive oft tissue structures
including the facet j oi nt capsules, the intervertcbral di sc and other
supporti ve segmental li gamentous structures. This is panicularly
problemati c whcn applied over degenerative hypermobile segments.
Even manipulative techniques which use manual contacts on adjacent
spinous processes but still incorporate the rib cage and pelvis into the
manipulati ve movemcnt are nOltrul y specifi c techniques and have the
potential to irritate hypcnnobil c spinal segments. For readers who are L ____________ = = = = : : : J
8 I Chapter 2 : Apptying TSM
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unl.1nu "lth the con\.. oft mg r for th'" reader \\ ho \\ Ishes to fe\ ie\\ the concept. please read the fo ll owing section.
Locking: an introduction
Locking is a technique used to re (riel intersegmental moti on for the purpose of stabili zing/constraining the 11 0n-
mampulated \ enebra in the spinal motion segment. The underl ying principle behind locking is that the spinal motion
:tegment ha!t a finite amOllnt or motion. \Vhen Illotion ill one plane is taken up, less mOLi on will be available for movement in
the remaining planes. To illustrate this poi nt , try the foll owing:
I) With your cervical spine in a mid-posi ti on, rotate your
neck ( 0 the right being careful not to dorsal or ventral
flex or sidebend your neck at the sa me time. Note how
far you can move and how easy it is to move into right
rotation.
2) Return your neck to the mid-positi on.
3) Next, side bend your neck all the way to the len. At the
end of your available range of cervical side bending to
the len. add rotati on lO the right. Note how far you can
rotate and how difficult it is to rotate from thi s side bent
position compared to when YOLI started in mid-position.
It is much harder to rotate from a full y side bent position
then it is from a non-side bent position.
This si mple example can be tried with a number of combinations of
movement. For each combinati on. the first cardinal plane motion
will decrease when additional cardinal plane motions are added
prior to performing the pri mary motion. In addit ion to changes in
the range of movement available wi th these various combinati ons of
movcment, there will also be changes in the ease in whi ch the end of
moti on is reached by the pati ent and the sensc ofstiflness perceived
at the end of motion. Thi s endfeel wi ll typicall y vary from a morc
clastic/ muscular end feel to a fiml er or more articular endfcel. How
quickly the moti on in the segment will r e ~ l h its end range and the
Comparison of right rotation in
neutral and left side bending
Compare how it feels to
rotat e from a mid
cervical position, to
easy it is to rotate from
a left side bent position.
endfeel pcrceived by the pati ent and therapi st at the end range of move men 1 will vary, depending on how many and in what
order planes of motion are combined inlhe movement segment.
Examples of two and three plane movement combinati ons and their typi cal endfeels are provided in the tables below.
C2- T3
Movement Endreel Movement Classifica ti on
Side bending and rotati on opposi te Finn Noncoupl ed
Side bending and rotati on same Elasti c Coupled
Ventral flexion, side bending and rotati on oppos it e Firm Noncoupl ed
Ventral fl exion. side bending and rotation same Elastic Coupl ed
Dorsal flexion, side bending and rotation opposit e Firm Noncoupled
Dorsal fl ex ion, side bending and rotation same Elastic Coupl ed
T3-L5
Movement Endreol Movement CI1I ssifi cation
Ventral fl exion. side bending and rotation oppos ite Firm Noncoupl ed
Ventral fl exion. side bending and rotation same Elastic Coupl ed
Dorsal fl exion, side bending and rotati on opposite Elastic Coupl ed
Dorsal fl exion. side bending and rotati on same Fiml Noncoupled
Translatoric Spinal Manipulation I 9
It is important to remember that these movements and spina l coupling patterns are dependent 0 11 the specific
anatomical and biomcchanical characteristics orlhe indi\ idua l spinal mot ion segments. Because the anatomy orlile
vertebrae (specifica ll y the facet joints) may \ ary between and \\ ithin spinal levels. it is necessary to pay close atlention to
the end feels pcrcci\cd with these dilTerent mo\ement combinations during the patient examination. When variations are
round. the subsequent mm'cmenl used to constrain 1110tion must also be modified in order to lock or constrain motion al the
segmcnt(s) adjacent to where the TSM will be applied.
For the purposes of this text. movement patterns that produce finn endleels arc classified as l1ol1collpled molions.
MO\cmcnt patt erns \\ hich produce morc clastic endfeels are classified as coupled mOlionf. The finnness or the endfccl
associated \\ ith non coupled motions is attributed to the interaction of the facet joints and the interconnecti ng ligamentous
tissues. Conversely. the elastic nature or coupled mOl ions is attributed to the lengthening of muscular tissues.
Because the combination of spinal segmcnt mO\cments that may be used during locking is extensive. noncouplcd
positions. as identified in the table abo\'e. are uscd to illustrate locking in association with TSM \\ ithin this text. Howevcr, il
is important to remember Ihat locking can be achic\ed through a numbcr of combinations ofsevcral planes ormation.
When using TSM to restore segmental motion. the therapist may either mobilile the cranial or caudal \crtebra.
When mobili7ing the caudal \ ertebra. locking may be used to constrain and protect the vertebral segments cranial to the
segment or joint being manipulated. This is called locking above. When mobilizing the cranial vcrtebra, locking is used to
stabi li ze/constrai n and protect thc vcrtcbra l segments caudal to the segment or joint being manipulated. This is ca ll ed locking
belo\\ and is described in further detail in the following two scctions.
Locking the segment(s) above the treatment segment or joint (locking above)
When locking is llsed to stabilize, constrain and protecl
the \crtebra l segments cranial to lhc segment or joint being Locking above
manipulated it is called locking abo\ e. An example of the use (see page 54 for fu rther detai ls regarding this technique)
or locking abo\ e is translatoric C5 cen ical facet Joinl traction
manipulation. During this technique. in order to traction the right
facct joint at lhe CS spinal segment, the supra-adjacent spinal
segments. including the C5 spinal segment. are Side bent lell
and rotated right in cnect locking thcm against lcn rotation. The
therapist Ihen applics a translatoric \entral. mcdial and caudal
fo rce on the right lamina and superior articular proccss ofC6
creating a slighl lell rotation ofC6. In Ihis example. C5 and the
scgments above arc restrai ned from turning 10 the left with C6
by their pre-positioning in lell side bending and right rotation.
The segments 010\ ing caudal to C6 \\ ill follo\\ into slight len
rotation \\ hi le already pre-positioned in lell side bending. This
combination of len si de bending and len rotation is a couplcd
motion. In this situati on. segments that end in a coupled position
or scgments that are mmed into or tm-.ard a coupled position are
referred to as III1/ocked.
Locking the segment(s) below t he treatment segment or joi nt (locking below)
When locki ng is used to stabi lize, constrai n and protect
the vertebral segments cauda l to the segmcnt or joint bci ng Locking below
manipul ated il is call ed locki ng belo\\ . A good exa mple of (see page 57 for further details regarding this technique)
locki ng belm\ is the translatoric C:? facet glide manipulation.
Duri ng thi s technique. in order to treat the right lacet joi nt at the
C2 spinal segment wilh a ventral-crani al trans latoric gl ide, the
infra-adjacent spi nal segments are si de bent right and rotated
lell. By ri ght side bending prior to le n rotaling when positioning
the lock, the thera pi st compresses the right racet joint s and takes
lip li gamentous and mllscular slack in the sidebcnt porti on of lhe
spine. Thi s in turn restricts the amount of avai lable left rotation
in the locked porti on or the spine. ext, the therapi t passi\ ely
and specifi call y side bends the C2 segment to the len to unl ock
only that segment (C2/3). At thi s pOint. \\ hen C213 is placed in a
coupl ed positi on (unl ocked). a short quick translatoric movement
is perfoml ed in H ventral and crani al directi on on the ri ght lamina
and inferi or art icular process ofC2.
10 I Chapter 2 : Applying T5M
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Placi ng the C2 segment, or any ot her spinal segment. in a coupled position (in thi s case len side bending and left
rotation) facilitates greater ease of movcment for the scgmcnt during the translatoric gliding manipulation. Therefore,
segmcntal mo\ ement ofC2 during the impul sc will generate the most effective stretching of intersegmental connective
tissues while minimi zing articular compression at the segment.
Testing prior to using locking during manipulation
\Vhile locking may prO\ idc greater stabili zat ion than direct manual stabili zati on during TSM, there arc timcs
when the pre-pos iti oning used during a locking maneuver may still cause too much stress across an irritable or hypennobile
spinal segment. To best determine if locking \\ ill provoke signs and symptoms in a patient . the therapi st must first perform
a comprehcnsi\c and passive movement examination on the section of the spine which will be placed in a locked
position. Afier the movemcnt examination has becn performed and hypermobility has not been identified, the therapist
should then passively move the section of tile spine to bc locked into a locked position and apply a small amount of
overpressure to determine if the segment s are still nonreactive. An example orlhis is when the therapi st is performing
a ventral crania l glide ofC]: on the ri ght and they want to usc locking bel o\\. Ancr the acthe and pass ive movement
examination has been performed and hypcrmobilit y has not been identifi ed, the therapi st will contact C3 and passively
position C3 and belo\\ into a locked position. Thc therapist monitors the patient's reacti on to the locking through both \erba l
responses from the patient regarding the posi ti oning and through nonverbal rcsponses such as facia l grimacing and muscular
guarding of the cervical paraspinals during the passive positi oning. Ifhypermobi lity is identified during the movement
examinati on or if the patient tolerance to the locking is poor, the therapist should either abandon the usc ofl ocking or
supplement the locki ng \\ ith manual stabi li zati on.
To determine \\ het her the locki ng should be abandoned all together, the therapist must decide if placing the
segments to\\ ards a locked position \\ ill prevent Ihem from mO\ ing into a position that is further irritating. An example of
this is \\ hen a therapist wants to imprO\ e ventral cranial gliding at C1 and the patienl does nOltoleratc len rotation at CS.
By posi ti oning C5 i11l0 right ide bending but not rotati ng C5 to the left. the segment is in elTect partially stabili zed aga inst
len rotation bccause movement has been taken up at the scgmcnt. This position is then flu1hcr reinforced through manual
stabili /ati on.
When applying a manual stabi liLati on procedure, the phys ica l therapist must continuously monitor the amount of
contact pressure he/shc is applying to a pati ent 's vertebral segment and rel ated soft ti ssll es. The pressure must be e fTecti ve
in restrai ning movement and tolerabl e lor thc pat ient. Thc therapi st may use a broader cont act such as the pad of the thumb
as opposed to the tip ofthc thumb to enhance patient tol erance. In addi tion. otht: r port ions of hi s/her hand may be used
simultaneously to further minimi ze cont act pressure points and stabili ze the non-manipul ated \ ert ebra. Furthennore, the
stabi li L.ation pressure should be appli ed in a graded manner with a li ght relaxed grir> initially. building to a more
stabi lization as the slack in the segment is taken up. and then reducing back to a light relaxed grip follo\\ ing the translatoric
thrust technique.
The amplitude of t he translatol'ic mobilizati on & impulse
When lIsing 10\\ \ elocity translatoric manipulation. the therapist may usc grade I. 1: or 3 mo\'ements from
Kaltenbom's scale. Gradcs I and 1: translatoric movcments are used to relie\ e pain. rcduce joint and neural swelling. reduce
muscle gua rding and imprO\e the qua lity of 1110\ Cl11c nt in a spinal motion segmcnt or region of motion segments. Grade 3
translatoric motion is used to stretch the intersegmental ti ssues restricting spi nal segmcntalmotion. Thcse ti ssues may include
segmental musclc(s). facet joint capsular ti ssue and discal ti ssllc. For a more detailed re\ ic\\ of the three grades of movement
advocated by the Kaltenborn-E\jenth concept , please consult Kaltenborn's Manual Mobilization of the Joi nts Vo lume I or II.
In genera l terms. \vheJ1l1sing hi gh velocity movement the translatori c impul sc should bc as short as possible. Thc
translatoric impulse should be del at the end or Kaltenborn's grade 2 (whcre the final stop occurs). In order to generate
a joint Cin itation and therapeutically streIch joint related restricti ons. the impul se must cross the final stop. In ordcr for thi s to
occur. the amplitude ofa TSM may \ary sl ightl y dependent upon the technique in qucstion. Ot her factors that will also play
a role in determining the amplitude ora TSM are dependent on: ( I ) the area of the body being manipulated (e.g. C2 \ entml
cranial glide \'s. lumbar disc traction \\ ith a bod) drop), (2) the physical allributes (size, strength and body weight) or the
therapist and (3) the motor skills (experience and quickness) of the therapist.
Generating speed during hi gh velocity translatori c manipulati on
When performing high \elocity TSM. the therapist uses an impulse or quick. high speed movemcnt to di stract or
glide the IVD or facet joints. One challenge encountered by clini cians learning this type of movement intcr.ention is the
tendency to gcnerate hi gher amplitude mo\ cments when trying to generate a hi gher \elocity movement. To properly protect
the joints and segments undergoi ng manipulation during thi s learning phase. the cl ini cian should reduce the amplitude and
at times the fo rce. That said. the practi tioner ofTSM must always bear in mind that when speed and force arc increased the
amplitudc of the movement must always rcmai n sma ll.
There will be some natural va riati ons in how speed is
generated when performing TSM to different parts of the spine Generating speed during TSM
dependent on the TSM technique used. For example, when
a cervical facci traction or glide is performed the impulse is
generated by the shoulder and shoulder gi rdle. In contrast. when
pcrfom1ing a TSM lumbar disc traction technique the impulse may
be generated lI sing a body drop.
To generate a high speed movement , the manipulator
must determine how they can prepare themselves to move quickly.
This is not an easy task. As mentioned previously. all physical
interfaces (manual contacts) with a pati ent must convey a sense
of confidence and relaxation. At the same time. the muscles
which will ultimatel y be used to move the therapist"s hand/arm
must be ill a "ready state." This ready state can be best described
as an ""active tension" in the muscle groups that wi ll power the
manipulating hand/a rm. This active tension is an athletic concept
that also needs to be appli ed to the therapist's lower extremiti es
and spi nal alignment. Greater neuromuscular enort is required to
reach a ready state in individuals who have a tendency towards
lower molor tone. poor hand/eye coordinati on and poor postural
sense. Conversely. for indi viduals with higher motor tone and
better athletic abiliti es it is equally important to relax thei r
neuromuscular system prior to delivering a translatoric impulse.
Ski llful application ofTSM can only be learned through
repeat ed practice and guidance from an experi enced and skill ed
TSM practiti oner. A therapi st interestcd in developing an
advanced level of ski ll in the applicati on of these techniques
should creatively find ways to practice improvi ng their motor sk ill s
in the area of speed generati on. The therapi st should cont inue
to train themselves to genemte as high a veloci ty movement as Lumbar disc traction TSM
possible us ing all of the techniques illustratcd within this text.
Using enough force with TSM: " As little as necessa ry, as much as needed"
The force applied during TSM is dependent on the treatment grade desired (Kaltenborn's grades 1-3) and the degree
of stiffness present within the spinal segment. It is not uncommon to find greater degrees of joint restriction in cases of
advanced segmental degeneration and afler prolonged periods ofsegrnentalmovement restriction. In these clinica l si tuati ons,
greater force is typica ll y required to restore 1110ti on using TSM. If too much force is required, then high velocit y TSM is not
indicated. Rather, low velocity TSM whi ch is under vo liti onal control orthe patient is used to reduce the st iffness to the point
where a high velocity TSM can be eflect ive.
I f performing a grade 3 high or low velocity techn ique. enough force must be lI sed to create joint separati on/ tracti on
or gliding. This applied force may vary based upon the length of time the motion segment has been restricted, the stage of
degenerative change and resultant connecti ve tissue changes and the physical size of the patient (i.e. more force is typically
required to move larger pati ents).
Integrating TSM into clinical practi ce
As clinicians put these newly Icamed techniques int o practice we would cauti on individua ls to pay carefu l attention
to technique select ion and the tcrnporal proximity of the use ofTSM to other interventions. Specifically. if the manipulative
intervention is used in combinat ion wi th other techniques it may be diffi cult (if not impossibl e) to son out the specific effects
of TSM. Regarding thi s, a clinician will never develop a sense of whi ch TSM technique appears best suited for certain
cl ini ca l presentations. On the ot her hand, wi th proper ment ori ng from an experienced TSM practitioner and with increased
experi ence usi ng the techniques it is possible for the novice to effecti vely integrate TSM with other therapeuti c interventions
to optimi ze patient outcome from treatment.
12 I Chapter 2 : Apptying TSM
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Prior to appl ying TSM, the clini cian may want to use isolated short arc acti ve spi nal movements, hold/relax
manua l muscle stretching. convent ional son tissue massage and functi onal massage to reduce muscle tension. TSM should
also be followed by movement reeducation aimed at cont rolling movement at adjacent sympt omati c hypermobile spinal
segments and encouragi ng isolated movement at hypomobil c segments that were recentl y mmlipulated. Thi s general
pract ice philosophy provides not onl y good immediate results ror pat ients, but is also crucial ror the long term management
or ymptomatic hypermobi le segment s that are adjacent to hypomobile spinal segment(s). For example, TSM may be used
to improve movement at the C7rrl motion segment when there is symptomati c hypennobili ty at the CS/C6 and/or C6/C7
spi nal segment s. With improved movement at C7rr 1 segment (a ft er TSM). the pat ient will potent ially recruit moti on through
the cervicothoracic j unction and into the upper thoracic region more efTecti vely. Thi s will reduce movement stress at the
sympt omatic hypermobile segments. The pati ent wi ll then be instructed in speci fi c selr-mobilizati on M the C7ff l segment,
and the upper thoracic segments and also instructed in movement reeducati on techni ques that Ini nil11i ze moti on through the
mi d-cervical region. Thi s comprehensive pl an of care is based upon sound orthopedi c biomechani cs and should serve as a
pl an for longitudinal management of symptomati c spinal degenerative change or inj ury.
Aft er years of clini ca l practi ce, the authors have observed trends in segmental movement patt erns. These trends
include reduced Ill oti on (hYPoI11 obili ty) or ill creased 1110ti on (hypermobility) in both symptomati c and pre-symptomat ic
spinal segments. Some or these trends are as roll olVs: ( I) decreased movement at 011, C2/3, C7ff I. TI -8 and L 1-3 and (2)
incrcased movemcnt at C4/5. C516, C617, T I2/ L I. L4/5 and L5/S I. Fail ure to recognize and acknowledge these common
motion tendencies leads to manipulat ive techniques and spinal exercise programs that are mult i-segmental in nature. These
non-specific management strategies may inadvertent ly lead to furt her degenerati ve changes in spinal moti on segments
that are hypermobil e. Because or th is commonl y observed tendency, a thorough interventi on plan must include both the
identi fication and management of the pri mary spinallevel(s) involved. as well as a careful examinati on of and intervent ion
fo r the surrounding regions of the spi ne that may contribute to symptoms and impaircd functi on at the primary spinal level(s).
Supporti ve and correcti ve inter vention techniques used in conjunction with TSM
Additional Aspects of Interventi on:
Impl ementati on of intervcllti on for a patient with orthopedic spinal pathology and associated movement impairments requires
a comprehensive examination and onen a multi -faceted pl an for interventi on. Typi ca ll y, the authors blend many different
forms of interventi on. In additi on to TSM techniques, our approach will consist of:
Suppor ti ve biomechanical ~ d v i c e regarding:
Moti on segment(s) protecti on through movement reeducation techniques including correct use of spinal moti on
coupl ing and restri cted or substitute forms of joint movement in order to minimi ze 111 0ti on through symptomati c
hypennobi Ie segments.
Controll ing vert ica l loading through symptomatic load sensiti ve moti on segment s through the instruction of
variolls and multi ple fonns of spinal self- traction.
Instruction in spinal muscle training exercises:
Postural and movement patt ern instructi on that emphasizes correct use or the deep cervical ventra l Hexor muscles
and pelvic/hip positi oning and movement patterns that fac ilitate the correct use of the deep lumbar extensor muscles and
abdominal muscles.
Spinal isomet ri c and spinal short arc isotoni c movement panerns that trai n the deep spi na l stabi lizer musc les
without causing signifi ca nt or pat hologica l segmental translati on.
Spinal stabili zat ion training that incorporates the use of equipment that support s the trunk, unloads the trunk and
trai ns pati ents in non-symptomati c spina l positi ons.
Self LV TSM exerci ses :
A combi nati on of specific active and passive segmental movement exercise prescribed to ma int ai n and enham:c
segmental mot ion after a session of manua l int ervent ion.
Soft t issue int erventi on:
Functi onal massage techni ques whi ch incorporate gentl e repetiti ve and pain free passive or acti ve assisted spinal
moti on whil e at the same time providi ng a comfortable massagi ng of the spinal muscle .
Hold-relax spi na lmusde stretching which provides a means to relax, warm up, stretch and train spinal
muscles.
Clinical condit ions, examination findings and common sequencing of TSM techniques
The following section includes several brief but comlllon case scenarios illustrating the selection and sequencing
or low velocity (LV) and hi gh velocity (HV) TSM techniques. This section will only include TSM interventi on
recol11mendations. The techniques are li sted with the 111 0St cranial segmcnt(s) li sted at the top oreach table progressi ng to the
most caudal spinal segment(s) li sted at the bottom. This is not intended to imply an order in whi ch the techniques should be
performed, rather it is sequenced to faci lit ate the reader in tracking and comparing the techniques li sted under the intervention
table and lhe reassessment tabl e. The techniques li sted are int ended to serve onl y as examples. 110 t as a prescription for the
practice or TSM.
The dosi ng orany physical therapy intervention, including TSM, requires careful considerati on of the benefits and
ri sks associated wi th the intervention. The benefits of adept application ofTSM include the immediate improvement of
segmental movement and reduction of symptoms fo r the patient. The risks of improper or overly aggressive applications of
TSM incl ude worsening of the pati ent's symptoms and reduct ion of segmenta l movement following its application. Because
TSM techniques are short and quick linear passive movements, they arc extremely sare when appli ed ski II rully to a spinal
joint or motion segment and rarely result in exacerbation of symptoms. That said, even the most skilled and experienced
practitiOller of these techniques ca nnot completely guarantee that certa in patients wil l not experience minor or brief flares of
his/her symptoms.
Regarding this, there are historical features and examination findings that can assist a clinician in detcmlining who
mayor may not react favorably to HV TSM. These historical rcatures and examination findings include: (I) the historical
time line or the patient's condition. (1) the reactivity or the patient's symptoms to movement and loading. (3) the degree
ofstifTness and the endfce l present in the restricted segments and (4) any comorbidi ti es thaI may slow recovery or may
be exacerbated by certain treatment selections and dosages. This infonnation is then e\aluated in order to estimate the
changeability of the patient's condition. The changeabi lit y or lack thereof is factored into the formation ofshon and long
term goa ls and the selection of intervention strategies for the patient.
While there are no hard and last rules for the opt imal nlll11ber oftotaltcchnique appli cat ions and the optimal
number of techniques used per treatment session the authors ha\ c observed the following. Patients who have impainncnts
that are more resistant to change require morc technique variations and oftcn repeated application of 'a rio us LV and HV
TSM tcchniques in order to receive optima l benefit. In many cases, multiplc repetitions of the same TSM technique may be
applied within the same treatment session \\ ithoUI negative erTect. Patient s who experience first time Illotion rcstrictions may
show significant improvcment with only a single application ofTSM.
To determine the elTect or both LV and HV TSM intel"\ention, the therapist should frequently retest movement
quantity and passive segmcntalmotion. The movements used to retest movement after the application ofTSM are identical
to the motions used during TSM, varying only in the speed in which they arc appl ied (lor further detail consult Kaltenborn's
A1cmual A10bili=aliol1 oflhe JOiI1IS. Volume II. The Spine). When improvement with one TSM technique diminishes. or if the
therapist wants to stretch a dilTcrent joint or tissue within the same segment, the therapist may change TSM techniques and
work on ot her pa ilS of the struClUres potentially restricting motion. During thi s multi-grade, multi-speed and multi-technique
treatment session. the therapist should dialogue with the patient to determine the location and intensity of the stretching
sensation he or she feels. Occasionally. a patient \\ ill experience soft tissue discomfon during the application of prolonged
grade III LV TSM. Often, this is the same patient \I ho will respond belter to I-IV TSM. With HV techniques. there is no
prolonged soli tissue contacL. Soreness that lasts morc than a le\\ minutes following stretchi ng may indicate that too much
stretching has been performed.
Practitioncrs ofTSM should engage his/her patient in an honest. opcn discussion regarding their physical therapy
diagnosis and prognosis foll owing the physical examination. The therapist should discuss the intcrvclllion options available
and the course or action the therapist feels would be the most beneficial. Fina ll y. lhe therapist and patient should arri\c at
a mutual decision regarding the course of action or intef\ention "hich will be taken within physical therap). While thc
therapist may not be able to predict with 100% accuracy how an indi\ idual patient ma) respond to a gi\'cn intcn ention. by
using continuolls exploration of the techniques and technique parameters pro\ idcd within this text it is possible to build a
knowledge base orhow patients generall y respond to TSM. This knowledge may then be used as a starting point lor the
applicati on ofTSM and may be adjusted as necessary to match the needs or indi, idual patients.
Lastly. therapists should a\oid making any unrealistic claims regarding the \alue or any ghen intervcntion
technique(s) and should especia ll y avoid any "fix it" language. This is especially true when providing manual imen-enllon
for comll1on degenerative orthopedic spinal conditions. In thesc cases and e\en in cases where there is no significant
radiological evidence of degcnerative spinal disease. the best therapeutic management requires thc establishment of long tenn
relationship between the patient and an orthopedic manual physical therapist. Thi not only benefits the patient who can call
upon " hi s/her therapi st' when h e s h ~ experiences a symptomat ic Illoti on loss in the cervical. thoracic or lumbar spine but the
therapi st benefits by seeing how spinal motion and certain spinal conditi ons tend to change over the years.
14 I Chapter 2 : Apptylng TSM
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Case I
C6 nerve root irritation with segmental hypomobility (Grade 2) at C2/3 and C7rrl.
Sequeuciug o/TSMtecimique(sl
Tl!chnlque Grade Veloclly Treatment Segment(s)
I.
Bt
Facet distraction III LV ipsilateral progressing to II V C2/3 segment
contralateral gapping
2.
Bt
Disc traction II LV C5/6 segment
3.
et
Ventral icranial III LV progressing to HV C7ffl segment
dorsal 'c3udal facet
glide
Sele!'1 examination techniques applied 10 C! 1'a/llale ,he reslIll.\' q(rSAJ il11en'elllioH
Spinal Lc\ci(s) Examination Tcchlliquc(s)
I . C2/3 Passi \ c facet distraction testing
") CS,6
"Doorbell and specific Spurling's test applied to reassess the irritubility or the C6 ne"e roo\.
3. C7ffl Ventral cranial (VC)/dorsal caudal (DC) facet glide testing
ote(s)
The Doorbell test is an examination procedure \\ here palpatory pressure is appli ed to the ventral primary ramus as it
lies in the cen ieal nene root gutter. The specific Spurling's test incorporales the passive translation ora superi or facet
in the movement segment into the cen ical inten crt ebra l forame n. Both examination procedures are used to assess the
provocability of the spinal nerve undergoing compression.
Translatoric Spinal Maniplllation I 15
Case 2
C4/5 and C5/6 symptomatic segmental hypermobility (Grade 5) with segmental hypomobility
(Grade 2) at CO/ I, C2/3 and TI-T4.
Sequencing oj TSM reclmique(s)
Technique Grade Velocity Treatment Segment(s)
I.
,
Traction III LV progressing to HV COli
2.
Et
Facet di straction III LV ipsilateral progressing to HV C213 segment
contralateral gapping
3. Bilateral fa cet III LV progressing to HV T 1-4 segments

di straction

4. Cervical movement reeducat ion and stabilizati on training for C4/S, CS/6.
Select examination techniques applied to evaluate the results oj TSM imen'el1liOI1
Spinal Level(s) Examinati on Techni quc(s)
I. COi l Joint play and passive coupled rotation testing
2. C2/3 Passive facet di straction testing
3. C4-C6 Joint play testing and re-examinati on of symptom localization testing for these spinal levels.
4. TI-4 Joint play testing
Note(s)
Symptom locali zati on testing is a comprehensive series of clini cal examinati on movements used to difTcrcntiate whether
symptoms are originating from different regions, segments or structures in the spine. For further details consult Evjenth and
Gloeck's The Symptom Locali:atiol1 in the Spine and the Extremity JoilJl availabl e from OPTP at www.OPTP.com.
16 I Chapter 2 : Apptying T5M
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Case 3
Generalized grade I hypomobility at all cervical motion segments
Sequencing o/TSM lechniqlle(s)
I.

