INDICATIONS FOR MANIPULATION It is absolutely necessary to be able to identify the

indications for manipulation. Here, we propose a classifi-cation of manipulation according to the movement as char-acterized by an observer.

Usually, the manipulative techniques are described according to the “lesions” they are supposed to correct on a given vertebra. For example, the manipulation for a right L5 posterior means that the fifth lumbar vertebra is rotated to the right relative to the sacrum; “subluxed” or “fixated”

in this malposition for some instances or having lost its freedom of movement in left rotation for others. The maneuver will have as its aim restoring a vertebra to its proper alignment in some cases or restoring a movement that has been judged limited in others.

Such nomenclature is, of course, extremely convenient.

It explains the corrective movement and visualizes it. The diagnosis and direction of the maneuver to be used are included in these few words, “right L5 posterior.” Two examiners can thus communicate easily. What remains to be known is the validity of diagnoses based on the pal-pation and the reality of such subluxations or hypomobil-ities. To describe a maneuver intended to correct a left atlas posterior or a right sacrum anterior means that one is able to assert that the atlas has lost partial or total possibility of right rotation (it is fixated in left rotation)

or that the right sacroiliac joint is blocked “in position of nutation.”

Even if this was true, it would remain to be proven that a loss in mobility in right rotation is treated by forcing the right rotation or that a loss of extension is treated by forcing the extension. Is a blocking of the knee, whose extension is limited by a meniscal lesion, treated by a sudden extension? If posterior disk blocking produces an acute low back pain and extension of the concerned seg-ment is made impossible (bringing together the spinous processes), is it logical to play “nutcracker” in forcing this extension? We shall come back to this essential point, but for now, let us stress that if we describe the maneuvers as they are seen from the outside, it is because we should not judge too early what a manipulation can correct. Pres-ently, it is the only way to proceed objectively, even if it is schematic, and it is the one we have always used (Maigne, 1959).

Manipulation is a global gesture that can be broken down in all cases to its elementary components with respect to the three cardinal planes; i.e., any manipulative movement can be defined perfectly by its coordinates, as long as the examiner takes into consideration that an ele-ment of segele-mental traction is practically always involved.

Consequently, it can now be concluded that there is a very great variety of possible maneuvers.

Components of Manipulative Movement The degrees of freedom available for spinal segmental motion are flexion, extension, lateroflexion (both to the right and left), and right and left rotation. Manipulation can, therefore, be performed in all these orientations, iso-lated or combined (Fig. 22.13 through Fig. 22.16).

During extension, the posterior edges of the vertebral endplates converge, the nucleus pulposus migrates anteri-orly slightly, the anterior edges of the spinal endplate diverge, and the facet joints converge.

Figure 22.12 Tape measure (see text).

Figure 22.13 Flexion.

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With flexion, the opposite occurs; i.e., the anterior edges of the vertebral endplates converge, the posterior edges diverge, the nucleus migrates posteriorly, and the facet joints diverge.

In right lateroflexion, the vertebral endplates and facets converge on the right side and diverge on the left.

In right rotation, the right transverse process of the concerned vertebra tends to move backward in relation to the subjacent vertebra.

By convention, spinal segmental motion is always described with respect to the subjacent segment. Imagine a male patient standing, with pelvis fixed. He rotates the trunk toward the right; i.e., his right shoulder becomes posterior in relation to the plane of the pelvis. It is a thoracolumbar rotation toward the right. Now consider the same person in the same position but this time with his shoulders fixed while his pelvis turns. His pelvis rotates to the left, and the left hip becomes posterior while the right hip becomes anterior. This is also considered a tho-racolumbar rotation toward the right because the rotation of the trunk is judged in relation to the pelvis (subjacent segment) considered fixed. This is true even for the rota-tion of only one spinal segment or a flexion, extension, or lateroflexion movement. Thus, its relation to the subjacent segment considered fixed is the defining element.

Description of Manipulation

To accurately and precisely describe a given manipu-lation so that it can be rapidly and easily conveyed to others, exactly reproduced, or recorded in the chart, the examiner should do the following.

• Designate the segmental level at which the manip-ulation is performed.

• Specify the exact direction given to the maneuver.

• Indicate the technique used.

