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Tra ns la to ri c Spin a l Ma nipul a ti o n™

Tra ns la to ri c Spin a l Ma nipul a ti o n™

ISBN

978 -1- 59975 -1 95 -5

Writte n by - Jo hn R. Kra uss PhD , PT, O C S, OPT, OCS, FAAOMPT

Illu s tra ted By - Jo hn R. Kra uss

A La kev iew Me di a L. L.C . Publi ca ti o n

FAA OMPT, Ol a f Evj enth , PT, OMT and Do ug C re ig hto n

T h is la bo ra tory g uide is int e nd ed to be used

stud yi

by li ce nsed ph ys ica l th e ra pi sts o r ph ys ica l th e ra pi st stud e nts

ng under th e su perv is ion of a n in stru c to r sk ill ed in th e a ppli ca ti o n of T S M.

O th e r

Th

Ka lte nbo rn- Evje nth based in stru ctio na l ma ter ia ls a re ava il a bl e thro ug h O PTP a t www.o ptp .co m .

ese in c lud e :

Ma nu a l Mo bili za ti o n of th e Jo int s Vo lum e I: The Ex tre miti es 6 th Editi o n by Fredd y M. Ka ltenbo rn ISBN 82 - 7054-043 -3.

II : Th e

ISB 82-7054-069-2. Evjen th , O. an d Ham berg, J . Mu scle Stretc hin g in

Ma nua l M ob ili za ti o n of th e Jo int s Vo lum e

Spin e 4th Editi on by Fre dd y M . Ka lt e nb o rn

Manua l The ra py: A

C lini ca l

Ma nu a l, Vo lum e I. A lfla Re ha b Fo rl ag : A l fta , Swed e n , 1998 . IS B : 9 1-8593 4-0 2 -X.

Evje nth , O. a nd Hamberg, J . Mu scle Stre tc hin g in Manua l Th e ra py: A Ma nu a l, Vo lum e 2. A lfta Re ha b Fo rl ag : A lfta , Swed e n, 1998. IS BN: 9

Evje nth , O. a nd Ha m berg, J. A uto S tre tc hin g. A lfta Re hab Fo rl ag: A lfta, Swed e n,

C lini ca l 1-8593 4 -03-8.

1997 . IS BN : 9 1-85934-05-4.

Co py rig ht 2006 - rev 1.3

Th is

Thi s manual is di stributed by O PTP. 800-367-7393

manu a l is th e co py right pro pe rt y of J o hn R. Kra uss.

www.optp .com

Ac kn ow ledge me nts

Th e deve lo pm e nt of thi s boo k was a n e no rm o us unde rta kin g, ta kin g ove r three yea rs to co mpl ete . We wo uld lik e to th a nk the indi vidu a ls li sted be low fo r vo lunteer in g th e ir time as mod e ls, tec hni ca l co nsulta nts a nd ed ito rs. Thi s proj ec t co uld no t have bee n co mpl e ted w ith o ut a ll of yo u r ge nero us assistance.

Dawn Gilbe rt, PT, OMPT

Jill C hri stin a

Marian, PT, O MPT Mi c hajl yszy n, PT, O MPT

Jessica Wetzel, PT, O MPT Me lodi e Ko ndratek, DS c, PT, O MPT Ma ri e - Eve Pe pin , MS , PT, OMPT Derek Chan, PT, O MPT Ja mes Wold, MS , PT, OMPT

Dedic a ti o n

For our wives, Jennifer, Grella and Kristin

our ch ildren , Dav id , Kri stin , Ane, Ka rl e igh , Kati e and Ca m

and our g rand children, O li via and Vendela

Thanks for your love and support

Contents - An Overview Chapter 1 - Introducing TSM - 3-6 Chapter 2 - Applying

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

Contents - In Detail

Ackn owl edgements -

Ded icat io n -

iii

II

Introducing TSM

Background -

3

Jo

int moti on -

3

Indicati o ns and co ntra indic ati ons for TSM -

Goa ls ofTSM -

Resea rc h in TSM -

Mechan ics ofTSM tec hniqu es -

Fea tures of thi s tex t -

App lyi ng TSM

4

5

5

6

Pati e nt & th e rapi st Locali za ti on of th e

Loc kin g: an introdu cti on -

pos iti o nin g fo r T SM

trea tm e nt segme nt -

9

8

8

4

Loc kin g

the

seg ment (s)

above

th e

trea tme nt seg ment

or

j o int

(l ockin

g a bove) -

10

Loc king

the

seg ment (s)

be low

th e

trea tme nt seg ment

or jo

int

(loc kin

g be low) -

10

Testin g pri or to using loc kin g durin g manipulati on -

Th e a mplitud e of th e tra nslatori c mo bili zati on & impul se

Ge neratin g speed durin g Us in g eno ugh fo rce with

Integratin g Supp orti ve

C lini ca l co nditi o ns, exa minati o n findin gs a nd co mm o n sequencing ofTSM techniques -

12

\I

- high ve loc ity translato ri c manipulati on

\I

- TSM : " As littl e as necessary, as much as needed "

II

-

12

TSM into clinica l prac ti ce - and co rrec ti ve int e rve nti on

tec hniqu es use d in co njun cti o n with TSM -

13

Deve lopin g skill with TS M -

24

Cerv ica l Spine

Th e Upp er Cervical Spin e -

Osseo us anatoni y -

Uppe r ce rvical a rti c ul a ti o ns -

27

Li ga me nt ous a na tomy -

26

Vasc ul ar a nato my -

Kin e mati cs -

28

27

26

26

14

Tra ns lato ri c ma nipul ati o n of th e upp er

ce rv ica l S pin

e

-

30

Se

lec tin g a contact for OA tractio n

-

30

O

A-Trac ti on Side-l y ing -

3 1

OA-Tractio n

OA -Trac tio n

Supin e -

32

Sea ted -

33

OA

glide tec hniqu es -

34

Occ iput- Dorsa l -

35

Atl as-Ventra l -

36

Al

ias-D orsa l -

37

Se

lec tin g a co ntact for AA trac tio n

 

38

Frequ ency of AA manipul ati on -

38

AA-Traction Side-lying - 39

AA -Traction Supi ne -

The Lower Cervical Spine - 41 Osseous a natomy - 41 Lower cervica l articulations - 42 Ligamentous anatomy - 43 Kinematics - 43

Bi o mec hanics of Lower Cervica l TSM - 45 C2-7-Disc Traction Supine - 47 C2-Disc Traction Side-lying - 48

C2- Di sc Traction Supine -

C2-7-Disc Traction Seated - 50

C3-6-D isc Traction

C3-6-Disc Traction Supine - 52 C2-7-Facet Distraction Supine - 53

C2-6-Facet Distraction Seated -

C2-6-Facet Distraction Seated - 55 C2-6-Facet Distraction Supine - 56

C2-6-Facet G lide Supine -

C2-6-Facet Glide Seated - 58

C7-Disc Traction Side- ly in g - 59

40

49

Side-lying - 51

57

54

C7-Facet

G lide

Supine -

60

C7-Face t

G

lid e

Side-lying -

61

C7-Facet G lide

Supine -

62-65

C7-Facet

G lide

Prone -

66-68

C7-Facet G lide

Seated -

69-70

C7-Facet Distraction -

71-73

Thoracic Spine

The Thoracic Spine -

76

The stable thoracic segments -

Osteological features of the thoracic spine -

Thoracic facet joints -

76

76

76

Biomechanics ofThoraciG Spine TSM - 78 Thoracic-Disc Traction Supine - 79

Thoracic-Facet Traction Bilateral Supine - 80-82

Thoracic- Facet Traction

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-Dis traction

Ribs2-12-Distraction Prone with Locking Above -

Ribs2-12-Distraction Seated -

Unilatera l Supine -

83-84

Prone with Manual Stabilization -

94

95

93

Lumbar Spine

The Lumbar Spine - 98 Osseous anatomy - 98 Ligamentous anatomy - 99 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 -

L 1-4-Side Bending in Dorsal Flexion -

LS-Side Bending in Dorsal Flexion -

113

114-116

117

L I-S-Facet Distraction Bilateral Prone -

L1-5-Facet Distraction Unilateral Prone - 119

L I-S-Facet Glide to Improve Dorsal Flexion Prone -

L1-S-Facet Glide Bilateral to Imp rove Ventral Flexion Prone -

LI-5-Facet Glide Unilateral to Improve Ventral Flexion Prone -

The SI Joint

118

120

121

122

SI Joint - 124 Osseous anatomy - 124 Ligamentous anatomy - 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

TSM Introducing TSM

TSM

Introducing TSM

Forward

a n d ph ysica ll herapis t s tude nt s i nt e res ted in deve lo pin g the ir

th co r C li ca lund crs t a ndin g a n d p h ys i cal sk i ll l eve l i n t h e ~lpp li ca t io n of t ra n sla t oric sp in a l ma ni p ul ation (TSM) . In keeping

co ns islenl wi lh Ih c sla nd ard of prac li ce defi ned by Ihe A meri ca n Phys ical T herapy Associal io n. Ihe aUlh ors ha l e adopled Ihe

Th e fo ll ow in g tex t is int e nd ed to be used by p hysica l th e rap is ts

fo ll ow in g d e fin iti o n of m a n ip ul a ti o n : '"A m an ua l th erapy tec h niq ue comp ri sed of

to th e j o int a nd/o r re la ted

ve loci ty th e ra pe uti c 1110 \ c me nt '".

so il ti ss u e th at a rc app lied a t vary in g spee d s a nd a m p lit

a conti nu um of ski

udes. in c ludin g a s m a ll amp litudclhigh

ll ed passive m oveme nt s

Wilhin Ihi s lex l. bOlh hi g h ( HV) a nd low ve loc il Y (LV) Ira ns latoric

ucat io n a nd olh e rs Ihal

a ppropri ale fo r e nl ry- Ie l e l (E L ) ph ys ica l lhe ra pi sl ed

ma nipula lio ns arc prese nl ed . so me of whi ch a re are more a ppro pri ale fo r pos l- pro fessio na l ( PP )

ph ys ica llh c rapi s l ed uca ti o n . Thi s is du e in pa rt lO th e e nt ry- leve l stu de nt ' s lac k o f expe ri e nce in eva luatin g, m nnag in g a nd ph ys icall y handlin g p a tie nt s w ho a re ex pe ri e nc in g s pin a lm ovc mc nt impa inn e nt s. Thi s d oes no t impl y th a t pos t-pro fess io na l

s tud e nt s do no t lac k si milar s kill s. howeve r.

necessary to to de ve lo p a

th ey a re no t face d wi th th e d a untin g tas k o f lea rnin g the w id e ra n ge o f sk ill s

beco m e tI lice nsed ph ysic al th e rapi s t in additi o n hi g h leve l o f p ro fi c ie ncy in a ll o f th e tec hniqu es

to th e hi g he r leve l cog niti ve and psyc ho mo lo r s kill s necessa ry

prese nt e d w

it hin th is tex t.

