HVLA: Mechanism?

[facetguy]

Can a current DO student, or perhaps even better a NMM resident, explain how HVLA manipulation works?

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[Bacchus]

A somatic dysfunction that is articular in nature (bone) is diagnosed at one of many places in the body (cervical verts, thoracic verts, inominates, pubic symphysis). The location is put in the position of treatment. With the help of the patient, "slack" is drawn up as the patient is moved to the restrictive barrier using breathing. The last round of inhalation/exhalation is used to apply a quick force with a fast speed.

Don't quote me for anything .

 

[facetguy]

Understood. I guess what I'm asking is what happens as a result of an HVLA manipulation. How and why does it work?

 

[pianoman511]

Well, it all goes back to homeostasis. Everything in the body likes to be in it's "natural state", in the spine that means all the vertebrae like to be lined up straight and stacked up on top of one another. With somatic dysfunction, one or more are rotated/sidebent so there is an aberration in that straight line. When you treat via HVLA or any other modality, you are correcting the problem and bringing everything in line again. Any muscles/ligaments/what have you that have been affected will also be placed in their "natural state". HVLA is just the quickest way to correct the problem.

 

[facetguy]

Well, it all goes back to homeostasis. Everything in the body likes to be in it's "natural state", in the spine that means all the vertebrae like to be lined up straight and stacked up on top of one another. With somatic dysfunction, one or more are rotated/sidebent so there is an aberration in that straight line. When you treat via HVLA or any other modality, you are correcting the problem and bringing everything in line again. Any muscles/ligaments/what have you that have been affected will also be placed in their "natural state". HVLA is just the quickest way to correct the problem.

So if I understand correctly, HVLA works by re-aligning vertebrae and placing soft tissues in a more relaxed state? It's a bone-position thing then?

 

[IDBasco]

Tell me why this seems like a baited question.

 

[Bacchus]

Tell me why this seems like a baited question.

That's what I was thinking.

 

[p30doc]

As with many things in medicine(especially pharmacology) the mechanism is unknown and there are theories to how it works.

 

[fozzy40]

I'm a physiatry resident and this is the way that I look at it.
Essentially, what you are trying to do with HVLA is trying to mobilize a joint (i.e. the zygopophyseal joints) which is not articulating correctly and might be causing pain and affecting the surrounding muscle, ligaments, and fascia. You are bringing the joint in question to it's restricted range and using a high velocity force to restore motion within it's normal physiologic range of motion. The thought is that by improving range of motion that pain will be decreased and the surrounding tissues and muscles around the joint will calm down as well.

That being said, somatic dysfunction is usually the "victim" and its your job to find the "culprit." As an osteopathic physician, you should be looking at the entire body and trying to put the pieces of the puzzle together. For example, is your patient's myofascial RT scapular pain due to an anatomically short left leg, which causes LT innominate anterior rotation, shortening the iliopsoas on the LT, causing a primary convex lumbar curve to the RT, secondary thoracic curve to the left, giving you a T4-6 flexed and rotated segments to the right.

From here, you can initiate symptom mangement by treating the segmental dysfunction in the thoracic spine and use soft tissue mobilization to treat any myofascial restrictions. In order to go for a "cure", you have to treat the leg length discrepency and have the patient work on scapular retractions in physical therapy.

Hope this helps!

 

[st2205]

It looks like you got a pretty good answer directly above. I was hoping you could share the proper context in which chiropractic views the mechanism of what the osteopathic world calls HVLA (a genuine question).

 

[fozzy40]

I attended a DO school and not a chiropractic school so I can give you my opinion...

When I was in med school, I have a friend (DO) who's girlfriend was in chiropractic school at the same time. Honestly, it seemed like the philosophy was VERY similar to me but they way they set things up the manipulations (Palmer trained) was different. It also seemed like we focus more on myofascial release although I know many chiropractors who do also. Whether or not they picked it up on their on vs. at school I'm not sure.

In my mind, osteopathic and chiropractic manipulation has the same idea: joint mobilization. In my experience, I am not a big fan of people receiving the 12 week package of manipulation treatments 3 times per week which is largely done through chiropractic practioners. I'm sure there are plenty of DOs out there that may practice this way as well but this is what I have seen in my clinics.

The bottom line for me is that manipulation for me is great for symptom relief but it's not a "cure." It's a great way to gain symptom relief so that the patient can participate in a directed therapy program though.

 

[st2205]

I attended a DO school and not a chiropractic school so I can give you my opinion...

When I was in med school, I have a friend (DO) who's girlfriend was in chiropractic school at the same time. Honestly, it seemed like the philosophy was VERY similar to me but they way they set things up the manipulations (Palmer trained) was different. It also seemed like we focus more on myofascial release although I know many chiropractors who do also. Whether or not they picked it up on their on vs. at school I'm not sure.

In my mind, osteopathic and chiropractic manipulation has the same idea: joint mobilization. In my experience, I am not a big fan of people receiving the 12 week package of manipulation treatments 3 times per week which is largely done through chiropractic practioners. I'm sure there are plenty of DOs out there that may practice this way as well but this is what I have seen in my clinics.

