(OSCE) Thoracic and Rib HVLA

Question 1

HVLA Supine T-Spine

(Kirksville Crunch)

Answer 1

Setup:

• Physician: stands on opposite side of PTP
• Patient crosses arms over chest, with PTP sided arm, superior

Steps:

1. Place your thenar eminence of caudal hand on the PTP.
2. Patient’s elbows are positioned in the examiner’s upper abdomen.
3. Use your cephalad hand/forearm to lift and position the patient’s head and neck to localize to the restrictive barriers (F/E, sidebending, rotation comes from fulcrum hand).
   
   • Type 1: Sidebend Away from physician
   • Type 2: Sidebend Towards physician
4. Instruct patient to inhale and exhale.
5. At the end of exhalation, the examiner will exert an anterior to posterior HVLA thrust through their abdomen toward the posterior transverse process.
6. Reassess

Question 2

HVLA Prone

(Texas Twist)

Answer 2

Setup:

• Type 1: Same side of PTP
• Type 2: Opposite side of PTP

Steps:

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

Question 3

Seated Lower T-Spine HVLA

Answer 3

Setup:

• Patient seated with ipsilateral hand to the PTP clasped behind
  their neck and holding that elbow with their other hand.
• Physician standing primarily posterior but slightly shifted to
  opposite side of PTP (same set up as seated ME treatment)

Steps:

1. Grasp patient’s biceps, with arm orientation dependent on type of SD (Type 1 vs Type 2), and engage restrictive in all 3 planes.
2. Physician places ipsilateral thenar eminence to the PTP of the dysfunctional vertebrae
3. At the end of 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.
4. Reassess

Question 4

Seated 1st Rib Inhalation Dysfunction HVLA

(J Stroke)

Answer 4

Setup:

• Patient seated with physician standing behind
• Physician places foot on the table opposite the dysfunction and patient drapes their arm over physician’s knee

Steps:

1. Physician contacts the dysfunctional rib with the second MCP
   joint of ipsilateral hand and with the other hand, contact the top
   of the patient’s head
2. Physician engages the barrier by sidebending the head toward
   the dysfunctional rib localizing sidebending and rotation to T1
3. During exhalation, the doctor gently loads the first rib.
4. At the end of exhalation, physician applies a thrust inferiorly/medially and slightly anterior through the superior rib.
5. Reassess

Question 5

Ribs 3-10 Bucket Handle Inhalation SD HVLA

Answer 5

Setup:

• Patient supine with physician opposite the dysfunctional rib
• Patient crosses arms over body with arm on the side of
  dysfunctional rib on the top

Steps:

1. Doctor places the thenar eminence of the caudad hand on the
   superior edge of the angle of the dysfunctional rib.
2. The other hand is used to elevate the patient’s head/neck and
   maintain thoracic flexion.
3. Physician localizes pressure through the patient’s elbows at the
   dysfunctional rib angle.
4. During exhalation the physician gently loads the barrier.
5. At the end of the next exhalation, the doctor applies a posterior thrust directed superior to the thenar eminence.
6. Reassess

Question 6

Ribs 3-10 Bucket Handle Exhalation SD HVLA

Answer 6

Setup:

• Patient supine with physician opposite the dysfunctional rib
• Patient crosses arms over body with arm on the side of
  dysfunctional rib on the top

Steps:

1. Doctor places the thenar eminence of the caudad hand on the
   inferior aspect of the angle of the dysfunctional rib.
2. The other hand is used to elevate the patient’s head/neck and
   maintain thoracic flexion.
3. Physician localizes pressure through the patient’s elbows at the
   dysfunctional rib angle.
4. With exhalation the physician gently loads the barrier.
5. At the end of the next exhalation, the doctor applies a posterior thrust directed slightly caudal to the thenar eminence.
6. Reassess