adding sidebending to the movement. Ensure the patient has time to breathe between repetitions as the flexed position may obstruct the ability to breathe.
22.2 • A r t i c u l a t i o n supine (hand hold) Form a
pivot with the pad of thumb and index or middle finger. Rest the back of the hand on the pillow. Apply the other hand to the forehead of the patient to be able to tip the head into all the directions that the technique allows.
Techniques for the occipital area 181 22.3 • Articulation into extension supine Apply
the hand hold shown in photograph 22.2 and tip the head into extension with the forehead hand while pivoting it over the occiput hand. Once the head is in extension it can be rolled into sidebend- ing to either side to focus the force to each condyle of the occiput.
22.4 • (bottom left) Articulation into flexion supine
This operator viewpoint photograph shows the hold from photograph 22.3 in use for flexion. Note that the pillow is retained, partly to allow it to be used as a fulcrum, and partly as most patients seem to prefer the security and familiarity of a pillow.
Tips: Allow the patient time to breathe between
pressures as the trachea can be obstructed in extreme passive flexion!
22.5 • (bottom right) Articulation into extension supine In this operator viewpoint photograph the
head is pushed up with the lower hand while tipping it into extension with the frontal hand. Note that this is an extension focused to the occiput rather than an extension of the whole neck.
Tips: Try alternating this movement with flexion
and sidebending to focus forces to one specific condyle of the occiput. Try varying the spacing of the lower hand to find the optimum for efficiency and comfort.
22.6 • T r a c t i o n to o c c i p u t ( h a n d hold) The
operator has his fingers close together and is hooking them so that they can pull cephalically under the occiput into localized traction. The backs of the forearms will be applied to the pillow with the elbows over the end of the table. This will allow him to produce traction partly by pulling, and partly by levering his forearms against the end of the table.
22.7 • T r a c t i o n to o c c i p u t supine Apply the
hand hold shown in photograph 22.6. Lower your elbows over the end of the table to form a fulcrum, and fix your hooked fingers under the occiput. As you lower your elbows, the traction force accumu- lates automatically. Although this would not seem to be very powerful, it does reach very specifically to the occiput and can be very useful if localized traction is desired.
Techniques for the occipital area 183
22.8 • Thrust to o c c i p i t o - a t l a n t a l j o i n t s i t t i n g (hand hold) This hold is used for a specific thrust
technique to be applied to the occipito-atlantal joint on the far side from the operator. The upper hand will be applied around the frontal bone, temporal bone and maxilla of the patient. The lower hand is to be applied with the index or middle finger placed gently in front of the transverse process of the atlas. The palm will be cupping the occipital bone.
22.9 • (top right) T h r u s t to o c c i p i t o - a t l a n t a l j o i n t s i t t i n g The hold illustrated in photograph
22.8 has been applied. Stand to the side and slightly behind the seated patient. Fix the frontal bone with your biceps avoiding the eyes. The forearm of the upper arm lies around the temporal bone and the inside of the elbow is in contact with the maxilla. The technique will not work effectively if the hand of the upper arm is in contact with the patient. The grip is only performed with the medial aspect of the forearm. Your lower hand grips gently around the anterior aspect of the transverse process of the atlas with the pad of the index or middle finger. Pull carefully backwards on the atlas while performing a bowing movement with your
body. As the head is in contact with your chest this bowing action will form a sidebending action of the neck so that the atlas is driven slightly toward you. You must simultaneously supinate your upper forearm. The patient's body is now in sidebending away from you, and you can rock into circumduc- tion from your ankles. As the barrier accumulates, increase the compression of the head toward you, and momentarily grip the atlas firmly as you adduct both arms. The cumulative effect of this is to produce a rotation of the head toward you, and of the atlas away.
Tips: Most useful in cases where it is best to
avoid excess rotation of the head on the neck. This technique works with the head in any degree of rotation so it is hardly necessary to torsion the neck at all. It is probably the safest of the thrust techniques that can be applied to this joint. Least useful if the atlas is extremely sensitive to touch as the pressure may be unacceptable. Extra
c o n s i d e r a t i o n s : Ensure that firm compression of
the head into your body is maintained throughout. Only pull back on the transverse process of the atlas for as short a time as possible to avoid excess discomfort.
