Cervical and Thoracic Set Ups

The neck and upper back are where most technique stations live, and they are where a few degrees of extra rotation, a contact one finger off, or a line of drive aimed at the table instead of along the facets matters most. This chapter walks region by region from the occiput to the ribs, giving each standard diversified style set up as a checklist you can perform and say aloud under time. Learn these as patterns: the same seven elements, adapted to the anatomy of each level.

Section 1Upper cervical set ups

Anatomy that shapes every upper cervical set up

The upper cervical complex (occiput, atlas and axis) is built for motion, not for load. The atlanto-occipital joints are cup shaped: the convex occipital condyles sit in concave superior atlas facets, and the joint moves mainly in flexion and extension (the "yes" motion) with small amounts of lateral flexion. The atlantoaxial joints are three joints: the median joint between the dens and the anterior arch (held by the transverse ligament) and two lateral joints whose nearly flat, biconvex surfaces allow large rotation, about half of all cervical rotation (roughly 40 degrees to each side). The alar ligaments check rotation and lateral flexion.

The vertebral artery runs up through the transverse foramina (usually entering at C6), passes through the atlas transverse foramen, then loops posteriorly and medially across the groove on the upper surface of the posterior arch before piercing the atlanto-occipital membrane to enter the skull. Rotation, especially combined with extension, stretches the contralateral artery at this loop. Upper cervical set ups therefore use minimal rotation, avoid end range, avoid combining rotation with extension, and rely on precise contact and a short, shallow impulse. They also demand screening for instability: rheumatoid arthritis, Down syndrome, inflammatory spondyloarthropathy, recent trauma, os odontoideum and congenital anomalies can all weaken the transverse ligament or the dens, making HVLA at this level contraindicated.

Listings at the occiput and atlas

Occiput faults are usually written as a motion restriction or a body position: occiput flexion or extension restriction, lateral flexion restriction to one side, or a posterior occiput on one side (rotation). The Palmer Gonstead atlas listing reads, in order, the sagittal tilt of the anterior tubercle (AS or AI), the side of laterality (R or L) and the rotation of that side (A or P). ASRP is therefore an atlas whose anterior tubercle is tipped superior, which has slipped to the right, and whose right side is posterior. In diversified terms you would contact the right side of the atlas, correct the right laterality with a lateral to medial component, and correct the right posterior rotation with a posterior to anterior component.

Two other upper cervical approaches appear in practice and on exams. In toggle recoil (Palmer upper cervical), the patient lies on the side with the head on a firm headpiece and the doctor delivers a very fast, very shallow thrust with recoil through a pisiform contact on the atlas transverse process along a line calculated from the listing. Instrument and low force methods apply a brief mechanical impulse to the same contacts and are a common choice when HVLA is relatively contraindicated or the patient declines it.

The supine atlas station, step by step

Section 2Lower cervical set ups

Contacts on the lower cervical vertebra

From C2 to C7 the useful segmental contacts are the articular pillar (the column formed by the superior and inferior articular processes, palpable about 1.5 to 2 cm lateral to the spinous processes, posterior to the transverse processes), the lamina (between the spinous and the pillar, used particularly in seated Gonstead style work) and, less often, the short bifid spinous process. The transverse processes are anterior and lateral, carry the vertebral artery in their foramina, and are not used as contacts for HVLA in the lower cervical spine. The usual contact point is the lateral surface of the proximal phalanx of the index finger at the MCP (the index MCP contact), with the forearm aligned behind the line of drive.

The rotary set up

The supine rotary set up (often called the rotary break) induces rotation. The contact goes on the articular pillar on the side of posterior body rotation, which is the side opposite the spinous listing: for C5 PR (spinous right, body rotated left) the left pillar is posterior, so the contact is on the left pillar and the drive rotates C5 to the right. The head is rotated away from the contact only far enough to bring tension to the target level, usually about 30 to 45 degrees and never to end range, and is laterally flexed slightly toward the contact. The line of drive is P to A and slightly I to S along the facet plane, often described as "toward the opposite eye."

The lateral flexion set up

The lateral flexion set up (lateral break) induces lateral flexion. The contact goes on the articular pillar on the side toward which lateral flexion is restricted, the head is laterally flexed over the contact so that the contact becomes a fulcrum, a little rotation away from the contact takes up slack, and the drive is lateral to medial through the pillar. Because it uses less rotation, many clinicians prefer it for patients in whom rotation is uncomfortable, and it is a natural choice when the listing is primarily a lateral flexion restriction or a Gonstead S or I wedge.

