HVLA Safety

Samantha Richter HVLA NOTES Page 1
Contraindications
Absolute
1. Bone Weakening
2. Vascular
3. Neurological
4. Lack of Patient Diagnosis
. Lack of Patient !onsent
". Lack of Patient Positioning Due to Pain or Resistance
1 Bone Weakening
Acronym
#$% !$#$
# & #umour
$ & $atrogenic
% & %eta'olic
! & !ongenital
$ & $nfection
# & #rauma
$ & $nflammator(
Tumour
eg %etastatic De)osits
!ommon Primar( #umours that metastasise to Bone*
1. #h(roi+
2. Breast & most common
3. Lung & eg Pancoast #umour
4. ,i+ne(
. Prostate
". -$# & .er( common tumours that +on/t necessaril( commonl( metastasise+ to 'one
0. Skin
Presentation
$nsi+ious onset
-ra+ual )rogression
Dee)1 unremitting )ain
Pain 2akes )atient at night
3nore4ia an+ 2eight loss
Risk factors eg Smoking
5istor( of )rimar( carcinoma
6amil( histor( of cancer
%a( im)inge 7%N/s or L%N/s1 es)eciall( 2orr(ing if im)inges multi)le L%N le.els.
Prostate Cancer
5as to 'e +ifferentiate+ from !au+a 89uina '( signs an+ s(m)toms 2ith 2hich inclu+e+*
1. Pain on 7rination :like )issing ra;or 'la+es<
2. !hange in 7rinar( 6re9uenc(
3. 7rinar( Retention +ue to com)ression on urethra )assing through )rostate
4. Difficult( sto))ing=starting or terminal +ri''ling
. !hange in 7rine !olour=>+our
". 7suall( refers )ain to #=L or lo2er lum'ars
Iatrogenic
eg Long #erm !orticosteroi+ 7se
7se+ in treatment of*
1. !hronic Res)irator( eg 3sthma & $nhale+ !orticosteroi+s
2. Dermatological eg 8c;ema & #o)ical !orticosteroi+s
3. 3utoimmune eg Se.ere 3rthritis & >ral !orticosteroi+s
Metabolic
eg >steomalacia
Softening of 'ones cause+ '( +emineralisation most nota'l( '( the +e)letion of calcium from
'one. %a( 'e cause+ '( )oor +ietar( intake or )oor a'sor)tion of calcium an+ other minerals
nee+e+ to har+en 'ones. 3 characteristic feature of .itamin D +eficienc( in a+ults. Similar to
osteo)orosis 'ut +oes not in.ol.e as much loss of organic minerals.
eg Rickets
3 +isease of infants an+ chil+ren that +istur's normal 'one formation :ossification<. Rickets is a
failure to mineralise 'one. #his softens 'one :)ro+ucing osteomalacia< an+ )ermits marke+
'en+ing an+ +istortion of 'ones. 7se to largel( 'e +ue to lack of +irect e4)osure to sunlight or
lack of .itamin D.
Congenital
eg D(s)lasia
3'normalit( of +e.elo)ment1 in )atholog(1 alteration in si;e1 sha)e an+ organi;ation of a+ult
cells.
eg S)ina Bifi+a
6ailure of the laminae of the neural arch to form a close+ .erte'ral arch at the s)inous )rocess.
>cculta .ersion +oes not in.ol.e hernial )rotrusion1 is fairl( common an+ often as(m)tomatic.
$f in the u))er thoracics1 it/s rarel( serious an+ +oes not usuall( affect osteo treatment. %a( 'e
more serious if foun+ in #=L region1 an+ ma( ha.e a neurological in.ol.ement.
!(stica .ersion is more serious as it in.ol.es hernial )rotrusion1 2hich causes neurological
s(m)toms. >ften causes motor neuron com)ression )ro'lems an+ associate+ s(stems.
Infection
eg #u'erculosis
3n infectious +isease cause+ '( the tu'ercle 'acillus1 Mycobacterium tuberculosis, an+
characteri;e+ )athologicall( '( inflammator( infiltrations1 formation of tu'ercles1 caseation1
necrosis1 a'scesses1 fi'rosis1 an+ calcification. $t most commonl( affects the res)irator( s(stem1
'ut other )arts of the 'o+( such as the gastrointestinal an+ genitourinar( tracts1 'ones1 ?oints1
ner.ous s(stem1 l(m)h no+es1 an+ skin ma( also 'ecome infecte+.
eg >steom(elitis
$nflammation of the 'one +ue to infection
Traumatic
eg Whi) Lash
eg 6racture
Inflammatory
eg Se.ere Rheumatoi+ 3rthritis
3 chronic s(stemic +isease marke+ '( inflammation of multi)le s(no.ial ?oints :often the
)ro4imal inter)halangeal ?oints of the han+s<. #he +isease usuall( affects similar grou)s of
?oints on 'oth si+es of the 'o+(1 creating 'on( erosions that can 'e seen ra+iogra)hicall(.
