1. Flexion Distraction

2. Objectives Review TMAP, LMAP Pelvis Sacrum/coccyx

3. 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

4. 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

5. 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

6. 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.

7. Write down the opposite letter Table flexed left restores motion, write down an “R” Add a “P” i.e. “RP” or “LP”

8. 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

9. 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

10. 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.

11. 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.

12. 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

13. 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%

14. 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

15. 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.

16. 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: –(1)Pelvic rocking –(2) Lateral press –(3) Pelvic shift –(4) Y - Translation of Lower extremity –(5) Hip rotation –(6) Pelvic derotation.

17. 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.

18. 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!!!

19. 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…)

20. 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

21. 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.

22. 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!

25. P.I. / I.N. Ilium 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

26. 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.

27. 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

28. 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.

29. A.S. / E.X. Ilium 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

30. 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

31. Exception to the rule... For the Posterior Ischium, make the adjustment when the table comes back to neutral…re-check listing.

32. 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

33. Sacral Analysis 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

34. 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

35. 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.

36. 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

37. 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.

38. Base Posterior 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

39. Sacrum Sacral nodding… Information may be obtained while performing stretches. Post/inferior--flexion Ant/superior--extension

40. 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

41. 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.

42. 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.