Cervical Upglide Thrust (C2-C7)

Patient Position: Supine on the table with the cervical spine in a neutral position.

Clinician Position: Standing beside the patient’s head. The superior forearm is placed under the patient’s neck to facilitate upper cervical side bending and rotation to the right. The superior hand rests on the patient’s chin. The lower cervical spine is positioned into left side bending. The segment to be manipulated should be aligned at the transition between these counteracting curves, resulting in relative neutral side bending.

Manipulation Technique: The inferior hand’s second MCP joint is positioned on the posterior facet column at the level to be treated.

Direction of Forces: The combined upper cervical spine right side bending and rotation, along with the lower cervical spine left side bending and right rotation, creates a joint lock above and below the target segment. An upward thrust is then applied at the barrier to facilitate the manipulation.

Indications: This technique is used to alleviate pain and muscle guarding at or around the targeted segment, and to enhance segmental cervical motion. It is particularly effective when the locking of the segment is executed precisely.

Cervical Upglide Thrust (C3-C7)

Patient Position: The patient’s cervical spine should be in a neutral position or slight extension for C2-C4. For lower cervical segments, slight flexion may be beneficial.

Clinician Position: Position at the head of the table, transitioning to a diagonal or martial arts stance as needed. The hand contacting the target segment will be placed on the posterolateral aspect of the articular pillar, while the opposite hand rests on the posterolateral aspect of the occiput. Alternatively, a bilateral cradle hold with both hands positioned at the same level can be used. As side bending and lateral glide are applied, the clinician’s body should shift diagonally with feet aligned in the direction of the thrust. As the body turns toward the thrust direction, side bending and lateral glide are induced by shifting weight onto the front leg. The clinician’s midline should be aligned with the vertex of the patient’s head. Ensure the table height allows for slight elbow flexion, keeping elbows close to the body.

Direction of Forces: This technique involves a combination of extension or flexion, side bending, lateral glide, and rotation, with rotation being the primary lever for the thrust, though minimal due to the combined levers. The vertex of the patient’s head should remain centered with the clinician throughout the procedure. The clinician should integrate side bending, lateral glide, rotation, and extension or flexion, with some posterior-anterior (PA) shift if needed. Compression can be added; both hands must work together to maintain force and ensure proper joint positioning before the thrust.

The hand on the occiput may be used to maintain a neutral position. The direction of the force will vary from the opposite eye to the ramus of the jaw depending on the segment being targeted. It is not necessary to pre-set forces or reach the maximum barrier; instead, engage the forces, ease into the barrier, and avoid excessive force. This is not a ligamentous lock. The clinician may use small impulses to gauge and feel the desired barrier, adjusting the direction of thrust accordingly and targeting the segment effectively.

Indications: This technique is used for segmental restrictions, localized pain, scapular pain, and headaches.

Cervico-Thoracic Distraction Manipulation

Patient Position: Seated with hands cradling the back of the neck, thoracic spine supported on the clinician’s chest, and cervical spine in a neutral position.

Clinician Position: Standing behind the patient with knees slightly bent. The clinician’s forearms are interlocked with the patient’s arms through the axilla. The clinician’s fingers palpate the C7-T1 interspinous space. The patient’s thoracic spine is supported on the clinician’s chest.

Direction of Forces: To engage the slack at the cervico-thoracic (CT) junction, the clinician slightly elevates and retracts the shoulder girdle while adducting the arms against the patient’s lateral trunk. The cranial impulse is generated by the clinician extending their knees while maintaining contact with the patient’s lateral trunk. The clinician must exercise caution to avoid applying any force that would cause cervical spine flexion.

Indications: This technique is used to reduce pain and muscle guarding, and to enhance motion in all directions at the CT junction and/or upper thoracic spine.

Cervico-Thoracic Lateral Glide Manipulation (T1-T3)

Patient Position: Prone, positioned close to the side being targeted. For a right cervico-thoracic (CT) junction manipulation, the patient should be positioned toward the right side of the table. The ipsilateral arm is elevated with the hand resting on the corner of the table, though this is not necessary if the patient is unable to maintain this position. The contralateral arm rests neutrally along the patient’s side. Rolled towels can be placed under the occiput to minimize full rotation and support the pre-manipulation position.

Clinician Position: Centered over the patient’s head. The upper hand contacts the patient’s front or temporal bone with fingers pointing superiorly to induce lateral flexion rather than rotation. The lower hand uses the first web space and index finger to contact T1, with the wrist flat and neutral, ensuring that forces are aligned with the forearm.

