The complete Thomson book Minardi integrated systems [1 ed.] 0978148800

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The Complete Thompson Textbook Minardi Integrated Systems

Dr. John Minardi BHK, DC.

Contact: Dr. John Minardi BHK, DC. Email: [email protected] Website: www.ThompsonChiropracticTechnique.com Copyright © 2006 to Present: This book is copyrighted. All rights are reserved. Under the copyright laws, this book may not, in whole or in part, be copied, photocopied, reproduced or reduced in any form ·without the expressed written consent of Dr. John Minardi. Copyright © 2006 to Present. All rights reserved.

ISBN: ISBN 0-9781488-0-0 Title: The Complete Thompson Textbook-Minardi Integrated Systems Publisher I Author: Dr. John Minardi Oakville, Ontario Canada

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From the Author Th.is book was created to fill an essential need in the chiropractic profession. In my teachings of this technique I was often asked by students if there was a textbook that included the rational of why this technique works, as well as the actual step by step procedures of how to perform the technique optimally. Since there was not such a textbook, I decided to create one. My vision was to produce a systematic method which integrated all relevant theories and procedures involved in Thompson, from its original work to the present day. This book will detail a step by step procedure on how to perform the technique, including all neurological and biomechanical rational. Furthermore, this book will also include all relevant moclifications and alternatives that have been created over the years to help advance this technique. The sole purpose of this extensive text is to advance and enhance the learning of Thompson. In no way shape or form is it intended to take away from the original work submitted by its creator, or other practitioners who have added to the technique over the years. In contrast, this book's intention is to unify this body of work, including their proper rational, in a pursuit to enhance the technique. My goal was to create a system that filled in any gaps that may have existed in the past, in an attempt to optimise learning. As founder and instructor of The Thompson Seminar Series, I have witnessed first hand the tremendous enthusiasm that students possess when the technique is presented in a way that encompasses all of the rationale and modifications detailed in this book. Fortunately, the seminars have experienced tremendous praise from attendants regarding the organization, practical application and detail to which this material is presented. I can only hope that this same praise will be carried forward to this textbook. I have been fortunate enough to learn from and be certified by world renowned lecturers in this classic technique. I have always, and continue to have a great passion for this technique and for Chiropractic. Thus, I strive to constantly improve my knowledge and teaching ability to help motivate others. I hope that I can share this passion with you. Dr. John Minardi BHI(, DC.

HI

Thank You

Thank you Sharron for all of your lo e, support and encouragement in this latest ambition. Thank you Dr. Jim Thompson for your friendship and for believing in my vi ion. I hope that I " as able to deli er. Thank you Christie Swail for the endless amount of advice that you provided throughout this entire creation process. Your photo editing and cover creation was outstanding. Quite simply your wisdom, generosity and talent is why this book's appearance turned out so well. Thank you Dr. David Rick for all of your help in the development of this book. Your encouragement and countless hours taking photos was a tremendous help. Thank you Dr. Richard Tutak for the many hours of picture taking to ensure this book was represented optimally. Thank you to my pediatric friends Sara, Evan and their mom Tanya Carlos for their special help in the pediatric section. Thank you Julie Roy, my student from Trois Rivieres, for the beautiful neurology picture and overview chart that you graciously provided. Thank you Vince Attisano for the use of the skeletal model present in many of the photos. Thank you Dr. Joe Stucky, Dr. Rob Jackson and all other Thompson Pioneers for all the hard work and dedication put into the development of this technique. I hope that I ha e made you all proud. Lastly, I would like to Thank You, the reader. I poured my heart and soul into this book, and I hope it exceeds your expectations.

Acknowledgement Musculoskeletal lmage of the semimembranosus/semitendino us, rectu femori vnstus mediali , iliop oas and pectorali minor are ourte y of the niversity ofWashingion "Mu culoskeletal Atlas: A Mu culo kele1al Atlas of the HumanBody" by Carol Teitz, M.D. and Dan raney, Ph.D. Copyright 2003-2004 University of Washington. All rights reserved including all phoiograph and image . o re-use, re-di tribution or commercial use without prior written permission of the authors and the University ofWashington. Mu ulo keletal Image of the pelvic, temoclavicular and co tot.rans erse articul:uions are courte y ofBartleby. m's edition f ray' Anatomy of the Human Body. Ant rior O ciput Di location X-ray i courte y of www.radiologyedu ation.com

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Disclaimer Th uth r would like to ackno ledge that this book is simply a guide to assist in the e lishment of Thomp on Chiropractic Protocols and Minardi Integrated Systems. This rextbook i intended to be used in conjunction with the Thompson Technique Seminar Series to en u.re proper learning of the treatment protocols. The reader must remember that no set of standards can dictate a complete treatment protocol for any given case, given the variables of age, gender complicating factors indh iduaJ response to treatment, psychosocial factors, work conditions, and other ariables that may present with any given case. Treatment should only continue if objective improvement on the part of the patient is being made within an acceptable time frame. If improvement is not being made, a reassessment should be perfonned to determine if the diagnosis should be altered. Lack of improvement should also prompt the clinician to consider a change in the treatment protocol, referral to another provider, or release of the patient with maximal medical improvement. Good clinical judgement should alv ays take precedent in decision making with regard to any particular patient. 1

I. Wordin of this disclaimer is credited to Lew Huff and David Brady's Instant Access to Chiropractic Guidelines and Prococols. Mosby. St. Louis, ' . 1999.

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Forward

The old adage that states that ''nothing is ever so good that it cannot be made better," is very real to me. It speaks to the drive within all professions and all professionals to strive to find a better way to do that which we do. The relentless process of taking a good idea to the next level is truly what professionalism is all about. With this thought in mind, it is my pleasure to introduce you to this book. I believe it is an important step in the evolution of chiropractic. From the early l 950's until the present, Thompson Terminal Point Technique has stood the test of time and proved itself to be an efficient and effective approach to spinal analysis and correction. My personal relationship with its creator Dr. J. Clay Thompson involved hundreds of hours of seminar time and personal interaction. Clay taught this work with passion, humour, and his own unique brand of humanity, that all who experienced his presence will long remember. This book is remarkable in that it does not contradict Clay's original thoughts and teachings. The book does, however, proceed to add what Clay could not, due to the science limitations of his era. Using the latest science in the fields of neurology and biomechanics, Dr. Minardi has advanced this body of work into the present day. This book carefully details a step by step approach of how to perform the technique, but more importantly, it also explains the reasons why. I know that many years of careful research and painstaking attention to detail have gone into the creation of this book. I find it to be amazingly complete and know it will become the authoritative text for the Thompson Technique. It is almost as if J. Clay Thompson constructed the skeleton of the technique and John Minardi has added the necessary flesh to make it a fully matured and useful tool for chiropractic. My heartfelt thanks go to Dr. Minardi for the creation of this book. In my opinion, this is the type of book that will help keep our profession strong. By enhancing Thompson's original work, the book takes a good idea and makes it better. It is with no reservations that I state that this textbook raises the bar in the advancement of Thompson. Those of us who use and teach this technique should be proud. Respectfully, James V. Thompson BA, DC Certified Thompson Instructor for 25 years Former President of the ICPA

Forward · ever in the course of human event ha so much been owed by so many to so few". This famou remark wa made by Sir Winston Churchill following the "Battle of Britain". A small number of heroic pilots flying Hurricanes and Spitfires defeated the mighty Luftwaffe in the kies over Southern England. That victory prevented the German invasion of the British Isles and aved civilization from the rule of a demented dictator and his sadistic minions. As a student of WWII I think of that phrase often in reference to the mentors I've had in chiropractic and the fulfilment I've enjoyed because of them. During my years of lecturing and teaching chiropractic philosophy and technique, I've encountered DC's that possess extraordinary enthusiasm, professional curiosity, inquisitiveness, intensity and a burning desire to become a master. Such a person is Dr. John Minardi. I first encountered this doctor while teaching in his native Canada (Toronto). He was a student at CMCC, but regularly attended seminars to advance his knowledge. Using the Thompson Terminal Point Table and the Thompson-Derefield Analysis & Technique as a basic framework, this doctor recognized that I uniquely integrated techniques of other chiropractic greats­ Gonstead and Pettibon into the work. As I have perused this wor� it is apparent that Dr. Minardi has a complete and thorough grasp of the principles taught and has elucidated them in a straight forward, easily understood format. Having studied the works of others, it is my opinion that this is a compilation of the best. It is my fervent hope and yes, prediction, that this outstanding treatise will become a standard text in chiropractic colleges everywhere and will be sought after by practitioners who will want to apply these advanced principles in their offices and clinics. A precise moment by moment full spine analysis of vertebral subluxations and their specific correction should be the right of every patient who seeks our services. Any doctor who attains a mastery of the material put forth by Dr. Minardi will experience unequalled patient satisfaction and enthusiasm, as well as an ongoing steady flow of referrals. That has been my personal experience and my observation of others who diligently practice the work. It has always grieved me that two of the finest chiropractors who ever adjusted me died without having had the opportunity to share their vast experience and knowledge with others. When Dr. Minardi called and asked if I thought it alright to teach the work of Dr. Thompson and others, I responded with a hearty cheer. He has my unconditional support and recommendation. My father taught that each of us has the responsibility to leave this world a better place than we found it. Who has a better opportunity than a chiropractor who understands the Above Down/ lnside Out Principle. One who is able to consistently, effectively and efficiently deliver a service that tells him what to do, where to do it, when to do it, and when not to do it. Does the all­ trusting public deserve any less? My hat is off to Dr. Minardi! I am pleased and proud to have played a small part in his education and training. To quote my late brother, Dr. William Stucky of Thomasville, Georgia, (there are 16 Chiropractors in our family due to his example, encouragement and selfless dedication to the philosophy, science and art of Chiropractic) "We serve best when we serve those who also serve". L. Joe Stucky DC, FICA(Hons). VII

Table of Contents SECTION ONE: History eurology ReliabiUty and Validity of Leg Length Analysis Patient Set Up on a 440 Drop Table Patient Set Up on a Non-440 Drop Table \Veighing a Patient on a 440 Drop Table Weighing the Patient on a Non-440 Drop Table Proper Leg Check Procedure Prioritization of the Spine Using the Drop Piece Mechanism to Assist the Adjustment

2 5

8 9 9 10 11 12 14 14

SECTION TWO: Primary Area - Cervical 16

Cervical Syndrome Classic Cervical Syndrome Classic Prone Side of the Table Adjustment Modified Prone Head of the Table Adjustment Double Cervical Lock Modified Prone Head ofthe Table Adjustment Atlas Subluxation Classic Thompson Toggle Recoil Adjustment Overcompensated Cervical Syndrome Classic Thompson Prone Adjustment Stucky Friction Lock Classic Two Part Prone Adjustment Stucky Stack Classic Supine Adjustment Anterior Cervical Modified Prone Adjustment Posterior Cervical Modified Prone Adjustment Modified Seated Adjustment Cl Flexion Lock Modified Prone Head ofthe Table Adjustment C7-Tl Extension Lock Modified Prone Adjustment

28 31 31 33 33 36 36 38 39 39 41 41

Cervical Syndrome Review Chart

43

16 19 20 20

22

22 25 25

28

SECTION THREE: Primary Area - Occiput Cervical Normal

45

Bilateral Cervical Syndrome Classic Prone Adjustment Modified Study Supine Adjustment Modified Seated Adjustment

46 46 48 49 VIII

fodifi d Toggle Board Adjustment Modifi d Supine Lift Adjustment Unilateral Occiput Syndrome Toggle Set Adjustment Modified Supine Adjustment Posterior Occiput Syndrome Modified Supine Adjustment Exception Derefield XD: Cervical Syndrome XD: Derefield Negative XD: Bilateral Cervical Syndrome XD: Unilateral Occiput Syndrome XD: Posterior Occiput Syndrome

54

Normal, BCS, UOS, POS and X-D Leg Length Analysis Review Chart

58

50 50 51 51 53 54

56 56 57 57 57

SECTION FOUR: Primary Area - Pelvis Negative Derefield (D-) Classic Thompson Two-Part Supine Adjustment Classic Thompson Two-Part Prone Adjustment Modified Stucky One Part Prone Adjustment Modified Al Sacral Push Adjustment Modified Stucky Bilateral Roll (Coup de Gras) Adjustment Positive Derefield (D+) Classic Thompson Prone Lower Boot Adjustment Lower Boot Modified Leg Distraction Adjustment Classic Thompson Supine Upper Boot Adjustment

60 63

65 67 69 71 73

75 76 78

SECTION FIVE: Secondary Area - Lumbar Lumbar Spine Classic Thompson Seated Adjustment Modified Split-Leg Adjustment Modified Prone Adjustment Hyperactive Psoas Classic Thompson Supine Adjustment LS-St Distraction Adjustment (Acute Low Back) Modified Prone Adjustment Spondylolisthesis Classic Thompson Supine Adjustment Modified Institutional Adjustment

81 81 84 86 87 87 89 89 91 91 93

SECTION SIX: Tertiary Area - Thoracic Thoracic Spine Pottinger's Saucer Classic Supine Adjustment Modified Prone Adjustment Lateral Listhesis Classic Thompson Prone Adjustment

96 96 96 97 99 99 IX

Dorso- enical Thumb Pull A1odifi d Prone Adjustment Dorso-Cenical Thumb Push Modified Prone Adjustment Modified Cross Bilateral Modified Prone Adjustment

101 101 103 103 105 105

Leg Length Analysis in the Flexed Position Review Chart

107

SECTION SEVEN: Clean Up Moves Rotated Sacrum Classic Thompson Prone Adjustment Posterior Rocked Ischium Classic Thompson Prone Adjustment Posterior Sacral Apex Modified Prone Adjustment Anterior Coccyx Modified Prone Adjustment IN Ilium Classic Thompson Supine Adjustment Modified Prone Adjustment EX Ilium Classic Thompson Supine Adjustment Modified Prone Adjustment Elevated Rib Cage Classic Thompson Supine Adjustment Rotated Rib Modified Supine Adjustment

109 109

111

111

113

113

115

115

117 117 119 120 120 122 123 123 125 125

Comprehensive Review Chart

127

SECTION EIGHT: Extremities Shoulder Complex Humerus Glenohumeral Joint Anterior Humerus Modified Supine Adjustment Modified Seated Adjustment Posterior Humerus Modified Prone Adjustment Clavicle Sternoclavicular Joint Modified Supine Adjustment Acromioclavicular Joint Modified Supine Adjustment

129 130

130

131 132 132 134 134 136 136

Scapula Medial Inferior Scapula Modified Prone Adjustment x

138 138

Rip Modified Externally Rotated Hip Adjustment Modified Internally Rotated Hip Adjustment Patella Superior Lateral Patella Modified Supine Adjustment Tibia InternalJy Rotated Tibia Modified Prone Adjustment Modified Supine Adjustment Fibula Anterior Fibula Modified Supine Adjustment Temporomandibular Joint (TMJ) Modified Stud.y Two Part Supine Adjustment

140 140 142 142 144 145 145 146 146 148 148

SECTION NINE: Pediatrics Webster's In Utero Constraint Technique Classic Two Part Adjustment Pediatric Case History Protocols for Adjusting an Infant Assessment of the Infant Infant Neurological Reflexes and Spinal Assessment Pediatric Cranial Assessment and Correction Webster's Coronal Suture Adjustment Pediatric Atlas Assessment and Correction Modified Infant Toggle Board Adjustment Pediatric Assessment and Correction of C2-C7 Modified Infant Toggle Board Adjustment Modified Sustained Contact Adjustment Pediatric Assessment and Correction of the Sacrum Modified Sacral Base Adjustment Modified Sacral Apex Adjustment Pediatric Assessment and Correction of the Ilium Modified Leg Distraction Adjustment Pediatric Assessment and Correction of the Lumbar Spine Modified Prone Adjustment Pediatric Assessment and Correction of the Thoracic Spine Modified Prone Adjustment

151 151 152 152 153 154 155 158 158 159 159 161 161 162 163 164 164 165 165 166 166 167 167

References

168

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ECTIO O E Hi tory eurology Leg Length Analysis VaUdity Patient Set Up on a 440 Drop Table Patient Set Up on a Non-440 Drop Table Weighing a Patient on a 440 Drop Table Weighing the Patient on a Non-440 Drop Table Proper Leg Check Procedure Prioritization of the Spine Using the Drop Piece Mechanism to Assist the Adjustment

Dr. John Minardi

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Copyright 2006

HlSTORY '"By eliminating spinal subluxations in an organized orderly fashion, from above down and inside out, the Thompson practitioner will begin to verify the corrections he is making on the patient's spine." - J. Clay Thompson. Dr. Joseph Clay Thompson became involved in chiropractic after a very interesting experience. At the age of 27, Thompson developed diabetes mellitus after suffering a severe blow to the head while unloading lumber from a truck. After Thompson did not respond to traditional medical treatment, a physician gave Thompson two weeks to live. Thompson was then taken to a chiropractor, Dr. J. Delk, with the thought that there was nothing left to lose at that point. Delk adjusted Thompson for 16 consecutive days, after which Thompson no longer had any symptoms of diabetes. Interestingly, Thompson did not become involved in chiropractic at this time. He first established a career as a mechanical engineer for the American Armed Forces. It was not until ten years later, at the age of 37, that Thompson's chiropractic studies began at Palmer College.'.2 At that time, Palmer Chiropractic College focussed on the toggle recoil adjustment, which emphasized that the bigger the recoil... the better the adjustment. However, when Clay Thompson delivered an adjustment, he felt his body pushing away from his patient, and felt as though this was a shock to both himself and his patient. Having such an in-depth knowledge of mechanics, Thompson knew that there must be a better way to deliver a high velocity thrust, with less amplitude. 1 , Ironically, when Thompson first began practising, he purchased an old table with a loose screw-jack that was used to elevate the headpiece. Because of this, the headpiece gave way when the patient was adjusted. When Thompson bought a new table, his patients complained, and he was not achieving the same results as he had with the old table. Around this same time, Thompson observed a doctor adjust an infant in a way that would impact the rest of his chiropractic career. The doctor would lay the baby on the mother's lap in a side posture position. When he was ready to deliver the adjustment, he asked the parent to raise her heel off the floor. As the doctor delivered the adjustment to the infant, the mother's heel dropped back to the floor. 1 With these two observations, combined with Thompson's vast experience in engineering, Clay realized that chiropractors could deliver an adjustment with less force if they utilized Newton's first law of motion. In 1952, Clay invented the first drop head piece. B.J. Palmer was so keenly interested in this innovation, that after its unveiling at the Palmer homecoming in 1952, he asked to be adjusted, and stated that the drop-piece would revolutionize chiropractic. i,2 Dr. W.H Quigley, B.J. Palmer's nephew, took the head-piece to the Clearview Sanitarium and used it in his work with mentally deficient patients, achieving remarkable result�. Thompson went on to construct the first drop-piece table incorporating cervical, dorsal, lumbar and pelvic drop-pieces in 1957. It is without question that the drop table is central to Thompson's technological innovations. However, equally as important is the establishment of the leg check procedure, which is central to the analytical perspective of the technique. Thompson credits Dr. Romer Derefield of Michigan with much of the initial research collected with the leg length analysis. Credit was also given to Dr. Alvin Niblo for adding a major pelvic dysfunction associated with the leg length inequality. Thompson later added to this information by including further cervical, pelvic, lumbar and thoracic subluxations. By chance, Thompson discovered that leg lengths could change with rotation of the head. Further examination revealed a tender nodule along the lamina pedicle junction, and that thrusting through the tender nodule would ameliorate prone leg length inequalities. It is from this point that Thompson began to understand and incorporate other areas of the spine, as they too had an effect on leg lengths. 2

Dr. John Minardi

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Philo ophical Perspectives A belief in the innate ability of the body to maintain homeostasis and signal the presence of organic disturbances by structural adaptation provide the basis for Thompson Technique. Clay was a finn believer and ad ocate of the above down inside out (A.D.I.O. principal and promoted the principles of allowing the body s innate intelligence to heal itself though the correction of vertebral subluxations. He was as his technique espoused a strong proponent of the use of drop table assisted adjusting for the correction of vertebral subluxations. These subluxations were detected using leg length analysis x-ray, palpation and instrumentation. 3 The Thompson philosophy also includes Newton's fust law which states that' a body is in equilibrium if no force is acting upon it. If at rest it remains so, if in action it persists in motion, unless an opposing motion is met". Utilizing drop pieces, the thrust imparts motion to the ertebral segment, which remains in motion until the conclusion of the drop, at which time all other segments in contact with the drop piece cease, with the subluxated segment continuing to move into its corrective position. This is precisely why the technique is called Thompson Terminal Point Technique, because the correction is made at the terminal point at which the drop piece stops. Critical to Thompson philosophy is the concept of prioritising the spine into primary, secondary and tertiary areas of subluxations. Primary subluxations are corrected fust, followed by secondary and then tertiary areas of subluxations. The primary areas of the spine are the cervical and pelvic areas, secondary are the C-T junction and lumbar spine, and tertiary area is the remainder of the t-spine. Hence, Thompson is a full spine chiropractic approach to health care. This concept is key and meshes with the leg check analysis, as one area is adjusted, then the legs are rechecked to see if a balance is achieved. If there is balance, then no further adjustments are preformed, if balance is not achieved then the chiropractor moves to the next area of subluxation. This is done so that the chiropractor only adjusts the major subluxations, and not simply every restriction that is noted. A final note on philosophy is that of sparing the chiropractor from physical degeneration due to difficult manual manoeuvrers. Thompson technique was and continues to be, a career sparing technique. 1• 3

