26. OMM | Introduction to High-Velocity Low-Amplitude (HVLA)

What type of technique is HVLA?

Passive, direct, articulatory technique

What does 'high velocity' mean in HVLA?

Rapid, therapeutic force

What does 'low amplitude' mean in HVLA?

Short distance, within anatomic range of motion

What barrier does HVLA target?

Restrictive barrier (pathologic end-range, not physiologic or anatomic)

What is the patient’s role during HVLA?

Relaxed→ physician does all work

What is the common audible release during HVLA and what does it represent?

A 'pop' due to cavitation

What is the physiologic barrier?

Limit of active motion (patient moves joint)

What is the anatomic barrier?

Limit of passive motion (physician moves joint further)

What is the restrictive barrier?

Pathologic barrier due to somatic dysfunction (HVLA targets this)

What is the neuromuscular reset mechanism of HVLA?

Sudden stretch changes afferent mechanoreceptor firing→ spinal reflex reset→ releases hypertonic muscles

What is the somatosensory integration mechanism of HVLA?

Alters brain sensory processing (N20, N30)→ unlearn dysfunctional pain patterns

What is the local proprioceptive effect of HVLA?

Afferent reset of joint capsules and ligaments

What is the global CNS effect of HVLA?

Improved autonomic balance and decreased pain

What physiologic benefits does HVLA provide for mobility?

Increases joint mobility

What physiologic benefits does HVLA provide for muscle tone?

Reduces spasms, improves strength

What physiologic benefits does HVLA provide for ROM?

Increases range of motion

What physiologic benefits does HVLA provide for pain?

Decreases pain, modulates CNS

What physiologic benefits does HVLA provide for autonomics?

Improves sympathetic/parasympathetic balance

What is the gas phase change theory for the 'pop' in HVLA?

Synovial fluid converts to gaseous bubbles

What is the elastic recoil theory for the 'pop' in HVLA?

Capsule snaps back after stretch

What is the tribonucleation theory for the 'pop' in HVLA?

Joint surfaces resist separation until critical point→ sudden separation→ gaseous cavity (20-30 min refractory)

What is the classic HVLA target?

Articular SD with firm barrier

When is HVLA strongly indicated?

Joint fixation or facet lock

What connective tissue condition can HVLA treat?

Adhesions (disrupt connective tissue)

When is HVLA used for chronic SD?

When resistant to other OMT

What neurologic effect can HVLA provide?

Reflex modification (neurologic reset)

How does HVLA treat hypomobile joints?

Restores bony alignment

What mechanical blockages can HVLA release?

Meniscoid entrapment and displaced disc fragment

What pain effect can HVLA provide?

Local and central pain modulation

How does HVLA alter the CNS?

Reprograms somatosensory input

What are the evidence-based uses of HVLA with strong support?

Low back pain, neck pain, epicondylalgia, TMJ disorders, shoulder pain, headaches

What are smaller-study uses of HVLA with limited evidence?

Fibromyalgia, carpal tunnel, scoliosis, dysmenorrhea, chronic pelvic pain, asthma, dysautonomia

What are the cervical instability conditions that are absolute contraindications for HVLA?

RA, Down syndrome, Achondroplastic dwarfism, Chiari malformation, Klippel-Feil syndrome

What joint pathologies are absolute contraindications for HVLA?

Fracture, dislocation, instability

What structural fusions are absolute contraindications for HVLA?

Ankylosis, surgical fusion

What vascular condition is an absolute contraindication for HVLA?

Vertebrobasilar insufficiency

What inflammatory or infectious joint conditions are contraindications for HVLA?

Inflammatory joint disease, joint infection

What neoplastic condition is an absolute contraindication for HVLA?

Bony malignancy

What patient factor is an absolute contraindication for HVLA?

Refusal

What disorders are associated with Atlantoaxial Instability (AAI)?

Achondroplasia, Down syndrome, Morquio syndrome, Neurofibromatosis, Osteogenesis imperfecta, Rheumatoid arthritis

What is the cause of AAI?

Lax transverse ligament at C1-C2

What are relative contraindications to HVLA?

Acute herniated disc, acute radiculopathy, acute whiplash/severe spasm, osteopenia/osteoporosis, spondylolisthesis, metabolic bone disease, hypermobility syndromes

What are common transient side effects of HVLA?

Local pain, headache, fatigue, dizziness, paresthesia, nausea, stiffness

What are serious but rare risks of HVLA?

Disc herniation, prolapse, nerve root compression, fractures, vascular complications (CVA 1-3/million), cardiac arrest

What is step 1 in HVLA application?

Obtain informed consent

What is step 2 in HVLA application?

Diagnose SD (named for freedoms)

What is step 3 in HVLA application?

Position into barriers (opposite of freedoms)

What is step 4 in HVLA application?

Stack barriers (flexion/extension, sidebending, rotation)

What is step 5 in HVLA application?

Engage restrictive barrier (firm end feel)

What is step 6 in HVLA application?

Deliver thrust (quick, short, usually one plane)

What is step 7 in HVLA application?

Reassess TART changes

In L3 ERS Left, what are the freedoms?

Extension, rotation left, sidebending left

In L3 ERS Left, what is the setup for HVLA?

Flexion, rotation right, sidebending right (FRSR)

In L3 ERS Left, what is the thrust vector?

Through the barrier→ rotation right

In L3 ERS Left, where is the hand placement?

