Cervical Manipulation Components, Contraindications, Cavitation

Question 1

Absolute contraindications?

Answer 1

1. Vascular (CAD, aortic aneurysm >5 cm, severe hemophelia)
2. Bone (tumor, infection [TB], metabolic [osteomalacia], congenital [dysplasias], fracture, iatrogenic [corticosteroids], inflammatory [RA])
3. Neurological (Cauda equina and myelopathy, not radiculopathy)
4. Excessive or extreme pain
5. Lack of clinical diagnosis
6. Lack of patient consent

Question 2

What is the popping sound?

Answer 2

Think it’s CO2 coming out of solution. Unsworth did study in 1971 cracking MCP’s. There was rapid increase in joint volume causing pressure to drop below partial pressure of CO2, this allowed it to come out of solution into a gas. Forms cavities (bubbles) in synovial fluid; these cavities visible with x-ray. A radiolucent cavity in the MCP joint has been seen on plain film following HVLAT, this radiolucent cavity represents collection of gas. The vacuum phenomenon can be seen as long as the joint is tractioned, but when it’s not it doesn’t demonstrate presence of radiolucent cavity (Sandoz 1969). Kawchuck (2015) said tribonucleation.

Question 3

Sandoz 1969?

Answer 3

Articular surfaces of non-cavitated MCP submitted to 8 Kg of traction separate 0.8 mm. Cavitated MCP submitted to 5 Kg traction separates 4.5 mm.

Question 4

OA, C1/C2, and SP’s?

Answer 4

OA sidebends and flexes/extends, very minimal rotation. C1/C2 has 39-45 degrees rotation. C2 is first spinous process you come in contact with. C6 moves anterior with extension. C7 not necessarily most prominent (1/2 time T1 most prominent).

Question 5

What is the post-refractory period?

Answer 5

15 to 30 minutes believed to be due to presence of micro-bubbles in synovial fluid, which remains unabsorbed in joint. Upon attempted recavitation this gas expands to prevent sudden drop in intra-articular pressure. The cracking won’t occur until all gas in joint completely reabsorbed (Sandoz 1969).

Question 6

Other components for cx HVLAT?

Answer 6

1. Feet diagonally parallel
2. Rotate your body to SB neck
3. SB your body to rotate neck
4. Keep elbows in with wrists straight
5. Use thin pillow
6. Contacting upside articular pillar for segment to manip for rotation and lower OR upper articular pillar for lateral break
7. C1/C2 use lateral border of 2nd digit, for C2-C7 use anterolateral
8. Do several mini-impulses to check barrier
9. Compression is non-torsional and reduces required amplitude
10. When contacting articular pillar, come into muscles and move up/down 2-3x so muscles relax
11. Keep vertex in midline throughout if performing rotary HVLAT, not in midline with lateral break though
12. Diagnose segment and put on levers slow, patients prefer this done slow

Question 7

Momentum induced vs combined leverage?

Answer 7

Locking, or combined leverage, attempts to remove all mobility from adjacent segments to allow force only to reach target segment. Focusing, or momentum induced, aims to place as little tension as possible through adjacent segments but target segment is at point of maximum focus of force.

Question 8

Shift Rule?

Answer 8

The shift that increases the contact pressure between the operator’s hand and the patient is the right direction. Thus, usually side shift in opposite direction to SB.

Question 9

Relative contraindications HVLAT?

Answer 9

1. Disc herniation or prolapse (49-63% individuals without significant bout of LBP have HNP on MRI [1500 hospital employees, Boston])
2. Pregnancy (don’t thrust at 12th and 16th weeks as you can lose baby at these intervals, but HVLAT never shown to cause miscarriage)
3. Osteoporosis
4. RA
5. Spondylolysis, spondylolisthesis (avoid extension and do primary lever of flexion)
6. Advanced DJD, spondylosis

Question 10

Supine Cx HVLAT Components?

Answer 10

1. 20-30 degrees rotation
2. Thumb on ramus of jaw, not carotid or neck
3. Proximal phallanx on posterolateral articular pillar
4. SB toward
5. Sideshift away
6. Extension (just a little)
7. PA shift (local compression by abd of 2nd finger before moment of truth)
8. Thrust into rotation towards opp. (or underside) eye

Question 11

Unsworth 1971 - Joint space changes?

Answer 11

Increase in resting post-cavitation MCP joint space of 0.42 mm 5 min after, 0.01 mm 10 min after, 0 mm 15 min after.

Question 12

Joint space post-HVLAT cervical spine?

Answer 12

Cascioli (2003) found no significant changes in width, area, and density values of z-joint immediately after HVLAT. Found no evidence of gas in joint space. This was in traction and traction-free post-HVLAT CT scan and plain film images.

Question 13

Lumbar HVLAT and disc herniation?

Answer 13

Oliphant (2004) showed risk of worsening LDH with spinal HVLAT is 1 in 3.7 million

Question 14

Capsular Detonization Theory?

Answer 14

Proposed by Sandoz (1969) when trying to propose why synovial joint doesn’t recrack. Collagen fibers of the articular capsule, when stretched beyond a certain point, slowly shorten to regain their original length. Thus, a second cracking sound can’t be elicited until collagen fibers have returned to their original length.