Continuing Education Activity

Lumbar spine high-velocity low-amplitude (HVLA) thrusting techniques are a form of manual medicine used by osteopathic providers. As the name implies, this technique involves high-velocity thrusting techniques under controlled pressure applied in order to correct a specific osteopathic diagnosis discovered previously on an osteopathic physical exam. This activity outlines lumbar high-velocity low-amplitude (HVLA) osteopathic techniques of the lumbar spine and explains the role of the osteopathic practitioner in evaluating and treating patients who are undergoing lumbar HVLA. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, Department of Defense or the U.S. Government.

Objectives:

• Outline the indications and contraindications for high-velocity low-amplitude of the lumbar spine to improve patient selection for this technique.
• Summarize the process of developing and osteopathic diagnosis of the lumbar spine to improve technique selection for a given patient.
• Review the available techniques for high-velocity low-amplitude (HVLA) techniques for the lumbar spine to improve treatment satisfaction and patient outcomes in patients selected for treatment with HVLA.
• Identify potential pitfalls and challenges associated with high-velocity low-amplitude of the lumbar spine in order to avoid potential complications and improve outcomes for patients receiving these techniques.

Introduction

Lumbar spine high-velocity low-amplitude (HVLA) thrusting techniques are a form of manual medicine used by osteopathic providers. As the name implies, this technique involves high-velocity thrusting techniques under controlled pressure applied to correct a specific osteopathic diagnosis discovered previously on an osteopathic physical exam. HVLA techniques are frequently used in osteopathic manipulative medicine as an adjunct to other treatment modalities for low back pain, among other conditions.

This article reviews the background anatomy and physiology behind these techniques as well as discusses the technical aspects of their application. This discussion includes patient screening for contraindications and discussion of alternate techniques to attempt prior to HVLA application. The technical aspects addressed include obtaining a proper osteopathic diagnosis for the vertebral segment in question as well as outlining the set-up and application of the thrusting techniques themselves. Also, common pitfalls and a discussion on improving healthcare team implementation of these techniques are both addressed.

Anatomy and Physiology

Anatomical consideration of these manipulative techniques deserves attention before addressing the technical specifics. The lumbar spine includes five vertebral segments and their corresponding nerve roots that exit below the corresponding vertebra. For example, the L3 never root exits through the foramen between L3 and L4.[1]

This anatomy is relevant when targeting a particular adjustment to a specific patient complaint. If a patient reports pain that radiates down a specified dermatome, one could conceivably tailor therapy toward that region based on the innervation and corresponding spinal segments. Likewise, osteopathic physicians are trained to target somatic dysfunctions that could be contributing to other ailments based on those dermatomes.

The inherent mechanics native to the lumbar spine also warrant attention. The lumbar spine contributes a large percentage of side-bending, rotation, and flexion ability of the axial skeleton. As such, the options for manipulation are more varied than other, more restricted regions of the spine. This articulation is made possible by several synovial joints that compose much of the surface of the lumbar vertebrae. King among these articulations is the intervertebral disc, which is a fibrocartilaginous structure that sits between vertebrae.

Other, smaller articulations include the zygapophyseal joints (facet joints). These synovial joints sit two on the superior surface, and two on each inferior surface of the vertebrae. The superior facets are oriented with the articulating surface posterior and medial and interface with the corresponding articular surface of the adjoining vertebrae. This arrangement leads to the majority of the vertebral motion to be in flexion and extension compared to rotation or side-bending.[2][1] This relative limitation of side-bending allows manipulation of the vertebrae in lumbar HVLA.

Indications

Proper patient selection is critical to avoid injury and ensure the efficacy of the treatment. Critical aspects to keep in mind when considering the use of lumbar HVLA are the indications and goals of treatment. HVLA is typically applied to treat acute or chronic low back pain when making a specific lumbar diagnosis. Lumbar osteopathic diagnosis follows many of the same principals as the diagnosis of other parts of the spine (Fryette's laws).

