From the Guidelines
High-velocity low-amplitude (HVLA) thrust techniques should be modified or avoided entirely in patients with decreased tissue extensibility, as recommended by recent guidelines 1. For these patients, I recommend using gentler osteopathic techniques such as muscle energy, myofascial release, or strain-counterstrain instead. If HVLA must be used, modifications should include:
- reducing the amplitude of the thrust,
- decreasing the velocity of the technique,
- using more precise positioning to minimize tissue stretch before the thrust, and
- employing shorter lever arms to reduce force transmission through compromised tissues. The practitioner should also consider using direct rather than indirect barriers when setting up the technique. These modifications are necessary because decreased tissue extensibility—whether from fibrosis, scarring, chronic inflammation, or degenerative changes—makes tissues more vulnerable to injury during forceful manipulations, as noted in recent studies 1. The reduced elasticity limits the tissue's ability to absorb and distribute forces, increasing the risk of tissue damage. Before attempting any manipulation, thoroughly assess the patient's condition through history, physical examination, and review of imaging studies to identify the extent and cause of the decreased extensibility. Always obtain informed consent after explaining the increased risks, and be prepared to stop if the patient experiences unusual discomfort during positioning. Recent guidelines from the Pan American League of Associations for Rheumatology also recommend avoiding spinal manipulation in patients with active axial spondyloarthritis and spinal fusion or advanced spinal osteoporosis 1.
From the Research
High-Velocity, Low-Amplitude (HVLA) Spinal Manipulation Technique Modifications
For a patient with decreased tissue extensibility, the following modifications can be considered:
- Pre-manipulative techniques to increase tissue extensibility, such as heat therapy 2 or connective tissue massage 3
- Gentle and gradual application of force to avoid further injury or discomfort
- Focus on mobilizing the affected joint or area with minimal force and amplitude
- Use of alternative techniques, such as myofascial release or muscle energy techniques, which may be more suitable for patients with decreased tissue extensibility 4
- Consideration of the patient's overall condition, including any underlying medical conditions or injuries, to determine the most appropriate technique and level of force to use 5, 6
Rationale for Modifications
The rationale for these modifications is based on the need to adapt the HVLA technique to the patient's decreased tissue extensibility, while still achieving the desired therapeutic effect. This may involve using pre-manipulative techniques to increase tissue extensibility, or modifying the technique itself to reduce the force and amplitude applied to the affected area. The goal is to promote healing and reduce discomfort, while minimizing the risk of further injury or complications.
Considerations for Patient Care
When caring for a patient with decreased tissue extensibility, it is essential to consider their individual needs and limitations. This may involve:
- Conducting a thorough assessment of the patient's condition, including any underlying medical conditions or injuries
- Developing a personalized treatment plan that takes into account the patient's decreased tissue extensibility
- Using a range of techniques and modalities, including heat therapy, connective tissue massage, and myofascial release, to promote healing and reduce discomfort
- Monitoring the patient's progress and adjusting the treatment plan as needed to ensure optimal outcomes 3, 2, 4, 5, 6