HVLA Ribs & T-Spine

Question 1

HVLA Supine T-Spine - The Kirksville Crunch

Answer 1

• Physician stands on opposite side of the PTP
• Pt crosses arms over chest with arm the side of PTP on top
• Place thenar eminence of caudal hand on the PTP
• Pt’s elbows placed into examiner’s upper abdomen
• Use your cephalad hand/forearm to lift and position the pt’s head & neck to the restrictive barriers (F/E/S/R)
  
  • -> Type I SD SB away from doc
  • -> Type II SD SB toward doc
• Instruct pt to inhale & exhale deeply
• Upon exhalation the examiner will exert and A/P HVLA thrust through their abd toward the PTP
• Reassess pt

Question 2

HVLA Prone - The Texas Twist

Answer 2

• Stand on opposite side of PTP
• Place hands facing opposite directions on either side of spinous
process to induce SB into restrictive barrier:
• Type 1: Hand facing caudad, place thenar eminence on PTP;
Hand facing cephalad, place hypothenar eminence on opposite
transverse process.
• Type 2 (Flexed): Hand facing cephalad, place thenar eminence
on PTP; Hand facing caudad, place hypothenar eminence on
opposite transverse process.
• Instruct patient to inhale and exhale fully. As patient exhales, follow
their motion to further engage the barrier.
• At the end of exhalation, a downward anterior HVLA thrust is
applied with a counter balance pressure (twist) in the direction the
fingers are pointing with greater force on PTP side
• Reassess

Question 3

Supine Knee Fulcrum HVLA: Upper and Middle Thoracics

Answer 3

• Patient supine with fingers clasped behind neck. Physician at head of table
• Position your ipsilateral knee to the PTP of the dysfunctional vertebrae to act as the fulcrum for the HVLA treatment.
• Pass your hands through the patient’s flexed UEs on both sides and encircle the patient’s rib cage with the fingers over the rib angles posterolaterally
• Have the patient inhale and exhale, and at the end of exhalation, the physician quickly but gently pulls the patient’s chest downward into the thigh while adding cephalad traction (white arrow)
• Reassess

Question 4

Seated Lower T-Spine HVLA

Answer 4

• Can perform MET prior to applying HVLA
• Patient seated with ipsilateral hand to the PTP clasped behind their
neck and holding that elbow with their other hand. Physician
standing opposite to PTP (same set up as seated ME treatment)
• Physician places ipsilateral thenar eminence to the PTP of the
dysfunctional vertebrae
• Grasp patient’s biceps, with arm orientation dependent on type of
SD (Type 1 vs Type 2), and engage restrictive in all 3 planes
• The patient inhales, and on exhalation, the physician quickly and
minimally pulls the patient through the rotational barrier while the thenar eminence imparts an anterior impulse on the PTP, causing an HVLA effect in the rotational barrier.
• Reassess

Question 5

HVLA Seated Knee Fulcrum

Answer 5

• Patient seated with hands clasped behind their neck. Physician behind patient
• Using a stool for your foot, position your ipsilateral knee to the PTP on the dysfunctional vertebrae to act as the fulcrum for the HVLA treatment. (You can also place a pillow between your knee and the patient’s back for comfort.)
• Pass your hands beneath the patient’s arms and then through their flexed arms to grasp their forearms just proximal to their wrists.
• Patient deeply inhales and exhales, and at the end of exhalation quickly and gently pull the patient superiorly and posteriorly to roll the PTP over your knee.
• Reassess

Question 6

Upper Ribs 1-4 Upper Chin Pivot

Answer 6

• Patient prone with physician standing at the head of the table – opposite the side of dysfunction
• Patient cups their chin with the hand ipsilateral to SD
• Physician places thenar/hypothenar eminence at the rib dysfunction
with one hand
• Physician moves patient’s elbow cephalad (SB head & neck away)
until motion is palpated at the dysfunction
• Physician places other hand on the patient’s head, rotating it toward
the side of dysfunction into the barrier
• The patient inhales, and with exhalation the doctor loads further into
the barrier
• At the end of exhalation, the doctor applies a rapid anterolateral thrust
onto the dysfunctional rib.
• Reassess
NOTE: This technique can also be done on upper thoracics. You contact the PTP instead of the rib and apply a directly anterior, instead of anterolateral, thrust
Do NOT thrust onto the patient’s head – you are only stabilizing the head, maintaining the sidebending/rotation barrier

Question 7

Seated 1st Rib Inhalation Dysfunction HVLA (J stroke)

Answer 7

• Patient seated with physician standing behind
• Physician places foot on the table opposite the dysfunction and patient
drapes their arm over physician’s knee
• Physician contacts the dysfunctional rib with the second MCP joint of
one hand and the top of the patient’s head with the other
• Physician engages the barrier by sidebending the head toward the
dysfunctional rib
• The patient inhales, and with exhalation, the doctor loads into the first
rib
• At the end of exhalation, physician applies a thrust inferiorly/medially
on the superior rib.
• Reassess

Question 8

Ribs 3-10 Bucket Handle Inhalation Dysfunction HVLA

Answer 8

• Patient supine with physician opposite the dysfunctional rib
• Patient crosses arms over body with arm on the side of dysfunctional
rib on the top
• Doctor places the thenar eminence of the caudad hand
posterior/superior to the angle of the dysfunctional rib.
• The other hand may be placed on the patient’s elbows, or may be used
to elevate the patient’s head/neck.
• Physician applies a pressure through the patient’s elbows localizing at
the dysfunctional rib angle
• The patient inhales, and with exhalation the physician loads further
into the barrier
• At the end of the next exhalation, the doctor applies a posterior thrust
directed toward the thenar eminence
• Reassess

Question 9

Ribs 3-10 Bucket Handle Exhalation Dysfunction HVLA

Answer 9

• Patient supine with physician opposite the dysfunctional rib
• Patient crosses arms over body with arm on the side of dysfunctional
rib on the top
• Doctor places the thenar eminence of the caudad hand
posterior/Inferior to the angle of the dysfunctional rib.
• The other hand may be placed on the patient’s elbows, or may be used
to elevate the patient’s head/neck.
• Physician applies a pressure through the patient’s elbows localizing at
the dysfunctional rib angle
• The patient inhales, and with exhalation the physician loads further
into the barrier
• At the end of the next exhalation, the doctor applies a posterior thrust
directed slightly caudal to the physician’s thenar eminence
• Reassess

Question 10

Same Side SD HVLA (Modified Kirksville crunch)

Answer 10

• Patient supine with physician on the same side of the dysfunction
• Patient crosses arms over chest, with side of PTP on top.
• Place your thenar eminence of cephalad hand on the PTP.
• Doctor grasps patient’s elbows and raises them until vector is felt on
  posterior hand.
• Posterior hand induces sidebending to stack barriers.
• Patient inhales and exhales deeply.
• Upon exhalation, the examiner will exert an anterior to posterior
  HVLA thrust through the patient’s body toward the posterior
  transverse process.
• Reassess