Thenar eminence on posterior TP of L3

What is the goal of HVLA in treating somatic dysfunctions?

Direct engagement of restrictive barrier

Summarize HVLA: Type

Passive, direct, articulatory

Summarize HVLA: Motion

High velocity, low amplitude

Summarize HVLA: Target

Restrictive barrier

Summarize HVLA: Mechanisms

Neuromuscular reset, CNS reprogramming, cavitation

Summarize HVLA: Benefits

↑ ROM, ↓ pain, ↓ spasm, improved strength, autonomic balance

Summarize HVLA: Indications

Articular SD, facet lock, hypomobile joints, pain modulation

Summarize HVLA: Contraindications

Absolute: Instability, RA, Down’s, fracture, malignancy, refusal; Relative: osteoporosis, radiculopathy, whiplash, hypermobility

Summarize HVLA: Risks

Mild soreness→ rare stroke/disc herniation

Summarize HVLA: Clinical Use

Position into barriers, thrust opposite freedoms, reassess

What inflammatory or infectious joint conditions are absolute contraindications for HVLA?

Inflammatory joint disease, joint infection

What is the underlying cause of AAI?

Lax transverse ligament at C1-C2

What are the relative contraindications for HVLA?

Acute herniated disc, acute radiculopathy, acute whiplash/severe spasm, osteopenia/osteoporosis, spondylolisthesis, metabolic bone disease, hypermobility syndromes

What are serious but rare risks of HVLA?

Disc herniation, prolapse, nerve root compression, fractures, vascular complications (CVA ~1-3/million), cardiac arrest

What cervical positioning should be avoided during HVLA according to safety guidance?

Avoid hyperextension and excessive rotation when positioning for cervical HVLA

When should HVLA setup be stopped during cervical positioning?

Stop and reassess if the patient reports pain, discomfort, or neurologic symptoms during setup

Why is proper diagnosis critical before HVLA is applied?

Proper diagnosis identifies the correct restrictive barrier and thrust direction to ensure safety and efficacy

What initial step must be obtained before performing HVLA?

Obtain permission (informed consent) for treatment from the patient

How should barriers be engaged before delivering the HVLA thrust?

Position into all three planes and stack the barriers until a firm end feel is reached

In spine HVLA, how many planes usually receive the thrust?

The thrust is usually delivered in one plane

How is somatic dysfunction named and how does that guide HVLA setup?

Somatic dysfunction is named for freedoms; HVLA setup reverses into the barriers (opposite of freedoms)

What artery is of concern in cervical HVLA positioning and why?

The vertebral artery; hyperextension and excessive rotation can compromise blood flow

What are the core indications for HVLA in articular dysfunction?

Articular somatic dysfunction with a firm articular barrier, joint fixation/facet lock, and adhesions

How is HVLA used in chronic dysfunctions?

It is used when dysfunctions are resistant to other treatment modalities and for maintenance in irreversible situations

How can HVLA influence reflex activity and CNS processing?

It can modify reflexes, modulate pain, and help reprogram central somatosensory integration

How does HVLA affect joint alignment and mechanical blockages?

It can restore bony alignment and address meniscoid entrapment or displaced disc fragments

For which condition is HVLA supported by strong evidence: Low back pain?

Yes→HVLA has evidence-based support for this condition

For which condition is HVLA supported by strong evidence: Neck pain (cervicalgia)?

Yes→HVLA has evidence-based support for this condition

For which condition is HVLA supported by strong evidence: Epicondylalgia?

Yes→HVLA has evidence-based support for this condition

For which condition is HVLA supported by strong evidence: Temporomandibular joint disorders?

Yes→HVLA has evidence-based support for this condition

For which condition is HVLA supported by strong evidence: Shoulder pain?

Yes→HVLA has evidence-based support for this condition

For which condition is HVLA supported by strong evidence: Headaches?

Yes→HVLA has evidence-based support for this condition

What is the evidence status for using HVLA in Fibromyalgia?

Smaller studies; additional research needed

What is the evidence status for using HVLA in Carpal tunnel syndrome?

Smaller studies; additional research needed

What is the evidence status for using HVLA in Scoliosis?

Smaller studies; additional research needed

What is the evidence status for using HVLA in Dysmenorrhea?

Smaller studies; additional research needed

What is the evidence status for using HVLA in Chronic pelvic pain?

Smaller studies; additional research needed

What is the evidence status for using HVLA in Asthma?

Smaller studies; additional research needed

What is the evidence status for using HVLA in Dysautonomia?

Smaller studies; additional research needed

Which mechanoreceptor system is specifically mentioned in the HVLA mechanism?

Type Ia afferents of the muscle spindle

Which cortical responses are referenced in the somatosensory integration mechanism of HVLA?

N20 and N30 areas

What is the current leading theory explaining the HVLA 'pop' and what does it describe?

Tribonucleation; opposing surfaces separate rapidly at a critical point, forming gaseous cavities with a 20-30 minute refractory period

What alternative theory explains the 'pop' via capsule behavior?

Elastic recoil of the synovial capsule snapping back from the capsule-fluid interface

What classic theory explains the 'pop' via synovial fluid behavior?

Gas phase change from liquid synovial fluid to gas bubbles

What global neurologic effect may HVLA produce in chronic pain?

Normalization of somatosensory integration helping patients 'unlearn' dysfunctional pain patterns