Overview of High-Velocity Low-Amplitude Manipulation Techniques
Dr. Kirkaldy-Willis first developed and shared ideas about how changes in our body’s mechanics can lead to spinal problems. These issues happen when there’s an imbalance in the way our spine moves. He defined a particular method called “high-velocity low amplitude” or HVLA in a way that’s quite complex. Basically, he said it’s a careful and controlled movement that pushes a joint slightly beyond its usual range without breaking it.
High-velocity low-amplitude (HVLA) involves using a strong and quick motion in a short span of time. This technique, which is often taught to osteopathic doctors, chiropractors, and physical therapists, basically pushes a joint a little past its normal limit to alleviate any stiffness or limitation. HVLA is especially useful in cases of sudden back pain.
In this treatment, the doctor positions you in a way that the limiting joint can be addressed. They then apply a quick and decisive push in the direction of the stiffness to ease it and enhance your mobility. This method is quite old but often used, especially in children. It’s also been thoroughly researched, mainly for its effectiveness in treating back and neck pain.
The main goal of this therapy is to restore movement to a stiff joint and improve its functionality.
There are some terms specific to HVLA. This method is often used interchangeably with “manipulation” and “thrust”, as they all describe the same kind of motion. An “adverse event” here means any kind of side effect, like a stroke, headache, or joint pain. “Cavitation” is the technical word for the process of creating a small pocket of gas within a joint. The term “Long Lever” means the extremities or backbone, while a “Short Lever” refers to any part of the backbone that holds force applied to the bone close to it.
Some stats on HVLA: Around 2 to 3% of children are known to have used it. The occurrence of a negative outcome for every procedure involving HVLA is 1 in 50,000, and roughly 1 in 5 of these are caused by the person carrying out the procedure. The incidence of negative outcomes in neck manipulation is about 1 in 400,000 to 1,000,000.
Anatomy and Physiology of High-Velocity Low-Amplitude Manipulation Techniques
The lower part of your back is called the lumbar spine and it’s made up of five blocks of bone called vertebrae. Each vertebra has certain nerves that exit from it, carrying messages from the brain to the rest of your body. For example, the nerve known as L3 leaves between the third and fourth lumbar vertebrae. This is important because when you feel pain along a certain pathway, which doctors call a dermatome, treatments can target these specific nerve pathways to help alleviate the pain.
The vertebrae are also connected by small joints, which help in spine movement. The joints that connect vertebrae work together to help you bend and stretch but they limit sideways movements to keep your spine stable and protected. If needed, doctors can adjust or manipulate these vertebrae to treat certain conditions.
Spinal therapy or treatment involves different methods to manage conditions related to the muscles and bones of your back. In one such method, a health care professional may apply a quick, gentle push to a specific vertebra to help improve movement and reduce pain. This is different from spinal mobilization, which does not involve any such thrust. Both these treatment methods have their own benefits and are selected based on your specific condition and symptoms.
Studies have shown that spinal adjustment can help with various conditions including back pain, migraines, and neck pain, among others. Depending on the condition, the treatment could involve movements applied to the entire spine or just a specific joint.
The major aim of such spine adjustments is to restore normal joint function. These adjustments involve a quick and gentle push that helps re-align the vertebrae, leading to mechanical and biological effects. These effects could contribute to the relief from certain symptoms but more research is required to understand the exact pathways involved.
In terms of physiology, or how the body works, a joint can only move to a certain extent due to the restrictions from the surrounding soft tissues, beyond which you may cause tissue damage. Certain changes at the level of nerves and the brain have been documented following spine adjustments. It is believed that this treatment can lead to the release of certain gases from the joints, which could help restore their function. Carbon dioxide is one of the gases that is commonly released following such treatments and has been associated with the improvement in joint motion.
The release of this gas is often accompanied by a popping sound from the joint. This however doesn’t necessarily mean that the treatment was effective. Even if there’s no such noise, the treatment might still have caused changes that can help improve your condition.
From a physiological perspective, there are several reasons why spine adjustments might be effective. One reason is that spine adjustments could help stretch a tight muscle, which in turn sends signals to the brain to relax the muscle. Alternatively, the adjustment could activate certain receptors in the muscle, leading to muscle relaxation.
