DIFFERENT TYPES OF MANIPULATION To classify, we divide the manipulative techniques into

three groups: (a) direct, because they consist of direct pressures performed on the spine itself; (b) indirect, because natural lever arms such as the head, shoulders, pelvis, and legs are used to move the spine; and (c) semi-indirect, since the examiner provides direct support to the spine during these maneuvers.

Direct Manipulation

Direct manipulations are maneuvers executed with the heel of the hand. Generally, the pisiform is the point of pressure. The thrust employed is sudden, brief, and flat;

it is applied to either the transverse or the spinous process.

Figure 22.4 a and b. Example of a cervical manipulation in left lateral flexion. The thin arrow (2) demonstrates a position that is being set in tension (T). The thicker arrow (3) demonstrates the direction of the manipulative thrust, which is brief and limited.

CHAPTER 22 SPINAL MANIPULATION 169

For example, as shown in Fig. 22.5, pressure on the left transverse process of B will produce rotation toward the right; if, using the other hand, a counterpressure is applied simultaneously on the right transverse process of C as indi-cated in Fig. 22.6, this movement will act electively on seg-ment BC.The pressure should be followed by a very quick release. These maneuvers are more difficult to execute than they may seem; the pressure is difficult to measure, and therefore, the maneuver is sometimes dangerous. In practice, however, these maneuvers offer unlimited possibilities.

Indirect Manipulation

In contrast to direct manipulation, indirect manipula-tions are of an infinite variety. With them, all of the spinal segments can be manipulated in all directions, always with a measurable strength; repeated and progressive mobili-zation can be executed, allowing excellent analysis of the segmental mobility. Indirect manipulation has an evident superiority over direct maneuvers. Briefly, the following is an example of indirect manipulation that should be executed according to the three steps described above.

Figure 22.5 a and b. Direct manipulation applied to the left transverse process of B with the palm of the hand. This results in a forced rotation to the right in vertebra B.

Figure 22.6 a and b. Direct manipulation with counterpressure applied in the same maneuver as in Fig. 22.5. In this case, however, the other hand is used to apply counterpressure to the transverse process to the right of C and helps to localize the movement to segment BC.

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1. Positioning the patient: As shown in Fig. 22.7, the patient has been placed in the right lateral decubitus position. The examiner stands in front of him, puts his left forearm under the patient’s left axilla, and rests his right forearm on the patient’s left ischium.

2. Taking up the slack: The examiner fixates the patient’s left shoulder at 45° relative to the plane of the table and maintains it in this posi-tion while with his right arm, he pushes in the opposite direction on the patient’s left hemipel-vis, rotating the lumbar spine until there is a feeling of resistance. Manipulation is useful at this point because it is the best time to take advantage of taking up the slack to obtain a more efficacious terminal thrust.

3. Manipulative thrust: Finally, while maintaining the tension (taking up the slack), the examiner exaggerates his pressure on the ischium with a sudden and brief thrust, resulting in a manipu-lation.

By changing the amount of inclination of the shoulders and pelvis, by placing the lumbar spine in lordosis or kyphosis, by using other points of support, and by modi-fying the direction of the manipulative thrust, the examiner has within his or her grasp various maneuvers meeting the different needs of the patients to be treated.

Semi-Indirect Manipulation

To obtain greater precision for some regions, semi-indirect manipulation techniques are used. In this type of maneuver, taking up the slack is always done by support at distance, but the examiner also provides direct support in the segment to be manipulated, with the hand, knee, or

chest. On the spine set in tension, the manipulative thrust can be performed in two ways: either by the sudden exag-geration of the movement at a distance, with the knee or the hand applying counterpressure to localize the manip-ulation —resisting it — or by exaggerating the local pres-sure that assists and locally accentuates the movement started by taking up the slack at a distance. Thus, we can describe manipulations that are “assisted semi-indirect”

or “resisted semi-indirect.”