Level at Which Manipulation Is Performed Most often, this level is the precise level (C5–6, T3–4, L5–S1) where a segmental dysfunction (painful minor intervertebral dysfunction or PMID) has been discovered.

In other cases, we cannot be as selective, and then the maneuver must be designated as a cervical (C), cervico-thoracic (CT), cervico-thoracic (T), thoracolumbar (TL), or lum-bar (L) manipulation on the superior (s), middle (m), or inferior (I) part of the region that has been considered;

e.g., superior cervical spine (Sc), midthoracic spine (Mt), inferior lumbar spine (Il).

Direction Given to Maneuver

The manipulation should be perfectly defined in the three planes: frontal, sagittal, and horizontal. Any move-ment, passive or active, of the spine is a combination of the elementary movements: flexion or extension, right or left rotation, and lateroflexion, right or left. The directions can be written as follows.

Flexion (forward flexion) F Extension (backward flexion) E

Right rotation RR

CHAPTER 22 SPINAL MANIPULATION 175

Direction of Manipulative Thrust. When an exam-iner writes “manipulation in right rotation,” the direction of the thrust is clear. When an examiner writes “manipu-lation in right rotation, right lateroflexion, extension,” the position of the segment during the manipulation is defined very well, but the direction of the manipulative thrust is not precisely described. The latter can be performed some-times in a direction resulting from the three orientations, although generally it favors one of them.

This example allows three possibilities. Based on the position, the thrust can be made either in extension, in right lateroflexion, or in right rotation. Daily practice demonstrates that the therapeutic effectiveness of each of these maneuvers is different. Note that rotation and later-oflexion are, as already seen, similar movements com-bined at the cervical and thoracic levels; this is true in some physiologic conditions for a normal segment. It is probably not the same in the case of the imposed, forced movement that the manipulation induces on a segment that is no longer functional. Furthermore, these different maneuvers are going to exert powerful stretching actions on different muscles, depending on the direction of the thrust. This point is essential in understanding the action of the manipulation. Nevertheless, it is convenient to limit ourselves here to mechanical notions only.

To define a manipulation and give it identity, the exam-iner should describe exactly the direction of the terminal thrust. For example, in the case of a manipulation in right rotation (RR) performed on a spinal segment positioned in right lateroflexion (RLF) and in extension (E), the movement can be written by underlining the direction of the thrust: RR + RLF + E.

Technique Used. As for the technique used, one can create a personal terminology. In later chapters, we give a few names to certain techniques: chin-free (Chapter 64), epigastric (Chapter 66), single-knee (Chapter 66), or dou-ble knee (Chapter 67) techniques. A technique can also be identified by describing exactly the position of the patient during the manipulation.

Recumbent

• On the back or in supine (S) position (Fig. 22.17)

• On the abdomen or in prone (P) position (Fig. 22.18)

• On the side or in lateral decubitus (LD) position (Fig. 22.19)

Sitting

• Normally, with both legs hanging over one side of table (Fig. 22.20)

• Seated astride table (SA; Fig. 22.21) Standing

• Note as (S)

Examples

Manipulation of lower cervical spine (C6–7) — The patient is lying on his right side (RLD; Fig. 22.22). The manipulation is performed on C6–7 in left lateroflexion (LLF); the examiner would write “C6–7 (RLD) (LLF).”

Manipulation of superior cervical spine (C2–3) — The patient is lying supine (S). The segment is in neutral extension, and flexion and is brought in left rotation (Fig. 22.23); the examiner would write “C2–3 (S) (LR).”

Manipulation on T12–L1 in left rotation — The patient is sitting astride (SA) the table (Fig. 22.24); the examiner would write “T12–L1 (SA) LR.

Low lumbar manipulation on L4–L5 — The patient is lying on his right side (RLD; Fig. 22.25); the segment is in left rotation (LR), and the spine is positioned in flexion; the examiner would write “L4–5 (RLD) F + LR.”

(LR is underlined here because it is the direction of the terminal thrust.)

Figure 22.17 Dorsal decubitus (DD) or supine position.

Figure 22.18 Ventral decubitus (VD) or prone position.

176 SECTION V TREATMENT

RULE OF NO PAIN AND OPPOSITE