Traction & disc III LV progressing to I-I V COli, C2/3, C3/4 and C7IT I
traction segment s
2.
et
Ventral/cranial III LV progressing to H V COli. C2/3. C3/4 and C7fTl
dorsa llcaudal facet segments
glide
3.
Et
Facel di straction III LV progressing to HV COli, C2/3. C3/4 and C7fT I
segment s
Select exomil1C1liol1lecilniqlles applied fO el'o/ual e the results oj TSM inlen'el1liol1
Spi nal Lc\cl(s) EX3mi naiion Tcchnique(s)
I. 011 Traction joint play testing and passive coupled Illation testing
2. C2/3, C3/4,
71T1
Translatoric joint play testing, passive segmental side bending testing, passive segmental coupled
motion testi ng and passive segmental facet distraction testing
3. Cervical Spine CROM measurements pre- and POSI intervention
Note(s)
I. For further infomlati on regarding passhe moti on testing in the cervical spine consult Kaltenborn's flvfclI1l1ol Alfobili:alion
of lite ) oil1ls. Volume II. The Spine.
2. In the case of grade I restrictions. facet di stracti on and gl iding LV TSMs are often performed with the patient in a seated
positi on to all ow the therapi st's chest and lower extremiti es to contribute to the manipulating force.
3. Facet di straction is appli ed unilaterall y in the cervical spine. Irbot h sides are restricted the technique is applied to both
sides. one at a time.
4. Grade I restrictions are tre.:1ted with LV TSMs until movement is improved to a grade 2 and then HV TSMs may be used
to further restore moti on.
Case 4
A painful block of left cervical rotation with a recent onset.
Seqllencing ojTSM tec!l/Jiqlle(s)
I.
Bt
Disc Traction II -III !-IV I nvolved segmcnt (s)
2.
st
Facet di stracti on III LV progressing to !-IV Involved segment (s)
3.
et
Ventral/ cranial III LV progressing to !-IV Involved segment (s)
dorsal/caudal facet
glide
Select eramil1nfiol1 techniques applied 10 eva/lillIe (he reslIlls a/T5M il1len'ellliol1
Spinal Le, el(s) Examination Tcchniquc(s)
I. Involved spinal segment s Joint play testing and fe-examination ofsymptorn locali zati on testing for these spinal
levels prc- and post treatment.
2. Cervical Spine CROM measurements taken pre- and post interventi on
Nole(s)
1. Left rotation can be limi ted due to either restri cted ventral crani al gliding or the ri ght facet of restricted dorsal caudal
gliding of the len facel.
2. If the moti on is limited due to restricted dorsal ca udal gliding of the len lacet it may be treated wih facet joint distraction
!-IV TSM with the ccrvical spine placcd in ri ght side bending and slight left rotation. If left rotation is still lacking and
the patient 's cervical spi ne shows no sign of increased irritation. then ventral/crani al facet joint glide HV TSM can be
applicd to the caudal vertebra of the involved segment with the cervical spine placed in dorsal flexion, left side bending
and len rotation. Applying a ventral cranial glide to the superior art icular surface of the caudal vertebra while stabili zing
the cranial vertebra generates a relati ve dorsal caudal glide of the len facet in the treatment segment .
18 I Chapler 2: Apptying TSM
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Case 5
Ri ght sided upper cer vical pain with referral of discomfort to the ri ght posterior aspect of the
head and grade 2 motion restriction at COI l and C2/3.
Sequencing oj'TSM feclll1ique(s)
I.
,
Traction III HV COi l
2.
et
Ventral/cranial III 1-1 V C2/3 segment
dorsal/cauda l facet
glide
Select eraminCll ion leclmiqlles applied 10 eva/lime lite results ofTSM inten'enliOI1
Spinal LeI el(s) Examination Tcchnique(s)
I. COli Traction joint play testi ng, passhc coupled motion testing and recheck of symptom locali zati on
testing for COli
2. C2/3 Tra nslatori c joint pl ay testing. pass ive segmcmal side bending testing, pass ive segmental coupled
moti on testing and passive segment al facet di stracti on testing and recheck of sympt om locali:U1ti on
testing for C2/3
' ote(,)
1. Passive upper cervical rotation testing involves manual stabil ization of the caudal vertebra orthe segment being tested,
either COi l or C 1/2. The examincr generates passive rotati on with sidebcnding in the opposite dircction. Quantity of
movement . qualit y of movement and endfeel are evaluated.
2. Passive upper cervica l coupl ed rotation testing and symptom loca lizati on testing may also be performed at CI /2 though
this segmcnt is rarely restricted given its inherent capsular and ostcological features.
Case 6
Mid-thoracic pain, decreased active ROM and grade I hypomobility at the T4-8 spi nal segments.
Seqllencing o/ TSM lecllll iqlle(s)
I.

Di sc traction III LV progressing to HV T4-8 segment s
2.

Bil ateral facet II oscill ati ons, progressi ng LV progressing to HV T4-8 segments
di straction to sustained grade II ,
progressing to sustained
grade III
Select examination techniques applied 10 eva/uol e the results ofTSM intervention
Spinal Level(s) Exami nat ion Techniquc(s)
I. T4-8 Translatori c j oint pl ay testing. passive segmental extension testing and recheck of symptom
locali zati on testing for T4-8
2. Thoracic Spine Movement quantifi cation using tape measure techniques or doubl e inclinometers (universal
goni omcters) belo re and at the conclusion of each interventi on.
Nole(s)
I. The authors commonl y test passive segmental extension in the thoracic spine with the pati ent positi oned in sidclying.
For funhcr detai Is consult Kaltenborn ' s Mall llal Mobili=alion o/Ihe Joinls, Volllllle II, The Spine.
20 I Chapter 2 : Applying TSM
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Case 7
Mid-thoracic pain that wraps around the rib cage with loss of segmental motion at the same
level(s) as the referred pain pattern.
Sequencing oj TSM teclll1ique(s)
Technique Grade VeiocilY Treatment
Segment(s)
I. Disc traction III LV progressing 10 HV Involved segmenl (s)
2. Bilaleral facel II osci ll ati ons progressing to LV progressing 10 HV Involved segmenl (s)
.Ii.".
di straction grade III
3.
rr::
Costotransverse II osci ll ations progressing to LV Involved segmenl(s)
di stracti on grade III
SeleCI examination techniques applied 10 evaluate the resulls ojTSM il1len'entiol1
Spinal Level( s) Examinalion Technique(s)
I. Mid-I horacic Mid-t horacic joint play tesling. manual compression and lracli on tesling. recheck of symptom
(involved loca lizati on testing for mid-thorac ic.
segmenl s)
2. Rib joint s Rib distracti on joint play testing and symptom loca li zation testing or the rib joints.
adjacent to
involved spinal
regIon
Note(s)
I. Rib di stracti on j oint play testing can be performed in a number of examination positions. For fu rther deta il s consult
Kaltenbom's Manllal Mobili:otion ojthe )oil1ls. Volullle II. The Spine.
2. For details regarding symptom localizati on for the rib arti culat ions, refer to Symptom Locali::atiol1 il1 the Spine and
rtl'emity Joil1ls by Evjenth and Gloeck.
Trallslatoric Spinal Manipulation I 21
Case 8
Lower lumbar ner ve irritation with segmental motion restrictions from L 1-3_
Seql/ellcillg of TSM techniql/e(s)
Technique Grade Velocity Treatment Segmcnt(s)
I.

Side bending III HV L 1-3 segments
2.

Di sc tracti on II LV progressing to HV L4/5 & L5/S 1
segments
Select examination techniques applied (a evaluate (he results ofTSM il11er vel1li0l1
Spinal Level(s) Examination Technique(s)
I. LI-3 Translatoric joint pl ay testing and segmental side bending testing.
2. L4-5 Translatoric joint pl ay testing and sciatic nerve tension test ing and bowstring testing to monitor the
results of LV and HV tracti on TSM.
Note(s)
I. Lumbar disc traction LV TSM appli ed to the L4/5 L5/S I segments if nerve bowstring testing is consistent with a very
irritated nerve root. Progression to HV lumbar di sc tracti on TSM i fnerve bowstring signs show mild irritation. Self
management wi th lumbar disc self tracti on techni ques.
2. Lumbar joint pl ay and passive side bending is often examined wi th the patient in a side-lying pos it ion. For fu rt her
detail s consult Kaltenbom's Malll/al Mobilizatioll of the Joillts. Voll/Ille II. The Spille.
22 I Chapter 2 " Apptying 15M
Case 9
Symptomatic grade 4 hypermobility at L4/S with concurrent grade 2 hypomobility at LS/Sl.
Sequencing of TSM rec/lI1iql/e(s)
Technique Grade Veloci ty Treatment Segment(s)
l.
l3
Bilateral facet III LV L5/S I segment '
di straction
2.

Ventral cranial and dorsal caudal facet III LV L5/S I segment"
glides
3. LUlTIbo-pclvic movement reeducation and stabil ization training.
SeleCI eraminotiolilechlliques applied 10 e\'o/UGle the results oj TSM inlerl'el1fion
Spinal Level(s) Exami nation Technique(s)
l. L5/S 1 Translatoric j oi nt play testing and passive segmental flexion and extension testing.
Note(s)
* To protect the L4/5 hypermobility. a firm lowe I roll or cufTweight is placed anteri or 10 the L3-5 vertebrae. then a wedge is
used to press the sacrum ventrall y.
" VC gliding of the L5 segment can be achieved by ha\ ing the L5 vertebra positioned at the edge of the table and the pel vis
and legs dangling. ext, the sacrum is manipulated in a caudal and sli ghtl y ventral direction. During dorsal caudal gliding of
the L5 segment, a cufTweight is placed anterior to the L3-5 vertebrae and the base of the sacrum is manipulated in a ventral
cranial direction.
Case 10
Acute onset of right lumbo-sacral pain with a slight antalgic posture (left lateral list).
Sequencing of TSM rechniql/e(s)
Technique Grade Ve locity Treatment Segment(s)
I.

Di sc tracti on II HV Involved segment(s)*
2.

Si de bending II progressing to grade III LV Involved segment(s)*
Selecl examination techniques applied 10 eWlluate the results ofTSM intervention
Spi nal Level(s) Examination Tcchniquc(s)
I. L5/S1 Le ft sciati c bowstring test monitored while in right si de lying and L5/S I joint play assessed pre-
and post HV TSM. Antalgie posture re-evaluated roll owing BV TSM
Not c(s)
* During these techni ques the patient is placed in ri ght side-lying with the len latera l li st supported (i.e. patient in hislher
actual resting posit ion) .
In cases ofacul c lumbo-sacral pain. it is onen beneficial to combine hold-relax and functi onal massage with TSM.
Developing skill with TSM
Developing a hi gh level orskill in the appli cat ion orTSM req uires detailed and accurate instruction. conti nual
feedback, years of psychomotor refi nement and a refl ecti ve practice pattern. This text and companion DVD are designed
to act as instructi onal/learn ing aids to facilitate in thi s developmenl. Ifyoll are interested in learning more about TSM.
the author's encourage you to contact one of four established U.S. res idency/ fell owship programs whi ch speciali ze in the
instruction of TSM: Oakland Uni versity in Rochester, Michigan, The Institute of Manual TherJpy in Boston. MassachusclI s.
Folsom Physical Therapy and Training Center in Folsom. Cali rornia and The Inst itute or Rehabil itati on and Traini ng in
Prattville. Alabama. Non-US residents may contact Lasse Thlle, the president or K-E Int ernati onal, at lasse-th@:onl ine. no ror
inrormation regarding TSM based courses olrered worl dwide.
24 I Chapter 2 : Applying TSM
Cervical Spine
u@lffi D1J 0 C9J (ill@
--
The Upper Cervical Spine
The upper cervical spine (consisting of the Occipital-Atlantal
(OA) and Atlanto-Axial (AA) joints) presents with unique anatomical and
biomechanical characteristics that require additional consideration for the
manual therapist. In addition to their unique joint structure and lack of
intervertebral discs, these segments also encompass the spinal cord, brain
stem, meninges and vertebral arteries. The particularly large amount of
rotation available at the AAjoint in combination with the angular path of
the vertebral arteries between occiput-atlas-axis places additional stress on
these important vascular structures at end-range upper cervical rotation.
The following section will present a concise review of upper cervical
anatomical and biomechanical characteristics followed by a detailed
explanation of the translatoric thrust techniques used in the management of
upper cervical movement impairments.
Osseous anatomy
The occipital bone (occiput) is the inferior portion of the skull.
The occiput articulates with the first cervical vertebra through two condyles
located on either side of the foramen magnum (a large opening in the base
ofthe occiput through which the medulla oblongata, spinal cord, vertebral
arteries and meninges pass). The occipital condyles are convex in all
directions, face inferiorly and laterally and converge anteriorly.
The atl as (CI) is a ring shaped vertebra that unlike typical
vertebrae has no vertebral body, spinous process or intervertebral disc. Two
lateral masses constitute the principal bony structure on the anterolateral
aspects of C I. On each side of C 1, the lateral mass gives rise to the
superior and inferior articular facets. The superior facets typically present
as a concave elongated oval. They are longer in an anterior-posterior
direction and their direction of orientation is superior and medial. The
inferior facets are oriented in an inferior and medial direction. Typically,
and based on cartilaginous thickness, these facets will be slightly convex.
The axis (C2) is a unique vertebra in several regards. First, it
presents with a large superior projection from its vertebral body called the
odontoid or dens process. This process acts as the vertebral body for C 1.
Second, the superior articular facets of C2 have the more typical upper
cervical orientation whereas the inferior articular facets of C2 show a
typical lower cervical facet joint orientation. Similar to the remaining lower
cervical vertebrae, C2 also possesses a spinous process. The C2 spinous
process is large, projects straight backward and is in line with the lamina
and inferior articular facet.
Upper cervical articulations
The OAjoint is the articulation formed between the convex
occipital condyles and the superior articular surfaces of atlas. These
joints are surrounded by a fairly thick capsule that encloses the synovial
membrane for this articulation. OA is a plane synovial joint or enarthrosis
with three degrees of freedom. The principal movements are ventral and
dorsal flexion with a total range of motion of 13-25. Smaller amounts of
side bending and rotation also occur at this joint.
The AAjoint is comprised offour distinct articulations which
form a central AAjoint and two lateral AAjoints. The central AAjoint is
comprised of two articulations, the atlanto-dental joint and the transverse-
dental joint. The atlanto-dental joint is formed between the posterior
aspect of the anterior arch of atlas and the anterior aspect of the dens.
The transverse-dental joint is the fibrocartilagenous joint formed between
the posterior aspect of the dens and the transverse ligament. The anterior
aspect of the dens process has a convex facet that corresponds to an oval
26 I Chapter 3 : Cervical Spine Application
Articular surfaces of the upper
cervical spine
OA joint articulations
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facet on the posterior aspect of the anterior arch of at las. The posterior aspect of the dens contains a groove which articulates
with the transverse li gament.
The lateral AAj oint comprises the two art iculations fonned between the infe rior arti cular surfaces of at las and the
superi or articular surfaces of axis. The articular sur faces of C I are slightly convex and face inferiorly and medially. The
superior articular surface ofC2 faces superiorl y and laterally. The capsular li gaments of the two lateral facet joints are thin
and loose allowing between 35-45 of transverse plane rotation.
Ligamentous anatomy
There are a number of supportive ligaments in the upper cervi cal region, some of which are continuations of their
lower cervical counterparts. These ligaments include the tectorial membrane, anterior atlanto-occipital membrane, posterior
atlanto-occipital membrane, anterior atlanta-axial membrane and posteri or atlanto-axial membrane. All assist in conveying a
dcgree of stability to this rcgion. Becallse there are no discs at OA and AA, stability of these joints is primaril y supported by
li gaments. Criti cal to the maintenance of upper cervical stability is the transverse portion of the cruciate ligament (transverse
ligament) and alar li gament. These stabili zing structures are unique to the upper cervical region and will be the focus of the
remainder of this section.
The transverse ligament is the primary ligamentous
constraint to excessive ventral fl exion at the at lanto-axial j oint. Thi s
li gament is a strong and thi ck band (7-8 mm thick in its central
portion). It attaches to the tubercles on the lateral masses of the
atlas, articulating with a groove on the posteri or port ion of the dens.
Together with the anterior arch of at las, the transverse ligament
forms an osteoligamentous ring around the dens preventing anterior
translation of the atl as on the axi s. An intact and healthy transverse
ligament wi ll allow less than 3 mm of separation between the
anterior arch of atlas during ventral flexion of the neck. In children,
5mm of separation is considered within normal limit s.
The alar li gament is an important ligamentous connection
between C2 and the occiput. It is a strong cord- like li gamentous
structure di vided into two bands. These bands run from the superior
and posterol ateral aspect of the dens traveling in a superior, ventral
and lateral direction to their eventual attachment on the medial
aspect of the occipital condyles. In a mid or neutral cervical spine
positi on, thi s li gament is taut. The alar li gaments (I) limit rotation
and side bending of the occiput and (2) limit distraction of the
OA and AAjoints. According to White and Panjabi, there is a
reported 30% increase in rotation of the head when the opposite alar
li gament has been cut. Clinically. if there is greater than 56 of AA
rotati on or greater than go of OA rotation, significant instabil ity of
the upper cervical region should be suspected.
Laxi ty in the alar or transverse ligament has important
implications for two primary structures, the spinal cord/brain stem
and the vertebral artery. Speci fi cally, if the transverse ligament is
lax or weakened due to injury, pathology or other abnormal physical
stresses, the dens may move relati vely dorsall y pressing on the
spinal cord/brain stem as a result of ventral translati on of C I on C2.
Thi s may cause serious neurological compromise. Thi s movement
abnormality is generally more pronounced with ventral fl exion of
the upper cervical spine or when lying supine without support under
C2. As menti oned previously, laxity in the alar ligament may all ow
excessive rotation between occiput , atl as and axis which in tum may
cause excessive tensile stress, lumen compromi se or intima l wall
damage to the vertebral artery. To understand this it is important to
review the anatomy of the vertebral artery whi ch will be presented
in the next section.
Vascular anatomy
The vertebral arteries are a maj or source of blood suppl y
to the cervical spine and spinal cord. The arteri es ari se from the
subclavian arteries as the fi rst and largest branches. They enter
The transverse ligament and upper
cervical flexion
The vertebral artery and upper cervical
rotation
Note the acute angulation
the right VA during left
rotation at the AA j oint.
the transverse foramen of the cervical spine at C6 ascending from transverse foramen to transverse foramen before entering
the foramen magnum. At the level ofC2, the vertebral arteries course laterally to enter the transverse foramen ofCl. They
then angle posteriorly passing over the posterior arch of atlas, through the posterior atlanto-occiptal membrane and continue
cranially through the foramen magnum where they anastomose forming the basilar artery. Of particular importance regarding
the path of the vertebral artery in the upper cervical spine is its lateral angulation/orientation between the transverse foramen
of axis and atlas, and its sharp posterior angulation after it exits the transverse foramen of atlas. It is at this third segment of
the artery, between atlas and axis, where anatomical injury may occur secondary to excessive rotational cervical movement.
Note the illustration on the previous page.
Kinematics
The OAjoint
The osteokinematic movements observable at the OA
joint include ventral and dorsal flexion (nodding ofthe head),
small amounts of side bending or tilting of the head and small
amounts of rotation. The arthrokinematics of the OAjoint follow
Kaltenborn's convex rule. Accordingly, the occipital condyles
glide posteriorly on the superior facets of C I during ventral flexion
and anteriorly during dorsal flexion. During these movements, the
posterior arch of atlas and the occiput will separate during ventral
flexion and approximate during dorsal flexion (see illustration at
the right). Side bending at the OAjoint also follow Kaltenborn's
convex rule where the occipital condyle will glide in a direction
opposite side bending (e.g. with right side bending the right oc-
cipital condyle will glide medially and the left occipital condyle
will glide laterally). The instantaneous axis of rotation for lateral
flexion of the occiput is 2-3 cm above the apex of the dens pro-
cess. Small amounts of rotation have been described at the the OA
joint which also follow Kaltenbom' s concave-convex rule. During
right rotation a small amount of dorsal gliding will occur at the
right OAjoint, and a small amount of ventral gliding will occur at
the left OAjoint. Rotation at the OAjoint occurs around a vertical
axis located in the dens process ofC2 when both joints are gliding
normally.
The AAjoint
The greatest observable movement between atlas and axis
occurs during rotation (35-45). This comprises approximately
50% of the rotation occurring in the cervical spine as a whole. In
addition to rotation, the atlas also moves into ventral and dorsal
flexion (10-20). This is evident by an increase or decrease in the
distance between the posterior arch of atlas and the spinous pro-
cess of axis during ventral and dorsal flexion viewed on a lateral
x-ray. A small amount of side bending (2_4), described as a lateral
shift of the atlas on the axis, has been observed by several authors.
Some clinicians, including the authors of this text, feel that any
amount of "lateral shifting" ofCI on C2 may be indicative ofup-
per cervical ligament laxity.
The arthrokinematics of the AAjoint are the most
complex of all the spinal segments. Assuming normal joint shape
and articular function, during rotation the atlas rotates around
the dens. During right rotation, the right articular surface glides
posteriorly and the left articular surface glides anteriorly. During
dorsal and ventral flexion, the posterior surface of the anterior
arch of atlas slides superiorly and inferiorly respectively along the
anterior edge of the dens. As discussed in the previous section, the
amount of anterior translation of the articular surfaces of atlas on
axis is largely determined and restricted by the transverse ligament.
During dorsal flexion at AA, posterior movement of the atlas is
blocked by the dens process. During upper cervical dorsal flexion,
the amount of superior sliding and perhaps the amount of subtle
Direction of joint rolling and gliding
occuring during OA ventral and dorsal
flexion
Ventral Flexion
Dorsal Flexion
Upper cervical dorsal and ventral
flexion radiograph
Note the change in space between the base of
the occiput, the posterior arch of atlas and the
spinous process of C2 during upper cervical
dorsal and ventral flexion.
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ventral or dorsal movement of atlas on axis is in part detennined
by the shape (banana vs. straight) and orientation (superior-
ventral , superior-dorsal or superior) of the dens. During side
bending, the degree of side-to-side translation of the atlas on the
axis is limited by the shape of the atlas and the fixed connection
occurring between the axis and occiput via the alar ligament (sec
illustration).
The C2-3 vertebral segment
While not classically considered a part of the upper
cervical spine, movement at the C2-3 segment and below will
influence the amount of mati on occurring in the upper cervical
spine, particularly in the coupled motions of side bending and
rotation. Thi s is due to the alar ligament 's attachments between
occiput and axi s combined with the articulations between
occiput-atlas-axis as previously described. This connection is
readily apparent when passively testing side bending in the
upper cervical spine. When the occiput is side bent to the right,
immediate movement of the spinous process of axis to the left
may be palpated. It is hypothesized that right side bending of
the occiput pulls the dens into right rotation (principally via the
left alar ligament). If C2 is unable to rotate to the right then side
bending orthe occiput to the right will be hindered. Because of
this osteoligamentous connection between the C2 movement
segment and the occiput, it is important to examine the coupled
side bending and rotation movements at the C2/3 segment as well
as the coupled side bending and rotation movements at the COi l
segment. Restriction of coupled rotation at either of these two
segments will cause a resultant motion loss at the other segment.
Thi s type (direction) of motion loss can be easily mistaken for
rotational motion loss at the C 1/2 segment if clinicians are not
fully trained in specific passive motion examination techniques for
all three segmental levels.
AA arthrokinematics
Right Rotation
Side Bending
During right side bending. the left alar ligament
prevents separation of the dens from the occiput.
As the atlas translates towards the right its
wedge-like shape will allow only a small amount
of movement before the atlas is "wedged"
between the occiput and axis.
Testing and treatment implications of AA uniarticular restrictions
Non-restricted rotation
axis of movement for an unrestricted AA joint
runs longitudinally through the dens process of C2.
Note the lack of proximity of the dens and the
anterior arch of atlas. Also note the space availabl e
cord and
Forced rotation and uniarticular restrictions
When one articulation between atlas and axis is restricted, the axis
rotation is displaced to the restricted joint. If the testing or treatment
procedure involves a forceful ventral force on the side opposite the
restriction, greater stress will be placed on the transverse ligament.
This may lead to its compromise and subsequentially may cause
compression of the spinal cord and meninges.
Translatoric manipulation of the upper cervical Spine
Because of the intimate relationship between occiput-atlas-axis and the unique neurological, arti cul ar, ligamentous
and vascular structures associated with thi s region of the spine, only certai n short amplitude techniques are recommended.
At the OAjoint, low velocity and high velocity manipulations are performed in three translatori c directions: ( I) joint tracti on
(separation), (2) OAj oint ventral gliding and (3) OA joint dorsal gliding.
At the AAj oint, low velocity mobilizations are only performed by a dorsal gliding of C I on C2 and rotational
manipul ation is avoided all together. Thi s is due to the ri sks associated wit h anatomical injury to the vertebral artery, alar
ligament and transverse li gament (see illustration). At the C1I2 level, translatori c traction manipul ati on is the manual
treatment of choice for the rarely observed AA joint rotati onal restri cti ons.
Selecting a contact for OA traction
To create a tracti on of one of the OAj oints, a contact point on the occiput must be selected that is both easy to
palpate and facilitates controll ed movement at the OAjoint during the manipul ati on. There are two possible contact points
on the occiput, the mastoid process laterall y and the base ofthe occiput posteri orly.
The posterior contact on the occiput is typicall y easier to identi fy and access, whil e the lateral contact to the mastoid
process is more diffi cult to access. However, it is more diffi cult to minimi ze unwanted fl exion occurring from a posterior
contact on the occiput, then it is to minimi ze unwanted side bending that may occur wi th a mastoid contact. Therefore, to
generate the purest tracli on between occiput and aUas, the mastoid contact is the contact of choice described in this text.
To counter any unwanted side bending that may occur between occiput and atlas during the manipul ation, the OAjoint is
positi oned in slight side bending towards the mani pul ating hand pri or to the manipulati on (see illustration below).
Lastly, the tip of the mastoid process may be sensiti ve to contact during the techni que. To minimi ze any patient
di scomfort the therapist should refrain from holding Movements that occur at OA based on bony contact
hi s/her manipulating hand too tense against the
mastoid process and pull some of the skin and
underl ying soft tissues over the mastoid process 1 2 '-----------,
Flexion -13-25 ROM Side Bending - 3-S ROM
when positioning the contact hand for the impul se. _ 1... ___________ -'
The combination of these two measures, in additi on
to the inherent brevity of an impul se, makes the
mastoid process an excell ent contact for thi s
technique.
Avoiding excessive side bending at OA
To avoid excessive right side bending when
impulsing the left mastoid process, the therapist
positions the occiput in slight left side bending prior
to the impulse.
The impulse will move the occiput towards the
midline position while at the same time tractioning
the left OA joint.
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OA-Traction
EL - I2J
PP -HV
Indication: To improve movement in all directions (Right OA Joint)
Position: Side-lying
Slack between occiput and
is taken up cranially by the i
left hand and chest prior to delivering
the impulse.
Troubleshooting your technique:
Note(s)
One cardinal sign that too much slack is being taken up by the manipulating hand is di scomfort on the
mastoid process prior to the impul se.
Furthermore, taking up too much slack with the manipulating hand may cause increased tension throughout
the manipulating upper extremity whi ch can "slow down" the speed of the impul se.
If the amplitude of the impulse is too large, the manipulating hand may slide over the mastoid process
during the technique resulting in an ineffecti ve and potentially uncomfortable manipulati on.
Fai lure to support the head against the therapist's chest may result in unwanted fl exion of the OAjoint
during the manipulation.
During thi s manipulation the lower cervical spine remains in a neutral or slightly extended position.
The author's have found both the side-lying and supine OA traction techniques to be helpful in reducing symptoms
assoc iated with cervicogenic headache.
OA-Traction
EL -0
PP -HV
Indication: To improve movement in all directions (Right OA Joint)
Position: Supine
Slack between occiput and atlas
is taken up cranially by the therapi st's
left hand and chest pri or to delivering
the impulse.
; ; ; ; ; ~ ; ; ; is positioned
the patient's head,
and right shoulder.
therapist's left hand and
are positioned behind
patient's head and against
left side of the patient's
with the index and middle
cupped around the
~ 0,,1;001'< chin.
Nole(s)
Fai lure to correctl y locate the mastoid process with the manipulating hand is a COl11mOIl error. The manipul ating
hand shou ld be pos iti oned laterall y under the mastoid (not posteri or and medial under the base of the occ iput ).
One cardinal sign that too much slack is being taken up by the manipulating hand is di scomfort on the
mastoid process pri or to the impul se.
If the amplitude of the impul se is too large, the manipulat ing hand may slide over the masto id process
during the technique resulting in an ineffecti ve and potenti all y uncomfortable manipul at ion.
Failure to support the head aga inst the therapi st's chest may result in excessive side bending motion of the OA
j oint during the manipulation.
In some cases, the therapi st must sli ghtly fl ex the patient ' s lower cervica l spine in order to gain access to the
mastoid process pri or to positi oning the OA joint for the TSM.

