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Michael L. Kuchera, DO, FAAO

March 2014 AAO Convocation

Cervical Fingertip HVLA Workshop

Colorado Springs, Colorado

1

“Cervical Spine – HVLA at Your Fingertips”

Hands-On Workshop

Michael L. Kuchera, DO, FAAO, FNAOME

Professor & Chairperson,

Marian University - College of Osteopathic Medicine

“Precise Facet Activation at Your Fingertips:

Cervical and OA HVLA”

Osteopathic Manipulative Treatment (OMT): HVLA in the Cervical Region

Lecture Prior to Hands-On Laboratory Sessions • I -- Indications & Contraindications : “Avoiding Trauma”

• II -- Finger Cervical HVLA Preliminary: Key Anatomy Review

(Typical Cervical & OA Somatic Dysfunction; DJD)

• III -- Interest: Research

Two Lab Sessions: OA (SB Activation) & Typical Cervicals (SB & Rotation Options)

Background: Bad “Rap” for Cervical HVLA Manipulation?

Indications & Contraindications: Rare but

potentially severe sequelae associated

with vertebral artery dissection

World Literature

• Vertebral artery “trauma” concern

• Most vulnerable position for “trauma” is

with rotational force (while extended?)

• Predicting adverse events?

AAO & FIMM Recommendation for

Diagnosis: To “DeKleyn or not to DeKleyn





2

Cervical HVLA: Contraindications (Some Relative)

Cervical Instability examples:

• Fracture

• Severe rheumatoid arthritis

• Down syndrome

• Significant cervical trauma without

definitive status knowledge

Many Other Pathologies (Cancer, vertebrobasilar insufficiency,

myelopathy, aneurysms, etc)

Neurological Symptoms with

Set-Up

Anti-Coagulation Rx;

Hypermobility; Inflammation

Spectrum of OMT Techniques

(Each with Optional Variations)

AOA Position Paper- Cervical Spine Treatment

Additional Risk Factors for VBA: – Migraine

– Hypertension

– Oral Contraceptives

– Smoking

Cervical Extension has not proven to be a “prominent”

risk factor, as previously hypothesized. It is still

important to minimize extension elements in treatment.

7 of 9

AOA Position Paper On Osteopathic Treatment of the Cervical Spine

Conclusion:

“… it is the position of the AOA that all modalities of

osteopathic manipulative treatment of the cervical

spine, including High Velocity / Low Amplitude,

should be taught at all levels of education, and that

osteopathic physicians should continue to offer this

form of treatment.”

Adopted / Reaffirmed by the AOA House of Delegates





3

HVLA: Some Common Indications (Some Generalities & Considerations)

Treating Somatic

Dysfunction without

Contraindications to

HVLA … including with: • Cervicogenic headache

• Isolated cervical pain

• Thoracic pain referred from the

neck

Chronicity (especially if

failure to respond to

other activating forces) Spectrum of OMT Techniques


HVLA: Risk-To-Benefit Ratio (Generalities & Considerations)

Spectrum of OMT Techniques


OMT Risk-to-Benefit Ratio

– HVLA Risk > Other OMT in area but

still small …

– AAO-AOA & FIMM Topical Papers …

DeKleyn test unreliable predictor

– Benefit doing OMT vs Time

preventing doing OMT to Neck?

– Skilled clinician listening to tissues in

least vulnerable position

Background for “Fingertip” Cervical OMT

Early experiences with

cervical HVLA (… my neck)

Fingertip Variation:

• Reduce discomfort & risk

with greater localization

• Focus to the articular pillar

• Gain specificity in “opening”

or “closing” the cervical facet

• Minimize activation forces

Proximal Phalanx (Index) –or–

Use Fingerpad (Index / Middle)





4

“H”

“V”

“L”

“A”

Cervical Diagnoses: Typical Cervicals (& Which Facet?)

Typical Cervical (C2-7)

Somatic Dysfunction

• F RxSx or E RxSx

Sagittal Plane not linked

to SB-Rot Combination

Accurate diagnosis

Accurate

visualization of

anatomy

Typical Cervical Vertebral Units: Physiological Motion

Typical Cervical (C2-7)

Somatic Dysfunction

• F RxSx or E RxSx

Sagittal Plane is not linked






5

Cervical Somatic Dysfunction: Open & Closed Facet Model

• Forward-bending or SB-Rot away: Opens facet

• Backward-bending or SB-Rot toward: Closes facet

• Upper cervical SD often can’t open; lower often can’t close

Left

Open

Facet Right

Closed

Facet

Pertinent Info from Checking SB Motion in Flexion & Extension

Flexion requires that the facets

open:

