Continuing Education Activity

Osteopathic manipulative treatment, or OMT for short, is a technique by which osteopathic physicians have used their hands to diagnose and treat numerous health conditions for years. This type of hands-on treatment has helped reduce the number of pain medications patients may need for a musculoskeletal injury. High velocity-low amplitude, or HVLA for short, is a type of manipulation in which the provider provides a rapid (high velocity) therapeutic force of brief duration that travels a short distance (low amplitude) within the anatomic range of motion of a joint and engages a restrictive barrier in one or more planes of motion to elicit the release of restriction. This activity describes the mechanics of thoracic HVLA and highlights the role of the healthcare team in evaluating and treating this condition.

Objectives:

• Describe the neurophysiologic mechanisms of HVLA.
• Identify the indications/contraindications of HVLA treatment.
• Outline the steps in performing HVLA on the thoracic spine.
• Summarize the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients receiving thoracic HVLA.

Introduction

Osteopathic manipulative treatment, or OMT for short, is a technique where osteopathic physicians have used their hands to diagnose and treat numerous health conditions for years. This type of hands-on treatment has helped reduce the number of pain medications patients may need for a musculoskeletal injury. High velocity-low amplitude, or HVLA for short, is a type of manipulation in which the provider provides a rapid (high velocity) therapeutic force of brief duration that travels a short distance (low amplitude) within the anatomic range of motion of a joint and engages a restrictive barrier in one or more planes of motion to elicit the release of restriction. This article describes the mechanics of thoracic HVLA and highlights the role of the healthcare team in evaluating and treating this condition.

High velocity, low amplitude manipulation is a common treatment used most often when patients are experiencing pain or loss of joint motion. The most commonly taught method of thoracic HVLA is the "Kirksville Crunch." This method is widely known in the osteopathic community and effectively treats most thoracic joint somatic dysfunctions. It is important to learn this technique as well as its alternatives if a patient is unable to be manipulated using one particular method. Learning how to perform effective thoracic HVLA is essential to the practicing osteopathic physician as it will help improve patient satisfaction by providing immediate results. Additionally, treating a musculoskeletal ailment with thoracic HVLA will decrease the number of pain medications prescribed to the patient.[1]

Anatomy and Physiology

Four major tenets that serve to guide the osteopathic physician are important in understanding the goals of HVLA treatment. They are (1) the body is a unit; a person is a unit combining body, mind, and spirit, (2) the body possesses the capability of self-healing, self-regulation, and maintenance, (3) structure and function are inter-related, (4) rational treatment is based upon an understanding of the other three tenets. When performing any osteopathic manipulation on a patient, it is crucial to keep these tenets in mind. Osteopathic physicians receive specialized training in using manipulation, and it is vitally important to understand the anatomy and physiology behind these maneuvers before performing them on patients.[2]

High velocity, low amplitude (HVLA) is a treatment modality utilized by many practitioners for the treatment of many different somatic dysfunctions. Thoracic HVLA specifically focuses on restoring structure and function to the thoracic spine. The thoracic spine is a unique segment of the spine as each vertebra is attached to a pair of ribs and is responsible for anchoring the rib cage. Fryette's Laws can describe somatic dysfunctions of the thoracic spine. Both type I and type II segment somatic dysfunctions can be effectively treated with thoracic HVLA if indicated. Often, one of the transverse processes on an affected thoracic segment is oriented posteriorly, and, when palpated, the patient reports pain in that area. The somatic dysfunction is then elicited by having the patient flex and extend at the affected segment and determining how the posterior transverse process reacts.[3]

From a physiological standpoint, there are some theories regarding why HVLA is an effective form of treatment. First, an HVLA thrust appears to stretch a contracted muscle, which, in turn, produces several afferent impulses from the muscle spindles to the central nervous system. The central nervous system then reflexively sends an inhibitory impulse to the muscle spindle to relax the muscle. An alternative theory suggests that instead of the muscle spindle, the Golgi tendon receptors become activated, ultimately relaxing the muscle.[4][5]

Indications

Indications for thoracic HVLA include the following:

• Palpable somatic dysfunction of a joint in the thoracic spine
• Firm distinct restrictive barrier
• Pain[6]
• Loss of range of motion

Contraindications

There are several absolute and relative contraindications that the practitioner should be aware of before initiating thoracic HVLA treatment on a patient.[7]

Absolute Contraindications

• Bony compromise (tumor, infection, trauma, inflammation)
• Neurological issues (acute myelopathy, spinal cord compression, cauda equina syndrome, nerve root compression)
• Vascular compromise (vertebrobasilar insufficiency or cervical artery abnormalities, aortic aneurysm, angina pectoris, acute abdominal pain with guarding)
• Increased risk of harm to the patient (lack of diagnosis, lack of skill/expertise by the clinician, lack of consent from the patient)

Relative Contraindications

• Hypermobility
• Serious kyphosis or scoliosis
• Disc herniation or disc protrusion
• Systemic infection
• Serious degenerative joint disease
• Adverse reaction to previous HVLA manipulation

The clinician should perform a thorough history and physical examination before any osteopathic manipulative treatment.