OA-Traction
EL --:-[v - l
Indication: To improve movement in all directions (Left OA Joint)
Position: Seated
The therapist's fight hand
holds around the left side
of the patient's head with
the fifth finger positioned
under the occiput.
The head is supported
against the therapist's
chest.
After the left and right hands
are in contact with the patient,
slack is taken up by the thentpist
applying (1) a gentle cranial force
with their right hand and chest and
(2) a caudal and slightly ventral
stabilizing force on the posterior
arch of atlas with their left hand.
The therapist stands in front
of and to the right of the
patient.
The therapist's left hand
contacts the posterior arch
atlas.
Nole(s)
Fai lure to provide an equal impulse from the chest and hanclmay result in a side bending movement at OA during
the manipulati on.
[fthe amplitude of the impulse is too la rge, moti on may be felt lower in the cervical spine during Ihe manipulation.
Discomfort may be felt by the patient if the therapi st squeezes the atlas and/or occiput with too much force during
thi s technique.
While it is difficult to stabilize the at [as, the use ofa short amplitude movement and the caudal stabili zing
force wil! help to minimi ze the amount of movement occurr ing at AA and below.
In clinical practice, it is common to blend var ious intervention techniques . TSM, translatoric mobilization and
functi onal massage can be readil y applied in the seated posit ion. This is true when treat ing throughout the cervical
sp1l1e.
Tt"anslaloric Spinal Manipulation I 33
OA glide techniques
While OA tracti on TSMs are excell ent treatment techniques, there are times when they are not sufficientl y effective
in restori ng ventral or dorsal gliding of the occiput. In these instances, a more isolated approach that is directed speci fi cally
at restoring ventral and dorsal gliding movement may be necessary. When using TSM to restore ventral flexion, the therapi st
may either perforo, a dorsal glide of the occiput or a ventral glide of the atlas. Performing a dorsal glide of the occiput in
supine is a particularl y good technique because it can be easily combined with PNF hold-relax stretching techniques to treat
both OA glide restrictions and suboccipital muscle tightness. The seated technique may be easil y combined with functional
massage which may help relax the suboccipitals. In additi on, the seated positi on is parti cularly useful because cervical
moti on can be measured usi ng a CROM immediately preceding and following treatment wit hout changing the patient 's
position.
It is the experience of the authors that the OAjoint is less commonly restricted in dorsal flexion, however, in cases
of advanced arthrosis or prolonged immobilizati on it may be necessary to use TSM to restore thi s motion. Because it is
easier to stabili ze the occiput, this technique is performed by gliding the atlas dorsally to create a relative ventral gl ide of
the occiput. To achieve the greatest movement of atlas in a dorsal direction, the therapist must contact the anteri or portion
of the transverse process ofatla5. Because there are a number of sensiti ve soft tissue structures located in thi s area, preci se
instructions on how best to contact atlas are included on the technique page.
Direction of gliding used to improve OA vental and dorsal gliding
Ventral Flexion Dorsal Flexion
I:
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Occiput-Dorsal
EL - LV
PP-LV
Indication: To improve left rotation and flexion (Left OA Joint)
Position: Supine
Slack between occiput and
atlas is taken up in the
direction of the stabilization
hand.
The left OA joint is
mobilized by the combi na-
tion of a dorsally applied
mobilization force applied
by the therapist's right
shoulder while the atlas is
simultaneously stabilized by
the therapist's left hand.
__ - --L.-
Troubleshooting your techni que:
The therapist stands facing the top of
the patient's head.
The therapist's right hand is placed
posteriorly under the patient's occiput.
The therapist's right shoulder is
positioned anteri orly on the patient's
forehead superior to the patient's right
eye.
The pati ent's occiput is positioned
in ventral flexion, sli ght right si de
bending and slight left rotation.
The therapist maintains thi s
position by gently pulling cranially
on the posterior aspect of the
occiput with their ri ght hand while
pressing caudally on the forehead
their i shoulder.
The therapist's left hand contacts the posterior
suriace of the left transverse process and posterior
arch of atlas with the MCP and radial border of their
The therapist's hand is positioned with the thumb
extended and the fingers "stacked" over each other.
This position provides support for the index finger
and the hand.
Compression through the top of the pat ient's head shou ld be avoided during this technique.
Pressure over the orbit , temple or bridge or the nose shou ld be avoided during thi s techni que.
Note(s)
Fai lure to properly pos it ion the occiput during thi s technique may lead to a poor ly loca lized and potentiall y
ille fTective techn ique.
This technique is predominantly used as a mobi li zat ion technique. Whilc an impulse is not nccessari ly
contraindi cated, it is di ffi cult to deliver an effecti ve impul se in thi s position. See the "Atlas vent ra l" technique on
the next page fa r a more eOecti ve manipulat ive technique to improve dorsal gl iding of the OAjoint.
Thi s technique as illustrated is a unilateral technique. It may al so be performed as a bi lateral technique. To
perform thi s as a bilateral technique, the stabi lizati on hand is moved to the midline posteriorl y, the therapist' s
shoulder contact is moved to the middle ort he forehead, the occiput is positioned in ventra l fl exion
(minus the side bendi ng and rotati on) and the mobil izati on force is directed purel y posteriorly.
Atlas-Ventral
EL - LV __
PP - HV_& LV
Indication: To improve right rotation and flexion (Right OA Joint)
Position: Seated
After the left forearm and right hand
are in contact with the patient.
slack is taken up by the therapist
applying (1) a gentle dorsal and
medi al force with their left forearm
and (2) a ventral force on the right
side of the posterior arch of atlas
with their right hand.
The therapist contacts
the posterior surface of
the right transverse
process and posterior
arch of atlas with the
radial border of their
right hand's 2nd MCP.
The therapist stands
behind and to the left of
the patient.
The therapist's left
forearm is placed against
the left side of the
rests gently on the
patient's head, avoiding
any cervical compression.
Troubl eshooting yo ur technique:
Nole(s)
The stab il izing force and impulse occur in an equal and opposite direction. Fai lure to provide adequate
stabili zati on aga inst the mid-portion o rthe face andl or an impul se with an amplitude t hat is too large may result in
upper cervical dorsa l flexion dur ing the manipulat ion.
Prcssure appli ed on the top or l he head or agai nst the eye may result in discomfort for the pat icnt and should be
avo ided.
This technique is onen effecti ve at restori ng coupled rotat ion at the OAjoints.
Translatoric mobi lization and fUll cli onall11assage are easily int egrat ed into a comprehensive session of manua l
intervention to the upper cervical region.
36 I Chapter 3 : Cervical Spine Applicati on
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Atlas-Dorsal
EL - 121
PP - HV & LV
Indication : To improve right rotation (Left OA Joint)
Posit i on: Supine
The therapist's right
hand presses in the
direction of the anterior
surface of the
transverse process of
the patient's atlas.
therapist maintains this
position by gently holding the
patient's head against the table and
between their left hand and right
The therapist stands with
their right thigh positioned
against the right side of
the patient's head.
therapist's left hand is
placed against the left
'-_AlIt...--t
side
of the patient's head
above the ear.
Tt'oubleshooti ng your techni que:
Note(s)
To maximi ze pat ient comfort during thi s technique, the contact on at las should be spread out over the therapist 's
hypothenar eminence. In addition, the hand delivering the impul se should be re laxed prior to the manipulati on. If
the contact is too firm or the pressure is directed too medial , the pati ent may experience discomfort when the slack
is taken up prior to the impulse.
To position the right ha nd 0 11 the atlas for this technique, the therapi st should start wit h their right hand 0 11 the son
tissues slightly anteri or to the lett transverse process of atlas . The ti ssues are then slackened by pulling mcdia ll y
being ca reful not to slide over the skin. The therapi st then presses in the direction of the anterior surlnL'c of
the transverse process of atlas until a firm stop is felt. Failure to slacken the skin or positi on the hand medial
enough may cause di scomfort and may lead to the ha nd sliding off the tra nsverse process.
Positioning the pati ent's occiput on the edge of the table and the therapi st's ri ght thigh on the side ortlle head will
provide addi tional stabili zation of the occiput.
This is a very specific manual technique that will ass ist in the restoration of dorsifl exion and coupled rotat ion
between occiput and alias.
The therapi st should vary the direction and amount of side bending and rOlation bet wee n occiput and at las when
testing and treat ing using this technique. When treating a joint with a greater amount of restriction, the therapisl
should treat in the position where the greatest amount ofmovelllcnl is felt during testing.
Selecting a contact for AA traction
Obtaining a good contact on Atlas to generate a traction
of one of the AAjoints requires the therapist to have both
excell ent paJpatory skill s and a sense for fine movement. Thi s is
in part why the AA traction techn iq ues are recommended onl y for
the post-professional student.
To contact the atlas, the therapist wi ll sli ghtl y side bend
the AA j oint away from the si de of contact and rotate the atlas
towards the manipulating hand. Rotating the atlas towards the
manipul ating hand moves the posterior arch of at las dorsa lly
allowing the therapist to ach ieve a better contact. In addition,
the manipulating hand will press the axis sli ghtl y ventral to
maintain atlanta-dental contact and to provide for contact of the
manipulating hand under the inferior edge of the posterior arch
of atlas. Thi s positioning is performed after the therapi st has
contacted the patient with both hands and is a very small motion.
Frequency ofAA manipulation
After many years of treating patient ' s with upper cervical
movement impairment s, it is the opinion of the authors of this
text that the AA joint is less commonl y restricted than Illany
pract iti oners of manual therapy think. We attribute the cont inued
mobility of the AAjoint to its articular configuration and
li gamentous anatomy.
If the CI /2 (AA) segment is clini call y diagnosed as
hypomobil e and joint restrictions are also found at COi l e ~ A and
e2/3, we recommend that the two segments immediately above
and below C 112 be loosened first. As di scllssed in the opening
to thi s chapter, given t he li gamentous connection between the
occiput and e2, once the COil and/or e2/3 segments are loosened,
movement at C I 12 can often be felt. If after the cranial and/or
caudal restri ctions are addressed and the AAjoint is still believed
to be restri cted, then the traction techniques which follow offer a
safe and effecti ve method of restoring AAjoint movement.
38 I Chapter 3 .- Cervical Spine Application
Contacting Atlas
Rotating atlas to the left
exposes the posterior edge
of the transverse process
and posterior arch of atlas.
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AA-Traction
EL-0
PP - HV
Indication: To improve movement in all directions (Ri ght AA Joint)
Position: Side-ly i ng
The radial border of
therapist's right index
finger contacts the
inferior edge of the
patient's transverse
arch of atlas.
The dorsal surface of the therapist's right
index finger contacts the lamina and
transverse process of C2.
Slack between atlas and
axi s is taken up cranially
by the therapist's lett hand
and chest prior to delivering
the
Troubleshoot ing your techni que:
The therapist is positioned
behind the patient's head,
neck and upper thoracic spine.
The therapist's left hand and
forearm are positioned under
the left side of the patient's
head with the index and
middle fingers cupped around
the ' chin.
Ifille amplitude o r lhc impul se is too large. the manipulating hand may slide cranially result ing in di scomfort and/
or a poor ly local ized and less effective impulse.
Note(s)
Failure to support the head against the therapi st's chest may result in a poorl y controlled movcment of the head
during the manipulat ion.
By pos iti oning in ri ght rotati on, the ri ght posterior arch and transvcrse process of the Atlas is moved dorsally
al lowing bettcr contact ro r the manipulating hand.
The dorsa l surface of til e index finger of the manipulating hand contacts the posterior lateral lamina of C2. By
pressing slightly ventral prior to the manipulation and by directing the impulse crani ally and sl ightl y ventrally, the
odontoid is pressed agai nst t he anterior arch of at las thereby protecting the trans verse ligament.
Using a coupl ed pos it ion at the AA leve l wi ll assi st at taking up the slac k in the upper cervical region whil e at the
same time placi ng mi nima l tensil e stress 0 11 the upper cervica l ligaments.
Translaloric Spinal Manipulalion I 39
AA-Traction
Indication: To improve movement in all directions (Right AA Joint)
Position: Supine
The therapi st's right
hand contacts the
inferior edge of the
patient's transverse
arch of atl as.
therapist's Jeft hand and
are posi tioned behind
patient's head and against
left side of the patient' s
with the index and mi ddle
cupped around the
l o" ti o,n!'s chin.
Note(s)
If the amplitude orl he impul se is too large, the manipulating hand may slide crani all y resulting in di scomlort and/
or a poorl y loca lized and less effective impulse.
Failure to support the head agai nst the therapist 's chest may result in a poorl y controll ed movement of the head
during the manipulat ion.
By posi tioning in right rOlation, the right posteri or arch and transverse process of the atlas is movcd dorsa ll y
all owing better contact for the mani pulat ing hand.
The dorsa l sur face of the index finger 0 11 the manipulating hand cont acts the posterior lateral lamina orC2. By
pressing sli ght ly ventral prior to the manipu lation and by directing the impul se craniall y and sli ghtl y ventrall y. the
odontoid is pressed aga inst the ant eri or arch of at las thereby protect ing the tra nsverse ligament.
In thi s posi tion to gain access to the transverse process and posterior arch of atlas. the therapist must sli ght ly tlex
the patient's lower cervical spine.
40 I Chapter 3 : Cervi cal Spine Appli cation
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The Lower Cer vical Spine
The lower cervical (Lie) spine works in conjunction with the upper cervical (U/C) spine to pos iti on the head in space.
Together the two rotat ional coupling patterns of the U/C and LIe spine maintain the eyes on a level plane and allow fo r a
field of vision through a range of almost 180 degrees in the hori zontal plane.
Osseous anatomy
The lower cervical spine includes the C2 through C7 spina l segments.
Simi lar to the thoracic and lumbar region, a lower cervical vertebra
consists oftwo fundamenta l parts, an anterior vert ebral body and a
posterior vertebra l arch. The body of a lower cervica l vertebra is
cylindricall y shaped, convex anteriorly and flatt ened posteriorl y. The
superior surface is concave and the inferior surface is slightl y concave in
the anteri or-posterior direction and slightl y convex transversely.
One of til e n10st un ique characteri stics of tbe LlC vertebral body are
the uncinate processes. These processes ari se from the upper posterolateral
borders of each vert ebral body. The uncinate processes are concave
transverse ly and convex anteroposteriorl y. Thcy are directed upward
towa rd a conca ve groove in the lateral margin of the inferior surface of the
venebral body above. At this int ersecti on, each process or uncus forms
ajoint call ed the uncovcrtebral j oint. Thi sjoint is unique to the cervical
SpIllC.
The vel1ebral arch is formed by the pedi cles and laminae. The
pedi cles are two short, thick processes, which proj ect posterolaterall y
and are attached to the superior pal1 of the vertebral body on each side.
Continuing from each of the pedi cles, laminae are angled posteromedi all y
to enclose a large tri angular vertebral foramen. The ve rtebral foramen is
bounded by laminae posteri orl y, the pedicles la tcrall y and thc vertebral
body anteriorl y. The vertebral foramen is the largest in the cervica l region
measuri ng approximat ely 17 111m in the sagittal direct ion and 18-20111111
transverse ly. Coll ecti vely, the vertebral foramina form the vertebral canal
which houses the thickest part or the spinal cord measuring approximate ly
8- I 0 mm in diameter.
The laminae of the vertebral arch are broad, fl at plates of bone that
extcnd posteromediall y and slightly interiorl y. La minae typi call y overl ap
from one level to thc next and, as mentioned above, form the posterior wall
ort he vertebral foramen. In comparison to the rest of the cervical spine,
the lami nae of' C2 are thicker than at lower levels. The laminae come
together in the midline to form the spinous process. The spinous process is
a si ngle process that proj ects posteri orl y and inferi orl y from each vel1ebral
arch at the junction of the laminae. The spinolls processes of C3 to C6 are
short and bifid whil e the spinous process of C7 is long and rou nded at its
end point.
Articular surfaces of the lower
cervical spi ne
The cervical vertebral arch has many projections, including four m1icular (the superior and interior facets bil aterall y) and
three non-al1icul ar processes. The three non-a rti cular processes include the two transverse processes (TPs) and one spinoll s
process. The TPs arise from the juncti on of the pedicl es and the vertebral body. Together the TPs divide the arch into
an terior and posteri or portions. The TPs of C3-C7 are bifid and proj ect laterall y and slightl y anteriorly ending in all anteri or
and a posterior tubercle. Together. the anterior and posteri or tubercle form the concave spinal nerve sulcus, whi ch provides
a "gutter" for the anterior primary ramus. In addit ion, the lower cervical spine may be di stinguished from the lumbar and
thoracic spines by the presence or all oval shaped foramen in each of the TPs call ed the foral11en transvcrsari ul11 . The
foramen tra nsversariulll is di rected superiorl y and inferiorl y and exists for the vertebral al1eries and veins to course through.
The vertebral artery enters the transverse foramen of the sixt h cervical vertebra. These transverse foramina are vert icall y
al igned from C3 through C7 but are more laterally placed at C I and C2 .
Concave shaped sections of bone on the superior and inferior POl1 iOI1 of each pedi cle are known as intervertebral
notches. \Vhen the LlC vertebrae are articulated, these two notches (pedicles) form the roof and floor of the intervertebral
foramen (I VF) through which spi na l ncrves and blood vessels coursc. The IVF is a small canal approximately 4 111111 in
lengt h that is directed anteriorly and inferiorly. It is ovoid in shape with a verti cal diameter of approximately 10 Illlll in
height and a hori zontal diameter ofapproximate[y 5 mill . Adjacent art icular processes, in parti cular the anteri or aspect of
the superior art icular process, form the posterolateral wall of the cervical I VF. The posterolateral portion of the vertebral
bodies and the uncovertebral joi nts rorm the anterolateral wa ll of the cervicall VF. Arthrit ic hypert rophy of the structures that
constit ute the cervicall VF pl aya ro le inlhe deve lopment of ne rve root compressioll and irritatioll .
Lower cervical articulations
There are five arti culations in the lower cervical spine: one
intervertebral disc ( IVO)joint , two uncovertebral joints and two racet
joints. In the lower cervical spine, there are six IVDs. Duri ng bending
movement s, the IYO fac ilitates and restrains moti on between the cervica l
vertebral segments. Further, the cervica l IVDs distribute weight over a
larger surrace area. In other words, wi thout the IYO, we ight would be
concentrated eccent rica ll y on the vertebral edge, toward the direct ion
the spine is bent. Thus, the dcformability of the ccrvica ll VO all ows
distributi on of forces over a greater sur face area. The amount or movement
poss ible for a parti cul ar region or the spi ne is largely determined by the
rat io or disc height and the corresponding vertebra l bodi es of a segment.
In the cervical spine, this ratio of disc thickness to vert ebra l body height
is 2 to 5. The cervica ll YDs are approx imately 5mm thick and are
considered to be the thinnest of all the intervertebral discs. The somewhat
saddl e-shaped IVOs are responsibl e for the cervica l lordosis in that the
anteri or aspect of the cervica l I VO is thicker than the posterior aspect. The
nuclear porti on of the cervica l disc is positi oned more ant eri orl y than in
any other port ion orthe spine. The cervica ll VDs are innervated from a
vari ety of sources. Posteriorl y, the IVOs are innervated from branches ofa
posteri or longitudinal plexus that is deri ved from the cervical sinuvertebral
nerves. Ant er iorly, the IVDs are innervated by a similar plexus deri ved
l1'om the cervica l sympathet ic trunks and the vertebral nerves. Latera ll y,
the discs receive penetrating branches from the vertebra l nerve. Nerve
fibers penetrate at least the outer 1/3 and up to the outer 1/2 of the annulus
fibrosus of the cervica l discs.
The cervica l arti cular processes ari se from the j uncti on of the
Lower cervical articulations
pedicles and .. are two superior art icular tl.,at project superiorl y alld two inferi ? r
processes that project Il1l enorl y and dorsa ll y. At the end of" the artlCll1ar process, a fl at surface IS formed ca ll ed the face!.
Each facet forms a joint wit h an adj acent vert ebra and is ca ll ed a facet j oi nt or zygapophysea l j oi nt. These j oint s are
class ifi ed as pl anar diarthrodial joints and li e in an obl ique frontal pl ane at approxi mately 45 degrees to the long axis of
the spine. The superior Hlcets of the infra-adj acent vertebra in a segment arc posit ioncd in front of (ant erior to) the inferior
facet of the supra-adjacent vertebra. The arti cul ar surface ofa super ior facet faces dorsa ll y and crania ll y whil e the articul ar
surface of an inferi or facet faces vent ra ll y and caudally. A practi ti oner of translatoric manipUlat ion !TI ust be able to see
these anatomi ca l rclationships in order to ful ly understand the biomechani cs oftranslatori c facet joi nt gliding and traction
techniques.
The facet j oint's capsular li ga ment s are att ached just beyond the margi ns of the adj acent al1i cular processes of the
joints. These capsul ar li gament s arc oriented approx i mately perpendi cular to the pl ane of the facet j oi nts. Studies by
Panj abi have found that these ligament s arc orient ed posteriorly at approximately 45 degrees to the transverse plane in the
lower cervica l spi ne. They are longer and less taut in the cervica l region as compared to the lumbar and thorac ic regions.
The capsul ar liga ments provide stabil ity in the lower cervical spine during fl ex ion and are onc or the princ ipal struct ures
stretched during translatori c face t joi nt gli di ng and face t joint di straction techni ques.
In addition to the facet j oint art iculations, each typica l cervica l vertebral body has two uncovcrtebra l joi nt s.
Although a synovial membrane has been found in the ul1covert ebral joint, there is some debate regarding the classifi cat ion of
the j oint. The presence of the di sc and fi brous tissue in the joint lead some anatomi sts to be lieve that it is fibrous in nature.
As menti oned earli er, the superi or pl ateau ora LlC vertebra l body is rai sed on each side in the sagi ttal plane forming the
uncinate process. The actual capsul e is located medial to the uncinate process and lateral to the disc. The unci nate processes
begin to develop at about 8 years of age and do not fu ll y develop until approximately 18 years or age. The average sizes of
the uncinate processes have been invest igated in many anatomi ca l studies. In genera l, it has been shown that the uncinat e
processes are higher at C4 to C6 levcls as compared to the C3 or C7 levels.
The roles of the uncovertebral joint s arc both to guide coupl ed moti on and to restrict moti ol1 . The uncovertebral
j oint s he lp prevent posteri or translati on and posterolatera l disc movement , limi t lateral bendi ng and help guide flexion and
extension. The uncinate processes themselves act to limi t mot ion, whereas the entire joint func ti ons to all ow moti on by
assisting coupled movcment.
42 I Chapter 3 : Cervicat Spine Application

