I. LUMBAR SPINE Protocol I and II Instructions

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Gwendolyn Fowler
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1 Prtcl fr Cx Technic Hands On Prtins f Cx Curses (7/21/14) step by step guide instructins fr treating patients with Cx Technic Flexin Distractin & Decmpressin Spinal Manipulatin prepared by James M. Cx, D.C., D.A.C.B.R. NOTE: This guide des nt preclude hands n training nr study f the full prtcls presented in the textbk. Please see the textbk, Lw Back Pain: Mechanism, Diagnsis, Treatment, 7 th editin, published by Lippinctt, Williams & Wilkins, 2011, fr the full explanatin and ratinale fr Cx Technic Flexin Distractin & Decmpressin Spinal Manipulatin and the diagnstic wrkup leading t a treatment plan fr each patient yu treat. This set f ntes serves as a simple guide f the prtcls fr training. I. LUMBAR SPINE Prtcl I and II Instructins 1. Patient Psitining Sequence Check that lcks are secure. Assist patient nt table: tighten abdmen and buttcks assist patient nt table have arms rest n arm rests Check patient Placement ASIS 2 frward n thracic piece adjust ankle rest Set spring tensin / pwer balance fr caudal sectin 2. Tlerance Testing (t determine the apprpriate means t induce distractin decmpressin and secure the patient during adjustment)* *NOTE: Start at L1 and wrk dwn the lumbar spine t avid engaging a level belw a disc herniatin if sciatica is present. Yu may tlerance test starting at L5 S1 and mve cephalward if n sciatica is present. Release Flexin Extensin Lck Central Distractin Testing by means f tiller bar nly IF PAIN LATERALIZES, ice, acupressure, etc., nly fr a day r tw. spinus prcess cntact dwnward table mvement till cciput extends r 2 hld fr 4 secnds test L1 level and test caudally ne level at a time t the lwest lumbar segment Lateral Distractin Testing by means f hlding each ankle nly IF PAIN LATERALIZES WITH HOLDING ANKLES, then nly mve the table with the tiller bar as in central testing. spinus prcess cntact hld ankle (first uninvlved, then invlved) dwnward table mvement till cciput extends r 2 hld 4 secnds test L1 level and test caudally ne level at a time t the lwest lumbar segment Test with cuff n by means f ankle cuffs IF PAIN LATERALIZES WITH THE CUFF ON, then nly mve the table and cntrl the patient by hlding the ankles as in lateral testing. spinus prcess cntact hld ankle (first uninvlved, then invlved) dwnward table mvement till cciput extends r 2 hld 4 secnds test L1 level and test caudally ne level at a time t the lwest lumbar segment NOTE: Muscle resistance in the frm f spasm is palpated fr. If any such sign is present, d nt use Cx Technic flexin distractin. If the patient reprts pain n tlerance testing with the cuffs n, adjust withut the cuffs. If the patient reprts pain n tlerance testing while the ankle is held, adjust withut hlding the ankle which allws just the weight f the legs t be the tractive frce. If the patient reprts pain n tlerance testing with n tractive frce (n ankle hlding r cuffs), ice alne, trigger pint, acupressure, alternating ht/cld and massage may be called fr until lcal irritatin reduces t allw distractin with n signs f discmfrt. 3. Palpatry Cntact fr Increasing Lcal Sft Tissue and Interspinus Tensin Place third digit at the interspinus space t be manipulated. The secnd and furth digits cntact adjacent muscles. Distract the table until the interspinus space feels taut under yur fingertip. At this taut pint the dctr will cntact the spinus prcess with the thenar r thumb index cntact. It is this taut pint that is the starting psitin fr all further table mvement fr distractin and range f mtin f the intervertebral disc and facet jints. 1 Cx Technic Prtcls

