HVLA

Question 1

Describe how Hippocrates contributed to the history of HVLA

Answer 1

Hippocrates wrote a book on joints - the hand, foot, seated body weight or a wooden lever could be used to impart spinal pressure or thrust to treat a prominent vertebra
Noted that this ts should be followed by exercises

Question 2

Describe how AT Still contributed to the history of HVLA

Answer 2

Lightning bone setter
Typically describing rapid joint repositioning by Central American healers
Manual techniques and body self healing was popular in mid 1800s

Question 3

Describe how Dr. DD Palmer contributed to the history of HVLA

Answer 3

Not a DO student
Used HVLA within his practice
Started the Palmer school of chiropractic medicine

Question 4

What is HVLA?

Answer 4

An OMT emptying a rapid, therapeutic force of bried duration that travels a short distance wihtin the anatomical range of a joint range that engages the restrictive barrier to elicit release of restriction
Also known as thrust technique

Question 5

Force is not quantified by what?

Answer 5

HVLA
Does not mean extreme or overpowering
Force is minimum required for release of one localized segment
The more precise the localization of positioning the less force is needed

Question 6

What is a physiologic barrier?

Answer 6

End ROM achieved during active motion in the absence of somatic dysfunction

Question 7

What is a restrictive barrier?

Answer 7

A functional limit that abnormally diminishes the normal physiologic range

Question 8

What is the anatomic barrier?

Answer 8

End ROM achieved during passive motion in absence of somatic dysfunction
Movement past this plane begins to cause tissue damage

Question 9

Barriers are not clear hard lines but rather what?

Answer 9

Regions where tension builds parabolically

Question 10

What is ROM quantity?

Answer 10

Quantity is determined by amount of movement available from a neutral position
Evaluated during PE and screening
Used to reference maximum distance available for thrusting techniques
Total movement quantity can be misleading

Question 11

What is quality of movement?

Answer 11

Palpatory appreciation of how smoothly and easily a joint can be moved - not how far

Question 12

What is end feel?

Answer 12

Quantity and quality of motion of a joint when it is brought passively near and up to physiologic or restrictive barrier of motion
“Firm and distinct” or mechanical is typically arhtrodial dysfunction
“rubbery” is typically from muscle, fascia or a reflex

Question 13

What are the indications of HVLA?

Answer 13

Dysfunction localizes to a joint
-greatest regional dysfunction is at the joint
-uncommonly HVLA is used for fascial restrictions
More 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 14

What is the neurophysiology of HVLA?

Answer 14

Thrust through the restrictive barrier —> restoration of motion at articulation —> restoration of normal propioceptive input —> reflex relaxation of muscles —> improvement of TART findings

Question 15

What is the pop sound during HVLA Tx?

Answer 15

Source of noise is still under debate
Conversion of N in joint fluid from liquid to gas by negative pressure
Eventration of gas into the synovial fluid which the breaking of surface tension
Snapping/releasing of ligamentous adhesions in the joint (non ever found on dissection)
Ballooning of joint capsule
Noise is NOT necessary for success

Question 16

What are the steps for HVLA?

Answer 16

1. Correctly diagnose SD
2. Provide some soft tissue preparation (MET, MFR, kneading, etc)
3. Localize forces to a segment or joint (engage the RB in all 3 planes of motion = stacking)
4. Release enhancing maneuver (pt exhalation is typical)
5. Accumulation of forces
6. Corrective thrust
7. Return to neutral
8. Reassess for effectiveness and SD persistence

Question 17

How do you prepare for HVLA?

Answer 17

Apply techniques to relax regional muscle and fascial structures
-reduces risk of soft tissue injury
-increases pt confidence in physician
Relaxation is critical
-Physician frees up cortex to receive kinesthetic input from hands and fingers
-physician - relaxed muscles are better prepared for rapid contraction
-pt - muscular relaxation prevents tensing that can interfere with correction
Pt reduces risk of muscle or tendon injury

Question 18

Describe engagement and stacking of barriers

Answer 18

Typical vertebra (C2-L5) assessed and treated i n3 planes of motion 
HVLA is utilized by stacking restrictive barrier in all three planes 
Not stacking restrictions 
Extremity restriction 
-typically major motion = muscles 
-minor motion = joint dysfunction 
E.g. posterior tibiofemoral glide = SD with sidebending and rotation

Question 19

Explain engagement and stacking of barriers in terms of force

Answer 19

Forces move from the top down through the dysfunction
Forces are applied from the bottom up to the dysfunction
Each level of the unit is used as an opposing counterforce

Question 20

What is accumulation of forces?