Ligamentous anatomy
The ligaments of the lower cervical spine have many important rUllctions. First, they allmv appropriate physiologic
Illation and fixed postural positions between vertebrae with minimal expenditure ofmusclc energy. Secondly, the li gaments
protect the spinal cord and other structures by restraining motions within we ll -defined limits.
What follows is a brief review of the cervical intra-canal ligamentous structures. The posterior longitudinal
ligament (PLL) is narrower and slightly weaker than the anterior longitudi nal li gament (ALL). It runs over the posterior
surfaces of the vertebral bodies from C2 to C7 within the vertebral canal. This ligament has an interwoven connection with
the intervertebral disc. In contr ast to the ALL, the PLL narrows over the cervical vertebral bodies and fans laterally over the
discs. On either side of the midline of the annu lus t-ibrosus, the PLL is only weakly distributed. This ligament is broadest
in size in the cervica l spine where it supports the posterior aspect orthe intervertebral joint, assisting to prevent posterior
displacement of the disc. This ligament tightens in ftexion and slackens in extension.
The ligamentum flavum, also known as the "yellow li gament ," extends longitudinally from the anterior inferior
border of the laminae above, to the posterior superior border of the laminae below. The fi bers of this li gament therefore run
in a ventral cranial and dorsal caudal fashion fl'om C2 to C7. There are two ligaments at each vertebral segment, a right and
a left, which are separated by a small fissure and merge with the interspinous ligament posteriorly and the facet capsules
anteriorly. Unlike the ALL and PLL, the ligamentum flavum is segmental beginning and endi ng at one vertebral segment .
The ligamentum ftava are important in controlling and stabili zing the spine during flexion , a motion that causes the Iigamcnts
to stretch. They then regain their original shape when the neck returns to thc neutral position. In extension, the ligaments
retract and thi cken by volume redistribution and relaxation of their fibers. Finally, being located immediately behind the
neural column within the vertebral canal, the more elastic nature of this li gament may reduce the risk of buckling into the
vertebral canal and causing spinal cord compression during lower cervical extension.
Kinematics
Segmental motion in the LlC region follows Kaltenborn's concave rule with regard to movement through the IVD joint.
For example, cervical ventral flexion is accompanied by a slight rocking of the c ranial vertebrae over the caudal vertebrae in
the segment. Slight translation wi ll occur in a ventral direction (concave rule) and the inferior articular facets of the cranial
vertebrae wi ll glide in a ventral and cranial direction. The arthrokinematic movements for cervical dorsal flexion (extension
or backward bending) are exact ly opposite. During dorsal flexion , the cranial vertebra rocks in a dorsal direction with slight
dorsal gliding through the IVD joint and dorsal and caudal gliding of the inferior facets of the cranial vertebrae.
The facet joint , uncovertebral joints and the capsulol igamentous structures of the LlC spine are responsibl e for the
coupled movement pattern seen in the Lie region. By definition, a coupled movement is one that is mechanically forced to
occur. The LlC segments show a mechanically forced pattern oCside bending and rotation to the same side. For example,
rotation and latera l ftexion to the same side accompany each other as a result of the inferior articular process of the superior
vertebra sliding down on the superior articular process oftJle inferior vertebra. During this motion, the facets stabi li ze and
guide coupled motion whi le helping to absorb the shock of weight bearing.
Direction of joint rolling and gliding during lower cervical coupled sidebending and
rotation
Left Sidebending and Rotation Right Sidebending and Rotation
Translalorie Spinal Manipulation I 43
Direction of joint rolling and gliding occuring during lower cervical ventral
and dorsal flexion
Vent ral Flexion
Dorsal Flexion
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Biomechanics of Lower Cervical TSM
Disc Traction
Lower cervical disc t racti on T5M t echniques use a coupled position of side bending and rotat ion to the same side and
t owards the therapist. This position both faci litates contact on the lami na and arti cul ar process and insures t hat the
spinal segment ends with neutra l sidebending when performi ng a singl e handed impul se. The impul se is directed
craniall y with either the hand on the concave side of the spine or with both hands when performing a t wo handed
impul se.
Positioning - right side bending right rotation
Facet Distraction

Two handed impulse
directed cranially
Lower cervical facet distract ion T5M techniques use a noncoupled position of side bending and rotat ion to the
opposite side to compress the facets on one side and gap or di stract the facets on the ot her side. To fur t her di stract a
specifi c facet j oint, t he therapi st then uses either a ventrally, medially and caudally direct ed force on the lamina and
art icular process of the caudal vertebra or he/she uses a mediall y directed force on the overlapping articul ar processes
of the caudal and cranial vertebrae from t he contralateral side.
Positioning - right side bending left rotation
Facet joint distraction
Facet distraction is facilitated by:
or
Medially directed impulse
the spinal segment
shifts from the
vertebral body to the
overl apped facet
joints.
Biomechanics of Lower Cervical TSM
Facet Glide
Lower cervical facet glide T5M techni ques use a coupled posi t ion of side bending and rotat ion to the same side. This
positi on facilitates gl iding motions in t he facet joint. The therapist uses eit her a ventrall y and craniall y directed force
or a dorsall y and caudall y di rected force. Ventral cranial gli ding of t he left facet assist s in restoring flexion, si de
bendi ng ri ght and rot at ion to the right. Dorsal caudal gliding of the right facet assist s in restoring extension and side
bendi ng right and rotation to t he ri ght. The caudal vertebra in the treatment segment is stabili zed either with manual
stabil izat ion, spi nal locking or some combinat ion t hereof.
Positioning - the segment in right side bending right rotation
Ventra! cranial directed
impulse
Caudal stabilization for ventral cranial gliding may be achieved by:
Applying a ventral,
medial and slightly
cranial force to the right
lamina and articular
process of the caudal
vertebra in the treatment
segment.
This maintains the axis
of motion in the disc
Applying a ventral, medial
and slightly caudal force
to the right lamina and
articular process of the
cranial vertebra in the
treatment segment.
This shifts the axis of
motion to the fight facet
joint and generates
greater leverage for
stretching on the left.
Dorsal caudal directed
impulse
Locking below in left
side bending, right
rotation and slight
ventral flexion.
This shifts the axis of
motion to the right facet
joint and generates
greater leverage for
stretching on the left.
c
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C2-7-Disc Traction
EL - HV & LV
PP - HV & LV
Indication: To improve movement in all directions
Position: Supine
A belt may be used to
o support the therapist's
hands and to assist in
taking up the slack in
the spinal segment
prior to the manipula-
tion.
placed around the
therapist's pelvis and
index fingers.
Troubleshooting your tcchnif.lue:
Note(s)
Irthe amplitude oflhe impul se is 100 large, the manipulating hand may slide crani all y resulting ill di scomfort and!
or a poorly locali zed and less effecti ve impul se.
Pl aci ng the belt on the therapi st's lumbar spine may resuh in discomfOJ1 l'or the practitioner.
Thi s tec hnique will effect vertebral segments caudal to the treatment segment. The actual amount of traction in
the in fra-adjacent segments is dependent upon the amount of force used, the amplitude of the movement and the
amount of moti on available at the indi vidual segments.
When performing a hi gh velocity TSM, the impul se should be del ivered from the therapi st's arms, not the pelvis.
When perfo rming a low ve locity tec hnique the pelvis is used to ge nerate the TSM. Att empts to generate a HV
impul se from the pelvi s typically result s in slow impul ses and large ampl itudes ofmovcment.
Thi s techni que may be e l ~ t i v e in reducing cervicogeni c upper extremity pain relcrra1.
Tl'anslatol'ic Spinal Manipulation I 47
EL-0
Traction
pp- HV
hand contacts the ri ght
inferior arti cular process
and lamina of C2.
Slack in the disc j oi nt
is taken up cranially by the
chest prior to delivering
the
The therapi st is positi oned
behind the patient's head,
neck and upper thoracic spine.
The therapi st's left hand and
head with the index and
Troubleshooti ng you r techni que:
Note(s)
If the amplitude of the impul se is too large, the manipul at ing hand may slide craniall y resulting in di scomfort and!
or a poorly locali zed and less effecti ve impulse.
Failure to support the head agai nst the therapi st' s chest may result in upper cervical fl exion or too much
side bending during the manipulation.
Pl acing the upper cervical and C2 in sli ght right rot ati on facil itates contact to the right inferi or arti cul ar process of
C2.
An impul se deli vered to the right side ofC2 will cause slight left side bend ing and rotat ion resulting in the
treatment segment ending in neutral side bending and rotat ion. Thi s minimi zes stress on the VA and alar ligament.
An alternative way of performing thi s manipulation is to impul se with both hands. Thi s typically results in a
greater sensation of traction for the pati ent but requ ires excell ent coordinati on and timing from both hands.
48 I Chapter 3 : Cervical Spine Appl ication
t:
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Traction
El-0
PP-HV I
Position: Supine
hand contacts the right
and lamina of C2.
The therapist's right hand
impulses craniall y, slightly
medially and slightly
I
Troubleshooting yo ur technique:
Note(s)
If the amplitude of lhe impul se is too large, the manipul ating hand may sli de craniall y resulting in di scomfort and/
or a poorl y loca li zed and less effect ive impulse.
Failure to support the head against the therapist 's chest may result in 100 mllch side bending during the
manipulat ion.
Placing the upper cervical and C2 in sli ght ri ght rotat ion and side bending facili tat es contact on the ri ght inferior
arti cular process of C2.
An impul se del ivered to the ri ght side of C2 will cause slight leli si de bcnding and rotation result ing in the
treatment segment ending in neutral side bending. Thi s min imi zes stress on the VA and Alar ligament s.
An alternati ve way of performing th is mani pulati on is to impul se with both hands. Thi s req uires excell ent
coordination and liming from both hands.
Whil e the pati ent is still in the supine positi on. vari ous passive segmental movements ca n be re-examined aft er
applicat ion of thi s TSM.
C2-7-Disc Traction
Position: Seated
The thE;!rapist's right hand
holds around the left side
of the inferior articulating
process and lamina of
the cranial vertebra in the
treatment segment.
The head is supported
chest.
and right hands
applying (1) a gentle cranial force
wi th thei r right hand and chest
and (2) a caudal and slightly
ventral stabili zing force on the
bilateral laminae and articular
Another contact option for the therapi st's
manipulating hand is to hook the fifth
finger around the spinous process of
cranial vertebra.
When using this contact, the therapist
may overlap the ring finger on the fifth
finger (see illustration to the right) for
additional support of the finger.
stands in
of and to the right of,
patient's ri ght side.
therapist's left hand
the bilateral
It, the caudal
EL - HV & LV
PP - HV & LV
Failure to provide an equa l impul se from the chest and hand may result in a side bending movement during the
manipul ation.
Note(s)
If the amplitude of til e impulse is too large, the right hand may slide craniall y and the left hand may slide cauda ll y
resulti ng in discomfort and/or a poorl y locali zed and less effective impul se. Ideally, the stabilizing fo rce should be
equal to the impulse.
Di scomfort may be felt by the patient if the therapi st squeezes too much wi th the caudal stabili zi ng hand dur ing
the manipulation.
Whil e it is difficult to stabili ze the infra-adjacent vertebra specifically. the lise ofa shon amplitude movcment
coupled with the caudal stabili zing force help to minimi ze the amount of movement occurring in the segmcnts
caudal to the impul sed segment.
In a symptomati c hypomobil e segment , manual intervention often includes a blend ofrSM, translatori c
mobi li zation and functi ona l massage. The scated position is parti cularl y good for the blending of these
techniques.
50 I Chapter 3 : Cervical Spine Appli cation

1

I:
Traction
EL-0
PP -HV
inferior articular process
and lami na of the cranial
vert ebra in the treatment
Slack in the disc joint
is taken up cranially by the
chest prior to delivering the
impulse.
The therapist's left hand and
head with the ulnar side of the
hand contacting the left
articular process and lamina
treatment segment.
Nole(s)
If the ampli tude ofl he impul se is too large, the man ipulating hand may slide craniall y resulting in di scomlorl and/
or a poorly locali zed and less e fl'ect ive impul se.
The medial fo rce appli ed by both the left and ri ght ha nds should be firm enough to avo id sliding crania lly during
the impul se but should not cause any di scomfort in the son ti ssll es . Irthe soft ti ssues arc sensiti ve, the
therapist should appl y the pressure graduall y unti l either the therapist feel s the underl ying bony surlaces or the
patient ex presses mild di scomfort . The therapi st should then take up the slack in the segment in a cranial
direction. Irt he hands slide oflthe segment or the discomfort increases to the point of intolerance fo r the pati ent,
the technique should 11 0t be performed. Rather, techniq ucs that reducc soft ti ssue sensiti vity should be used.
The techn ique may be attempted again upon reducti on of soft ti ssue tenderness.
Failure to support the head aga inst the therapi st's chesl may result in a nodding motion o rlhe head or too much
side bending during the manipul ation.
The medial force appli ed from both hands are necessary to maintain contact to the treatmcnt scgment.
All alternative method of perfor ming thi s mani pulati on uses an impulse delivered from both hands. Thi s requires
excell ent coordinati on and liming from both hands.
EL-0
Traction
PP - HV
Position: Supine
and lamina of the cranial
segment.
disc joint
is taken up
cranially by the
therapist's left
hand and
The therapi st is positioned beside the
patient' s head, neck and right shoulder.
The therapist's left hand and forearm
are positioned under the left side of the
patient's head, with the ulnar side of the
hand contacting. the left inferior articular
process and lamina of the cranial
vertebra in the treatment segment.
Troubl eshooting your tec hnique:
Note(s)
Ifill e ampl itude orl he impul se is too large, the manipulat ing hand may slide craniu1ly resulti ng in discomrort and!
or a poorly loca lized and less efTccti vc impul se.
Fai lure to use a fi rm enough medial force from both hands pr ior to the impulse may result in a cranial sliding of
the hands during the manipulation resu lti ng in di scomfort and/or a poorl y loca li zed and less e ffec tive impul se.
Fai lure to support the head against the therapi st's chest may result in a nodding motion of the head or too much
side bending during the manipulat ion.
As with the previous technique, both hands may be lIsed to generate the impulse during thi s techn ique. It is tile
author' s experience that impul sing simultaneoLi sly wit h both hands typicall y generates a greater sensation of
traction for the patient.
52 I Chapler 3 : Cervical Spine Appli cation
IIC
Distraction
EL - HV & LV
PP - HV & LV
Indication: To improve movement in all directions (R Facet Joint)
Position: Supine
hand contacts the
lamina and superior
caudal vertebra in the
treatment segment.
Slack in the facet joint
is taken up in a ventral.
medial and caudal
direction by the
therapist's right hand prior
to delivering the impulse.
impulses ventrally,
mediall y and caudall y.
facing the top of the
patient's head.
hand and forearm are
positioned under the
left side of the patient's
head wi th the ulnar
side of the hand
contacting the left
inferior arti cular
the cranial vertebra in

-
Troubl eshoot ing your t echnique:
Failure to sumciently support the side bendi ng and rotat ional positio;li ng of the supra-adjacent spinal segments
may result in unwanted cervical moti on dur ing the manipul at ion.
Notc(s)
The treat ment segment may be placed in ventral or dorsal flexion based 0 11 the pati ent' s speci fi c restriction.
Lower cervical facet tracti on performed in a nOll coupled posi ti on will facilitate maximal di stract ion orthe
articular sur races. Thi s resu lt s in the greatest amount or racet j oint capsular stretching.
This technique may al so be perfofmed with the patient's head/neck resting on a pill ow.
Translatoric Spinal Manipulat ion I 53
Distraction
EL - LV
PP -HV & LV
Position: Seated
lamina and superior
treatment
hand impulses ventrall y,
medially and caudally.
-
patient
SUIJoc,rtirlQ the patient's
and neck position
i left hand,
and abdomen.
SUIDO(JrtS the left side of

-
Note(s)
Fa ilure to s upport the s ide bending and rotational positioning of t he supra-adjacent spina l segments may result in
unwanted s ide bending during the manipu lati on.
Pressure aga inst the anterior neck by the stabilizing hand shou ld be avoided and may lead to di scomfort during the
manipulation.
During thi s technique, the OA and AA segments are in a coupl ed position. The remaining supra-adjacent segments
are positioned in a Iloncoupled position.
The treatment segment may be placed in ventral or dorsal tlexion based on the specific rest ri ctioll .
Lower cervica l facet traction performed in a noncoupled position wi ll facilitate maximum distraction of the
articu lar surfaces. Thi s results in the greatest amount of ~ l e t joint capsular st retchi ng.
Lower cervica l facet traction performed in a noncoupled position is a very specific technique . Thi s techn ique is
typicall y tol erated well by patients who are experiencing hypermobility caudal to the treatment segment.
54 I Chapter 3 .- Cervical Spine Application
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C2-6- Facet Distraction
PP - HV & LV
Pos i tion: Seated
therapist stands
beside the patient
supporting the patient's
head and neck position
i their fight hand,
I fore,,,m and chest.
ulnar border of the
I th,eralPist's right hand
supports the right
posterior edge of the
process,
articular process and
lamina of the cranial
vertebra in the
treatment segment.

