Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation. Cervical Fingertip HVLA Workshop Colorado Springs, Colorado

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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 1

2 Cervical HVLA: Contraindications (Some Relative) Spectrum of OMT Techniques (Each with Optional Variations) 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 R x ; Hypermobility; Inflammation 7 of 9 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. 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 2

3 HVLA: Some Common Indications (Some Generalities & Considerations) Spectrum of OMT Techniques (Each with Optional Variations) 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) 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 Proximal Phalanx (Index) or Use Fingerpad (Index / Middle) 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 3

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 4

5 Cervical Somatic Dysfunction: Open & Closed Facet Model Left Open Facet Right Closed Facet 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 Pertinent Info from Checking SB Motion in Flexion & Extension X ERSR Either right facet stuck closed or left facet stuck open Flexion requires that the facets open: So if E S R R R 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 Pertinent Info from Checking SB Motion in Flexion & Extension Extension requires that the facets close: X FRSR Either right facet stuck closed or left facet stuck open Mitchell, Vol. I, p.195 So if F S R R R 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 5

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-toleft suggests that right facet is stuck open Translation Checks to See if a Facet is Stuck Open SPINOUS PROCESS FACET/PILLAR Finger Pads over the FACETS/PILLARS TRANSVERSE PROCESS 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 6

7 PILLAR Cervical Fingertip HVLA: OA & Typical Cervicals HANDS-ON LAB: Typical Cervicals 1. Make Diagnosis Example C 4 S L R L 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 C 4 articular pillar (R hand finishes cradle) Translate from C 4 and add SB right (head stays in midline) 4. Rotate left down to C 4 (Takes these segments outta the way ) 5. HVLA SB pull with middle finger at articular pillar (see description) 7

8 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 S L R L with right facet locked open engage with SB R rotate other parts of neck to left (protective) translational impulse (HVLA) LEFT TRANSLATION creates RIGHT SIDEBENDING Typical Cervical Sidebending HVLA (In picture below, force through left middle finger) 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 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 HANDS-ON LAB: Typical Cervicals 1. Make Diagnosis Example C 4 S L R L 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 C 4 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) 8

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 Planes of facets not parallel Meet near tip of SP of C7 Angles of planes upward degrees-avg. incline of 45 degrees CIBA, Vol. 8, p. 11 Typical Cervical Rotational HVLA C5 FS R R R Extend to Level Right facet locked closed 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 9

10 Rotation (Best activation bet for C2-4) Fingerpad contact on the posterolateral aspect of the articular pillar to glide superoanterior along the facet Glide facet open rotation left CIBA, Vol. 8, p. 11 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) Convergent Anterior Facets Rt Lt Diagnose OA: 80% will prefer OA S R R L 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 10

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 3 rd Law of Physiological Motion: Motion in 1 plane modifies & limits other 2 planes Always use flexion: Loose packs OA joint Flex SB to barrier 3-5 o rotation Localization with Finger Pad SB fingertip activation (Direct force toward opposite eye) OA: Sidebending HVLA Activation (Treating Sidebent Right, Rotated Left SD) May 1 st rotate lower neck to position OA to hand Pull right middle finger in direction towards right orbit to create SB HVLA 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 11

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 Grasp superior part of cervical spinal unit & under chin Cervical Curve Neutral to Flattened Prepare Cervical Tissues with: Compression Traction Repeat X3 Longitudinal HVLA Impulse (Both Hands) No F / E Introduced Cervical HVLA Documentation: Research Using Pressure Monitors OA & Typical Cervical (C2-7) Somatic Dysfunction Palpation Pressure Monitors Tissue Texture Change Using Durometer Measurement 12

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 Monitors provided by Neuromuscular Engineering, Nashville TN USA 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. 13

14 lbs HVLA of C4 F R L S L HVLA Treatment of a C4 Segment E Thrust Diagnosis of Barriers SB right Rot right R L S R Left Middle Right Index Time (half-seconds) -2 Time (half sec) Note diagnostic barriers & set-up pressures are same pounds total 8 sweet spot 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 Durometer provided by Sigma Instruments (Pittsburgh PA) We used diagnostic capabilities of the Spineliner (SA-101) Sensor head placed in the condylar plane: the angle of the joint surface (~90 o 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 14

15 Percentage (%) The Spineliner Analysis of Typical Cervical Spine Tip Facet Joint C2-C6 The sensor head is placed at 45 o below the spinous process being treated. Fixation: Resistance Frequency: Length of the Curve Difference in activating forces on cervical soft tissues Neck pain pretreatment vs postreatment No pain Mild pain Moderate pain Severe pain Pretreatment Postreatment 15

16 Questions? I ll try to answer to the best of my capacity mkuchera@marian.edu Dig On in Osteopathy! Cervical HVLA at your Fingertips Thanks again for any of the extra hands of volunteer table trainers! 70 Total Number of Dysfunctions at Each Cervical Level OA AA C2 C3 C4 C5 C6 C7 16