To ide ntify w he th er o r no t th e a utho rs fee l a g i\ c n tec hniqu e is a pp ro priate fo r a n e nt ry- leve l or po s t- p ro fess io na l

s tudent

a nd w he ther hi g h o r low ve loc it y is reco mm e nd ed, eac h tec hniqu e page in cl udes two boxes in th e up pe r ri g ht co rn e r.

ne xll o Ihe le chniqu e lill e (sec Ihe illu slra lio n be low for fun her delai l).

C Z''J- Dlsc Traction '''lull , 1 , 1.-.11 .10 ' n ---· - -.--
C Z''J- Dlsc
Traction
'''lull
,
1
,
1.-.11 .10
'
n
---·
-
-.--
·==.::::
· -_-
----
""':
------.-~
-
-
-
":-
-
_--
·
-
-
·:-•
::.'::;.:.=.-= o:.:::~-:.=:=-
--- "
Exa mples Key 13":\1·'" EL = Entry-level @a;" ."" PP = Post-professional HV = This
Exa mples
Key
13":\1·'"
EL = Entry-level
@a;" .""
PP = Post-professional
HV = This technique is appropriate for high velocity
LV = Th is technique is appropriate for low velocity
12' = This technique is not recommended for thi s student
group/population

Background

TranslalOric Spi nal Manipulation (TSM) co nsists of a series of high and low velocity manipulative spina l techniqu es

do, eloped by Olar Evje nth PT, OMT in collabora ti on wi th Freddy Kaltenborn PT, OMT or No rway,

spanned over 50 years or clinical practice,

realized that there were controversia l 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

Each or their careers has

Kaltenb orn

Early in their careers

as educators a nd clinicians, Mr, Evjenth a nd Dr.

spina l segments.

Following years of st ud y and critica l eva luali oll oftcc hniqu cs used by osteopat hs, c hiropracto rs and

physical therapists they co ncluded that thesc issues and problems stemm ed rrom the lack or spcc ific app lication of rorces to \ ertebra l segments and from the reliance on large r. angular and principally rotational forces during manipulation.

With these issues in mind. they e nde avored to develop a me thod of manipulation that more spec ifi ca ll y isolates motion to a single spi nal segment. What they developed is now called '"Trans latoric Spinal Manipulation" (TSM) and

consists

ofa sys te m of manipul ative tec hnique s whi ch emphasize the

use of s mall amp litude and straight lin e (Iranslatoric)

traction

o r gl idin g impu lses de l ivered parallel or at a righ t angle

LO an

individua l ver tebral joint or movement seg ment . To

further localize the effects of these lrans latoric techniques. TSM emp hasizes the use of eit her direclmanual s tabili za tion or the usc of spinal pre-positioning to restrict the amount or motion occurring al adjace nt sp inal segments during the tran sla toric 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 s tabiliLation provides th e malllial therapist w ith a manipulative too l that

has a predictable c lrcct in terms of sy m ptom reduction

and motion rcstoration with minimal po tc ntial ri sk o r pati e nt 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 lin g and gliding differs w ith in and bet\\een joints depending on the specific functional

requirements and osseo us

config urati on of the joint. Changes in the normal proportion of rolling and g liding in the

joint

due to pathological or age related changes in the joint and its surrounding sofl ti ssues may lead to excessive ro llin g or

gliding between joint surraees. Excessive joint gliding is defined as h.lper/llobilil)' and decreased jo int g lid ing is defined as hypomobili~r. I-Iypennobility is managed through phy ical therapy inten entions that assist in restricting motion. such as

stabilization exercises, mQ\cmcnt re-education techniques.

is managed throu gh ph ys ica l therapy interventions suc h as manual muscle stretc hin g. fl.lllclionalmassage a nd low and hi gh

ve locity TSM.

cervical collars. lum bar braces corsets and taping.

Hypo mobility

Tab le I - R'llin gs of joint motion . th e ral)i s t I) Crc ept ion s ~lnd joint e nd fee ls

 

Ratin g of Joint Motion (6 point sca le)

Res ista nce Perceived During Testing

Endfeel

6

~ Unstable

Little force required to move segment. little resistance to movement perceived.

Least firm, if non-guarded

 

Finn. pre se nt

if significant guard ing

5

= Moderately increased Illotion

Moderately decreased resistancc to sp inal Illotion

Less firm. soficr and later endrecl

4

= Mildly increased mot ion

Mildly decreased resistance to passive spinal motion.

Firm and later end feel

3

- Normal Motion

Anticipated resistance. similar in quality LO adjaccnt spina l segment (assuming no regional hype rm ob il it y)

Firm

 

2

~ Mildly decreased motion

Mildly increased resistance to spinal Illotion. Increased force required to move spina l segment

Firm. endreel pcrccived mildl y earlier in range of motion

 

I - Moderately decreased motion

Moderately increased resistance to sp ina l mot ion. Moderate force rcquired to move spinal segmen t

Finllcr cndfeel percci\ cd mod c rntel y earlier in the rangc o f motion

0 - No perccivable motion

Segment resistant to mOlion. eve n when s ignifi cant force is used

l'lard endreel perceived immediate ly upo n initiation of passive motion

Th e di ag n os is o f segm e nt a l o r r eg io na l s pinal h y p e r o r hYPOl n o b i lit y is d e te ml i n e d

th ro u g h the ca re ful an a lys is

o f the pa tient hi s tory. o bse rva tio n of ac ti ve mo ti o ns a nd passive a ng ul a r a nd tra ns lato ri c mo t io n tes t ing.

a patien t/cli e nt: ( I ) repo rt s that he/s he feels wo rse w iLh s tati c posi ti o nin g o f hi s/ he r lumba r s pin e a nd bc tt e r durin g a nd

fo ll o win g mo vcm e nt , (2 ) dem o ns t rates ea rl y excessi ve mo ti o n in th e lumb a r s pine upon bac k wa rd bendin g, (3 ) dem o ns trate s inc rea sed lum bar s p inal mo tion upon pass ive seg me ntal mo tion te stin g and (4 ) repo rts tenderne ss upon pa lpation o f th e int e rs pin o us s pa ce at th e co rres po ndin g s pinal seg ment (s) th e n he/ s he wo uld be c at ego ri zed as hy pe nn o bile in the involved

Fo r ex ampl e. if

lumbar s pinal seg menl (s). T he a mo unt o f s pinal mo ti o n c an be ca tego ri z ed by th e thera pi s t by us in g a s ix po int sca le

(see

Tabl e I ).

When perfo rmin g pa ss ive se g me nta l mo ti o n tes tin g, th e th e ra pi s t w ill percei ve less res is ta nce to move me nt

and

a large r ran ge o f av ail a bl e mo ti o n in hyperm o bile s pina l seg me nts

irr itabilit y).

mo tio n in h y po mobil c s pin a l segm e nt s ( i.e. an earl y e ndfee l).

rell at th e end o r pa ss ive mo ti o n te s tin g. Abn o rmal/ path o log ical e ndl'e e ls ma y be pe rccived a s e ither ( I ) less finn , as ma y

be th e case wi th h y perm o bil it y, (2) mo re firm as ma y

seg me nt s wh e n th e pa tient is usin g hi s/he r mu scl es to

(ass umin g th e re is no mu scl e g uardin g due to se g me nt a l

Co nversel y, th e th e rap is t will percei ve inc rease d resis ta nce to move me nt a nd a dec re ased ran ge o f av ail a bl e

Las tl y, th e th e ra p is t may pe rce ive a diffe re nce in the re s is ta nce

be the case w ith hy pom o bilit y o r (3) mo re firm o ve r a re g io n o f s pina l res is t mov em e nt du e to pa in o r a ppre hen s io n.

Indications and contraindications for TSM

In s impl e a nd bri ef teml s, T S M is indi cat ed w he n pa ti e nt/c li e nt s a re di ag nose d w ith d ec rease d j o int mo ti o n. co rre s po nd s w ith th e mo ti o n ratin gs o f g rad e 2 a nd g rad e I li s ted in Ta bl e I . Ty pi ca ll y. pati e nts ex perien c in g mo ti o n

res tricti o ns o r a g rad e 2 will

Illa y s ti ll re s pond to tra c ti o n

peri o d a nd lo w e r v el o cit y

T hi s

de mo ns tra te th e qui c kes t a nd bes t re s po nse to TSM . Pati e nt s w ith g rad e I mo ti o n res tri c ti o ns

TSM s, how eve r, imp ro vem e nt in s eg mental

T S M s

in a dditi o n t o m a llu a lmu sc le s Lre t c hin g

ran g e of mo ti o n ty pi call y requires a lo nge r pro c edure s.

time

Factors that th e a uth o rs

have fo und to be assoc iated w ith good ma nipUl ati ve o ut co mes includ e: ( I ) rece nt o nse t

o r impaired mo ti o n. (2) lowe r lev el o r j o int o r se g menta l irrit a ti o n. pass ive ran ge o r mo ti o n, (4) good pa ti ent a nd th e ra pi s t rappo rt a nd

(3)

(5) good co mpli a nce w ith se lrm a nage me nt prog ra ms.

e ndle el s th at a re firm a nd a rri ve s li g htl y ea rl y in th e

Fac to rs that th e auth ors

have fo und to be assoc ia ted

wi th

poo r manipul a tive o ut co mes inc lude: ( I) co nstant unremittin g pa in ,

(2) pain that is pul sa til e

a nd wavel ike in q ua lit y. (3)

pa in

th a t awa ken s th c pa ti e nt from s leep a nd is unrelated to pos iti o n

o r c hangc s in pos ition . (4 ) pain and assoc iated se nsory di s turban cc s that a re ex pe ri e nced mo re pe riph e rall y than centra ll y. (5) pa in that is provo ke d by a ll s pina l move ment s, (6) s ig nifi c ant s ke leta l d e ro rmity. (7) poo r re s pon se to prior s pinal

manipUlati ve interventi o n, (8)

unabl e to rel ax e no ug h

pa ti e nt s wh o are a ppre he ns ive a bo ut mov in g th e ir s pi ne a nd (9) pati e nt s w ho a re unwillin g! T S M. Additi o na l fac to rs assoc ia ted w ith poo r o ut co mes fro m T S M a re li s ted in Ta bl e 2.

dur ing

Table 2 - Reasons for poor outcomes with TSM

 

Therapist Related Reasons

Pati e nt

R e lat e d Re ~lso n s

Pathological and Structural Related Reaso ns

Inadequ a te dia g nos ti c s kill s

Emo ti o na l li abi lit y

Co nn ec tive ti ss ue la x it y/ wea kn ess

Inadequ a te experi e nce recog ni zi ng a nd ma nag ing s pina l pa th o logy

Psyc ho log ica l in vo lve me nt

Wo rsening o f an inflamm ato ry episode

Re liance o n a positio na l vs. movem e nt re la ted dia g nos is

 

Too mu c h pai n in too ma ny

Multiple medica l co mo rbidities

d

irec ti o ns.