In sitting, the patient's
cervical spine down
through the treatment
segment is positioned
in left side bending
and ri ght rotation.
The impulse is directed ventral ,
medial and caudal wi th the
therapist's left thumb.
lamina and superior
"--- ..,.-1 articular process of the
After the left and i are i contact with the patient, caudal vertebra in the
slack is taken up by the therapist applying (1) a gentl e cranial , treatment segment.
medial and slightly dorsal force wi th their right hand and forearm
and (2) a ventral , medial and caudal force with their left thumb.
-
If the impulse has 100 largc an amplitude, the manipulating hand may slide caudall y resulti ng in di scomrort and/or
a poorly locali zed impul se.
Note(s)
Failure to support the side bending and rotational pos iti oning of the supra-adjacent spinal segment s may result in
unwanted side bending during the manipulat ion.
During thi s technique, the OA and AA segment s are in a coupled positi on. The rema ining supra-adjacent segments
are positioned in a noncoLipl ed position.
The racet joint may be placed in neutral , ventral or dorsa l ll ex ion based on til e speci fie restri ction.
Lower cervica l racet traction performed in a noncoupl cd position will racilitate maximum di straction orille
arti cular surfaces. This reslI It s in the greatest amount or capsular stretching in the facet joint.
Lower cervi ca l facet traction performed in a noncollplcd positi on is a very specific technique. Thi s Icci1'nique is
typi call y tolerated we ll by patients who are experiencing hypermobil iry caudal to the treatment segment.
Thi s form of lower cervica l facet joint tract ion al so gives the therapist the latitude to appl y the technique whil e
giving a cranially directed traction to the di sc joints. Given thi s, hypomobil e facet articulations can be
manipulated or mobili zed with thi s technique in the presence of radicular irritation caudal to the treatment
segment.
C2-6- Facet Distraction
EL - 121
PP - HV & LV
Indication: To improve movement in all directions (L Facet Joint)
Position: Supine
impulses medially and
slightly cranially and
dorsally.
i ii uw
of noncoupled side bending and rotation.
Additional slack is taken up in the segment
and left facet joint by the therapist pressing in
a medial and slightly cranial direction with the
right hand prior to delivering the impulse.
The therapist is
positioned beside the
patient's head, neck and
right shoulder.
and forearm are
positioned under the left
side of the patient's
head with the ulnar side
of the hand contacting
the left inferior articular
the cranial vertebra in
the treatment segment.
Note(s)
If the manipulating hand is placed too lateral , it may contact the tip of the transverse process result ing in
di scomfort when taking up the slack and/or during the manipulation.
Ifwhen posi tioning the neck, the therapist positions the si de bending prior to add ing rotation, there may not
be enough space for the manipulative hand because orlhe proximity of the shoulder. It is therefore impol1ant to
take up the side bending and rotation in combination. The manipulating hand should be placed on the cranial
vertebra prior to positioning the neck.
Prior to manipulating, the therapist should verify that the pati ent fee ls a localized stretching sensation over the
contra lat eral ly treated facet joint.
The facet joint may be placed in neutral , ventral or dorsa illex ion based on the specific restriction.
J f right side bending and dorsal flexion are rest ricted on the right side, the thrust must be applied to the right
inferior articular process of the caudal vertebra of the segment treat ed.
If the impulse is directed too cranially or ventrally, a gl iding will occur in the right facet joint.
Lower cervical flexion performed in a noncoupJed position will faci litate maximal dist raction of the articular
surfaces. In this case, the facet di straction occurs on the opposite side of the manual contact making this an
excell ent technique if there is soft ti ssue tenderness on the same side as the facet joint restri ction.
5 6 I Chapter 3 ." Cervi cal Spi ne Application
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E:
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II:
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IC
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IF!
C2-6-Facet Glide
EL-0
PP - HV & LV
Indication: To improve left rotation (R Facet Joint)
Position: Supine
is taken up in a ventral and cranial
direction by the therapist's right
hand prior to deli vering the impulse.
The therapist is posi tioned beside the patient's head, neck and
right shoulder.
The therapist's left hand and forearm are positioned under the
left si de of the patient's head with the ulnar side of the hand
contacting the left inferior arti cular process, lamina and
spinous process of the cranial vertebra in the treatment
segment.
i 'treatment segment is positioned
in left side bending and left rotation.
maintains the caudal
spinal lock by supinating
forearm and
lifting/pulling towards
right side of the patient's
neck, thus maintaining
right side bending of the
sub-adj acent spinal
segments.
By supinating the left
lorealrm. the therapist
introduces left side
bending in the treatment
The therapist then
carefull y takes up the
remaining left rotation in
the treatment segment
by pulling the vertebra
into left rotation.
Troubleshooting your tec hnique:
Note(s)
One common mi stake made when performing this technique is the loss of right side bending caudal to the
treatment segment when the therapi st side bends the treatment segment to the len. If thi s occurs, the locking wil l
be less efTectivc and the technique less specific. To counter this mistake, the therapi st should supinate his/her
forearm to ma int ai n the caudal lock wh il e creat ing coupled motion in (he treatment segment.
If the pat ient is unable to relax or reports di scomfort once the cervical spine is positi oned for the technique, the
therapi st should attempt to det ermine if slight adjustments in posit ioning improve relaxation and reduce the
patient's di scomfort. Techniques such as hold-relax, soft ti ssue massage or fUll ct ionalmassage may al so be used
to facilitat e re laxat ion and may be used pri or to thi s technique to enhance pat icnt tolcrance.
The use orthe lel't (non-manipulat ing) hand during the positioning of the treatment segment reduces the stress
pl aced on the art icular pillar/ lamina by the manipulating hand. If the left hand is not used during the posit ioning,
slack may not be taken up eflecti vely and the pati ent may fee l di scomfort under the manipul at ing hand.
The axis ror thi s movement will be in the len racet oflhe treatment segment.
TranslalOric Spinal Manipulation I 57
C2-6-Facet Glide
Indication: To improve right rotation (L Facet Joint)
Position: Seated
In sitting, the patient's
treatment segment is
positioned in right side
bending and right rotation.
The vertebral segments
caudal to the treatment
segments are positioned in
left side bending and right
rotation (locked below).
The fifth finger of the
therapist's right hand
contacts the left
inferior articular
process of the
cranial vertebra in
the treatment
segment.
The contact of the
manipulating hand
may be reinforced by
overlapping the ring C : : ~ . ; I .
and middle finger
dorsally over the
little finger.
is taken up in a ventral
and cranial direction by
the therapist's right
hand prior to deliveri ng
the impulse.
hand impulses ventrally
and cranially.
EL-LV
PP - HV & LV
L
The ri ght hand must provide a sli ght ventral and medial force (right side bending) to create coupl ing in the \
treatment segment. Fai lure to coupl e the treatment segment will red uce the amount of gliding avai labl e during the
manipulation and may result in a less effective technique.
Note(s)
Fai lure to maintain the locking below may result in a poorly locali zed and ineffective manipul at ion. Using the
spinous process as described in the "Note(s)" below will aid in maintaining the ca udal spi na l lock.
The therapi st/student must be sure that they are on C2 and not C l when performing thi s technique for the C2
spinal segment. Thi s can be checked by palpat ing the spina Li s process of C2 (the first spi naLI s process below the
occiput). The the ulnar border of the therapist's ri ght hand should be placed immediately latera l to the C2 spinous
process.
The caudal spinal lock is maintained by the medial fo rce applied by the therapist 's thumb combincd with thc
therapi st's ri ght hand pulli ng the spinous process of the cranial vertebra in the treatment segment towards the left
to further reinforce the caudal locking.
t:
c
c
c
c
C
J:
Jt:
-I:
I:
I:
I:
-=
Traction
EL-0
PP - HV & LV
Slack in the disc joint
is taken up craniall y by the
chest pri or to delivering the
impulse.
Troubleshooting your tcchni(luc:
Note(s)
Maintaining cont act to C7 is orten difficult . Irthe ampli tude ofl he impul se is too large, or the medial contact
forces appli ed by both hands is 11 0t forceful enough, the hand may slide craniall y resu lt ing in di scomfort or a
poorl y loca li zed impul se.
Fa ilure to support the head aga inst the therapi st 's chest may result in side bending during the manipulation.
The medi a l forces app lied from the stabili zi ng and mani pulat ing hands helps the therapi st maintain contact to the
impul sed segment.
An a lternative method of performing thi s man ipulati on uses an impul se de li vered from both hands. Thi s requires
excell ent coord ination and liming from both hands.
Translataric Spinal Manipulation I 59
Glide
EL - f2J
PP - HV & LV
Position: Supine
The right hand
contacts the right inferior
articular and transverse
processes of the cranial
vertebra in the treatment lifting/pulling towards
fight side of the patient's
neck, thus maintaining
right side bending of the
sub-adjacent spinal
segments.
Slack in the facet j oint
is taken up in a ventral and cranial
hand prior to delivering the impulse.
The therapist is posi ti oned beside the patient's head, neck
and right shoulder.
The therapist' s left hand and forearm are positioned under
the left side of the patient's head with the ulnar side of the
hand contacting the left inferior articular process, lamina
and spinous process of C7.
forearm, the therapist
introduces left side
The therapist then
carefully takes up the
remaining left rotation in
the treatment segment
by pulling the vertebra
into left rolation.
Note(s)
One common mi stake made when performing thi s technique is the loss oflhe cauda l spinal lock, resulting in a less
specific technique. The greatest reason for thi s is dropping of the therapist 's left hand when unlocking the
treatment segment. To unlock the treat ment segment without los ing the caudal spina l lock, the therapi st Illust use
both hands to pos it ion the coupling in the treatment segment, movi ng the supra-adj acent spina l segments as a unit.
I f the therapi st's len hand pull s too mllch from the chin, the pati ent may experi ence di scomfort during thi s
technique. To reduce this tendency. the therapi st mllst LIse the pa lmar and ulnar surface ofhi s/her left hand to
pull the transverse process of C7 dorsa ll y to assist in left rotating as well as fl exing and side bending the crania l
spinal segments.
The ax is for thi s movement wil l be in the len nIcet ofC7.
It:
It:
It:
C7-Facet Glide
EL-0
PP - HV & LV
The right hand
The patient's C7 segment is positioned in left
side bending and left rotation.
contacts the right inferior
articular process and
posterior edge of the
The spinal segments cranial to the treatment
segment are positioned in the resting or actual
resting position.
The spinal segments caudal to the treatment
segment are posi tioned in right side bending
and left rotation. (locked in flexion)
C7.
The therapist is positioned behind the patient's head, neck
and upper thoracic spine.
The therapist's left hand and forearm are positioned under
the left side of the patient's head with the ulnar side of the
hand contacting the left inferior articular process and
lamina of C7.
maintains the caudal spinal
side bending by supinating
the forearm and lifting/pulling
towards the patient's right
shoulder.
forearm, the therapist
introduces left side bending
into the treatment segment.
The therapist then carefully
uses their left hand to take
Nole(s)
Maintaining contact to C7 is often difficult. If the amplitude of the impul se is too large the direction o rthe
impul se too crani al or the medial contact force appli ed by both hands is not forcefu l enough, the hand may sli de
craniall y resulting in discomfort or a poorly loca li zed impul se.
Fa ilure to support the head against the therapi st's chest may result in additional unnecessary movement in spinal
segments crani allO the trcatment segmcnt during the manipulation.
The medial force s applied from the stabili zing and manipul at ing hands help the therapist maintain contact to the
impul sed
The axis for this movement will be in the lett facet ofC7.
Translatoric Spinal Maniplilation I 61
Glide
EL-LV
PP - HV & LV
Indication: To improve left rotation (R & L Facet Joint)
Position: Supine
The therapist stands facing the
top of the patient's head.
The therapist's ri ght hand
contacts the patient's ri ght
posterior surface of the
transverse process, the lamina
and inferior articular process of
C7.
The therapist's left hand contacts
the patient's left lamina, inferior
articular process and left side of
the of C7.
are in contact with the patient ,
applying (1) a ventral cranial
with their right hand and (2) a
caudal and slightly medial force
wi th their left hand.
Troubleshooting your techniq ue:
cervical
spine, excludi ng C7, is
positioned in a neutral
position.
The C7 segment is
positioned in left side
bending and left
rotation.
hand impulses
ventrally and cranially.
stabil izes the left side of
C7.
One common mi stake whcn performing th is technique is insufficient contact 011 the C7 spina l segment. To
identify where C7 is located, slide both hands down the lat era l surface of the neck until the first rib is contacted.
The vertebra crania l to this point is C7.\
NOle(s)
Anot her common mi stake is directing the impul se too medially with the left hand. This may cause discomfort for
the pat ient and may limit dorsa l caudal gl iding of the Ic fll acet joint.
By using both hands to position C7, the therap ist may determine where the axi s of movemcnt wi ll bc plnced. The
axis for movement at C7 is in the lell facet joint.
A belt may be placed across t he manubrium to stabili ze against unwanted movement of TI during the
manipulati on.
Glide
EL - HV & LV
PP - HV & LV
Position: Supine
beside the patient's head, neck
and left shoulder,
contacts the patient's right
C7.
The patient's cervical
spine, excluding C7, is
position.
The C7 segment is
bending and left
rotation.
Slack in C7 is taken up in a
cranial and slightly medial direction
by the radial border of the right hand
prior to delivering the impulse.
Note(s)
One comlllon mistake when performing this technique is insuffici ent contact on the C7 spina l segment. To
identify where C7 is located, slide the manipulating hand down the lateral surface of the neck until the fi rst rib is
contacted with the radial border orthe second MCP. The vertebra cranial to this point is C7.
In sutlicient stabili zation of the shoulder may lead 10 a poorly locali zed and less effect ive manipulation ofC7.
When performed properly, very litLl e movement wi ll occur in the spinal segments cranial to the treatment segment.
Failure to contact C7 properly, or to deliver the impul se to C7 through the second MCP, may cause unwanted
movement above the treatment segment. T9 assure continued contact to C7 the manipulating hands radial border
of the 2nd MCP should maintain contact to the first rib during the TSM.
The therapi st supports his/ her index finger with their middle finger dorsa ll y. The cervical spine above C7 is
contacted by the remainder oflhe therapist 's hand and is moved as a unit wit h C7.
For patients presenting with more thoracic kyphosis, the impulse may need to be directed more ventrally.
In clinical practice, comprehensive manual intervention often consists of the application of functional massage,
translatoric mobilization and translatoric manipulation all being applied to reduce soft tissue sensi tivity and to
enhance symptom free motion. Transitioning from one intervention technique to another can occur quite easily
EL-LV
Glide
PP - HV & LV
Indication: To improve left rotation (L Facet Joint)
Position: Supine
left side of the patient's head,
neck and left shoulder.
C7.
the ofC?
slack is taken up by the
applying (1) a ventral cranial
caudal and slightly medial force
with their left hand.
For restricted dorsal caudal
gliding on the left.
stabilizes the right facet joint of
C7 by pressing ventrally and
medially.
I and
The patient's cervical
position.
The C7 segment is
bending and left
rotation . r----.J
This technique may be
performed with an emphasis on
either the right or left facet of
C7.
See below for further details.
For restricted ventral cranial
gliding on the right.
stabili zes the left facet joint of
C7 by pressing ventrally and
medially.
The therapist' s right hand
I I and
For the dorsal caudal version of th is technique, if the manipulating force is directed too medially, t he patient may
experience discomfort during t he manipulation.
Note(s)
Slack is taken up in an equa l manner by both hands in order to keep the axis of movewent in the C7 segment.
Too large an amplitude or movement Illay result in unwanted Illovemcnt of t he thoracic spine and excessive stress
in the cranial cervical segments.
A wedge Illay be used to ass ist in stabi li zing the upper thoracic spinc. To allow clearance for movement of the
manipulat ing hand, the base of the wedge should be placed under T2 or T3.
The thoracic spine may also be stabili zed by placing it in flexion, left rotation and right side bending.
Ie
Ie
Ie
Glide
EL - I2J
PP - HV & LV
Indication : To improve left rotation (L Facet Joint)
Position: Supine
ri ght side of the patient's head,
neck and right shoulder.
C7.
the spinous process of C7.
applying (1) a medial and dorsal
force with their right hand towards
the left facet of C7 and (2) a
caudal and medial force with their
left hand.
Troublcshoot ing your tec hniq uc:
The patient's cervi cal
position.
The C7 segment is
bending and left
rotation.
The therapist may
impulse with either the
right or left hand.
If impulsing with the
right hand the impulse
is directed mediaUy and
dorsally towards the left
facet of C7.
If impul si ng with the left
hand the impulse is
directed caudally and
medially.
To effectivel y mobili ze C7 using thi s technique, the therapist must stand on the ri ght side of the patient. The
therapist 's right elbow is supported against the ri ght side ofhis/ hcr abdomen and pelvis.
Note(s)
A wedge may be used to assist in stabil izing the upper thoracic spine. To all ow clearance for movement of the
manipulating hand, the base orthe wedge should be placed under T2 or n.
The thorac ic spine may al so be stabili zed by placing it in t1 ex iol1, left rotat,ion and right side bend ing.
During thi s technique. the emphasis is placed on the dorsa l cauda l glide occurring in the left facet joint.
EL-LV
Glide
PP-HV & LV
Position: Prone
Troubleshoot ing your technique:
Nole(s)
As menti oned previously, it is important to be sure the therapi st is properly contacting C7 during thi s techni que.
To avoid any cranial sliding during the manipul ati on, the ulnar border of the ri ght hand shoul d maintain contact
with the first rib throughout the techni que.
InsutTi cient stabili zation of the shoulder may lead to a poorly locali zed and less effective manipul ati on or C?
Irthe manipul ati ng hand is located above C7 or i f the impul se is too large or deli vered by the pal mar surface
instead or lhe ulnar border of the hand, unwanted movement including dorsal ncxi ol1 or the supra-adjacent spinal
segment s may occur.
TI is stabili zed by pulling the shoulder girdle posteriorly thereby approximati ng the clavicle into the first rib and
the first rib int o T I.
A fi fm pill ow or sandbag may be placed under the pati ent 's right shoulder to support the positioning orlhe thoracic
spine in ri ght rotation. The therapist may then use the left hand to support the ri ght when deli ve ring the
i mpui sc.
--=
--=
-=
-=
-=
JC
-=
11:
11:
JC
a:
11:
JC
a:
Jt:
C
..IiI:
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C
IC
Jt:
C
IC
C
.a:
IC
C