Why do People Need High-Velocity Low-Amplitude Manipulation Techniques
Some hints that a person might benefit from high-velocity, low-amplitude (HVLA) therapy include if they’ve had lower back pain for two weeks or less, a recent onset of lower back pain, or an absence of regular joint movement throughout the body. This special type of therapy involves a quick, precise thrust applied to a joint to improve its range of movement.
On the other hand, there are certain signs that suggest a person may not benefit much from this therapy. These signs include pain located behind the knee, frequent episodes of lower back pain or existing, long-standing upper back pain. When there’s only lower back pain without pain in knee or any extending pain to the knee region, or increasing knee pain with activity; these are also indicators suggesting HVLA therapy might not be effective. Additionally, if you are taking certain medications like blood thinners, have chronic joint diseases or abnormalities, have had recent surgery, or have any unidentified pains and conditions that suggest clinical instability, HVLA may not be the best option.
Certain situations also deem it unsuitable for someone to undergo manipulative therapy. For example, if an individual is diagnosed with severe osteoarthritis or osteoporosis in the spine, has cancerous growths near the area, inadequate blood supply to the neck’s vertebral artery, or if there’s blood within a joint. Also, the presence of a loose body in the joint, maximum mutual substitutions or the presence of an abnormal or a degenerative joint are all disqualifying conditions. A manipulation should never be performed until a full diagnosis has been reached.
When a Person Should Avoid High-Velocity Low-Amplitude Manipulation Techniques
A contraindication is a situation where a specific treatment could potentially cause more harm than good to a patient. For instance, some methods might not be suitable for patients with injuries, serious illnesses, undiagnosed conditions or delicate states of health. These patients may be moved away from a restrictive position to allow loose or relaxed tissue, which is less risky. Direct strategies, where the transition happens towards any restriction, are less suitable for these conditions, but may work well for many chronic illnesses.
Some conditions entirely rule out certain treatments. These absolute contraindications include infections like meningitis, issues with the skeletal system like bone diseases or dislocations, cancer, heart diseases, refusal by patients for some treatments, blood clot disorders like thrombosis, neurological or nerve disorders, spinal cord damage, and serious slipped discs in the spine.
Then there are relative contraindications, where a treatment might not be the best option but could still be used if required. These include ankylosing spondylitis (a type of arthritis that affects the spine), blood-thinning treatments, hardened arteries, use of blood-thinning medications like aspirin and warfarin, conditions causing fragile bones, Down syndrome, use of blood thinner heparin, slipped disc, extreme discomfort, medication like clopidogrel (which prevents blood clots), extreme sprains and strains, and vertigo (a condition that creates a sense of spinning).
In some cases, the HVLA technique, a type of forceful medical manipulation, may not be suitable. Students aren’t allowed to use this technique due to the potential harm of repeatedly applying force to the same area of a patient. In fact, a 2010 study showed that HVLA was used in less than 0.01% of over 24,000 documented cases of osteopathic manipulative treatment (a type of physical therapy).
Equipment used for High-Velocity Low-Amplitude Manipulation Techniques
The patient may be asked to lie down on a custom-made, cushioned bench. This type of bench helps the therapist provide the appropriate care comfortably. Usually, therapists use their hands for treatment, but sometimes they might use a specific tool to help with the treatment. The therapist might also use specially designed chairs and tables to position the patient properly. This ensures the best possible comfort and effectiveness of the treatment.
Electromyography
This device can be used to monitor the technique applied during a treatment or therapy. It does this by consistently measuring the High-Velocity, Low-Amplitude (HVLA) technique – that is, quick but gentle manipulations in therapy. Research has shown that as the intensity of these quick, gentle thrusts increases, there’s a related increase in the readings or responses from the electromyography device. These responses can be recorded both before and after the ‘false thrust’, a term used to describe a pretend motion or action used as part of the therapy.
Who is needed to perform High-Velocity Low-Amplitude Manipulation Techniques?
The team members who use this hands-on method need to have gone through a prior training program.
Preparing for High-Velocity Low-Amplitude Manipulation Techniques
Before a medical procedure, it’s important that the medical team is well-prepared. This involves studying the procedure’s complete method, both in theory and practice. They need to know exactly what they’re going to do, and how they’re going to do it, to ensure the best possible outcome for the patient.
