OMM 8- HVLA (Thoracic Spine)
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HVLA
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Key Concepts
HVLA (thrust) approach is characterized by positioning to engage the restrictive barrier, followed by a corrective
maneuver to move through the barrier.
Accurate diagnosis is the key to performance of HVLA (thrust) techniques.
Positioning against the restrictive barrier in all planes is followed by a rapid and brief corrective thrust.
HVLA (thrust) techniques can be taught and learned easily. The necessary motor coordination for effective use
requires extensive practice and experience.
HVLA definition:
• An osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short
distance within the anatomic range of motion of a joint, and that engages the restrictive barrier of an
articular somatic dysfunction in one or more planes of motion to elicit release of restriction. Also know
as thrust technique.
AT Still used very little thrust technique—more of a myofascial release (indirect)
Distinct barrier mechanics
Within anatomic ROM (actually physiologic ROM)
Engages restrictive barrier (within physiologic ROM)
Goal: 1. move restricted joint through its dysfunctional barrier.
2. restore appropriate physiologic motion to the dysfunctional joint.
Reassessment shows immediate increase in ROM and freedom of motion
Safety and Success:
Low distance (amplitude) = safety
High Acceleration (velocity) = success
T: Are there palpable tissue texture changes?
A: Is there visual asymmetry?
R: Is there a restriction of motion?
t: Does the palpatory exam elicit tenderness?
HVLA: think “TARt”—restriction of motion most important
Counterstrain: think “TARt” –Tenderness and texture change
Quantity of motion: amount of movement from joint’s midline or neutral joint to a motion barrier
 Amount of movement from neutral point
Quality: palpatory sense of how smoothly a joint can move through its ROM
PASSIVE
(involuntary)
MOTION
NEUTRAL
ACTIVE (VOLUNTARY) MOTION
PHYSIOLOGICAL BARRIERS
ANATOMICAL BARRIERS
Physiologic Barrier: end of motion when a healthy
joint is actively moved
Active ROM is within this barrier
Anatomic Barrier: furthest motion an examiner can
test passively
if you go beyond, orthopedic problem!
OMM 8- HVLA (Thoracic Spine)
Restrictive Barrier (Pathologic Barrier): when a joint
experiences motion loss as a result of “somatic
dysfunction.”
A functional limit within the anatomic ranges of motion,
which abnormally diminishes the normal
physiologic range.
In other words--within the range permitted by the
physiologic barriers
Generally not preceded by the normal joint end feel.
Remember the firmer end feel, less elastic at the end of
motion
MIDLINE IS IN THE MIDDLE OF THE RANGE OF
PHYSIOLOGIC MOTION
MIDLINE = MIDRANGE
Direct Method: Engage the Restrictive Barrier
Indirect Method: physician directs patient’s
tissues to the perceived, palpated neutral
(midrange)
Direct Methods
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Stretching
Inhibition
Range of Motion (ROM), Articulatory
Soft Tissue (ST)
Myofascial Release (MFR)
Springing
Muscle Energy (ME)
Thrust (HVLA)
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Steps of HVLA thrust
Gently position patient against restrictive barrier.
Apply constant gentle pressure against barrier.
Encourage patient to breathe and relax.
Apply a gentle high velocity, low amplitude thrust through restrictive barrier.
Reposition patient to neutral position and reassess.
OMM 8- HVLA (Thoracic Spine)
Goal: Remove motion loss, Regain normal ROM, Restore normal barriers (remove restrictive barrier)
Mechanism of Treatment:
ROM Segment or joint inhibited from completing its full motion potential
Reflex hypertonicity of surrounding musculature
Restoration of Motion: restoration of normal proprioceptive input and reflex relaxation of mm surrounding jt.
