Thoracic and Rib HVLA Lab

Question 1

Steps for HVLA

Answer 1

1) correctly diagnose
2) provide soft tissue prep
3) localize forces to a segment or joint
4) release enhancing maneuver
5) accumulation of forces
6) corrective thrust
7) return to neutral
8) reassess

Question 2

Prone Kneading

Answer 2

1) stand on opposite side to be treated
2) place thenar and hypothenar eminence on paravertebral muscles opposite side you are standing on
3) keeping elbows straight and using own body weight, engage soft tissues with a ventral force and move out laterally creating a perpendicular stretch
4) do not slide

Question 3

Lateral Recumbent soft tissue

Answer 3

Lower Thoracic:

1) place hands under humerus
2) finger pads places on paravertebral muscles, lateral to spinous processes
3) engage muscle with anterior force and pull laterally to give perpendicular stretch
4) do not slide or roll over the skin

Question 4

T-Spine Supine HVLA (Kirksville Crunch)

Answer 4

1) physician stands opposite side of PTP; patient crosses arms over chest with PTP sided arm on top
2) Align elbows: place a round pillow under elbows if elbows cross midline (flexible shoulders)
- CAUTION for patients with shoulder injuries as some force goes to that joint
3) rotate pt to side and place thenar eminence on PTP, cradling the spinous processes
4) keeping the other hand on the elbows, un-rotate the patient
5) flex the thorax and place pt’s elbows in physician’s upper abdomen
6) place cephalad hand on occiput or neck to lift and this increase flexion past the lesion
7) roll cephalad until elbows and pressure are over TP
8) utilize head and neck to induce sidebending
9) release enough pressure to allow the pt to breathe; pt inhales and exhales deeply
10) accumulate the localization forces against the barrier during exhalation
11) at the end of exhalation, the examiner will exert an anterior to posterior HVLA thrust through their abdomen toward the PTP
12) reassess

Question 5

Common errors in Kirksville crunch

Answer 5

• loss of thoracic flexion when trying to find side bending position
• pt’s elbows are not in operators abdomen
• don’t do any running starts; have a controlled drop from the barrier

Question 6

How to correct inaccurate hand placement

Answer 6

• pull elbows laterally to rotate 45-90 degrees for full access of spine
• find dysfunctional segment again
• spinous process should lay into the palm
• find spinous process with 3rd finger pad
• flex hand to pull thenar eminence onto TP
• extend perpendicular to the spine
• flex the thumb adductors to increase fulcrum force

Question 7

Type 1 flexed kirksville crunch

Answer 7

side bend away from physician

Question 8

Type 2 flexed kirksville crunch

Answer 8

side bend toward physician

Question 9

Type 2 extended kirksville crunch

Answer 9

• hand on spine supports vertebrae below

- thrust direction is above the hand and towards the dysfunctional vertebrae body

Question 10

Prone Pressure with Counter Pressure

Answer 10

1) place thenar eminence and thumb of caudad hand over thoracic paravertebral muscles opposite the side you’re standing
2) place hypothenar eminence of cephalad hand on paravertebral muscles on same side you are standing
3) apply gentle anterior force rhythmically for soft tissue or hold for myofascial release
4) reverse hand sides left and right and repeat

Question 11

Prone HVLA (Texas Twist) Positioning

Answer 11

For corrective side bending induction:
-Type 1 stand on same side of PTP
-Type 2 stand on opposite side of PTP
For additional side bending correction:
-Type 1 PTP hand facing caudad; pisiform ENDS on TP
-Type 2 (flexed) PTP hand facing cephalad; hypothenar ends on opposite transverse process

place other hand facing opposite direction with pressure on affected vertebrae anterior TP

Question 12

Prone HVLA

Answer 12

1) as pt exhales, increase anterior pressure to engage barrier
2) at end of exhalation, deliver anterior HVLA thrust, perpendicular to the spine through both hands with slightly more pressure on the PTP
3) the counterbalance pressure creates a twist in the direction of the fingers
4) reassess

Question 13

Seated Direct Techniques and Ergonomics: patient positioning

Answer 13

place hand of PTP behind neck and grasp elbow with other hand

Question 14

Seated Direct Techniques and Ergonomics: Neutral Type 1

Answer 14

physician behind pt and loops arm beneath pt’s arm and grasps PTP sided bicep/humerus to induce sidebending and rotation to restrictive barrier