The patient’s preparation is also important. This involves explaining to them what exactly the procedure involves, what will happen, and why it’s being done. The patient’s agreement, or consent, to the procedure is also incredibly important. They have to understand and agree to what will be done before the procedure can take place.
How is High-Velocity Low-Amplitude Manipulation Techniques performed
When a joint in your body isn’t moving as freely as it should on all sides, physiotherapists use a special set of procedures to improve its movement. The steps in this process are:
- Find out what kind of movement is limited in your joint.
- Try to move the joint in the directions where it feels stiff or tight by applying the right pressure.
- Give a quick, gentle push in one of the directions where the movement is tightest.
- Check to see if the movement has improved.
Physiotherapists use some popular techniques for this process:
Diversified Technique – This is the common method used in physical therapy. The therapist applies a speedy, light twist in different directions to your joint to make moving easier. Your body will be placed in specific positions to make the joint adjusting process more effective.
Palmer Gonstead Adjustment – This method is similar to the first one, but it uses a different way to identify and fix the problem joint. Special tools like a neck chair or a chest-knee table are used to position your body.
Thompson Terminal Point – In this method, the therapist uses a special treatment table. Some parts of this table drop a short distance when a gentle force is applied. This pushes the joint gently, helping it to move better. This method does not always make a “cracking” sound, and can be considered a gentler version of joint manipulation.
Alternative Lumbar Manipulation – These methods aim to provide a more relaxed experience for patients. They include techniques such as a soft tissue manipulation, which is similar to a massage and helps to release any tension in your muscles before the main treatment.
Balance and Control – For the best results, both you and your therapist need to have a good balance and control during the therapy. This includes getting into a comfortable position on the table and staying relaxed during the treatment. Therapists use their hand or forearms to guide the movement of your joint and apply gentle force in the right direction.
Possible Complications of High-Velocity Low-Amplitude Manipulation Techniques
After spinal care therapies, sometimes people might experience temporary side effects that can be overlooked if they are not given clear instructions for their aftercare. Studies have shown that between 30 to 61% of patients can face common side effects as a result of a therapy involving the spine.
The common side effects can range from feeling tightness in certain areas, headaches, weakness, soreness spreading in the body, numbness, dizziness, fatigue, body stiffness, experiencing a sensation of warmth in the body, and sometimes even fainting. On the rarer side, patients may experience early or intense menstrual cycles, discomfort in the stomach and intestines, body twitching, irregular heart rhythms, and excessive sweating. These side effects usually appear around 4 hours after the therapy and go away within the next 24 hours.
Some people might experience a mild headache after therapy on the neck or feel sore after therapy on the back. Particularly, those with sensitive skin may notice some redness and tiny spots of bleeding under the skin, which can last for several hours. As people move forward with their therapy, some of these issues might come back, and if therapy is stopped, the problems may become worse.
What Else Should I Know About High-Velocity Low-Amplitude Manipulation Techniques?
The main purpose of medical treatments is to:
* Increase the mobility of a stiff joint
* Line up the parts of your skeleton again so that the natural functions of your joint can be restored
* Lower the overly tightness (hypertonicity) of muscles and/or spasms to bring back balance to the muscles around the joint
* Lengthen the reduced connective tissue linked to the joint
Research suggests that certain techniques involving quick and forceful movements (called HVLA thrust techniques) could be riskier than other methods due to their intensity. They, therefore, receive a lot of attention in medical studies, focusing mostly on their negative side effects. The most crucial side effects are linked to situations where these HVLA techniques combine speedy thrusts with rotational movements or anesthesia. Self-turning or accidental twisting of the head has also been related to unexpected and unintended injuries. An investigation involving 283 reviews only found adverse results in 118 of them. The most commonly reported negative effects were strokes, headaches, and tears in the artery in the neck (vertebral artery dissection). Of the studied 118, 46% suggested that HVLA is safe, 13% maintained that HVLA was harmful, and 42% were unsure or had no opinion on HVLA’s effects.
The American Osteopathic Healthcare Association is committed to continually studying patient care. They focus on a variety of areas such as hospital visits, chronic pain, women’s infection with a sexually transmitted bacterium called chlamydia, deep vein thrombosis (a blood clot in a deep vein), preventing falls in older people, and many other conditions.