The bottom line for me is that manipulation for me is great for symptom relief but it's not a "cure." It's a great way to gain symptom relief so that the patient can participate in a directed therapy program though.

Sorry, I should have clarified a bit better. I was referring to your post as a good answer but the rest was directed at the OP, as he is a chiropractor. The fact that he has been around and should know a great deal about OMM and the differences/similarities between OMM and chiropractic was probably why a few of the above posters may have felt it was a baited question. In any case, I'll give him the benefit of the doubt, but I am curious why the question was asked when he, if anyone, should have a clear understanding of the supposed mechanism, as the osteopathic theory of mechanism doubtfully would vary much from the chiropractic theory of mechanism. Also, what's the standard term for HVLA in the chiropractic world?

 

[fozzy40]

Gotcha...well I'm here are if there are any other related questions

 

[facetguy]

Sorry, I should have clarified a bit better. I was referring to your post as a good answer but the rest was directed at the OP, as he is a chiropractor. The fact that he has been around and should know a great deal about OMM and the differences/similarities between OMM and chiropractic was probably why a few of the above posters may have felt it was a baited question. In any case, I'll give him the benefit of the doubt, but I am curious why the question was asked when he, if anyone, should have a clear understanding of the supposed mechanism, as the osteopathic theory of mechanism doubtfully would vary much from the chiropractic theory of mechanism. Also, what's the standard term for HVLA in the chiropractic world?

You're sort of right. There is a motivation behind my question. 2-fold. 1) I've been out of school for awhile and was simply curious as to the latest and greatest in teaching manipulation, thus the question being directed at those going through presently; 2) As anyone who's been around SDN knows, there's no shortage of vitriol, or at least misunderstanding, toward chiropractors. This is always worst among pre-meds, who know the least but don't always realize it, followed by MD medical students, who don't get any training in manipulation-related concepts. DO students are of course more open to pro-manipulation ideas. I've also found that many attending MDs and DOs aren't completely closed-minded toward manipulation because they've had patients who have benefitted from it (I'm not saying they are always big fans, just a bit more willing to accept some benefit). Anyway, despite the openness toward manipulation in the DO forums, I'm unaware of many discussions among DO students here regarding the proposed mechanisms of how and why manipulation works, particularly HVLA.

This has me wondering if DO students cover this at all in training. There must be some kind of discussion about this during OMM lab, I would think. So, I thought I would ask. Was it a "baited" question? Perhaps. But I am truly interested.

So far, we've seen bone re-alignment as a reason why HVLA works, as well as ROM improvement, both of which benefit area soft tissues. Any other thoughts?

To answer st's question, HVLA is also called HVLA in chiro circles.

 

[Styria]

From our HVLA lecture:

Theory #1
An HVLA thrust is thought to forcefully stretch a contracted muscle producing a barrage of afferent impulses from the muscle spindles to the CNS. The CNS reflexively sends inhibitory impulses to the muscle spindle to relax the muscle.

Theory #2
An HVLA thrust is thought to forcefully stretch the contracted muscle pulling on it's tendon activating the Golgi tendon receptors and reflexively relaxing the muscle

Either way, the body is acting to protect the muscle or joint from strain or damage.

 

[peoplespeep]

From our HVLA lecture:

Theory #1
An HVLA thrust is thought to forcefully stretch a contracted muscle producing a barrage of afferent impulses from the muscle spindles to the CNS. The CNS reflexively sends inhibitory impulses to the muscle spindle to relax the muscle.

Theory #2
An HVLA thrust is thought to forcefully stretch the contracted muscle pulling on it’s tendon activating the Golgi tendon receptors and reflexively relaxing the muscle

Either way, the body is acting to protect the muscle or joint from strain or damage.

Theory me this and theory me that...A.T Still whittled a wonder 'that'...seriously, we are on the verge of 2011...I challenge all osteopathic professionals to use some critical thinking skills.

 

[facetguy]

Theory me this and theory me that...A.T Still whittled a wonder 'that'...seriously, we are on the verge of 2011...I challenge all osteopathic professionals to use some critical thinking skills.

I'm not sure I understand your reply. Can you explain your critical thinking skills as it relates to this thread? It may be helpful to all of us.

 

[fozzy40]

From our HVLA lecture:

Theory #1
An HVLA thrust is thought to forcefully stretch a contracted muscle producing a barrage of afferent impulses from the muscle spindles to the CNS. The CNS reflexively sends inhibitory impulses to the muscle spindle to relax the muscle.

Theory #2
An HVLA thrust is thought to forcefully stretch the contracted muscle pulling on it’s tendon activating the Golgi tendon receptors and reflexively relaxing the muscle

Either way, the body is acting to protect the muscle or joint from strain or damage.

Agree .

Changing the tension of the muscle and/or the fascia around irritated structures and subsequently decreasing nociceptive afferent input and facilitating inhibitory reflexes is a common theme in musculoskeletal medicine. These apply not only HVLA techniques but other direct and indirect techniques.