The most fundamental way to diagnose the lumbar spine involves direct palpation to assess the posterior aspect of the transverse processes. After the provider determines the facet orientation in a neutral position, the spinal level in question may be placed into flexion and extension via direct manipulation of the spine or, more fundamentally, by patient positioning. The flexion/extension portion of the diagnosis is determined by which movement results in greater neutralization of the spinal segment.[3][4] 

This method describes the most classic means of diagnosing a type 2 dysfunction or dysfunction at one specific level. Type 1 dysfunctions involve multiple spinal segments that side-bent and rotated in opposite directions, generally involving three or more segments. These methods of diagnosis are subject to inter-evaluator bias, though training can improve consensus between providers.[5]

Contraindications

In addition to proper diagnosis, it is important to consider the contra-indications, both relative and absolute. It is helpful to think of relative contra-indications as those that will not result in severe debility/disability if the manipulation occurs. Relative contraindications (to HVLA in general) include acute whiplash, pregnancy, post-surgical, herniated disc, anticoagulation use/hemophilia, tense or malingering patient, female patients who smoke or use oral contraceptive pills (increased risk of thrombus), atherosclerosis, or vertebral artery ischemia.

Relative contra-indications would necessitate a discussion with the patient about the possible risks and benefits before the treatment application to inform them of specific risks associated with each condition. Absolute contraindications include osteoporosis, osteomyelitis, fractures in the area of thrusting, boney metastasis, severe rheumatoid arthritis (especially true in cervical HVLA), cauda equina/conus medularis syndrome (or symptoms of numbness/weakness suggestive of these diagnoses), fused spinal joints, osteomyelitis, joint instability, Down syndrome (also especially true in cervical spine manipulation), and patient refusal. Typically, the presence of an absolute contraindication excludes HVLA, as the risks would heavily outweigh any benefit.[6][4]

Equipment

Minimal equipment is necessary for lumbar HVLA. A treatment table designed for osteopathic manipulation is helpful, but a standard treatment table is still appropriate for use. The benefits of the osteopathic treatment tables include the ability to adjust the height of the table for the practitioner's preference and a larger area for the patient to lay flat. The typical orientation and location of articulation points on a standard office chair or treatment table may create points of discomfort for patients and limit options with respect to patient positioning.

Preparation

The performance of the technique begins with the positioning of the patient. The patient should be placed in a position of comfort with the patient lying down on one side. Depending on practitioner comfort, the posterior spinous process may be positioned close to or far from the table (the patient either laying on the side with the spinous process posterior or anterior given the diagnosed rotation).

The goal will be to rotate the patient against the pathologic rotation of the diagnosis (also known as the restrictive barrier), and so the practitioner can push or pull on the patient’s pelvis and thorax for the desired rotation (practitioner preference as above). For example, a patient is evaluated and found to have L3 Flexed Rotated and Sidebent (L3 FRS right) right (the L3 vertebra has rotated to the right relative to L4). The goal is to manually rotate the L3 vertebra to the left to correct the dysfunction as HVLA is a direct technique (acts in a direction to counteract the dysfunction).[7]

Technique or Treatment

For a planned thrust where the practitioner is pulling on the patient's pelvis and pushing the thorax, the posterior transverse process is oriented down (closer to the table) with the patient in a lateral lying position. It may be helpful to imagine manipulation of the patient's upper body as manipulation of the superior vertebra (the vertebra diagnosed with dysfunction) and the patient's bottom half as manipulating the lower vertebra, with additional positioning to assist in directing forces to the area of concern.

Additional positioning continues with the practitioner taking hold of the patient's legs with their more inferiorly directed arm, while their other arm palpates the spinous process of the dysfunctional vertebral segment. While palpating for movement, adjust the flexion of the patient's hips with the goal being to detect initial flexion in the dysfunctional vertebral segment (or just below). This step helps to direct the eventual thrust forces to the segment in question. Once the desired flexion in the lumbar spine is achieved, the practitioner instructs the patient to straighten the leg closer to the table and hook the foot of the higher leg (with the leg still bent) over the posterior knee (in the popliteal fossa) of the straightened leg that is in contact with the table.

