Download P.P.4

Flexion Distraction
Objectives
•Review TMAP, LMAP
•Pelvis
•Sacrum/coccyx
Thoracic Motion Assisted Palpation (TMAP)
•Locate LAF
•Side of head rotation that restores some
movement…
•Write down that letter…
•either “L” or “R”
•add a “P” i.e. LP or RP
•this names the TVP
Thoracic Listing continued
•Determine body listing
•LP = BL and RP = BR
•Determine spinous listing
•LP,BL = PR and RP,BR = PL
•Determine orthogonal listing
•LP,BL,PR = +Y
•RP,BR,PL = -Y
Thoracic Adjustments
• Patient rotates head away from side that restored motion
•In general, stand on side of TVP posteriority
•Double Transverse, Single Transverse
•T1-T3 inferior hand
•LOC – P-A, I-S through the plane line of the disc at full
flexion
•Recheck listing
Lumbar Motion Assisted Palpation
(LMAP)
•Locate LAF
•Laterally flex table left and right
•Side of lateral flexion that restores
some motion is side of spinous
rotation.
•Write down the opposite letter
•Table flexed left restores motion, write
down an “R”
•Add a “P” i.e. “RP” or “LP”
Listings
•Determine body listing
•LP = BL and RP = BR
•Determine spinous listing
•LP/BL = SP-R & RP/BR = SP-L
•Determine orthogonal listing
•LP,BL,SP-R = +Y
•RP,BR,SP-L = -Y
Lumbar Adjusting-Spinous
Contact
•Lateral flex table away from the side that restored
movement
•Stand on convex side
•Spinous contact
•Superior hand L1-L2
•Inferior hand L3, L4, L5
•LOC is P-A through the plane line of the disk at full
flexion
•Recheck listing
Lumbar Adjusting - Mammillary
• Patient in Neutral position
• Mammillary contact…Stand on the side of
posterior segment.
• Adjust accordingly…P.O.T., S.H.C., D.T.,
etc.
Lumbar Adjusting - Mammillary
• Using a Drop piece is not essential, however, if
you desire to use them…follow the guidelines
below.
• L1, L2, & L3…if you want to use the drop
piece…slide the patient up and adjust. Adjust
the tension to an appropriate setting.
• L4 & L5…Slide the patient down and use the
pelvic drop piece…decrease tension to
appropriate level.
Side Posture Alternate
•Stop the table!
•Leave abdominal piece down
•Raise cervical piece to match abdominal piece angle
•Position patient and find SCP
•Now laterally flex the table to take the segment to tension and
adjust
•Recheck initial listing
L5 Spondylolisthesis
•Do not treat if asymptomatic
•For Grade 3 or better leave abdominal piece up
•Position top of iliac crest in middle of abdominal
pad
•If patient still experiences discomfort, move more
cephalid
•Decrease speed of table by 50%
L5 Spondylolisthesis cont.
•Contact L4 spinous and exert cephalic
stabilization
•Contact S2 with increasing caudal pressure
as the table flexes and let up when it returns
to horizontal.
•Cycle 5 times
L5 Spondylolisthesis cont.
•On subsequent visits, gradually place the
patient lower on the table until the top of the
iliac crest is at the top of the pelvic pad.
L5 Spondylolisthesis - Adjusting
• Always evaluate the Psoas musculature prior to
adjusting. As well as the Ø X, Ø Y, and Ø Z
• (+) Ø X…Anterior rotation
• Normal A.P.I. (+ Ø X): Males: 0 - 5°
• Normal A.P.I. (+ Ø X): Females: 5 - 10°
• Treatment:
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(1)Pelvic rocking
(2) Lateral press
(3) Pelvic shift
(4) Y - Translation of Lower extremity
(5) Hip rotation
(6) Pelvic derotation.
L5 Spondylolisthesis - Adjusting
• (-) Ø X…Posterior rotation
– Treatment:
• (1) Pt. supine
• (2) Involved hip extended slightly off the
table…Stabilize A.S.I.S. with inferior hand. With the
superior hand apply A-P pressure on the distal thigh
while distracting the knee
• (3) pt. resists doctor’s force.
Spondylolisthesis--Adjusting
• Table Off: Pt. supine
• Adjustments: Two Types…#1) Field
Method…#2) Institutional Method.
– Field Method: No Thrust---Only pressure until
table drops.
– Institutional Method: 3 Thrust!!!
P.I. Ilium
•Analysis…Thompson, Activator,
A.K., etc...
•Short Leg…usually the side of P.I..
–Check in position #1 and position #2…Short leg that
lengthens.
•Challenge…Motion the joint via
static and motion palpation (spring test;
pressure / stress test; etc…)
P.I. Ilium
• Table off
• Analysis: Short leg in
extension--lengthens
to some degree upon
flexion.
• Reference point:
P.S.I.S.
• Pivot point:
Acetabulum
P.I. Ilium
• “True” P.I. Ilium
• Look for an I.N. Ilium
on the same side.
• Resistance may be felt
in the legs with knee
flexion, with a possible
jerky motion when
flexed.
Table / Patient settings
• P.I. Ilium:
• Set the Patient: Patient Prone. Align the top aspect of the
Iliac crest with the top of the pelvic pad.
• Set the table: Turn the table on. Elevate the pelvic pad
opposite P.I. listing. Activate the directional drop on the PI
side.