Equipment

Equipment required for this procedure includes an OMT or a massage table on which the patient can sit or lie down.

Personnel

A patient who has given consent and an osteopathic physician who has had formal training in OMT during medical school or post-graduate training are necessary for this procedure.

Preparation

The physician must obtain informed consent from the patient before proceeding with intervention. A clear discussion with the patient of the risks, benefits, and alternative treatment options should be documented prior to starting treatment. Additionally, a complete osteopathic structural exam of the thoracic spine should occur before beginning the procedure.

Technique or Treatment

Two main thoracic HVLA techniques are performable on a patient with a thoracic somatic dysfunction. There is the seated method and the supine method (also called Kirksville Crunch). Descriptions of both techniques will follow, but it is ultimately provider preference and overall comfort level, which will ultimately dictate the choice of the technique.[8]

After diagnosing somatic dysfunction, the physician will position the dysfunctional segment such that all restrictive barriers are engaged. This process occurs by reversing all three planes of motion of the dysfunctional segment. For example, if the thoracic segment T7 has demonstrated the somatic dysfunction ERSr (extended, rotated, and side-bent right), then the segment would be placed in flexion, rotated, and side-bent to the left until motion is felt; this is called the restrictive barrier. A short quick thrust is then applied, and the patient then undergoes reassessment.

There are two different variations to performing thoracic HVLA: seated and supine. The steps for performing these various maneuvers appear below.

Seated Position Technique

1. The clinician stands behind the patient with their hands clasped behind their head.
2. The clinician places their epigastric area behind the posterior transverse process of the dysfunctional segment.
3. The clinician reaches under the patient's arms and holds the forearms. The patient is then instructed to take a deep breath, and during exhalation, the clinician pulls the elbows together and extends the trunk.
4. The clinician should then push their abdomen into the posterior transverse process.
5. At maximal exhalation, a short quick thrust is applied by the clinician's abdomen into the patient's posterior transverse process. The patient should then be rechecked after the manipulation.

Supine Position Technique (so-called "Kirksville Crunch")

1. The clinician stands opposite the side of the thoracic rotation.
2. The patient crosses their arms with elbows together. From the clinician's perspective, the patient's arm opposite where they are standing should be on top; this is referred to as opposite over adjacent. From the patient's perspective, the arm on the side of the thoracic rotation should be on top. For example, if the patient has a somatic dysfunction at T5 that is flexed, rotated, and side-bent to the right, the patient's right arm would be on top of the left arm.
3. The clinician reaches their caudad arm across the patient and places their thenar eminence behind the posterior transverse process.
4. The clinician leans their epigastric area into the patient's crossed elbows. The clinician's other hand then lifts the patient's head and trunk until pressure from leaning on the elbows is felt by the hand on the posterior transverse process.
5. The patient is asked to take a deep breath as the clinician leans into the elbows during exhalation.
6. At maximum exhalation, the clinician applies a short quick thrust from their abdomen onto the patient's elbows to mobilize the joint. The patient should then be rechecked after the manipulation.

Complications

Aside from some muscular soreness or possible symptom exacerbation, there are relatively few side effects of HVLA in the thoracic region. There are more serious side effects if performing HVLA in the cervical or lumbar region, but these are outside of the scope of this article.[9]

Clinical Significance

Back pain is a very common problem seen in many primary care offices and ERs. Usually, back pain is musculoskeletal, caused by turning, twisting, pulling, or lifting incorrectly. Many times these patients are amenable to some hands-on treatment as opposed to taking medication. Osteopathic physicians have received training in these special hands-on procedures, which can help with back pain. These include counter strain, kneading, and stretching techniques, muscle energy, and HVLA.

Many factors account for which procedure the practitioner chooses, but it is most often based on provider comfort and preference, as well as if the patient is willing and able to receive treatment. Thoracic HVLA is an important method of OMT in the osteopathic physician's toolkit as it can serve to treat musculoskeletal ailments while concurrently allowing for a reduction in the number of NSAIDs or other pain medication that a patient may be taking.[1][10]

Enhancing Healthcare Team Outcomes

Osteopathic manipulative treatment is a form of hands-on therapy that, in the appropriate setting, can help to enhance patient-centered care and improve outcomes. HVLA is a specific treatment modality that is more suited for the younger population. Some of the contraindications mentioned previously occur more in the elderly population, thus not allowing them to receive HVLA treatment. It is crucial to weigh the risks and benefits of HVLA treatment in these patients before attempting this type of maneuver. Other, less forceful techniques such as counter strain, kneading and stretching, muscle energy, or articulatory techniques should merit consideration before HVLA.[11] 

Regardless of treatment modality, osteopathic manipulative treatment serves as a manner by which to reduce the number of pain medications a patient is taking.[1][10] Overall, this can help improve patient outcomes by effectively reducing the number of pills a patient takes per day. Ideally, however, this helps patients stop an NSAID or an opioid medication completely.