Locking with opposite coupling

In the lower cervical spine, lateral flexion and rotation couple to the same side. If you combine lateral flexion toward one side with rotation toward the other, the segments above the contact reach tension sooner because you are asking them for a non physiological combination. This locking confines motion to the level under the contact, which lets you use less total rotation and less force. It is the reason the rotary set up adds slight lateral flexion toward the contact while rotating away.

Section 3Cervicothoracic junction set ups

Why the junction is its own region

From C6 to T3 the spine changes character. The mobile, lordotic cervical spine meets the stiff, kyphotic thoracic spine braced by the first ribs; the facet planes steepen; the large C7 and T1 spinous processes become reliable landmarks; and the shoulders and upper trapezius pile up soft tissue over the contacts. Pure cervical set ups struggle to reach this area without excessive rotation, and pure thoracic set ups struggle to get past the shoulders, so the junction has its own family of set ups. The first rib, the brachial plexus and the subclavian vessels also pass through this region, so ask about arm symptoms and screen for thoracic outlet signs before adjusting.

Find the levels carefully. C7 is usually the most prominent spinous process (vertebra prominens), but T1 can be as prominent. On passive extension of the neck the C6 spinous moves anteriorly and becomes hard to feel, C7 moves slightly, and T1 does not move; on rotation C7 moves more than T1. Use two of these tests before contacting.

Prone set ups

The prone thumb move (a spinous push at the junction) is the classic station set up for a rotated C7, T1 or T2. The patient lies prone with the face in the headpiece and the arms at the sides. The doctor stands at the side of the table at the level of the patient's shoulders, on the side of spinous rotation. The thumb of the caudal hand contacts the lateral surface of the spinous process on the side to which it has rotated; the other hand rests on the side of the patient's head and laterally flexes it toward the contact, which brings tension down to the junction and stabilizes the segments above. The line of drive is lateral to medial (pushing the spinous back toward the midline), with a slight P to A component. Variations include the swimmer's position, in which the patient's arm on one side is raised overhead to rotate the scapula out of the way and take up slack, and a prone pisiform spinous push with the head rotated slightly away.

For extension restrictions at T1 to T3, a prone bilateral transverse contact (as in the mid thoracic spine) works if the headpiece is lowered so that the upper thoracic spine is not forced into flexion and if the doctor's arms are angled to clear the shoulders.

Supine and seated set ups

The supine cervicothoracic lateral flexion set up extends the lower cervical lateral break down to C7 and T1. The patient is supine; the doctor stands at the head of the table. The index MCP (or the thumb web) contacts the lamina or transverse process region of T1 (or the C7 pillar) on the side to be laterally flexed, the head is laterally flexed toward the contact with slight rotation away, and the drive is lateral to medial, with a slight superior to inferior angle to reach down to the junction. The other hand cradles the occiput. The supine upper thoracic set up adapts the anterior thoracic technique: the patient clasps the hands behind the neck with the elbows together, the doctor's contact hand lies under T1 to T3, and the drive goes A to P through the elbows. A seated junction set up is also used (doctor behind the patient, thumb or pisiform on the spinous, other hand laterally flexing the head), particularly for patients who cannot lie prone.

Section 4Thoracic set ups

Thoracic anatomy for the set up

The thoracic facets lie at about 60 degrees to the horizontal, close to the frontal plane, so the region favors rotation and lateral flexion, with flexion and extension limited by the ribs and the overlapping spinous processes. The spinous processes are long and angled downward, most steeply in the mid thoracic spine, so the tip of a spinous often lies at the level of the transverse processes of the vertebra below (the rule of threes, Chapter 9). The ribs articulate with the bodies and transverse processes, so a thoracic thrust always loads the costal joints too. The thoracic spine is also the most common site of osteoporotic compression fracture, and mid back pain is a classic presentation of visceral disease (myocardial ischemia, aortic dissection, pulmonary embolism, gallbladder, peptic ulcer and renal disease). Screen accordingly.

Prone set ups

Prone bilateral transverse (often called the double transverse or "butterfly" when the hands are crossed): the patient lies prone with the arms at the sides or hanging over the table edge; the doctor stands at the side in a square or slight fencer stance; the pisiforms (hands crossed, wrists extended, fingers pointing in opposite directions) contact both transverse processes of the involved vertebra. Ask the patient to breathe out, take up slack at end exhalation, and drive P to A with a slight I to S component using a body drop. It induces extension and is used for extension restrictions or a Palmer Gonstead posterior listing without rotation.

Crossed bilateral: one pisiform on the transverse process of the involved vertebra on the side of posterior body rotation and the other pisiform on the opposite transverse process of the vertebra below. The drive (P to A, slightly I to S) rotates the involved vertebra relative to the one below. For T6 PR (spinous right, body left), contact the left TP of T6 and the right TP of T7.

