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

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1 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 James M. Cx, D.C., D.A.C.B.R. NOTE: Please see the textbk, Lw Back Pain: Mechanism, Diagnsis, Treatment, 6 th editin, published by Lippinctt, Williams & Wilkins, fr the full explanatin and ratinale fr Cx Distractin Manipulatin and the diagnstic wrkup leading t a treatment plan fr each patient yu treat. This serves as a simple guide f the prtcls fr training. 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 ftpiece Set spring tensin / pwer balance fr caudal sectin 2. Tlerance Testing (t determine level f securing patient during adjustment) Release Flexin-Extensin Lck Central Distractin Testing 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 L5-S1 first, mve cephalward Lateral Distractin Testing 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 L5-S1 first, mve cephalward Test with cuff n 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 L5-S1 first, mve cephalward NOTE: Muscle resistance in the frm f spasm is palpated fr. If any such sign is present, d nt use 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 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 Tensin Third digit cntacts interspinus space Secnd and furth digits cntact adjacent muscles Be sure nt t make yur cntact hand perpendicular t the spine, make it mre parallel Apply distractin with cuff n ankles End pint is tautness f interspinus space r muscles This new taut pint becmes the TREATMENT START POSITION fr all further table mvement fr treating the disc r facet 4. PROTOCOL I: Treatment f Sciatic Patients Patient Psitining Tlerance Testing Cuff n Disengage flexin-extensin lever 1

2 Apply palpatry cntact t set treatment start pint Apply 3 twenty secnd distractins 5 pumps f 4 secnds each with F/D r lng-y-axis Depth f caudal distractin = cciput extensin r 2 5. PROTOCOL I: Trigger Pint Between each 20-secnd sessin, treat apprpriate trigger pint f the affected dermatme (ex: L5 sciatic nerve in gluteus, back f thigh, ppliteal fssa, back f calf and ankle) 6. PROTOCOL II: Treatment f Nn-Sciatica Patient - Full Facet ROM Prepare the patient as fllws: patient psitining tlerance testing cuff n (r ff if patient experiences pain with cuff n) mve ftpiece caudally until taut 7. Flexin Disengage flexin-extensin lever. Apply palpatry cntact t set new taut treatment psitin. Make spinus prcess cntact with thenar r finger/thumb. (Remember: parallel, nt perpendicular.) 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. 8. Lateral Flexin Perfrm under distractin. Disengage levers fr flexin and lateral flexin. Apply palpatry cntact t set taut new treatment psitin in flexin. (Remember: parallel, nt perpendicular.) 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. 9. Circumductin Perfrm frm neutral starting psitin (n taut starting psitin set). Cuples flexin/distractin and lateral bending. Grasp spinus prcess between thumb and index finger r use palmar thenar cntact. (Remember: parallel, nt perpendicular.) Apply 2 secnd mvements t right and then t left. Amplitude and dsage applied t patient pain and tlerance levels. Mvement is smth, rhythmical, scillatry mtin. Return table t neutral psitin and secure all lcks. 10. Extensin Release flexin-extensin lever. Cntact SP between index-thumb r palmar cntact. 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; secure all lcks. 11. Getting Patient ff Table / Ending Adjustment sessin Return table t hrizntal/neutral psitin. Check that all lcks are secure. Remve ankle cuffs. Assist patient ff the table (instruct patient t push up ff f the arm rests). 2

3 OTHER TREATMENT OPTIONS: A. Attended Autmated Axial Distractin (nn-sciatica patients nly) Lumbar Spine Adjusting Using the ftswitch The switch must be in the DOWN psitin n the caudal tiller bar. Make the cntact with the spinus 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 Release the ft/tapeswitch t allw table t cme back t neutral Make the next cntact with the spinus 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 switch must be in the DOWN psitin n the caudal tiller bar. Make the cntact with the spinus 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 at the next level desired & repeat prcedure Using the cntrller The switch must be in the UP psitin n the caudal tiller bar. 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. Push the start buttn n the frnt f the bx. Starting at L5S1 and wrking up the lumbar spine, make a tw-handed cntact r nehanded cntact (with the free hand resting n the ball handle) with the spinus 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 7, 8, 9, & 10, 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 switch must be in the UP psitin n the caudal tiller bar. Apply the ccipital restraint, if apprpriate. 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. 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 ccasinally during the sessin. C. Thracic Spine Adjusting Using Lumbar Attended Autmated Axial Distractin 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 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. 3

4 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 cntrller 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 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. 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 during: 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 cntrller 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. 4

5 D. Cervical Spine Adjusting 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. PROTOCOL 1 FOR THE CERVICAL DISC HERNIATION PATIENT (PAIN BELOW THE ELBOW): Psitin the patient with the specific area t be treated ver the divisin between the cervical and thracic pieces. 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. Test fr tlerance. 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. (Alternative Plan: Use the patient s headweight as the tractin frce s that very gentle distractin is given if the hand cntact causes pain.) Hld 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. Apply lng y axis distractin t set treatment start pint which is the pint f tautness f the interspinus space. Apply 3 twenty secnd distractins 5 pumps f 4 secnds each with F/D r lng-y-axis Between each 20-secnd sessin, treat apprpriate trigger pints f the affected dermatme. End the adjustment sessin. Instruct patient t push up n the arm rests. Assist patient t upright psitin. PROTOCOL 2 FOR THE NON-DISC HERNIATION PATIENT (NO PAIN BELOW THE ELBOW): Psitin the patient Place the specific area t be treated ver the divisin between the cervical and thracic pieces. Test fr tlerance. Cntact cervical spinus prcess-transverse prcess with ne hand while lng y axis tractin and all ranges f mtin with the cervical headpiece are applied with the ther hand n the tractin handle at the head f the table.. (Alternative Plan: Use the patient s headweight as the tractin frce s that very gentle distractin is given if the hand cntact causes pain.) Hld 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 reduce t allw distractin with n signs f discmfrt. Test the next level mving caudad. 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. Mve t the next level, and repeat. 5

6 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. Mve t the next level, and repeat. 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 ntes nrmal physilgical mtin. (This is a strng mvement and imprtant t regain mbilizatin f the cervical facets.) Mve t the next level, and repeat. 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. Rtatin Grasp the spinus-transverse prcess f the vertebra at the level f rtatin mtin desired. Unlck the rtatin twist 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. Mve t the next level, and repeat. End the adjustment sessin. Instruct patient t push up n the arm rests. Assist patient t upright psitin. REFERENCES: Lumbar Spine and Thracic Spine Techniques Lw Back Pain: Mechanism, Diagnsis, Treatment, 6 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 by Chir-Manis, Inc,

I. LUMBAR SPINE Protocol I and II Instructions

I. LUMBAR SPINE Protocol I and II Instructions 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,