HVLA Flashcards
Cervicothoracic spine C7 - T3 Rotation Gliding (push)
Myofascia ligamentus
same side head and thrust
Apply sidebend and tuck chin
Thoracolumbar spine T10 - L2 - neutral positioning
Neutral
coupled motion type 1
Facet apposition type 2
Thoracolumbar spine T10 - L2 - flexion positioning
Flexion
Coupled motion Type 2
facet apposition Type 1
Lumbosacral Joint L5 to S1 - Neutral positioning
Cervicothoracic Spine C7 to T3 - Rotation gliding
(scissor)
myofascia ligamentus
Cervicothoracic C7 to T3 - Extension Gliding
myofascia ligamentus
Atlanto Axial Joint C1 to C2 - chin hold
AA coupled motion primary rotation
Rotation thrust
Atlanto occipital joint C0 to C1 - contact occiput
OC joint coupled motion Type 1
Facet apposition Type 2
thrust is C-scoop
Thoracic Spine T4-T9 - extension gliding
(seated)
Ligamentous myofascial
Thoracic Spine T4-T9 - Rotation gliding
(“Dog” - Supine)
Ligamentous myofascial
Cervical C2-C7 - Upslope chin hold
coupled motion type 2
facet apposition type 1
Primary leaver rotation secondary side bending
Cervical C2-C7 upslope cradle hold
coupled motion type 2
fascet apposition type 1
Cervical spine C2-C7 Downslope chin hold
Type 2 normal
type 1 lock up
Cervical spine C2 - C7 downslope cradle
Normal Type 2
Coupling Type 1 - opposite rotation and side bending
Lumbar L1 - L5 - flexion
Coupled motion Type 2
facet apposition Type 1
Lumbar L1 - L5 - neutral
Coupled motion Type 1
facet apposition Type 2
What are red flags for HVLA?
Fracture
Tumour
infection
Neurological condition
Aneurism
Haemorrhage
Other serious condition
What are the absolute contraindications for HVLA?
- Bone: weakening, osteoporosis, tumour
- Neurological: cord compression, myelopathy
- Vascular: cervical dissection, aneurysm
- Lack of diagnosis
- Lack of patient consent
- Patient positioning can’t be achieved due to pain or ROM
What are the relative contraindications to HVLA?
- Averse reactions to previous treatment
- Disc herniation or prolapse
- pregnancy
- vertigo
- Osteoporosis
- Psychological dependance to HVLA
- inflammation
- Spondylolisthesis / spondylosis
- Corticosteroid therapy
- Degenerative joint disease
- ligamentous instability
- Arterial calcification
What are the risks of HVLA to each spinal segment?
- *Cervical:** Low (when the practitioner is well trained and the patient is well screened)
- *Thoracic:** Not documented
- *Lumbar:** Rare (when the practitioner is well trained and the patient is well screened)
What are the four classifications of HVLA complications?
- Transient effect < 48-72h
- Substantive reversible impairment (take longer to recover)
- Substantive non-reversible impairment (wont recover)
- Serious non reversible impairment (adverse events - permanent damage)
What are transient effects?
Local pain or discomfort
Stiffness
A headache
Tiredness/fatigue
Radiating pain or discomfort
What are some Substantive reversible impairment to each spinal segment?
Cervical: Disc herniation, spinal compresion, Cs strain
Thoracic: Rib fracture, VB compression fracture, Posterior fracture, shoulder and rib cage strain.
Lumbar: VB compression fracture, posterior fracture, Disc herniation, nerve root compresion, strain
What are some non-Substantive reversible impairment to each spinal segment?
- *Cervical:** unresolved disc herniation and radiculopathy
- *Thoracic:** Significant VB fracture, Post fracture with spinal canal disruption.
- *Lumbar**: unresolved disc herniation and radiculopathy, Significant VB fracture, Post fracture with spinal canal disruption.
What are some serious non-reversible impairment?
- *Cervical:** stroke, Spinal cord compression = cervical myelopathy.
- *Thoracic:** Spinal cord compression
- *Lumbar:** Spinal chord compresion = cauda equina
What are the causes for complications on HVLA relating to a patient selection?
Incorrect diagnosis
Inadequate palpatory assessment
lack of awareness
lack of patient consent
What are the causes for complications on HVLA relating to poor technique application?