Terminal Point in Adjusting

As mentioned earlier, terminal point refers to the table's drop piece which corrects vertebral subluxations at the terminal or end-point of its travel distance. The use of the tenninal point enables the chiropractor to provide an alternative to forceful or leverage type adjusting techniques. Thompson has had a long relationship with the Williams Manufacturing company, who have built and continually upgrade the Zenith series of Pneumatic drop tables. Thompson has become synonymous with this Cadillac of adjusting tables due to the superiority of the pneumatic drops to all other types. However, this table is not required to utilize the leg check analysis. Furthermore, any good quality drop table can be utilized for this technique. With the Zenith drop table, each point is weighted by the doctor using tension control regulating air flow to the appropriate mechanism. There are four distinct drop sections, including cervical, dorsal lumbar and pelvis, with the ability of having adjacent sections act in unison with one another. This creates a more gentle technique that benefits not only acute patients but also the elderly and children. 3 Analytical Procedures

There are four main analytical procedures in Thompson Technique: palpation, x-ray analysis, instrumentation and leg check analysis. First, the Thompson practitioner must have excellent palpation skills to assist in the detection of subluxations. With respect to x-ray, Dr. John Minardi

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Thompson agreed with Dr. Russ Erhart in that x-rays are used to tell the doctor what not to adjust, as much as what to adjust. Although Clay x-rayed many of his patients, he did not t�ly heavily on x-ray analysis. Clay felt that an x-ray catches structures one moment in time, but does not indicate the segment's function. Thompson believed that it was more important to have a balanced spine than a straight one. Hence, the leg check always takes precedence over the x-ray for detecting subluxarions in this technique. X-rays are used primarily as aids in distinguishing the type of subluxation involved, to rule out pathology and to assist the doctor's leg check analysis. Instrumentation was an important part of Thompson practice. Initially, Clay used a neurocalometer (NCM) until the development of the derm therm-o-gram (DTG). Instrumentation was used because it provided an indicator of autonomic function in the body, and can determine neurophysiological dysfunction. Again, instrumentation was used as another tool to determine the location of the subluxation. Finally, the leg check analysis is used to detect neurophysiological dysfunction through spastic muscular contractions. There are main subluxation categories associated with the leg check analysis, from which several different sub-categories exist. Furthermore, several other components incorporating rare and obscure subluxations are assessed by the leg check. There are basically two scenarios that will be present when preforming a leg check. Following the initial examination, the prone leg length analysis will reveal either even legs, or a contracted leg in the extended position. Depending on what clinical signs and symptoms the patient displays, will influence what the leg length analysis determines. Technique Influences Thompson lived during a time with many of the pioneers of chiropractic. Clay would regularly discuss patients, protocol and new ideas with the likes of BJ. Palmer, Clarence Gonstead and Major DeJarnette. Thus, it is obvious to those who observe or practise Thompson, that the technique incorporates some of the ideas of these great leaders. Contra-indications to Care As in all manual adjustive therapy, any contra-indications must be observed. It is important to note that Thompson is considered a less ballistic approach to adjustive therapy, especially if the patient is properly weighed on the table. However, the force can still be aggravating to an acute disc, spondylolisthesis greater than Grade 3 or an aortic aneurysm. 2 As in all chiropractic procedures, if any contra-indications to care are present, no adjustment would be provided to the affected area.

Dr. John Minardi

Copyright 2008

Neurology of the Short/Contracted Leg As mentioned previously, Thompson technique gives a chiropractor a systematic approach for the location and correction of the ertebral subluxations. The technique utili zes the contracted leg as a tool for detennining which area of the spine should be addressed first, and th e Thomp on table is used to gi e a low force, high-velocity adjustment. What then is the short leg concept? Why is this analysis chosen? To understand the short leg analysis, the reasoning behind the contracted leg must be explained. Originally, Thompson emphasised that the term contracted leg indicated the origin of a neurological imbalance, which appears as an innervational overload to the extensor muscles, causing unilateral spastic muscle contractions and unequal extremities. Normally the facilitory mechanisms increases the normal spinal stretch reflex, while the inhibitory mechanisms act to decrease the reflex. The systems constantly react to maintain postural balance. The cortex notes normal values of body function, while the actual state of the body is monitored and compared to the cortical data by the cerebellum and the hypothalamus. Many individuals are under the impression that the Thompson leg length inequality(LLO " analysis is based on the dentate ligament theory(DLT). This assumption is incorrect. The DLT may in fact have an influence on leg lengths, however, it is not a Thompson theory, it is a Grostic upper cervical technique theory. The primary reason that a contracted leg exists with a subluxation, is based on the neurological response of the muscle spmdle, as well as the proprioceptive changes that are detected in the facet joint, intervertebral disc and Golgi tendon organ. Lets quickly review these four stmctures and the ' changes that occur with a subluxation. The muscle spmdle contains both intrafusal and extrafusal muscle fibres. Contained within the intrafusal muscle fibres are two specific types of nerve fibres. I) Nuclear bag fibres also referred to as annulospiral endings, are contained mainly within the belly of the muscle spindle, and detect dynamic/quick stretches that occur. 2) Nuclear chain fibres also referred to as flower-spray endings, appear throughout the entire length of the muscle spindle and detect slow stretches. As the extrafusal muscle fibres are stretched with a subluxation the intrafusal nerve fibres will detect the change. The second structure directly affected by the subluxation is the facet joint. The facet joint is involved in both proprioception as well as pain sensation. A subluxation causes a distortion of the facet joint, which results in an accumulation of inflamation within the capsule. This accumulation adds to the stretch of the capsule and attracts an accumulation of asoactive mediators such as prostaglandins, potassium and bradykinin within the facet joint. These chemical mediators are the critical elements involved with the pain associated in a subluxation. As bradykinin accumulates within the capsule, this will irritate the nociceptive nerve endings located within the facet joint, resulting in an increased sensation of pain. This increase in fluid also adds to the stretch of the capsule. The third structure affected is the Golgi tendon organ (GTO). The GTO functions to detect the amount of tension that the muscle exerts on the tendon. Any distortion to the connecting musculature produces an increased tension to the tendon, causing the GTO to be increasingly stimulated by the activity. The fourth structure affected is the intervertebral disc. A subluxation causes a distortion to the connecting intervertebral discs. This distortion is detected by the proprioceptive receptors located in the disc's fibrocartilage, sending stimuli of the aberrant mechanics. Therefore, when a subluxation exists, the aberrant mechanics associated with the misalignment produces a distortion of the muscle spindle, facet joint, intervertebral disc and Golgi tendon organ attached to the segment. This distortion/change is detected by the nuclear chain and nuclear bag fibres within the muscle spindle, the GTO within the tendon, and proprioceptive receptors located in the facet capsule and intervertebral disc. All four of these l;. ,.,,..,

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structures are innerv ated by Type IA nerve fibres. When the distortion produced by the subluxation is detected, these structures send this infonnation via the Type 1 A afferent fibres. Type I A afferent nerves send this information to the cerebellum through two primary ascending this proprioceptive tracks; the entral and dorsal spinocerebellar tracts. These tracts information and send it to the cerebellum. The cerebellum is primarily responsible for proprioception and motor control, and tells the brain what is happening in the body(ie. it senses the stretch information). This cerebellar information is sent to the thalamus, which is the main integrator of the brain. The thalamus takes the information and sends it to the motor and sensory cortex. Simultaneously, pain originating in the facet joint, caused by the increase in bradykinin, irritates the free nerve ending within the capsule. This pain information wilJ ascend by C fibres, through the lateral spinothalamic tract to the thalamus. The thalamus then integrates this information and sends it to the primary sensory cortex. The motor and sensory cortex contain information about what should be happening within the body(ie. the distortion should not be occurring). If the information of the cerebellum and motor cortex are the same, then everything is normal and no response is sent. However, if the information differs, which is the case with a subluxation, then the motor/sensory cortex will send a response through the brainstem using four primary descending tracks, which fire simultaneously. 1) The tecto-spinal tract is responsible for head and eye movements, due to sight and sound stimulus 2) the rubro-spinal tract responsible for bringing information from the cerebellum and red nucleus, 3) the reticulo-spinal tract responsible for intraspinal reflex loops and 4) the vestibulo-spinal tract. The vestibulospinal tract is most important with regards to the short/contracted leg because unlike the other spinal tracts, the vestibulospinal tract is always excitatory and always "' facilitates postural muscles, primactly located in the 1o{ve'tffi:.ib and i,eYvi� girdle. Thus, when this descending tract fires, it travels down through gamma efferents to the intrafusal muscle fibres, activating a gamma motor neuron and causes a l��gth��g of those intrafusal fibres. The activated gamma motor neuron sends a response to an inter-neuron within the spinal cord, which results in two events Iiappiri'g simultaneously. Firstly, the inter-neuron activates an alpha motor neuron of the agonist muscles. This results in a physiological shortening/contraction of the extrafusal fibres of the postural muscles, thus causing a short/contracted leg. Secondly, the inter­ neuron also inhibits the antagonistic muscle group. The last mechanism involved with the subluxation response occurs within the cortical inhibitory tracts. Under normal circumstances, these tracts provide an inhibitory response to balance facilitory tracts. However, when a subluxation exists, the cortex inhibits this inhibitory tract. This phenomena is termed "dis-inhibition" and refers to the fact that when an inhibitory tract is inhibited, it results in an activation. The:ifore, furthei-""encouraging the contracted leg. The reason that the leg length inequality balances so quickly after the subluxation is corrected, is because the Type IA afferent nerve fibres that carried the aberrant infonnation are the fastest nerve fibres contained within the body. They have a large diameter, are myelinated and travel at a speed of 80-l 20m/second. Thus, when the problem is corrected, changes in leg lengths are seen instantly because the aberrant afferent information from the muscle spindle, facet joint, GTO and disc are no longer being sent. Therefore, no corrective response needs to be sent by the cortex to compensate.4• The reason that an area may continue to be painful after an adjustment is because time is required for the lymphatic system to clear out the inflammation and chemical mediators that irritate the nerve fibres. (See Figure Titled "Thompson's Basic Neurology")

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Dr. John Minardi

Thompson's Basic Neurology 5

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�,

I I

tracts:

Originates tom cortex Usualy inhibitJry

I I

2. Rubrosplna/: Motor coordination 3. Reticulospinal: lrtrasegmenta/ Reflex 4. Vestibu lospinal: AIMBys FACVTORY (no inhibition tract in it) -> facilitate postural m,scles located in LB arr! pfillis

Contraclion olthe tn)Ofibri/les Lenr;/ltering of Ile intrafusa f. Caitracfonofthe extrafusal f

...;, r-.lJdear bag fiber,; (annulo-,p1ral endings): in tre center. detect quickstmtch ...;, r-.lJdearchain fibe,s (11 ov.er ,pray endingSj: In entire mus::I e ,pindl e, deled elow streiches --"Both lnne,vated by type 1 a afferents

............ .._ ............

--

'. '

2 Ascending tracts (proprlootption) 1. Dorsal spincErebel/ar Ir. 1. Ventra spino-cerabelartr.

\

I I

-I ...... �

-.._

-

-

--

.,,.

.,,

Charges can be seen so quckly alter a carecliai, because the l;pe 1e afferents no laiger daect lheslralr:h oflhe swlUJCation

---, ---, en

-i�,fl

....

� .,,, I Inhibition of the I

a rrotor ne uron / (postural rm,) "'

antagonist muscle

..,

h the f a:et capsue. pan associated with cremi:als medators of lnflanmaticn, travel in C fbera by the iatera spino-thalarric Iract to the thaiatnJs

Facet Joint

I;: (.) Q)

- _,

Disc

- Facet capsule Is hlgHy dependert on lnflanmation - Distasi:ln --> nflanmation -> bradykrlin, prostoglandns & K -> sensltivly of noclceptille aidlngs -> sensation of pan (!raveling in C fibers)

( Dr. John Minardi

\

EXTRAFUSAL FIBERS:

.. -

.._

I

'.

/NTRARJSAL FIBERS:

Contrac6on d the m,sc/e

'---

wha

,,

Corf/ca/ descending

1. Tectosplnal: Detects changes in head & ned< mo� based on sight & sound

------

3 Cerabdlum receives all proprioception (conscious & incorr;clous). The lnfxmallon contained inthe cerebellum k IS ha,:penirg in the body

68

lrlubllS it's°"'" cortical inhibilion ll"BCI = DIS.//l#fBfTKJN (resulting ,nan sctivation)

6A ltllllil serd a corrective �e thtougl 4 main decending traclS:

If dislorsion present= i propriocepdve Input to type 1a fbers

Twe 1 a afferent fibers are the faslast fbErS (80-120 rrr'sec) inlf>e body (large diamelBr & m;@lirn saled)

M.Jscle Spindle

Golgi Tendon

Also inervated by type 2 fibers

Senses tensiontha a ITIJSCie exerceon atend:>n

Subluxation Alters These 4 Structures

7

Reliability and Validity of Leg Length Analysis For years. many individuals questioned the reliability and validity of the Thompson technique because of its use of the leg length analysis. Many critics have claimed that there is no cientific literature supporting the reliability and validity of the leg len�h analysis and thus should not be preformed. These comments are simply incorrect, and s· tatea-by individuals who ob iously ne er completed a proper literature search regarding leg length inequalities(LLD. Pioneer research on LU, and the reliability of there utilization as a clinical tool began in the late 70's and early 80's. In that time period, researchers concluded that the gold standard for LU was by using x-ray. 9 Further research then focussed on prone and supine visual LLI observations, as researchers in the l 980's indicated that visual methods of measurement did not differ significantly from the x-ray method of measuring LLI. In fact, when compared, the literature demonstrated that there is a strong relationship between visual and x-rays methods of measurements. 10 In 1988, more detailed research of the Thompson leg check was performed and demonstrated that the clinicians studied could reliably measure a LLI to less than 3mm, with both intra and inter­ examiner reliability. 11 DeBeor ( 12) also found good agreement, as welJ as significant interclass correlation between the examiners studied. More recent literature by Rhodes et al (13) indicated that the intraexaminer reliability was excellent for the prone leg check, and that prone measurements were highly correlated with x-ray measurements. In the only study done that observed the validity of LLI, the researchers found that when comparing prone leg lengths to x­ ray measurements, 54% of the prone measurements were within 3rnm of the x-ray measurement, showing a strong correlation (.71). 14 However, the same study demonstrated that in 12% of the subjects tested, the opposite legs were viewed as being shorter. Thus the research concluded that despite the strong correlation between x-ray and prone measurements of LLI, more research was needed. 14 One should keep in mind, however, that even though x-ray is seen as the gold standard, it is usually taken weight bearing, and prone measurements are viewed non-weight bearing, which may account for some of these millimetre discrepancies. More recent literature continues to indicate good reproducibility to detect LLI using either prone or supine protocols, 15·16 and are also beginning to use LLI for the detection of other dysfunctions. For example, Brink ( 17) found a statistically significant association between LLI and the side of radiating pain in patients with lumbar disc herniations. Thus, LLI may be used as an inexpensive and quick tool for evaluating these types of disorders, but more literature and clinical experience is needed. I've only touched the surface of the literature that is available for using LLI as a clinical tool. Thus, most individuals should read the literature on LLI further before making blanket statements regarding unreliability or invalidity. We should remember that all diagnostic, orthopaedic and palpatory assessments have been criticised and in some cases disproved in the literature, however, none of these have been discarded. LLI as any other assessment tool bas its limitations, but we should incorporate as many tools as possible when assessing a patient to ensure that we are correcting the primary problem. In closing, Dr. Thompson was a major pioneer in the field of chiropractif .�Voducing new ideas, concepts and adjustive procedures. He was an avid researcher who headed the Palmer Research Institution for l O years, and his technique has Weathe�ed over 50 years of professional scrutiny. 1).qlJl,RS� L n not only wanted a technique that was comfortable and patient friendly, he 1 wanted to lengthen the life of the chiropractors career, "adding 15 years of solid productivity". .2

Dr. John Minard

I

PATIE T SET UP ON THE THOMPSON 440 TABLE I. Make sure that all of the four pieces are in the dmvn position and le el before beginning. 2. Bring the table into the upright position using the either the side kick plate or the arrow buttons at the top of the table. • t

-

3. Have the patient remove anything bulky (keys, wallet etc ... ) from of his/her pockets. 4. Have the patient step onto the footplate, facing the table. A hf'

,

.I"'

5. ave the patient's nose centred into the headpiece, by loosening the star knob on the upper ccJriage and using the power handle to raise or lower the heigit as needed. Tighten the star knob once it is in place. The upper carriage is now in the ready position for the patient. (If working on a Automatic 440 table, simply use the arrow keys at the side of the headpiece to raise or lower the upper carriage as needed). 6. Loosen the star knob on the bottom carriage and adjust the pelvic piece to align with the ASIS. If this is not possible due to the patient's body structure, provide a 3 finger width difference between the bottom of the lumber piece and the top of the pelvic piece. Tighten the star knob once it is in place. The bottom carriage is now in the ready position for the patient. 7. Have the patient lean forward and rest against the table. 8. Place the patient's arms on the arm rests. 0

•

9. Lower the patient down, using either the side kick plate or the arrow buttons at the top of the table. While the table lowers to its horizontal position, keep your hand on the patient's back to eliminate any shifting or distortions. PATIENT SET UP ON ANY DROP TABLE (without a Hi-Lo function) 4..J �· I(

Although this section concentrates on set-up on the Thompson 440 table, any quality drop table will be sufficient in the practice of the this technique. 1. Make sure that all of the four pieces are in the down position and level before beginning. 2. Have the patient remove anything bulky (keys, wallet etc ... )out of his/her pockets. .. � ... " ... ,11

., ••

3. Have the patient step behind the table, kneel on the edge of the table and bring him/herself down to a prone position. 4. Have patient's arms resting on the armrests. 5. Ensure that the patient's nose is centred in the headpiece. 6. When adjusting the pelvis, have the patient positioned so that the ASIS are level with the top of the pelvic piece.

Or. John Minardi

9

"\VEIGHING" THE PATIENT TO ENSURE PROPER TENSION IS SET ON THE THOMPSON ZENITH 440 Cervical C."lfrl

,r.. w c.c,�,u.