2 Align the dctr hand cntact parallel with the spine in a cephalward directin. D nt cntact the spinus with a perpendicular pressure with the cntact hand; it is a cephalward pressure. Apply distractin with r withut the ankle cuff depending upn patient tlerance results. The end pint f distractin is the interspinus prcess space feeling elastic resistance. When releasing distractin, return t the taut pint nly. 4. PROTOCOL I: Treatment f Sciatic Patients / pain extends belw the knee Prepare the patient as fllws: Patient Psitining Tlerance Testing Cuff n (r ff if patient experiences pain with cuff n r as tlerance testing directs) Mve ankle rest caudally until taut, and lck it in place. Disengage flexin extensin lever. Apply palpatry cntact t set treatment start pint. Apply 3 twenty secnd distractin sets. 5 pumps f 4 secnds each with F/D r lng y axis Depth f caudal distractin = cciput extensin r 2 Trigger Pint Applicatin: Between each 20 secnd sessin, treat apprpriate trigger pint(s) f the affected dermatme (ex: L5 sciatic nerve in gluteus, back f thigh, ppliteal fssa, leg, ankle and ft). 5. PROTOCOL II: Treatment f Nn Sciatica Patient (r sciatic patients wh have 50% relief) / n pain belw knee Full Facet ROM Prepare the patient as fllws: Patient Psitining Tlerance Testing Cuff On (r ff if patient experiences pain with cuff n r as tlerance testing directs) Mve ankle rest caudally until taut, and lck it in place. a. Flexin Disengage flexin extensin lever. Apply palpatry cntact t set new taut treatment start pint. Make spinus prcess cntact with thenar r finger/thumb. (Hand cntact applied in a cephalward directin.) Lift spinus prcess cephalad as table flexes. Apply ne secnd velcity flexin mvements. Amplitude and dsage are applied t patient pain and tlerance levels. Stp caudal table flexin as cciput extends r 2 f dwnward table mvement. Mvement is smth, rhythmical, scillatry mtin. Return table t neutral psitin and secure lcks OR leave unlcked fr lateral flexin. b. Lateral Flexin Perfrm under distractin using flexin (r lng y axis as apprpriate and/r cmfrtable). Disengage levers fr flexin and lateral flexin. Apply palpatry cntact t set taut new treatment start pint in flexin. (Hand cntact applied in a cephalward directin.) Apply flexin t cciput extensin r 2 f dwnward table mvement. Hld spinus prcess between index finger and thumb r use thenar cntact. Apply 1 secnd velcity lateral flexin mvements t each side (right and left). Amplitude and dsage applied t patient pain and tlerance levels. Resist spinus prcess with thumb r index finger. Mvement is smth, rhythmical, scillatry. Return table t neutral psitin and secure lcks OR leave unlcked fr circumductin. c. Circumductin Perfrm frm neutral starting psitin (n taut starting psitin set). This mtin cuples flexin/distractin and lateral bending, and it may even cmbine with lng y axis as apprpriate r cmfrtable. Grasp spinus prcess between thumb and index finger r use palmar thenar cntact. (Hand cntact applied in a cephalward directin.) Apply 2 secnd mvements t right and then t left. Amplitude and dsage applied t patient pain and tlerance levels. Mvement is a smth, rhythmical, scillatry mtin. Return the table t neutral psitin, and secure all lcks. d. Extensin Release flexin extensin lever. Cntact SP between index thumb r palmar cntact. 2 Cx Technic Prtcls

3 Apply anterir pressure as table cmes int extensin. Apply ne secnd repetitins (10 fr test). Amplitude and dsage applied t patient pain and tlerance levels. Mvement is a smth, rhythmical, scillatry mtin. Return table t neutral psitin, and secure all lcks. 6. Getting Patient ff Table / Ending Adjustment sessin Return table t hrizntal/neutral psitin. Check that all lcks are secure. Remve ankle cuffs, if used. Assist patient ff the table (instruct patient t push up ff f the arm rests). This step als allws yu t share tips n hw t get ut f bed at hme and such. II. CERVICAL SPINE Prtcl I and II Instructins The textbk Neck, Shulder, Arm Pain: Mechanism, Diagnsis, Treatment, 3 rd ed., is recmmended fr cervical spine care. The additin f lng y axis fr cervical spine distractin adjusting ffers a mre cntrlled, safer applicatin. IMPORTANT NOTES: Cervical spine adjusting is perfrmed withut the ccipital restraint system. All ranges f mtin are dne in cnjunctin with lng y axis distractin. The cntact hand n the spine mves parallel with the instrument s cervical axial distractin with the same frce and velcity. Each mvement is perfrmed t the barrier f elastic resistance as determined by the dctr s tissue tensin sense and taken then slightly beynd that barrier. Patient tlerance is mnitred at all times. 1. Patient Psitining Sequence Have the patient lie with the specific area t be treated ver the divisin between the cervical and thracic pieces. The eyes may rest in the eye cututs. If there is need fr mre length f the headpiece, unlck the headpiece lng y axis feature, psitin the head, then lck it. 2. Tlerance Testing *NOTE: Start at C1 and tlerance test each level f the cervical spine t C7. Cntact cervical spinus prcess transverse prcess with ne hand while lng y axis tractin with the cervical headpiece is applied with the ther hand n the tractin handle at the head f the table. The headpiece and yur hand cntact mve in parallel. (Alternative Plan if the patient expresses lateralizatin f pain: Use the patient s headweight as the tractin frce nly s that very gentle distractin is given if the hand cntact causes pain.) Repeat with each cervical spine level, hlding each spinus prcess transverse prcess segment fr 4 secnds. Ask patient if he/she feels any pain in the neck shulder, arm r thracic spine. NOTE: Muscle resistance in the frm f spasm is palpated fr. If any such sign is present, d nt use distractin. Instead use trigger pint, acupressure, alternating ht/cld and massage until lcal irritatin reduces t allw distractin with n signs f discmfrt. Test the next level mving caudad. 3. PROTOCOL I: Treatment f Radiculpathy Patients / pain extends belw the elbw NOTE: Only lng y axis distractin (with an ptinal slight degree f flexin set at a cmfrt level fr the patient) is used t treat acute radiculpathy. Prepare the patient fr treatment, and perfrm tlerance testing. Apply lng y axis distractin t set treatment start pint which is the pint f tautness f the interspinus space. Apply 3 twenty secnd distractin sets 5 pumps f 4 secnds each with F/D r lng y axis Trigger Pint Applicatin: Between each 20 secnd sessin, treat apprpriate trigger pints f the affected dermatme. 4. PROTOCOL II: Treatment f Nn Radicular Patients (r radicular patients wh have 50% relief) / n pain extends belw the elbw) Prepare the patient fr treatment, and perfrm tlerance testing. 3 Cx Technic Prtcls