Unilateral transverse: a single pisiform contact on the posterior TP, reinforced by the other hand (the reinforcing hand grasps the contact wrist or overlies it). Unilateral spinous push: the pisiform or hypothenar contacts the lateral surface of the spinous on the side of rotation and drives L to M with a P to A component, while the other hand reinforces. In Gonstead style prone work the spinous contact is combined with a tissue pull and a line set by the listing.

The supine anterior thoracic set up

The supine set up (sometimes called the anterior thoracic adjustment) is used for flexion restrictions (a segment fixed in extension, sometimes listed as an anterior or "A" thoracic), for patients who cannot lie prone, and when a prone body drop would be too forceful for the ribs. The patient lies supine and crosses the arms over the chest, each hand to the opposite shoulder, elbows stacked. The doctor stands at the side of the table, rolls the patient toward them, and places the contact hand under the patient at the lower vertebra of the restricted motion segment: a loose fist or an open hand with the thenar eminence and the flexed fingers on the two transverse processes, the spinous lying in the gap. The patient is rolled back onto the hand, the upper trunk is flexed slightly over the fulcrum (often with the doctor's other hand supporting the head and neck), and the doctor places the chest or epigastrium on the patient's crossed elbows. The drive is A to P through the arms, angled slightly toward the contact (S to I) so that the force flows down the trunk into the fulcrum.

Modifications and precautions

• Osteoporosis or long term corticosteroid use: avoid body drops and supine thrusts through the ribs; use mobilization, drop pieces with light force, instruments or soft tissue methods.
• Breast tissue and implants: place a pillow or towel under the chest for prone work, use a flat hand or pillow barrier in supine work, explain before touching.
• Pregnancy: avoid prone positioning without a pregnancy support table or cushions; side lying or seated options are alternatives in later pregnancy.
• Shoulder problems: a patient who cannot cross the arms may hold a rolled towel against the chest instead.
• Visceral warning signs: chest pain, dyspnea, diaphoresis, pain unchanged by movement or palpation, or pain with fever or weight loss: stop and refer.

Section 5Rib and costal set ups

Rib anatomy and motion

Each typical rib (2 to 9) has a head with two demifacets that articulates with the bodies of two vertebrae and the intervening disc (the costovertebral joint), a neck, and a tubercle that articulates with the transverse process of the lower of those two vertebrae (the costotransverse joint). Ribs 1, 10, 11 and 12 articulate with a single vertebral body, and ribs 11 and 12 have no costotransverse joint. Lateral to the tubercle, the shaft turns sharply forward at the rib angle, the most posterior point of the rib and the usual posterior contact. In the upper ribs the axis of motion through these two joints favors an anterior rise of the sternum, the pump handle motion; in the lower ribs it favors a lateral swing, the bucket handle motion; ribs 11 and 12 move in a caliper fashion.

Rib dysfunction is usually described by the phase of breathing in which the rib stops moving. In an inhalation restriction (exhaled rib) the rib is held down and does not rise with inspiration; in an exhalation restriction (inhaled rib) it is held up and does not fall. Posteriorly, a rib may be described as a posterior rib angle (prominent and tender) or a rib held in a subluxated position at the costotransverse joint. The most common station tasks are a prone posterior rib angle set up, a supine rib set up and the first rib.

Prone and supine rib set ups

For a prone posterior rib set up the patient lies prone, the doctor stands on the side opposite the rib (reaching across) or on the same side, and the pisiform or thenar contacts the rib angle, just lateral to the transverse process at the level of the rib. The other hand reinforces or stabilizes the opposite side of the thorax. The drive is P to A with a lateral and slightly inferior component, following the line of the rib as it curves forward and down from the angle, applied at the end of exhalation. For a contact closer to the costotransverse joint (rib head and neck), the drive is more purely P to A. A supine rib set up mirrors the anterior thoracic technique: arms crossed, the thenar eminence of the contact hand under the rib angle on the involved side, and a drive A to P through the patient's crossed arms.

The first rib

An elevated first rib is common with scalene tightness and upper trapezius strain and may contribute to neck, shoulder and thoracic outlet symptoms. The contact is on the superior surface of the first rib, felt at the base of the neck just anterior to the upper trapezius and posterior to the clavicle. In the supine set up the doctor stands at the head of the table, contacts the rib with the lateral index MCP or the web of the hand, laterally flexes the head toward the contact (to slacken the scalenes) with slight rotation away, and drives S to I and slightly L to M, toward the opposite hip. In the seated set up the doctor stands behind the patient, uses the same contact, and drives in the same direction. The brachial plexus and subclavian vessels cross the first rib between the anterior and middle scalenes, so ask about arm numbness, color change or swelling and use only a light, shallow impulse.

Red flags around the ribs

Words worth knowing