HVLA Flashcards
What family moved from Europe to America to begin thrust techniques
Sweet family in New England
Theories of joint dysfunction
Alteration/disruption of normal tracking of the opposing joint surfaces
Articular capsule problems occur when the synovial fluid changes and causes synovium to be trapped between opposing surfaces
HVLA theory of action
Sudden stretch or change in the joint alters the afferent activity of the mechanoreceptors resulting in neural change related to that spinal cord segment
- releases hypertonic muscles that surround the joint that HVLA treatment is focused on
The body automatically rests the articular surface apposition
- due to “overload” of the CNS with too much information causes
Joint play
Small movements at synovial joints
- approximately 1/8th of movement
- NOT CONTROLLED by voluntary muscle contraction
- without joint play , the motions in the joint become restricted and possibly painful
Coined by John mennell
Secondary effects of HVLA
Alter length and tone of connective tissue and facia
Increases blood/lymph flow
Remove compression on nerves
- normalized autonomic balance
- allow improved neurotrophic flow of proteins
- decreases nociceptor activation (pain)
Primary effects of HVLA
Decrease pain and increase ROM of a joint
HVLA principles
1) Accurate intersegmental triplanes diagnosis for vertebrae
2) use ST/ MFR techniques to “warm up” area
3) position patient into ALL direct barriers
- be very specific with barriers
- could feel like “its going to click” which means you are engaged towards the barrier the best as possible
4) thrust directly into the barrier
- sometimes isnt even needed if stacked properly
“Locking”
Positioning a joint into direction of restriction, just short of being fixed in place, but there is a small amount of “joint play” allowed
It is required to lock a joint and have a hard end feel before applying HVLA
Steps in performing HVLA
1) accurate diagnosis by palpatory examination and motion testing
2) make sure the patient understands the procedure
3) decide whether to do tissue prep (ST/MFR/CS/Still technique)
4) gross level positioning in the direction of the restrictive barrier
- NOTE: if barrier is soft/rubbery and not a hard end-feel, DONT do HVLA, pick something else.
5) fine-tuning with accumulation of forces centered at the dysfunctional joint
- “lock” into place all 3 barriers
6) have patient breath in and on exhalation, you apply the HVLA thrust towards the appropriate barrier
Superior facets direction in the thoracic vertebrae
Backwards, upwards, lateral (BUL)
What two hand positions can you use as a fulcrum in throacic HVLA?
Open hand or closed fist
- can be perpendicular to spinal segment or 30 degree tilt to spinal segment
Where does the physician stand in thoracic supine HVLA?
Always on the opposite side of the posterior transverse process (which ever way the vertebral segment is rotated)
How is the patients arms supposed to be crossed during thoracic HVLA?
Contralateral side (same side as somatic dysfunction rotation) is to be on top
“Opposite over adjacent” as it pertains to the physician side
Where is the HVLA force applied in thoracic HVLA?
Straight down towards the fulcrum hand (usually down to the floor and through the epigastric region)
Why is the fulcrum placement different on flexion somatic dysfunctions in thoracic HVLA?
The fulcrum is placed below the posterior transverse process in order to induce extension of the dysfunctional vertebrae
Which vertebrae do you treat in a neutral somatic dysfunctional for a group of thoracic vertebrae in thoracic HVLA?
The “APEX” vertebrae (one that induces the most curvature of the spine)
- is almost always the middle one (i.e T6-8 = T7)
How do you change arm placements for upper thoracic vs lower thoracic in throacic HVLA?
Upper = have patient place hands behind neck or
- this is to better localize movement to those vertebrae
- upper include (T1-4)
Review: which ribs are atypical and why?
Rib 1 = articulates on with T1 and has no angle
Rib 2= large tuberosity on shaft for serratus anterior
Rib 10 = articulates only with T10
Ribs 11-12 = articulates with corresponding vertebra and lack tubercles
How do ribs 11 and 12 move with inhalation and exhalation?
Inhalation = ribs move posteriorly and inferiorly
Exhalation = ribs move anteriorly and superiorly
moves in a transverse plane with cephalad-pedad (vertical line) axis of motion
Tissue texture abnormalities for rib somatic dysfunctions
Skin lesions
Red reflex
Pseudo motor findings
Temperature changes
Biggie s and edema
Rosiness
Hypertonic muscles
What are the common sites of thoracic outlet syndrome to occur at?