4 a. Lng Y Axis Axial Distractin Grasp the spinus transverse prcess f the vertebra at the level f distractin mtin desired. (ex: Grasp C5 t mve the C5 segment.) Release the axial distractin lck. Standing at the side f the instrument, gently push the headpiece axially using the ball handle and the vertebra cntracted with the dctr s hand until tissue tensin sense ntes the barrier f elastic resistance (the treatment start pint). G slightly beynd the barrier f elastic resistance, carefully mnitring patient tlerance. The cntact hand and the instrument s mtin guided by the cervical tiller bar mve parallel. b. Lateral Flexin Grasp the spinus transverse prcess f the vertebra at the level f lateral flexin mtin desired. Unlck the lateral flexin lck. Mve the headpiece int lng y axis distractin. Laterally flex t the left first, then the right. Stabilize the transverse prcess away n the side f lateral headpiece flexin with the cntact hand as the level t be laterally flexed is brught int lateral flexin by the headpiece mtin. Laterally flex the headpiece until tissue tensin sense ntes nrmal physilgical mtin. c. Circumductin (a cmbinatin f lateral flexin and flexin mvement) Grasp the spinus transverse prcess f the vertebra at the level f circumductin mtin desired. Unlck the flexin and lateral lcks. Mve the headpiece int lng y axis distractin. Circumduct t the left, then t the right. Circumduct the headpiece until tissue tensin sense ntes nrmal physilgical mtin. (This is a strng mvement and imprtant t regain mbilizatin f the cervical facets.) d. Extensin Grasp the arch f the spinus transverse prcess f the vertebra at the level f extensin mtin desired. Unlck the flexin extensin lck. Extend the headpiece until tissue tensin sense ntes nrmal physilgical mtin. Repeat as necessary at each jint level. Mve t the next level, and repeat. e. Rtatin Grasp the spinus transverse prcess f the vertebra at the level f rtatin mtin desired. Unlck the rtatin lck. Mve the headpiece int lng y axis distractin. Rtate t the left, then t the right. Rtate the headpiece until tissue tensin sense ntes nrmal physilgical mtin by hlding the arch securely while the segment rtates. 5. Ending The Adjustment Sessin Return table t neutral psitin. Check that all lcks are secure. Remve ccipital restraint, if used. Instruct patient t push up n the arm rests. Assist patient t upright psitin. 4 Cx Technic Prtcls