11,,.11•

J . Set the select knob to "D' with the cervical button pushed in, or cervical latch down. ( 2. Tight�� the cervical tension knob at the head of the table (turning to the right). 3. Step on the white foot strip and hold foot down until both the cervical and dorsal pieces raise. Once both have raised, step off of foot strip. 4. Looseh the cervical tension knob (turning to the left) until the piece drops. 5. Tum the cervical tension knob 2-3 turns to the right to set tension. 6. Tum "Silver Dot" on DL tension knob to sit midway between the thoracic and lumbar pieces. 7. Step on the white foot strip and hold foot down until the cervical and dorsal pieces raise again. Once raised, step off of the foot strip. The table is now ready for the cervical adjustment. Thoracic 1. Set the select knob to "D" with the cervical button pulled out to an off position. 2. Step on the white foot strip and hold foot down until the dorsal piece raises. Release foot strip. 3. Tum the dorsal /lumbar tension knob so that the "Silver Dot" points away from the dorsal piece (moving towards the lumbar piece). 4. Once the dorsal piece drops, return the "Silver Dot" slightly towards the thoracic piece. This will provide the necessary tension required. 5. Step on the white foot strip and hold foot down until the dorsal piece raises again. Release foot strip. The table is now ready for the thoracic adjustment. Lumbar I. Set the select knob to "L" 2. Step on the white foot strip and hold foot down until the lumbar piece raises. Release foot strip. 3. Tum the dorsal/lumbar tension knob so that the "Silver Dot" points away from the lumbar piece (moving towards the dorsal piece). 4. Once the lumbar piece drops, return the "Silver Dot" slightly towards the lumbar piece. This will provide the necessary tension required. 5. Step on the white foot strip and hold your foot down until the lumbar piece raises again. Release the foot strip. The table is now ready for the lumbar adjustment. Thoracic and Lumbar Pieces Simultaneously I. Set the select knob to "DL" 2. Position the tension knob so that the "Silver Dot" is at the midpoint of both pieces. 3. Step on the white foot strip and hold foot down until both the thoracic and lumbar pieces raise. Release foot strip. 4. If either the lumbar or thoracic piece drops, tum the "Silver Dot" slightly toward the fallen piece, this will provide an increase in tension to that area. The key is to have the "Silver Dot" in a position between the thoracic and lumbar pieces in that both pieces stay in the raised position. For Example: When both pieces are raised, the thoracic piece drops, while the lumbar piece stays raised. Turn the "Silver Dot" towards the thoracic piece slightly, and re-set the drop pieces. If both pieces stay raised, the table is in a ready position. However, if the thoracic piece drops again, then tum the Dr. John lllrwdl

10

·• ii r Dot" towards the thoracic piece slightly again. Repeat thls until both pieces stay rai sed hen stepping on the white foot strip. 5. Table is now ready for a thoraco-lumbar adjustment. Pelvis 1. Set the select knob to "P". 2. Tighten the pelvic tension knob at the side of the table (turning to the right). 3. Step on the white foot strip and hold foot down until the pelvic piece raises. Release foot strip. 4. Loosen the pelvic tension knob (turning to the left) until the piece drops. 5. Turn the pelvic tension knob 2-3 turns to the right, to set tension. 6. Step on the white foot strip and hold foot down until the pelvic piece raises again. 7. Keep your foot on the strip and set the clutch located on the side of the table to set the direction of the pelvic drop. (Positioning the clutch straight will have the pelvic piece drop straight down. Pelvic Clutch set 45 degrees cephalad will have the pelvic piece drop down and up toward the head of table. Pelvic Clutch set 45 degrees caudad will have the pelvic piece drop down and back toward the foot of table. Release foot strip. 8. The table is now ready for the pelvic adjustment. Lumbar and Pelvic Pieces Simultaneously 1. Set the select knob to "LP" 2. Position the tension knob so that the "Silver Dot" is at the midpoint of both thoracic and lumbar pieces. 3. Step on the white foot strip and hold foot down until both the pelvic and lumbar pieces raise. Release foot strip. 4. If the lumbar piece drops, tum the "Silver Dot" slightly toward the lumbar piece, this will provide an increase in tension to that area. If the Pelvic piece drops, turn the pelvic tension knob to the right 2-3 times. Re-set both drops and repeat this procedure until both pieces stay in the raised position after stepping on the white foot strip. Note: In the majority of lumbo-pelvic adjustments, the pelvic clutch is set in the straight position, in order for the pelvis to drop straight down as the lumbar piece drops. 5. Table is now ready for a lumbo-pelvic adjustment. WEIGHING THE PATIENT ON A NON-440 DROP TABLE Weighing the patient on a any other drop table, other than a 440 table, is a much easier process. 1. Simply raise the drop piece that is needed using either the hand or foot lever, located at the side of the table. 2. Loosen (turning to the left) the tension knob located adjacent to the piece, at the side of the table, until the drop piece falls. 3. Increase the tension by turning the knob to the right 3-4 turns. 4. Re-set the drop piece using the hand or foot lever. 5. Table is now ready for the doctor to deliver an adjustment.

Dr. John Minardi

11

Proper Leg Check Procedure The leg check has mistakenly been interpreted as a simple procedure. In fact, an accurate leg check analysis is one of the most difficult aspects of the Thompson anaJysis. Quite simply, if the leg analysis is inaccurate the entire Thompson procedure will be compromised. There ore, to ensure accuracy and consistency in the leg length analysis, the following must be performed: I)_ Once the patient has been placed on the table, make sure he/she is comfortable and does not shift. Lower the table to its horizontal position. If not working on a Thompson 440, Have the person step from the backi of the table, Kneeling down into the proper prone position. When in the prone position, t,\i�fly lift the patient's hips and legs off of the table to decrease any distortion of musculature. o,r

2) If working on a Thompson 440 table, Raise the footrest so that the patient's toes do not touch the footplate. This is necessary, because if the patient's toes touch the footplate, it will result in excessive dorsi-flexion, which will increase the tension in the musculature of the legs, and decrease the accuracy of the leg check. 3) Place the hands around the ankJes so that the index and middle fingers separate around the lateral malleoli, and the thumb rests under the calcaneus. This is referred to as the "Guns Position". If the doctor has incredibly small hands, an acceptable alternative is to grasp the foot so that the palmar surface of all index finger are on the dorsum of the patient's foot, while the thumb rests under the calcaneus. Whichever is chosen, it is imperative that the doctor perform it the exact same way each time, as it will increase the accuracy and reliability of the leg check. 4) Be sure that the thumb applies no excessive cephalad pressure. Apply only enough cephalad JCAt ,A pressure to have the patient's shoe touch the plantar surface of their foot. Excessive pressure will make the leg check inaccurate, and will make assessing the subtle changes in the leg length very difficult. 5) Raise the feet 3-4 inches off of the footrest. This is important to decrease any friction between the table and the patient's legs. Do not leave them on the table, it does make a difference! 6) Remove any dorsi or plantar flexion, as well as inversion or eversion that may be present in the feet. However, any foot flare (toeing in or out) can remain present, as it will provide clues for pelvic subluxations discussed later on. 7) Bring the feet closer together, leaving approximately one half inch space from each other. Without touching the feet together, look where the upper meets the sole of the shoe. It is import.ant to use this area of the shoe for our sight marking, as this area will be the same bilaterally. The doctor should not use the bottom of the shoe for sight markings, as different wear patterns on the sole of the shoe will cause inaccuracies. 8) To ensure the accuracy of our leg length analysis, line up the space between the shoes with centre of the spine. Accomplish this by sighting that space through the gluteal crease, continuing through the spinous processes and ending at the external occipital protuberance (EOP). 9) Make a mental note of which leg is contracted (short) if any.

12

l

K ing th hand in the ame position bring the legs to 90 degrees flexion. Again, sight \vn th v elt of the shoe through the gluteal crease, continuing through the spinous processe nd nding at the EOP making a note of the position of the previously contracted leg. Checking the Patient's Legs while in the Extended Position

"" ,,

p� I

Even

Uneven

.11

ll

•N • BCS • uos • POS • X-D

• cs • D• D+

Figure 1 Leg Length Analysis in the Extended Position.

Simply put, when a doctor checks a patient's leg lengths, only one of two things will be observed. The patient will have a contracted (short) leg, which occurs 80 percent of the time or the patient will have even legs. (See Figure 1) If the patient has a short leg, then the patient can only have three possibilities of categories: • • •

Cervical Syndrome Derefield Negative Derefield Positive

If the patient has even legs, then the patient can only have five possibilities of categories: • • • • •

Normal Bilateral Cervical Syndrome Unilateral Occiput Syndrome Posterior Occiput Syndrome Exception Derefield

Dr. John Minardi

13

eopyriQ/ltzaol

Prioritization of the Spine m ntion d pre iously Thompson is a full spine chiropractic approach to detecting and rr ting ubluxations. Critical to Thomp on philosophy is the concept of prioritising the spine into primary, econdary and tertiary areas of subluxations. Primary subluxa6ons are corrected first, followed by secondary and then tertiary areas of subluxations. Thompson s game plan is to adjust the highest and lowest subluxations first and working its way to the centre of the spine onJy if neces ary. The primary areas of the spine are the cervical and pel ic areas secondary are the C-T junction and lumbar pine, and tertiary area is the remainder of the thoracic spine. (See Figure 2 This concept is key and meshes with the leg check analy is, as one area is adju ted then the legs are rechecked to see if a balance is achieved. If there is balance then no further adjustments are preformed if balance is not achieved then the chiropractor moves to the next area of subluxation. This concept of checking, correcting and rechecking is termed 'Chasing the Derefield.. and is done so that the chiropractor only adjusts the major subluxations and not imply every restriction that is noted.

ct- D1

-'-

lut16AL j,,.,f ---:---

\}

1' 2' 3' 2' 1'

Figure 2 Prioritizing of the Spine into Primary, e ondary and Tertiary Areas ofSubluxations.

Using the Drop Piece Mechanism to Assist the Adjustment As mentioned previously in the philosophy of Thompson, drop pieces are utilized to incorporate ewton's First Law of Physics - The Law of Inertia. Newton s First Law basically states that a body in motion will stay in motion unless acted upon by an equal and opposite force. When at rest, it remains at rest, when in motion it remains in motion. When the doctor positions a patient correctly using a drop piece, a combination of the doctors thrust, and the falling of the drop piece sets the subluxated vertebrae in motion. When the drop hits its terminal point the vertebrae will continue to fall using the Law of Inertia, until it sets into its neutral position. Furthermore, the doctor can decrease the amplitude of thrust, as the drop piece mechanism increases the velocity of the adjustment, resulting in a less jarring and more comfortable adjustment for the patient. The use of the drop piece will also provide less physical stress to the doctor, thereby increasing a doctor's career considerably. Dr. John Minardi

14

Copyright2006

SECTIO

TV 0:

PRIMAR AREA: CERVICAL Cervical Syndrome Classic Cervical Syndrome Classic Prone Side of the Table Adjustment Modified Prone Head of the Table Adjustment Double Cervical Lock Modified Prone Head of the Table Adjustment Atlas Subluxation Classic Thompson Toggle Recoil Adjustment Overcompensated Cervical Syndrome Classic Thompson Prone Adjustment Stucky Friction Lock Classic Two Part Prone Adjustment Stucky Stack Classic Supine Adjustment Anterior Cervical Modified Prone Adjustment Posterior Cervical Modified Prone Adjustment Modified Seated Adjustment Cl Flexion Lock Modified Prone Head of the Table Adjustment C7-Tl Extension Lock Modified Prone Adjustment Cervical Syndrome Review Chart

Dr. John Minardi

15

CERVICAL YNDROME (CS) Classic Side Table Position

One of the primary areas of sub I uxation, and one of rhe most powerful areas of correction, is the cervical spine. When adjusted properly, the cervical correction has tremendous effect . With this in mind, the cervical yndrome is the initial problem that a Thompson practitioner must rule in or out within the patient. The following procedures are required to detect and correct the cervical yndrome ubluxation: I. Patient must pre ent with a contracted leg in extension. • Doctor instructs the patient to tum his/her head to the left then to the right. • In order for a cervical syndrome to be diagnosed, the patient's legs must balance upon head rotation to one or both sides. If the patient's legs balance with head rotation, the cervical syndrome is then labelled a left or right cervical syndrome according to the side of head rotation. (See Figures 3&4) • For example, if the patient presents with a contracted right leg, and head turning to the left balances the patient's legs, then this would be labelled a left cervical syndrome, simply because the patient's head is turned to the left. However, the actual problem is located on the opposite side of head rotation. In this example the problem would be on the patient's right side. • The doctor must note that the patient's legs must balance I 00 percent with head rotation in order for a cervical syndrome to be present. If the legs partially correct but do not become completely balanced, this would not be considered a cervical syndrome, and the doctor would continue to the next area of concern prior to adjusting the cervical spine. Following correction of that area, the doctor will re- isit the cervical spine by ha ing the patient tum their head to both sides again to verify if a cervical syndrome is now present.

Figure 4 Left or Right Head Rotation Produces Even Legs.

2. Palpate along the lamina-pedicle junction from C2-C7 contralateral to the side of head rotation (right side in our example above) for a tender "P�·��Shaped" nodule. This nodule is an inflamed facet capsule, which is extremely tender due to inflammatory mediators that are gathered within the capsule. It is important to locate the capsule itself, and not simply contracted musculature in the cervical region. Thus, a simple test to confirm the capsule is the "Roll Test": • When the doctor finds the pea shaped nodule, he rolls the mass between his fingers up and down and side to side. If the omass is able to be rolled, then the doctor is on muscle. fun• � � The facet capsule is located beneath this muscle mass is firm and does not move. This nodule confirms the location of the cervical subluxation. (�\,.,.,

Dr. John Minardi

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Copyright 2006

3. Bi m h m

yndr me ubluxation.

Th following diagram i0ur 5) dem n trate the biomechanic involved in a cervical yndrom pr ent anywhere from 2- 7. ote that the affected egment ubluxates posterior away from the ide of the nodule black arrow . The subluxation and rotate pinou proc pattern stretche the facet cau ing inflamation to build and re ult in a palpatory nodule within the facet joint (gr y arrow).

CS Subluxation p

C3

A

C4 Figure 5 Cervical Syndrome.

Based on these biomechanics, the doctor must correct for the both the posteriority and rotational components of the subluxation. This is accomplished by the doctor t�sting P-� perpendicular to the facet, and parallel to the disc plane. In order for this to be achieved, the doctor s line of correction must change throughout the cervical spine to compensate for a patient s natural cervical lordosis. Therefore, in superior cervical segments, the line of correction will be cephalad, and will gradually become caudad with each inferior segment. (See Figure 6&7)

l\:phalad

A

p

Caudad

Figure 6 Line of Drive C2-C7.

Figure 7 ervi I pine Line f Ori, e - Parallel to the Dis Plane. from The diagram (Figure 6) and x-ray (Figure 7) display how the angle of the di and f th fa ets in the cervi al pin change th to ar ul C2-C7. To correct for both the po terior and rotational aspe t of the ublux ti n, the d t r mu t thru t perp nd1c l facets and in line with the disc. Therefore, the doctor's lin of correcti n i ph l d in th higher egm nt , gradually beCiJO if]g th more caudad when adju ting the lower egment . By thru ting in thi dire ri n, th d t r imultaneou l correct for bo posterior and rotational components of the subluxated egment.

Dr. John Minardi

17

Copyright#Jf

4. Po itioning: Clas ic Side Po ture Cer vical Syndrome Correction: (See Figures 8&9) Doctor: Side of table. Patient: Prone. Table: Cervical Piece in the ready po ition. Contact: MCP or PIP joint on the LPJ (location of nodule). Stabilization: Oppo ite side zygomatic arch or parietal bone. LOC - P-A, L-M perpendicular to the facet joint and in line with disc plane.

Figure 8 CS Correction. PIP Contact on Affected LPJ.

Figure 9 CS. Side of Table Doctor Positioning.

The anterior to posterior thrust corrects for the posteriority of the subluxation and the unilateral contact on the lamina-pedicle junction corrects for the rotational component in olved. Thus the doctor will be thrusting into the patient's natural cervical lordosis, restoring the affected segment back into a normal position. The doctor must note that the tenderness within v� the•"facet capsule 4AJQ.#L JC will persist at the lamina-pedicle junction. Although this tenderness will be slig tly decreased immediately following the adjustment, the body requires time to flush out the inflammation caused by the subluxation. 5. Recheck the legs, and continue analysis for other subluxations.

Sample Ca e: A 35 year old female presents to the clinic with neck pain. Following a complete examination Thompson anal sis reveals a short right leg in extension. The doctor instructs the patient to tum her head to the right, which produces no change to the leg lengths. The doctor then instructs the patient to turn her head to the left, which results in balanced leg lengths. Left head turning producing balanced legs indicate a Left Cervical Syndrome but the problem is on the opposite side. The doctor will then palpate along the lamina pedicle junction on the patient' right side. A tender nodule is present at CS. The doctor is of small stature and decides to utilize the side of the table cervical syndrome correction. The doctor will talce his/her contact at the site of the nodule, and thru t P-A in line with the disc and perpendicular to the facet. The doctor will then re-check the leg lengths and mo e on to the next area of problem.

Dr. John Minardi

18

Copyright2006

CERVICAL SYNDROME - Modified Head of Table Position The head of the table modification may be more biomechanically advantageous to the doctor of a larger frame, as the original side posture position is more comfortable to those doctors of a smaller frame. The result to the patient is identical in both, provided that the adjustment is performed correctly. This modification is strictly for doctor comfort. 1. All components are the same as pre iously discussed, with the exception of positioning. 2. Po itioning: Cerv ical Syndrome Head of the Table Modification: (See Figures 10&1 l) Doctor: Head of table. Patient: Prone. Table: Cervical piece in the ready position. Contact: MCP or PIP joint on the LPJ (location of the nodule). Stabilization: Opposite side zygomatic arch or parietal bone. LOC: P-A, L-M perpendicular to the facet joint and in line with disc plane. When performing this alternative adjustment, the doctor must be sure to position himself behind his contact to maintain a biomechanical advantage. This positioning will ensure optimal speed and proper line of correction.

Figure 11 CS. Head of the Table Doctor Positioning.

3. Recheck the legs, and continue analysis for other subluxations.

Sample ase: A 35 year old female presents to the clinic with neck pain. Following a complete examination, Thomp on anal reveals a short right leg. The doctor instruct the patient to turn her head to the right which produce no chang to the leg lengths. The doctor then instructs the patient to turn her head to the left which result in balanced 1 g lengths. Left head turning producing balances legs indicates a Left Cervical Syndrome, but th problem i on the oppo ite ide. The doctor will then palpate along the lamina pedicle junction on the patient' right side. A tend r nodule i pre ent at 5. The doctor is not of small tature and decides to utilize the moclified head of th tabl cerv ical yndrome correction. The doctor will take hi /her contact at the site of the nodule, and thru t P- in line with the di c and perpendicular to the facet. The doctor will then re-che k the leg length and mo e on to th next area of problem.

Dr. John Minardi

19

Copyrlght2006

CERVIC L

ORO.ME - DOUBLE CERVIC L LOCK (D L)

There are o ca ion � here both ide of the cerv ical pine are ubluxated and require adju tment. Thi phenomenon i labelled a Double Cervical Lock, and i confirmed when the patient pre ent � ith a ontracted leg that i balanced with head rotation to both ide . The doctor would then palpate for the nodule at the lamina-pedicle junction bilaterally, and correct a ordingly. The doctor hould alway begin by adjusting the higher egment, followed by th lo\l. r egment. It i al o important for the doctor to remember to re-check the leg following the fir t orrection, a the lower ertebra may only be a secondary compen ation and may not require adju ting. Therefore, if the doctor re-checks the legs and they remain balanced with head rotation following the fir t correction, then the second(lower) segment i not required to be adju ted. However, if the patient's leg continues to pull short following the fir t adju tment and continue to balance with head turning, then the lower segment requires an adju tment a well. The following procedure are required to detect and correct a Double Cervical Lock: 1. Patient pre ent with a contracted leg in extension. Head rotation to the left and to the right balance the leg 2. Palpate along the lamina-pedicle junction from C2-C7, on both the left and right ide for a tender "Pea haped" nodule. 3. Biomechanics of a Double Cervical Lock is identical to the Cervical Syndrome previou ly de cribed. Figure 12 demonstrates how the angle of the disc and of the facets in the cervical pine change from C2-C7. To ensure that the doctor is thrusting perpendicular to the facet and in line with the disc, the doctor's line of correction is cephalad in the higher egment gradually becoming more caudad when adjusting the lower segments. Figure 13 di play how two independent nodules, one on either side, would be present in a DCL. In thi example nodule are pre ent at C3 and C5 (black dots). The doctor would correct the superior egment C3) re-check the legs, and then proceed to adju t the inferior segment (C5) if nece ary. C.:ph.ilatl

A

p

Caudad

Lateral View

A-P View

Figure 12 Linc of Drive For All r.i I yndr me. Thru t Perpendi ular to the Fa , nd

ule Found

Paroll I to th 01

Dr. John Minardi

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rr ti n: Double er v ical Lock: (See Figure 14& l 5) D tor: Head of table. Pati nt: Pron T bl : er v ical pie e in the ready po ition. nta t: .f P on LPJ (I cation of the nodule of Superior egment. t bilizati n: Opp ite ide zyg matic arch or parietal bone. P- , L-M perpendicular to the facet joint and in line with disc plane. L Re- h k leg and repeat for inferior egment if necessary.

Figure 15 Double Cervical Lock. Doctor Po itioning on the lnfenor Vertebra.

4. Re heck the legs and continue analysis for other subluxations.

ample Ca e: A 22 ear old male occer player presents to the clinic with neck stiffness. Following a complete examination, Thompson analysi reveal a hort left leg. The doctor instructs the patient to turn his head to the right which produce a balance to the leg length . The doctor then instructs the patient to turn his head to the left, which al o r suit in balanced leg lengths. Left and right head turning producing balanced legs indicates that the patient ha a Cervical ndrome bilaterally, called a Double Cervical Lock. The doctor will then palpate along the lamina pedicle junction on the patient' left and right sides. A tender nodule is present at C3 on the left and C6 on the right. The doctor will take bis/her initial contact at the site of the superior nodule (C3) and thrust P-A in line with the di c and perpendicular to the facet. The doctor will then repeat this procedure with the inferior nodule (C6). The doctor will then re-check the leg lengths and move on to the next area of problem.

