Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado “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 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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 Spectrum of OMT Techniques (Each with Optional Variations) Anti-Coagulation Rx; Hypermobility; Inflammation 7 of 9 AOA Position PaperCervical 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 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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 Spectrum of OMT Techniques other activating forces) (Each with Optional Variations) HVLA: Risk-To-Benefit Ratio (Generalities & Considerations) 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? Spectrum of OMT Techniques (Each with Optional Variations) – 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 Proximal Phalanx (Index) –or– Use Fingerpad (Index / Middle) • Gain specificity in “opening” or “closing” the cervical facet • Minimize activation forces 3 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado “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 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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 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 X ERSR Either right facet stuck closed or left facet stuck open 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: • So … if F SRRR … motion will be worse trying to translate right (sidebend left) when extended … better motion flexed X FRSR Either right facet stuck closed or left facet stuck open Mitchell, Vol. I, p.195 • Means … Left facet joint is stuck open … it cannot close well Pivots Rt-Rt around left facet when patient tries to extend 5 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado Key Typical Cervical Anatomy Checking sidebending over each articular pillar Use translation with slight SB (use index &/or middle finger) If SD present, then restriction in translation from right-toleft suggests that right facet is “stuck open” Dennis Dowling graphics 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) If SD, left finger glide restriction suggests left facet is “stuck closed” Dennis Dowling graphics 6 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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) 7 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado Dx SLRL with right facet “locked open” Instead of this, the workshop will feature the Kuchera fingertip variation. Slide left hand under neck & place L middle finger on Rt articular pillar • engage with SBR • rotate other parts of neck to left (protective) • translational impulse (HVLA) X LEFT TRANSLATION creates RIGHT SIDEBENDING 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 FLEX to LEVEL: Engage SB Flip wrist towards abduction; pulls pillar with middle finger Note other C’s rotated “out of the way” Especially C4-7 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 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) 8 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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  10-60 degrees-avg. incline of 45 degrees CIBA, Vol. 8, p. 11 Typical Cervical Rotational HVLA C5 FSRRR 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 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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 SR RL 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 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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) May 1st rotate lower neck to position OA to hand 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 Pull right middle finger in direction towards right orbit to create SB HVLA HVLA to cranial base (with same SB pull through finger) but in direction of opposite orbit 11 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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 12 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation HVLA of C4 F RL SL Cervical Fingertip HVLA Workshop Colorado Springs, Colorado Thrust HVLA Treatment of a C4 Segment 1010 E 88 Diagnosis of Barriers SB right Rot right 6 6 lbs 44 RL SR Left Middle Right Index 22 0 0 10 20 30 40 50 60 70 80 90 100 Time (half-seconds) -2 Note diagnostic barriers & set-up pressures are same 2.5-3.5 pounds … total 8 pounds @ “sweet spot” Time (half sec) 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 (~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 14 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado The Spineliner® Analysis of Typical Cervical Spine Tip Facet Joint C2-C6 • The sensor head is placed at 45o 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 68 70 60 Percentage (%) 50 No pain 40 32 30 Mild pain 31 Moderate pain 28.5 24.5 Severe pain 20 10 8.5 7.5 0 0 Pretreatment Postreatment 15 Michael L. Kuchera, DO, FAAO March 2014 AAO Convocation Cervical Fingertip HVLA Workshop Colorado Springs, Colorado 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! Total Number of Dysfunctions at Each Cervical Level 70 60 50 40 30 20 10 0 OA AA C2 C3 C4 C5 C6 C7 16