Intro to HVLA

Question 1

When was HVLA first discovered?

Answer 1

2700 bce is earliest Chinese recording

Question 2

Who wrote a book on joints in which body weight or a wooden lever could be used to impart spinal pressure or thrust?

Answer 2

Hippocrates (460-385 bce)

Question 3

What did Hippocrates note that his treatment should be followed with?

Answer 3

exercise

Question 4

What was A.T. Still known as?

Answer 4

lightning bone setter

-typically describing rapid joint repositioning by Central American healers

Question 5

Who started the Palmer school or Chiropractic and used HVLA within their practice?

Answer 5

Dr. D.D. Palmer

Question 6

Who were early students of Dr. Still further developed different approaches of thrust techniques?

Answer 6

Dr. Hulett
Dr. Hazzare
Dr. McConnell

Question 7

What kind of treatment is HVLA?

Answer 7

direct

Question 8

Definition of HVLA

Answer 8

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 (thrust technique)

Question 9

How is the forced described in HVLA?

Answer 9

• not overpowering
• minimum required
• the more precise the localization of positioning, the less force is needed

Question 10

Define range of motion quantity

Answer 10

determined by the amount of movement available from a neutral position; used to reference maximum distance available for thrusting techniques

Question 11

Define end feel

Answer 11

quantity and quality of motion of a joint when it is brought passively near and up to physiologic or restrictive barrier or motion

Question 12

What does firm and distinct normally refer to?

Answer 12

arthrodial dysfunction

Question 13

What does rubbery usually refer to?

Answer 13

muscle, fascia, reflex

Question 14

What are the indications for HVLA?

Answer 14

• dysfunction localizes to a joint
• most likely effective when there is a distinctive barrier with a firm or hard end feel
• may be successful when other techniques have either failed or provided only partial release

Question 15

Steps of neurophysiology of a SD

Answer 15

1) loca segment irritation
2) focal edema and swelling
3) tightening of myofascial and capsular components of the joint
4) reflex hypertonicity of regional muscles (facilitation)
5) TART changes palpable
6) diagnosis of somatic dysfunction

Question 16

Mechanism of Treatment: Neurophys of HVLA

Answer 16

1) thrust through the restrictive barrier
2) restoration of motion at articulation
3) restoration of normal proprioceptive input
4) reflex relaxation of muscles
5) improvement of TART findings

Question 17

How does HVLA differ in barrier positioning compared to others?

Answer 17

HVLA localizes firmly against the RB

Most other treatments localize to feather edge of RB

Question 18

What is the goal of HVLA?

Answer 18

OMT’s goal is restore motion and tissue balance

Question 19

What are the steps for HVLA?

Answer 19

1) correctly diagnose SD
2) provide some soft tissue preparation
3) Localize forces to a segment or joint; engage the RB in all 3 planes of motion
4) release enhancing maneuver (patient exhalation)
5) accumulation of forces
6) corrective thrus
7) return to neutral
8) reassess for effectiveness and SD persistence

Question 20

Why is preparation done before HVLA?

Answer 20

• reduces risk of soft tissue injury

- increases patient confidence in physician

Question 21

Why is relaxation critical for HVLA?

Answer 21

• frees up cortex to receive kinesthetic input from hands and fingers (physician)
• relaxed physician muscles are better prepared for rapid contraction
• patient muscle relaxation prevents tensing that can interfere with correction
• reduces risk of muscle or tendon injury

Question 22

Where are the forces localized?

Answer 22

facet joints between the two vertebrate

Question 23

How do forces move?

Answer 23

from top down

Question 24

How are forces applied?

Answer 24

from the bottom

Question 25

Accumulation of forces

Answer 25

• move firmly against the barrier on patient exhalation
• engaging force must be maintained once all RBs are stacked
• forces that do not accumulate at SD dissipate into adjacent structures (unwanted iatrogenic effects)
• if localization is lost DO NOT THRUST; reassess and restack

Question 26

Corrective Thrust

Answer 26

• direction of force is typically towards the culmination of all vectors used for localization
• as the engaged barrier, deliver a short, rapid thrust with sudden acceleration and deceleration
• dont release barrier engagement force prior to thrust
• exhalation, muscle relaxation, more effective thrust
• MINIMUM force: speed and force is modified to fit pt’s need

Question 27

How do older patients respond to HVLA?

Answer 27

need more recovery time between treatments

fewer total treatments per encounter

Question 28

Why is it discouraged to thrust the same segment more than once a week?

Answer 28

• tissues need time to recover from the trauma of treatment

- frequent treatment can lead to hypermobility of segments

Question 29

What should you do if the same SD keeps recurring?

Answer 29

evaluate and address the underlying factor

Question 30

Benefits of HVLA

Answer 30

• time efficient
• well tolerated
• patient typically experiences immediate relief, decreased pain, and increased ROM
• modality of choice for SDs with distinct firm barrier

Question 31

Indications for HVLA

Answer 31

somatic dysfunction
articular somatic dysfunction
joint motion restriction with a firm articular barrier

Question 32

What are specific benefits HVLA can achieve?

Answer 32

• reduce joint fixation
• release chronic dysfunction resistant to other treatments
• modify reflexes via CNS reprogramming
• more effective with HYPOmobile joints
• restore bony alignment
• reduce meniscus entrapment
• pain modulation (greater reflex relaxation of associated muscles)

Question 33

What is the stroke risk?

Answer 33

6. 39 in 10 million
   - from vertebral artery dissection and subsequent thrombosis
   - if any clinical suspicion of vertebral artery compromise, HVLA and extreme neck motions should be avoided

Question 34

Incidence of severe complication estimates

Answer 34

1:1,000,000

Question 35

What should be avoided with the cervical spine?

Answer 35

avoid hyperextension and excessive rotation

Question 36

What are some safety considerations?

Answer 36

• patient consent and comfort
• accurate diagnosis
• if barrier doesn’t feel right, don’t thrust
• use minimum force necessary for one joint only
• hypermobility of joints could be exacerbated by HVLA
• excessive treatment can lead to hypermobile joints

Question 37

What are the ABSOLUTE contraindications?

Answer 37

• local cancer or metastases
• local osseous or complete ligamentous disruption
• severe osteoporosis
• RA
• down syndrome
• osteomyelitis
• spinal cord dysfunction including severe acute herniated disc with radiculopathy, cauda equina syndrome, etc.
• patient refusal
• carotid insufficiency
• joint infection
• fracture, dislocation, joint instability

Question 38

What are some relative contraindications?

Answer 38

• acute herniated nucleus pulposus
• acute radiculopathy
• acute injury (spasm, sprain)
• osteoporosis
• spondylolisthesis
• metabolic bone disease
• hypermobility syndromes
• joint replacement