How does spinal HVT work? Theories of its physiological effects?
Answers:
Manipulation involves encouraging the "stiff" area of the spine to begin moving again, and comprises soft tissue massage, gentle mobilisation movements (articulation), and firmer carefully controlled movements (high velocity low amplitude thrusts - HVT's) which stretch the stiff part often accompanied by a series of "clicks" or "pops".
Each "pop" or "click" represents a spinal facet joint being released from its restricted state. This is similar to clicking your knuckles. These maneouvres often result in a very rapid reduction in spinal muscle spasm and pain, accompanied by a noticeable increase in the range of spinal movements. Manipulation combined with regular specific exercises seem to the most successful at maintaining the mobility of a previously stiff area.
For those who cannot relax, and where HVT manipulation is considered to be safe, intravenous sedation can be used. This may help both the patient and the therapist to achieve success.
One would expect to see at least 75% improvement in symptoms with 3-5 treatments. If this is not the case then other techniques or further investigation should be considered.
Spinal Nerve Root Pain
HVT Spinal Manipulation is a useful technique for a range of spinal nerve root complaints. However, whenever manipulation is considered in the presence of nerve root symptoms, these tests should always be performed to reassure the patient and the doctor that nerve root function is normal:-
Normal reflexes
biceps reflex = C5/6 nerve function
brachioradialis reflex = C6 nerve root function
triceps reflex = C7/8 nerve root function
knee reflex = L3 nerve function
ankle reflex = S1 nerve function
Normal motor power
normal power in the leg motor groups L1 to S1
normal power in the arm motor groups C4 to T1
No dural tension signs in the legs using the slump test (sitting straight leg raising with trunk flexion)
No root pain down the arm using the nerve root provocation test (neck extension combined with side bending and rotation to the same side)
Normal S2/3/4 nerve root function - normal buttock muscle tone, and saddle sensation
If there is any doubt about neurological function, then an MRI scan should be performed before HVT manipulation is performed. See Contra-indications for more information about when not to perform HVT spinal manipulation.
Disc Prolapse - after a bout of nerve root pain caused by annular tears and disc prolapses there is often persisting back or neck pain and restricted spinal movements (Spinal Dysfunction). After a series of Epidural Injections when the nerve root pain component has recovered, HVT Spinal Manipulation is a useful treatment for the spinal pain component.
Spinal Stenosis - in this condition the internal diameter of the spinal canal can be reduced by excessive lumbar extension (backwards bending). Lumbar muscle spasm holds the spine in extension and therefore can worsen spinal stenosis. An exaggerated thoracic spinal curve (round shouldered posture) tends to produce a compensatory opposite curve in the lumbar spine (hollow backed), which can again worsen spinal stenosis. HVT Spinal Manipulation can be useful for reducing lumbar extension caused by lumbar muscle spasm. Freeing up the thoracic spinal movements can also unlock the movements in the lumbar area, reducing the hollow lumbar curve.
Foraminal Stenosis - narrowing of the spinal nerve root exit holes can be worsened by additional paravertebral muscle spasm, worsening the degree of spinal nerve root irritation. HVT Spinal Manipulation can be a useful technique to reduce the local muscle spasm, allowing the foramen to open up again, giving the nerve root more room as it exits. If there is severe nerve root pain with weakness, an MRI scan would be advisable, and either an Epidural Injection OR Nerve Root Block for pain relief before considering manipulation.
Spinal Muscle Spasm and Facet Joint Syndrome can cause Non Nerve Root Referred Pain in the arms and legs. HVT Spinal Manipulation is the treatment of choice for this condition once a annular tear / disc prolapse has been ruled out.
Yellow Flags
HVT spinal manipulation requires a fair degree of understanding and co-operation during treatment. It should be avoided in the following circumstances:-
Where the patient is not able to give informed verbal or written consent.
Where the patient is not able to understand the nature of the problem or its treatment.
Where there is a high degree of anxiety which precludes adequate relaxation or co-operation.
If the patient is displaying disproportionate pain behaviour.
Vertebro-Basilar Insufficiency
VBI occurs most commonly in the elderly, where tipping the head backwards into extension causes dizziness, vertigo and even blackouts.
The cause is due to arteriosclersosis (hardening of the arteries) affecting the two small vertebral arteries that run upwards in the neck to supply the balance centre in the brain stem. These arteries are more likely to kink when the head is tipped backwards, temporarily reducing the blood flow to the balance centre, causing the balance centre to stop functioning, leading to dizziness and vertigo. The situation is normally resolved back bringing the head back into line with the trunk again. Some elderly people already have one artery blocked due to severe arteriosclerosis.
Excessive force during HVT manipulation of the neck can sometimes produce a small tear in one of these vertebral arteries, and if the artery clots off afterwards, this causes permanent reduction of blood flow to the balance centre in the brain stem, and permanent symptoms of severe vertigo afterwards.
A new type of surgery is available where the blocked vertebral artery can be bypassed using a graft similar to that used in coronary artery bypass surgery in the heart. This is a new technique and therefore the risks and benefits have not yet been determined.
Osteoporosis
Osteoporosis affects the structure and strength of the bones. Caution is urged in patients with severe osteoporosis due to the risk of causing a vertebral / rib fracture during treatment.
In skilled hands gentle HVT spinal manipulation is safe in those with mild osteoporosis, where the risk of fracture is much lower.
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