(e.g. c irc ul a tory co mp ro mi se)

In adequ a te ma nipul a ti ve s kill s

S

ig nifi ca nt j o int res tri c ti o n

Sig nifi cant osteophytos is

Cas ua l use o f manipulati on without adequat e phys ica l exa minati o n

1-1is to ry o f Illulti p le ma nipu la ti o ns w ith o nl y tra ns ie nt be ne fit.

Ce ntra l co rd s ig ns Lo ng track signs

Goals ofTSM

T he ove rall goa l or TSM is the res to ra ti o n o r

mo ti o n in hypomobi le s pin a l segme nt s an d the redu c ti o n orpai n in

sy mpt o ma ti c s pin a l seg me nts. Th e exac t mec ha ni s ms

T S M. have been di sc llsse d a mo ngs t pra ctiti o ne rs fo r ma ny yea rs.

nc uro log ic . (3) hydrauli c.

ti ss ue adh es io ns. stre tc hin g o f li ga ment s

intra- art ic ul a r me nisco id s th a t a re trappe d or impin ged be twee n jo int s urface s may be freed . Ne uro log ic al e ffec ts in c lud e

th ose e ffe c ts ge ne ra ted by s timul a ti o n of th e mec ha no recept o r sys te m a nd inc lud e c ha nges in res tin g mu sc le to ne a nd pain

pe rce pti o n . Hy d ra uli c e fTec ts in cl ude c ha nges in sy n ov ia l fluid dis tri b uti o n w ithin th e j o int as well as sy n ov ia

C irc ul a tory elfec ts in c lud e a redu c ti o n o f c irc ul a tory co nges tio n a nd a re pos tul a ted to occ ur seco nd ary to re du c ti o n in

includ e th ose th a t res ult rro m th c pa tie nt's

belief that manipulati o n w ill be e ffe cti ve, th e ir tru s t in th e ph ys ica lth c ra pi s t 's co mpc te nce and th e be ne fit s assoc iated with

human touch. Whil e th e a uth o rs do no t c la im to have a ny pa rti c ul a rl y un iqu e ins ig ht int o th e s pec ifi c mcc ha ni s m(s) be hind

prcss ure in th e int e rve rt ebral fo ramen a nd mu scle ti ss ues.

be hind th c e ffec t of a ll s pin a llll a nipul a ti o n tec hniqu es. in c ludin g

Pro posed mec han is ms includ e: ( I) mec ha ni ca l. (2)

Mec ha nical e nec ts inc lud e

th e bre akin g o f co nn ec tiv e

In additi o n.

(4 ) c irc ulalOry and (5) psyc ho log iGal.

a nd j oi nt ca ps ul es a nd res to ra ti o n o f g lidin g w ithin fasc ia l pl a ne s.

l flu id v iscos it y.

Psyc ho log ica l.e ffec ts

the effect of manipu lation. we ha ve see n benefits from TSM that would likely indi cate that more than o ne o f the above

mec hani sm are invo lved . Fo r

function have been see n with TSM s delivered us ing Kalte nbo rn 's grade II and II I at both hi g h and low ve locity.

example, c hanges in quality and quantity of ove rall spinal motion and specific segmenta l

For a review

of the se g rad es,

see Table 3 bel ow. Log ica ll y, the se move ment chan ges would see m to be related to non-mechanica l effect s.

While scic ntific theory regarding the pro posed efTec ts of manipulation remai n important, our focu s over the past few years

has shifted to o utcome analysis ofTS M.

The author 's pos iti o n re ga rding this researc h is

di sc ussed be low.

Research in TSM

The authors strongly encourage further resea rch into the effectiveness of TSM . A number of case studies a nd case

se ri es performed a t Oakland Uni\ e rs il y will pro vidc a fo undati o n for continued

assess the efficacy of TSM in term s o f mo ti on restora tion and sy mpt o m reduction . The authors a lso recommend that studie s

in spina l manipulative therap y sho uld

the outcomes of joint manipulati o n of hypomob il e seg ment s that are adjacent to

a re in various sta ges o f publication . It is the hope of the authors that these s tudie s deve lopme nt o f co ntrolled case se ries and rand o mi zed controlled tria ls in o rder to

not just address manipu lati ng through the sy mptoma tic segment but sho uld a lso assess

sy mptoma t ic

hypermobi le se gment s.

Table 3 ~ Ka ltcnborn 's three trea tm ent gr ades

 
 

Defined

 

Trentm ent Use

 

A

very small traction force used

 

to

nullify the no rmal co mpress ive

lorces acting in a joint. No

Grade I

appreciable joint

eparation or

movement occ urs. No

ti ss ue

resistance is perceived by the

therapist.

 

Grade I and II are used to reduce

 

Moveme nt from grade I to the end o rthe s lac k in ti ss lles s urroundin g

pain/sy mptoms and restore qua lity o f motion within the joint.

the joint.

Little res istance is

Grade II

pe

rcei ved

in the beg inning of grade

II

while a g rea t dea l of resis tance is

 

relt at the end or gra de II . A greater amount of moti on is relt by the therapi st.

 

Stretching o f the ti ss ue surroundin g the joint occurs. Little to 110 movement is felt by the practitioner, however a great deal

 

Grade II I is used to stretch tight

Grade II I

stru c tures crossing the joint.

of

resistance is perceived.

Mechanics ofT S M

There are thre e

tec hniqu es

prim ary type s o fTSM te c hniqu es: di sc tra c tion . facet di s tra cti o n and face t g lidin g. Di sc traction s

are app l i e d at a ri g ht ang l e t o the SU rf~lCC orthe

fo ram e n. Durin g disc trac ti on tec hnique s, th e pati e nt is positioned in hi s/ he r actual re sting pos iti o n (the pos ition of greatest

co mfort or

ass ure the patient's sp ine ends in ge ne rate the spinal traction. the n

a midline pos ition durin g th e TSM . If the th e ra pi st is usi ng a bilateral co nta c t a nd force 10

di sc joinl and are intended La un l oa d / decompre ss the di sc and intervertebr a l

y mpt o l11 relief).

Irth e patient is mosl co mfo rtabl e with hi s/he r spin e in a mid-pos iti on, then care is tak e n to

the patient may start in a mid -posi ti o n. If

used. the patie nt will be pla ce d in s li ght

impulse pri o r to th e manipulation . The

ge nerall y pe rform ed with th e spinal

Cervical disc traction example

Cervical disc traction example

a unil atera l force or co nt ac t is being

side bending towa rd s th e si de o rthe

re sultant ma nipulative fo rce ge nerat ed during th e tec hni q ue wili return th e spinal seg me nt to a mid-pos iti o n.

Facet jo int di strac ti ons are

segme nt posi ti oned in

techniques use facet jo int co mpress io n o n one side

create face t jo int distraction o n th e oth e r. While

o nly placed in thi s pos ition for a s ho rt time , tw o

O ne. th e articulations undergo ing co mpre ss io n mu st to lerate th e co mpress ive

and movement used d urin g facet di stractio n ma y the intervertebral lora men .

lorces and two. the cause na rrow in g to

side bending a nd rotati on in opposi te dire cti o ns. Th ese

of th e sp inal segment to

the patient's s pinal seg ment is fa c tors s hould be co nsidered .

pos itio n occ ur in

Facet jo int g lide techniques a rc pcrfonncd w ith the sp ina l segment in a coupled position (see Chap ter 2 for a

description of cou pl ed patterns in the var ious spinal regions). The TSM impulse is directed parallel to the articular surface durin g facet gliding tec hn iq ues. Stab ili za ti on of adjace nt spin al segments is ac hieved through direct manual contact or through spinal lock in g (see Chap ter 2 for further details).

Cervical facet distraction example

'V
'V

Ventrally. medially and caudally directed impulse

Cervical facet glide example

A ventral cranial directed impulse on the left. A dorsal caudal directed impulse on the
A ventral cranial
directed impulse on the
left.
A dorsal caudal
directed impulse on
the right

Caudal stabilization

Features of thi s tex t

The tec hnique pages o f thi s tex t have been designed to reduce th e I11cntalload imposed on th e learne r w he n stud ying 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.

we recommend that the technique and its description boxes be studied first. followed by the other sections as appropriate.