Glide
EL -/21
PP - HV & LV
Position: Prone
The therapist is positioned beside
the patient's head, neck and left
shoulder.
The ulnar border of the therapist's
right hand contacts the patient's
right posterior surface of the
C7.
The patient's shoulders
are positioned in
approximately 120. 130
0
of nexion.
The patient' s cervical
spi ne, down to and
including C7. is
positioned in ventral
flexion, left rotation and
left side bending.
A pillow may be used to
assist in supporting the
Dalierll's head and neck.
Notc(s)
As mentioned previoLi sly, it is import ant to be sure the therapi st is properl y contacting C7 during this techni que.
To avoid any cranial sliding dur ing the manipulation, the ulnar border of the ri ght hand shoul d maintain contact
with the first rib throughout the technique.
Insuni cicnt stabilizati on of the shoulder may lead to a poorl y locali zed and less effec tive manipul ati on of C7.
Irt he manipulating hand is located above C7 or irt he amplitude of the impul se is too large or delivered by the
palmar surface instead of the ulnar border of the hand, unwanted movement including dorsa l nexion of the supra-
adjacent spinal segments may occur.
Tl is stabili zed by the posi tioning of the shoulders and shoulder girdl e bil aterall y. For proper stabili zation ofTI
the pati ent must relax thei r serratus anteri or and allow their chest to si nk anterior towa rds the table. This allows
the first rib and clavicle to approxi mate and stabili ze Tl .
Th is pos iti on all ows the therapi st to generate a good deal of force when man ipul at ing C7 with hi gh or low
velocity TSM.
Glide
Position: Prone
The therapist is positioned beside
the patient's head, neck and left
shoulder.
The therapist contacts the patient
by (1) placing the ulnar border of
the left hand on the patient's right
C7 and (2) positioning the ulnar
border of the right hand over the
left hand.
in C7 is taken up in a
ventral and cranial direction by
the therapist's right hand and
shoulder prior to delivering the
impulse.
EL -"
PP-HV & LV
As ment ioned previously, it is important to be sure the therapist is properly contacting C7 dur ing thi s techni que.
To avoid any cranial sl iding during the manipulat ion, the ulnar border orthe right hand should maintain contact
with the first rib throughout the technique.
NOle(s)
Insuffici ent stabi li zation or the shoulder may lead to a poorly locali zed and less effecti ve manipulation or C7.
If the mani pulati ng hand is located above C7 or the amplitude orthe impulse is too large or delivered by the
palmar surface instead of the ulnar border of the hand. unwanted movement including dorsa l flexion orthe supra-
adjacent spinal segment s may occur.
TI is stabil ized by the posi ti oni ng ort he shoulders and shoulder girdle bilaterally. For proper stabilization of TI
the patient must relax thei r serratus anter ior and allow their chest to sink anteri or towards the table. This allows
the fi rst rib and clavicle to approximate and stabilize T I.
68 1 Chapter 3 : Cervical Spine Appli cation
II:
Ie
II:
II:
Glide
EL -LV
PP - HV & LV
Indication: To improve right rotation (L Facet Joint)
Position: Seated
beside the patient's head, neck
and right shoulder.
The ulnar border of the
therapist's right hand contacts
the patient' s left posterior surface
of the transverse process, the
lamina and inferior articular
process of C7.
cervical spine,
The impul se may be
given in two ways:
(1) the therapist's right
hand impulses ventrally
and cranially and
I e)(CllJdiillg C7, is Posltioned in
neutral or slight left side bending.
(2) the therapist's left
hand impulses mediall y
against the spinous
process of T1 while the
therapist's right hand,
arm and chest stabili ze
C7.
pulls the patient's left
shoulder girdle and
I tho",cic spine into left
rotation.
The thumb presses
mediall y on the left side
of the spinous
of T1 .
Note(s)
One common mi stake when performi ng thi s technique is insuffici ent contact on the C7 spinal segment. To
identify where C7 is located, slide the manipulating hand down the lateral surface of the neck until the first rib is
contacted. The vertebra cranial to thi s point is C7.
Insuffi cient stabili zat ion ort he shoulder may lead to a poorl y locali zed and less dTcctivc manipulation ofC7.
Undesired and extraneous mid-cervicalmovemcnt will occur if the who le hand contacts cervica l segments above
C7 instead or the ulnar border Only the ulnar aspect of the hand should cont act the C7 segment and only thi s
port ion or the hand del ivers the translatori c impulse.
The therapi st may also take up the last porti on o rthe slack at C7 with a small amount of traction appli ed by hi s/ her
chest and manipulating hand.
The contact orthe manipulating hands may be reinforced by overl apping the ring and middle finger dorsally over
the fifth finger.
In cl ini ca l pract ice, comprehensive manual int ervention often consists of the appl icat ion or functional massage,
cont ract relax manualll1l1sc le stretching, translalOri c mobili zati on and translatori c manipulation all being applied
to rcduce son tissue sensiti vit y and to enhance symptom Cree motion.
Tmns/atoric Spina/ Manipu/ation I 69
...
Glide
Indication: To improve right rotation
Position: Seated
The therapi st stands facing the
patient.
left posterior surface of the
C7.
left hand contacts the patient's
right lamina, inferior articular
process and right side of the
spinous process of C7.
After the left and fight hands
are in contact with the patient ,
applying (1) a ventral cranial force...-___ -.
caudal and medial force
with their left hand.
The therapist's right knee
is positioned against the
patient's left anterior
shoulder.
Troubleshooting your tech ni que:
, left hand
right facet
by pressing
vernt",lIv and medially
therapist's right
impulses ventrally
and cranially:-
EL -12/
PP - HV & LV
cervical spine,
I e,<cllJdir'9 C7, is positioned in
C7 segment is positioned in
right side bending and right
rotation .
A number of options are available to
improve movement of C7 using this
technique; two of the more common
movement combinations are de:scriberj I
below.
hand stabilizes the left
facet joint of C7 by
pressing ventrally and
medially
The therapi st's left hand
impulses dorsaUy and
caudally.
One common mi stake when performing thi s technique is insufi'icient contact on the C7 spinal segment. To
identify where C7 is located, sl ide the manipulating hand down the lateral surface of the neck until the first rib is
contacted. The vertebra cranial to thi s point is C7.
Note(s)
Insuffi cient stabili zati on of the shoulder may lead to a poorly locali zed and less efTecti vc manipulat ion orC7.
This is an cxce llent technique to appl y when the C7 segmcnt is very hypomobilc (Grade I).
This technique ca n provide a very strong and safC stretch to the connective tissues tllat may be limit ing movcmcnt
at the C7 segment.
70 I Chapter 3 : Cervical Spine Appl ication
I:
It:
It:
I:
I:
Distraction
EL -"
PP - HV & LV
Position: Seated
back of the patient .
right hand presses medial and in
the direction of the anterior
surface of the transverse process
of C7.
left hand stabi li zes the left side of
C7 by pressing the left lamina,
inferior articular process and left
transverse process of C7 ventral ,
medial and caudal.
Troubleshooting you r technique:
/
Slack in taken up in a
dorsal and Slightly cranial
hand prior to del ivering the
impulse.
The patient's cervical spine
including C7 is positioned in
ventral flexion, left side bending
and right rotation.
The patient's thoracic spine is
positioned in flexion, left side
bending and right rotation
(locked below).
i
patient's left lateral
shoulder.
The therapist ' s left leg is used to supportlhe pat ient's trunk posit ion. It should not block the positioning of the
thoracic spine into side bending which is necessary for locking below.
Note(s)
Pressure against the tip of the transverse process ofTI may cause discomfort to the pat ient and should be avoided.
Stabili zation ofTI is generated by the locking occurring below in flexion le ft side bending and right rotation. An
alternati ve or supplemental method of stabili zing TI can be achieve by placing the therapist' s right knee behind
the patient 's ri ght shoulder thereby manually stabi li zing the thoracic spine and TI.
EL -121
Distraction
PP - HV & LV
Indication: To improve movement in all direct i o ns (R Facet Joint)
Position: Seated
i j
including C7, is positioned in
flexion, left side bending and
right rotation.
posi tioned in ventral flexion, left
side bending and right rotation
(locked below).
taken up by the ulnar border
of the therapist's ri ght hand
pressing ventrall y and
medially to stabilize C7.
Slack in the ri ght facet j oint is
taken up by the ulnar border
of the therapist's left hand
pressing dorsally and slightly
cranially.
Troubles hooting your technique:
The therapist's right knee
pati ent's left anterior
shoulder girdle.
front of the patient.
The ulnar border of the therapi st' s'
left hand presses medially and in
the direction of the anterior
surface of the right transverse
process of C7.
left lamina, inferior articular
process and posterior surface of
the transverse process of C7.
(
The therapi st's ri ght knee must be pressed against the pati ent's len. shoul der girdl e to effective ly stabili ze T l .
NOle(s)
A towe l may be placed anterior to the therapist' s ri ght knee to reduce any discomfort ex perienced during the
stabi lizat ion.
This technique variation generally provides better stabili zat ion than the one pi ctured 0 11 the previoLi s page,
however, it is typica ll y more difli cult to push C7 than pull ii, as pictured on the previous page.
The axis of'movcmcnt for thi s technique is the left fa ce! j oin! orC7.
72 I Chapter 3 : Cervical Spine Appli cat ion
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Distraction
EL -"
PP-HV & LV
Indi cation: To improve movement i n all directions (R Facet Joint)
Position: Seated
back of the patient.
right hand contacts the patient' s
right lamina, superior articular
surface and right posterior
surface of the transverse process
efT1.
left hand presses in the direction
of the patient's left transverse
process and ventral lateral aspect
of the vertebral body of C7.
In addition to the contact
described above, the therapist's
left hand supports the patient's
head and neck position.
-----
taken up by the ulnar border of
the therapist's left hand
pressing dorsally and medially
to stabi lize C7.
Slack in the right facet joint is
taken up by the ulnar border of
the therapist's ri ght hand
pressi ng ventrall y, mediall y and
caudally.
Troubles hooting your techniq ue:
impulses ventrall y, mediall y
and
Discomf'ort in the len side of tile pati ent's neck may be caused by pressing mediall y with the left hand when
support ing thc pat icnt 's neck.
Note(s)
Duri ng thi s technique. it is expected and necessary that some minima l movement occ ur in the thoracic spine ca uda l
10 TI.
The axi s of movement l'or th is technique is the left facet j oi nt ofC7.
The impul se may also be given by the radial border of the 2nd Mer and index fi nger of the right hand with the
forearm posit ioned in pronat ion.
Transla/oric Spinal Manipula/ion I 7 3
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Thoracic Spine
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The Thoracic Spine
The stable thoracic segments
The twelve thoracic motion segments are the least mobile of the
spinal column. There are a number of factors that contribute to the rel ative
stiffness of this region. The first factor relates to thoracic disc height. The
thoracic disc is narrow relative to other regions of the spine. In addition,
the nucleus pulposus ofthe thoracic disc is smaller in size reducing the
overall water content within the disc. The smaller disc height relative
to thoracic vertebral body height reduces overall segmental mobility. A
second factor contributing to the overall stiffness of the thoracic spine
is the thickness of the ligamentum ftavum. In the thoracic region of
the spinal column, the ligamentum ftavum is thicker and well suited to
enhance thoracic segmental stability. The third factor contributing to the
stiffuess of the thoracic spine is the attachment of the ribs to the spine and
sternum. This thoracic cage increases the resistance of the thoracic spine
to all movements in the sagittal, frontal and transverse planes. Regarding
movements in the transverse plane, the thoracic vertebrae that attach to
the sternum via the ribs demonstrate the greatest increase in resistance to
motion in the transverse plane. The remainder of the thoracic segments not
attaching directly to the sternum show less resistance to torsional motion
Lastly, regarding the the overall stabi lity of the thoracic spine, the thoracic
facet joint capsular ligaments are thinner when compared to the other
regions of the spine. This may be a factor in the relative ease in obtaining
joint cavitation with both unilateral and bilateral facet joint distraction
manipulations.
Osteological features of the thoracic spine
Clinicians providing manual intervention to the thoracic segments
should be aware of the general angle of orientation of the thoraci c
spinous processes. At the T I through T3 segments, the spinous processes
point nearly straight backward. At the T4 through T6 segments, the
spinous processes angle downward slightly. This trend continues even
more so at the T7 through T9 segments. This osteological characteristic
is particularly important when locating and contacting the transverse
processes in the thoracic spine for testing and treatment purposes. When
contacting thoracic spinal segments in the mid-thoracic spine, the tip of
the spinous process is more caudal than the transverse process for a given
spinal segment. Due to the normal variation of osseus structures between
and within individuals, this principle should be used as a guide for the
location of transverse processes. The location of the structures may be
further clarified/confirmed through the use of translatoric joint play testing
in prone, si de-lying or in a seated position.
Thoracic facet joints
The thoracic facet joints are principally orientated in the frontal
plane. Given this, the thoracic facets and the thoracic intervertebral discs
are the primary stabilizers to anterior/posterior di splacement of any given
thoracic segment. In the lower portion of the thoracic spine, typically
somewhere between the T I 0 and T 12 segments, the general orientation
begins to change slightly toward the sagittal plane.
In more specific terms, the thoracic superior articular facet in any
given segment lies anterior to the inferior articular facet. The articular
surface of a superior thoracic facet is orientated in a cranial , lateral
and posterior direction. The inferior thoracic facet lies posterior to the
superior facet and its articular surface faces somewhat caudally, medially
and anteriorly. On a clinicallbiomechanical note, significant increases in
segmental mobility follow the removal of these facets. Loss of the facets
due to tumor, trauma or surgery will result in increased segmental motion.
76 I Chapter 4 : Thoracic Spine Application
Articular surfaces of the thoracic
spine
~ vertebral body I
(
Thoracic spine articulations
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Direction of joint rolling and gliding during thoracic ventral and dorsal flexion
Direction of joint rolling and gliding during thoracic coupled side bending and
rotation in ventral flexion
Left Side Bending and Rotation Right Side Bending and Rotation
Biomechanics of Thoracic Spine TSM
Disc Traction
Thoracic disc traction TSM techniques are performed with the patient in a seated or supine postion.The caudal
vertebra is stabilized with a wedge or through direct manual stabilization. The impulse is directed cranially through
the patient's shoulder girdle and upper trunk.
Position - the actual resting position
Facet Distraction
Thoracic facet distraction TSM techniques can be performed unilaterally or bilaterally. They may also be performed
moving the cranial vertebra (typically in supine or sitting) or caudal vertebra (in prone). Stabilization of the cranial or
caudal vertebra is achieved through either the use of the hand, the wedge or through spinal locking above or below.
Unilateral distraction techniques are performed with sidebending away and rotation towards the treatment side.
Bilateral Facet Distraction
Positioning - actual resting position
Cranial stabilization
Unilateral Facet Distraction
Positioning - sidebending away, rotation towards
the side of facet distraction
Impulse directed
posteriorly towards
the left facet joint
Facet joint distraction
Impulse directed
ventrally, medially
and slightly
caudally
Facet joint compression
Cranial stabilization
Facet joint compression
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F
Thoracic-Disc Traction
EL - LV
PP - HV & LV
Position: Supine
The therapist faces the patient's
chest.
The therapist supports the patient
posteriorly with their left hand and
forearm supporting the patient's
upper back and neck.
The therapist's right hand is placed
on the midline of the patient's
crossed forearms.
The patient is positioned in
supine with their thoracic
spine, including the treatment
segment, positioned in the
actual resting position.
The patient's arms are
positioned across their chest
along the ribs connecting to
Note(s)
Monitor that the patient's cervical region is relaxed, well supported and not hypertlexed or hyperextended when
performing this technique.
Translatoric thoracic disc traction is a good initial treatment option if a thoracic segment is very hypomobile
(Grade I restriction on the 0-6 KE mobility scale). Once the thoracic segment demonstrates improved mobility,
translatoric thoracic unilateral or bilateral facet traction manipulation may be applied.
Translatoric thoracic disc traction is a good initial treatment option if there is intercostal pain radiation.
In technique variation A pictured above, the therapist uses a "pistol grip" (see illustration on next page) to support
the caudal vertebra. A pillow or the movable head section of a manual therapy table may be used to support the
position of the treatment segment and the spinal segments cranial to the treatment segment.
In technique variation B, a wedge is used to support the caudal vertebra in the treatment segment. The therapist
then uses both oftheir hands placed on the patient's overlapping forearms and elbows to generate the manipulative
impulse.
Thoracic-Facet Traction
EL - HV & LV
PP - HV & LV
Position: Supine
The therapist's right wrist
is positioned in ulnar
deviation. The fingers are
positioned with the index
finger straightened and
fingers 3-5 flexed. The
distal phalanx of fingers
3-5 are positioned
perpendicular to the palm.
The spinous process of
the caudal vertebra is
placed between the flexed
fingers and the thenar
Slack in the treatment
segment is taken up by
pressing dorsally and
cranially towards the
transverse process of the
treatment
The impulse is directed
flexed fingers and thenar
eminence and slightly
cranial to the transverse
process of the caudal
segment.
The therapist faces the
patient's chest.
The therapist contacts the
patient posteriorly with their
right hand stabilizing the
transverse processes of the
treatment segment (see box
3).
The therapist's left hand is
placed on the midline of the
pat.isnt's crossed forearms.
The patient is positioned
in supine with their
thoracic spine, including
the treatment segment,
positioned in the actual
resting position.
It is important to maintain a light contact with the patient when positioning for this technique.
Note(s)
This may require additional support for the patient's upper body to minimize discomfort prior to and immediately
following the manipulation. This may be accomplished by reaching behind the patient's upper back as illustrated
on the previous page.
The section of the table located under the thoracic spine may also be elevated to reduce pressure against the
stabilizing hand or thoracic wedge.
For these pictures, the middle thoracic spine is treated with the patient's head and upper thoracic spine positioned
on the head section of the table which is then elevated slightly. The lower thoracic spine is treated with the head
and the middle thoracic spine positioned on the foot portion of the table which is then elevated.
The patient's anns are positioned across hislher chest cranial to the treatment segment.
Note the orientation of the therapist's arm and hand under the patient. The therapist's arm and hand should be
placed medial to the inferior angle and medial border of the scapula.
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IC
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IC
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EL - HV & LV
PP - HV & LV
Position: Supine
segment is taken up by
the therapist's chest and
hand pressing dorsally
and cranially towards
the transverse process
of the caudal vertebra in
The base of the wedge is
placed against the
treatment segment.
The therapist supports the
patient's upper back and neck
.-.:::::...-, posteriorly with their left hand
and forearm.
The therapist's right hand is
no';onll'. crossed forearms.
supine with their thoracic
spine, including the treatment
segment. positioned in the
actual resting position.
positioned across the chest
along the ribs connecting to
Troubleshooting your technique: ,
Note(s)
As with any of the thoracic facet traction techniques, care should be taken to avoid movement into thoracic
dorsal flexion during the impulse.
In cases of significant hypomobi lity, in order to generate the greatest improvement in motion in a given spinal
segment, it is necessary to manipulate the treatment segment in the position where the greatest joint play is
nonnally felt. Specifically, if the therapist is unable to determine where the joint moves the easiest or greatest,
then the manipulation should be performed where the segment's resting position is estimated to be.
To achieve this position in the treatment segment, whil e stabilizing the caudal vertebra, the therapi st must
test the movement of the treatment segment in varying degrees of ventral and dorsal flexion. The impul se
is performed in the position where the movement is felt to be the greatest and the end feel the most firm and
nonmuscul ar.
The patient's arms are positioned across hi slher chest cranial to the treatment segment.
The dorsal cranial movement should occur immediately above the wedge during thi s technique.
In the Haltemative arm position" picture, the patient's arms are not crossed, rather the shoulders and elbows are
fl exed and the hands are overlapped behind the neck.
F
EL - 0
PP - HV & LV
Position: Supine
segment is taken up
dorsally and craniall y
towards the left
treatment
placed under the left
treatment
The therapist stands on the
right side of the patient facing
the patient's chest.
left hand and forearm
supporting the patient's upper
back and neck. The thenar
eminence of the right hand
stabilizes the caudal vertebra
as described under box 2.
Anteriorly, the therapist
contacts the patient's elbows
with their chest.
treatment segment, is
positioned in ventral
flexion, right side
bending and left
rotation
Troubleshooting your technique,
Note(s)
It is important to be sure that the stabilizing hand is positioned medially and on the spine as described above. If
the hand is positioned laterally on the rib and the impulse is directed dorsally, the rib may bend. Thi s may result in
pain and potentially a rib injury, including fracture, if treating a patient with osteoporosis.
This technique is often applied when thoracic rotation is restricted and painful.
Thi s technique is also good when a therapist with a small stature is treating a patient with a relatively large stature.
Thi s technique may be applied prior to bilateral facet traction in a segment that is slightly more hypomobile.
If the arm/hand used to stabilize the caudal vertebra is not long enough to reach around the patient, this technique
may be perfonned with tbe therapist using bis/her right hand while standing on the left side of the patient (see next
page).
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EL - I2J
PP - HV & LV
Position: Supine
Slack in the treatment segment
is taken up by pressing
dorsally and cranially with the
therapist's chest and left hand
towards the left transverse
The impulse with the chest
and left hand is directed
slightly cranial to the left
treatment segment.
The therapist's right wrist
is positioned in the mid-
position. The thumb is
adducted and placed
anteriorly to the second
metacarpal and index
finger. The thenar
eminence is placed under
the left transverse process
of the caudal vertebra in ,..-_....:::=-.c= '---== '--__ -'
left side of the patient facing
the patient's chest.
right hand stabilizing the
transverse processes of the
treatment segment (see box
2).
The therapist's left hand is
patient's crossed forearms.
spine, down to and
..... ~ = __ including the cranial
segment, is positioned in
ventral flexion, right side
bending and left rotation
(locked above).
Note(s)
The patient should feel greater pressure posteriorly on the side of the spine that the therapi st's hand is positioned
under.
During the impulse, support under the left transverse process of the caudal vertebra will allow the cranial vertebra
in the treatment segment to rotate to the left, generating traction in the left facet joint during the manipulation.
The spinal positions, therapist contacts and arm placements, all of which have been described in the previous
bilateral facet distraction techniques in supine. may be used with this technique to create unilateral facet
distraction.
When choosing the arm position for this or any other thoracic techniques using pressure through the shoulders,
the therapist must confirm that the patient 's shoulders are comfortable throughout the technique. The alternati ve
ann position pictured above uses a cross armed positi on where the right hand is placed on the left shoulder and the
left hand is placed on the right shoulder.
EL - HV & LV
PP - HV & LV
Position: Supine
The right transverse process
of the cranial vertebra in the
treatment segment is placed
on the right side of the base of
the wedge.
- __ facet traction. A notch is cut
on one side to remove
stabilization of one side of the
cranial vertebra in the
treatment
Note(s)
The patient's treatment segment should be positioned without side bending or rotation prior to the manipulation,
however, segments cranial to the treatment segment may be locked in either dorsal or ventral flexion.
During the impulse, the notch in the wedge will allow the cranial vertebra in the treatment segment to rotate to the
left, generating traction in the left facet joint during the manipulation.
The spinal positions, therapist contacts and arm placements, all of which have been described in the previous
bilateral facet distraction techniques in supine, may be used with the modified wedge to create unilateral facet
distraction.
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EL - HV & LV
Thoracic-Facet Traction PP - HV & LV
Position: Prone
The slack and impulse
are directed ventrally,
'0:"--__ ventrally caudally and
ventrally cranially
depending on where in
the thoracic spine the
facet traction is
performed. See arrows
patient's head.
The base of the wedge is placed on
the transverse processes of the caudal
vertebra in the treatment segment.
The therapist places both hands on
the base of the wedge as illustrated
below.
The manubrium is supported on a firm
roll when T1 and T2 are treated with
for the general direction of ILIiII..::il1iI
movement.
Note(s)
Fai lure to properly contact the caudal vertebra with the wedge or failure to identify the proper direction of the
impulse may lead to a less effective technique.
The direction of the impulse used during this technique must be adjusted to compensate for patients with either
extremes of thoracic flattening or kyphosis.
EL - LV
PP - HV & LV
Position: Prone
left side of the patient facing
the patient's thoracic spine.
left pisiform on the right
articular process, lamina and
treatment segment.
The patient's thoracic
;"" __ .J spine, down to and
including the cranial
segment, is positioned in
dorsal flexion, right side
bending and right rotation
(locked above).
The thoracic spine is supported in dorsal flexion, right side bending and right rotation through the use of a firm
roll. If the roll is too soft, the locking may not be firm resulting in a less specific and potentially ineffective
technique.
Note(s)
To be most effective, the impulse should be directed at a right angle to the articular surface of the facet joint.
Locking in dorsal flexion may not be comfortable for patients who are kyphotic and significantl y hypomobi le. In
these cases, the thoracic spine may be positioned in flexion left side bending and right rotation.
This technique may also be performed by pulling the shoulder in a dorsal and caudal direction with the right hand.
This is technique variation is illustrated in the lumbar spine on page 119.
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Thoracic ribs
There are different anatomical classifications for the thoracic ribs and rib joint articulations. For example, ribs 2 through 9
can be referred to as the typical ribs. Typical ribs articulate with their vertebral body and the vertebral body one level above.
The atypical ribs are numbers I, 10, II and 12. These ribs articulate only with their numerically corresponding vertebrae.
The articulation of ribs to the vertebral body is known as the costovertebral joint. These are very stable articulations with
strong capsoligamentolls reinforcement. The costovertebral joint are synovial and subject to the development of symptomatic
motion restrictions.
The ribs may also be classified based on their attachment to the sternum. For example, ribs I through 6 can be
referred to as the vertebrosternal ribs in that they have direct attachment into the sternum. Ribs 7 through 10 can be referred
to as the vertebrochondral ribs. The development of symptomatic irritation at these anterior rib articulations can at times be
improved by the appl ication ofTSM to hypomobile posterior rib articulations. Regarding the other posterior rib articulations,
the recognition of the positional relationship between the ribs to the corresponding thoracic transverse process is of both
anatomical interest and clini cal importance. Regarding the upper (vertebrosternal) ribs, they articulate both anteriorly and
inferiorly to their numerically corresponding thoracic transverse process. The lower (vertebrochondral) ribs li e anteriorly
and slightly superiorly to their transverse process. These articulations are known as the costotransverse joints. Similar to the
costovertebral joints, these synovial articulations are also subject to the development of symptomatic movement impairments.
Lastly, and very generally, is a brief review of rib movement or kinematics. From an osteokinematic
perspective, all ribs can be generally seen to move obliquely upward, outward and forward during inspiration. On an
arthrokinematic level , the motion thought to produce this rib cage movement is a long axis rotation through the mechanically
combined costovertebral and costostemal articulation.
Position of the ribs relative to the transverse processes
Orientation of the transverse costal facet
Upper thoracic
Middle thoracic
Lower thoracic
Direction ofTSM impulse
Upper thoracic
Middle thoracic
,
Biomechanics of Rib TSM
Costotransverse and Costovertebral glides and distraction
Arthrokinematic movements occurring during rib T5M vary depending on the direction of force used. When the
impulse is directed more ventrally, distraction occurs at the costotransverse (CT) jOint and gliding occurs at the
costovertebral (CV) joint. When the impulse is directed more laterally, gliding occurs at the costotransverse joint and
distraction occurs at the costovertebral joint. During rib T5M, it is difficult to generate much lateral movement of the
rib due to lateral sliding of the manipulating hand on the rib. Therefore, ventral forces combined with inferior, superior
and lateral forces (dependant on the level of the rib) are most commonly used to treat the costotransverse joints.
During rib T5M, the spine may be stabilized (prone and seated techniques) and the rib moved or the rib may be
stabilized and the spine moved (supine technique).
Positioning -In prone, the spine and rib are in the actual resting position; in seated and supine, the spine is in
flexion, side bending away and rotation towards the treatment rib.
CT and CV joints at rest
Prone technique with spinal stabilization
Ventrally and slightly
laterally directed
impulse
Seated and supine technique with rib stabilization
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First Rib-Distraction
EL - LV
PP - HV & LV
Position: Supine
costotransverse joints is
taken up in a ventral and
caudal direction by the
therapist's left hand prior
I the
the left side of the patient's head.
The therapist's left hand presses
ventrally and medially through
upper trapezius muscle in the
direction of the first rib.
= =====. position of C7 by (1) stabilizing
against the lamina and tra'1Sv<ers,,1
~ _ . . process of C7 with the right
(2) supporting the right side of
head with the right forearm and
(3) supporting the left side of the
patient's head with the right side
of the therapist's chest.
Note(s)
In order to lock from above and maintain the lock, right side bending must be maintained when the neck is left
rotated.
Tbe therapist may also apply a craniall y directed traction to the neck by using the right side ofbislher cbest and
right hand. The traction acts as a counterforce to the caudally directed force used during the manipulation.
I f the cervical muscles on the left side of the neck are significant ly tight, they may hinder the movement of the first
rib during this technique wben using locking above. In these cases, stretching of the muscles (i.e. the scalene
muscles) should be perfonned prior to and following successive high and low velocity translatoric manipulation.
In addition, locking from below may be used to stabili ze Tl, ifllsing locking above is contraindicated due to
patient discomfort or pathology in the cervical spine.
First
EL - LV
Ri b - D i st racti 0 n PP - HV & LV
Position: Seated
taken up in a ventral and
caudal direction by the
therapist's right hand
to delivering the
hand impulses
'-----I ventrally and
r caudally.
. patient.
(1) posteriorly and cranially on
first rib with the radial border of
their ri ght second MCP and (2)
anteriorly and laterally with their
left medial forearm and distal arm
against the left side of the
patient's neck supporting the
position.
Note(s)
The therapist's left forearm must be firmly placed agai nst the left side of the patient's cervical spine for proper
stabilization of the cranial vertebra in the locked position. Caudal pressure against the shoulder girdle and sternum
should be avoided and may cause patient discomfort.
If the scalene muscles are tight and are restricting the movement of the first rib, the therapist should perform
manual muscle stretchi ng prior to mobilizing the first rib. This principle is typically used in cycles where the
muscles are stretched, the joints are mobilized and the muscles are stretched again until the movement is restored.
This technique can also be performed as a facet traction manipulation by moving the right hand medially onto the
articular process, lamina and transverse process of the caudal vertebra.
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First Rib-Distraction
EL - 121
PP - HV & LV
Position: Seated
After the slack in the lock
is taken up with the
therapist's left arm and
body, slack in the
costovertebral and
taken up ventrally.
caudally and slightly
medially.
The therapist stands behind the patient.
The therapist contacts the patient (1)
posterior1y and cranially on the first rib
with the radi al border of their right
second MCP and (2) anterior1y with
their left hand and forearm on the
patient's crossed arms, supporting
thoracic flexion. right side bending and
I
positioned in ventral flexion, right
side bending and left rotation
(locked in flexion).
The patient's lumbar spine is
positioned in dorsal flexion, left
side bending and left rotation
(locked in extension).
A roll is placed behind the
low back.
A wedge is placed under the
left ischial
The position used for locking below must be painfree for the patient. If the patient experiences pain during
positioning, the therapist should try to vary the position and lock accordingly to find a position of minimal to
no discomfort prior to performing this technique.
Note(s)
The movement used during treatment will facilitate greater locking in the thoracic spine.
In this position, the right cervical muscles are slackened and will not hinder the movement of the first rib during
this technique.
When two forms of locking are used during a technique it is called "double locking".
Ri bS2-12- Distraction
EL - I2J
PP - HV & LV
Position: Supine
posteriorly with their left hand and
forearm supporting the patient's upper
back and neck. The thenar eminence
of the right hand stabilizes the rib being
treated as described under box 2.
The right side of the therapist's chest
contacts the patient's right lateral
humerus and left distal forearm and
hand.
The i
directed across the body in the
direction of the tip of the thumb
to maximize vertebral
movement on the rib, while
minimizing rib compression.
Slack in the costotrans-
verse and costorvertebral
joints is taken up during
the positioning of the
thoracic spine in flexion,
right side bending and left
rotation.
The thumb is adducted and placed anterior
to the second metacarpal and index finger.
The thumb and thenar eminence are
placed under the rib, with the tip of the
thumb placed immediately lateral to the left
transverse process of the adjacent
vertebra.
A direct dorsal pressure may "bend" and injure the rib.
Note(s)
In supine, the patient's thoracic
spine is positioned in ventral
flexion, right side bending and
left rotation.
positioned across their chest
above the level of the rib
Ifthe therapi st is having difficulty generating the impulse using the chest alone, the right hand may additionally
apply a quick, short lateral impulse along the the rib.
EL - LV
PP - HV & LV
Position: Prone
The therapist stands either at the head of the patient
(upper-middle ribs) or beside the patient (lower ribs).
The therapist contacts the patient with the ulnar border of
their left hand placed next to the spinous process. pressing in
the direction of the patient's left transverse processes and ~ ~ 1 ) I l
ribs and the pisiform of their right hand on the rib slightly
lateral to the corresponding thoracic vertebra's transverse
process.
transverse and costo-
vertebral joints is taken up
in a ventral and slightly
lateral direction with the
right hand.
Note(s)
During thi s technique. failure to properly stabilize against the transverse processes can lead to movement of the
vertebral segment. In order to properly stabi lize the vertebra, the stabil ization pressure should increase during the
impulse.
Jfthe stabi1ization force is reduced, this technique can be used to begin small rotational movements in the thoracic
spme.
The stabilization force should be gradually increased as the slack in the costovertebral and costotransverse joints is
taken up prior to the manipulation.
When giving the impulse, the right hand may slide in the direction of the arrow which will help generate a quicker
impulse.
EL - 121
PP - HV & LV
Position: Prone
side of the
patient.
The therapi st contacts the patient (1) with their
right hand on the patient's right shoulder girdle
pulling the shoulder posterior1y to rotate the
thoracic spine to the right and (2) with the ulnar
border of their left hand on the rib. The
pisiform is placed lateral to the transverse
process of the vertebra adjacent to the treated
rib.
segment is taken up
during the positioning of
the thoracic spine in
dorsal flexion, right side
bending and right rmatlc,n.'
A roll. pillow or other support may
be placed under the patient's right
arm, shoulder girdl e and torso to
assist in positioning the patient in
right rotation.
The therapist may then use their
right hand to support their left wrist
and hand the
The left hand impulses
ventral, ventral caudal or
ventral cranial depending
on which rib is being
treated. See the
The therapist should confirm that the patient tolerates the contact to the anterior shoulder when positi oni ng for this
technique. If the contact is not tolerated, the therapist may ( I) try diffusing hi s/her contact pressure throughout the
hand or (2) try positioning the patient by pull ing from the anterior/superior chest instead of the shoulder.
Note(s)
If the force used during this technique is directed too ventral, the rib may be bent and potentially injured.
The superior ribs are suspended below the transverse process, so the direction of the impulse is ventral and slightl y
caudal.
The middle ribs are positioned in front of the transverse process, so the direction of the impulse is ventral.
The inferior ribs are positioned slight ly above the transverse process, so the direction of the impulse is ventral and
slightly cranial.
The direction of the impul se will also further reinforce the locking above.
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Position: Seated
(1) posteriorly and laterally with
the left side of their lower chest
and abdomen (supporting the
locked noncoupled ventral flexion
position of the thoracic spine),
(2) anterior with their left hand
and arm holding the patient's
right shoulder and controlling the
patient' s ventral flexion, left side
bending and right rotation and
(3) posteriorly on the rib, lateral to
the thoracic transverse process
with the radial border of the right
hand and index I
The right hand impulses
ventrally, ventrall y
caudally or ventrally
cranially. See the
I "n"tel's)" section below
I In" I"rth,,, detail.
take up the slack, the rib is stalbiilized
the thoracic spine above is moved into
right rotation (while the ventral
flexion and side bending are maintained).
Next, the right hand takes up the slack in
the costotransverse and costovertebral
by pressing the rib in a ventral,
ventral caudal or ventral cranial direction
dependant on which rib is treated.
EL - LV
PP - HV & LV
Failure to adequately lock through the adjacent vertebral segments may lead to motion in the spine in addition to
the rib.
Note(s)
The patient's arms must not be pressed against the rib cage as this may block movement of the rib undergoing
treatment.
The seated position is potentially less aggressive than the supine position because the patient's trunk weight is not
being used to generate the stretch.
The superior ribs are suspended below the transverse process, so the direction of the impulse is ventral and slightly
caudal.
The middle ribs are positioned in front of the transverse process, so the direction of the impulse is ventral.
The inferior ribs are positioned sli ghtly above the transverse process, so the direction of the impulse is ventral and
slightly cranial.
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Lumbar Spine
u@W ITiJ 0 CQ] OJ]@
The Lumbar Spine
Osseous anatomy
The smallest functional unit of the spinal column is the motion segment.
The motion segment consi sts of two adjacent vertebrae and all of their
interconnecting structures. Vertebrae can also be divided into other
anatomical or functional components such as the vertebral body, the
pedicles and the posterior elements. What follows is a brief review of
these components in the lumbar region.
The lumbar vertebral body is clearly larger than both thoracic and
cervical vertebral bodies. It is flat on its superior and inferior surfaces and
slightly concave on the anterior and lateral surfaces. The vertebral body
has a greater transverse diameter as compared to its anterior diameter and
height. The shape of the lumbar vertebral body reflects its responsibilities
in terms of supporting longitudinally applied loads. While stable for these
longitudinal loads, the lumbar segments are dependent on the posterior
structures for stabi lity in other planes. The body of the vertebra and the
intervertebral disc support 85% of the weight-bearing requirements of the
movement segment.
The pedicles attach to the upper posterior portion of the vertebral
body. They are the only connection between the posterior elements and the
vertebral bodies. All forces sustained by any of the posterior elements are
ultimately channeled to the pedicles which then transmit these forces to the
bodies.
The posterior elements provide attachment sites for many of the
lumbar ligaments and muscles. They provide rigid levers for the restriction
and enhancement of movement. The laminae project from each pedicle
towards the midline and serve to protect the contents of the spinal canal.
Forces that act on the spinous and articular processes are transmitted to
the laminae. The part of the lamina that is found between the superior
Articular surfaces of the lumbar
spine
and inferior articular process on each side is the pars interarticularis. Lumbar spine articulations
The pars is thicker than other portions of the lamina and is typically able
to withstand large bending forces. Individuals with insufficient bone
structure in this area are susceptible to fractures (spondylolysis) as a result
of excessive or sudden forces applied to the interarticularis region. The
posterior extension of the lamina is the spinous process. This structure
represents the uniting of the two laminae in the midline. The spinous
processes are broad and thick and extend horizontally. Another structure
considered a part of the posterior elements is the transverse process (TP).
The TPs extend from the junction of the pedicle and lamina. The TPs are
flat and rectangular and extend in a posterior and lateral direction.
The facet joints are also an important component of the lumbar
posterior elements. In the most basic sense, the facet joints are formed
by the articulation of the inferior art icular process of the cranial lumbar
vertebra and the superior articular process of the caudal vertebra in the
spinal motion segment. The facet joints support 15% of the weightbearing
requirements of the lumbar motion segment. Viewed from behind, the
articular facets appear as straight surfaces, suggesting that they are planar.
When viewed from above, it can be seen that the lumbar facets vary in the
shape of their articular surfaces and in the general direction they face. In
the transverse plane, the articular facets may be flat, planar, slight ly curved
or curved in a "C" or "J" shape. The classic C-shaped orientations are
particularly well suited to resist and constrain against excessive motion in
two principal directions. The sagittal portion of a C-shaped facet will limit
excessive rotation in the transverse plane while the more frontal portion
of the facet surface wi ll limit excessive anterior translation. Certain
developmental and degenerative changes reduce the ability of the facet
joint to resist loading. When these joints develop with an asymmetrical
unilateral variation it is called facettropism.
Articular cartilage covers the superior and inferior articular
98 I Chapter 5 : Lumbar Spin. Application
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processes and assumes the same concave or convex curvature of the underl ying facet. The cartil age is generall y thickest
over the center of each facet. Around its dorsal, superior and inferior margins, each lumbar facet joint is enclosed by a
fibrous capsule. The anterior capsule is reinforced by the ligamentum fl avom. The posterior portion of the lumbar facet j oint
capsule blends with fibers of the deep lumbar extensor muscles. Situated around the borders and within each facet joint are
meniscoid bodies composed of fat and surrounded by fibrous ti ssue. These meni scoids move into and out of the facet joints
during movement to enhance the articular congruency.
The vertebral foramen is formed anteriorly by the vertebral body, the intervertebral disc and the posteri or
longitudinal ligament. The posterior aspect of the vertebral foramen is formed by the lamina and li gamentum fl ava. The
lumbar vertebral foramen shows three typi cal shapes, oval, triangular and trefoil. Generally, the upper lumbar region
foramen are oval in shape and the lower lumbar region are more triangular or trefoil in shape. When articulated together, the
fi ve lumbar vertebrae form the lumbar canal. The size and shape of the lumbar canal will vary based on a number of potential
factors, including the size and shape of the pedi cles and facets.
Ligamentous anatomy
There are three princi pal li gamentous structures that interconnect the lumbar vertebral bodies. These structures
include the annulus fibrosus, the anterior longitudinal li gament (ALL) and the posteri or longitudinal ligament (PLL). Based
on its size and strength, the peripheral porti ons of the annulus fibrosus are arguably the principal stabilizing structure that
unites the lumbar vertebrae at the intervertebral di sc joint.
The ALL consists of muhiple sets of both long and short collagen fibers. The most superficial fibers are the longest
and may traverse four to five vertebral segments. The deep sets of fibers connect adj acent segments. The principal function
of the ALL is to resist excessive separati on of the anterior aspects of the lumbar vertebral bodies.
The PLL runs along the dorsal surfaces of the vertebral bodies and widens laterally over the posterior surface ofthe
intervetebral di scs where it bl ends with the annulus fibrosus. Thi s ligament runs inside of the vertebral canal and anterior to
the spinal cord and cauda equina. Its principal biomechanical function is to resist separation of the posteri or aspects of the
lumbar vertebral bodies.
Simil ar to the PLL, the ligamentum fl avum is an intracanalli gament. This structure is primaril y composed of elastin
fibers. It is short, fairly thick and connects successive lumbar laminae. The li gamentum fl avum primarily resists excessive
separation of the laminae.
The intervertebral disc (lVD)
The IVD consists of three principal components, the nucleus pulposus, the annulus fibrosus and the vertebral end-
plates and forms the principal connection between the vertebral bodies. The nucleus pulposus is a semi-fluid substance that is
subj ected to muhi-directionalloads. Given its structure and anatomical constituents, the nucleus will deform, aher its shape
and subsequentl y transmit or di stribute loads equall y in all di rections.
The annulus fibrosus consists of 6 to 20 sheets or rings, also known as lamellae. The annul ar rings are arranged
in a concentri c fashi on around the nucleus. Centrall y, the annul ar fibers become more loosely arranged and blend wi th
the nucleus pulposus. Similar to other ligamentous structures, the principal function of the annulus fibrosus is to constrain
motion. The annulus not only binds the two vertebral end pl ates together, but also functions as the principal stabilizing
structure between the two vertebral bodi es at the lVD joint. Examination, evaluation and biomechanical intervention for
the IYD j oint is paramount to the practice of TSM. Joint play testing examines the translatoric mobility at the IYD joint and
various translatoric disc traction manipul ation techniques seek to improve mobil ity and reduce load at this same articul ation.
The vertebral end plates are found between each IYD and adjacent vertebral bodies. The end plates consist of both
fibrocartil age and hyaline cartil age. Thi s structure covers the nucleus pul posus, allows fluid diffusion into the IYD and
further serves to protect the vertebral body by transmitting a porti on of the weight-bearing requirement.
Vascular anatomy
In brief, the principal blood supply for the lumbar spine comes from the lumbar arteries. Paired lumbar arteries arise
from the aorta and descend along the anterior and lateral aspect of the lumbar vertebral bodies. Dorsally directed branches
of the lumbar arteries pass under the transverse processes and supply the deep lumbar extensor/rotator muscles as well as
the facet joints. Further branching of thi s artery occurs opposite the lumbar intervertebral foramen. These branches suppl y
important anatomi cal structures within the vertebral canal.
i
Direction of joint rolling and gliding during lumbar ventral and dorsal flexion
Direction of joint rolling and gliding during lumbar coupled side bending and
rotation in ventral flexion
Left Side Bending and Rotation
Right Side Bending and Rotation
100 I Chapter 5 : Lumbar Spine Application
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Biomechanics of Lumbar Spine TSM
Disc Traction
T5M techniques generate lumbar disc traction by either (1) lifting the thoracic spine off the lumbar spine in sitting, (2)
moving the pelvis and sacrum caudally in side-lying or prone or (3) moving the pelvis away from the thoracic cage by
performing a body drop into the side of the patient while simultaneously pressing the pelvis and sacrum caudally. In
effect, these techniques elongate the lumbar spine, reducing the lumbar lordosis. Traction provides a uniform stretch
to the discal tissues and surrounding segmental structures in addition to facilitating intervertebral foraminal
decompression.
In side-lying
i
generated by
the supoort roll and
treatment table.
In sitting
force
patient's
loil,e",non. humerus
The arms and
forearms are pulled
against the patient's
rib cage prior to the
Ii
Translatoric Spinal Manipulation 1101
...
Biomechanics of Lumbar TSM
Side Bending
Lumbar side bending techniques are used to restore side bending while minimizing associated coupled rotation. Side
bending techniques are performed in side-lying with the spine side bent towards or away from the surface of the
table. When performing a right side bending technique in ventral fiexion, the thoracic and lumbar spines are
positioned in right side bending and left rotation prior to the TSM, thereby locking the spine, to minimize coupled
right rotation. When performing a right sidebending technique in dorsal fiexion, the thoracic and lumbar spines are
positioned in right side bending and right rotation prior to the TSM, thereby restricting the coupled left rotation that
will occur with right side bending. When performing side bending towards the table, a towel roll or bolster is used to
position the spine. Side bending may then be applied to one or more spinal segments. When treating a specific
spinal segment, the TSM impulse is directed over the cranial portion of the roll (when positioned in ventral flexion) or
over the caudal portion of the roll (when positioned in dorsal fiexion).
L1-4 Side Bending
Right side bending TSM in ventral flexion
Side bending towards the table
Side bending away from the table
The patient is positioned in side-lying with their lumbar
and thoracic spine in ventral flexion, right side bending
and left rotation.
L5 Side Bending
Right side bending TSM in dorsal flexion
Side bending towards the table
Side bending away from the table
The patient is positioned in sidENying with their lumbar
and thoracic spine in dorsal flexion, right side bending
and right rotation.
Right side bending TSM in ventral and dorsal flexion
102 I Chapter 5 : lumbar Spine Application
Side bending TSM for the L5 segment can be performed in both
ventral and dorsal flexion, the same as when treating L 1-4.
However. when side bending lS, the sacrum is stable. Therefore.
the direction that L5 is moved is relative to the pelvis. To improve
right side bending at LS, L5 is translated to the right. To improve
left side bending at LS. L5 is translated to the left.
Noncouplingllocking is used as described above to stabilize
against coupled rotation at L5.
Facet Distraction
As discussed previously, the lumbar facet joints are typically (- or J-shaped. Therefore, facet distraction TSM
techniques in the lumbar spine generate different amounts of facet distraction between the anterior, middle and
lateral surfaces of the facet joint depending on how they are performed. To emphasize distraction at the anterior
aspect of the joint, a bilateral ventral force is applied to the caudal vertebra in the treatment segment. To emphase
distraction of the lateral aspect of the right facet joint, a unilateral ventral, lateral and slightly caudal force is applied to
the right lamina and posterior aspect of the transverse process. The thoracic and lumbar spine, down to and including
the treatment segment, is positioned in extension, right side bending and right rotation (locked in extension). This
position causes compression of the facet joint on the left and assists in generating facet distraction of the right facet.
In prone
Bilateral facet distraction Unilateral facet distraction
fStiiliiiii a f u ~ i
above in extension, right
sidebending and right
rotation.
i
ventrally. laterally and
slightly caudally against
the caudal vertebra in
Facet Glide
Lumbar glide techniques may be performed unilaterally, with the therapist's hands, or bilaterally with a firm wedge.
Ventral cranial glide to improve ventral flexion
Bilateral technique
To improve flexion the patient is positioned in ventral flexion, the caudal vertebra is stabilized and the cranial vertebra
is moved in a ventral, cranial direction with a bilateral force.
Unilateral technique
When applying a unilateral force to improve ventral
flexion in the right facet joint, the patient is positioned in
coupled ventral flexion, left side bending and left rotation.
The caudal vertebra is stabilized and a unilateral ventral
cranial force is applied in the direction of the right lamina
and posterior edge of the transverse process of the
cranial vertebra.
i is directed
the lamina, articular ~ - . . . ~ ~
and posterior edge
caudal vertebra.
1041 Chapter 5 : Lumbar Spine Application
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Facet Glide
Lumbar glide techniques may be performed unilaterally, with the therapist 's hands, or bilaterally with a firm wedge.
Ventral cranial glide (relative dorsal caudal glide) to improve dorsal flexion
Bilateral technique
To improve extension, the patient is positioned in dorsal flexion, the cranial vertebra is stabilized anteriorly with a cuff
weight and the caudal vertebra is moved in a ventral and cranial direction.
Anterior stabilization
Unilateral technique
When applying a unilateral force to improve dorsal flexion
in the right facet joint the patient is positioned in
non coupled extension, right side bending and right
rotation (locked above in extension). The T5M is applied
in the direction of the right lamina and posterior edge of
the transverse process of the caudal vertebra.
The thoracic and lumbar
_---"1 spine, down to the cranial
vertebra. are positioned in
noncoupled extension
(locked in extension).
is directed
Lumbar-Traction
EL - HV & LV
PP - HV & LV
Slack in the lumbar spine is
taken up caudally by the
therapist's right arm and torso.
The therapist stands facing the patient's
abdomen and pelvis.
posteriorly on the sacrum with their ri ght
forearm and anteriorly on the pelvis with
the side of their torso.
The patient is positioned in side-lying with their
lumbar spine in a resting or actual resting
position (see seclion below for further
information regarding positioning).
arm.
A sandbag or a towel roll may be used to
support the resting position for narrow waisted
individuals or to accommodate an antalgic
position.
Note(s)
Do not let your proximal medial forearm slide over the skin of the sacrum.
The impul se remains very short.
This technique is most effective if performed on a table with a sliding foot section. If a sliding foot section is
not avai lable, the patient's lumbar spine must be positioned in slight left side bending prior to the impulse to avoid
ending in an right side bent position.
When providing a sustained or intermittent low velocity traction using this technique, the therapist uses his/her
arm and body to generate the traction. When performing a high velocity traction, the therapi st uses bis/her arm to
generate the quickest impulse.
A painful lumbar shift or list can be accommodated and supported using the moveable head section of a
mobilization table. This wi ll allow the translatoric traction technique to be delivered in the patient's actual resting
position.
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Lu m ba r-Traction
EL - HV & LV
PP - HV & LV
To provide an impulse using a
body drop, the therapist must
maintain the same pressure
the patient anteriorly, laterally
and posteriorly.
The therapist then lifts their
head, neck and upper thorax
slightly while maintaining the
tension in the slack described
in box 3.
medially by dropping the chest
and head towards the patient,
in combination with a caudal
impulse delivered by the right
forearm.
Slack in the lumbar spine is taken up
caudally by leaning fOlWard and
pressing the therapist's body between
the patient's thorax and pelvis.
It is necessary to take up a small
amount of slack with the right forearm
avoid extending the lumbar spine when
taking up the slack with the body.
Slack is taken up prior to delivering the
impulse.
abdomen.
The therapist contacts the patient (1) with
the flexor surface of the right forearm on
the dorsal midsurface of the patient's
sacrum, (2) with the left arm and forearm
on the left side and dorsal surface of the
rib cage and (3) with the abdomen
between the lower ribs and pelvis.
The patient is positioned in side-lying with their
lumbar spine in a resting or actual resting
position (see "note(sr section below for further
information regarding positioning).
A sandbag or a towel roll may be used to
support the resting position for narrow waisted
individuals or to accommodate an antalgic
During the body drop, avoid excessive pressure on the lateral aspect of the patient's pelvis or lower ribs.
Note(s)
This technique is most effective ifperfonned on a tabl e with a sliding foot section. If a sliding foot section is
not available, the patient's lumbar spine must be positioned in slight left side bending prior to the impulse to avoid
ending in a right side bent position.
When treating a unilateral radicular condition, the therapist must determine which position improves the patient's
signs and symptoms the most. This can be assessed in side-lying by examining key signs such as muscle strength
and nerve tension sensitivity. In addition, the therapist may monitor dural tension symptoms after taking up the
slack in the spine prior to the impulse. If dural symptoms are worsened after taking up the slack, the impulse
should not be delivered. Rather, the therapist should attempt to find a position which relieves dural symptoms.
L5 translatoric disc traction may assist in reducing patient symptoms by subtly moving the L4, L5 or S I nerve
root(s) away from an anatomical source of irritation such as a degenerated and/or hypertrophic structure.
Lu m ba r-Traction
EL - LV
PP - HV & LV
Position: Seated
posteriorly by placing a
mobilization wedge, base down,
against the transverse processes
of the cranial vertebra in the
treatment segment.
The therapist places both hands
anteriorly on the patient's
abdomen or crossed arms.
The therapist then pulls the
patient posteriorly against the
and the torso.
taken up cranially by the slight
straightening of the therapist's
knees.
The impulse is directed cranially
and is generated by a quick
straightening of the therapist's knees.
belt may be placed around the
table and the proximal anterior
portion of the patient's thighs to
stabilize the lower
extremities/pelvis to the table.
The patient is seated with their
lumbar spine positioned in a resting
or actual resting position.
Note(s)
If the table is positioned too high, it may be difficult/impossible for the therapist to generate enough cranial
movement to effectively traction the lumbar spine.
The picture above illustrates a lower rib cage and abdominal contact by the therapist. This technique may also be
perfonned by contacting the patient's foreanns and elbows. With this second contact, the therapist must pull the
anns against the rib cage prior to taking up the slack.
The actual resting position of the lumbar spine can be found by making slight adjustments in lumbar ventral
flexion, dorsal flexion, side bending and/or rotation. This position may be used in the treatment of acute
conditions when it may be necessary to maintain the patient's antalgic position during treatment.
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Lumbar-Traction
EL - HV & LV
PP - HV & LV
Position: Seated
taken up cranially by slightly
elevating and retracting the
shoulder girdle bilaterally and
slightly adducting and extend-
ing both shoulders.
When taking up the slack, the
therapist flexes their knees as
they pull up on the patient's
cranially and is generated by
quickly elevating and
retracting the shoulder girdle
bilaterally whi le slightly
adducting and extending both
A belt may be placed around the
table and the proximal anterior
portion of the patient's thighs to
stabilize the lower
I i to the table.
The therapist stands behind the
patient.
posteriorly by placing a
mobilization wedge, base up,
against the caudal vertebra in the
treatment segment.
The therapist places both hands
anteriorly and inferiorly on the
patient's crossed arms.
The therapist then pulls the patient
posteriorly against the wedge and
the therapist's torso.
The patient is seated with their
lumbar spine positioned in a resting
or actual resting position.
Note(s)
The therapist must make sure that all the slack in the patient's shoulder girdle is taken up in a cranial direction
prior to the impulse.
Tfthe table is positioned too high it may be difficult/impossible for the therapist to generate enough cranial
movement to effectively traction tbe lumbar spine.
The therapist should avoid leaning back prior to delivering the impulse as this may lead to spinal dorsal flexion
over the wedge during the manipulation.
The therapist must not straighten hislher knees when taking up the slack or delivering the impulse.
Further slack can be taken up in a caudal direction by lowering the treatment table immediately prior to delivering
the impulse.
The actual resting position of the lumbar spine can be found by making slight adjustments in lumbar ventral
flexion, dorsal flexion, side bending and rotation.
This technique can be very effective for unloading, providing traction and assisting in the correction of a lumbar
lateral list (antalgic position/sciatic scoliosis). The antalgic position can be supported by the therapist while the
lumbar spine is unloaded (tractioned) by lowering the treatment table.
r
EL - HV & LV
L1-4-Side Bending
PP - HV & LV
Indication: To improve right side bending
Position: Right side-lying & ventral flexion
The impulse is
directed medially with
the fingers, caudally with
the right forearm and
cranially with the left
forearm and is gener-
ated by quickly flexing
the elbows, extending
the shoulders and
retracting the shoulder
girdle bilaterall y.
abdomen.
The therapist contacts the pati ent
posteriorly with both hands pressing
mediall y on the right side of the spinous
processes of the lumbar vertebra.
The right forearm contacts the left side of
the pelvis posteriorly and laterally.
The left forearm contacts the left side of
the rib cage posteriorly and laterally.
The therapist supports the patient
anteriorly by contacting the patient's
abdomen with their torso.
In side-lying, the patient is positioned with
their lumbar and thoracic spine in ventral
flexion, right side bending and left rotation
down to and the treatment
Note(s)
This TSM uses a very short amplitude movement. Do not let your fingers slide laterally to the left side of the
spi nous processes.
The therapist can also change his/her contact to the left side of the spi nous processes and provide functional
massage to the left lateral paraspinal muscles.
In clini cal practice, it is common to blend various intervention techniques such as translatoric manipulation,
translatoric mobilization and functional massage. All three fonns of intervention can be readily applied in this
position.
By virtue of thi s contact on the lumbar spi nous processes, thi s technique is less forceful then the manual contact
used for the specific translatoric lumbar side bending. As such, this is an excellent first manipulative maneuver to
apply as a therapist begins to integrate quick movements into his or her treatment session.
Choosing to perform this or any lumbar side bending techniques in either lumbar ventral or dorsal fl exion is
based on the position of greatest side bending restriction. When the onset of restricted side bending is recent and
the disc or facet joint is suspected as the cause of the restriction, it is often beneficial to treat by side bending away
from the direction of greatest restriction. As movement improves, the patient position can be progressed towards
the midline.
110 I Chapter 5: Lumbar Spine Application
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Ll-4-Side Bending
EL - LV
PP - HV & LV
Position: Left side-lying & ventral flexion
To provide an impulse using a body
drop, the therapist takes up the slack
medially (described in step 3).
The therapist then lifts their head, neck
and upper thorax slightly while
maintaining the same end slack tension
within the segment (described in step 3).
The impulse is directed medially through
the dropping of the chest and head
towards the patient.
The patient is posiUoned in left side-lying
with their lumbar and thoracic spine in
ventral flexion, right side bending and left
rotation.
The therapist kneels on the table facing
the patient.
The therapist's right thigh is pressed
gently but firmly against the patient's
lower abdomen.
The therapist presses in the direction of
the right articular sulfaces of the cranial
and caudal vertebrae with the ulnar
border of the right hand.
The therapist's right wrist is slighUy
extended and radially deviated.
The therapist uses their left hand to
reinforce the position of the right wrist.
Note(s)
The manual contact will be uncomfortable if it is too lateral and on the lumbar transverse process.
The entire lumbar spine is locked in noncoupled ventral flexion. This allows for much of the nonnal soft tissue
slack to be taken up prior to application of the translatoric impulse. Utilizing noncoupled spinal locking and
straight-line impulses will minimize rotational movement that may occur in the treatment segment.
Subtle adjustments in the amount of dorsal flexion, side bending and rotation can be made if the set-up position
causes discomfort.
L1-4-Side
EL - HV & LV
Bending
PP - HV & LV
i
The therapist kneels on the table facing the patient.
The therapist's left knee is pressed gently but firmly against the abdomen to support lumbar ventral flexion.
The therapist presses in the direction of the left
articular surface and spinous process of the cranial
vertebra with the ulnar border of either the left or
right hand (lett hand pictured on the lett, right hand
pictured below).
The hand contacting the patient's spine is slightly
The therapist uses their other hand to reinforce the
position of their wrist.
drop, the therapist takes up the slack
mediaUy (described in step 3).
within the segment (described in step
3).
The patient is posiboned in right side-lying with their lumbar and
thoracic spine in ventral flexion, right side bending and left rotation.
The impulse is directed medially
through the dropping of the chest and
head towards the patient.
A roll is used to support the caudal vertebra in the treatment s""m,mt.
Note(s)
In addition to the medial direction, lumbar side bending impulses using this manual contact should also be applied
in a slightly ventral direction.
The therapist must lean over the patient and roll the patient toward him or herself in order to facilitate a
translatoric impulse that is in a slightly ventral direction.
This is a very specific technique and can be applied to the adjacent segments of a bypennobile and sensitive lower
lumbar segment.
As noted previously, specific side bending impul ses are applied in a medial and ventral direction. In comparison
to a rotational movement, this ventraVrnedial translational movement promotes greater arthrokinematic motion
of one facet joint in relation to another, given the common saginal and frontal plane development/orientation of a
mid-lumbar facet joint. Furthennore, emphasis on the creation ofa side bending motion during the application of
these techniques will more effectively elongate the connective tissue of the intervertebral disc joint.
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Ls-Side Bending
EL - HV & LV
PP - HV & LV
the therapist takes up the slack medially
(described in step 3).
The therapist presses in the direction of the left side of
the spinous process of L5 with the ulnar border of
either the left or right hand (right hand pictured).
The therapist's right thigh is placed anteriorly against
the lower abdomen to support lumbar ventral flexion.
The therapist's right thigh also contacts the patient's
left thigh and is used to control the pelvic position and
subsequently the right side bending at L5.
The hand contacting the patient's spine is slightly
position of their wrist.
The patient is positioned in right side-lying
1_"";;;;"'';'';''==''1 with their lumbar spine, including L5, in slight
ventral flexion.
The patient's left hip is flexed approximately
90.
If the impulse is directed dorsally, the therapist's hand may slide off of the lumbar spinous process resulting in a
less effective technique.
Note(s)
Given the anatomy of the L5 segment, the therapist must finnly press the ulnar aspect of hi s or her manipulating
hand in a ventral direction in order to achieve solid contact on the L5 spinous process.
Pre-positioning the L5 segment in noncoupled dorsal flexion will constrain rotational movement during the
application of this technique.
To pre-position L5 into further right side bending prior to this manipulation, a roll may be placed under the
patient's ilium to right side bend the lumbar spine down through L5. To further restrict rotation from
occurring at L5, the patient may be positioned in further left rotation from above down through the L5 segment.
Ll-4-Side Bending
EL - HV & LV
PP-HV&LV
Position: Right side-lying & dorsal flexion
The therapist stands facing the patient's abdomen.
The therapist contacts the patient posteriorly with both
hands pressing medially on the right side of the
spinous processes of the lumbar vertebra.
The right forearm contacts the left side of the pelvis
posteriorly and laterally.
The left forearm contacts the left side of the rib cage
posteriorly and laterally.
The therapist supports the patient anteriorly by
contacting the patient's abdomen with their torso.
The impulse is directed medially with the
fingers, caudally with the right forearm
and cranially with the left forearm and is
generated by quickly flexing the elbows,
extending the shoulders and retracting
the shoulder girdle bilaterally.
In side-lying, the patient is positioned with
their lumbar and thoracic spine, down to
and including the treatment segment, in
dorsal flexion, right side bending and right
rotation.
Note(s)
This TSM uses a very short amplitude movement. Do not let your fingers slide laterally to the left side of the
SplllOUS processes.
The therapist can also change his/her contact to the left side of the spinous processes and provide functional
massage to the left lateral paraspinal muscles.
In clinical practice, it is common to blend various intervention techniques such as translatoric manipulation,
translatoric mobilization and functional massage. ~ three forms of intervention can be readily applied in this
position.
By virtue of this contact on the lumbar spinous processes, this technique is less forceful then the manual contact
used for the specific translatoric lumbar side bending. As such, this is an excellent first manipulative maneuver to
apply as a therapist begins to integrate quick movements into his or her treatment session.
Choosing to perform this or any lumbar side bending techniques in either ventral or dorsal flexion is often based
on where the side bending restriction is the greatest.
1141 Chapter 5: Lumbar Spine Application
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L1-4-Side Bending
EL - LV
PP - HV & LV
Position: Left side-lying & dorsal flexion
taken up medially by leaning
the body weight onto the right
hand.
drop, the therapist takes up the
slack medially (described in step 3).
The therapist then lifts their head,
neck and upper thorax slightly while
maintaining the same end slack
tension within the segment
The impulse is directed medially
through the dropping of the chest
and head towards the patient.
side-lying with their lumbar
thoracic spine in dorsal i
right side bending and right
rotation.
The therapist kneels on the table facing
the patient.
The patient's right knee is pressed gently
but firmly against the patient's lower ribs
anteriorly.
The therapist presses in the direction of
the right articular surface of the cranial
and caudal vertebrae with the ulnar
border of the right hand.
The therapist's right wrist is slightly
The therapist uses their left hand to
reinforce the position of the right wrist.
Note(s)
The manual contact will be uncomfortable if it is too lateral and on the lumbar transverse process.
The entire lumbar spine is locked in noncoupled dorsal flexion. This allows for much of the nonnal soft tissue
slack to be taken up prior to application of the translatoric impulse. Utilizing non coupled spinal locking and
straight-line impulses will minimi ze rotational movement occurring in the treatment segment.
Subtle adjustments in the amount of dorsal flexion, side bending and rotation can be made if the set up position
causes di scomfort.
EL - HV & LV
Ll-4-Side Bending
PP - HV & LV
provide an impulse using a body drop,
The therapist's right thigh presses gently but firmly
against the lower abdomen.
posterior surface of the transverse process, the left
articular surface and left side of the spinous process
of the caudal vertebra with the ulnar border of either
the left or right hand (right hand pictured).
The therapist's wrist, for the hand contacting the
patient's spine, is slightly extended and radially
deviated.
of their wrist.
..:........;,.,..,,...:..:;
with their lumbar and thoracic spine in dorsal
flexion, right side bending and right rotation.
A roll is used to support the cranial vertebra
in the treatment segment.
In addition to the medial direction, a lumbar side bending impulse using this manual contact should also be applied
in a slightly ventral direction.
Note(s)
The therapist must lean over the patient and roll the patient toward him or herself in order to facilitate a
translatoric impulse that is in a slightly ventral direction.
This is a very specific technique and can be applied immediately adjacent to a hypermobile and sensitive lower
lumbar segment.
As noted previously, specific side bending impulses are applied in a medial and ventral direction. In comparison
to a rotational movement, this ventral/medial translational movement promotes greater arthrokinematic motion
of one facet joint in relation to another given the common sagittal and frontal plane development/orientation of a
mid-lumbar facet joint. Further, emphasis on the creation ofa side bending motion during the application of these
techniques will more effectively elongate the connective tissue of the intervertebral disc joint.
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Ls-Side Bending
EL - HV & LV
PP - HV & LV
i
and upper thorax slightl y while
The therapist kneels on the table facing the
patient. The therapist's right thigh is placed
anteriorly against the lower abdomen.
side of the spinous process of LS with the ulnar
border of either the left or right hand (right hand
pictured).
The therapist's wrist. for the hand contacting the
patient's spine, is slightly extended and radially
deviated.
The therapist uses their other hand to reinforce
the position of their wrist.
with their thoracic and lumbar spine,
including L5. in dorsal flexion, right side
bending and right rotation (locked above).
A roll is used to support the position of right
side
If the impulse is directed dorsally, the therapist's hand may slide off of the lumbar spinous process resulting in a
less effective technique.
Note(s)
Given the anatomy of the L5 segment, the therapist must firmly press the ulnar aspect of hislher manipulating
hand in a ventral direction in order to achieve solid contact on the L5 spinous process.
Pre-positioning the L5 segment in noncoupled dorsal flexion wi ll constrain rotational movement during the
application of this technique.
L1-S-Facet Distraction
EL - HV & LV
PP - HV & LV
Indication: To improve movement in all directions (bilateral facets)
Position: Prone
segment.
The therapist places their hands,
one over the other, on the base
of the wedge.
A cuff weight or sand bag is placed
anteriorly and in the midline to
stabilize the cranial vertebra of the
treatment
Slack in the treatment segment is taken
up in a ventral and slightly caudal
direction by the therapist leaning their
body weight over the wedge.
Prior to the application oftranslatoric mobilization in the prone position, correct placement of the
mobili zation wedge may be confirmed by palpating at the interspinous space as the caudal vertebra of the
treatment segment is translated with a ventral/caudal test pressure.
Note(s)
By moving the caudal joint partner, a hypomobile LS/S I segment can be loosened even when the L4/S segment is
hypermobile and sensitive.
11 B I Chapter 5 : Lumbar Spine Apptication
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L1-S- Facet Distraction
EL - LV
PP - HV & LV
Indication: To improve movement in all directions (right facet)
Position: Prone
The therapist places their left hand next to
the spinous process of the caudal vertebra
in the treatment segment and presses in
the direction of the lamina and transverse
Once both hands are in contact with the patient,
slack in the treatment segment is taken up by
pulling the right shoulder towards the treatment
segment and subsequently right side bending,
right rotating and dorsiflexi ng the thoracic spine
down to and induding the treatment segment.
The caudal vertebra in the treatment segment is
stabilized with the manipulating hand when the
slack is taken up.
The therapist contacts the patient's right anterior-lateral shoulder
with their right hand. The therapist pulls the shoulder in the
direction of the treatment segment, thereby moving the cranial
segments into right side bending, right rotation and dorsal flexion.
The patient is positioned in prone with their thoracic and
lumbar spine, down to and including the treatment
segment, in right side bending, right rotation and dorsal
flexion (locked in extension).
Note(s)
A common mistake occurs when the therapist does not take up enough slack when pulling dorsally with the non-
manipulating hand.
To ensure complete locking above, the therapi st must pull the patient's shoulder caudally as well as dorsally.
The moveable head or foot section on a mobilization table may be elevated to support and hold the thoracic spine
dorsal flexion porti on of this locking pattern.
This technique may be applied to specifically loosen the upper and mid lumbar spine when L415 and L5/S I are
hypermobile and sensitive.
Ll-S- Facet Glide
EL - HV & LV
PP - HV & LV
Indication: To improve dorsal flexion (bilateral facet joints)
Position: Prone
The therapist stands beside the
patient's thigh.
A wedge is placed against the
caudal vertebra in the treatment
segment.
The therapi st places their left
hand over their right on the base
of the wedge.
A cuff weight or sand bag is placed
in the midline anteriorly to stabilize
treatment
Note(s)
Pressure on the wedge should be placed evenly so the patient does not feel more on one side of the spine verses the
other.
The weight may be moved cranially when the treatment segment is higher in the lumbar spine. Pressure on the
xyphoid process may be uncomfortable for the patient and may require additional padding to increase patient
comfort.
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Ll-S- Facet Glide
EL - HV & LV
PP - HV & LV
Indication: To improve ventral flexion (bilateral facet joints)
Position: Prone
Slack in the treatment segment
by pressing the wedge in a ventral and
cranial direction.
i i
hand on the base of the wedge.
The therapist stabilizes the
caudal vertebra (the sacrum in
this illustration) with the ulnar
border and palmer surface of
their left hand.