• So … if E SRRR … motion will be worse

trying to translate right (sidebend left)

when flexed … better extended

• Means … Right facet joint is stuck

closed … it cannot open well

Pivots Rt-Rt around right facet

when patient tries to flex

ERSR

X

Either right facet stuck closed

or left facet stuck open

Pertinent Info from Checking SB Motion in Flexion & Extension

Extension requires that the

facets close:

• So … if F SRRR … motion will be

worse trying to translate right

(sidebend left) when extended …

better motion flexed

• Means … Left facet joint is stuck

open … it cannot close well

Pivots Rt-Rt around left facet

when patient tries to extend

FRSR

X

Either right facet stuck closed or

left facet stuck open

Mitchell, Vol. I, p.195





6

Key Typical Cervical Anatomy

Checking sidebending over each

articular pillar

Use translation with slight SB

(use index &/or middle finger)

Dennis Dowling graphics

If SD present,

then restriction

in translation

from right-to-

left suggests

that right facet

is “stuck open”

SPINOUS PROCESS

FACET/PILLAR

TRANSVERSE

PROCESS Finger Pads over the FACETS/PILLARS

Translation Checks to See if a Facet is “Stuck Open”

Key Typical Cervical Anatomy

Checking rotation over each

articular pillar: Note facets

Use “come hither” finger motion

(use index or middle finger)

Dennis Dowling graphics

If SD, left finger

glide restriction

suggests left

facet is “stuck

closed”





7

PILLAR

Cervical Fingertip HVLA: OA & Typical Cervicals

HANDS-ON LAB: Typical Cervicals

1. Make Diagnosis … Example C4 SL RL

2. Localize sagittal plane to that level

3. Set Up for Sidebending Activation (Will close side of neck where facet

is “locked open”)

• Reach with left hand across cervical spine

• Place left middle finger over right C4 articular pillar (R hand finishes cradle)

• Translate from right-to-left @ C4 and add SB right (head stays in midline)

4. Rotate left down to C4 (Takes these segments “outta the way”)

5. HVLA SB “pull” with middle finger at articular pillar (see description)





8

LEFT TRANSLATION

creates

RIGHT

SIDEBENDING

Instead of

this, the

workshop

will feature

the Kuchera

fingertip

variation.

Slide left

hand under

neck & place

L middle

finger on Rt

articular

pillar

X

Dx SLRL with

right facet

“locked open” • engage with SBR

• rotate other

parts of neck to

left (protective)

• translational

impulse (HVLA)

Typical Cervical Sidebending HVLA (In picture below, force through left middle finger)

“Thrust” is initiated

by pulling elbow

towards own hip

& flipping wrist

into abduction

Creates an HV LA

pull on articular

pillar through

left middle finger

Slight counter force

through left

forearm

FLEX to LEVEL: Engage SB

Flip wrist towards abduction;

pulls pillar with middle finger

Especially C4-7

Note other

C’s rotated

“out of the

way”

HANDS-ON LAB: Typical Cervicals

1. Make Diagnosis … Example C4 SL RL

2. Localize sagittal plane to that level

3. Set Up for Rotation Activation (Will open side of neck where facet is

“locked closed”)

• Index fingers of both hands on C4 articular pillars applying anterosuperior

traction to engage facets at that level

• Rotate slightly right and glide left facet to barrier (use anterosuperior

“come hither” direction)

• Head stays in midline

4. HVLA nudge with left index finger at articular pillar (see description)





9

Dx: Facet on left locked closed. Engage along plane of facets at that

level; rotate right to begin to open the left locked facet; HVLA impulse

along plane of facet to complete opening

CIBA, Vol. 8, p. 11

Planes of facets not parallel

Meet near tip of SP of C7

Angles of planes ⇑ upward

10-60 degrees-avg. incline of

45 degrees

Typical Cervical Rotational HVLA

Anterosuperior traction

along facets bilaterally

to feather-edge of

tension (engages

them) – add pressure

on right

Add few degrees of left

cervical rotation into

the barrier (opens Rt)

HVLA into left rotational

barrier in “come

hither” direction

Extend to Level

Right facet

locked closed

C5 FSRRR





10

CIBA, Vol. 8, p. 11

Fingerpad contact on the posterolateral aspect of the

articular pillar to glide superoanterior along the facet –

Glide facet open rotation left

Rotation (Best

activation “bet”

for C2-4)

Cranio-Cervical Diagnosis: Occipito-Atlantal (OA) Joint

Occipital-Atlantal (OA)

Somatic Dysfunction

• F SxRy or E SxRy



Motion Testing OA Joint (Sx Ry)

Translate from right-to-left and palpate

end-feel (ease or bind) in gliding left

occipital condyle (SB right) … add few

degrees (3-5) of rotation left

Repeat & compare to opposite directions

Diagnose OA:

80% will

prefer

OA SR RL Rt Lt

Convergent Anterior Facets





11

Cranio-Cervical HVLA OMT: Occipito-Atlantal (OA) Joint

Occipital-Atlantal (OA)

Somatic Dysfunction

• F SxRy or E SxRy



Key OA (Cranio-Cervical) Anatomy

Safety using HVLA

• 3rd “Law” of Physiological Motion: Motion

in 1 plane modifies & limits other 2 planes

• Always use flexion: Loose packs OA joint

• Flex SB to barrier 3-5o rotation

Localization with Finger Pad

• SB fingertip activation (Direct force toward

opposite eye)

OA: Sidebending HVLA Activation (Treating Sidebent Right, Rotated Left SD)

SB Activation Just like Typical Cervicals!