• Set the Doctor: Dr. stands on either side--Right P.I.…Right
Thenar. Stabilize with other hand--mid heel or M.C.P of the
index finger.
• S.C.P.’s: Medial, inferior aspect of the P.S.I.S. on the
involved side. Posterior, inferior aspect of the ischial
tuberosity on the uninvolved side.
• Adjust: Adjust in full flexion…3 times if needed!
P.I. / I.N. Ilium
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•
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•
No leg length analysis
“Toe out” foot flare
Wide gluteal and “Flattened” P.S.I.S.
Wider Ilium on X-ray
Narrow obturator foramen on X-ray
P.I. / I.N. Ilium
• Table on
• Adjustment procedure: Activate the directional drop
on the involved side.
• Iliac crest in alignment with top of the pelivc pad.
• S.C.P.: Medial aspect of the Ischial tuberosity on the
involved side.
• Superior hand contact (S.C.P. Pisiform)
• L.O.D.: Medial to Lateral, slight P-A with an axial
torque.
• Adjust in full extension or flexion.
A.S. Ilium
• Usually on the long leg side.
• Identified by palpation of a taut and tender
gastrocnemius on the involved side. Opposite the
side of a P.I. Ilium.
• Challenges…Pressure / stress test; x-ray analysis;
spring test; Motion Palpation; etc…
• X-ray analysis
A.S.
(Posterior Ischium Adjustment)
Activate the same side pad.
Adjust 3 times if needed.
Look for an E.X. Ilium on the same side.
•Stand on side of posterior ischium
•Set drop piece on this side
•Contact ischial tuberosity with superior hand…Fingers
running down the thigh…Toggle grip!!!
•Adjust in full extension.
A.S. / E.X. Ilium
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•
•
•
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No leg length analysis for the EX Ilium
“Toe in” foot flare
Narrow gluteal and prominent P.S.I.S
Narrow ilium on X-ray
Wide obturator foramen on X-ray
A.S. / E.X. Ilium
•Lateral aspect of the involved
PSIS…contact w/superior hand
•Shallow L.O.C. L - M
•Involved side…set drop piece
Exception to the rule...
For the Posterior Ischium, make the
adjustment when the table comes back
to neutral…re-check listing.
Sacral Analysis
• Table off: Pt. prone
• No leg length analysis
• Stabilized, prone leg raiser test to identify
the Left or Right Sacral subluxation or the
Base posterior
Sacral Analysis
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Table off
Patient is prone
Doctor assumes a straight away stance
Places heel of the superior hand on the sacral
base with fingers pointing inferior
• Apply P - A pressure…appropriate amount to
stabilize the sacrum
• Instruct the patient to raise the left or right leg of
the table, while maintaining a straight leg
Sacral Analysis
• Observe the elevation of the leg being
raised…then have the patient to raise the
opposite leg…compare the two heights
• The leg that does not raise as high is
considered the side of sacral subluxation
• The sacrum should be listed and adjusted
on the low leg side
Sacral Analysis
• List the sacral subluxation on the low
leg side:
• A) 4 inch or > difference between the left and right
leg
• B) Less than 4 inch height difference; difficulty and
or pain when raising the low leg
• C) If neither leg raises off the table and there is pain
and/or difficulty--Base Posterior.
Sacral Adjustment
• Table On: Activate the table prior to adjusting
• Set the table: Drop pieces activated
• Set the Patient: Prone; Iliac crest in line with the pelvic pad;
cross the involved leg over the uninvolved leg at the popliteal
fossa
• Set the Doctor: Facing the feet; Superior hand on the
uninvolved P.S.I.S (pisiform/knife edge contact); Inferior hand
(pisiform/knife edge contact) on the uninvolved sacral notch
• Adjust in full flexion:
• L.O.C.: Rt.--CCW torque; Lt.--CW torque; Scissor action to
create a torquing of the sacrum…slight P - A
Base Posterior--Analysis
• If neither leg raises off the table and
there is pain and / or difficulty when
raising the legs, the sacrum should be
listed and adjusted as a Base posterior
subluxation.
Base Posterior
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•
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Table On: Pt. prone
Set the table: Drop pieces activated
Set the Patient: Iliac crest in line with pelvic pad
Set the Doctor: Inferior hand contact…Mid heel
contact on Superior aspect of the sacral base--in
midline
• L.O.C.: P - A, S - I through the lumbo sacral angle
Sacrum
•Sacral nodding…Information may
be obtained while performing stretches.
•Post/inferior--flexion
•Ant/superior--extension
Coccyx
•Radiographic analysis
•Localized pain
•Challenge
•Palpation
•List Apex: A, A-R, A-L
•Covered thumb contact
•Adjust at full flexion with drop on side of listing
Practice Notes
• Pain at the Sacroiliac articulation may be due to sacral or lumbar
involvement
• Base posterior and L5 spondylolisthesis will mimic each other with
similar findings…Hard to raise either leg and painful--Base posterior.
However, Rule out spondylolisthesis via lateral pelvic films.
• If patient continually bends the knee when performing the leg raiser
test, a lumbar subluxation may be present and will need to be
corrected.
• A post adjustment, prone leg raise test should demonstrate an equal
raising of both legs, with a decrease or elimination of any pain and /
or difficulty. If the legs are not equal…they may have a lumbar
subluxation.
Post-treatment Protocol
•Stop table in horizontal position
•Have patient roll up on side opposite
major involvement/treatment and swing
legs off table to front while they push up
with their hands.