Introduction to points of safety with regard to beginning level cervical spine high-velocity, low-amplitude manipulations.

1.  
Donna M. Maitlen, B.S., D.C., C.C.S.P.

2. Vertebral Subluxation Complex
Mechanical Components
*Joint Malposition and Hypo and hyper-mobility
Neurobiologic Components
*Nerve Root Compression (theory)
*Visceral-Somatic dysfunction (autonomic)
Inflammation
*Vascular and soft-tissue responses

3.  Most of the time, we are adjusting patients based on the
functional evaluation of the spine, typically using motion
palpation techniques.
 This means, most of our adjustments will be due to hypo-
mobility as detected using our motion palpation with
confirmatory static palpation findings.
 You may also use devices that detect and measure pain
and temperature to determine spinal joint dysfunction.

4. The facets of the cervical
spine angle upward from
P-A at 45 degrees.
Contact points for adjustments
are typically the articular pillars,
the postero-lateral border of
the spinous process, or the
transverse process.

5. Each joint has its own range
Remember the segmental ranges of motion –
these ranges help you define the subluxation
complex.
The occipito-atlantial joint (C0-C1) has the
most flexion / extension in the upper c-spine.
The atlantoaxial joint (C1-C2) has the most
rotation in the upper c-spine.

6. DUE WITHIN 1 WEEK FROM
TODAY
 Find out what the actual arch angle of a
“Roman Arch” is – it is specific.
 Compare and contrast this to the cervical
lordosis of a newborn and the effect of a
shallower or greater lordotic angle on the
resistance to injury.

7. Discovering contraindications to manipulation
Ruling out dangerous pathology
1. Vertebral Artery Testing – integrity of the vertebral artery
2. Compression Testing – integrity of foramen and body
3. Distraction Testing – integrity of musculature and foramen
4. Percussion Testing – integrity of bony structures
5. Valsalva Maneuver – integrity of neural structures

8.  Down’s Syndrome: possible lack of a transverse ligament
 Multiple risk factors of Osteoporosis
 Atherosclerotic Plaque – CVA
 History of sinus infection in conjunction with c-spine pain
 Remember that much of your pathology DX comes from the
proper history of the patient - listen AND ask.

9.  In George's test, we first measure the bilateral blood
pressure, pulse rates, and auscultate the subclavian and
carotid arteries.
 The patient is next asked to rotate the head right and
left, and then rotate, laterally bend and extend in the seated
position (Maigne's test) and in the supine position
(DeKleijn's test).
 Look for : Nystagmus and fatigue,
 Ask: Do you feel anything different? (do not lead patient)

10.  Seated
• Observe active ROM (measure-especially before first adjustment)
• Static Palpation
• Motion Palpation with end range overpressure
• Flexion, extension, lateral flexion / medial glide, rotation
• Instrumentation
 Supine
• Static Palpation – is anything different?
• Motion Palpation
• Flexion, lateral flexion / medial glide, rotation

11. Indication: restriction of rotation lateral flexion or extension of C1
Patient Position: relaxed, seated
Doctor Position: behind patient toward side of contact
Contact point: ventral surface of index finger
(wrist straight as possible, forearm 90 degrees flex)
Segmental Contact Point: Atlas transverse process (lateral or
posterior)
Indifferent hand: cradles patient’s head
Vector: P-A with rotation, P-A with Extension, or M-L
IMORTANT CONSIDERATIONS BEFORE ADJUSTING:
*is patient relaxed?
*have you maintained joint tension before thrust?

12. Indication: Restricted rotation, lateral flexion or extension
Patient Position: Patient lies supine
Doctor’s Position: Standing at head of table, 45 degrees to 90
degrees to patient
Contact Point: Ventrolateral surface of index finger, thumb or thenar
rests on patient’s cheek
Segmental Contact Point: Posterior articular pillar
Indifferent hand: Cradles patient’s head supporting occiput and
cervical spine
Vector: medial to lateral and superior to inferior
IMORTANT CONSIDERATIONS BEFORE ADJUSTING:
*is patient relaxed?
*have you maintained joint tension before thrust?

13. The physical health of your body directly relates to and
impacts your ability as a doctor to help people and to make a
living.
TAKE CARE OF YOURSELF!!!!!!
Always consider your posture and core strength

14.  Why is the subluxation or restriction present?
o Evaluate cervical spine for strength
o Biomechanics of neck curvature
o Posture
o Evaluate nutritional status, especially minerals
o Sleeping considerations – of posture and pillows

15. Approach the patient with your questions in mind
 Do your seated assessment before the patient lies down
• Observation, A-ROM, Orthopedics, R/O Pathology, vascular tests
 Do your supine assessment
• P-ROM, Vascular tests…
 Pleasantries: assure the patient (before and after)