Rather

C 2-7-Disc Traction Indication : To improve movement in all dir ectio ns Position: Supine
C 2-7-Disc Traction
Indication : To improve movement in all dir ectio ns
Position: Supine
~~~~
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Start by read ing 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 integrat ion of separate pictures and technique descriptors.

The next section , titled "trouble- shooting your technique~, 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

the source of a student's error and for students r The last section includes clinical ~===========~

r The last section includes clinical

~===========~

and

authors regarding a given

technique .

practical insights of the

-'

TSM Applying TSM

TSM

Applying TSM

co mple x and prese nt a learnin g description of tec hlliqu c

paramet ers s uc h as patient and therapi s t positioning. loca li za ti o n of movc mcnt within the s pin e a nd th e ge ne rati o n of s peed ,

c hall e nge to even the Illos t experienced c lini c ian . The fo llow in g

Trans latori c thru s t tec hniqu e co ns is ts of a se rie s of manipulati ve maneu vers which arc quite

secti on provides a de tail e d

for ce and

appropriate amp litude ofmovcmcnt when performing TSM . Finally, s ugges tion s regarding trainin g arc di sc usse d.

Patient

& th erapist positioning for TSM

As with a ll ph ys ica l exa minati o n and trea tment te c hnique s, proper pos iti oni ng is essential for bo th the patient and

th e rapi st. Wh e n posi ti o nin g a pati e nt

it is c nl c iai that he/ s he is co mfo rtabl e

for tran s lato ri c manipul ati o n,

and able to rela x hi s/ he r

who le bod y, espec ially th e reg io n of the bod y that wi ll be treated . In

addition to se lecting a pos iti on that pro motes patie nt relaxation, the

th e rapi s t mu s t also cons ider patient posi ti o ns

effective in ac h ievin g a s uccess fu l manipU lation.

a number of different pos itio ns the thera pi st may

the sa me manipulati ve effec t. T herapi sts s tud ying these vario us positional options are encouraged to pra c tice a ll va riation s to ach ieve

the sa me cflectiveness regard less of patient position. The therap ist

s ho uld always pos it io n them se lves with : ( I ) a stabl e (w ide) base of

support, (2) good spinal alignment/position

body. This will ass ist in the process of co rre ct patient positioning and promote more precise control of the patient's body part during the

manipulative technique.

Finally, th e ra pi st to be in

the th era pi st should be

w here th ey are mos t

Thi s te x t in c lude s

use to ac hieve

and (3) a rela xed upper

the s killful app li ca ti o n ofTSM require s thc

c lose

proxi mit y to hi s!her patient. Regarding th is ,

awa re of a ll phy sica l co nta cts that

occ ur

w he n positioning the patient. These con tacts. in addition

s pec ifi c pre- posi tio nin g, manual s ta bili za ti o n a nd pre-stressing ofa ve rtebral seg me nt , s ho uld at the minimum , be no n- painful and s hou ld

to the

also allow the pat iel1l to relax.

providing adequa te and skillfu l suppon of a ll body pans s uppo n ed

Patient relaxation is facilitated by

by th e therapist 's hand s.

the pa ti e nt fo r th e tra ns la to ri c thru st technique s ho uld be preCise and

In add iti on, th e move ment use d to posi ti o n

purpose/ul. Therapists sho uld avo id repetitive

pre-positioning. The

cons iderati o n of o ur phys ica l presence a nd th e

purpose ful move me nt e nhan ces

as experienced and professional practitioners of manual therapy.

U ltimatel y, bo th patient re laxa tio n a nd patient confide nce in o ur

abilities will furth e r impro ve the o utcome ofTSM.

use of precise and

pati e nt co nfid e nce in Ollr ab il iti es

Loc ali za tion of th e treatm ent seg ment

TSM emphasizes th e loca li zed app li ca ti on of joint specific

and segme nt s pecific ma nipulat io n. This is ac hi eved by manua l contacts directly on the joint or segme nt to be moved. The use of

s tabi li zat io n techniques of th e adjace nt vertebra

is in con tras t to so me co mm o nl y applied me th o d s of manipulative

trea tm e nt

trea tment

s uc h as locking o r direct manual stab ili za ti on

further

enha nces treatment specificity. This

that lI SC co nta c ts w hi c h may be far away from th e intended

seg ment , such as the pelvis or the head . Typically, the se

tec hnique s a re co mbin e d w ith la rge r rotational mo ti o ns th a t move mUltiple s pin al segments. These no nspecific rotational techniques not only prod uce multiple cav ita ti ons in a n unpredictable pallem bUlmay

also unnecessarily includin g th e facet

stress weake ned and se ns it ive

oft tissue st ru c tures

j oi nt ca ps ule s, the inte rve rt cbra l di sc and o th er

suppo rti ve segmental li ga ment o us stru ctures. This is panicularly

pro blema ti c whcn applied over dege ne rative hy permobile Even manipulative tec hniques which use manual co ntacts

s pino us processes but still incorporate th e rib cage and pe lvis into th e

manipulati ve movemcnt are nOltrul y spec ifi c

po te nt ial to irritate hypcnnobil c spinal segments. For read e rs w ho a re

seg ment s. on adjacent

tec hniques a nd ha ve the

8 I Chapter 2 : Apptying TSM

Therapist & patient positioning i with his/her spine in good alignment avoiding excessive ventral. dorsal
Therapist & patient positioning
i
with his/her
spine in good alignment
avoiding excessive
ventral. dorsal and
lateral flexion.
i
To ach ieve 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

appropriate height and the therapist uses a wide base of support . Localization of the treatment

L

~====:::!J

~

unl.1nu

"lth

the con\

oft

mg

r for th'" reader \\ ho \\ Ishes to fe\ ie\\ the conce pt. p lease read the fo ll owing sec tion .

Locking: an

intro d uctio n

Locking is a technique used to re (riel intersegmenta l m o ti o n

for th e purp ose o

f s tabili z in g/co n s trainin g the 110 n-

mampulated

\ enebra in the spinal motion segme nt. The

a

und erl ying prin c iple behind loc kin g is

that the spinal motion

:tegment ha!t

finite amOllnt or motion . \ Vhe n Illotion ill

o ne

plane is taken up, les s m OLi o n will

be availab le fo r movement in

the remaining

planes. To illu stra te this poi nt , try the fo ll ow in g:

I)

With yo ur cervica l spine in a mid-po si ti on, rotate yo ur neck ( 0 the right being careful not to dorsa l or ventral

flex or sidebend yo ur nec k at the sa me

tim e. Note ho w

far yo u can move

and how easy it is to

move

into righ t

rotation.

2)

Return yo ur neck to the mid-p os iti on.

 

3 )

Next, s ide bend yo ur ne ck all the way

to th e

len .

At th e

end of yo ur available range of cervical side bending to

th e len. add ro ta ti o n lO th e rig ht.

No te how far yo u can

ro tat e and how difficult it is to rotate from thi s s ide bent

position compared to when YOLI

It is mu ch hard er to ro tate fro m a full y s id e bent position then it is from a non-side bent position .

s tarted in mid-position.

This si mple example can be tr ied with a number of combinations of

move ment. For eac h co mbinati on. th e

will decrease when additiona l ca rdinal plane motions are added

prior to perfo rmin g th e th e range of move me nt

pri ma ry motion.

first ca rdin a l plane motion

In addit io n to c ha nges in

available wi th th ese vario us co mbinati o ns of

movc me nt, th e re will also be changes in

moti on is

rea c hed by th e pati e nt and th e

the ease in whi c h th e e nd of se nsc ofs tifln ess pe rceive d

a

t th e end

of motion . Thi s e ndfee l wi ll typicall y vary from a morc

c

las tic/ mu sc ular end feel to a fiml er or mo re articular e ndfc e l.

How

quickly th e m o ti o n in the seg ment w ill re~lc h its e nd range and th e

Comparison of right rotation in neutral and left side bending Compare how it feels to
Comparison of right rotation in
neutral and left side bending
Compare how it feels to
rotate from a mid
cervical position , to
easy it is to rotate from
a left side bent position.

e

ndfe e l pc rce ived by the pati e nt a nd th e rapi st at the e nd ra nge of move me n1 w ill vary, depe ndin g on how ma ny a nd in what

o

rd e r plan es of mo tio n are co mbin ed inlh e move men t seg me nt. Exam ples of two and three plane movement co mbinati ons a nd their ty pi ca l e ndfee ls are prov id ed in the tab les below.

C2- T3

 

Movement

End ree l

Move ment C lass ifica ti on

Side bending and rota ti on op posi te

Finn

No ncou pl ed

Side bending and ro tati on same

Elas ti c

Co upled

Ventral fle xio n, s ide bending a nd rotati o n oppos it e

Firm

No ncou pl ed

Ventral fl ex ion . s ide bending and rotation same

Elastic

Co upl ed

Dorsa l fle xion , s ide bendin g and rotation op pos it e

Firm

Noncoupled

Dorsa l fl ex io n, s id e bendin g a nd rotation sa me

Elastic

Co upl ed

T3-L5

 

Movement

E ndreo l

Move ment CI1Issification

Ventral fl exio n. side be ndin g a nd ro ta t io n oppos ite

Firm

No ncou pl ed

Ventral fl ex io n. side be ndin g a nd rotation sa me

Elastic

Coupled

Dorsal fl ex ion, s id e bending a nd ro tati o n oppos ite

Elastic

Co upl ed

Dorsa l fl ex io n. s id e bending a nd ro tati o n sa me

Fiml

Noncou pled

It is i m po rt a n t to remember tha t t hese moveme n ts and spina l coup li ng patterns are dependent 0 11 t he specific

anato mical and bio mcchanica l characteristics orlhe indi\ idua l spinal mot ion segme nts. Beca use

vertebrae (specifica ll y the facet joints) may \ ary between and \\ ithin spinal levels. it is necessary to pay c lose a tlen tion to

the endfeels pcrcci\cd with these dilTerent mo\ement combinations during the pa tient examination.

the a natomy orlile

When variations are

round. the subseq uent mm'cmenl used to constrain 1110tion must also be modified in order to lock or constrain motion al the

segmc nt(s) adjacent to where the

For the purposes of this text. movement patterns that produce finn endleels arc c lassified as l1ol1collpled molions. MO\cmcnt pa tt erns \\ hich produce morc clastic endfeels are classified as coupled mOlionf. The finnness or the endfccl associated \\ ith no ncoupled motions is attributed to the interaction of the facet joints and the interconnec ti ng ligamentous