Dr. John Minardi

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R I

L YNDROME - TL UBLUXATIO Toggle Correction

Th ti nd it neurological influence are integral to chiropractic. There are technique within h1r pra tic that focus olely on the atla , due to the important neurological consequences that x1 1- when it become ubluxated. In the Thomp on Tecbnjque, the atlas subluxation is n ompa ed in the Cervical Syndrome family. Howe er, its detection i slightly different then the detection of a C--C Cervical yndrome, and aries completely in i correction. I. The leg analy i i identical when detecting any Cerv ical Syndrome, including the atla : Patient mu t present with a contracted leg in extension. • Have the patient tum his head to the left then to the right. In order for a cervical yndrome to be diagno ed, the patient legs must balance upon head rotation to one or both ide . The cervical yndrome i then labelled a left or right cervical yndrome according to the ide of head rotation. For example, if the patient presents with a contracted right leg, and bead turning to the left balance the patient's legs, then trus would be labelled a left cervical syndrome imply becau e the patient' head is turned to the left. However, the actual problem is lo ated on the opposite ide of head rotation. In our example, the problem would be on the patient right side. 2. Palpate along the lamina- edicle junction from C2-C7, on the affected side right side in our example a o e) for a ten�er�'P�-Shaped" nodule. • 0 no u e 1s resent. • When a cervical s ndrome erists (head rotation balances the leg yet the doctor_§Q!Lot locate a nodule this indicates that the atlas is the subluxated cervical ertebrae. • Remember that the atlas has no lamina- edicle junction for t ate. v Therefore, trus cer ical syndrome is ruled in when no nodules are resent The biomecharuc of an atlas subluxation is completely different than those located from C2-C7. As mentioned pre iously, cervical subluxation from C2-C7 ubluxate po terior \l ·th rotation. The atlas, however, subluxates lateral, superior and slightly posterior folio ing the occipital condyles. The subluxation occurs to the side where the doctor would ha e found a nodule if the ubluxation had occurred in a lower cervical segment. For example, if the patient presented with a hort leg in ex ten ion that balanced with the patient's head turned to the left, the doctor would palpate th right ide for a nodule. When no nodules are found, this implicate atla a the ublu ation. The atla would ubluxate lateral, superior and lightly po terior on the right ide. See Figure 16)

C 1 Subluxation co

Cl C2

upmor and P terior.

Dr. John llinwl

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e recoil adjustment is used. correc(moa the atlas, the toggl en h W : ion ect rr Co 3. ure� 17-19) 4. Positioning: (See Fig . . . . or· Behind patient. Doct . · S1.de pos ture. Ankles together & m hoe with spme. Superior hand str a1.ght Patient: . . . I ong a n stomac h pos1t1o . 4 re Late figu ra . a in . hty hand side of c ·or along s1de, mien 17) ure the atlas up. (See Fig

Figure 17 Patient Positioning for a Toggle Recoil Adjustment.

Table: Cervical headpiece in the ready position. Contact: Pisiform on lateral1�6AO

_______ coa trtZOo'

Figure 31 Friction Lock Correction Part 2. PIP Contact on Affected ide LPJ.

Figure 32 Fricuon Lock Part 2. Doctor Positioning.

6. Continue analysi for other subluxations. Sample Case: A 65 year old male retired hockey player presents to the clinic with chronic neck pain and lack of movement. Following a complete examination, x-rays are taken due to the chronicity of the problem. X-ray analysis reveals severe degeneration and osteoarthritis. Thompson analysis reveals a Right Cervical Syndrome is present at C4. The doctor adjusts the segment using Classic CS corrections for six visits and is not achie ing de irable results. Due to the amount of degeneration present, and the lack of success with the Classic CS correction , the doctor now performs a Friction Lock adjustment. In this case, the patient has a right CS, nodule appearing at the left C4 lamina pedicle junction. The doctor performs part one "pre-stress" on the patient's right lamina pedicle junction of C4 to initiate some motion, followed by part two "correction" on the left lamina pedicle junction of C4. The doctor will then re-check the legs and move on to the next problem.

I have often been asked ifa doctor should still assess the cervical spine ifthe patient's only complaint is low back pain. When using the Thompson analysis, the doctor hould always rule out the presence ofa cervical problem regardless ofthe complaint. Thi may puzzle some doctors, as it is well documented that low back pain can be treated effecti ely with chiropractic treatment ofthe lumbar and pelvic area. 1 •3•5•8• 1 However, many researchers al o indicate that low back pain can be successfully treated by adjusting only the cervical spine. 4· 1 1• 12·13• 14•1 6·1 A ariety of research indicates that chronic low back pain and post surgical low back pain syndrome which have previously been unresponsive to medical treatment, could be successfully treated through chiropractic cervical adjustments. • • According to the literature a complex neurological interaction between proprioceptors, pinal cord distortion and efferent facilitation ha connected a significant link between the cervical and lumbar segments ofthe spine. 10• 11 • 15 Ironically, Kumrnel ( 1996) found that patients with decreased cervical and shoulder motion had an increased incidence oflow back pain. 6 Furthennore, other studies indicate that cervical treatment produced significant changes in the hip and lumbar mu culature 10• 12• 1 3 and other suggest that when a cervical adjustment was delivered incorrectly iatrogenic low back pain would re ult. 7 Additionally Lew and Bri s (1997) indicate that there is a direct neurolo ical relationshi between the cervical s ine and the hamstrin muscle 9 and Brown and Vaillancourt ( 1993) found that an individual with kne in re p,on e favourabl to a cervical adju tment QTOtocol. 2 This briefreview ofliterature simply reinforce the fact that the doctor hould a e the patient th�o;oughly, and correct the affected areas detected and not imply the location of pain. 4 14 17

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CER ICAL SYNDROME - STUCKY STACK (Chronic C2 Subluxation) The Stucky Stack, a de eloped to correct a chronic C2 problem. As discussed previously with the Stucky Friction Lock chronic cer v ical subluxation sometimes do not respond to the clas ic Cervical S ndrome adjustments. The Stucky Stack is a manual adjustment that was created specifically for a chronic C2 ubluxation however it can be performed at any cervical level. Con idering the fact that the ertebra subluxates posterior and rotates spinous process away from the nodule, thi problem will result in a decrease in the natural cervical lordosis. Thus the purpo e of this adjustment, is to re-align the cervical spine by compressing the facet joints back into a closed packed po ition. Furthermore, the line of correction is concentrated anteriorly, restoring the natural cervical lordosis. 1. Leg Analysi i the same in detecting any Cervical Syndrome. • Patient presents with a contracted leg in extension. • Head rotation to one side balances the legs. 2. There are two criteria required to justify the use of the Stucky Stack: 1) Loss of proper cervical curve as seen on x-ray.(See Figure 34). 2) Chronic C2 cervical syndrome. 3. Subluxation Biomechanics. (See Figure 33) The C2 vertebrae subluxates posterior with rotation away from the side of the nodule (thick black arrow), which causes the facet joints to separate (thin black arrow). The line of drive (dashed grey arrow) is focussed P-A to correct the subluxation and restore the cervical lordosis.

C2 Subluxation A C2 C3 Figure 33 C2 ubluxation Biomechanics (black arrows) and Line of orrection (grey arrow).

Current research has demonstrated a statistically significant a ociation between a de reased cervical lordo is and neck pain. The study suggests that a cervical Iordo is of 31 degrees to 40 degree hould be maintained, and hould be a clinical goal for chiropractic tr atment. 19 Patient having a cervical lordosis less than 3l degree had a higher incidence of neck pain. 19 Dr. John Minardi

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4. 1rrecti n: tu t...-y tack Adjustment: (See Figures 35&36) P tient: upine. Table at a 45 degree incline (if working on a hi-lo table). Do tor: Head of table, facing caudad. Contact: Thumb pad on LPJ (nodule of C2. Stabilization: Cradle the patient s head. Ha e them rest their head aero your arm. while imultaneou ly holding their chin. The head will be turned away from the contact. LOC: P-A. 1-S.

Figure 35 C2 Stack Correction. Thumb Pad Contact on the Affected C2 Facet Joint.

Because this adjustment was developed for a chronic C2 subluxation the doctor mu t also rule out the possibility of an overcompensated cervical syndrome (OCCS) di cu ed pre iou ly. If the patient has a chronic C2 subluxation that is not re ponding to the typical Cerv ical Syndrome adjustments: The doctor must assess if the patient has all 5 criteria nece ary to determine if an overcompensated cervical syndrome is present. • If all five criteria for the OCCS exi t then the doctor, ill correct for the OCC If any of the OCCS criteria are mi ing the Stucky tack hould be performed pro ided that it two criteria are pre ent. If the OCCS criteria, a w II a the Stucky tack crit ria are not fulfilled then the do t r will continue to adju t 2 with the cla i ervical yndrome orr ction .

Dr. John Mln•rdl

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L Y DROME-

TERIOR CERVICAL

Th ant ri r c r. ical ublu, ati n i al o c n idered a part of the cervical yndrome category. How \ r. th bi me hanic f thi erv ical yndrome i completely different than any oth r r. i I ubluxati n ·. The d t r h uld only con ider an anterior cervical ubluxation if th p tient ha- b n und r are fi r h rt \! hile, yet continues to pre ent with the ame ce rvical ) ndr m \ r nd ver again. Furthermore, the patient now complains that hi /her ymptom ar b ming w r·e. T a urately detect and correct an anterior cervical ubluxation, th doctor will und rg the foll wmg: l. Leg Len0 th Anal is re eal a contracted leg in extension. Head rotation to one side bala nc th patient' l g . thu , a ervical Syndrome is present. '-· Palpation of th c rvical spine's lamina pedicle junction reveals that a nodule is pre ent. Doctor ha been corr cting the cervical subluxation with classic cervical syndrome adjustment , howe er, the patient now complains that his/her symptoms are becoming worse. 3. The cervical mu culature along the nodular side is visualized to have a flaccid tonicity. 4.When an Anterior Cervical is suspected, there are three criteria that are required to confirm a doctor' su picion. l) Cervical Syndrome nodule is present. 2) Ip ilateral posterior cervical muscular concavity and or flaccidity is pre ent. 3) A-P cervical x-ray reveals spinous deviation toward the side of the nodule. 5. ubluxation Biomechanics: The Anterior Cervical subluxates anterior with spinou rotation toward the nodule ide. This is the exact opposite of the Classic Cervical Syndrome which explain why the patient's symptoms become worse with initial treatment. (See Figure 37-39)

A. Cervical

Classic CS p

p

A

Figure 37 Cervical Syndrome. Subluxates

A

Figure 38 Anterior ervical. ublw ate Anterior with Rotation Toward the odule.

Posterior with Rotation A\.\ay from the odule.

Figure 37 and 3 display the differences occurring between a Clas ic Cervical Syndrome ubluxation and 1111 Anterior ervical subluxation. Note that the clas ic ervical Syndrome sublu ate po terior with light pino rotation away from the nodule (thick grey arrow). The Anterior Cervical ubluxate anterior and ha a gr at r rotational component with pinous deviation toward the nodule (thick black arrow). Al o note that the nodul IXC� at the ame facet location. However, with the classic ervical Syndrome, the uperior ertebrae ublu ; at an� l cau e the facet to tretch through the segment's inferior articular facet (thin black arrow). The Ant rior er,ica ul;)( ubluxat the inferior ertebrae producing the stretch on the facet capsule through the egrnent' uperior aroc facet (thin grey arrow). Dr. John Minardi

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Fioure 39 Loc3110n of).odule (grey x) \\ 1th re·pe t to pinous de,iation (circle ).

Figure 40 uperior and lnfenor rti ular Fa ets.

Figure 39 di play the palpatory difference , a -. ell a the i ual difference found on an A-P cervical -ra b t w en a Cla ·ic Cerv i al Syndrome and an Anterior Cervical. ote that on the Cla ic CS, the pinou de iation i to the ontralateral ide of the nodule, wherea the nterior Cervical ha pinou de iation i to the ip ilateral ide. This \·i ·ual aid i pre ent becau e of the biomechanical difference that occur betw een the Cla ic C and the Anterior C r\'i al. The lateral cervical x-ra in Figure 40 pro ide a better i ualization of the inferior and uperior ani ulation in\'Ol\'ed in the Cer vical Syndrome and the Anterior Cerv ical.

6. The doctor must instruct the patient to slow! raise hi er head (from prone po ition) and lower it. When an Anterior Cervical i present the doctor will notice a premature rela ation of the mu culature on the in olved side. This further confirm the pre ence of thi ubluxation. 7. Correction: Anterior Cervical Adjustment: (See Figures 41 &42) Patient: Prone. Doctor: On the invol ed side head of table. Table: Cervical piece in the ready position dor al piece inclined. Contact: PIP of index finger on the anterior aspect of affected TVP and tip of the thumb on the lateral aspect of the spinous process (on the in ol ed side). Stabilization: Opposite zygomatic arch or parietal bone. LOC: A-P with rotation.

Fi&urt 41 Anterior C erv ical Correction. PfP onta ton the Anterior Aspectof the TVP, and Thumb Contacton Lateral A pect of the pinous Proce

Dr, John Mlntrdl

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In thi adju tinent, the -P thru t with rotational torque corrects for two biomechanical components of the ubluxati n. The thumb contact on the lateral aspect of the spinous pr oce IS riti al with re pe t to th rrection of the rotational aspect of thi subluxation pattern. Wb rea , the inde finger conta t on the anterior a pect of the TVP corrects for the anteriority. The d rsaJ pie

light! in lin d t create additional room for the doctor's contact hand.

It i important to n te that the d ctor cannot change the contact to posterior aspect of the p ite tran er e proce . Th doctor must alway be cogniti e of the biomechanic involved with th ubluxation: • Th oppo ite tran er e proce is not subluxated posterior, it is in its neutral position. It i nl po terior relati e to the subluxated anterior transverse process on the affected ide. • If th oppo ite tran erse process is contacted, the doctor will move the entire complex ant rior and thu cause a greater problem. • Ther fore contacts on the anterior aspect of the TVP and lateral aspect of the spinou pro e of the affected segment are required to properly correct the anterior cervical ubluxation. . Re-check the leg , mo e on to the next subluxation.

ample as : A 21 ear old female dancer presents to the clinic with neck pain following a strenuous rehearsal. Following a ompl te e amination, Thompson analysis reveals a short right leg. The doctor instructs the patient to turn her head to th right, " hich produces no change to the leg lengths. The doctor then instructs the patient to turn her h d to the left, which re ult in balanced leg lengths. Left head turning producing balanced leg indicate a Left Cervical yndrome, but the problem is on the opposite side. The doctor will then palpate along the lamina pedi I junction on the patient's right side. A tender nodule is present at C3. The doctor will take his/her contact at the ite of the nodule and thru t P-A in line with the disc and perpendicular to the facet. 0 er the next few treatments, th do tor continu to find the same cervical subluxation occurring. Also, the patient now complain that h r ymptom are getting wor e with each treatment. Because the doctor is unable to clear the reoccurring cervical ubluxation, combined\ ith the fact that the patient's symptoms are getting worse, the doctor\ ill now con id ra po ible Anterior erv ical. In this ca e, the painful nodule, muscular concavity and spinous deviation were all on the ip ilateral ide. The e three criteria have now confirmed the presence of an Anterior Cervical. The docton1 ill corre t the ubluxation contacting the anterior aspect of the TVP and the lateral aspect of the spinous ofC3, thrusting A-P with rotation. The patient's symptoms will begin to subside, and the legs will balance following the adjustment. The doctor will then re-check the leg lengths and move on to the next area of problem.

Dr. John Minardi

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RVICAL YNDROME - POSTERIOR CERVICAL (Prone Correction) Another unique ituation within the Cervical Syndrome category is the Posterior Cervical -ubluxation. This ub]uxation pattern differs from the classic Cervical Syndrome in that there is no rotational component involved in the subluxation. In the Posterior Cervical, just as its name implies, the entire cervical segment subluxates posteriorly. In order for the doctor to adequately detect and correct the problem, the following steps must be taken: I. A in all Cervical Syndromes the patient presents with a contracted leg in extension. 2. The doctor has the patient tum their head left and right, and detects that head turning to both ide balance the legs. 3. The doctor palpates the C2-C7 lamina pedicle junctions on the patient's left and then palpates the lamina pedicle junctions on the patient's right. Nodules are discovered on the left and right lamina pedicle junctions of the same vertebrae. 4. X-ray analysis confirms a decreased cervical lordosis (military neck), caused by the Posterior Cervical subluxation pattern. (See Figure 43)

f Lordosis

Normal \

,...-, Cephalad

Cephalad

\

p

'I I

I

A

p

A

I I

� ' that take pla c \.\ nhm the peh i . Both erv I al and p I\ 1c area are on,1JereJ pnmal) area� ofpr blem. there re, one d e not take pnonry O\er the other. If the d)Ctor ·hoo ...e'>. he ...he can tart to rule ut pr blem at either th pelv1 or the ef"\, teal pme. HO\\t!\t:r. tt ha been lai,\1call:y taught fi r the d ctor t imply check the cent al area fir t, and orrect an) problem that are pre ent befi re mo ing on to the pelvi . Ifno clear findmg ar pr ...ent m the cen 1cal �pin , then the d tor mu t a e and correct the pel i fir t, th n re­ hecl-.. and Lorre ·t the cen I al pine afterward . The key for the doctor to remember 1 that both the ef\ ILJI ...pme and peh, 1 are primary area , and mu t be a e ed and corrected before m \ mg onto an} ther area in the pine. The egati e Derefield repre ent a ubluxated acrum on...1den:d the key t ne of the pelvi . Sacral ubluxation often lead to further mi alignment throughout the lumbar and thoracic area . The Negati e Derefield i con idered to be the mo t ommon peh ic ublu ation detected in patient , occurring in more than 80 per cent ofca e . In order to ac uratel dete t and correct for a egati e Derefield the following mu t occur: 1. Patient pre ent with a contracted/ hort leg in exten ion, and the ame leg continue to be hon or balan e in flexion. For example: The doct r detect a hort left leg in exten ion. When the leg are brought to 90 degree of flexion. the l ft leg continue to be hort. (See Figure 7 & 8 )

2. Any time that the doctor detect the h rt to hort (or hort t balance phen m na d ribed above, the doctor mu t then confirm that the finding i indeed a D refield gati e. Confirmation occur by the tatic palpation of pecific tender p int a iated with the Derefield egati e. Only one f the following tender point i required t b eli it d for confirmation:

• •

The proximal a pect of the medial tibia - Ip ilateral to the hort leg. The i chial tubero ity - Ip ilateral to the hort leg. The P I - Ip ilateral to the hort leg. The pubic tubercle - Ip ilateral to the hort leg. The thora ic TVP T2-T6 - ontralateral to the hort leg.

!f �n or more tender point \ unphe an

are palpated a tende�, thi c?n�rms the_pr ence fa D-. Thi anterior inferior (Al) acral ba e ublu ation on 1p ilateral tde of ontract d I g.

Dr. John Minardi

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ral

4.

hanjc .Oblique

Post.

Ant.

. .Respiratory

Oblique Figure 89 Anterior and lateral vie, s representing the axises and planes of motion within the sa.crum. The A i e are the Left Oblique, Right Oblique, Respiratory and Transverse (TA). The Planes are the Coronal (CP) and Sagittal Plane (Involved in P-A Motion). HH

The biomechanics of the sacrum are straight forward, however, the doctor must always understand the sacral planes and axises of motion. Also, the doctor must realise the complex interplay between the sacrum, ilium, and the lumbar spine; because as the sacrum subluxates both the ilium and lumbar spine must compensate. As Figure 89 displays, the sacrum moves along four main axis and two planes. 16 • •

The sacrum nutates I counter-nutates along the sagittal plane through the respiratory axis. Also moving within the sagittal plane, the sacrum moves anterior-inferior independently on both left and right sides through its oblique axises. By travelling along these oblique �is�s, tbe sacrum is able to move in its classic "figure-8" pattern during gait. 1 1-1 urthe�ore, the sacrum travels along the coronal nlane, through its trans erse axis, in ,roLu,te order for the sacrum to rotate, much like a steering wheel. doctor to understand that the sacrum does not have a sagittal axis It is im ortant e:,1p.A'1E i�i'O.t •>If• for the �ll,,o� 11. 1•al therefore, it cannot spin like a top, causing one aspect of the sacral base to go anterior, and the other side of the sacral base to go posterior. When the left or right aspect of the sacral base subluxates anterior then this is accomplished through its oblique axis, and therefore, the only compensating component to travel posterior will be the opposite sacral apex. The opposite sacral base is in its neutral position, and is sometimes labelled posterior. However, the doctor should never forget that this posteriority is merely a relati e statement to the opposite sacral base's anterior subluxarion. Furthermore, the relative posteriority of the sacrum should never be corrected, as it is in its neutral position. Any attempt to force it anterior will only subluxate the entire sacrum in a nutated po ition. and cause further problems. The only exceptions to this are with pregnancy and infant .

• • • •

To fully understand the mechanism of how these tender points indicate a Derefield egati\e, individuals must first comprehend that with an AI Sacrum subluxation, the ilium on that ipsilateral side must move in relation to the subluxation. The reason for this is that the ilium mu compensate for the AI sacrum, to allow locomotion to continue. •

ln "normal" pelvic mechanics, assuming that everything is functioning optim ll., wh n the sacral base moves AI, the ipsilateral ilium moves PI (posterior sagittal rotation) to compensate. t':oni�r�ely, when the ilium moves AS (anterior sagittal rotation) then the ip ilateral acral base will be posterior RELATIVE to the ipsilateral PSIS on the ilium.

•

If the sacrum is subluxated AI, the ilium does not move in its normal PI formation.