22.10 • T h r u s t to o c c i p i t o - a t l a n t a l j o i n t s i t t i n g (rear view) The technique described in photo-
graph 22.9 is set up. Note that the patient is sidebent toward the operator at the pelvis, and away at the neck. Note the supinated upper arm that is maintaining the compression. Note that the upper arm hand is not in contact with the patient. Note that the patient's head is in a position of almost no rotation but a contra-rotation force is, nevertheless, being applied to the occipito-atlantal joint.
22.11 • Thrust using m i n i m a l leverage to gap o c c i p i t o - a t l a n t a l j o i n t supine This technique is
designed to gap the occipito-atlantal joint on the side where the thrust is applied. It is a minimal leverage technique as the neck is not taken to full rotation, but merely placed in an available position so that the contact point is available for the thrust. Some small quantities of levers are used, but the emphasis is mostly on carefully applied compres- sion, and high velocity with very short amplitude. Keep the vertex of the head in the midline and take up the chin hold with one hand. Keep the head resting on the forearm applied anterior to the ear. Ensure that the head is against your upper arm and thorax so that it is firmly controlled, cradled and supported. Place the applicator, the first metacarpo- phalangeal joint of your thrusting hand, on the posterior aspect of the arch of the atlas. Keep the vertex midline and press firmly into the atlas to take up the slack in the soft tissues. Apply the thrust with a rapid force toward the patient's opposite eye and a simultaneous force of the other forearm against the side of the head.
The total of these forces should keep the head still while the atlas is driven forwards underneath the occiput. This is not a torsional force of the head on the neck, but a force of the atlas under the occiput to break fixation on the side of the thrusting hand. If excessive head movement is allowed, the occipito-atlantal joint on the other side will be strained, with a sidebending force. There will also be a tendency to strain the atlanto-axial joint into excess rotation. Note: this is an extremely difficult technique to perform well as there is no sense of accumulating barrier. The control of acceleration and braking and accurate directions of force are the governing factors. If it is performed as de- scribed here there is little chance of trauma but if torsion is added instead of the method described it is then no longer a minimal lever technique and tissue stress is more likely.
Tips: Most useful where torsion is best avoided
and fixation is not too severe. Least useful if the operator is not able to develop the skill to apply the necessary ultra-high velocity, and the strict control of the braking force. Extra c o n s i d e r a t i o n s : Try asking the patient to look over the shoulder of the side to which the head is being rotated. This will increase the effect of the small amount of levers applied as the eye torsion tenses the cervical musculature. Conversely, try asking the patient to turn the eyes to the other side if the tension accumulates too fast as this will have the effect of reducing neck tension.
22.12 • (see previous page, bottom right) Thrust atlanto-axial joint cradle hold supine As the main
movement of the atlanto-axial joint is into rotation, thrust techniques normally used are rotatory types. This technique is designed to break fixation on the side of the thrusting hand. Apply the proximal metacarpo-phalangeal joint of the thrusting hand behind the arch of the atlas. Support the head in the palm of the underneath hand and apply a compression force toward the thrusting hand to absorb the slack into compression to avoid excess torsion. Keep the vertex in the midline and gently rotate the head to about 5 0 % of its available range. Apply a small amount of sidebending opposite to the rotation and a very small extension of the head on the neck to take the posterior tissues off tension. This will make room for the applicator to reach the atlas. Slowly increase the compression while gently oscillating the head into rotation until a sense of barrier accumulates under the thrusting hand. Apply a short amplitude and high velocity force to the atlas to break fixation in a forward or rotation direction of the atlas on the axis.
Tips: Most useful in older necks as the compres-
sion force helps to minimize the torsion necessary. Least useful if the operator is not able to develop the speed necessary to break fixation in this type of technique. Extra c o n s i d e r a t i o n s : This hold makes several variations of the technique available. It is possible to thrust into sidebending to gap the other side of the occipito-atlantal joint. It is possible to thrust on the occiput itself to gap the occipito- atlantal joint on the same side. It is possible to thrust on the posterior aspect of the atlas while holding the head still to gap the occipito-atlantal joint of the same side.