tissues.

TSM will be app lied.

Converse ly. the e lastic 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.

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.

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\\ a nd is described in further detail in the following two scctions.

Howevcr, il

When mobilizing the cranial vcrtebra, locking is used to

Lock ing th e seg ment(s) abo ve th e

treatm ent seg ment or joint (lockin g a bo ve)

When locking is llsed to stabilize, constrain and protecl

the \crtebra l segments cranial to lhc segment or joint being Locking above

ma n ipulated it is called locking abo\ e. An example of the use

o r locking abo\ e is trans lato ric 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

segmen ts. including the C5 spinal segment. are Side bent lell

and ro tated righ t in cnect locking

therapist Ihen applics a translatoric \entral. mcdial and caudal

fo rce on the right lamina and superior articular proccss ofC6

c reating

scgments above arc res trai ned

by their pre-positioning in lell side bending and right rotation. The segments 010\ ing caudal to C6 \\ ill follo\\ into slight len

rota t ion \\ hi le a lready pre-positioned in lell side bending. This

comb in at ion of

mo tion. In th is situa ti on. segments that end in a coup led position or scgments that are mmed into or tm-.ard a coupled position are

refe rred to as III1/ocked.

(see page 54 for fu rther detai ls rega rdin g this tech nique)

page 54 for fu rther detai ls rega rdin g this tech nique) thcm against lcn

thcm against lcn rotation. The

In Ihis example. C5 and the

a sligh l lell rotation ofC6.

from turning 10 the left with C6

len si de be nd ing and len ro ta tio n is a co up lcd

Loc kin g

the segment(s) below the

When locki ng is used to stabi lize,

treatment segme nt or joint (loc king below)

co nstrai n and protect

th

e ve rt eb ral seg me nt s ca uda l to th e segmc nt o r jo int bci ng

ma nipul ated

il

is

ca ll ed locki ng be lo \\ . A good

exa m p le of

locki ng be lm\ is

the trans latoric C:? facet g lide

man ipulation.

Locking below

(see page 57 for further details regarding this technique)

(see page 57 for further details regarding this technique) Duri ng thi s tec hn ique.

Duri ng thi s tec hn ique. in o rde r to treat the rig ht lace t joi nt at t he

C2 s pinal seg me nt w ilh a ve ntral-cra ni a l trans lato ric

infra-adjacent spi na l

lell.

th e loc k, th e th era pi s t co m presses th e r ig h t race t jo int s a nd takes

lip li g ament o us a nd mll sc ul ar s lac k in th e s id e bc nt po rti o n of lh e

s p ine . Thi s in turn res tric ts the a mo unt of avai lab le left ro ta tio n

in th e loc ked po rti on or th e sp ine.

gl ide, th e rota ted pos itio nin g

segme nts a re si de ben t righ t a nd ro ta ling w he n

By ri g ht s ide be nd in g prio r to le n

ex t, the therap i t pass i\ e ly

a

nd s pec ifi ca ll y

s id e bend s th e C2 seg me nt to th e le n to unl oc k

o

nl y th at seg m e nt (C2 /3). At thi s pO int . \\ he n C213 is pl aced in a

co upl ed pos iti o n ( unl oc ked). is pe rfo ml ed in H ve ntra l a nd

a nd infe ri o r art ic u la r p rocess

a s ho rt q uick tra ns la to ric move me nt c ra ni a l d irec ti o n on th e ri g ht la min a

ofC2.

10 I Chapter 2 : Apply ing T5M

~

Placi ng th e C2 seg me nt, or any ot her spinal seg me nt. in a co upled pos ition (in thi s case len s ide bending and left rotation) facilitates greater ease of movcm e nt for the scgmcnt during the tran s latoric g lidin g manipulation . Therefore, segmc ntal mo \ e ment ofC2 during the impul sc will ge nera te the most effective stretc hin g of interseg mental connective tissues while minimi zing articular co mpression at the segment.

Testing prior to using lockin g durin g manipulation

\Vhile locking may prO\ idc g reate r s tabili zat ion than dire c t ma nu a l s tabili za ti o n during

TSM, there arc timcs

when the pre-pos itio ning used durin g a locking maneuver may still cause too much stress across an irritable or hypennobile

s pinal segment. To best det e rmine if lockin g \\

a co mpreh c ns i\c ~Ictive and pass ive movement

pos ition . Afier the movem c nt examination ha s becn performed and hypermobilit y ha s not been ide ntified , the therap is t

should then pa ss ive ly move the section of tile spine to bc loc ked into a locked pos ition and apply a s mall amount of

overpress ure to determine if the segment s are

a ve ntral c rania l glide examination has bee n

position C3 a nd belo\\ into a locked pos iti o n . Thc th erap is t monitors the patient's rea cti on to the loc kin g through bo th \erba

ill provoke s ig ns and sy mpt o ms in a patient . th e therapi st mu st first perform

examination o n

the sec tion of the s pine which w ill be p laced in a locked

still nonreactive . An examp le orlhis

is when the therapi st is perform ing

th e acthe and pa ss ive movement

ofC]: on the ri g ht and they want to usc lock in g bel o\\. Ancr

pe rfo rmed and hypc rm ob ilit y ha s no t been identifi ed, the therapi st will co ntact C3 and pass ively

l

responses from guarding of the

the patient regarding th e posi ti o nin g and throu g h no n ve rbal rcspo nses s uc h as fa cia l g rima c ing and mus c ular cerv ical pa ra spin als during the passive pos iti oning. Ifh ypermobi lity is identified during the mo ve ment

exa minati o n or

if th e patient to lera nce to the locking is poor, the therapist s hou ld e ith e r aba nd o n the usc o fl oc king or

su pplement

the

lo cki ng \\ ith manual s tabi li za ti o n.

To determine \\ het her th e locki ng sho uld be abandoned all together, the

therapist must decide if plac ing the

segme nt s to\\ ards a locked position \\ ill prevent Ihem from mO\ ing into a position that is further irritating. An exa mple of this is \\ hen a therapist wan ts to imprO\ e ven tral cranial g lid ing at C1 and the patienl does nOltoleratc len ro tati o n a t CS.

By posi ti o nin g C5 i11l0

len rotation bccause move me nt has been taken up at the scgmcnt. This position is then flu1hcr re inforced throu g h manual

s tabili /a ti on. When applying a manual s tabi l iLa ti o n

co nta c t p ressure he /s h c is applying to a pati e nt 's vertebral seg ment a nd rel a ted

in restrai nin g mo vemen t and to lerabl e lor th c

as opposed to th e tip o fth c thumb to e nh ance patient tol era nce . In addi tion . o th t: r port io n s of hi s /her hand ma y be use d

sim ult aneous ly to further minimi ze co nt act pressure points and stab ili ze th e

right

ide bending but not ro tati ng C5 to the left. the segment is in elTec t partially s tabili zed aga ins t

pro ce dure, th e ph ys ica l therapist

must co ntinu ous ly monitor the amount of

soft ti ss ll es. The pressure mu s t be e fTec ti ve

pat ie nt. Thc th e rapi s t may use a

broader co nt ac t suc h as the

pad o f the thumb

no n-ma nipul ated \ e rt ebra.

Furthennore, the

s

ta bi li L.ation press ur e s h ou ld be app li ed in a graded manner with a li ght relaxed grir> initially. building t o a m o re sec ur~

s

tabi lization as the slack in th e segmen t is taken up. and then reducing back to a light re laxed g rip follo\\ in g the tran s latoric

th

rust technique.

T he a mp litude of t he

tra nslatol'ic mobiliza ti on & impu lse

When lIsing 10\\ \ elocity translatoric manipulation. th e therapist may

usc grade I. 1: or 3 mo\'ements from

Kaltenbom's scale.

muscle gua rd ing and imprO\e the qua lity of 1110\ Cl11c nt in a spinal motion segmc nt or region of motion segme nt s.

translatoric mo tio n is used to s tre tc h the intersegmental ti ss ues restricting

seg me nt al musclc(s). facet joint caps ular ti ssue a nd discal ti ss llc. For a more detailed re\ ic\\ o f th e three gra des of move me nt

advoca ted by the Ka lt e nb o rn -E\je nth conce pt , please co nsu lt Kaltenborn's Manu a l Mobilization o f th e J oi nt s Vo lum e I o r II.

Gradcs I and 1: translatoric movcments are used to relie\ e pain. rcduce joint and neural swe llin g. reduce

Grade 3

spi nal segmcnta lm otion. Thcse ti ss ue s ma y includ e

In genera l term s. \vheJ1l1sing hi g h ve locity move me nt th e

tran s latori c impul sc s ho uld bc as s ho rt as po ssib le.

Thc

translatoric impulse shou ld be de l i\l,~rcd at th e e nd o

a jo int Cin itation a nd therapeutically streIch joint rel ated res tr ic ti ons.

occ ur. th e amplitude ofa TSM may \ary sl igh tl y dependent upon the tec hniqu e in qucstion. Ot her factors that w ill also play

a role in determining th e amplitude ora TSM are dependent on: ( I ) the area of the body being manipulated (e.g. C2 \ e ntml

cran ia l glide \'s. lumbar disc traction \\ ith a bod) drop), (2) th e physical a llr ibutes (size, therapist and (3) the motor skills (experie nce and quickness) of the therapist.

r Kaltenborn's

gra de 2 (whcre the final stop occ urs). In o rder to ge ne rate

th e impul se must cross th e final s top.

In o rdcr fo r thi s to

streng th and body weight) or the

Ge neratin g s peed dur in g

hi g h ve loc ity tr a nsla to ri c m a nipul a ti on

When performing high \elocity TSM. th e therapist uses an impulse o r quick. high speed move mcnt to di stra c t o r

glide th e IVD o r facet jo ints. One challenge encountered by c lini cia ns lea rnin g thi s type o f moveme nt intcr.ention is the

tendency to gc nera te hi g her a mplitud e mo \ c ment s w hen

the joints and seg ment s undergoi ng manipulation durin g thi s learning phase. the cl ini c ian s hould reduce the a mplitude and at times the fo rce. T hat said. the practi tioner o fTSM mu s t always bear in mind that when s peed and force arc increa sed the am plitudc of the movemen t mu s t always rcmai n s ma ll.

trying to generate a

hi g he r \elocity move ment. To proper ly protect

There will be so me na tural va riati o ns in ho w s peed is ge nerated when performing TSM to different parts of th e sp ine

dependent on the T S M technique

used . For examp le, when

a ce rvical

fa cc i tra ctio n or glide is perfo rmed the impu lse is

ge nera ted by the s ho ulder a nd s ho uld e r gi rdle.

pcrfom1ing a TSM lumbar disc tra ction

be ge nerated lI sing a body drop.

To ge nerate a high s peed move ment , the manipulator must determine how they ca n prepare themselves to move quickly.