Dr. John Minardi

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ut nt ri rl refi rr d t a an IN ilium and r tat lightly r und th p teri r a p t f the a rum. Th e abn rmal p I ic t whi h th tender p int originate. plain d in mu h greater d tail .

hat happen at th T furth r under tand the t nd r p in we mu t quick.Jy re 1e J \ I f the mu cle pindle. hen any mu le i tretched the mu le pindl i al o tr tch d. n ed mainly by Type l a afferent fiber whi h th n a nd The tretch in the mu le pindle i rebellum thr ugh th v ntral and dor al pinocerebellar tract . The thalamu then to th reb llum to the en ory cortex. If the information within the integrate infi rmati n fr m th c r helium i difli r nt than the infi rmation held within carte , which i the ca e with a ubluxation) th c rte e ecute a re p n e to the efferent gamma motor neuron . The gamma efTer nt tra el thr ugh the de cending tract which innerv ate the mu cle and cause it to ontract. Thi will re ult in a c ntraction of the po tural mu cle in the lower leg and pel i (through the e tibul pinal tract). Al o, a contraction will result in response to the original lengthening f the mu le and pindle at the sight of the subluxation. With all thi in mind the fi e tender point are in olved as follows: Ip ilat r l medial a pect of the tibia. Thi is the location where the semimembrano us emitendin u and artoriu muscles in ert. Remember that the ilium is in the abnormal flared out (TN ilium) AS position mentioned earlier. Con idering the fact that the e mu cle riginate at the i chial tuberosity and in ert at the medial aspect of the pro imal tibia the abnormal pel ic position lengthen tretches these muscles cau ing them to ntract through the muscle spindle neurology . Hence causing a tender point upon palpation. Ip ilateral i chial tubero ity. This marks the origin of the semimembranosu and emitendino u mu cle . The abnormal pelvic position and the muscle spindle me hani m a mentioned above causes these muscles to be tender at their origin. Hence a tender point i present at this location. Ip ilateral PSIS. Remember that the PSIS is abnormally po itioned by being r tated lightly and wrapped around the acrum po teriorly. Thu provoking pain through palpation in thi area indicate that the PSIS i colliding with the acral ba e. Hence imp ding normal motion and producing a tender point. Ip ilateral pubic tubercle. Again, abnormal pelvic mechanic are to blame. Since the ilium i in the ASfN po ition thi causes the pubic tubercle to be po itioned inferior and lateral from it original po ition. This causes surrounding tructures to be taught, produ ing the tender point upon palpation.

•

ntralateral T2-T6 tran ver e proce se . The contralateral mu culature in thi area c ntra t to compen ate for the original hort leg cau ed by the AI acrum. The hort leg au e th entire body to ift to that ide, thu , the contralateral mu culature in the Tpin mu t contract to bring the body back to a level position with re pect to gravity. The tend r p int i pre ent due to the ten e mu culature.

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EG TIVE DEREFIELD (D-) la ic Thomp on upine Adju tment This adju ttncnt wa th original t\ o-part mo e that lay Th mpson created lo adju t the ant ri r-infcrior acral �ublu ati n. What make thi adju tment unique i that Thomp on nta t d the ilium ancl LI d it t indirect I cl the acrum back t it neutral po ition. h mp on utilized the p \ rful ligament that onnect the acrum and ilium, namely the 'a r tub r LI , '3 r ·pin u and p tcri r intern eL1s ligament . Thomps n rationed that b • au" f the nat mi al placement of the e tructure , the ilium could be used to correct the primar y antcri r inferior ublu ation within the sacrum, a well a correct for the econdary l c mp n'ation that oc ur within the ilium. 5.

rrc ti n : l acrum dju tment - Supine two-part mo e: I t Part: ( ec Figure 90&91) D ctor: n invol ed ide. Patient: Fl x in olved leg so that th foot i flat on the table. Un-in ol ed leg extended. Table: Pel i piece in the ready po ition. ( 440 Table clutch po itioned to drop cephalad). nta t: Thcnar contact on i chial tubero ity of in olved ide. tabilizati n: A I on in ol ed ide. L : 1- with light A-P. Repeat 3 times.

Figure 91 0-: Supine orrection Part I Doctor Po iuonmg.

Thi fir t part \ ill dri e the entire pel ic tructure superior, and will correct for the inferiority of the acrum. 2nd Part: ( ee Figure 92&93) D ct r: On in ol ed ide. Patient: lex un-in ol ed leg o that foot is flat on table. Involved leg i extended. Table: Pel ic piece in the r ady po ition.(440 Table clutch positioned to drop cephalad). ontact: Midp int of inguinal ligament. tabilization: pp ite knee. L : light A-P with hea y medial t rque. Repeat 3 time . Thi� ec nd part will flare the ilium into an X po ition, allowing the P J to extcmall r tote. hi will pr duce the pace nece ary for the a rum to fall po terior at the terminal p int fth dr p piece, c rrecting it anteriority. Furthenn re, the compen ating IN ilium i al o rr cted due to the naturl.! of the torque placed n the inguinal ligament. This t rque will dri "the ilium rnt a correcll e • po ition, o that when the a rum fall into it neutral po iti n, th ilium n longer need t c mpen ate. Dr. John Min rd/

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nth

that m fr mth

rm

tend dt th fle, d lift in mpari nt th un bthlg,th a . . n. m c m an

id

ultu r ,th r "ill l th

ID\

.th n IIthr

h d withth 0th

nt

i

du t th

h ni

Jim rth t i thi.

NEGATIVE DEREFIELD (D-) Classic Thompson Prone Adjustment Thi modification was implemented by Clay Thompson as an alternative for doctors to ke ep the patient prone for the entire two-part adjustment. Similar to the supine correction, the Cl assic Thomp on Prone adju tment utilizes the ilium to adjust the sacrum, and corrects for the anterior inferior ublu ated sacrum using a two-part move. 1. Leg length analy is, subluxation pattern biomechanics and neurology are all the same as explained for the supine adjustment. 2. Correction: AI Sacrum Prone Two-Part move 1st part: (See Figures 94&95) Doctor: On involved side. Patient: Prone. Table: Pelvic piece in the ready position. ( 440 Table clutch positioned to drop cephal ad). Contact: Knife-edge contact on ischial tuberosity of involved side. Stabilization: Anatomical Snuffbox of contact hand. LOC: I-S and slight P-A. Repeat 3 times.

Figure 94 D-: Prone Correction - Part I. Knife-edge Contact on

Figure 95 0-: Prone Correction - Part I Doctor Po itioning.

I chial Tuberosity.

Similar to the supine adjustment explained previously, the first part of the Classic prone adjustment drives the entire pelvic structure superior, and thus corrects for the inferiority of the sacrum. 2nd part: (See Figures 96&97) Doctor: On involved side. Patient: Prone. Table: Pelvic piece in the ready position.( 440 Table clutch positioned to drop cephalad). Contact: Ulnar ridge of forearm on medial PSIS. Stabilization: Anterior thigh of involved side. LOC: M-L, P-A with thrust following contour of pelvis. Repeat 3 times. It i important for the doctor to note that bending the patient's leg while supporting the pa tient' Dr. John Minardi

s

. ht h \\ ill reat le train on the doctor, and be more com fonable for the patient. Toe . 1�' 1 d t of... · p rti ular ad ustm a ent J i th occur in thi 0 eco t nd part as the compensating tinut t ilium · · · · 1 d with th1 move, b owe er. the anteno n of the sacrum ometun es 1 not. The th ory � thi move i when the pelvis hi the tenninal point of the drop. the sacrum will pop in o " ht n the thru t pattern is anterior and the acral sublu However. considering that xation i · Pia · omettme i not thi corre ell cte d . w as r ant n· o rt move i a beneficial altemati e that Thomp on provided for patients who The prone two-pa v . ing freely on the table, such a the elderly. ha,·e d1ffi ult� turn

• tedtal Aspect of P I

3. Recheck the legs, and continue to t he next area of subluxation.

Dr. John llin ardi

66

Copyright 2006

DEREFIELD NEGATIVE (D-) Modified Stucky One Part Prone Adjustment

Dr. Joe tucky implemented a modification to the correction of a Derefield Negati ve in which both the anteriorit and th inferi rity of th acrum subluxation could be corrected in one mo. e Thi v a a c mpli hed by onta ting the acrum directly, rather than the indirectly through th: . ilium. U ing th obliqu axi present within the acrum biornechanics Dr. Stucky co nta ct ed th e pp ite a ral ape of th Anterior Inferior sacral base subluxation. Furthennore, by impl m nting a t rque within the adju tm nt thrust the transverse axis was utilized allowing th a rum to r tat al ng it coronal plane. Combining the two results in correcting for the ant ri r-inferior a rum in one fluid motion. l. Patient pre nt in fl ion.

\l

ith a contracted leg in extension. This leg continues to be short or balances

2. Doctor confirm the presence of a Derefield Negative by static palpation of specific tender point mentioned pre iously. Reminder that only one of the tender points needs to be elicitedia ord r to confirm the pre ence of a Derefield Negative. Presence of a tender point indicates that the primary ubluxation is an anterior-inferior sacral base ipsilateral to the contracted leg. 3. acral Mechanics: The fol lowing diagram displays how the contact (grey circle) is taken on the acral apex opposite to the side of the original Al sacral base. (See Figure 98) • Thi contact utilizes the sacrum's oblique axis to correct for the anteriority. • Addition of a lateral to medial torque at this contact also enables the sacrum to utilize its tran er e axi to rotate along its coronal plane. Correcting for the inferiority.

Oblique

Obliqu Figure 98 D-: Modified One Part Adju tment. ontacting the acral Apex on the Oppo ite ide of the Al acrum.

4. Correction: Modified Stucky One Part Adjustment (See Figures 99&100) Patient: Prone. Cross the short leg over the opposite leg to gap the involvedjoinL Doctor: Opposite side of the lesion. Table: Pelvic piece in the ready position. 440 Table clutch positioned straight). Contact: Fle hy hypothenar on opposite sacral apex. Stabilization: PSIS of short leg side. LOC: P-A with torque towards in olved ide. Repeat 3 times. It is important for the doctor to note that cro ing the affected leg over the unaffected leg produc a gapping in the in ol ed SI joint pro iding the room nece ary to ork within the Dr. John Minard

67

Co,,/---

J()tnl.

Th

•

d_1u�tm nt rr t or both dire tions of the ubluxation simultaneou ly. Th P-A thru t and drop piece component on th opposite acral ape , utilize the bliqu axi of the acrum and thu corre t for th anteriority of th ublu ation. The torque that i implem nted rotate the acrum along it tran erse axi within the oronal plane. corr ting for the inferiority.

A mentioned pre iou ly the D- ubluxation ha a direct influence on the tate of the ham tring mu le . Th r fore, correction of the D- re ult in an equalization of the ham tring . Re earch into the neurological effect of adju ting the acroiliac joint ha found neural re pon e that ma b re pon ible for the reduction of mu cle tension following an adju tment. 1- Chibulka et al. 3 on entrated pecifically on the re pon e of trained ham tring mu cle to mobilization of the a roiliac j int and di co ered increa ed peak torque in the treatment group in compari on to the ontrol, ugge ting an a ociation between ham tring mu cle train and acroiliac d function. ther re arch al o found ignificantly increased traight leg rai e SLR te t p t lumbo acral joint adju ting. 1.-i Re earch ha hown that the neurological effect of the adju tment produces a r du ti n in motor neuron acti ity, re ulting in a change in ham tring tle ibility fi ll wing a roilia adju tment. 5 Further tudie ha e concluded that hypomobility and it adju tment are a iated with modulation of pinal information. They state that thi cau e a reduction in the en itive and re ulting in the lengthening of itabilit of the mu cle pindle rendering it le th intra-fu al mu cle fibre cau ing a reduction in the T-r fle . They also hypothe i ed that the d r a d pindle en iti ity po t acroiliac joint adju tment may explain the reduction in mu cle tightn after and adju tment. 2•6• 7 Other research conclude that the adju tment pro ide quick tra tion and e citation of the Golgi tendon organs located in the muscle tendon junction that may r la mu le , known a autogenic inhibition. Finally Herzog 9) believed that the adju tment timulate th low and high thre hold mechanoreceptor and nociceptor to generate a bur t of matic afferent re eptor activity, thu producing a relaxation of the soft tis ue. Thi brief re iew f literature r in for e the fact that an adju tment ha a direct effect on the nerv ou y tern, whi h au e a rela ation in the ham tring mu cle a een in the detection and correction of th D-.

Copyright 2001

EG Tl E DEREFIELD (0-)

Modified

I acral Pu h

djustment

Th M difi d Al a ral Pu h adju tment \ a er ated as an altemati e to adju ting the AI acrum fi r th do tors r patient \ h prefer a id p ter t up but al o wi h to incorporate th u of th drop piece . i , bi m chani

and ubluxati n pattern ar the rune a di cussed

2. Patient pre ent \ ith a D- ( hort to hort or hort to balanced leg length analysis) confinned \ ith at l a t n p iti e tend r point. rr ction: Modifi d AI acral Pu h Adjustment: (See Figures 101-103) Pati nt: ide po ture with the in ol ed side down, split leg position. D tor: ide of Table. Table: Pel ic piece in the ready position. (440 Table clutch positioned to drop traight). onta t: Pi iform on acral apex (approximately S4). tabilizati n: Elbow or houlder of patient. LO : P-A, L-M. ( W torque with left side up CW torque with right ide up). Repeat 3 time . The following diagram di play the po itioning of the sacrum in the side posture position. ate how the le ion ide i down, and that the doctor's contact (grey circle) is on the oppo ite acral ap to utilize the oblique axis.

Oblique

···.Oblique Ill Figure 101 D-: Split Leg Adjustment ontact.

In order for the adju tment to be executed effecti ely:

• • •

The doctor must bring the sacrum to tension, followed by the thru t given with a bod drop and a pu h. A alway patient placement will make a sub tantial difference in the e ecuti n of the adju tment. By u ing the plit leg position, the weight of the patient' leg will rem e mo t of the lack within the pet i and will a i t the do tor tremendou ly. The plit leg po ture al o as i t in gapping the SI joint pace, providing a more efficient and e fective adjustment.

Dr. John Minardi

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figur 102 [). \;Kral Pu�h Correction. Le i n Con ct on Oppo II a ral pe"\.

Th P-A thru ·t and drop piece correct for the anteriority of the sacrum and the L-M torque orr t for the inferiority. The adju tment can be done manually without the use of drop pieces. Howe er the doctor must alway remember that the adju tment mu t be done exactly a de cribed above. At no time hould the doctor ever ub titute the oppo ite acral apex contact for an oppo ite acral ba e contact. A mentioned pre iou ly the acrum ha no agittal axi . Thu a acral ba e contact will re ult in the doctor forcing the entire acrum into nutation creating a whole new problem.

r pr ent to the clini with I w back pain. h

that the pain i

EGA TIVE DEREFIELD (D-) Modified Stucky Bilateral Roll (Coup de Gras) Adjustment

The Bilateral Roll adjustment i designed as a side posture two part move to correct for chronic Derefield egati e subluxations that are not responding to traditional or modified Thomp on adjustments. When a doctor experiences cases in which chronic D- subluxations are not correcting properly a unique phenomena may be occurring between the sacrum and lumbar pine. In such cases the ubluxated AI sacrum, further complicates itself by rotating along its coronal plane, no longer forming a perpendicular angle with the lumbar spine. Due to the chronicity of the problem as well as the patient's lack of improvement the doctor must take x­ ray . Radiological analysis will verify that the sacral base is no longer at a perpendicular angle , ith the lumbar pine. The doctor must now convert to the Bilateral Roll Adjustment in order to correct for the original AI sacrum and the additional rotational malposition of the sacrum. Resulting in the restoration of the perpendicular angle. l. Leg length analysis and subluxation pattern are the same as discussed previously for the D-. 2. D- is chronic, and has not been improving with previously discussed corrections. 3. The doctor takes X-rays of the area, and finds the following on the films: (See Figures 104 &105)

Normal

D- :BR

Figure 104 D- Bilateral Roll: distortion of the normal perpendicular angle present between the sacrum and lumbar spine.

Figure 105 a rum is not Perpendicular to the Lumbar pine.

The diagram and x-ray displays how the sacrum has rotated so that it no longer forms a perpendicular angle \\ith th lumbar spine. Because of this rotation, two angles are formed; an acute angle, and an obtuse angle. The a ut anc l will always be on the ipsilateral side of the short leg, and therefore is the side of the AI sacrum. The obtu e angl i the wider angle produced by the rotational component of the sacral subluxation.

4. Correction: Modified Stucky Bilateral Roll (Coup de Gras).

Part I A

l st Part: (See Figures I 06, l 08 & 110) Patient: Side posture with the short leg down (obh.1se angle up) acute angle down. Doctor: Side of table. Table: Lumbar and Pelvic pieces in the ready position. ontact: Fie hy pisiform on sacral apex. LOC: P-A light I-S. Repeat 3 times.

Dr. John Minardi

71

figur 106 Part I· (l)ITCI:

Ant ri nt).

dJu� tm m rr 'rum. It al o en

th Al acrum on the oppo ite ide by utihzine the to reduce the obtuse angle lightly through th; uperior

Part _

_nd Part: ( ee Figure IO , I 09 &111 Patient: Lie on oppo ite ide acute angle up . Doctor: ide of patient. Table: Lumbar and Pelvic piece in the read po ition. Coma t: Pi iform on acral apex. LOC: L-\1. with torque. Repeat 3 time

Fi ure 10 Pan 2: Restonng th Perpend, ular Angle.

Toe e ond part of the adju tment correct for the remaining di tortion of the obtu e angle, and r tore the acrum' perpendicular angle with the lumbar spine.

figure IO 81lat ral Roll Correction Part I. Acute Angle D01m. Pi 1form Contact on Oppo ite acral Apex.

Or. John

Minardi

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PO ITIVE DEREFIELD (D+) Lower Boot ublu ation

The D refield P iti (D+) i the final pet i c mp n nt a ciated with the primary areas of ti n fo u ed entirely with the 0-, and it implicati n on acral ublu 'ati n. The pr i u ubluxati n pattern impact the ilium. It ti n will fi u n th D+, wh ubluxati n . Thi i imp rtant fi r th d t r t n te that wh n the pel i i ubluxated, th D+ pr blem occur nl 2 p r nt f th tim in mpari n t th D- which c ur O perc nt of the time . Ith ugh b th th - and D+ ublu ati n cur within th pet i their ign , ymptom and anal i are quite diffi r nt. In rd r fi r the d t r t accurately d tect and correct for a D+, the fi 11 v ing mu t ur: I . Patient pr ent v ith a ntra t d I g xten ion. In fl xion, however, the contracted leg b m 1 ng r. ( Figur 1 12&113) hi i a mpl te cro o er in length, and not a r lative change in leg length a may be e n in ther technique . For example if the right leg i short by one inch in exten ion h we er, in flexi n i only ho11 one-half of an inch, thi would represent a relative lengthening. Thi i OT considered a D+, a Thompson always compare the right ide t th left. • Th refi r an example of a D+ in Thompson is that a patient present with a hort left leg in exten i n f Yi inch in comparison to the right side. In flexion, the left leg completely er and b c mes longer by one inch in comparison to the right side.

Figure 112 Patient Pre eats with a hort Left Leg in Extension.

2. The short to long leg length analysis implies a D+, which indicates that the ilium ha ubluxated po terior-inferior (PI) on the involved side. 3. ince the sacro-iliac (SI) joint is comprised of two separate joint spac the doctor mu t erify whether the superior joint or inferior joint is affected. Considering that the I joint i "L" haped, or "Boot" shaped (See Figure 114), Thompson referred to this tep as verifying b tw en an upper or lower boot subluxation. It is ess ntial to differentiate b tween the upp r and lov r boot ubluxation , a each area will exhibit a unique subluxation pattern. A a result, the mo ement f the ilium will vary con iderably, a will the adju tment that must b u d. 4. P l ic Mechanic and Difference Between Upper and Low r B ot Subluxation. Dr. John Minardi

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Figur J 14 .. Boot- haped.. Aniculation ofth

I Joint.