2 Neurological
Cervical Myeloat!y
%(elo)ath( is an( of .arious functional +istur'ances or )athological changes in the s)inal cor+1 'ut
+oesn/t inclu+e inflammator( lesions of m(elitis. $t can 'e cause+ '( a +irect )ro'lem 2ith the
s)inal cor+ or +ue to ischemia often from a )ro'lem of the anterior s)inal arter(. !er.ical
m(elo)ath( is m(elo)ath( in the cer.ical s)ine1 resulting from com)romise to si;e of s)inal canal
+ue to +egeneration or com)ression eg '( a 'ulging=)rola)se+ +isc or a tumour. 3 com)lication
that occasionall( arises from Rheumatoi+ 3rthritis or >steoarthritis.
%(elo)ath( causes 7))er %otor Neuron :7%N< lesions 'elo2 le.el of the m(elo)ath(1 2ith
!er.ical %(elo)ath( causing signs in the lim's1 2ith s)asticit( +e.elo)ing in the lo2er lim's
'efore the u))er lim's. #here is a )ossi'ilit( of Lo2er %otor Neuron :L%N< lesions at the le.el of
the m(elo)ath( if it affects the anterior horn of the s)inal cor+ or ner.e roots.
Cord Comression
!or+ com)ression causes 7))er %otor Neuron :7%N< lesions 'elo2 le.el of com)ression of
s)inal cor+1 +ecreasing motor signals coming +o2n the s)inal cor+. #here is a )ossi'ilit( of Lo2er
%otor Neuron :L%N< lesions at le.el of the com)ression1 if there is com)ression onto the anterior
horn 2here the u))er :central< motor neurons s(na)ses 2ith the outgoing lo2er :)eri)heral< motor
neurons1 sto))ing motor signal e4iting the s)inal cor+ at that le.el.
Nerve "oot Comression
!auses Lo2er %otor Neuron lesions at the le.el of the ner.e root.
Cauda #$uina Comression
3 'un+le of s)inal ner.e roots1 2hich arise from the en+ of the s)inal cor+1 the conus me+ullaris. $t
is calle+ the cau+a e9uina 'ecause it resem'les a horse/s tail. #he cau+a e9uina com)rises of the
roots of all the s)inal ner.es1 usuall( 'elo2 the L2 .erte'ra.
!om)ression of !au+a 89uina causes Lo2er %otor Neuron lesions of affecte+ ner.e roots. S2
com)ression is consi+ere+ a re+ flag as it has im)ortant inner.ation to 'la++er an+ 'o2el. #here
might 'e other Lo2er %otor Neuron lesion signs of other root le.els if com)ression a'o.e S2.
#here also might not necessar( 'e com)ression on S2 or 'elo21 'ut it is in+icati.e of )ossi'le
)rogression later to com)romise+ S2 ner.e roots.
Persistent com)romise of S2 ner.e roots or s)inal ner.es ma( lea+ to necrosis :cellular +eath of
tissue< causing )ermanent loss of function of 'la++er an+ 'o2el1 2hich results in incontinence &
)ermanent +istur'ances=loss of control of urination :micturition< an+ +efecation. !8 com)ression is
a me+ical emergenc( an+ the )atient nee+s to 'e sent +irectl( to hos)ital.
,e( Re+ 6lag S(m)toms
1. Difficult( in 7rination=%icturition & 7rinar( Retention an+ #erminal Dri''ling
2. Difficult( in or 7ncontrolla'le Defecation
3. Paraesthesia or 3naesthesia in Sa++le 3rea & Buttocks1 -enitalia1 an+ #high
4. 6lacci+ Paral(sis an+ Weakness in S2 m(otome
. Possi'le +istur'ances in se4ual function i.e. im)otence
#his inclu+es com)ression of ner.e su))l( to*
%b&ect Nerve 'uly "esult of C# Comression
Smooth %uscle
of Bla++er
Pel.ic S)lanchnic Ner.es
:S1@S21 )aras(m)athetic< & constricts
$nferior 5()ogastric Ple4us
:#11@L21 s(m)athetic< & rela4es
Decrease in )=s(m) lea.ing
s(m) to rela4 'la++er1
hol+ing the 'la++er/s
contents.
$nternal 7rethral
S)hincter
:S1@S21 )aras(m)athetic< & rela4es
:#11@L21 s(m)athetic< & constricts
Decrease in )=s(m) lea.ing
s(m) to close=constrict1
)re.enting outflo2.
