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High-velocity low amplitude (HVLA) techniques employ a rapid use of force over a short duration, distance, and/or rotational area within the anatomical range of motion of a joint to engage the restrictive barrier in one or more planes of motion to elicit the release of restriction. This activity outlines high-velocity low amplitude manipulation techniques and explains the role of the healthcare team in improving care for patients who undergo HVLA manipulation. Objectives: Describe the common terminology associated with HVLA. Identify the common complications of HVLA procedures. Summarize the proper procedural considerations for HVLA manipulation. Outline the prevalence of HVLA procedures. Access free multiple choice questions on this topic.

Dr. Kirkaldy-Willis first conceptualized and published theories regarding the Biomechanics and Biology of the Spinal Degenerative Cascade. He defined the HVLA technique as "a skilled, passive manual therapeutic maneuver during which a synovial joint is beyond the normal physiological range of movement (in the direction of the restriction) without exceeding the boundaries of anatomical integrity."[1] High-velocity low amplitude techniques employ a rapid use of force over a short duration, distance, and/or rotational area within the anatomical range of motion of a joint to engage the restrictive barrier in one or more planes of motion to elicit the release of restriction. This manipulation technique uses high velocity and low amplitude thrusts to manipulate joints. Osteopathic physicians, chiropractors, and physical therapists are trained in HVLA and commonly perform these techniques. Both therapies are used in cases of acute musculoskeletal back pain. The physician positions the person at the barrier of limited movement and then gives a rapid thrust in the isolated barrier's direction to resolve the restriction and improve motion. This method is among the oldest and most frequently used, and it is among the most common types of complementary medicine for children. Most clinical research has focused on evaluating the efficacy of this form of manipulation, particularly for low back, mid-back, and neck pain. Purpose — restore motion to a restricted joint and improve function. Terminology High-velocity low amplitude is interchangeable with manipulation and thrust because of the different biomechanics. Nevertheless, these all unify in describing the process of increasing the range of motion. Abbreviations — (AOA) American Osteopathic Association; (DO) Doctor of Osteopathic Medicine; (HLVA) High-velocity low amplitude; (HVLA-SM) High-velocity low amplitude spinal manipulation; (L) Lumbar; (ms) milliseconds; (N) newtons; (OMT) Osteopathic Manipulative Treatment; (RCT) randomized controlled trials Adverse Event — Stroke, headache, joint pain, and vertebral artery dissection are possible adverse events associated with an HVLA OMT technique. Amplitude — The thrust's distance attempts to create a movement of about 1/8th inch at the joint treated. Cavitation — The process of using a mechanical force to precipitate a gas bubble in a joint space.

Adverse Event — Stroke, headache, joint pain, and vertebral artery dissection are possible adverse events associated with an HVLA OMT technique. Amplitude — The thrust's distance attempts to create a movement of about 1/8th inch at the joint treated. Cavitation — The process of using a mechanical force to precipitate a gas bubble in a joint space. Fulcrum — This describes when a hand or body localizes a thrust's force into the segment or joint that is restricted. Long Lever — The extremities or multiple segments of the vertebral column. Manipulation — Synonym for a high-velocity low amplitude technique. Manipulation occurs at the end of and often beyond the available motion of the joint to break adhesions that disrupt or prevent joint movement. Short Lever — Any portion of the vertebra held while force is applied to the adjacent vertebra's bony prominence. Thrust — Synonym for a high-velocity low amplitude technique. Thrust may refer to cracking or popping sounds. Statistics Prevalence Of Use Amongst The Pediatric Population: 2 to 3% [2] Approximately Incidence Adverse Event Per OMT Procedure: 1/50,000 [2] Approximate Number of Adverse Events Which Are Operator-Induced: 1/5 [2] Approximate Number of Adverse Events In Cervical Manipulation: 1/400,000 to 1,000,000, 1 every 177.5 weeks [2]

Patients' temporary adverse effects from manipulation can persist undetected if nonspecific guidance to patients is provided aftercare. Prospective research has estimated that approximately 30 to 61%  of patients encounter typical side effects arising from spinal stimulation.[14][15][16] Most often, localized tightness, headaches, weakness, soreness radiating, numbness, dizziness, exhaustion, rigidity, body warmth, and consciousness loss. Premature or severe menstruation, gastrointestinal discomfort, twitching, dysrhythmia, and sweating are the least frequent.[17] These intermittent side effects generally occur about 4 hours after therapy and then improve throughout the following 24 hours.[16] A few individuals may develop a slight headache after cervical manipulation or soreness after back stimulation. In persons with delicate skin, some erythema and petechiae may occur, which may persist for hours. As therapy progresses, some problems can resurface, and when treatment is interrupted, effects can worsen.

Skills Teaching aids improve skill-based outcomes, patient safety, and overall team performance among physicians, nurses, pharmacists, and other health professionals. Studies have shown that teaching aids can improve the rate of skill acquisition. Additionally, it appears that mentoring, coaching, and feedback, in addition to training aids, are the most efficacious.[18][19] [Level 4] Strategy A cost-benefit-based approach to HVLA training amongst physicians, nurses, pharmacists, and other health professionals appears to be best. There is a significant gap in the cost-to-benefit ratio, such that teaching aids might be most effective within a defined curriculum structure. Studies seem to suggest that early implementation leads to longer-lasting consistency. At the same time, downstream implementation enhances more technical aspects of manipulation. Timing is an important consideration when designing curricula for training programs. Using lower ratios of contact hours and teaching aids to augment practice may result in better performance gains when introduced later than if added early in the curriculum. Teaching aids and a hands-on approach may result in better performance gains when introduced later in the curriculum than earlier for programs with lower contact hours.[1][20] [Level 4] Ethics To enhance the ethical aspects of HVLA in patient-centered care, clinicians, nurses, pharmacists, and other health professionals should consider the legality of HVLA techniques. One study summarized the various legal challenges. A survey of California disciplinary data showed a case rate of 4.5 per 1000 chiropractors a year compared to 2.27 per year for physicians, with fraud incidents nine times higher among chiropractors (1.99 per 1000) than among physicians.[21] [22] [Level 5] Responsibilities

To enhance the ethical aspects of HVLA in patient-centered care, clinicians, nurses, pharmacists, and other health professionals should consider the legality of HVLA techniques. One study summarized the various legal challenges. A survey of California disciplinary data showed a case rate of 4.5 per 1000 chiropractors a year compared to 2.27 per year for physicians, with fraud incidents nine times higher among chiropractors (1.99 per 1000) than among physicians.[21] [22] [Level 5] Responsibilities To enhance the role HVLA has in patient-centered care, physicians, nurses, pharmacists, and other health professionals must strive for uniformity. A study investigated the significance of uniform standards. One study looked at the Gonstead technique in 81 simulated adjustments on a mannequin force plate. Analysis of over 800 thrusts showed wide variations in peak loads. Thrust rates are most consistent amongst clinicians. To improve the role HVLA has in outcomes, patient safety, and overall team performance, physicians, nurses, pharmacists, and other health professionals should therefore focus on reproducibility. While reliability is relatively high for manual rotational HVLA thrust on C1-C2, reliability for flexion-extension and lateral bending remains low.[23][24][25] [Level 4] Interprofessional Communication Clinicians, nurses, pharmacists, and other health professionals must also consider how the general public views manipulation and HVLA techniques. A paper described some of the views concerning cervical spine manipulation. HVLA is viewed unfavorably by mainstream medicine. Approximately 36% of respondents considered HVLA favorably.[26][27] [Level 5]