Toe bO\ e diagram di pla the unique 'Boot- Shaped" SI joint. The upper boot is composed hi ly of fibro-cartilage and ha a poor neurological supply. The ilium will only subluxate ;thin th upper boot 20% of the time, and is called a False D+. Con\· rsely. the lower boot i a yno ial joint and has a strong neurological supply. The ilium ;u ubluxate within the lower boot 80% of the time, and is called a True D+. \ 'hen the ubluxation occur in the lower boot the ilium rotates along that lower axi re ulting in the P IS ubluxating PI. Altemati ely if the ilium rotates along the upper boot the bluxation i till labelled a PI ilium, because it does go slightly PI. Howe er because the ilium · rotating along the upper axis it predominately forces the pubic tubercle anterior which i the primary ublu ation. . To verify whether the PI ilium i a lower or upper boot subluxation the doctor mu t perform an Ann Fo a Te t, which Clay Thompson incorporated from the Sacra-Occipital Technique ( OT). Patient i upine. Doctor is tanding on the affected ide. In tru t the patient to extend their arm to 90 degrees, palm facing caudad. The doctor applie caudad pressure to the patient' arm, to which the patient re i t m order to maintain hi /her arm at 90 degree . A the doctor applie the caudad pre ure the doctor will palpate the inguinal ligament from lateral to medial, tarting from the ASIS to the Pubic Tubercl . A the doctor i palpating the ligament, there will be a pecific point in which the patient will experience a "blow out" or extreme weakne . Once thi "blow out" occur the patient wi 11 be unabl to keep their arm at 90 degree . If the '·blow out' occur anywhere from the ASIS to th midway point of the ligament it indi ate a lower boot ubluxation. If the ' blow out occur from the mid ay point to the pubic tubercle, then it i an upper boot ubluxation. See Figure l l 5& 116) If the pati nt did not ha e a D+ then no blow out would occur and the patient ould be ab! to tain equal re i tance throughout the entire palpation of the inguinal ligam nt. Although man y indi idual ha e que tioned the r liability of the arm fo a te t r earch ha con i tently found thi te t to be a alid method for a e ing acroiliac j int dy fun ti n. 11• arm fo a t t h pro d to b an e tr m ly aluable Thomp on t ol, and i n of th fi alid t that pr p rly e the upper and lower acroiliac joint . 1

Dr. John Minardi

74

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t,.

rr c11on: D

o-Cen i al Thumb Pull Adju tment: See Figure 154_ 156

n . Pat1ent: P ro of the table. . O ror: H ad . en·1cal piece and LD the ready po ition. al o Table: D high tran ad o p erse proces . � Canta t: Th umb _ panetal bone ne or ppo zygo matic arch. tabilize: O LOC: P-A.

Rotation

The diagram in Figure 154 represents a rotated thoracic segment from Tl-T4 (black arrow). The figure displays the contact for the dorsal-cervical thumb pull. Note how the thumb pad contact is on the contralateral TVP of the rotated segment. (dashed grey arrow).

Figure 154 Dorsal Cervical Thumb Pull ContaCL

The unilateral contact, and the P-A line of drive corrects for the rotational subluxation. The doctor must take a large tissue pull from three or four segments below the desired segment to reduce the probability of slipping off of the contact. When perfonned correctly this a very comfortable adjustment for upper thoracic area.

Finr, I SS Dorsal CMcal Thumb Pull Correction. Thumb Pad Coiiract 00 High Transverse Proc

Figure I 56 DorsaJ-Cervical Thumb Pull Doctor P

102

THORACIC PINE (TS) Dor o-Cenical Thumb Push The Dorsal-Cervical Thumb Pu h \ a created to correct for rotational subluxations occurring within the thoracic pine, primarily from T 1-T4 as a modification to the dorsal-cervical thumb pull adju tment de crib d pre iou l . For rotational subluxations occurring from T5-Tl2 it is recommended that the doctor utilize the Modified Cross Bilateral Thoracic adjustment de cribed later in thi ection. A mentioned pre iously, all primary and secondary areas of ubluxation mu t be corre ted prior to the thoracic area. To accurately detect and correct for this thoracic ubluxation the following must occur: 1. Leg length analy is demonstrates that a short leg persists following correction of primary and econdary areas of subluxation. 2. Doctor continues to the thoracic spine for palpatory analysis. 3. Static and motion palpation reveals a spinous deviation of the upper thoracic segments. 4. The doctor must confirm the presence of a rotational subluxation and rule out a Lateral Listhesi ubluxation. (See Figures 157 & 158) • • •

Rotational subluxation: the doctor will palpate muscle tension bilateral to the deviated spinous process Also, no muscle bulking will be present. Reminder: Lateral Listhesis only has muscle tension opposite to the side of spinous deviation, in addition to non painful muscle bulking ipsilateral to the deviation. In x-ray analysis, a rotational subluxation demonstrates a break only in the spinous line, whereas, a Lateral Listhesis disrupts the spinous line as well as the ertebral body lines in the A-P view. Rotated S gm nt T 1-T4

Normal

I

I I

I

I I

I I I

Figure 157 TS ormal Finding .

I I

I

I I

Figure 158 TS Rotational ublwcation Findings.

Figures 157 and 158 display the clinical and x-ray findings as ociated with a rotational ubluxation. ote the tens muscles bilateral to the deviation (solid grey line ), and the ab ence of mu cle bulking. Al o not how only th spinous line is disrupted on x-ray analysis (deviation of central dashed line).

5. The doctor must alway be mindful that if Tl is the ertebrae involved, an Over Compen ated Cerv ical Syndrome (OCCS) must al o be ruled out. (Explained in detail in the cervical ection). Dr. John Minardi

103

humb Pu h Adju tment: ee Figure 159-161 ti ,11 l)l,r l -( t.:J"\ 1 PJtl nt Prone. ·wr He d f the tab I . T ble. Dor I and el"\ i al piece in the ready po it ion. ont t: Th umb pad on lateral a pect of the rotated pinou proce . tabilize: ppo ite parietal bone or zygomatic arch. L : Lateral with light P- from the tabilization hand to initiate the drop piece.

The diagram in Figure 159 represents a rotated thoracic egment from T 1-T 4 (black arrow). The figure displays the contact for the dor al-cervical thumb pu h. Note the thumb pad contact is on the ip ilateral a pect of the rotated segment's spinous process. (da hed grey arrow).

Rotation

Figur 1-9 Dorsal Cen I al Thumb Pull Canta t.

The unilateral contact and the P-A line of dri e corrects for the rotational subluxation. The do tor mu t note that lateral flexion and rotation of the cervical spine is required to lock out the affected joint in the upper thoracic spine. Ju t a in the thumb pull adjustment the lateral flexion and rotation i toward the contact ide. Howe er with the thumb pu h adjustment the doctor will be thru ting lateral with the drop wherea the thumb pull will be P-A with the drop.

ample Cas e: A 30 year old female ecretary pre ent to the clinic with back pain and o ca ional beada he . She mentions that ining in front of the computer for long periods of time aggra ate the problem. Following a complete examination, Thomp on Analy i re\ a hon left I g in e ten ion and a hort left leg in flexion. Tb doctor will a e if a Cervical Syndrom i pre ent and correct it if nece sary. The hon to hort leg length analy i points to a D- so the doctor cbe k if pecilic t nder poinrs are pr nt. In thi c , no tender point are pre ent. Therefore, th sacrum i not ubluxat d and the doctor mu t now mo e to the lumbar pine. Th patient' L5 has ubluxated po terior with pinou rotation to� ard the hort leg id pinou left . Th doctor correc thi econd.ary area and finds that the patient' left leg continue 10 pull hon during leg length anal i . The doctor now se e the thoracic pine and palpate a lateral spinou proce de iation at T2. lini al and -ray criteria rule out the pr nc of a lat ral Ii the i , indicating that a rotational problem i pres nt. The doctor then onta tS th lat ral a pe t ofth T2 spinous pr e and perform a dorsal-cervical thumb push to orre t for the rotated egm nt. The do tor re heck I lengths nd move on.

Or. John lin1ral

104

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THO

Pl

1

rr t or rotation I lower than T4. For do tor utilize ither th m ntion d arli r, 11 pine. To

Bilat ral Th

Th

ur:

that a h rt I g per i t folio\! ing orre tion of primary and

d m ntinu

t th thora 1c pm for palpatory anal

and moti n palpation re\' al a pmou d pm .

iation within th T -T 12

gm nt of th

4. The d tor mu t onfinn the pre ence of a rotational ubluxation and ru1 out a Lat ral Li th ubluxation. ee Figure 162 & 163 • •

Rotational ubluxation: the doctor will palpate mu cle ten ion bilateral to th de iat d pinous pro Al o no muscle bulking will be pre nt. Remind r: Lateral Li the i only ha mu cle ten ion oppo ite to th id of pinou de iation, in addition to non painful mu cle bulking ip ilat ral to th d \ iation. In -ray analy i , a rotational ubluxation demon trat a br ak onl in th pinou lin . wherea , a Lateral Li the i di rupt th pinou lin a 11 a th rtebral body !in in the A-P i w.

R tat d

ormal I I

I

., ,,,:,,, �,

I

I I

, I I

I

Figure 162 T

bm nt TS-TL

I I

I I I I I I igur 163 T R 1at1 nal ublu at11Jn FinJmgs

ormal Finding .

I l 62 and l 3 di play the linical and -ray finding a iated with a r tati nal ublu: atio n. ' t th th mu le bilat ral to the d iation ( olid grey lin ) , and th ab en f mu l bulking. I n t ho " only pinou !in i di rupted on -ray analy i (d iation f entral d h d lin .

Dr. John Minardi

105

. dju tm nt:( eeFigure 164 16: thlf' \ 1 J, ti ,J rn . BilJt r I Thor n P.tt nt Pr,l ' bl . ntr I teral to pin u de\·i tion. r t ,r . ,J, f th T hi, D ,r. I p1 � m th re dy po iuon. tlOl �t Pi. 1fonn n p uenf T\·p of ublux ted \ rtebra. t b1h · Contr I ter I T\"P of the egment ab , e the affe t d vertebr . LOt P-

Rotation

Figure 164 repre ent a rotated thoracic egment from T5-T 1 � (black arrow). The diagram di play the contact for the modified cro bilateral thoracic adju tment. ote the pi ifi nn contact i on the contralateral TVP of the deviated pmou proce . ( da hed grey arrow).

figur l(H T · \lod1fied Cr � Bilat'ral nl,1"1.

The unilateral ontact. and the P-A line of dri e correct for the rotational ubluxation. Thi adju tment an be perforn1ed manually if the doctor prefer . However the modified de ign of the adju tment allow for the drop of the table to correct the ublu.xation. making it le forceful and more comfortable for the patient.

Or. John Minardi

10G

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Leg Length Analysis in the Fie ed Position

Tender Points Eh cited

Original Short Leg Remains Short or Balanced

Tender Points Not Elicited

Correct For 0-

Recheck Legs Produce Balance Recheck legs: Leg Sllll Pul s Short

lumbar Sub luxation

Check And Correct Hyperactive Psoas If Criteria Present Bnnging Legs To The Flexed Position

Original Short Leg Becomes Longer

Perform Arm Fossa Test

Blow Out Occurs: ASIS to Midline = Lower Boot Midline to Pubic Tub = Upper Boot

Recheck Legs: Leg Still Pulls Short

Assess and Correct Lumbars ·ne

Recheck Legs Produce Balance Correct For D+

Check Clean Up o es And Finished

Assess and Correa Thoraoc Spuie

Check Clean Up And Fll1IShed Recheck Legs· Produce Balance

Dr. John Minardi

107

Chee Clean Up Moves And Finished

E Tio.· E\'E.·:

LE

P JO\I

Cl an Cp Adju tment Rotated acrum Cla ic Thompson Prone Adjustment Posterior Rocked Ischium Cla ic Thomp on Prone Adjustment Posterior Sacral Apex .\fodtfied Prone Adjustment Anterior Coccyx .\!odified Prone Adjustment I� Ilium Cla sic Thompson Supine Adjustment Vodified Prone Adjustment EX Ilium Classic Thompson Supine Adjustment Modified Prone Adjustment Elevated Rib Cage Classic Thompson Supine Adju tment Rotated Rib Modified Supine Adjustment

Or. John Minardi

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ROT TED

R

wi 11 d t I. T b •

he k d and

rr t d after all categorie ha e been cl ared .

. The d t r will p rfom1 a Rotated Sa rum L g E ten ion Test: Pati nt pr ne. Do tor tabilize th patient s acral base with the palm of hi r hand. D tor in truct the patient to keep leg straight and lift extend each leg off of the table, one at a time. onnal = both leg hould raise off of the table equally and will exhibit none of the follo\J ing in #3:

3. The doctor analy is of the patient s leg raise will denote a problem on the in ol ed ide if one or more of the following are present: One leg will not rai e off of the table as high a the other. One leg will way off to one side before going back to centre. One leg will xhibit cog-wheeling in which the in ol ed leg will rai e lightly top rai e slightly more then stop again etc... One leg will ha e pain and clicking as ociated with the leg exten ion. If the patient doe not exhibit an of the abo e, then the patient is normal and do not h a e a rotated acrum. Therefore thi adjustment is not required. Howe er if one or more of the symptoms are present a rotated sacrum ublu ation i confinned and mu t be corrected. Thi mi alignment indicates that the sacral ba e ha rotat d in it coronal plane toward the affected side subluxating the sacro-iUac joint cau ing the aforementioned ymptom . (See Figures 166 & 167)

Lat ral

nt rior Vi w

Post.

Figure 166 Rotated acrum Anterior

Figures 166 and 167 di play how the r tat d Lateral i w-black Im , using i tran er

Dr. John Minardi

\V

Ant.

Figure 167 R rated a rum L t rat

ie .

i ,,.

I ng th rum' r nal plan (Ant rior Vi w-black arro\\ • -gre ir I , Lat ral i -grey da h d lin .

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R tat d a rum Adjustment:

eeFigure 16 &169) Patt nt: Prone'"' ith the in\olv d ide leg cro ing the oppo ite leg. D tor: Either id of tab I . Tabl : P )\ i pie e in the ready po ition. Conta t 1- Knifi - dg cont.a t on apex of sacrum on unin olved side. Conta t _: Knife-edge contact lateral to S2 tubercle on involved side. LO : P-A with rotation in oppo ite direction of subluxation. Repeat 3 time .

Cro ing the patient' affected leg over the unaffected ide create space within the involved a ro-iliac joint. Thi pro ide the doctor with the room nece ary to perform the adju tment. Due to the awkward orientation of the acrum between the ilia See Figure l O the do tor must initiall pu h P-A on the acrum in order for rotation to occur. Similar to opening a pill bottle with a child-proof top· one mu t fir t pu h down then rotate. The drop piece me bani m a i t with the P-A movement and the thru t rotate the acrum back into it neutral p i6on. After the adju tment i completed, the doctor mu t re-perform th acral leg ten ion te t. If th adju tment i done correctly both leg will be equal and pain fr e. If the ymptoms till persi t re-perform the adju tment with two more thru t and re he k again.

Thi figure demon trat th a k\ ard orientation of the sacrum with re pect to the ilium. Thi al o reinforce why it i necessary to thru t P-A befor r tating the acrum can be accomplished.

Dr. John Minardi

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PO TERJOR ROCKED I CHIUM (PRI) Clean-up Move 1. To be performed after all categorie have been cleared. 2. Short leg per i ts after the primary secondary and tertiary areas have been corrected. 3. Palpate along the calf of the short leg. A PRI is confirmed by an extremely tender point located within the gastrocnemius and soleus muscles on the involved side. (See Figure 171 4. Static palpation of an ip ilateral fixated ischial tuberosity assists in confirming that the i chi um has ubluxated posteriorly ( extension).

PRI

Figure 171 demonstrates the biomechanics of the PRI. A the ischium subluxates posteriorly, it causes the ilium to rock into extension (white arrow). Extension of the ilium produces a stretch and subsequent neurological contraction of the hamstrings (grey line). The ham tring originate at the ischial tuberosity and insert into the proximal aspect of the tibia and the fibular head. A the e muscles cross the knee joint line the fascia} attachment that exist within the hamstring muscle ga trocnemius soleus and inter-osseous membrane produce ten ion within the gastrocnemius and soleu mu cle cau ing the tender point (black dot).

Figure 171 PR! Biomechanics lnvol ed in Causing the Tender Point Located within the Soleus Muscle.

5. Correction. Prone PRI Adjustment: (See Figure 172-174) Patient: Prone. Doctor: On involved side. Table: Pelvic piece in ready position. Contact: Hypothenar contact on involved i chial tubero ity. Stabilization: Anatomical snuffbox of contact hand or oppo ite ide PSIS. LOC: P-A and slight S-1. Repeat 3 time .

Po terior

Ant nor Figur 172 PRI orrecti n. H Tubero ity. Dr. John Minardi

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Pri

tment. the doctor must rule out thrombophlebiti in high ri k individuals. r to t:h AdJu

Figure 174 PR! Correcuon 2 Doctor Posnion.. ·01 Contact on lschial Tuberosity \\bile Stabilizing the Conta Hand

Following the adju tment, the doctor will note that the oleus tender point should decrea e immediately. • The pain will not be completely gone, but substantially decreased. The doctor ma also find that tension/tenderness also exi ts \) ithin the patient ham tring musculature, in addition to the calf tendeme . It i important for the doctor to remember that the gastrocnemius/soleus tender point is what Clay Thompson originally found with thi problem, howe er, hamstring tenderness may also be pre ent. The hamstring tension helps to explain why thi subluxation is commonly a ociated \vith a 0- . In many instances, the doctor will correct for a D- initial! , then continue on to detect and correct for a PRJ, as both subluxation patterns in ol e aberrant ten ion within the leg flexors. As a clinical note, the doctor should be aware that the PRI i commonly a ociated \vith runners who perform a tremendous amount of training on hilled terrain.

Sample Case: A 30 year old male marathon runner pre ent to the clinic ith back pain and tiffne within the legs. He mentions that he has been training in ten ely for an upcoming race, and has been doing much of hi training in the mountain . Following a complete examination, Thompson Analysi re eals a short left leg in extension and a short left leg in flexion. The doctor will a ses if a Cervical Syndrome i pre ent and correct it if nece ary. The short to bort leg length analysi points to a D-, so the doctor checks if specifi tender point are pre nt. In thi case a tender point wa present at the PSIS, confirming the D-. The doctor correct the acrum ublu ation, howe er, the hort leg persists. The doctor mu t now mo e to the lumbar pine. The patient' L5 ha ublu: ated posterior with spinou rotation to the short leg ide ( pinou left). The doctor corrects thi e ondary area, and finds that the patient continues to pull hort during leg length analy i . The do tor no a e e the th ra ic pine 3:"d palpate a lateral pinou proce de iation at T2. Clinical and -ra criteria rule out the pre ence of a lateral It� i , indicating that a rotational problem is present. The doctor then contact the lateral a p ct of the T2 5Ptnous proce and performs a doral-cervical thumb pu h to correct for the rotated egment. The leg ontinue to pull hon, now the doctor move on to clean up mo es. Gi en the patient' hi tory a a runner, the d tor Palpate the gastrocnemiu and oleus of the affected side, , hich cau e the patient to jolt in pain. Thi confirms the pre nee of a PRl, thu , the doctor contacts the left i chial tuberosit and thru t P-A. The doctor will che k if any other clean up mo e are required. The patient i fini hed treatment for that day.

Or. John Mlnirdl

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PO TERIOR . Clean-

RAL APE

1. T b h ked fi r and orr t d nly after all primary, econdary and t rtiary categorie have b n l ared. -· The d tor will b er ve through Clinical nalysi that the patient exhibit the following igns: • • •

Prone leg exten ion rai e ( ame a rotated sacrum leg raise te t) analy i hov limi tat ion on both side . Therefore, the patient's leg only extend off of the table a few inche bilaterall . The patient ha hyperlordosis of the lumbar spine. The doctor will notice that the patient exhibits toeing out of the feet which i often a ociated with a bilateral IN Ilium (explained in detail in a later section).

If the patient displays these signs, these clinically confirm the presence of a Po terior Sacral Apex. Thi indicate that the sacrum has nutated along its respiratory axis, resulting in the acral apex to subluxate posterior. (See Figures 175&176)

t

p I

A Figure 175 Posterior Sacral Apex.

LS

Figure 176 Posterior Sacral

Sacrum

t

pe, .

The above figures display the Posterior Sacral Apex sublu ation. ln Figure 176 note ho the sacrum has nutat cl, forcing the sacral apex posterior (solid arrow). Correction is via a P-A thru t through the a ral ape dashed arrow). Figure l 5 demonstrates how a posterior sacral apex appears on x-ray, which will re ult in a hyperlordosi of the lumbar pine.

3. Correction: Prone Sacral Apex Adjustment: (See Figures 177&178) Patient: Prone. Doctor: Either side of table. Table: Pelvic piece in the ready position. Contact: Palmar contact on S4 sacral tubercle, in the midline. Stabilization: Bilateral tibia with patient's legs bent past 90 degrees. LOC: P-A and slight S-I. Repeat 3 times. Flexing the legs past 90 degrees assists in remo ing the remainder of ten ion within the p lvi , thereby promoting an optimal adjustment. The P-A thrust combined with the drop piece mechanism sends the sacrum into counter-nutation, allowing the sacrum to return into it neutral position. Dr. John Minardi

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Following the adju rment, the doctor must re-visit the clinical signs formally displayed b the patient, and en ure that they have been corrected with the treatment. If the doctor prefers to perform this correction by way of a side po ture manual adju trnent. the biomechanic are till correct, provided that the doctor contact the sacral apex and not the acral ba e.