tec hnique the impulse may

In co ntras t. w hen

This is no t an easy

interfaces (manual

ta sk. As menti o ned pre vio us ly. a ll ph ys ica l co ntacts) w ith a pati ent must convey a se nse

of co nfid e nce and relaxation. At which will ultimatel y be used to

the sa me time. the mu sc les move the therapist"s hand/arm

must be ill a "ready s ta te ." This r eady s t a te ca n be best described

as a n ""active te ns io n" in th e mu sc le manipulating han d/a rm . This active

that a lso nee d s to be app li ed to th e th erapis t's lowe r ex trem iti es

a nd spi nal alignm en t. Grea ter neuromuscular enort is required to

reach a ready s tate in individuals w ho have a tend e ncy towards

lower molor to ne. poor hand/eye coordination and poo r postural

se nse. Co n ve rse ly. for better athletic ab iliti es

neuromuscular system prior to delivering a translatoric impulse.

Ski llful application ofTSM ca n only be learned through

re peat ed pra c ti ce and g uidan ce from

TSM prac titi o ne r. A therapi st interes tcd in deve lo pin g a n advanced leve l of ski ll in the app lica ti o n of these tec hniqu es

s ho uld c rea tive ly find ways to prac ti ce impro vi ng th e ir m o tor sk ill s

groups that wi ll power th e te nsio n is an athletic co nce pt

indi v idu a ls w ith higher

motor to ne a nd

it is equally important to relax th ei r

a n ex pe ri e nced a nd s kill ed

in

the area of s peed ge nera ti o n. The

therapi s t s ho u ld co nt inue

to

train th e mse lves to ge nem te as hi g h a ve loci ty m ove me nt as

poss ibl e us in g all of th e techniques illustratcd w ithin this text.

Generating speed during TSM

illustratcd w ithin this text. Generating speed during TSM Lumbar disc traction TSM Us in g

Lumbar disc traction TSM

Us in g enou g h forc e with T SM: " As little a s necessa r y, a s much a s

n eed ed "

The force applied during TSM is d epe ndent o n the trea tment grade desired (Kaltenborn's grades 1-3) and the deg ree

of s tiffn ess prese nt w ithin the s pin a l seg me nt.

In th ese clinica l si tuati o ns,

g rea te r fo rce is ty pi ca ll y req uire d to re s to re 1110 ti o n us in g T S M .

indicated.

where a high ve locity TSM can be eflect ive. If performing a g rade 3 high o r low ve loc it y te c hn iqu e. e n o ug h force mu s t be lI se d to crea te joint se para ti o n/ tra c ti o n

o r g liding. This app lied fo rce ma y vary based upon th e length

dege nera t ive c han ge a nd resultant co nnec ti ve tissue c hanges a nd the physical s ize of th e patient (i.e. more force is

required to m ove la rger pati e nt s).

fo rce is required , then high ve loc it y TSM is no t patient is used to re du ce th e st iffness to th e po int

adva nced seg ment a l degeneration and afle r prolonged period s ofseg rne nt almove ment restriction.

It is no t uncommon to find g re a ter degrees of joint restriction in cases of

If too

mu c h orthe

Rather, low velocity TSM w hi c h is under vo liti o nal control

of time the motion segment has been res tricted, the

s tage of typically

Integ ratin g T SM into clinical pr ac ti ce

As c linicians put these new ly Icamed techniques int o prac tice we wou ld ca uti o n individua ls to pay ca refu l attention

to te c hniqu e inte rve nti o n

of TSM . Regarding thi s, a clinician

cl ini ca l presentations. On th e ot her hand , wi th p rope r ment ori ng from a n expe ri e nce usi n g the techniques it is possible for the nov ice to effec ti ve ly

to o ptimi ze patie nt o utco me from trea tment.

se lect io n and th e tcrnpora l proximity of the use ofTS M to o th er interventions.

Specifically. if the m a nipulativ e

is used in co mbin at io n wi th o th e r tec hn iq ues it may be diffi c ult (if no t imposs ibl e) to so n o ut th e s pecific effects

will never de velop a se nse of w hi c h

TSM technique appears bes t s uited for certa in experienced TSM practitioner and with increased int egra te TSM w ith o ther thera peuti c interventions

12 I Chapter 2 : Apptying TSM

Prior to a ppl yin g TSM , the c lini c ia n may wa nt to use iso lated sho rt a rc ac ti ve spi na l move me nts, ho ld/re lax

manua l musc le stre tc hin g.

also be fo llowed by move me nt reed uca tion aimed a t co nt ro llin g move me nt a t adjace nt sy mpt o ma ti c hype rm o b ile s pin a l segme nt s a nd e nco uragi ng isola te d moveme nt a t hy pomob il c seg me nts th a t we re rece ntl y mmlipul a te d . Thi s gene ra l

pract ice ph ilosop hy prov id es

or y mpto matic hypermobi le segme nt s that are adjace nt to hypo mo bil e spina l seg me nt (s).

co nve nt io na l son tiss ue massage a nd fun c ti onal massage to

redu ce mu sc le ten sio n . TS M s ho uld

no t onl y good imm ed ia te res ult s ro r pat ie nt s, but is a lso cruc ial ro r th e long te rm mana ge me nt

For exa mp le, TS M may be used

to

imp rove move me nt at th e C7rrl mo t io n seg me nt whe n there is sy mp to mati c

hype nn obili ty at th e CS/C6 a nd/o r C6/C7

spi

na l segme nt s. With imp rove d move me nt at C7rr

1 seg me nt (a ft e r TS M). th e

pat ie nt w ill po te nt ia ll y rec ruit mo ti o n th ro ug h

the ce rvico th oracic j un c ti on and int o th e u p pe r th oracic reg io n more efTec ti ve ly. T hi s w ill redu ce move me n t s tress at th e

sym pt o ma tic hy permobile seg me n ts. T he pa ti e nt wi ll th e n be in stru c ted in s peci fi c se l r- mob iliza ti o n M

a nd the up per th orac ic seg me nt s a nd a lso in struc te d in

mi d-cervic al regio n . Thi s co mpre he nsive pl a n of ca re

pl a n for lo ng itudin a l ma nage me nt o f

th e C7ff l seg me nt ,

move me nt reed uca ti on tec hni q ues th at Ini nil11i ze moti o n throu g h th e

is ba sed upo n so und o rth o pedi c b io mec ha ni cs a nd s ho u ld se r ve as a

sy mpt o ma ti c s pinal dege ne ra t ive c han ge o r inj ury.

A ft e r yea rs of c lini ca l prac ti ce, th e a uth o rs have o bse rved trend s in seg me nt a l move me nt pa tt e rn s. Th ese t re nd s

include re du ced Ill oti on ( hYPo I11ob ili ty) o r ill c reased 1110 ti o n (hype rm ob ility)

sp

incrcased

mo tio n te nde nc ies leads to ma nipul at ive tec hn iques a nd spina l exe rc ise progra ms th a t a re mult i-seg me nt a l in nature. Th ese non-specific manageme nt stra tegies may inadvertent ly lea d to furt he r dege nera ti ve c ha nges in spin a l moti o n seg me nt s

th at a re hype rm ob il e.

ide nti fication and ma nage me nt

fo r th e s urro un d ing reg io ns of the spi ne that may co ntr ib ut e to sympto ms

in

bo th sy mpt o ma ti c a nd pre-sy mpt o mat ic

in a l seg me nts.

So me or th ese tre nds a re as ro ll olVs : ( I ) dec reased move me nt a t

011, C2 /3, C7ff I. TI -8 a nd L 1-3 a nd (2)

move mc nt at C4 / 5. C5 16 , C617, T I 2/ L I. L4/ 5 a nd L5/ S I.

Fa il ure to recog nize a nd acknow ledge th ese co mm o n

Because or th is commo nl y observed te nde ncy, a th o ro ugh int erve nti o n p la n mu st inc lud e both th e

of the pri mary s pina ll eve l(s) in vo lved. as

we ll as a care ful exa min a ti o n o f a nd int erv e nt io n and im pa ircd fun c ti o n at th e pr imary spin a l leve l(s).

Supporti ve a nd correc ti ve inter ve nti o n tec hniqu es used in conjunction with T SM

Addition a l As pects of Inte r ve nti on :

Impl e me nt a ti o n of int e rvc llti o n for a pa tie nt w ith orth o ped ic s pin a l pa th o logy a nd assoc ia ted move me nt

imp a irments requ ire s

a co mpreh e ns ive exa minati o n a nd o n e n a

fo rm s o f int e rve nti o n. In additi o n to TS M

multi - face ted pl a n fo r int e rventi o n. Ty pi ca ll y, th e a uth ors b le nd man y d iffe re nt

tec hniqu es, o ur a pproac h w ill co ns is t o

f:

S

uppo r ti ve biom e chanical ~,d v ice r eg ardin g:

Moti o n seg me nt(s) pro tec ti o n thro ug h move me nt reedu ca t io n

cou pl ing a nd res tri c ted hy pennobi Ie segme nts.

Co ntro ll ing var io lls an d

tec hniqu es includin g co rrec t use o f

spin a l moti o n

o r s ub stitute for m s of jo int move me nt in

ord er to minimi ze 1110ti on th ro ug h sy mpt oma ti c

mo ti o n seg me nt s th ro ug h th e in s tru c t io n o f

ve rt ica l loa d ing th ro ug h sy mpt o mat ic load se nsiti ve m ulti ple fonns of s pin a l se l f- trac t ion.

In struc tio n

in spin a l mu scle trainin g exercises:

Pos tura l a nd move me nt pa tt e rn instru c ti o n th a t e mph asizes co rrec t use or th e dee p cervica l ve ntra l He xo r mu scles

and pe lvic/ hip pos iti onin g an d moveme nt

abdom inal mu scles.

S pina l iso met ri c a nd s pinal sho rt a rc iso to ni c move me nt pa n e rn s th at trai n th e de e p s pi na l s ta bi lizer mu sc les

w ith o ut ca us ing s ig nifi ca nt o r pat ho log ica l seg me nta l tra ns lati o n.

pa tte rn s th a t fac ilit ate th e co rrec t use o f

th e dee p lumba r ex te nsor mu scles a nd

 

pin a l s ta bili zat io n tra inin g tha t in co rpora tes th e use of trai ns pa ti e nt s in no n-sy mpt o ma ti c sp ina l pos iti o ns.

S

e quip me nt

th a t s uppo rt s th e tr un k, unl oa ds th e

trunk a nd

S

e lf

LV TSM exerci ses :

 

A

combi nati o n of specific ac t ive a nd pass ive seg me nt a l move me nt

exe rc ise presc ribed to ma int ai n a nd

e nh am:c

seg me ntal mot io n after a sessio n of ma nua l int e rve nt io n.

Soft t issue int er ve nti on:

Func ti ona l massage tech ni q ues w hi ch incorpora te ge ntl e re pe titi ve

mo ti o n whil e a t th e sa me Ho ld -re lax spi na lmu sde muscles.

a nd pa in free pass ive or ac ti ve ass isted spin a l

th e sp ina l mu sc le . wa rm up , stre tc h a nd tra in spin a l

tim e prov idi

ng a co mfort ab le massagi ng o f

stretc hin g w hic h prov ides a mea ns to re lax,

C lini cal condi t ions, ex amin a ti on findin gs a nd co mm o n sequ enci ng o f TSM tec hni q ues

The following sectio n inc ludes severa l brief but comlllon case scenarios illustra tin g the selection and sequencing

or low ve locity ( LV ) and hi gh ve loc it y ( HV ) TSM techniques. This section w ill on ly include TSM int erve nti on

recol11mendations. Th e tec hniqu es are

li sted with the 111 0S t cranial segmcnt (s) li ste d

at the

top oreach tab le pro g ressi ng to the

mos t

