High Velocity Low Amplitude Manipulation Techniques: Mid-Cervical Biomechanical Goal
If you're wondering, "What, Precisely, is the Biomechanical Goal of Performing a Mid-Cervical HVLA Manipulation?," you've come to the right place.
To become proficient, and then an expert, in performing cervical manipulations, it is necessary to grasp what you are trying to accomplish on a biomechanical level. This improves safety, which is the most important factor. However, it also improves efficacy and overall patient outcome. If you can properly conceptualize the biomechanical goal of manipulating the mid-cervical spine, you can abandon the rigid thought process of performing a manipulation exactly the same way each time.
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The general biomechanical goal and safety guidelines should be followed during each manipulation to ensure safety and efficacy. However, this does not mean every manipulation must be performed the same way. There are general safety precautions and biomechanical rules to follow, but aside from this, each person’s joints are different and require slightly different manipulative forces. Some patients may be more comfortable in supine, some in sitting, etc. This is why developing proficiency in multiple techniques, along with soft hands and a good feel for a person’s joints, is necessary to becoming really good at manipulation. Strictly following rules will limit your efficacy and can lead to poor patient outcomes. Each patient is different, treat them that way.
The mid-cervical spine, C3-C7, has normal mechanics of side-bending (SB) and rotation (ROT) to the same side. The only reason we can SB our necks and still keep our eyes looking forward is that C1-C2 rotates in the opposite direction of the SB and ROT of C3-C7. It’s awesome how our body works. So cool! Another biomechanical aspect of the cervical joint facets is that they sit at about 45 degrees, with an upward slope from P🡪A. Everyone is a slightly different. These are essential mechanical factors to comprehend in order to become a proficient cervical manipulator.
Think About C4 SB and ROT to the R on C5: Focus on Applying Force to the Posterior Aspect of the C4 Transverse Process.
OK, think about the R C4 inferior facet sitting on top of the R C5 superior facet. Remember, joints are spoken about in ResearchLand (that’s my invented word, feel free to use it) as segments, one vertebra on top of another. This is necessary to properly understand the intricacies of arthrokinematic movement. So, when we speak about the movement of the C4 vertebra, we are talking about the movement of C4 in relation to C5.
When we SB our cervical spine to the R, the R C4 inferior facet slides down and back on the R C5 superior facet. At the same time, the L C4 inferior facet slides up and forward on the L superior C5 facet. These arthrokinematic glides occur at about 45 degrees in a cephalic direction from P🡪A. If the joint gets stuck in this position for some reason, we now have a C4 that is rotated to the R on C5. The vertebrae, however, cannot slide directly in an A🡪P or P🡪A direction. They rotate around the spinal cord. So, if the R inferior C4 facet is sliding down and back on the R superior C5 facet, the R inferior C4 facet is also moving in a medial direction, down-back-medial toward the center of the spinal cord. For this reason, think about applying the force in an A🡪P direction, towards the patient’s opposite knee. At the same time, add in a 45-degree angle from P🡪A, in the cephalic direction.
It is not applicable to apply force through the anterior aspect of the cervical spine secondary to neurovasculature in the area. The external and internal jugular, along with the carotid artery and brachial plexus nerves, are just a few of the structures located anterior to the transverse processes in the cervical spine. Typically, the sternocleidomastoid (SCM) attachment, just behind the ear, is a good marker. If you are standing, go from the inferior aspect of the mastoid process directly toward the ground. That is about the line of the transverse processes (TP) of your cervical vertebrae.
If you dig your fingers in there and find the most firm and painful spot to palpate, that is the lateral aspect of a cervical TP. We want to push on the posterior aspect of the transverse processes in between the spinous process (SP) and the TP. This is commonly referred to as the articular pillar of the cervical spine. This keeps us away from any major neurovascular structures and allows us to push vertebrae back into anatomic position in a safe and effective manner.
Think about pushing the downslid segment of C4 on the R, back up onto the top of C5, so the two vertebrae are in proper alignment. The force should be directed in an anterior / superior / medial direction. So, push the posterior aspect of C4 TP, at a 45-degree cephalic angle, toward the seated patient's L knee. Think about turning C4 to the L on C5 and follow that 45-degree angle joint line. This is not an easy idea to conceptualize, but once you get it, something clicks in your brain, and manipulation becomes much simpler and more effective. It’s like an epiphany, of sorts.
Since the normal mechanics of C3-C7 are SB and ROT to the SAME side, we always place the spinal segment to be manipulated in SB and ROT to the OPPOSITE side. This puts the vertebral artery (VA) on slack through the transverse foramina at the joint where the force will be delivered. Opposing the R C4 inferior facet with the R C5 superior facet keeps the VA from getting kinked as it passes through the transverse foramina from C5 to C4. The VA is going through the transverse foramina of C6 to C1 and then into the brainstem. The VA has a stress failure point of about 130% of its resting length. This means that the average VA can stretch 130% of its resting length before anything bad happens to it that may cause an embolus and subsequent CVA. A skilled manipulator stretches the VA far less than that with any given manipulation. The average VA stretch during a skilled manipulation is about 10-15%. Passive, end-range cervical ROM places far more stress on the VA than does a skilled manipulator.
Think about how the VA goes through the transverse foramina and think about opposing the R C4 inferior facet with the R superior C5 facet so the VA is not getting kinked through the transverse foramina. We want to tension the cervical spine ligaments down from the Occiput to C4 and up to C5 from the thoracic spine. If this is accomplished, minimal force is needed to get the R inferior C4 facet back up onto the R superior C5 facet. This aligns the transverse foramina and takes any abnormal tension off the vertebral artery, soft tissue, and nerve roots. This also places the R C4/C5 joint capsule on slack as the bony structure of the R inferior C4 and the R superior facet surfaces come into alignment. If this can be accomplished, a fast, small amplitude force in the proper direction will stretch the R C4/C5 capsule fast enough to create a negative pressure inside the capsule that results in a cavitation and reduction of the C4/C5 segment to neutral.
If we stretch the capsule quickly enough, we increase the volume of the capsule, which has an enclosed liquid, synovial fluid. This increase in joint capsule volume rapidly decreases the pressure on the synovial fluid. Gas is more soluble in fluid at low temperature and high pressure. Quickly stretching the capsule increases the temperature and decreases the pressure. This allows nitrogen and CO2 that are dissolved in aqueous solution to change phases from liquid to gas. This is what creates the cavitation sound. We can see this in real time with fMRI, and it is really cool. This phenomenon is called tribonucleation. You see an air bubble form inside the joint. This creates negative pressure inside the joint capsule and provides internal distraction. A cavitation also releases endogenous opioids such as beta endorphin and other substances that create microvascular vasodilation.
Manipulation is the hardest thing to learn that we are able to perform, by far. Manipulation is much more of a physical skill than is DN. Just like with any physical process or sport, repetition is the only way to become proficient at what you are doing. I have a good friend of mine who is a DC, and he says that he was always told in school that it takes 5 years after you get out of school, manipulating the entire time, to get really good at it. I totally believe this, as it took me numerous years following grad school to feel really proficient with my manipulative skills. Do not get frustrated, learn from your failures, and focus on becoming the best manipulator you can be.
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