Joints
• C2-L5
– Assessed in the 3 cardinal planes of motion—SB, R, F/E
• Unique motion patterns:
– OA, AA, SI (still need summed vector)
• Appendicular—one major motion (minor motion loss
Pop Sound
• Theories:
– Eventration of gas into synovial fluid
– Snapping or releasing of ligamentous adhesions
– Bone slightly pulled out of place (subluxed) and snaps back into place
– Ballooning of the joint capsule
Contraindications to HVLA
• Absolute (regionally or segmentally specific):
1. Upper Cervical (OA, AA)
Rheumatoid Arthritis
Down Syndrome
Achondroplastic dwarfism
Chiari malformation
Vertebrobasilar insufficiency
2. Fracture / Dislocation / spinal or joint instability
3. Ankylosis / Spondylosis with fusion
4. Surgical fusion / ankylosis/ spondylosis with fusion
5. Klippel – Feil Syndrome
6. Inflammatory Joint Disease
7. Joint Infection
8. Bony Malignancy
9. Patient Refusal
 Relative (regionally or segmentally specific)
1. Acute HNP (herniated nucleus pulposus)
2. Acute Radiculopathy
3. Acute whiplash / severe mm spasm / sprain / strain
4. Osteopenia / Osteoporosis
5. Spondylolisthesis
6. Metabolic Bone Disease
7. Hypermobility
Osteopathic Manipulative Medicine (prerequisite knowledge and skill)
• Competent diagnostician
• Know anatomy, physiology and pathophysiology
• Understand somatic dysfunction
• Manual medicine technical skill
• Ability to integrate all of this knowledge and skill to the patient’s best benefit
OMM 8- HVLA (Thoracic Spine)
HVLA Technique Methodology
1. Initial Positioning
Both Physician and Patient!
Physician: relaxed and balanced
Patient : comfortable & trusting
2. Engagement and stacking barriers
Restrictive barrier: all 3 planes: SB, R, F/E
Setup painful?
something’s wrong!
pt back to neutral and reassess
incorrect dx or technique?
SD that is not amenable to HVLA?
3. Accumulation of forces
Tx of a dysfunctional relationship between 2 bones
hold one still and move the other the way it would
really rather not go at the moment
Discomfort: moment all forces are stacked against restriction
Novice: loses concentration, relaxes forces on segment, does not maintain localization of barriers
4. Final corrective thrust
Short rapid thrust once the barrier is engaged
“impulse”: sudden acceleration & deceleration
do not “back up” prior, hold localization (use intuition!)
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Benefits of Cervical Spinal Manipulation
Relief of acute neck pain
Reduction in overall neck pain
Short term relief of tension headache
Relieves cervicogenic headache
Major Complications
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Vertebral artery dissection
– 1 per 400,000 to 1 per 10,000,000
– Complication rates from medication, surgery, and most other neck pain treatments for which data are
available are estimated to be higher than those from Cervical Spinal Manipulation.
– Because most VBA dissections result in neck pain or headache, it is likely that in at least a percentage of
patients, it is the dissection that causes the patient to seek manipulation rather than the manipulation
causing the dissection.
Lateral disc herniation – radiculopathy,
– Myelopathy, VBA compression
– *Lessened by exclusion criteria
Greatest risk of bad outcome: HVLA with hyperextension, rotation, and traction
“It has been proposed that thrust techniques that use a combination of hyperextension, rotation and traction of
the upper cervical spine will place the patient at greatest risk of injuring the vertebral artery.”
NSAIDs
• Most commonly prescribed agent for neck pain.
• 13 million Americans use NSAIDs regularly.
• GI tract complications
• 3.9 billion dollars
• 103,000 hospitalizations/year
• 16,500 deaths/year (GI toxicity from NSAIDs) the
15th most common cause of death in
the USA.
OMM 8- HVLA (Thoracic Spine)
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Epidural Steroid Injections – Pain Mx Specialist
• Complications:
• Subdural injection: ~1 in 100 procedures
• Intrathecal injection: ~ 0.6 to 10.9 in 100 procedures
• Intravascular injection: ~2 to 8 in 100 procedures
“Osteopathic manipulative treatment of the cervical spine, including but not limited to High Velocity/Low
Amplitude treatment, is effective for neck pain and is safe, especially in comparison to other common
treatments. Because of the very small risk of adverse outcomes, trainees should be provided with sufficient
information so they are advised of the potential risks. There is a need for research to distinguish the risk of VBA
associated with manipulation done by provider type and to determine the nature of the relationship between
different types of manipulative treatment and VBA.”
“Therefore, it is the position of the American Osteopathic Association that all modalities of osteopathic
manipulative treatment of the cervical spine, including High Velocity/Low Amplitude, should continue to be
taught at all levels of education, and that osteopathic physicians should continue to offer this form of treatment
to their patients.”