ca udal s pinal seg me nt (s) li sted a t the bottom. This is not int en de d to imply a n

orde r

in w hi c h

the techniques shou ld be

perfo rm ed, rather it is seq uenced to faci lit ate th e reade r in tracking and comparing th e tec hniqu es li sted und er the intervention

t ab le and lh e re assessme nt tabl e. The t ec hniqu es li s ted a r e int e nd ed to

pra ctice or TSM .

serve o nl y as exam pl es. 110 t as a prescription for th e

Th e d osi ng ora ny physical th erapy intervention, includ ing TSM , requires careful co nsidera ti on of the benefits and

ri sks assoc iated wi th the int ervention. The benefits of adep t app lica ti o n ofTSM include th e immediate improvement of

seg me nt al movement and reduction of

TSM incl ud e worse nin g o f th e pati e nt's sym pto ms and redu ct io n of segmenta l mo ve me nt fo llow in g its application.

sy m p to m s fo r the patient. The risks of improper or over ly aggressive applications of

Because

TSM tec hniqu es a re s hort

a nd quick lin ear passive

move ments, th ey arc extremely sare whe n app li ed sk iII rully to a spina l

joint or motion segment a nd rarely result in exacerbation of symptoms. That said, even the most skilled a nd experienced practitiOller of th ese techniq ues ca nn ot complete ly guara nt ee that certa in patients wil l not experience minor or brief flares of his/her sy mpt o ms. Regarding this, there a re historical fea tures and examina tion findings th at can assist a c linician in detcmlining who

mayor may not react favorably to HV TSM. These historical rcatures and examination findings include: (I) the historical tim e line or the patient's condition. (1) the reactivity or the patient's symptoms to movement and loading. (3) the degree

ofstifTness a nd the e ndfce l present in the restricted segments and (4) any comorbidi ti es thaI may s low recovery or may be exacerbated by certain treatment se lections 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 th e selection of intervention s trategies for th e patient. While th ere a re no ha rd and last rules for th e opt im a l nlll11ber oftota lt cchnique app li cat io ns and the optimal num ber 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 app lication 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. Pa tie nt 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 segmcn ta lm otion. T he 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 wa nts to stretc h a dilTcrent joint or tissue within the same segment, the therapist may change TSM techniques and

wo rk o n ot her pa ilS of the struClU res potentially restric t ing motion.

treatment session. the therapist shou ld dialogue with the patient to determine the location and intensity of the stretching sensa tion he or she fee ls. 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

During thi s multi-grade, multi-speed and

multi-technique

prolonged soli tissue con ta cL. So reness that lasts morc th an a le\\ minutes following stre tchi 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 fo ll owing the physical examination.

The therapist should discuss the intcrvclllion options available

and th e course or action the therapist feels wo ul d be the most beneficial.

Fina ll y. lhe therapist

and patient should arri\c a t

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 co ntinu olls exp loratio n of the techniques and technique parameters pro\ idcd within this text it is possible to build a

knowledge base orhow patients genera ll y respond to TSM. This knowledge may then be used as a starting point lor the applica ti o n ofTSM and may be adjusted as necessary to match the needs or indi, idua l patients.

Lastly. therapists should a\oid making any unrealistic claims regarding the \alue or any ghen intervcntion technique(s) and s hou ld especia ll y avoid any "fix it" lang uage. This is especially true when providing manual imen -enllon

for comll1o n degenerative orthopedic spinal conditions.

In th esc cases and e\en in cases where th ere is no significant

radiological ev id ence 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

o nl y benefits the patien t who can call

upon " hi s / her th era pi st'· w h e n he/sh~ experiences a sy mpt o mat ic therapi s t benefits by see ing how s pinal motion and ce rtain s pinal

14 I Chapter 2 : Apptylng TSM

Ill o ti o n l oss in th e co nditi ons tend to

ce r v i ca l. thoracic or lumb a r sp in e but th e c ha nge ove r th e years.

Case I C6 nerve root irritation with segmental hypomobility (Grade 2) at C2 /3 and C7rrl.

Sequeuciug o/TSMtecimique(sl

Tl!chnlque

 

Grade

Veloclly

Treatmen t Segme nt(s)

I.

 

Facet distraction

III

LV

ipsilateral progressing to II V

C2 /3 segment

Bt

contralateral gapping

2.

Bt

Disc traction

II

LV

C5/6 segme nt

3.

 

Ventral icranial

III

LV

progressing to HV

C7ffl segment

et

dorsal 'c3udal facet glide

 

Sele!'1 examination techniques applied 10 C! 1' a/llale ,h e reslIll.\ ' q(rSA J il11en ' elllioH

 

Spinal Lc\ci(s)

Examination Tcchlliquc(s)

I.

C2/3

Passi \ c facet distraction tes ting

")

CS , 6

"Doorbell and specific Spurling's test applied to reassess th e irritubility or the C6 ne"e roo \.

3.

C7ffl

Ventral cranial (VC)/dorsal caudal (DC) facet g lid e testin g

ote(s)

• The Doorbell test is an examination procedure \\ here palpatory pressure is app li ed to the ve ntral primary ramu s as it

lies in the cen ieal nene root g utter. The specific Spu rlin g's test inco rporale s the passive tra nslation o ra s uperi o r facet in the move me nt seg me nt int o th e cen ical inten c rt ebra l forame n. Both examination procedures a re used to assess the provocability of the s pin al nerve undergo in g co mpress io n.

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)

Techniqu e

 

Grade

Veloc it y

 

Trea tme nt Segme nt(s)

I.

 

,

Traction

III

LV

progre ss in g to HV

COli

2.

 

Face t di stracti on

III

LV

ips ilateral prog re ss ing to HV

C213 segme nt

Et

co ntralateral gapp ing

3.

 

Bilateral fa ce t

III

LV

progre ss in g to HV

T 1-4 segments

di straction

 

4.

Ce rv ical mo ve ment reeducat ion and s tabili za ti o n trainin g for C4/S, CS /6.

 

Select exa mination t ec hniqu es applied t o eval ua t e th e results oj TSM imen 'e l1li OI1

 

Spina l Level(s)

Exa min a ti o n Tec hni q uc(s)

I.

COi l

Joint play a nd pass ive coupled rotation tes tin g

2.

C2 / 3

Pa ss ive facet di stra cti on testin g

3.

C4- C6

Joint play testin g and re-examinati on of sympt om loca l iza ti on· te stin g for the se sp inal levels.

4.

TI-4

Joint play testing

Note(s)

• Symptom loca li za ti on testin g is a comprehensive ser ie s of clini ca l exa minati on movements used to difTcrcntiate whether

spine . For further

G loeck 's Th e Sympto m Locali:atiol1 in th e Spine and th e Ext remi ty JoilJl ava ilabl e from OPTP at

symptom s are originating from different re gio ns, segment s or stru cture s in the

details co nsu lt Evje nth and www.O PTP.com.

Case 3 Generalized grade I hypo mobility at all cervical motion segments

Sequencing o/TSM lechniqlle(s)

Technique

 

Grade

Velocity

Treatment Segment( s)

I.

 

Traction & disc

III

LV

progres s in g to I-I V

COli, C2/3, C3 /4 and C7IT I

traction

 

segme nt s

2.

 

Ventral/cranial dorsa llca udal fa ce t glide

III

LV

progress ing to HV

COli. C2 /3. C3 /4 and C7fT l

et

 

segments

3.

Et

Face l di stra ction

III

LV

progres s in g to HV

COli, C2/3. C3 /4 and C7fT I

 

segme nt s

Select exomil1C1liol1leciln iqlles applied fO el'o/ual e the results oj TSM inlen'el1liol1

 

Spi nal Lc\cl(s)

EX3minaiion Tcchnique(s)

I.

011

Traction joint play testing and pass ive coup led Illation testing

2.

C2/3, C3 /4 ,

Translato ric joint play testing, pass ive segmental s ide bending testing, pass ive segmental coupled motion tes ti ng and pas s ive segmenta l facet distraction te stin g

71T1

3.

Ce rv ica l Sp in e

C ROM mea s ureme nt s pre- a nd POS I interven tion

Note(s)

I.

For further info mlati o n regarding pa ss he mo ti o n te stin g in th e cervical spine consult Kaltenborn's flvfclI1l1ol Alf obili:alion

of lite

) oil1ls. Volume II. The Spine.

 

2.

In

the

case

of

grade I re stricti o ns. facet di stracti o n and gl iding

LV TSMs are often performed

with the

patient in

a sea ted

po s iti o n to

a ll ow the therapi st 's c he st a nd

 

3.

Face t di straction is app li ed unilaterall y in

lower ext remiti es to con tribute to the manipulating force . th e cervical s pine . Irbot h sides a re restricted the technique

is app lied

to both

4 .

s ides. one at a time . G rade I re s trictions a re tre.:1ted with LV TSMs until mo ve ment is improved to a g rade 2 and then HV TSM s may be used to further restore moti o n.

Case 4

A painful block of left cervical rotation with a re ce nt onset.

Seqllencing ojTSM tec!l/Jiqlle(s)

Technique

 

Grade

Velocity

Treatment Segment(s)

I.

Bt

Disc Traction

II - III

!-IV

Involved segmcnt (s)

2.

 

Face t di stracti on

III

LV

progressing to !-IV

Involved segment(s)

st

 

3.

 

Ventral/ cran ial

III

LV

progre ss in g to !-IV

Involved seg ment (s)

et

dorsal/ ca ud al face t

 

glide

Select era mil1nfiol1 techniqu es applied 10 e va/lillIe (h e reslIlls a/T5M i l1len'ellliol1

 

Spina l Le, el(s)

Exam ination Tcchniquc(s)

I.

Involved sp inal segment s

Joint play testin g and fe-examination ofsy mpt orn loca li za ti on· te stin g for th ese spinal

levels prc- and pos t trea tment.

2.

Ce rvica l Spine

C ROM measureme nt s taken pre- and post interventi on

Nole(s)

1. Left rotatio n can be limi ted du e to eith er res tri cted ve ntral cra ni al glid ing or the ri ght facet of re stri cted dorsa l ca udal

g lidin g of the len fa ce l.

2. If the moti o n is limit ed due

to restricted

!-IV TSM with the cc rvica l sp ine placcd

do rsa l ca udal g lid ing o f th e len lace t it ma y be treated wih face t joint distraction

in ri ght s ide bending a nd s light left ro tati o n.

If le ft rotation is still la ckin g a nd

the patient 's cerv ica l spi ne shows no sign of in crea sed irritation. then ve ntral/cra ni al facet joint glid e HV TSM ca n be

ap plicd to th e caudal vertebra of th e in volved seg ment with the cerv ica l spin e placed in dorsal fle xion, left side bending

