Intro HVLA Flashcards
What does HVLA stand for?
High Velocity, Low Amplitude
How important has HVLA been historically?
HVLA was the major type of technique taught in osteopathic medical colleges prior to the1970’s
After 1970’s, school curriculum’s began expanding to include other modalities
What is HVLA?
An osteopathic technique employing a RAPID, therapeutic force of brief duration that travels a SHORT DISTANCE within the anatomic range of a joint and that engages the Restrictive Barrier to elicit release of restriction
Also known as the Thrust Technique
What is the Physiologic Barrier?
End Range of Motion achieved during ACTIVE MOTION (patient moving) in the absence of Somatic Dysfunction
What is the Anatomic Barrier?
End Range of Motion achieved during PASSIVE MOTION (doctor moving patient) in absence of Somatic DYsfunction
What is the Restrictive Barrier?
A functional limit that abnormally diminishes the normal physiologic range of motion
What is a shifted neutral?
Neutral is the middle point between the physiologic barriers
When a Restrictive barrier is present, it reduces the range of motion forcing a new middle point, known as the shifted neutral
What is a contraindication of HVLA?
Vertebral Artery thrombosis
If patient complains in history of symptoms referable to the vertebral artery, or if there are related physical signs, vertebral artery tests should be conducted
If there is clinical suspicion of vertebral artery compromise by the history and physical findings, then HVLA manipulation of the cervical spine should not be attempted
What is Range of Motion Quantity?
ROM Quantity is determined by the amount of movement available from a neutral position
It is evaluated during physical exam
Typically symmetric in a non-dysfunctional joint
Measured in 3 distinct planes of motion
- Sagittal
- Coronal
- Transverse
What is Range of Motion Quality?
Refers to palpatory “sense” of how smoothly a joint can be moved through its ROM
What is End Feel?
Quality of motion of a joint when it is brought passively to its final barrier of motion
Function of focal tissue turgor and tethering of attached muscles and fascia
Firm and Distinct
Typically mechanical type of arthrodial dysfunction
Rubbery - reflex somatic dysfunction
What kind of technique is HVLA?
Direct technique
What are indications for HVLA?
Quantity and Quality allow examiner to determine and define Restriction of Motion
HVLA is particularly effective when there is a DISTINCTIVE BARRIER WITH A FIRM END FEEL
What is the mechanism of treatment for HVLA?
Perform Soft Tissue treatment prior to performing technique
Ask Permission form Pt is they’re okay with you potentially cracking joints
Thrust through the restrictive barrier
Restoration of motion at articulation
Restoration of normal Proprioceptive Input
Reflex Relaxation of Muscles
Improvement of TART findings
What is the source of the cracking noise heard during HVLA treatment?
Source of noise is under debate
- Eventration of gas into the synovial fluid with the breaking of surface tension
- Snapping/releasing of ligamentous adhesions in the joint
- Ballooning of the joint capsule
- Bone itself being pulled out of place and snapping back into the neutral position
Is the cracking noise necessary for a successful HVLA treatment?
NO
What is the goal of performing HVLA?
OMT’s goal is to restore motion loss and restore neutral point back to normal
What is not a dysfunctional segment?
When it is:
- Subluxed
- Out of place
- Out of Joint
- Dislocated
As Osteopathic physicians, we DO NOT:
Adjust
Put back into place
What are the Steps for HVLA?
Correctly Diagnose SD
Localize Segment
Engage the Restrictive Barrier in all 3 planes of motion-stacking
Release enhancing maneuver
- Patient Breathing
Mobilize force-corrective thrust
Reassess
What is the Vertebral Unit?
Two Adjacent vertebrae with their associated disc as well as their:
- Arthrodial Component
- Ligamentous Component
- Muscular Component
- Vascular Component
- Lymphatic Component
- Neural Component
Where are forces localized in the vertebral unit?
Forces will be localized at Facet Joints between the two vertebrae
What are the two approaches to applying forces to engage barrier?
Forces are either applied:
- Top-down through the superior vertebra, “THROUGH the dysfunction”
- Bottom-up through the inferior vertebra, “TO the dysfunction”
How does stacking barriers work?
You put patient into 3 planes of restriction:
- Rotation
- Side-bending
- Flexion/Extension
Should you perform a thrust without feeling a Hard-End Feel?
NO
How often should you perform HVLA on a patient?
Depends on the patient
Generally:
- Less frequent on sick patients
- Older patients responds more slowly
- Most cases discourage thrusting the same segment more than once a week
- If the same SD keeps recurring, evaluate and address for underlying inciting factor
What are the benefits of HVLA?
Well tolerated and time efficient
Modality of choice for SDs with DISTINCT FIRM BARRIER mechanics
Patient typically experiences immediate relief, decreased pain, and increased ROM
What are indications for HVLA?
Articular somatic dysfunction
Joint motion restriction with a firm articular barrier
When SD is judged to be an actual joint motion restriction, not exclusive soft tissue restriction
In the face of joint fixation
To disrupt connective tissue adhesions
To treat chronic dysfunction resistant to other treatment modalities
To modify reflexes
A maintenance treatment in irreversible situations
HYPOmobile joints
Restoration of bony alignments
Meniscoid Entrapment
Pain modulation
Reprogramming of the CNS
Displaced disc fragment
Reflex relaxation of affected muscles
Is manipulation safe?
Yes (especially indirect treatments) more safe than most treatments
- No adverse affects like drugs
- No risk of infections
What are precautions for using HVLA?
It is important to conduct a thorough history and physical exam, so you can uncover any contraindications for HVLA
Avoid hyperextension and excessive rotation of the cervical spine
What is the Risk:Benefit Ratio?
If risk outweighs the benefit of the technique, it is NOT INDICATED
When would you not want to perform HVLA?
Fracture
Ehlers-Danlos Syndrome (hyper-mobility; lots of connective tissue)
Recovering from surgery
Would you perform HVLA on a pt with a herniated disc?
It is a relative contraindication
Depends on the patient
What are some safety considerations for HVLA?
ACCURATE DIAGNOSIS is crucial
Pt’s consent and comfort
Listen with your hands
- If barrier doesn’t feel right, DO NOT THRUST
Excessive force can damage tissue
Hypermobility of the joints could be exacerbated by HVLA
What are ABSOLUTE CONTRAINDICATIONS for HVLA?
Local Metastases
Osseous or Ligamentous Disruption
Severe osteoporosis
Rheumatoid Arthritis
- Alar ligament instability
Downs Syndrome
- Alar ligament instability
Achondroplastic Dwarfism
Chiari malformation
Osteomyelitis in the area being treated
Joint replacement in the area being treated
Vertebrobasilar insufficiency
Severe Herniated Disc with Radiculopathy
Fracture/dislocation/Spine or joint instability
Ankylosis/Spondylosis with fusion
Surgical Fusion
Klippel-Feil Syndrome
Joint infection
Bony Malignancy
Patient Refusal
What are relative contraindications?
Acute herniated nucleus palposus
Acute Radiculopathy
Acute Whiplash/severe muscle spasm/strain/sprain
Osteopenia/Osteoporosis
Sponylolisthesis
Metabolic Bone DIsease
Hypermobility syndromes
Apprehension by the Pt
- Always ask permission and explain expectations
Rheumatoid Arthritis disease other than in the spine