Excessive Force, amplitude and leverage
an incorrect plane of thrust
Wrong leverage
Poor patient positioning
Poor operator
lack of patient feedback
What are the principles of HVLA
Exclude contraindications
•Obtain informed consent
•Ensure patient comfort
•Ensure operator comfort and optimal posture
•Achieve spinal positioning by either facet apposition locking or the utilisation of ligamentous myofascial tension
•Identify appropriate pre-thrust tissue tension
•Apply HVLA thrust
Elbow traction thrust
Joint: gapping/restriction at humero-radial joint
One hand applies compression to shoulder/humerus
Other hand compresses over wrist/hand
Thrust is downwards and slightly outwards
Elbow Humero-Ulnar gap
Joint: humeroulnar
locate one hand on the humerus and the other on the forearm.
Find a neutral position with arm extended apply
thrust on the direction of the cubital fossa line.
Overview of the osteopathic test for the shoulder
What are the shoulder impingment tests
- Hackings Kenedy: Supra pushed against coracoid ligament
- Neers: Supra jams greater tuberosity on anterior inferior acromion space
- Tests Supra for inflamation or injury
When do I perform a upper limb neuro test?
An osteopath may perform a neurological exam when a patient has changes in;
- Sensory system: Changes in sensation in the arms and/or hands
- Motor system: muscle wasting, involuntary movements, weakness in arms or hands
- Coordination: difficulty with fine motor tasks of hands
Wrist whip
Lunate on radius – plane synovial joint
take patients wrist prone
create tension by expanding the thenar and hypothenar immanence
use the thumbs to find a restricted carpal joint
articulate and then apply thrust in a down and towards me
Thumb CMC HVLA
joint: Trapezium on 1st Met – saddle synovial joint
- Restriction: gliding of CMC joint or Intercarpal joint (trapezium on scaphoid)
- Contact affected bone (e.g. 1st met or trapezium) with thrust hand
- Other hand stabilises wrist and hand
- Thrust is a distraction/traction thrust along line of thumb
Thoracic Rotation - short leaver
Patient prone
apply hypothenar eminence on TP on each side of the spine
take up the slack by rotating contact point on opposite directions
apply downward thrust
Thoracic supine flexion thrust (DOG for T1/2)
T1-T4 (usual technique but add steps below)
Place your applicator across SP/TPs of the level BELOW the joint you are aiming to thrust (e.g. T2 for T1/2)
Manoeuvre the patients crossed elbows towards their head (allows you to direct the thrust straight down towards T1/2) while maintaining tension
Thrust down towards your contact hand
Lower Thoracic supine flexion thrust
(DOG T10-T11)
T9-T12 (usual technique but add steps below)
Place your applicator across SP/TPs of the level BELOW the joint you are aiming to thrust (e.g. T11 for T10/11)
Manoeuvre the patients crossed elbows towards their feet (allows you to direct the thrust straight down towards T11) while maintaining tension
Might be useful to increase ligamentous tension by asking the patient to bend their knees up
Thrust down towards your contact hand
Thoracic rotation adapted to ribs
Patient supine
One hand on TP closer to the practitioner
the other hand before Rib angle on the opposite side
thrust is down and outward
FIbular thrust
Patient supine
internally rotate fibular head under knee line from posterior to anterior in a clockwise direction.
Externally rotate leg above ankle joint
flex the knee
thrust is amplifying flexion
Talar tug
patient supine
interlock fingers and apply contact of 5 digit on talus
lift leg
lean back
thrust down and out towards practitioner
SIJ tug
patient supine
grab leg above ankle joint
elevate adduct and internally rotate leg
lean back
short sharp tug towards the practitioner
Hip tug
patient supine
grab leg above ankle joint
elevate abduct and externally rotate leg
lean back
short sharp tug towards the practitioner
Metatarsal thrust (toes)
Condyloid joint
apply pressure on the sole of the foot over the metatarsal-phalangeal joint.
contact proximal phalange toes 2-5
apply downward thrust
Navicular/cuneiform thrust
Medcuneiform-navicular - gliding synovial joint
move the patient foot of the table
patient supine
Isolate ankle joint over navicular
second contact over middle cuneiform
apply downward thrust - shear motion