5 III. THORACIC SPINE Prtcls 1. Using Lumbar Attended Autmated Axial Distractin Apply ankle cuffs, if apprpriate. Allw the table t axially distract per yur cntrl during the distractin adjustment and pen the jint space. Mve up the thracic spine, as apprpriate. Using the ftswitch Use a tw handed cntact f the spinus prcess at the apprpriate level. Tap the ft/tapeswitch t allw the table t mve axially. Release the ft/tapeswitch t allw the table t return t neutral. Using the finger buttn Use a ne handed cntact f the spinus at the apprpriate level. With the free hand, tap the finger buttn n the tiller bar beneath the ball handle t allw the table t mve axially. Release the finger buttn t allw the table t return t neutral. Using the cntrl bx On the bx n the side f the table, Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Use a tw handed cntact f the apprpriate spinus prcess at the apprpriate level. NOTE: A high velcity, lw amplitude adjustment may be given during lumbar attended autmated axial distractin as just described. This can be applied at any desired level f thracic spine accrding t patient need and tlerance in a gentle, nnfrce manner. 2. Using Cervical Axial Distractin Sectin OPTION 1 Manually Applied Apply the ccipital restraint system t stabilize the head. Stand at the head f the table. Use a palmar cntact n the spinus belw the thracic segment t be distracted Pull n the ball handle f the cervical headpiece t distract the segment t the pint f elastic resistance. Mve slightly beynd that pint, minding at all times patient tlerance. Gently return t neutral. Mve caudad t the next thracic spinus, and repeat. OPTION 2 Applied in Cnjunctin with Autmated Axial Distractin Caudally Apply the ccipital restraint. Allw the table t axially distract the caudal sectin. Adjust the thracic spine while Using the ftswitch Use a tw handed cntact f the spinus at the apprpriate level. Tap the ft/tapeswitch t allw the table t mve axially. Release the ft/tapeswitch t allw the table t return t neutral. Using the cntrl bx On the bx n the side f the table, Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Use a tw handed cntact f the apprpriate spinus at the apprpriate level. NOTE: A high velcity, lw amplitude adjustment may be given during thracic attended autmated axial distractin as just described. This can be applied at any desired level f thracic spine accrding t patient need and tlerance in a gentle, nnfrce manner. IV Autmated Lng Y Axis Distractin Applicatins A. Lumbar Spine Attended Autmated Axial Distractin (nn sciatica patients nly r a sciatica patient wh has attained 50% relief f pain) Prepare patient fr treatment, and perfrm tlerance testing. Using the ftswitch The aut/manual selectr must be in the MAN(ual) mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate frm tlerance testing. Make the cntact with the spinus prcess at the level desired with bth hands r with ne hand and rest the free hand n the ball handle. Tuch the ft/tapeswitch with yur ft. Allw the table t distract as far as necessary t pen the jint space. 5 Cx Technic Prtcls

6 Release the ft/tapeswitch t allw table t cme back t neutral. Make the next cntact with the spinus prcess at the next level desired & repeat prcedure. Using the finger buttn (n the caudal tiller bar at the back f the bar beneath the ball handle) The aut/manual selectr n the tiller bar must be in the MAN(ual) mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate. Make the cntact with the spinus prcess at the level desired with ne hand. Rest the ther hand n the ball handle cmfrtably enugh that the middle finger is in reach f the buttn. Tuch the buttn with yur finger. Allw the table t distract as far as necessary t pen the jint space. Release the buttn t allw the table t cme back t neutral. Make the next cntact with the spinus prcess at the next level desired & repeat prcedure. Using the cntrl bx The aut/manual selectr n the tiller bar must be in the AUTO mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate. Set the cntrl bx n the side f the table, Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Push the start buttn n the frnt f the cntrl bx. Starting at L5S1 and wrking up the lumbar spine, make a tw handed cntact r ne handed cntact (with the free hand resting n the ball handle) with the spinus prcess at the apprpriate level(s). Once each level has been distracted, ranges f mtin may be cmbined with axial distractin, per instructins as explained in Steps 5a, b, c, and d f the LUMBAR SPINE sectin (page 2), as apprpriate fr the patient and his/her cnditin. Always first distract the spinal segment, then g int the ROM desired. Flexin Extensin Lateral flexin Circumductin B. Unattended Autmated Axial Distractin (nn sciatica patients nly) Full Spine Adjusting The aut/manual selectr n the tiller bar must be in the AUTO mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate, OR apply the ccipital restraint, if apprpriate (nt bth at ne time). Set the cntrl bx n the side f the table: Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Shw the patient where the patient emergency stp buttn is under the right armrest. Explain that it can be pushed if the patient feels pain during the sessin. Allw the table t deliver an unattended tractin therapy sessin as setup. Check in n the patient during the sessin. The thracic restraint belt can be psitined and used t apply specific level unattended lng y axis distractin. Special Cx F/D and distractin adjustment prcedures demnstrated in lecture and vide include Side lying F/D and distractin adjusting fr patients wh cannt lie prne t include pregnancy sclisis treated in the prne, supine, side lying pstures fr Cx prcedures supine sclisis (adlescent and degenerative) cmpressin defects f steprsis hyperkyphsis f the thracic and lumbar spine spndyllisthesis retrlisthesis steprsis DISH spinal stensis aged spine cnditins REFERENCES: Lumbar Spine and Thracic Spine Techniques: Lw Back Pain: Mechanism, Diagnsis, Treatment, 7 th ed, published by Lippinctt Williams and Wilkins, Cervical and Thracic Spine Techniques: Neck, Shulder, Arm Pain: Mechanism, Diagnsis, Treatment, 3 rd ed, 2005, privately published, Mechanisms f table descriptins per features n The Cx 8 Table by Haven Innvatin. 6 Cx Technic Prtcls

o hold ankle (first uninvolved, then involved) o hold 4 seconds

o hold ankle (first uninvolved, then involved) o hold 4 seconds Prtcl fr Cx Technique Hands-On Prtins f Curses step by step instructins fr treating patients with Cx Distractin Decmpressin Adjustment & Manipulatin Prtcl I and II Instructins Lumbar Spine prepared by