Index finger on squamous portion of occiput

(rotate lower neck so comfortable

holding region)

Flex OA slightly (loose pack OA joint/safe)

Translate / SB to barrier (head in midline)

Rotate 1-5 degrees to barrier

HVLA to cranial base (with same SB pull

through finger) but in direction of

opposite orbit

Pull right middle finger in

direction towards right

orbit to create SB HVLA

May 1st rotate lower neck

to position OA to hand





12

If Time: Traction HVLA OMT For Mild Osteoarthritic Pattern

Cervical Somatic

Dysfunction

Accompanying a

Capsular Pattern

lateral flexion & rotation

equally limited,

extension less limited

Patient with Mild Osteoarthritis: Gentle Longitudinal Traction Tug HVLA

Cervical Curve Neutral

to Flattened

Prepare Cervical

Tissues with:

• Compression

• Traction

• Repeat X3

Longitudinal HVLA

Impulse (Both Hands)

• No F / E Introduced

Grasp superior part of cervical spinal unit & under chin

Cervical HVLA Documentation: Research Using Pressure Monitors

OA & Typical Cervical (C2-7)

Somatic Dysfunction

• Palpation Pressure Monitors

• Tissue Texture Change Using

Durometer Measurement





13

Cervical HVLA Research

Details of Technique

Palpation Monitors Document Pressure Used & Durometer Measures Tissue Texture Change

Thanks to IsoTechnologies / Neuromuscular Engineering & Sigma Instruments

Thanks also to Precious Barnes, DO & the former Human Performance &

Biomechanics Lab at the Philadelphia College of Osteopathic Medicine

IsoTOUCH® Pressure Sensor Palpation Monitor System

Non-invasive, pressure deformation sensors on finger pads & thenar eminences

Bluetooth data to computer for realtime graphic display of measured forces used during manual diagnosis and treatment of somatic dysfunction.

Better understanding of tissue loading, end-feel test impulses and OMT activation forces to diagnose or treat somatic dysfunction.

Monitors provided by Neuromuscular Engineering, Nashville TN USA





14

HVLA Treatment of a C4 Segment

-2

0

2

4

6

8

10

0 10 20 30 40 50 60 70 80 90 100

Time (half sec)

lbs Left Middle

Right Index

2

4

6

8

10

HVLA of C4 F RL SL

Time (half-seconds)

Diagnosis of Barriers

SB right Rot right

Note diagnostic barriers & set-up pressures are same 2.5-3.5 pounds … total 8 pounds @ “sweet spot”

SR

RL

E

Thrust

OA: Measured HVLA Activation IsoTOUCH® Pressure Monitors

“HVLA”: Thrust used ≈1 pound ; lasted

fraction of second

(in duration)

The Spineliner® Durometer Analysis of the Cervical Spine

We used diagnostic capabilities of the Spineliner® (SA-101)

• Sensor head placed in the condylar plane: the angle of the joint surface

(~90o to the skin)

• Loading compressive pressure of 6 lbs prior to delivery of consistent

piezoelectrically generated test impulse

• Deformation of tissues over site tested with computer record including the

subsequent hysteresis response

Durometer provided by Sigma Instruments (Pittsburgh PA)





15

The Spineliner® Analysis of Typical Cervical Spine

C2-C6

• The sensor head is placed at 45o below the spinous

process being treated.

Tip

Facet

Joint

Fixation: Resistance

Frequency: Length of the Curve

Difference in activating forces on cervical soft tissues

0

10

20

30

40

50

60

70

Pretreatment Postreatment

32

68

28.5

24.5

31

7.5 8.5

0

Perc

enta

ge (%

)

Neck pain pretreatment vs postreatment

No pain

Mild pain

Moderate pain

Severe pain





16

Questions?

I’ll try to

answer to the best of my capacity

[email protected]

Dig On in Osteopathy!

Cervical HVLA at

your Fingertips

Thanks again for any

of the extra hands

of volunteer table

trainers!

0

10

20

30

40

50

60

70

OA AA C2 C3 C4 C5 C6 C7

Total Number of Dysfunctions at Each Cervical Level

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