84ternal 7rethral
S)hincter
Pu+en+al ner.es
:S2@S41 somatic< & constricts
Decrease in somatic1
rela4ing s)hincter1 causing
terminal +ri''ling
Smooth %uscle
of Rectum
:S2@S41 )aras(m)athetic<
Lum'ar S)lanchnic Ner.es
:L1@L21 s(m)athetic<
Decrease in )=s(m)1
rela4ing rectum1 +ecreasing
e4)ulsion of faeces
3nal !anal Visceral Part &
:#11@L21 s(m)athetic an+
S2@S41 )aras(m)athetic<
Somatic Part &
$nferior Rectal Ner.es1 Branches of
Pu+en+al Ner.es :S41 somatic<
Visceral Part & +ecrease in
)=s(m)1 rela4ing anal canal1
+ecreasing e4)ulsion of
faeces
Somatic Part & +ecrease in
somatic1 rela4ing anal canal
$nternal 3nal
S)hincter
:S21 )aras(m)athetic< & constricts
Decrease in )=s(m)1
rela4ing s)hincter1 allo2ing
faeces to )ass through
uncontrolla'l(
84ternal 3nal
S)hincter
$nferior Rectal Ner.es1 Branches of
Pu+en+al Ner.es
:S41 somatic< & constricts
Decrease in somatic1
rela4ing s)hincter1 allo2ing
faeces to )ass through
uncontrolla'l(
Samantha Richter HVLA NOTES Page
( )ascular
)BI
Aortic Aneurysm
3n out)ouching1 a local 2i+ening :aneur(sm< of the aorta1 in.ol.ing that .essel in its course a'o.e
the +ia)hragm :thoracic aortic aneur(sm< or1 more commonl(1 'elo2 the +ia)hragm :a'+ominal
aortic aneur(sm<. Because of the .olume of 'loo+ flo2ing un+er relati.el( high )ressure 2ithin the
aorta1 a ru)ture+ aneur(sm of the aorta is a catastro)he.
Bleeding *iat!eses
3 )re+is)osition or ten+enc( of 'lee+ing.
eg Se.ere 5aemo)hilia
3 set of inherite+ 'lee+ing +isor+ers in 2hich the a'ilit( of 'loo+ to clot is im)aire+.
eg $atrogenic & 3nticoagulants
3n agent that )re.ents or +ela(s 'loo+ coagulation=clotting.
7se+ for treatment of )ulmonar( em'olism1 DV#1 #$3=Stroke1 artificial heart .al.es an+ atrial
fi'rillation.
Drugs that ha.e this effect inclu+e 2arfarin1 he)arin1 an+ as)irin.
+ ,ack of -atient Consent
Informed Consent
Definition*
A#he .oluntar( an+ re.oca'le agreement of a com)etent in+i.i+ual to )artici)ate in a
thera)eutic or research )roce+ure1 'ase+ on an a+e9uate un+erstan+ing of its nature1 )ur)ose
an+ im)lication.B
Re9uirements*
$nformation !om)onent
C Disclosure & '( health )ractitioner
C !om)rehension & message recei.e+ '( )atient
!onsent !om)onent
C Voluntariness & 2ithout un+ue )ressure
C !om)etence & to 'e a'le to reach a rational +iscission
Tyes of Consent
1. 84)resse+ & Where the in+i.i+ual e4)licitl( in+icates his or her agreement1 either orall( or in
2riting
2. $m)lie+ & When the in+i.i+ual +oes not s)ecificall( in+icate agreement1 'ut )erforms some
action that suggests consent
3. #acit & Referre+ from the )atient/s failure to +issent
Reference*
D Sim1 A$nforme+ !onsent an+ %anual #hera)(1B Dournal of %anual #hera)(1 1EE"1 21 ))1F4@1F"
. ,ack of -atient *iagnosis
/ ,ack of -atient -ositioning *ue to -ain or "esistance
Samantha Richter HVLA NOTES Page "
"elative
'ondylolysis
S)on+(lol(sis is the name gi.en to a +efect in the )ars interarticularis1 the narro2 stri) of 'one on
the neural arch 'et2een the su)erior G inferior articular )rocesses. #he +efect takes the form of a
s)lit in the )ars. $t most commonl( occurs at L1 an+ the +eficit is fille+ 2ith fi'rous tissue.