“No statement could be made linking OMT with cervical spinal manipulation-severe adverse events.”
Lab Techniques
Supine Thoracic HVLA
• Pt supine with Dr on either side of pt
• Pt arms are crossed with arm on side opposite of Dr placed on top
• Pt’s upper torso is rolled toward Dr and flexed with cephalic hand
• Dr flexes fingers of caudal hand to leave crease between knuckles and thenar/hypothenar eminences
• SP of segment is contacted in crease
• Place SP of the segment you are treating in crease
• Supports bilateral TP while cradling SP
• Roll pt onto caudal hand using it as a fulcrum while maintaining flexion at lesioned segment
• Pt inhales deeply then exhales completely
• Dr follows exhalation completely, compressing pt and isolating lesion
• Flexion: Apply HVLA thrust perpendicular to floor (straight down)
• Extension: Apply HVLA thrust on lower vertebrae of dysfunctional segment at 45 degree angle
Kirksville Crunch (Neutral)
1. Pt supine, physician on opposite side from rotational component
2. Patient’s arms crossed in “V” formation with opposite arm on top
3. Physician either rolls patient gently towards themselves or lifts patient shoulder girdle to access back
4. Thenar eminence of caudad hand placed posterior to the transverse process of the dysfunctional spinal unit
– Can use clenched or open hand
5. Patient’s elbows are directed into physician’s upper abdomen, inferior to xiphoid process
6. Physician’s cephalad hand and arm support patient’s head and neck
7. Extend thorax over fulcrum.
(may maintain slight forward bending of thoracics above the segment you are treating)
8. Maintain sagittal position while adjusting side-bending to left or right.
9. Patient inhales and then on exhalation and give impulse or thrust straight down
10. Determine effectiveness of technique by rechecking motion
• Neutral: Thenar eminence at apex of lesioned segments—flat hand—all 3 planes localized until restrictive barrier
is engaged (sidebending will occur AWAY from doctor)
OMM 8- HVLA (Thoracic Spine)
Direct HVLA (Neutral)
 Pt. supine with doc on opposite side of rotation
 Cross pt’s arms w/arm on side of rotation placed superiorly (i.e. L arm on top)
 Doc grasps pt.’s L shoulder w/ her L hand and rolls pt toward her, placing R thenar eminence against L TVP @
apex of lesioned group.
 Pt. is rolled back over the doc’s hand and tension is applied by the doc’s trunk through the pt’s arms.
 Doc lifts pt’s head and shoulders to localize the sagittal plane and sidebends L (away from doc) to apex of
lesioned segment(s).
 Pt. takes deep breath while doc adjusts localization
 At end of exhalation doc applies HVLA thrust through pt’s elbows into the fulcrum
 Vector of force applied through pt’s arms through their back into thenar eminence (red arrow)
Direct HVLA (Extended)
• Pt. supine. DO on side opposite rotation of vertebrae (L)
• Pt. crosses arms w/ R arm on top (side of rotation)
• DO grasps pt.’s R shoulder w/ his R hand and rolls pt. toward him, placing L thenar eminence against R
transverse process of segment
• Pt. is rolled back over the DO’s hand and tension is applied by the DO’s trunk through the pt’s arms.
• Fulcrum: DO’s thenar eminence is against the transverse process of the lesioned segment
• Vector of force applied through pt’s arms to their back
• DO lifts pt’s head and shoulders to localize the sagittal plane with sidebending towards DO such that the
lesioned segment is at the apex of these induced spinal curves.
• ENDPOINT: all 3 planes are localized until the restrictive barrier is engaged
• REMINDER: sidebending will occur TOWARDS the DO
• FINALLY: patient takes a deep breath, follow exhalation to end, then HVLA thrust postero-superiorly.
Prone Technique (Flexed Dysfunction)—Texas Twist
1. Patient lies prone.
2. Physician on opposite side of the rotation, preferably, but can be on either side.
3. Physician places caudad thenar eminence on opposite transverse process with fingers facing head and cephalad
hypothenar eminence on near transverse process with fingers facing towards feet.
4. Patient inhales and then exhales and on exhalation the physician delivers a thrust impulse in the direction of the
fingers with a slight rotatory motion. Slightly greater force is applied through the hand that is over the
transverse process of rotation.
5. Determine effectiveness of technique by rechecking motion.