Sample Case: A SO year old male con truction worker pre ents to the clinic with chronic Jo-. ba k pain, and lately has been having difficulty standing from a seated po ition. Due to the chronic nature of th problem. the d tor de id to take x-rays of the lumbar spine, which reveal the pre ence of a hyperlordo i . Following a ompl t e amination. Thompson Analysis reveals a short right leg in exten ion and a hort right I g in flexion. Th d tor al o notices that the patient's feet toe out bilaterally. The doctor will as e if a ervical yndrome i pre nt and correct it if necessary. The short to short leg length analy is points to a D-, o the do tor he k if pe ifi tend r point are present. In this case, no tender point are pre ent. Therefore, the acrum i not ublu; ated and the doctor mu t now move to the lumbar spine. The patient's LS ha ubluxated po t rior \ ith pinou rotation to the hort leg side( pinous right). Thi correction produce balanced leg , th refore there i no need to ontinu into th thoracic pine. The doctor now move on to check for lean up mo e . The d ctor p rforrns the prone leg rai test and find that both of the patient' leg rai e only a fe,; inc he off the table. Thi ombin d \ ith the bilateral toeing out and hyperlordo i that the patient pre ent with confirms the pre enc of a po terior a ral apex. The doctor contacts the sacral apex while imultaneou ly bending the patient leg pa t O d gr e to remo any pelvic tension. The doctor then thru t P-A to c rrect the p terior acral apex. Th do tor che k if an oth r clean up moves are required. The patient i fini hed treatment for that day.

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TERIORCO lean-up love

I. To b h ked fi r and b n 1 ared.

rre t d nl aft r all primary,

ndary and t rtiary cat gori ha\e

.... Th d tor will ob r ve thr ugh clini al anal i that the patient exhibit the following 1gn : •

Th patient omplain of pain that i pecifically located o er th cocc . Th patient indi ate that they ha e e perienced a r cent fa]l onto th buttock .(Typical! u d b kiing, ic kating or tripping backward down the tair tatic palpation on the apex of the coccyx re-produce the pain.

If the patient di play the e sign these clinically confirm the pre ence of an anterior coccyx, in which the apex of the occyx ha subluxated anteriorly. 3. ubluxation Diagram and Biomechanics. (See Figure 179) The following diagram di pla how the apex of the coccyx has subluxated anteriorly (solid arrow). Al o di played i the posterior acro-coccygeal ligament, attaching the posterior aspects of the acrum and coccyx (gre line). Correction will utilize this ligament to adjust the coccyx back into it normal po ition (da hed arrow). 4. The doctor must take x-rays due to the history of a fall. X-ray analysi confirm the anterior occyx and rules out fracture. (See Figure 180) If any fracture of the coccyx is pre ent. thi would be a contra-indication to adjusting.

p

A

Sacrum

Coccyx

Figure 179 Anterior Coccyx Biomechanic

5. Correction: Anterior Coccyx Adjustment: (See Figure 1-1 3) Patient: Prone. Doctor: Either side, facing cephalad. Table: Pelvic and lumbar pieces are elevated then et to a ready po ition. Contact: Thumb pad on posterior acrococcygeal ligament at Cx 1. Stabilization: Opposite hand pisiform on initial contact for r infor ement. LO : I-S, with slight P-A to initiate the drop piece. Repeat 3 time . Both lumbar and pelvic piece of the table mu t be ele at d t pla po ition for adjusting.

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the coccy in an op timal

Thi

adju tment u e the po teri r acr -c cc geal lioarn nt t ull th '° ne u . tral po ttlo · n · 1a the ligament' Th dju tment pr vid attachm nt . . mvas1. ve altemat1 · e to any coccy adju tm nt that mu t r th anal verg en Ure that the patient i ympt mati but that n fr ture i pre ent within th

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IN ILJ

1 - Classic Supine Correction Clean Up Move

An IN Ilium refer to an internally rotated ilium. The point of reference is the PSIS there fore an IN Ilium indicate that the patient's PSIS ha de iated closer to midline. This is usually found as a econdary compen ation to an original Al acrum subluxation (D-) that was not completely corrected. An IN Ilium ubluxation can also occur independently without the influence of a D-. 1n either ca e, the doctor mu t detect and correct for the IN Ilium in the following manner: l. To be checked for and corrected only after all primary, secondary and tertiary categories have been cleared. 2. In order for the doctor to accurately assess that the patient has an IN Ilium, the patient must present with both clinical and x-ray findings. The clinical signs that are present with an IN IJium are: • Toeing out of the foot on the affected side. • Flattening of gluteal musculature on the affected side. 3. The doctor' x-ray analysis reveals the following signs: (See Figure 184-186) • • • •

The ize of the iliac crest is increased. There is a decrease in the distance from the PSIS to midline. The obturator foramen appears small and lit-like The pubic tubercle shifts away from midline.

EX

IN 1

l

2

3 Figure 184 The four x-ray signs involved with an IN Ilium.

The doctor must have both X-ray and Clinical findings in order to accurately label the subluxation as an IN Ilium. Both findings must be present because other categories may have similar clinical symptoms, but will not have the x-ray findings to correlate. ote that both x-ray and clinical findings for the IN Ilium are the exact oppo ite of the EX Ilium explained later.

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Figure 186 (', !hum on the Right

Th x-ra� d1 pla� the differen ·e bet\\ en a :"\ormal Peh is and an [;\ Ilium. ;\Ote the � !hum demon!>trate· the b3ra ten 11 fearur _ noted earlier.

4. When both lini al and x-ray finding are pre ent. it confirms an I� Ilium ubluxation. whereb) th ilium ha ubluxated into internal rotation with re pect to the acrum. -. Corr tion: Cla ic upine Adju tment: ( ee Figure l & I Patient: upin with im·olwd ide leg flexed at the knee and hip. Do tor: On im·ol\'ed ide. Table: Pel\'i piece in the ready po ition. Conta t: Th nar contact on lat ral a pe t of tabilization: Po ition the invoh d I g pa t midline. LOC: L-M, into the table through th -I joint. Repeat 3 time-. The doctor bould note that the patient' kn hould b tak n a ro the midlin toward the oppo ite hip to induce the de ired EX corrective pla em nt f th ilium prior to the thru t. The thrust hould be ombined with a mall bod drop to a i t the movement. !he doctor may al o be required to increa the ten ion in th dr p pi t mpen ate for the m rea ed weight added by lifting the leg.

Or. Jo,,

nM n a

r d/

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I ILIUM - Modified Prone djustment Clean-up Move Thi m difi ati n wa r ated a an alternati e to the rN Ilium upine adju tment, and i intend d for m n wh uffi r from an incr a ed amount of articular damage within the Sl joint. The pron method pro ide le articular and os eou tre s to the patient, by eliminating ry m ment a the pati nt i already ituated in the proper po ition to be adjusted. 1. To be heck d for and corrected after all other categories have been cleared. 2. In ord r for the d ctor to accurately asses that the patient has an fN Ilium, the patient must pr ent with both clinical and x-ray finding described previously. 3. Clinical and X-ra finding confirm that the subluxation is an fN Ilium. 4. Correction: Modified Prone Adjustment: (See Figure 189& 190) Patient: Prone. Doctor: Opposite side of involvement. Table: Pelvic piece in the ready position. Contact: Superior or Inferior Hand Knife-edge on medial aspect of the ischia1 tuberosity. Stabilize: Contact hand. LOC: Medial to lateral, slight P-A. Repeat 3 times. The doctor has the choice to alternately contact the medial aspect of the PSIS as the

Figure 189 IN Ilium Prone Correction. Knife-edge on Medial Aspect of lschial Tuberosity.

Figure 190 [N Ilium Prone Correction Doctor Position. the Doctor Stabilizes the Contact Hand.

biomechanics would be the same. However, it is easier for the doctor to contact the medial aspect of the ischial tuberosity. The doctor also has the choice of using a superior or inferior hand contact, as Figures 189 and 190 display. The doctor should note that IN Ilium subluxation are common! seen in atient's with hi com laints. Sample Case: A 50 year old male accountant presents to the clinic with chronic low back pain. Following a complete examination, Thompson Analysis re eals a hort right leg in extension, and a short right leg in flexion. The doctor al o notices that the patient toe out on the right ide. The doctor first as esses if a Cervical yndrome is present, and corrects it if nece ary. ince the short to hort leg length analy i· pom towards a Derefield egative, the doctor palpates for the specific tender points on the hort leg ide. In thi case, the patient omplains of tenderness upon palpation of the ischial tuberosity, which erifies the D- subluxation. The doctor will then correct the Al rum ublu: ation. Correciing the primary areas have balanced the patient's legs, therefore the econdary and teniary areas will not be as d. Ho"e' r, lhe patient continue to have toeing out and a flat buttock on the right side. Becau e the patient i toeing out, the do tor must rule out a hypera tive psoas, and an I Ilium. The criteria of groin pain and refle tender point on the great t e are not pre ent for a hypera ti\ p • which rules it out. The doctor take x-rays as the clinical findings of a flat buttock and toeing out for an Ilium mu t be ,erified b) A-ray. In th1 case, x-ray confirm the clinical findings that an f ilium i present. The doctor adjusts the IN ilium nod ch clcs if any oth r I an up move are required. The patiem's treatment is finished for the day.

Dr. John Minardi

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EX ILIU 1 - Cla ic opine djustment Clean op Move Th EX Ilium. quite -imply, i the exact opposite problem as the IN Ilium. An EX Ilium refers to an xtemall) rotated ilium. Preci ely a in the fN Ilium, the EX ilium point of reference is the p I . Therefore. an EX Ilium indicate that the patient' PSIS has deviated further away from midline. The do tor mu t detect and correct for this subluxation in the following manner: I. To b hecked for and corrected after all primary secondary and tertiary categories have been l ared. _. In order for the doctor to accurately a es that the patient has an EX Ilium, the patient mu t pr ent with both clinical and x-ray finding . The clinical sign that are pre ent with an EX Ilium are: Toeing in of the foot on the affected ide. lncrea ed ize of gluteal mu culature is pre ent on the affected side. 3. The doctor' x-ray analy i reveal the following signs: (See Figures 191-193) The ize of the iliac ere t i decrea ed. There i a increa e in the di tance from the PSIS to midline. Th obturator foramen appear large and round. The pubic tubercle hift toward and ometimes pa se the midline.

EX

IN

1

imilar to the IN Ilium, th E ilium al r qutr th d ctor t ha b th -ra and lini al finding in order to a urately lab I th ublu ation a an E Ilium. The combinati n of -ray and clini al ign will nfirm th pr en fan Ilium and rul out any other cat g rie th t may h e imilar lini al ympt m , but la k th x-ra finding t correlate .

Or. Joti Mi n nardi

1,n

Cnnvdnht ,11n1:

Figure 193 EX Ilium on the The e -ra dt pla the difference between a ormal Pelvis and an EX Ilium. feature noted earlier.

Right.

ote the EX Ilium demon trat

4. When both clinical and x-ray findings are present, the EX Ilium subluxation is confirmed. Therefore, the ilium has subluxated into external rotation with respect to the sacrum. 5. Correction: EX Ilium Supine Adjustment. (See Figures 194& 195) Patient: Supine with invol ed side leg flexed in the figure 4 po ition Doctor: Opposite the invol ed side facing cephalad. Table: Pelvic piece in the ready position. Contact: Thenar on medial aspect of involved ASIS. LOC: Medial to lateral and P-A. Repeat 3 times.

I

Figure 194 EX Ilium upine Correction Al

Thenar on Medial

A

pect of

lt i important for the doctor to learn that hi torically this adju tment wa p ro rmed by contacting the patient's knee on the affect d side. on idering th potential damag that th original contact posed on the knee and hip joint the contact wa lat r modifi d to conta t the ASIS to reduce any potential damage.

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EX ILIUl\1 - l\1odified Prone Adjustment Clean-up Move imilar to the Modified Prone adjustment for the TN Ilium, the Modified Prone adju tment for the EX Ilium was developed for an elderly patient, or a patient who suffers from an increased amount of articular damage within the SI joint. The prone method provides less articular and O eou stre s to the patient, and eliminates excessive movement, as the patient is already in the proper position to be adjusted. I. To be checked for and corrected after all primary, secondary and tertiary categories have been I eared. 2. In order for the doctor to accurately assess that the patient has an EX Ilium, the patient must present with both clinical and x-ray findings described previously.

3. Clinical and X-ray findings confirm that the subluxation is an EX Ilium. 4. Correction: Modified Prone Adjustment: (See Figure 196& 197) Patient: Prone. Doctor: Ipsilateral side of involvement. Table: Pelvic piece in the ready position. Contact: Superior or Inferior Hand Pisiform on lateral aspect of the PSIS. Stabilize: Contact hand. LOC: Lateral to medial, slight P-A. Repeat 3 times. It is important for the doctor to note clinically that the EX Ilium is commonly associated with patients who suffer with knee ailments.

F'agure 196 EX llium Prone orrcction. Pisiforrn Contact on Lateral Aspect of P I . uperior or Inferior Hand can be Uti I ized.

Figure 197 EX Ilium Prone Correction Doctor P iuon Superior or Inferior Hand ontact can be tillzl'd

ample Case: A 35 year old female pre ents to the clinic complaining that be� ears out the inside le of h r left also mentions that she experiences neck pain occa ionally. Following a complet e amination, Thomp on anal) 1 re, al a Mion right leg. The doctor also notices that the patient toes in on the left. The doctor in tru.cts the pallent to tum her head t the right, which produce no change to the leg lengths. The doctor then in tructs the patient to tum her head t the I ft. \\ht h re ults JO balanced leg length . Left head turning producing balanced leg indic t s a Left erv ical ymlrom , but the problem i on the opposite ide. The doctor will then palpate along the lamina p dtcl juncuon on the patient' nght id . tender nodule i pre eat at 5. The doctor will talce his/her contact at the ite f the n dul and 1hru t P- tn hoe v.1th th d1. and perpendicular to the facet. In thi ca e, adju ting the ervical yndrome resul in balanc d leg1. in b th ext ndcd and nt fleited po itions. Therefore, further as e sment of the se ondary and tertiary area I not n ce r) . The J ctor mO\ clean up mo e . Because the patient toe in and has protruding gluteal muscul ture on the I ft, -ray re taken to , n if an X lhum 1s pre enl In thi case, -ray confirm the E llium i pr eat, therefore, the d tor c rr ct it a cording) The doctor then checks if any other clean up mo es are required. The patient 1s fini hed the treatment for that day

_-...._,John llln

,,..,

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ELE A TED RIB CAGE (ERC) Clean up Move The Ele ated Rib Cage adjustment was created for patients who suffer from asthma-type' er do not have a thma but rather a subluxation within the ribymptoms. These patients, ho cage that places torque on the pericardium and myocardium. Excessive torque on these structures produce the re piratory symptoms involved in an ele ated rib cage and is detected in the following manner: 1. To be checked for and corrected after all categories have been cleared. 2. The doctor will observe that the patient presents with a high shoulder, and flexion throughout the thorax. Following the correction of all other categories the high shoulder and flexed thoracic posture continues to be present. 3. In addition to the postural deviations, the patient will exhibit respiratory symptoms, such as coughing and wheezing. 4. Once postural and respiratory signs and symptoms are established, the doctor must confirm that the subluxation is indeed an elevated rib cage, by eliciting a specific tender point. To locate this tender point, the doctor will do the following:

•

Patient is supine. Doctor stands on affected side (high shoulder side). Doctor will palpate along the mid-clavicular line, in the second intercostal space. (See Figure 198) If a tender point is elicited in this location when postural and clinical symptoms are present, it confirms the Elevated Rib Cage Subluxation.

Pectoralis Minor lmage Copyright 2003-2004 University of Washington. All rights reserved including all photographs and images. o re-use, re-distribution or commercial use without prior written permission of the authors and the University of Washington.

Figure 198 ERC Tender Point Location_

In normal situations, the second intercostal space along the mid-clavicular line would produce no tenderness. When tenderness is easily produced, this represents tension located within the pectoralis minor muscle, which originates at the coracoid process and inserts along the first, second and third ribs. The combination of postural and clinical symptoms in addition to the presence of pectoralis minor tenderness confirms that the subluxation pattern is an elevated rib cage, in which the entire rib cage has shifted superior and slightly anterior. (See Figure 199) Figure 199 displays how the entire rib cage has subluxated superior and slightly anterior, which causes the abnormal high shoulder and flexed thorax posture. The subluxation also causes torque on the pericardium and mediastinum which results in the respiratory symptoms that are present. Note the tender point present at the second intercostal space (black dot) along th e mid-clavicular line (grey dashed line). Figure 199 Elevated Rib Cage.

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·. C rre non: Elevated Rib Cage dju tment: (See Figure 200&20 I) Patient: Supine. Doctor: On either side. Table: Dor al piece in the ready position. Contact I: Knife-edge contact on tender point of high shoulder ide. Contact 2: Web contact on lower angle of rib cage on oppo ite ide. LOC: P-A with scissor-like fashion. Repeat 3 times. The ci oring motion will correct for the superior rib cage, and the drop mechani m will correct for the light anteriority.

F'igure 200 Elevated Rib Cage Correction. Knife-edge Contact on Tender Poiot of High Shoulder Side. Web Contact on Lower Angle of Rib Cage on Oppo ite Side.

Figure 201 Elevated Rib Cage Correction Doctor Po ition. ote How the Doctor is Positioned Over th Pati nt's Midhne to ist the Scissor-Type Thru t.

When a male doctor is working on a female patient, the doctor must modify the contacts. In this situation, the female patient should place her hands over the contact points, and then the doctor can place his contact over the patient's hands. This simple modification allows the doctor to avoid any confusion with the patient. The doctor should note clinically that an elevated rib cage is usually associated with AI sacrum (D-), in which the high shoulder and the short leg will be on same side. This is due to the contra­ lateral overcompensation of the thoracic musculature (tender point on contralateral thoracic TVPs T2-T4) involved in the D-. Sample Case: A 25 year old machinist pre ents to the clinic with headaches, back pain and a per i tent cough. F llo\ ing a comp! te examination, Thomp on Analy i reveal a short left leg in e tension and a hort left leg in fle ion. Postural analy i r veal anterior head carriage a high left houlder and thoracic flexion The doctor, ill a se ifa Cervi al yndr m i pr nt and correct it ifnece ary. The hort to hort leg length analy i point to a D-, so the doctor che ks if p cifi tender point are pre eat. In thi case, the patient had a tender point, and therefore, the D- ubluxation was correct d. Howe er, the patient' left leg continue to be hort following the correction of the primary area of ubluxation. Now the d tor m e t th lumbar spine. The patient' LS ha ubluxated posterior with pinou rotation t th hort leg id pinous left). The d tor correct the lumbar ubluxation, and the patient' leg be ome balanced. Therefore, th thoracic pine i n t a e d or corrected. Because ofthe patient' re piratory ymptom and p tural pre entation, th d tor mu t be k f, r the el at d rib cag clean up mo e. The doctor palpate the econd intercostal space along the mid-cla i ular lin n th high h ulder id . The patient complain that it i tender, which in combination with the patient' ympt m onfinn the pre�enc fan elev ated rib cage. The doctor contact the sup rior a pect of the left rig cage, and the inf, rior a pe t of the right rib age and thru t P-A. in a ci r-type fa hion. The doctor then che k ifany other clean up m are required. The pati nt i fini hed the treatment for th day.

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ROTATED RIB Clean-up Mo e l . T b ch ked for and corre ted after all categorie ha e been cleared. 2. The pati nt present vvith sharp and tabbing pain in the chest which is aggravated by inhalation. uall wh n a pain is produced or aggra ated by inspiration, the rib is somehow invol ed. The doctor mu t now detennine how the rib has subluxated. 3. Th doctor will palpate along the anterior and posterior aspect of the rib cage. Palpation r veal a , idened intercostal space inferiorly on the posterior aspect of the patient and up riorly on the anterior aspect (See Figure 202). Motion palpation confirms the static palpation findings and re eals a subluxation of the costotransverse joint and corresponding costostemal joint of the affected rib. 4. Subluxation Mechanics and Diagram:

A

p Figure 202 Rotated Rib Subluxation.

The diagram in Figure 202 displays that the affected rib (grey) has subluxated in a rotational mann r. ote how the anterior aspect of the rib has misaligned inferiorly, as the posterior aspect has misaligned superiorly creating a widening of the inter o tal spaces (black arrows).

5. Correction: Rotated Rib Adjustment: (See Figure 203) Patient: Supine. Doctor: On involved side. Table: Dorsal piece in the ready position. Contact I: Thenar contact on tubercle of rib (posterior). Contact 2: Pisiforrn or knife-edge on costochondra1 junction of rib (anterior). LOC: Contact I: S-1. Contact 2: I-S with slight A-P to initiate the drop table.

•

This adju tment can be done with the table slightly raised to ea e the doctor's back.

Ju t a in the Elevated Rib Cage, if a male doctor is working on a female patient the docto r mu t modify hi contacts. • The female patient should place her hand over the anterior contact point, and then th doctor can take his contact on top of the patient' hand.

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Figure 203 Rotated Rib Correction Doctor Position. Anterior and Posterior Aspects of the Affected Rib.

