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TRANSCRIPT
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
(Each with Optional Variations)
HVLA: Risk-To-Benefit Ratio (Generalities & Considerations)
Spectrum of OMT Techniques
(Each with Optional Variations)
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)
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
to SB-Rot Combination
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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”
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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)
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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)
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
Sagittal Plane not linked
to SB-Rot Combination
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
11
Cranio-Cervical HVLA OMT: Occipito-Atlantal (OA) Joint
Occipital-Atlantal (OA)
Somatic Dysfunction
• F SxRy or E SxRy
Sagittal Plane not linked
to SB-Rot Combination
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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)
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
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
Michael L. Kuchera, DO, FAAO
March 2014 AAO Convocation
Cervical Fingertip HVLA Workshop
Colorado Springs, Colorado
16
Questions?
I’ll try to
answer to the best of my capacity
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