22.13 • Thrust to occipito-atlantal joint supine
This hold is useful if a traction component is found to be necessary to gap the joint. It is also useful if a sidebending component is necessary. Pronate the arm of the thrusting hand and apply it behind the occiput on one side of the head. Rotate the head to the other side and fix the head against your chest and the pillow with the underneath hand. Rotate the head to about 5 0 % of the neck range and apply a traction force with the underneath hand. Com- press the head between the hands and push firmly up into the occiput with the pisiform of the thrusting hand. Apply very slight extension and sidebending toward the thrusting hand to take the tissues off tension and allow the thrusting hand to reach the target tissues. Perform the thrust as a traction with the underneath hand and a rapid adduction with the pisiform.
Tips: Most useful in cases where there is a
sidebending component in the lesion complex. Least useful where operator arm strength may not be sufficient or where the patient may have an extremely large head. Extra c o n s i d e r a t i o n s : A sidebending, rotation or traction force can be used according to which gives the optimum barrier.
Techniques for the occipital area 187 22.14 • Thrust to occipito-atlantal joint supine
This technique is useful for breaking fixation in a sidebending or rotation direction. Leave the head on the pillow and take a small step to the corner of the table. Slip your upper hand under the occiput so that the fingertips just curl under the base of the skull. Pull gently upwards under the occiput on the lower side as you apply the other hand to the maxilla and mandible on the upper side. Use a small compression between the hands to hold the head firmly, but avoid excessive pressure on the mandible as otherwise the temporo-mandibular joint can be strained. Tip the head into very slight extension to take the posterior tissues off tension, but not enough to reach the end of range of movement in the occipito-atlantal joints.
Increase the rotation to about 5 0 % of full range and then balance all the components together until tension accumulates on the occipital condyle nearer the table. Apply a short amplitude thrust into sidebending with the maxilla hand while tugging upwards with the occiput hand. Note that this thrust can also become a rotation thrust with the maxilla hand around the fixed axis of the under- neath hand. This will have the effect of gapping the upper condyle rather than the lower as in the sidebending thrust.
Tips: Most useful in cases of sidebending re-
striction. Least useful in patients who have a very mobile mid cervical spine as the force will too easily dissipate there and not accumulate at the occipito- atlantal joint. Extra c o n s i d e r a t i o n s : Try using this position as a firm articulation procedure, but do not carry it on for very long as the forces generated are very strong and will provoke discomfort.
22.15 • Thrust to o c c i p i t o - a t l a n t a l j o i n t 'fly- w h e e l ' t e c h n i q u e (hand hold) This technique is a
complex one where both hands work in opposition to hold the axis and rotate the occiput on it. The axis hand is to be placed with the thumb gently applied in front of the transverse process and the reinforced middle finger posterior to the transverse process on the other side. The chin hand will be rotating the head to one side as the atlas is held to the other. Even though momentum is used, the head should not reach full rotation even at the end of the technique. It is the effect of the one hand pulling back on the atlas as the head is rotated which causes the joint to gap, not full rotation of the head on the neck.
22.16 • Thrust to occipito-atlantal joint 'fly- w h e e l ' t e c h n i q u e Stand to one corner at the head
of the table. Take up the chin hold with one hand while using the other to take a hold on the atlas. The atlas hand is applied with the thumb placed just in front of the transverse process. The reinforced middle finger is placed on the other side just behind the transverse process of the atlas. As you drop the elbow of the atlas hand toward the table while pulling carefully back on the transverse process you will rotate the atlas slightly back toward the neutral position. As you rotate the head toward the pillow, you will tend to carry the atlas with the head. Make a few gentle rotation movements with both hands moving in the same direction of movement of the chin toward the pillow. At the optimum moment accelerate the chin hand to rotate the head sharply toward the pillow. At the same time grip for as short a time as possible on the atlas to hold it from joining the head rotation. Release the atlas immediately the technique is completed as the transverse process is usually very tender to pressure.
Tips: Most useful in fairly flexible necks where the
mobility makes normal locking techniques difficult. Least useful in stiff necks with degenerative changes as the torsional forces, however carefully applied, can be potentially problematical. Extra considera-