Answer 20

Move firmly against the barrier on pt 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 stack

Question 21

What is a corrective thrust?

Answer 21

The direction of force is typically towards the culmination of all vectors used for localization
At the engaged barrier deliver a short, rapid thrust with sudden acceleration and deceleration
-Don’t release barrier engagement force prior to thrust
Exhalation -> muscle relaxation -> more effective thrust
Minimum force: speed and force is modified to fit patients need
Well engaged dysfunctions may have an audible or palpable click prior to thrust (articulatory release)
An audible or palpable click is not needed to produce tissue release - the goal is not the pop

Question 22

What are the general rules of dosage for OMT?

Answer 22

The more acute or sick the less the dose
Older pts respond more slowly
-more recovery time is needed b/w tx
-fewer total tx (of any type) per encounter
Most cases discourage thrusting the same segment more than once a week
-tissues need to recover from the trauma of tx
-frequent tx can lead to hyper mobility of segments
Decrease tx as pt improvement duration increases

Question 23

If the same SD keeps recurring what should you do?

Answer 23

Evaluate and address for underlying inciting factor such as posture, leg length imbalances, scoliosis or growth inequities, strength imbalances, scar tissue from injury, large instability, interdependence with other SD

Question 24

What are the benefits of HVLA?

Answer 24

Time efficient, well tolerated, pt typically experiences immediate relief, decreased pain and increased ROM
Modality of choice for SDs with distinct firm barrier

Question 25

What are the indications for HVLA?

Answer 25

Somatic dysfunction
Articular SD
Joint motion restriction with a firm articular barrier
-when regional dysfunction is judged to be a joint motion restriction, not a primarily soft tissue restriction

Question 26

You should use HVLA to achieve the following benefits

Answer 26

Reduce joint fixation such as adhesive capsulitis
Release chronic dysfunction resistant to other tx modalities
Modify reflexes - CNS reprogramming, neurologic input and output briefly shut off post HVLA
More effective with hypomobile joints
Restoration of bony alignment
Reduce meniscus entrapment
Pain modulation
-greater reflex relaxation of associated muscles

Question 27

What are the precautions for HVLA?

Answer 27

In general adverse effects of HVLA technique can be avoided by following certain principles
Uncover possible diseases or conditions which would contraindicate the use of HVLA
-take a thorough history
-provide a careful PE
C spine: avoid hyperextension and excessive rotation

Question 28

What are the guidelines for safety when performing HVLA?

Answer 28

Risk:benefit ratio
-if risk outweighs the benefit of the technique it is not indicated
Safety considerations include pts consent and comfort, accurate dx, if barrier doesnt feel right dont thrust, use min necessary for one joint only, hyper mobility of joints could be exacerbated by HVLA, excessive tx can lead to hyper mobile joints

Question 29

What are the absolute contraindications of HVLA?**

Answer 29

Local cancer of metastasis, local osseous or complete ligamentous disruption, RA, Down syndrome (both may lead to alar ligament instability), severe osteoporosis, osteomyelitis, spinal cord dx like a severe acute herniated disc with radiculopathy, cauda equina syndrome, etc

Question 30

List further absolute contraindications

Answer 30

Pt refusal, osteogenesis imperfecta, vertebrobasilar, carotid insufficiency, acute local inflammatory joint disease, joint infection, bony malignancy, fracture/dislocation/spinal or joint instability, fusion, upper cervical RA, Down syndrome, achondroplastic dwarfism, chiari malformation

Question 31

What are the relative contraindications?

Answer 31

Acute herniated nucleus pulposus, acute radiculopathy, acute injury (severe muscle spasm, sprain, strain, osteopenia/osteoporosis), spondylolisthesis, metabolic bone disease, hyper mobility syndromes, joint replacement or other implant in the area being treated

Question 32

Precautions and contraindications of HVLA

Answer 32

Apprehension by the pt (always ask permission and explain expectations)
Mild to moderate strain or sprain in area being treated
Mild osteopenia or osteoporosis (avoid compression)
RA disease other than in the spine - creates fusion and spurring

Question 33

Review

Answer 33

Study concepts slide