Note(s)
An additional folded towel or soft cushion may reduce pressure from the edge of the table.
Too much hip flexion may cause the pel vis to move off the table resulting in a less specific and ineffective
technique.
This is a recommended treatment position if the lower lumbar segments are hyperrnobile and sensitive in
dorsal flexion. Patients with movement restrictions and severe degenerative changes (stenosis) often find this
treatment position comfortable.
Ventral/cranial impulses promote improved dorsal flexion at mid and upper lumbar segments and may reduce
mechanical stress and symptoms coming from L4/S and LS/S I.
L1-S- Facet Glide
EL - HV & LV
PP - HV & LV
Indication: To improve ventral flexion (right facet joint)
Position: Prone
The therapist places the ulnar border of their
right hand next to the spinous process of the
cranial vertebra in the treatment segment
and presses in the direction of the lamina
and transverse process (L5 illustrated).
The therapist stabilizes the caudal vertebra
(the sacrum in this illustration) with the ulnar r====------.:=..l
of their left hand.
Note(s)
The L5 transverse process is a deeply located structure. Therefore, the manipulating hand must attempt to "catch"
the tip of the L5 spinous process and move it ventrally and laterally during the translatoric impulse.
Too much hip flexion may cause the pelvis to move off the table resulting in a less specific and ineffective
technique.
This technique is used to loosen a hypomobile L5/S I segment. It can be applied even when the adjacent L4/5
segment is hypermobile.
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The 51 Joint
u@cg[}u UU 0 CQJ Ql]@
SI Joint
The SI joint is included in this text because of its proximity to
the lumbar spine and because of the common tendency for patients with
lumbar pathology to experience pain that is referred over the SI joint. This
is due in part to the fact that the SI joint is innervated by multiple spinal
segments (anteriorly by the L2-S2 spinal levels and posteriorly by L4-S2
levels).
While it is the author's experience that pain in the SI region is
seldom caused by SI dysfunction, there are situations where primary SI
joint dysfunctions occur. Primary SI joint dysfunctions typically result
from either trauma or ligamentous laxity. Two common traumas that may
result in SI joint dysfunction (i.e. positional fault) include MVAs where
the passenger's knee strikes the dashboard or walking injuri es where the
lower extremity is forced in a cranial direction. Trauma not withstanding,
SI joint positional faults may occur as a result of ligamentous laxity.
During pregnancy or other times (such as when breast feeding or during
menstruation) when there is a higher circulating amount of the female
hormone relaxin, it is possible for the sacrum to become slightly displaced
in relation to the ilium(s) when an individual bends fully forward. This
can potentially result in a symptomatic positional fault where the sacrum is
nutated in relation to the ilium.
The purpose of SI joint translatoric manipulation (TM) is to
reducefcorrect painful positional faults. These faults are diagnosed using
symptom localization techniques and joint play techniques described
by Evjenth and Kaltenbom in their respective texts. Upon reduction!
correction of these positional faults, the movement of the SI joint must be
retested. Ifhypermobility is present, it is often necessary to use an SI belt
to stabili ze the joint until the ligaments have healed or the hormone levels
of relaxin have decreased.
Osseous anatomy
The sacrum is a fused block of five bones that is situated at the
base of the lumbar spine. The sacrum supports the weight of the vertebral
column and transmits loads from the trunk into the lower extremities
and from the lower extremities into the trunk. The SI joint is classified
as part synovial and part syndesmosis. The size, shape and roughness
of the articular surface varies greatly among individuals. In a chi ld,
these surfaces are relatively smooth. In an adult, they develop irregular
depressions and elevations that interlock. The sacral articular surface
consists of hyaline cartilage that is approximately 1-3 mm in thickness.
The iliac articular surface is composed of approximately I mm of
fibrocartilage.
Ligamentous anatomy
The SI joints are supported by several strong ligaments. The
posterior sacroiliac ligament limits anterior rotation of the innominate
Fitting the 51 joint together
1241 Chapter 6 : 5t Joint Application
Articular surfaces of the sacrum
Articular surfaces of the iIIium
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or sacral countemutation. The short posterior sacroiliac ligament limits all pelvic and sacral movements. The posterior
interosseous ligament forms part of the sacroiliac articulation (the syndesmosis). The sacrotuberous and sacrospinous
li gaments limit nutation and posterior rotation of the innominate. The anterior sacroiliac ligament stabili zes the Sf joint
anteriorly. Lastly, the iliolumbar ligament stabilizes L5 to the ilium.
Muscular support of the SI joint
The sacroiliac joints and symphysis pubi s joint have no muscles that control their movement directly. although
there are muscles that provide pelvic stability. These joints are influenced by the action of muscles that move the hip and
lumbar spine because many of these muscles attach to the pelvis. The muscles that support the pelvic girdle, as well as the
lumbar spine and hips, can be divided into two groups. The inner group consists of deep muscles including the transverse
abdominus, diaphragm, multifidus and pelvic floor muscles. The outer group consists of four groupings that act primarily
in crossing or oblique patterns of force couples to stabilize the pelvis. The superficial posterior oblique system includes
the lati ssimus dorsi, gluteus maximus and the intervening thoracolumbar fascia. The deep longitudinal system consists of
the erector spinae, thoracolumbar fascia and the biceps femorus muscle along with the sacotuberous ligament. The lateral
system consists of gluteus medius and minimus and the contralateral hip adductors. The anterior oblique system consists of
the internal and external obliques, the contralateral hip adductors and the abdominal fascia in between. The muscle systems
help to actively stabilize the pelvic joints and contribute significantly to the load transferred during gait and pelvic rotational
activities.
Kinematics of the SI Joint
In terms of joint kinematics, the principal SI joint axis is in the transverse plane at the S2 level. The SI joint is
unique in that its range of movement is extremely small and there are no muscles that directly produce active motion at
thi s joint. In effect, SI joint movements are passive and occur in response to the loads it must transmit and the stresses it
must relieve. The SI joint has two principle motions, nutation and counter nutation. During nutation, the sacral promontory
moves anteriorly and inferiorly and the coccyx moves posteriorly. During counter nutation, the sacrum moves in an opposite
direction with the sacral promontory moving posteriorly and superiorly and the coccyx moving anteriorly. The movements
that occur in the SI joint and symphisis pubis are small compared with the movements occurring in the spinal joints.
51 joint kinematics
Movements of the ilium in relation to the sacrum involve movement of the entire innominate bone. This means that a
posi tional fault of the ilium in relation to the sacrum would have to involve movement through the pubic symphysis
joint. Clinical evaluation of the pubic symphysis joint is required if a positional fault of the ilium in relation to the
innominate is suspected. Although these joints are relatively mobile in young people,
they become stiffer with age. In some cases, ankylosis occurs. The pubic symphysis
The symphysis pubis
The symphisi s pubis is a cartilaginous joint. A fibrocartilage disc, called the
interpubic disc, separates the two joint surfaces. The joint is supported by the inferior
and superior pubic ligaments. The inferior pubic ligament is thought to provide the
primary stability to this articulation. The superior pubic li gament is more easily
palpated and may be tender if there is di splacement or hypermobility affecting the
joint.
Mechanisms of injury at the 51 joint
The stepping injury
The dashboard injury
1261 Chapter 6 : SI Joint Appl ication
The ground reaction forces are
transmitted through the hip creating a
dorsal and cranial force on the right
innominate relative to the sacrum.
If the force is great enough. the
resultant positional fault would be a
ventral caudal position of the sacrum
relative to the ilium.
i are i
through the left femur and hi p joint
located inferior to the transverse axis
of motion for the SI joint.
Thi s results in an anterior rotation of
the inominate and a counter nutation
of the left 81 joint.
The resultant positional fault for this
injury is a dorsal cranial position of
the sacrum relative to the ilium on the
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Biomechanics of 51 joint Translatoric Manipulation
Translatoric manipulation (TM) techniques are used to reduce/correct SI joint positional faults. The
principle directions of intervention with TM techniques include moving the sacrum in a cranial direction relative
to the ilium and moving the base of the sacrum ventral or dorsal relative to the ilium subsequent to the traumas
discussed on the previous page.
To correct a caudal positional fault of the sacrum
TM techniques to correct a caudal positional fault of the SI may be performed by either gliding the sacrum cranially on
a stable innominate or gliding the innominate caudally on a stable sacrum.
iliac crest.
Innominate caudal"
'The authors do not recommend this technique unless
there is an associated malposition of the pubic symphysis
joint.