Sample Case: A 20 year old male hockey player presents to the clinic with neck pain, back pain and stiffness foJJov ing a rough game last night. He also mentions that he experiences a sharp pain in the back when he breaths in. X-rays are taken and are absent of fractures or abnormalities. Following a complete examination, Thompson Analysis reveals a short left leg in extension and a long left leg in flexion. The doctor will assess if a Cervical Syndrome is present and correct it if necessary. The short to long leg length analysis points to a D+ so the doctor will perform an arm fossa test and correct for either an upper or a lower boot subluxation. In this case, the patient continues to pull short following correction of these primary areas. Now the doctor moves to the lumbar pine. The patient's LS has subluxated posterior with spinous rotation away from the short leg side(spinous right). The doctor corrects this secondary area, and finds that the patient continues to pull short during leg length analy is. The doctor now assesses the thoracic spine and palpates a lateral spinous process deviation at T5. Clinical and x-ray criteria rule out the presence of a lateral listhesis, indicating that a rotational problem is present. The doctor then corrects the rotated segment, which balances the legs. Considering that the patient experience a sharp pain with inspiration, the doctor will check for a rotated rib clean up move. In this case, the doctor palpates a large intercostal space inferiorly at the posterior aspect of the fifth rib. The doctor also palpates a large intercostal space superiorly at the anterior aspect of the fifth rib. Palpation findings and clinical symptoms onfi.rm the presence of a rotated rib. The doctor contacts the subluxated segment both anteriorly and posteriorly and adjusts it accordingly. The doctor then checks if any other clean up moves are required. The patient is fini bed the treatment for that day.

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If SbyUNEVEN arter tr.. tlng Prlm8ry .. Secondary ! areas: ··> TliCRACIC SANE Pattver S. (prono "4)1rn) Ele.latecl rlb cage Rocatod rib POiiterlcr sacr ol epCK

Knlfo·Edge

i.n1u_, Tlul'lbil:7..C,,',ja,1 pJ!ap.,-.(T1-T4) T Slint-i:J1T5·T12 1� corrected by• R.QB.L hmd rotatlon

100% corrected by a RAW L heed rotet Ion t'lll!d rotatlon

Noduesat dlffenn eiel

Nodue atC7 with/d. l.. tu:i:J1,., mot!ul

4) per boot SI.DC•

lo.ler boot !lbx llfj.J. Modi llod Ilg distraction

R bocorm SI-ClRT with R road rOIDt ion anl Vic&-1/0'SII BILATERAi.CERViCAL SO (Occl p.t AS)

A· Clll!lslc Ttanp,rn prcn, B- Modlrled stu:ky "4)111! C· Modlflccl _. D Moditied Toggb Board Cc Correction [)(x.1or Po"t• n otc the Remfon:cd Pml..1e ontuct that the Doctor ll C\

Sb. AI acrum orrection: Su tained ontact: (See Figure 254) Patient: Pr ne. Doctor: ame ide a le ion. ontact: Pink-y finger under ipsilateral sacrotuberou ligament. LO : L-M, 1-S u tained contact. 2-6oz of pres ure. Hold contact until ten ion ub ide . In thi correction, the doctor is u ing the acro-tuberou ligament a an anchor to et the a rum back to it neutral po ition. Thi is the preferred adjustment for infant , due to patient c mfort.

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PEDIATRIC

E

ME T ND CORRECTION OF THE ILIUM (D+)

Ju t a in th adult, the pediatri ilium denote a primary area of ubluxation. l. Ob ervation during p dfatric e amination reveals a low gluteal fold on the involved side. . tatic palpation of a po terior inferior (Pl) ilium is present on the low gluteal fold side. 3. Leg length anal i indicate a short leg in extension and crosses over to be long inflexion. As tated pre iou 1 the accurac of the leg check is increased significantly when child is in weight bearing ear . Until that time observation and palpatory analysis will be the primary detection tool for the PI ilium in the child. 4. Ob erv ation palpation and leg length analysis indicates a D+ on original short leg side. 5. Correction: Infant D+ Adjustment: (See Figures 255&256) Patient: Prone. Doctor: Either side of table. Table: Pelvic piece or toggle board in the ready position. Contact: Pinkie Contact on the affected PSIS. Stabilize: Applying caudal traction to involved side thigh, or stabilizing contact. LOC: P-A. 2-6oz of pressure. ote how the doctor's stabilization hand implements the distraction necessary for an effecti e adjustment.

Figure 255 Pediatric Ilium Correction. Pinkie Contacts on Affected PSI . ote that Stabilization Hand Can Reinforce the Contact, or Distract the Thigh of the Involved Side.

It is important for the doctor to note that in a pediatric patient there i no need to perform an Arm Fossa Test to differentiate between an upper and lower boot ubluxation a \: a nece ary for an adult. • In a child, the upper, more fibrous boot i not fully formed. Therefore all children with a D+ posterior inferior ilium subluxation, will be a lower boot ubluxation. (PSIS ha gone Pl).

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PEDIATRIC A

ES !VIENT AND CORRE TIO OF TH L MB R Pl

Ju ta in the adult , the pediatric lumbar pine den tes a econdary area of ubluxation. I. The leg anal i fi r the lumbar ubluxation i extremely imilar to that of a 0-. The patient will present with a contracted leg in exten ion. In flexion the contracted leg balan e or tay hort. Greater than 90% of the time, a lumbar ubluxation is econdary to an original 0- which i the r a on that the leg length analysis is identical. When thi i the ca e, the doctor would initiall correct for the subluxated D- a di cu ed pre iou ly then continue to c01Tect the lumbar sublu ation. 2. The only e ception to the tatement above i if the lumbar ubluxation occurre� or remained independent of a D-. When this is the ca e, the doctor will encounter the hort to hort leg length phenomena de cribed pre iously however no tender point v ill be pre ent. Lack of tender points rules out a D- sacrum subluxation, and point to a lumbar ublu ation. In thi ca e the doctor would not adjust the acrum but would rather mo e directly to the lumbar pine. 3. Static palpation will reveal a posterior spinou de iation. Motion palpation i a hie ed u ing a preci e finger contact o er the interspinous space while flexion/exten ion motion i pr formed. Thi re ea! a lack of proper joint movement and hard end feel confirming a lumbar ubluxation. It i important for the doctor to under tand that unlike adult an infant lumbar pme will ubluxate posterior but will ha e no rotational component. If the pediatric patient i non-ambulatory tatic and motion palpation would be the primary tool to detect the lumbar ubluxation. Leg length analy i would lack accuracy before \i alking begin . 4. Correction: P-A Lumbar Adju anent: (See Figures 257&25 ) Patient: Prone. Doctor: Either ide of table. Table: Lumbar piece or toggle board in the ready po ition. ontact: Pinkie finger conta t n affected pinou proc Stabilize: Contact with oppo ite pinkie finger. LOC: P-A. 2-602 of pre ure.

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PEDIATRlC

E

ME T

D CORRECTIO OF THE THORACIC SPINE

Ju t a in the adult the thoracic pine r pre ent a tertiary area of ubluxation and is as e ed and orr ted onl after the primary and econdary area of ubluxations ha e been cleared. Due to th angl of th facet the p diatric thoracic pine subluxates posterior. I. The doctor will begin tatic palpation of the thoracic spinous processe with the child in the pr n po ition. If the pediatric patient is an infant having the mother supine on the table followed by the infant prone on the mother' chest will be more comforting for the infant. This doe not compromi e the qua lit of the examination, and ensures that the infant will cooperate throughout th balance of the pinal e aluation. During static palpation, the doctor is as es ing , hether an thoracic spinous proces es have subluxated posteriorly often identified as a protuberance or hard end feel when compared to the remaining spinous processes. -· The doctor will motion palpate the thoracic region, emphasizing posterior to anterior mo ement. Th do tor an ha e the parent a sist by holding the chjld providing stabilization. Motion palpation should be performed with the pinkie finger and a essing for a lack of motion or a hard end feel. 3. Leg length anal i ould indicate that a short leg persists after primary and secondary areas ha e been cleared. As mentioned previou ly the cruld must be ambulatory to pro ide an accurate leg check. If the child is an infant, and non-ambulatory palpation finding will be the primary as e ment tool. If the child is ambulatory leg length analy is will be the primary a e ment with static and motion palpation confirming leg check findings. 4. Correction: Prone P-A Adjustment: (See Figures 259&260) Patient: Prone (laying on top of mother if patient is an infant). Doctor: Either ide of patient. Table: Toggle board placed under affected area or dorsal piece in the ready position. Contact: Pinkie finger on the affected spinous process. LOC: P-A. 2-602 of pressure.

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REFEREN E History, Neurology & Leg Length In equality ection : mp n Technique: a 1 \ fi rce, high

ity ppr a h. T d y'

-· Cooperstein, R. Thomp on Technique. hir pra tic te hnique. I

hir pra t r.

5; 7(2):6 -

3. Ja k on. R. Thomp on terminal point technique. (Sour e unknown 73-74. .i. Guyton. Medical Phy iology Textbook 91h Ed. Chapter 54 and 56. 5. Berne R & Levy, M. Physiology 3ro Ed. Chapter 12 and 13. Mosby Year Bo k. t. Loui . I 92 . . Thompson J.C. Thompson technique reference manual. Elgin Illinois: Thomp on educati nal workshops Williams Manufacturing Co. 1987. . Lebeouf C. et al. The SOT: the so-called arm fossa test. Intraexaminer agreement and p t treatment changes. J. Aust. Chiro. Assoc. 1988. 18:67-68. 8. Hyman R.C. Table assisted adjusting: An exposition ofthe Thompson technique. Dalla . Enchantment Publishing 1995. 9. Yochum, T. & Barry, M. Examination and treatment of the short leg. ACA Journal of Chiropractic. 1994· 29-32. 10. Aspergen� D. Short leg correction: a clinical trial ofradiographic vs. non radiographic procedures. JMPT. 1987; 10(5):232-237. 11. Shambaugh P. et al. Reliability ofthe Thompson-Derefeild test for leg length inequality, and use of the test to demonstrate cervical adjusting efficacy. JMPT. 1988; 11(5):65-67. 12. DeBeor K. et al. Inter and intra-examiner reliability ofleg length differential measurement: a preliminary study. JMPT. 1983; 6(2):61-66. 13. Rhodes, W. et al. Comparison ofleg length inequality measurement methods as estimators ofthe femur head heights differences on standing x-ray. JMPT. 1995· 18(7):448-491. 14. Rhodes, W. et al. The validity ofthe prone leg check as an estimate ofstanding leg length inequality measured by x-ray. JMPT. 1995; 18(6): 343-346. 15. Nguyen, H. Inter-examiner reliability of activator methods' relative leg length evaluation in the prone extended position. JMPT. 1999; 22(9): 565-569. 16. Knutson, G. Tonic neck reflexes, leg length inequality and atlanto-occipital fat pad impingement: an atlas subluxation complex hypothesis. CRJ. 1997; 4(2). 17. Ten Brink, A. Is leg length discrepancy associated with the side ofradiating pain in patient with a lumbar herniated disc. Spine. 1999; 24(7): 684-686.

Cervical Syndrome Sections: I. Assendelft, WJ. et al. Effectiveness of chiropractic and phy iotherapy in the treatment of low back pain: A critical discussion ofthe British randomized clinical trial. JMPT. 1991 · 14(5): 281-286. Dr. John lllnanl

1U

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-1

r wn

aillancourt BS. Ca

Rep rt: upper cervical adju ting for kne pain. RJ. 1993; 2(3):

. H \\k, C. et al. hiropractic care fi r women with chronic pelvic pain: A pro pective ingle group int rvention tudy. JMPT. 1997· 20 2): 73-77. 4. Hoiri KT. Case Report: management ofpo t-surgical chronic back pain with upper cervical adju tments. CRJ. 19 9· 1(3): 37-42. 5. Ke t n B. Multiple ca e study offi e patients with pelvic unleveling. CRJ 1991; 2(1 : 51-56. 6. Kummel B. Nonorganic signs of significance in low back pain. Spine 1996; 21(9): 1077-1081. 7. Knut on GA. Case tudies ofupper cervical adjusting errors: the possibility ofchiropractic iatrogenisis. CRJ. 1996· 3(3): 20-24. 8. Koes BW. et al. A randomized clinical trial ofmanual therapy and physiotherapy for persistent back and neck complaints: subgroup analysis and relationship between outcome measures. JMPT. 1993; 16(4): 211-216. 9. Lew PC. et al. Relationship between cervical component ofthe slump test and changes in hamstring muscle tension. Manual Medicine 1997; 2(2): 98-105. I 0. Nansel, DD. et al. Effects ofcervical spinal adjustments on lumbar paraspinal muscle tone: evidence for facilitation ofintersegmental tonic neck reflexes. JMPT. 1993; 16(3): 91-95. 11. Oliverio, A. Review ofthe literature: adjusting only the cervical spine and its effect on low back pain. CRJ. 1994; 3(1): 3-6. 12. Pollard, H. & Ward, G. The effects ofupper cervical or sacroiliac manipulation on hip flexion range ofmotion. JMPT. 1998; 21(9):611-616. 13. Pollard, H.& Ward, G. A study oftwo stretching techniques for improving hip flexion range of motion. JMPT. 1997; 20(7): 443-447. 14. Robinson , S. Patients with chronic low back pain managed with specific upper cervical adjustments. CRJ. 1993; 2(4): 10-23. 15. Rogers, RG. The effects of spinal manipulation on cervical kinaesthesia in patients with chronic neck pain: a pilot study. JMPT. 1997; 20(2): 80-85. 16.. Schofferman, J. Successful treatment oflow back pain and neck pain after a motor vehicle accident despite litigation. Spine 1994; 19(9): I 007-1010. 17. Vaillancourt, PJ. Case report: management of post-surgical low back pain syndrome with upper cervical adjustments. CRJ. 1993; 2(3): 1-15. 18. Williams, SE. et al. A progress report ofchiropractic efficacy in the treatment oflow back pain neck pain, headaches and related peripheral conditions. CRJ. 1989; l (3): 11-21. 19. McAviney, J. Determining the relationship between cervical lordosis and neck complaints. JMPT. 2005. 28(3):187-93.

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Bilateral Cervical Syndrome, Unilateral Occiput Syndrome, Po terior Occiput yndrome & Exception Derefield Sections: I. Hart\vell. S. et al. Soft ti ue connection betv een rectus capitu po terior minor and the po terior atlanto-occipital membrane: a cada eric tudy. Journal of hiropracti ducation. 20 ; 2 (I). 2. Hack, G. et al. Anatomic relation between the rectu capitu po terior minor muscle and the dura mater. Spine. 1995. 20(23):24 4-2486. 3. Lew P. et al. The effect of neck and leg flexion and their equence on the lumbar pinal cord. Spine. 1994· 19(21): 2421-2425.

Derefield Negative and Derefield Positive Sections: I. Gomes A. et al. Effects on hamstring stretching compared to hamstring tretching and acroiliac joint manipulation. Clin Chiropr. 2006.9(1):21-32. 2. Charbonneau M. et al. Segmental modulation ofT and H reflexes and M wave following a chiropractic adjustment: a pilot study. In: Proceedings ofthe International Conference ofSpinal Manipulation FCER: Arlington VA' 393-8. 3. Cibulka, M. et al. Hamstring muscle strain treated by mobilizing the sacroiliac joint. Phys Therap. 1996.76(6):836-49. 4. Hoehler, F. et al. Low back pain and is treatment by spinal manipulation: measures of flexibility and asymmetry. Rheumatol Rehabil. 1982. 21(1): 21-26. 5. Murphy B. et al. Sacroiliac joint manipulation decreases the H-reflex. Electromyogr Clin Neurophysiol. 1995. 35:87-94. 6. Perrin D. et al. Comparison ofnon-ballistic active knee extension in neural slump po irion and static techniques on hamstring flexiblity. J Orthop Sports Phys Therap. 1997. 26(1):7-13. 7. Herzog, W. et al. Electromyographic responses ofback and limb muscles associated with spinal manipulative therapy. J Orthop Sports Phys Therap. 1993. 4: 172-176. 8. Bergman, T. et al. Chiropractic Technique Principles and Practice. Churchill Livingstone, New York· 1993. 9. Herzog, W. et al. Biomechanical studies ofspinal manipulative therapy. J Can Chirop Assoc. 1991. 35(3):156. 10. Hestbaek, L. Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A y tematic critical literature review. JMPT. 2001. 23(4):258-75. l l. LeBoeuf, C. Sacro-occipital technique: the so-called arm fossa test. Intra-examiner agreement and post treatment changes. J Aust Chiro Assoc. 1988. 12. LeBoeuf, C. The sensitivity and specificity ofseven lwnbo-pelvic orthopedic te t and th arm fos test. JMPT. 1990. 13. Gomes, A. et al. A pilot study comparing the effects ofspinal manipulative therapy with tho e of extra-spinal manipulative therapy on quadriceps muscle strength. JMPT. 2006.29(2):145-149. 14. Herzog, W. et al. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with knee pain. JMPT. 1999. 22(3):149-153.

15. Suter, E. et aJ. onservative low back treatment reduce inhibition in knee-extensor mu cles: a randomized controlled trial. JMPT. 2000. 23 2 :76- 0. 16. Montgomery D. Palpable unilateral sacral prominence a a clinical sign of lower limb anisomelia: a pilot tud . JMPT. 1995. l 6): 353-355.

Spondylolisthesis Section: l . 'x ochum TR. & Rowe LJ. Natural History of Spondylolysis and Spondylolisthesis. ln Es ential of Skeletal Radiology. 200 Ed. 1996. Williams and Wilkins. Baltimore, Maryland. 2. Boden SD. et al. Orientation of the Lumbar Facet Joints: Association with Degenerative Di c Disease. Journal of Bone and Joint Surgery. 1996. 78A(3): 403-41 l . 3 . Bull, P. e t al. The Effects of Spondylolisthesis on the Lumbar Spine: A Cross-Sectional Radiological Survey. Chiropractic Journal of Australia. 2000. 30(1):5-12. 4. Antoniades, SB. et al. Sagittal Plane Configuration of the Sacrum in Spondylolisthesis. Spine. 2000 25(9): I 085-1091. 5. Nagaosa Y. Pathoanatomic Mechanisms of Degenerative Spondylolisthesis. A Radiographic Study. Spine. 1998. 23(13): 1447-1451. 6. Berlemann U. et al. The Role of Lumbar Lordosis, Vertebral End Plate Inclination Disc Height, and Facet Orientation in Degenerative Spondylolisthesis. Journal of Spinal Disorders. 1999. 12(1): 68-73. 7. McGregor, AH. et al. Global Spinal Motion is Subjects with Lumbar Spondylolysis and Spondylolistbesis. Spine. 200 I. 26(3): 282-286. 8. Ramsbacher, J. et aJ. Ultra structural Changes in Paravertebral Muscles Associated with Degenerati e Spondylolisthesis. Spine. 200 I. 26(20): 2180-2185. 9. Moller, H. et al. Symptoms Signs and Functional Disability in Adult Spond lolisthesis. Spine. 2000. 25( 6): 683-689. I 0. Harbaugh, K. et al. Lower Back Pain and Thigh Paresthesia in a Patient with Spondylolisthesis. Journal of the Neuromusculoskeletal System. 1999. 7(2): 78-82. 11. Roberts, S. et al. Mechanoreceptors in intervertebral discs. Morphology distribution and neuropeptides. Spine 1995; 20:2645-265 l . 12. McLain, RF. Mechanoreceptor endings in human cervical facet joints. Spine 1994· 495- 501. 13. Guyton. Medical Physiology Textbook, 9m Ed. 1992. Chapters 54 and 56. 14. Berne, R. & Levy, M. Physiology, 3n1 Ed. Chapters 12 and 13. 1992. Mosby Year Book.. St. Loui . 15. Vogt MT. et al. Lumbar Olisthsis and Lower Back Symptoms in Elderly White Women. The Stud of Osteoporotic Fractures. Spine. 1998. 23(23): 2640-2647. 16. Massari, MA. Spondylolisthesis Evaluation, Management, and Long-Term Progno is. Journal of the American Chiropractic As ociation. 1997. 34(9): 41-46. 17. Rouse, J. Spondylolisthesis: Re ponse to Chiropractic Rehabilitative Care. Journal of Sport Chiropractic & Rehabilitation. 1996. 10(1): 41-43. Dr. John Minardi

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18. Al-Khav a hki, H. et al. ombined Dy plastic and lsthmic pondyloli thcsi : Po iblc ·tiology. pin 2001. 26(23): E542-546.

Extremity Sections: I. Schemerl, M. et al. Labra I injuries of he hip: a review of diagnosis and manngmcnt. JMPT. 2004. 3(8):632-638. 2. Lefeb re, R. et al. Vastus medialis: anatomical and functional considerations and implications based upon human and cadaveric studies. JMPT. 2006. 29(2): 139-144. 3. Alcantara, J. et al. Chiropractic care of a patient with temporomandibular disorder and atlas subluxation. JMPT. 2002. 25( 1 ):63-70. 4. Tuz, H. et al. Prevalance of otologic complaints in patients with temporomandibular disorder. Am J Orthod Dentofacial Orthop. 2003. 123(6): 620-623.

Pediatric Section: I. Videman, T. Journal of Clinical Biomechanics. 1987.