Direction of Forces: Begin by using the lower hand to induce lateral flexion, causing the patient’s head to move from rotation to a neutral position. At this point, engage the upper hand to further create lateral flexion. As the lower hand induces lateral flexion and the head returns to neutral, the lower hand thrusts into a lateral glide/translation while the upper hand thrusts into lateral flexion. This technique results in a “bend” of C7 over T1. It is crucial to apply more force with the lower hand, which has a shorter lever arm, rather than relying solely on the upper hand with a longer lever arm, which is less effective.

Indications: This technique is used to address limited mobility at the C/T junction and is particularly effective for patients with upper trapezius and scapular pain.

Upper Thoracic Manipulation (T1-T3)

Patient Position: Supine with arms crossed in a ‘V’ shape. Place 1-2 rolled towels between the arms and chest for added comfort. The patient may flex the legs to increase tension or keep them straight in extension, depending on the desired effect.

Clinician Position: Positioned directly over the patient, around the xiphoid process or slightly inferior. The top arm should hold both of the patient’s arms to provide better control and localization of the barrier. The inferior hand forms a closed/relaxed fist, with the spinous process of the desired segment centered within the hand. For T2/T3, the T3 spinous process will align with the middle phalanx of the third finger, and the T2 spinous process will be centered under the middle finger.

Direction of Forces: Begin by pulling down to align the patient’s elbows vertically, with the clinician’s epigastric region positioned just inferior to the xiphoid process on the patient’s elbows. The primary lever for the thrust is an anterior-posterior force. Secondary levers, such as compression, rotation, side flexion, or extension, can be added. This can be achieved by radially deviating or pronating the inferior hand and using the upper arm to assist. Additionally, a “scoop” motion can be employed to add traction and bring the thoracic spine into extension. The thrust is delivered by dropping the clinician’s knees at the moment of thrust, ensuring the clinician’s spine remains upright and the head is held up.

Indications: This technique is used for segmental restriction into extension and can also assist with rotation and side bending. However, techniques that primarily use side bending or rotation as levers may be more effective for those specific motions.

Rib PA Manipulation (Side Lying) T3-T10

Patient Position: The patient is positioned side-lying over a bolster placed under the targeted rib level. For example, if the target is T6, the bolster should be placed under T5-6, resulting in left side bending and right rotation of the thoracic spine, which helps lock the level from rotating left. The legs should be flexed at the hips.

Clinician Position: Positioned facing the patient. The superior hand, using the ulnar border, is placed on the desired rib level. The lower hand stabilizes the patient’s pelvis to ensure stability.

Direction of Forces: The superior hand stabilizes the upper trunk and applies slight counterforce to the thrust hand. It may also induce some rotation to assist in achieving the barrier and improving localization at the targeted level. During the patient’s full expiration, a ventral/lateral high-velocity thrust (HVT) is applied perpendicular to the costovertebral joint.

Indications: Assess the symmetry of segmental motion and observe relative movement with inhalation and exhalation to identify restrictions. This technique focuses on anterior glide to enhance exhalation and ipsilateral rotation.

Rib PA Manipulation (Supine) T6-T10

Patient Position: Supine on the table with arms crossed and hands placed along the rib cage to tighten the fascia.

Clinician Position: Positioned facing the patient. The radial side of the clinician’s hand or thumb is placed along the rib to be manipulated. The superior hand is placed on the patient’s elbows anteriorly.

Direction of Forces: The superior hand delivers an anterior-posterior (A-P) force through the patient’s elbows. Simultaneously, the inferior hand applies a force along the rib to move it anteriorly. This produces a ventral/lateral high-velocity thrust (HVT) directed perpendicular to the costovertebral joint as the patient’s body moves posteriorly into the table.

Indications: This technique is used for treating a hypomobile, non-painful rib.

Lumbar Spine Rotation Manipulation

Patient Position: The patient is side-lying over a bolster placed below the targeted level. For example, if the manipulation is at L2-3, the apex of the bolster should be at L4. The patient should be flexed from below up to the L2-3 level by bringing one hip into flexion. In this position, side bending and rotation will occur in the same direction due to the flexion, which helps lock the segment. The patient should be in flexion with right side bending and right rotation, while the targeted segment remains in neutral.

Clinician Position: Facing the patient, the superior hand is pronated over the ribs, while the inferior hand is placed on the ilia for stabilization.

Direction of Forces: The clinician’s superior hand delivers the high-velocity, low-amplitude (HVLA) thrust through the superior arm and body, while the inferior hand creates a counterforce to stabilize the pelvis.