Question 15

Seated Direct Techniques and Ergonomics: Type 2

Answer 15

physician stands behind pt and loops arm above pt’s arm and grasps PTP sided bicep/humerus to induce sidebending and rotation to restrictive barrier

Question 16

Seated Lower T-Spine HVLA

Answer 16

1) position and localization identical to MET
2) pt seated with ipsilateral hand to PTP clasped behind neck and holding that elbow with their hand; physician standing opposite to PTP
3) physician places thenar eminence on the PTP of dysfunctional vertebrae
4) grasp pt’s biceps with arm orientation dependent on type of SD and engage barrier in all 3 planes
5) on exhalation, quickly and minimally pull pt through rotational barrier while thenar eminence imparts an anterior impulse on the PTP, causing HVLA effect in rotational barrier
6) reassess

Question 17

Anterior Rib SD

Answer 17

• rib angle less prominent in posterior rib cage contour
• prominence of anterior portion
• restriction of movement in inhalation and exhalation
• rib angle tender with tension of intercostal muscles
• pain or tenderness in superior or inferior intercostal space
• causes medial scapular border or shoulder pain

Question 18

Posterior Rib SD

Answer 18

• rib angle more prominent in posterior rib cage contour
• anterior portion less prominent
• restriction of rib movement in both inhalation and exhalation
• rib angle tender with tension of intercostal muscles
• pain or tenderness in superior or inferior intercostal spaces
• causes medial scapular boarder or shoulder pain

Question 19

Seated Rib 1-2 Exhalation SD HVLA

Answer 19

1) physician thumb monitors T1 or T2 for localization, index MCP at rib angle, elbow and hand in line with the thrust
2) physician places foot on table opposite the dysfunction and pt drapes arm over physician’s knee
3) physician contact dysfunctional rib angle with 2nd MCP joint of the hand ipsilateral to dysfunction
4) the other hand engages pt head, sidebending head toward dysfunctional rib and rotating away until motion felt at T1
5) with exhalation, the doctor loads into the first rib and further sidebends and rotates into the barrier
6) at the end of exhalation, on the inhaled rib, thrust inferiorly and medially toward mid inferior pectoralis 45 degrees inferior and medial, slightly anterior
7) reassess

Question 20

Supine Rib 1-2 Inhalation SD HVLA

Answer 20

1) physician contacts dysfunctional rib angle with second MCP joint of one hand; engage pt head with other
2) sidebend head toward and rotate away until motion felt
3) with exhalation, load into first rib and further sidebend and rotate into barrier
4) at end of exhalation, apply thrust inferiorly/medially on superior rib towards mid inferior pectoralis
5) reassess

Question 21

Exhaled rib thrust direction

Answer 21

thrust helps drive the rib superior compared to the chest and vertebrae

Question 22

Inhaled rib thrust direction

Answer 22

thrust helps drive the rib inferior compared to chest and vertebrae

Question 23

Ribs 3-10 Exhalation SD, supine HVLA

Answer 23

1) pt supine with physician opposite of dysfunctional rib
2) pt crosses arms over body with arm on side of dysfunctional rib on top
3) doctor places thenar eminence of caudal hand posterior and inferior to angle of dysfunctional rib
4) other hand may be placed on pt’s elbows or may be used to elevate pt’s head/neck
5) apply pressure through pt’s elbows localizing at the dysfunctional rib
6) pt inhales and with exhalation, physician further loads into barrier
7) at end of next exhalation, doctor applies posterior thrust directly slightly caudal to physicians thenar eminence
8) reassess
6) at end of exhalation, doctor applies posterior thrust directed superior to thenar eminence
7) reassess

Question 24

Ribs 3-10 Inhalation SD, supine HVLA

Answer 24

1) pt supine with physician opposite of dysfunctional rib
2) pt crosses arms over body with arm on side of dysfunctional rib on top
3) doctor places thenar eminence of caudad hand posterior and superior to angle of rib
4) other hand placed on pt elbows or used to elevate head
5) apply pressure through elbow at dysfunctional rib level
6) with exhalation, load further into barrier
7) at end of exhalation, doctor applies posterior thrust directed superior to thenar eminence
8) reassess