li
Biomechanics of 51 Joint Translatoric Manipulation
To correct a ventral positional fault of the sacrum
TM techniques to correct a ventral positional fault of the 51 are performed by stabilizing the sacrum and gliding the
illium ventrally.
To correct a dorsal positional fault of the sacrum
TM techniques to correct a dorsal positional fault of the 51 are performed by stabilizing the sacrum and gliding the
illium dorsally.
1281 Chapter 6 : SI Joint Application

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Sacrum Cranial
EL HV & LV
pp. HV & LV
Indication: Pain reduction and correction of caudal positional
fault of sacrum (R side)
Position: Prone
The therapist stands to the left of the
patient's left thigh and pelvis.
therapist's right hand contacts
the right lateral angle of the
The therapist's lett hand contacts and
stabilizes the patient's right innominate by
placing the radial border of their left index
finger, hand and ulnar border ot their thumb
the right iliac crest.
,..-------
Note(s)
One common mistake made during thi s technique is failure to properly contact the sacrum, either by positioning
the hand too caudally or too mediall y. When properly positioned, the therapist's ann should be roughly parallel to
the table.
Another common mi stake is failure to properly stabili ze the pelvis resulting in a right side bending of the lumbar
spine.
The lumbar spine may be side bent sli ghtly to the left , if discomfort is felt in the lumbar spine during this
technique.
Note how the therapist uses the right side of his chest to support hi s right hand. This will facilitate greater
force generation during the technique.
Illium Caudal
EL - HV & LV
PP - HV & LV
Position: Prone
The therapist stands to the left of the
patient's left thigh and pelvis.
The therapist's left hand contacts and
stabilizes the patient's right innominate by
placing the radial border of their left index
finger, hand and ulnar border of their thumb
along the patient's right iliac crest.
The ulnar border of the therapist's right hand
contacts the right lateral angle of the sacrum.
Note(s)
In addition to the stabilization comments made on the previous page, the most difficult aspect of this technique
is properly timing the impulse and the stabilization between the two therapists. Failure to properly stabilize may
result in lumbar side bending to the left.
This technique should not be used ifthere is pathology that is intolerant to traction at the ankle, knee or hip.
This technique allows for the generation of a greater amount offorce at the SI joint but may also stress the lower
extremity joints and soft tissues.
130 I Chapter 6 : SI Joint Application
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5:
EL - HV & LV
Sacrum
Cranial
PP - HV & LV
The therapist stands in front of the
patient.
The therapist's left arm and forearm
stabilize the patient's left leg against the
left side of the therapist's chest and
waist.
A belt is used to stabilize the patient's
rtght thigh to the table.
Note(s)
Care must be taken to assure that the therapist is properly contacting the sacrum.
While this technique is particularly awkward in appearance, for pregnant patients with SI pain there is little
recourse other than trying to reduce the positional fault in side-lying.
Taking up slack in hip flexion with the therapist's left shoulder, ann, foreann and hand may assist in reducing a
positional fault where the sacrum is in a ventral and caudal (nutated) position.
The therapist may try reducing the patient's discomfort in supine by pulling from the distal leg as illustrated on
the previous page. However, the movement of the sacrum will be less direct and potentially less effective than this
technique.
Illium
EL - HV & LV
Ventral
PP - HV & LV
Indication: Pain reduction and correction of ventral positional
Position: Prone
The therapist stands to the
left of the patient's pelvis.
The heel of the therapist's
right hand contacts and
stabilizes the left lateral
angle of the patient's
sacrum.
therapist's left hand and fifth
finger contact the patient's right
iliac crest.
Note(s)
Care must be taken to assure that the stabilization of the sacrum is equal in magnitude to the TM force. This can
be achieved by the therapist leaning his/her torso over his/her hands to take up the slack in the joint. Failure 10
stabilize with equal force will result in a less specific and potentially less effective technique.
Another common mistake when perfonning this technique is failure to contact the sacrum properly resulting in
ineffective stabilization.
The patient may be positioned in slight right side bending to slacken the right iliolumbar ligament and minimize
movement at L5 during this technique.
132 I Chapter 6 : 51 Joint Application
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Illium
EL - HV & LV
Dorsal
PP - HV & LV
Indication: Pain reduction and correction of dorsal positional
fault of sacrum (L side)
Position: Supine
The therapist's left anterior
thigh supports the patient's
left thigh.
The therapist's right thenar
eminence contacts the
patient's left ASIS.
patient's sacrum is positioned
at the edge of the table.
The patient's left hip is flexed
approximately 80' .
Care should be taken to avoid pressing medially when using this TM. Medi al pressure may provoke symptoms
from an irritated SI joint secondary to joint compression.
Note(s)
One challenging aspect of this technique is controlling the patient's left thigh and body position. To reduce any
perception by the patient that he/she is not well supported on the table, the pati ent should be instructed to lay at a
slight angle with hislher trunk fully supported.
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References
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Baltimore New York: University Park Press; Gower Medical Pub. 1 v. (various pagings).
Clausen, J.D., et aI., Uncinate processes and Luschkajoints influence the biomechanics of the cervical spine:
quantification using afinite element model of the C5-C6 segment. J Orthop Res, 1997. 15(3): p. 342-7.
Connell, M.D. and S.w. Wiesel, Natural history and pathogenesis of cervical disk disease. Orthop Clin North Am,
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Evjenth, O. and C. Gloeck Spinal Mobilization Translatory Thrust Technique 2nd Edition. 2nd ed. 2002,
Minneapolis: OPTP.
Evjenth, O. and F. Kaltenborn, Spinal Mobilization Translatoric Thrust Techniquefor Physical Therapists. 1991 :
Oslo.
Grant, R., Physical therapy of the cervical and thoracic spine. 3rd ed. 2002, New York: Churchill Livingstone. x,
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Hartman, L., An Osteopathic Approach to Manipulation, in Orthopedic Physical Therapy Clinics of North America,
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London,: E. & S. Livingstone. 3 v.
Kirkaldy-Willis, W.H. and T.N. Bernard, Managing low back pain. 4th ed. 1999, New York: Churchill Livingstone.
xiii, 434 p.
Levangie, P.K. and C.C. Norkin, Joint structure andfunction : a comprehensive analysis. 4th ed. 2005, Philadelphia,
PA: FA Davis Co. xix, 588 p.
Lu, J., et aI., Cervical uncinate process: an anatomic study for anterior decompression of the cervical spine. Surg
Radiol Anat, 1998.20(4): p. 249-52.
McCulloch, J. and E. Transfeldt, McNab's Bachache. 3rd ed. 1997, Baltimore: Williams & Wilkins.
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Moore, K.L., A.F. Dalley, and A.M. R. Agur, Clinically oriented anatomy. 5th ed. 2006, Philadelphia: Lippincott
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Paris, S. and P. Loubert, Foundations of Clinical Orthopedics Seminar Manual. 1999: St. Augustine.
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722 p.
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