Assisted Semi-Indirect Manipulation

At the start, this type of manipulation is indirect. The examiner applies to the spinal region to be manipulated a movement in the desired direction by an action at a dis-tance. At the same time, with the other hand, the examiner localizes its action on the precise segment where the maneuver should act. Thus, the examiner accentuates the global movement by acting in the same direction.

Consider, for example, a manipulation of the thoracic spine in which a left forced rotation of T9 on T10 is desired. The patient is sitting astride the end of the table, with his hands behind his neck (Fig. 22.8). The examiner, standing behind him, passes his left arm under the patient’s left axilla and grasps the patient’s right shoulder. Pulling his left hand toward the left and backward, the examiner imparts a rotatory moment to the patient’s trunk while the heel of his right hand is placed over the right transverse process of T9. Taking up the slack occurs in two steps:

first, by the left hand for the global movement, and then by a slow and progressive pressure of the right hand on the transverse process of T9. In practice, these two move-ments are simultaneous. The manipulative thrust is pro-vided by the right hand, which increases the rotation locally by assisting the movement. This is why we call

Figure 22.7 Indirect manipulation.

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this technique assisted manipulation. In this case, it is an assisted manipulation in left rotation.

Resisted Semi-Indirect Manipulation

The converse to the procedure described above, resisted semi-indirect manipulation allows the examiner to localize the actions of some maneuvers to a precise point on the spine. Consider again the manipulation of the same seg-ment, T9–10. To impart a manipulation that produces max-imal segmental flexion, we employ the technique of manipulation that makes use of the examiner’s knee, described below and illustrated in Fig. 22.9.

The patient is seated on a stool, with hands crossed behind the neck. The examiner passes his forearms under the patient’s axilla and grasps the patient’s wrists. By the position in which the patient’s body is placed and the actions of the examiner’s forearms, the patient’s spine is brought to a position of global flexion; i.e., the disks are

“gapping” backward. To localize the maneuver, the exam-iner performs it in such a way that the global curvature imposed to the spine has its apex at T9–10 and then applies counterpressure with the right knee against the spine, pro-tected by a small pad or towel over the spinous process of T10. Taking up the slack is performed by raising the patient’s axillae. Then, while firmly maintaining counter-pressure with the knee, the examiner delivers the thrust vertically and slightly toward himself, which produces a manipulation with the usual cracking.

Let us now analyze what happened. Figure 22.10 shows the vertebrae in maximal flexion, and the arrow at G is the point of counterpressure of the knee at T10. Suddenly, flexion is exaggerated, while at the same time the physi-cian pulls the patient’s whole spine toward himself; the point of counterpressure provided by the knee prevents vertebra A from following the movement. When raising the axillae, the physician brings the spine into flexion, and the maximum force of distraction is imparted to the joint between A and B. When the physician suddenly exagger-ates the raising of the shoulders and brings them slightly toward himself, he has exerted a force F opposing force G of the motionless knee maintaining the spinous process, pressing on it to the front and bottom. The knee is a fixed point of resistance toward the imposed global movement, and this is thus a “resisted” maneuver. Thus, to obtain forced flexion of a spinal segment, the examiner needs to support the spinous process of the inferior vertebra of the

Figure 22.8 Semi-indirect assisted manipulation.

Figure 22.9 Semi-indirect resisted manipulation.

Figure 22.10 See text.

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segment while maintaining the supra-adjacent region in forced flexion. Conversely, to produce extension on this same segment, the region is brought into extension, then counterpressure is applied to the spinous process of T9 (superior vertebra of the concerned segment). This is con-sidered an assisted semidirect manipulation, since the local support increases simply the imposed global move-ment.

Figure 22.11 demonstrates a resisted semi-indirect maneuver used currently for lateroflexion on the inferior cervical spine or on the cervicothoracic junction. The patient is lying on his right side. With one hand (here the left one) the physician holds the patient’s head and pulls the neck into left lateroflexion while applying counter-pressure with the pad of his thumb to the left side of the C7 process to apply the essential manipulative impact to the supra-adjacent segment C6–7.

LOCALIZATION OF MANIPULATION