The end result should create a sort of hinge effect of the top leg over the straight bottom leg with the patient still on their side. Keeping the patient in the established positioning, the practitioner can take their superiorly oriented hand and place it on the patient's lateral rib cage (away from the table). The inferior arm now can come to the patient's hip as the patient is guided in a gentle twisting motion such that the patient's shoulder blades should both nearly touch the table and the patient's hips are rotated toward the practitioner (this motion should create a twisting motion to counter the dysfunctional segment). Continuing this motion, one should reach a limit of the rotation of the spine based on the new dysfunctional limit of rotation, colloquially known as "locking out the segment." "Locking out" demonstrates utilizing Fryette's principles to isolate the desired joint and to minimize movement in other joints that may hinder the manipulation. This position should occur before the physiologic limit of rotation, given the dysfunction's presence further limits spinal motion (the aim of the treatment is to improve this range of motion).

Once the segment is in this limited position, the patient is instructed to take a deep breath in and release. The goal of the practitioner is the thrust through this barrier of motion in a controlled manner when the patient is totally relaxed (at the end of expiration is a common method). The thrust is directed primarily with the hand/arm on the patient's hips toward the table, perpendicular to the axis of rotation. The thrust should be quick and only with sufficient force to move the segments without causing injury to the patient. Following the thrust, the patient may be returned to a neutral rotation and re-examined. Assessing for the degree of change in the segments following the adjustment is a crucial aspect of the treatment as it guides whether the technique should be repeated.[7][8]

Performing the thrust with the opposite transverse process orientation is another option. The primary difference will be to push the hips of the patient away while the patient's upper body rotates toward the examiner (opposite of the above setup). Regardless of the choice of treatment options, the patient should still be re-assessed following completion of the adjustment.

It should be noted that the patient's torso can be further manipulated in either of these techniques to create elements of side-bending as well. These elements should counteract the direction of the dysfunction. Based on the dysfunction, the practitioner can direct the arm of the patient cephalad or caudad while initiating the locking step to induce side bending. For example, in a patient with the diagnosis of L4 flexed, rotated, and side-bent right, the side-bending component of the dysfunction is to the right; this would mean that while positioning the patient in the transverse process side down technique above (where the posterior transverse process is towards the table), the patient's table side arm can be directed cephalad (relative to the patient orientation) to induce leftward side-bending prior to the thrust.

Complications

Complications of the lumbar spine HVLA are very rare, but naturally, the chances of occurrence increase with the above contraindications. These complications can include fractures of lumbar vertebrae, soft tissue strains, and other soft tissue injuries. In rare cases, the patient's subjective pain may be made worse following an HVLA adjustment. These complications once again speak to the importance of practitioner-patient communication as well as the importance of proper setup, isolation of the dysfunction, and reevaluation after an attempted HVLA adjustment.

Clinical Significance

Lumbar spine HVLA represents a possible adjunctive therapy for lower back pain, as previously discussed. These techniques have shown measurable effects on the surrounding neurological structures of the spine.[9][10] Such measurable results lend credibility to the technique efficacy when properly applied. As outlined above, the proper application includes careful patient selection and diagnosis before the HVLA procedure. Following, the procedure patient evaluation through subjective means is typically the method of eliciting feedback on treatment success or failure. This subjective aspect is a principal criticism of osteopathic manipulation at large. Despite this limitation, there have been numerous studies outlining improvements of symptoms and patient satisfaction following osteopathic manipulative techniques.[11]

Enhancing Healthcare Team Outcomes

The practical application of osteopathic manipulative treatment, in particular, high-velocity low-amplitude, into a patient treatment regimen can pose several challenges to a provider. The first such obstacle can be finding a provider proficient in the desired technique. While osteopathic physicians are a growing population of the modern health care team, not all providers retain proficiency in a wide range of osteopathic techniques. This situation is increasingly true as osteopathic providers continue to branch out into various specialties.

Even for providers who themselves feel comfortable providing osteopathic treatment to their patients, finding time in a standard visit to perform manipulation can be challenging.[12] [Level 5] One approach adopted by several facilities has been to have a dedicated clinic for osteopathic and other manual medicine techniques. In this way, the visit can be geared specifically toward discussing treatment options and performing techniques with patients.

This approach greatly increases the time available to the provider performing the technique, rather than rushing to fit it into an otherwise narrow time window of a regular visit. Along these lines, the provider should become aware of specialty clinics that specialize in the implementation of OMT if the provider suspects a patient may benefit from such a visit.[13] [Level 5]