Anterior and middle scalenes
- brachial plexus and subclavian artery gets impinged here
Clavicle and anterior Rib 1
- brachial plexus, subclavian artery and vein gets impinged here
Costo-pectoral-coracoid region
- brachial plexus, subclavian artery and vein gets impinged here
Absolute contraindications for RIB HVLA
Interferes with patients breathing in anyway
Open wound
Flail chest/fractured or cracked ribs
Osteopenia or osteoporosis
Bone cancer or Mets
Potts disease
Non compliant or patient who can relax
Superior 1st rib superior shear findings inTART
Tissue texture abnormalities
- scalene hypertonicity and upper cervical/thoracic muscle imbalances
Asymmetry
- posterior shaft at tubercle is elevated 5mm compared to normal side
- T1 is usually sidebent away from the side of the superior shear
ROM
- respiratory motion is poor at R1 and is associated with inhalation or exhalation SD (usually inhalation; rarely exhalation)
- greater resistance is felt when pressing inferiorly on dysfunctional R1
Tenderness
- marked tenderness at R1s superior aspect
TART with ribs 2-10 HVLA
Tissue texture
- hypertonic illiocostalis muscles at rib angle
Asymmetry
- anterior aspect of ribs are less prominent
- posterior rib angle is more prominent
- should confirm moth to be sure*
ROM:
- marked restriction in both exhalation or inhalation (usually inhalation)
Tenderness:
- marked tenderness at rib angle and “intercostal neuralgia complaints”
Examples of documentation of techniques similar to HVLA before AT Stills time
Hippocrates
Asian bonesetters
European practitioners
Native American healers
What are intrafusal muscle fibers and golgi tendons theorized to do after HVLA treatment?
Intrafusal muscle fibers:
- send sharp afferent signals that cause reflex reduction in afferent muscle tones surrounding the joint.
Golgi tendon sensors:
- cause reflex inhibition of stretched muscles around the joint
overall results in a joint that did not permit normal motion -> gapped -> slips back into appropriate position with normal physiologic motion
Definition of HVLA
also called thrust technique
Is a direct method of manipulation where a dysfunctional joint is passively brought to its restrictive barrier, with a rapid therapeutic force (High velocity, low amplitude) is pallid to the joint.
- the joint moves through the restrictive barrier, but not through the anatomic range of motion
This causes the dysfunctional joint to reset itself and appropriate physiologic motion restored
Is a click or pop sound diagnostic of proper HVLA?
NO
- although it is often heard
Absolute contraindications to HVLA
Upper throacic only:
- advanced rheumatoid arthritis
- Down syndrome
- achondroplasia dwarfism
- chiari malformation
ALL HVLA:
- fracture/dislocation/spinal instability
- joint fusion of any kind
- klippel-feel syndrome
- carotid/vertebrobasilar patholgoy
- active inflammatory arthritides: SLE/IBD/psoriatic arthritis/Scleroderma
- joint infections
- malignancy involving bone/soft tissue
- myelopathy
- cauda equina syndrome
Relative contraindications for HVLA
Acute herniated disc
Acute radicals patchy
Acute whiplash/muscle spasms and sprains
Osteopenia/osteoporosis
Spondylolisthesis
Regional implanted devices or mechanical joint replacements
History of inflammatory arthritides
Difference between short lever and long lever technique HVLA
Short lever HVLA:
- force is imparted through your body which is close to the dysfunctional joint.
- force is directly applied to the dysfunctional joint
Long lever HVLA:
- force is imparted through your body which is far away from the dysfunctional joint
- force is indirectly applied to the dysfunctional joint by passing through the patient body in another way (i.e ribs HVLA with epigastric and arms)
Combined lever technique HVLA
Same as long lever HVLA except you also apply an imparting corrective force directly on the dysfunctional joint
What tests should be done before conducting lumbar HVLA?
Adams test = screen for scoliosis
Straight leg raise = sciatic nerve irritation
Nachlas test = higher lumbar herniated discs (L2-3 and L3-4)
Schober/modified Schober test = screens for spondyloarthropies
What is the spinal motion for lumbar spinal cord?
50-60 degrees = flexion
25-30 degrees = extension
25 degrees = sidebending
10 degrees = rotation
the amount of motion per lumbar segment is roughly 2 degrees
What position does the patient always take in lumbar HVLA?
They lay lateral recumbent on the side of rotation dysfunction
Planes of motion for Flexion/extension, sidebending and rotation
Flexion/extension = sagittal plane along a horizontal axis
Sidebending = frontal/coronal plane along an A/P axis
Rotation = transverse plane along a vertical axis
Pump handle motion of ribs
Inhalation:
- anterior portion moves anterior and superior
- posterior angle moves posterior and inferior
Exhalation:
- anterior portion moves posterior and inferior
- posterior angle moves anterior and superior
motion is in the sagittal plane and costovertebral-costotransverse axis
Bucket handle motion of ribs
Inhalation
- lateral margin moves superior/lateral
- increased transverse diameter
Exhalation
- lateral margin moves inferior/medial
- decreases transverse diameter
motion is in the coronal plane and axis of motion is costovertebral-costosternal
Where are each section ribs best felt at?
Pump handle = mid-clavicle are line
Bucket handle = mid-axillary line
Caliper = 3-5 cm lateral to transverse process
Rib HVLA goals of treatment
Improve rib motion
- improves respiration and diaphragm motion
- increases intrathoracic pressure during respiration
- modulates sympathetic function
Decreases pain
Improve throacic somatic dysfunctions