Indications: This technique is used to improve segmental motion and decrease pain and guarding at the targeted segment or adjacent levels

R Ilium Anterior Rotation Manipulation

Patient Position: Prone over a bolster with the anterior superior iliac spine (ASIS) off the edge of the table. The lumbar spine is in flexion and left side bending, which locks L5-S1 into left rotation.

Clinician Position: Positioned behind and to the left side of the patient. The left hand is placed on the right iliac crest, while the right hand supports the distal thigh in adduction to induce left side bending while maintaining lumbar flexion.

Direction of Forces: The clinician directs the right ilium in an anterior and slightly lateral direction.

Indications: This technique addresses restrictions in the anterior rotation of the right ilium relative to the sacrum.

L Ilium Posterior Rotation Manipulation

Patient Position: Side lying with the spine in flexion and left side bending, which locks L5-S1 into left rotation.

Clinician Position: Standing in front of the patient in a side stance. The superior hand applies the heel of the hand to the left ASIS, while the inferior forearm is positioned at the ischial tuberosity. The clinician’s body supports the left hip in flexion and slight adduction. The clinician’s fingertips palpate the sacroiliac joint (SIJ).

Direction of Forces: The clinician directs the left ilium in a posterior and slightly medial direction.

Indications: This technique is used to address restrictions in the posterior rotation of the left ilium relative to the sacrum.

Glenohumeral Anterior Glide

Purpose: To increase shoulder external rotation and extension.

Patient Position: Prone with the shoulder at the edge of the table, abducted to 90 degrees, and the elbow flexed to 90 degrees.

Clinician Position: Mobilizing hand placed on the posterior humeral head, stabilizing hand on the mid-humerus.

Direction of Forces: Apply an anterior force with the mobilizing hand to the humeral head while the stabilizing hand provides gentle traction.

Indications: Useful for enhancing shoulder external rotation and extension.

Glenohumeral Posterior Glide

Purpose: To increase shoulder flexion and internal rotation.

Patient Position: Supine with the shoulder at the edge of the table, abducted to 45 degrees, and the elbow slightly flexed. The scapula is stabilized by the table or a towel roll.

Clinician Position: Mobilizing hand on the anterior humeral head, stabilizing hand supporting the elbow.

Direction of Forces: Apply a posterior force with the mobilizing hand to the humeral head while the stabilizing hand provides gentle traction.

Indications: Effective for improving shoulder flexion and internal rotation.

Glenohumeral Inferior Glide

Purpose: To increase shoulder abduction and flexion.

Patient Position: Supine with the arm in 30 to 45 degrees of abduction.

Clinician Position: Stabilizing hand supports the scapula in the axilla, while the mobilizing hand grasps the distal humerus.

Direction of Forces: Apply an inferior force with the mobilizing hand while the stabilizing hand holds the scapula steady.

Indications: Facilitates improved shoulder abduction and flexion.

Acromioclavicular Joint Anterior Glide

Purpose: To increase joint mobility.

Patient Position: Sitting, with the scapula stabilized by the clinician’s thumb along the scapular spine and fingers along the acromion.

Clinician Position: Mobilizing hand placed on the posterior clavicle near the joint line.

Direction of Forces: Apply an anterior force with the mobilizing hand to the clavicle.

Indications: Enhances mobility at the acromioclavicular joint.

Sternoclavicular Joint Superior/Inferior and Anterior/Posterior Glides

Purpose:

Superior glide increases depression.
Inferior glide increases elevation.
Anterior glide increases protraction.
Posterior glide increases retraction.

Patient Position: Supine with the stabilizing hand on the sternum and the mobilizing thumb or thumb and index finger on the proximal clavicle.

Clinician Position:

For superior glide: Index finger applies a superior force to the clavicle.
For inferior glide: Thumb applies an inferior force to the clavicle.
For anterior glide: Thumb and index finger lift the clavicle.
For posterior glide: Thumb applies a posterior force to the clavicle.
Direction of Forces:

Superior Glide: Apply superior force.
Inferior Glide: Apply inferior force.
Anterior Glide: Lift the clavicle.
Posterior Glide: Apply a posterior force.

Indications: Adjusts the movement in the sternoclavicular joint to improve various directions of motion.

Scapular Mobilization

Purpose: To increase mobility at the scapulothoracic articulation.

Patient Position: Prone.

Clinician Position: Superior hand along the scapular spine, inferior hand grasping the inferior angle of the scapula.

Direction of Forces: Mobilize the scapula in elevation, depression, adduction, abduction, or rotation by pushing in the appropriate direction.

Indications: Enhances overall scapular mobility and articulation at the scapulothoracic joint.