and len ro tation. App lying a ve nt ral cranial glid e to the superi or art ic ular sur face of th e ca udal verteb ra while stabili zing th e cranial ver tebra ge nerate s a rela ti ve dorsa l cauda l g lide of the len facet in th e treatment segment .

18 I Chapler 2: Apptying TSM

C a se 5 Ri g ht sid ed upp e r ce r vical pain with r efe rral of di sco mfort to th e ri ght po st erior as pect of the head and g rad e 2 motion res triction at C OI l and C 2/3.

Sequencing oj'TSM feclll1ique(s)

Technique

 

Grade

Ve locity

Treatment Segment(s)

I.

,

Traction

III

HV

COi l

2.

 

Ve nt ral/cra n ia l

III

1-1V

C2/3 segme nt

et

dorsal/ca uda l face t glide

Select eraminCll ion leclmiqlles applied 10 eva/lime lite res ults ofTSM inten 'enliOI1

 

Spinal LeI el(s)

Examination Tcchnique(s)

I.

COli

Trac t ion jo int p lay testi ng, passhc coupled motio n tes ting and rec heck of sy m pto m loca li za ti o n testing for COli

2.

C2/3

T ra ns lato ri c jo int pl ay tes tin g. pass ive seg mc ma l s id e be nd in g tes tin g, pass ive seg me nta l co up led

m o ti o n tes tin g a nd pass ive seg m e nt a l face t di strac ti o n te s tin g a nd rec hec k o f sy mpt o m loca li:U1ti o n

tes ting for C2/3

'ote(,)

1. Pass ive u pp e r cervica l ro tat io n tes tin g in vo lves m a nu a l s tab il izatio n of th e ca u dal ve rt ebra o rth e seg m e nt be in g tes te d , e ith e r COi l or C 1/2. T h e exa m i n cr ge n era tes p assive ro ta ti o n w ith s id ebc nd i n g in th e o p pos it e dircc t io n . Q u a n t it y o f move me nt . qu a lit y o f move me nt a nd endfee l a re eva lu ate d .

2. Pass ive upp e r ce rvica l co upl ed ro ta t io n tes t in g

a nd sy mp to m loca liza ti o n tes ting may a lso be pe rfor me d at C I /2 th o ugh

th is seg mc nt is rare ly res tr ic ted g ive n its inhe re nt ca ps u lar an d ostco log ica l fea tu res.

Case 6 Mid-thoracic pain, decreased active ROM and grade I hypomobility at the T4-8 spi nal segments.

Seqllenci ng o/ TSM l ecllll iq ll e(s)

Technique

 

Grade

 

Velocity

Treatment Segment(s)

I.

 

Di sc trac tio n

III

LV

pro g ress in g to HV

T4-8 seg m e nt s

2.

 

Bilatera l facet di straction

II

osc ill a ti o ns , p rogressi ng

LV

pro g ress in g to HV

T4-8 segments

to

s us ta in ed

g rad e II ,

 
 

progress in g

to sustained

g rade III

Select exa mination techniques applied 10 eva/uol e the results ofTSM intervention

 

Spinal Level(s)

Exami nat ion Techniquc(s)

I.

T4-8

Tra ns la to ri c j o int pl ay tes tin g . pass iv e seg m e nt a l ex te ns io n tes tin g a nd rec hec k o f sy mpt o m loca li za ti o n tes tin g fo r T4- 8

2.

Th o ra c ic Spin e

Mo ve ment quantifi cati o n us ing tape mea s ure tec hniques o r doubl e inc linom e te rs ( universal go ni o mc te rs) be lo re a nd at the co nc lu s io n o f e ac h inte rventi o n.

Nole(s)

I .

Th e auth o rs co mm o nl y tes t pass ive seg m e nt a l ex te nsio n in th e th o rac ic s pine w ith th e pa ti e nt pos iti o ned in si d c ly in g. For funh c r d e ta i Is co ns ult Kalt e nb o rn ' s Ma ll ll al M obil i=a li on o/ Ih e J o inl s, Vol lllll e II , Th e Spin e.

Case 7 Mid-thoracic pain that wraps around th e rib cage with loss of segmental motion at the same level(s) as the referred pain pattern .

Sequencing oj TSM teclll1ique(s)

Techniqu e

 

Grade

VeiocilY

Treatment

     

Segment(s)

I.

 

Disc traction

III

LV

progressing 10 HV

Involved seg me nl (s)

2.

 

Bilaleral facel

II

osci ll a ti o n s progressing to

LV

prog re ss ing 10 HV

Invo lved segmenl (s)

.Ii.".

di stra ction

grade III

 

3.

 

Costotransverse

II

LV

Invo lved segmenl(s)

rr::

distracti on

osci ll atio ns progress in g to grade III

SeleCI exa mination techniques applied 10 evaluate the resulls ojTSM il1len 'entiol1

 

Spinal Le ve l( s)

Examinalion Technique(s)

I.

Mid-I horac ic

Mid -t ho racic joint play tes lin g . ma nual co mpress io n and lra c li on te sling. rech ec k o f sy mptom

( in vo lved

loca liza ti o n te s t ing for mid-th o rac ic.

segmenl s)

2.

Rib joints

Rib distra cti o n jo int pla y te s tin g a nd sy mpt o m loca li zation tes tin g or the rib joint s.

adjacent to

involved spinal

regIon

Note(s)

I .

Rib di s tra c ti o n j o int p lay te s tin g ca n be performed in a number of examination pos ition s.

For fu rth er deta il s co ns u lt

Kalt e nbom's Manllal Mobili:otion oj the )oil1ls. Volullle II. The Spine.

2.

For details regarding sy mpt o m localiza ti o n for the rib a rti c ulat io ns, refe r to Symp tom Locali::atiol1 il1 th e Spine and

£rtl'emity Joil1ls by Evje nth a nd Gloeck.

Case 8 Lower lumbar ner ve irritation with segmental motion restrictions from L 1-3_

Seq l/ellcillg of TSM techniql/e(s)

Technique

~

Grade

Ve loc ity

Trea tme nt Seg mc nt (s)

I.

Side

bending

III

HV

L 1-3

seg me nt s

~

2.

Di sc

trac ti on

II

LV prog ress in g to H V

L4/5

& L5/S 1

seg me nt s

Select examina tion techniques applied (a evalua te (he results ofTSM il11e r vel1li0l1

 

Spinal Level(s)

Examination Technique(s)

 

I.

LI-3

Tra ns lato ric jo int pl ay tes tin g a nd seg me nta l sid e be ndin g tes t ing.

2.

L4-5

Tr ansla toric jo int pl

ay testin g

and sciatic nerve tension test ing and bows trin g testin g to monit or th e

res ult s of LV a nd H V trac ti o n

T S M .

No te(s)

I. Lumba r d isc trac t io n LV

TS M a ppli ed to th e L4/5 L5/ S I seg me nt s if nerve bows trin g tes tin g is co nsis te nt w ith

a very

irrit ated ne rve roo t. Prog ress io n to HV lum ba r di sc trac ti on T SM i fn erve bows trin g signs show mild irr it atio n. Se lf

 

manage ment wi th

lumb ar d isc

se lf tra cti o n techni ques.

2.

Lumba r j o int pl ay

a nd pass ive

s ide be ndin g is ofte n exa min ed wi th th e pati e nt in a s id e -l y in g pos it io n. Fo r fu rt her

de ta il s co ns ult Ka lte nbo m 's Malll/al Mobilizatioll of the J oillts. Voll/Ill e II. The Spille.

Case 9 Sy mptomatic 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

Trea tm e nt Segme nt(s)

l.

 

Bilateral facet

III

LV

L5 /S I seg me nt '

 

l3

di stracti on

2.

 

Ventral cranial and dorsa l ca udal facet

III

LV

L5/S I segment"

g lides

3.

LUlTIbo- pclvic mo ve ment reeducation and stabil iza tion training .

 

SeleCI e raminotiolilechlliqu es applied 10 e\'o/ UGl e the resul ts oj TSM inlerl'el1fion

 

Spinal Level(s)

Exami nation Technique(s)

l.

L5 /S 1

Translatoric j oi nt play tes tin g and pa ss i ve seg mental fle x ion and ex tension tes tin g.

Note(s)

* To protect the L4/ 5 hypermobility. a firm lowe I ro ll or cufTweight is placed anteri or 10 the L3-5 ve rt ebrae. th en a used to press the sacrum ve ntrall y.

" VC g lidin g of the L5 seg ment ca n be achieved by

ha\ ing th e L5 vertebra pos itioned at the edge of th e tab le a nd

and legs dan glin g.

the L5 seg ment , a cufTwe igh t is placed ant erior to th e L3-5 ve rt ebrae and the ba se of th e sacrum is manipulat ed in a ven tral

crania l direction.

wedge is

the pel v is

ex t, the

sacrum is manipul ated in a ca udal and sli ghtl y ve ntral direc tion . Durin g dorsal ca udal glidin g of

Case 10 Acute onset of right lumbo-sacral pain with a slight antal g ic po sture (le ft late ral li st).

Sequencing of TS M rechniql/e(s)

Technique

~

~

Grade

Ve loc it y

Treatment Segment(s)

I.

Di sc trac ti o n

II

HV

Invo lve d seg me nt (s)*

2.

Si de bendin g

II prog ress ing to gra de III

LV

Invo lved seg me nt (s)*

Selecl exa mination techniques app lied 10 eWlluate the res ults ofTSM intervention

 

Spi nal Level(s)

Exa mination Tcchniquc(s)

I.

L5 /S 1

Le ft scia ti c bows tr ing test mo nito red a nd pos t HV TS M. Anta lg ie post ure

wh ile in right si de lyin g a nd L5 /S I j o int pl ay assesse d pre - re-eva lu ated ro ll ow ing B V TSM

Notc(s)

* Durin g th ese tec hni q ues the pat ient is pla ce d in ri g ht s ide- ly in g with th e le n late ra l li st supp o rt ed ( i.e. pat ie nt in h isl he r

ac tu al

res t ing pos it io n).

•• In

cases ofac ul c

lum bo-sacral pa in . it is one n be neficia l to co mb ine ho ld-relax a nd func ti o na l massage w ith TSM.

Developing skill with T SM

Deve lo pin g a hi g h level orsk ill in th e app li cat ion orTSM req

uires detaile d and acc urate instru ctio n. conti nua l

feed back, years of psyc ho moto r refi ne me nt and a to ac t as instru cti o nal/lea rn ing a ids to fac ilit ate in

re fl ec ti ve prac

thi s deve lopm enl.

tice pa tt e rn . Th is tex t and co mp a nio n DV D are designed

Ifyo ll are int eres ted in lea rnin g mo re abou t TSM.

th e a uth or's e nco urage yo u to in s tr uct io n o f TS M : Oak lan d

co nt ac t o ne of fo ur

Uni vers ity in Roc hes te r,

estab lis he d U.S. res id e ncy/ fe ll ows hip p rog ra ms w hi c h s pec ia li ze in th e

Mic h iga n, T he Ins titut e

o f M anu al T herJpy in Bos ton. Massach usc lI s.

Fo lso m

Pra tt v ill e. A l abama. No n-US

inro rma t io n rega rd in g TS M based co urses o lre red wo rl dwide.

Ph ys ica l Th era py and

Train ing Ce nt e r in Fo lso m. Ca li ro rn ia

a nd T he Inst itut e or Re hab il itati o n and Tra ini ng in

res id e nt s m ay co nt act Lasse Thlle, t he p res iden t or K -E Int

e rn a ti o n a l , a t lasse-th @: o nl i n e. n o ror

Cervical Spine u@©lffi D1J 0 C9J (ill@

Cervical Spine

u@©lffi D1J0C9J(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 vascu lar structures at end-ran ge

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.

upper cervical rotation.

Osseous anatomy

The occipital bone (occiput) is the inferior portion of the skul l. 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

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.

e longated oval. They are longer in an anterior-posterior

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 offo ur 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

Articular surfaces of the upper cervical spine
Articular surfaces of the upper
cervical spine

OA joint articulations

Articular surfaces of the upper cervical spine OA joint articulations 26 I Chapter 3 : Cervical

facet on the posterior aspect of the anterior arch of at las. The poste rior aspect o f the de ns co ntains a groove which articu la tes

with the

tran sve rse li