$t is 'est .ie2e+ on an 4@ra( in an o'li9ue .ie21 2ith the +efect looking like Aa Scott( +og 2ith a
'roken neck.B
!auses*
!ongenital & no2 thought unlikel(
6racture from +irect trauma
Stress fracture & consi+ere+ most likel(
& 3 high inci+ence in cricket fast 'o2lers1 'ase'all )itchers1 2eight lifters an+ ro2ers
'ondylolist!esis
#he +is)lacement in )osition of one .erte'ral 'o+( on another. 7suall( an anterior sli))age1 'ut
retro@listhesis can occasionall( occur1 es)eciall( in the neck. -ra+e+ 1@ +e)en+ing on +egree of
sli))age1 2ith 1 'eing 1cm sli))age an+ 'eing full sli))age. %ost common at L=S1.
!auses*
!ongenital
S)on+(lol(tic
Degenerati.e
#rauma
Pathological
'ondylosis
Degeneration of the inter.erte'ral +iscs1 also calle+ osteoarthritis. %ost common in the lo2er
cer.ical s)ine.
Results in :can 'e seen on 4@ra(<*
Loss of articular cartilage
Su'chon+ral 'one sclerosis
De.elo)ment of marginal osteo)h(tes
>steo)h(tic change in facet ?oints
Advanced *egenerative 0oint *isease 1A*0*2
%steoorosis
%ore 'one is resor'e+ than lai+ +o2n1 an+ the skeleton loses some of the strength that it +eri.es
from its intact tra'eculation.
%ore common in*
>l+ age+ "FH (ears
Postmeno)ausal 2omen
>o)horectom( & Remo.al of >.aries
Poor +iet & !alcium an+ Vitamin D
$mmo'ilise+=Be+ Ri++en
7se of !orticosteroi+s an+ some 3nticon.ulsant +rugs
Patients 2ith cortisone e4cess :!ushing/s +isease< or h()er)arath(roi+ism
*isc 3erniation or -rolase
Inflammatory Art!ritides
,igamentous ,a4ity
Anticoagulant or ,ong5Term Corticosteroid 6se
3s )re.iousl( e4)laine+ in a'solute contrain+ications.
)ertigo
#he in+i.i+ualIs surroun+ings seem to 2hirl +i;;il(
Arterial Calcification
8g atherosclerosis is arterial har+ening cause+ '( the focal accumulation of li)i+ an+ accom)an(ing
fi'rosis in the intima of me+ium to large arteries. $t results in the narro2ing of the arterial lumen1
2eakening of the arterial 2all an+ )re+is)osition to throm'osis.
Risk 6actors*
$ncrease+ 'loo+ cholesterol le.el
Stressful life )atterns
Smoking
5()ertension
Dia'etes
Ph(sical $nacti.it(
-regnancy
Adverse "eaction to -revious Manual T!eray
-syc!ological *eendence uon 3),A Tec!ni$ue
Samantha Richter HVLA NOTES Page J
)BI 5 )ertebrobasilar Insufficiency
Anatomy
)ertebral artery
$t arises as the first 'ranch of the su'cla.ian arter(1 from the su)erior an+ )osterior )art of the first
)ro4imal )ortion of the .essel. $t ascen+s through the foramina in the trans.erse )rocesses of the
!" :sometimes ! or !0< through to !1 .erte'rae. $t then 2in+s )osterior an+ then me+ial1
su)erior to the groo.e of the )osterior arch an+ )osterior to the su)erior articular )rocess of the atlas
:!1<. $t then enters the skull through the foramen magnum1 unites 2ith the .essel of the o))osite
si+e to form the 'asilar arter(.
'ites of -ossible Comression
1. Le.el of the .erte'ral foramen of !" '(*
a. 3nterior Scalene
'. Longus !olli
2. Within foramen trans.ersariums 'et2een !" an+ !2
3. Le.el of !1 an+ !2
'igns and 'ymtoms of )BI
Acronym
# 5 5 5 3 N N N D D D D D 3N1 D/s H more
K L Sign
M
L S(m)tom
N
L $m)ortant to ask a'out e.er( .isit
#
M
& #innitus
5
MN
& 5ea+aches & >cci)ital
5
M
& 5i+rosis=Pallor
5K & 5orner/s S(n+rome
3K & 3ta4ia & -ait Distur'ances
NK & N(stagmus
N
MN
& Neurological Deficit
N
M
& Nausea
D
MN
& Di;;iness=Vertigo=Light 5ea+e+ness
D
M
& Dro) 3ttacks=6ainting=Blackouts
D
M
& Di)lo)ia=Blurre+ Vision
D
M
& D(sarthria
D
M
& D(s)hagia
Tinnitus
Ringing in ears
3idrosis7-allor
Pallor* +eficienc( of colour es)eciall( of the face & )aleness
5i+rosis* S2eating
3orner8s 'yndrome
3 com)le4 of a'normal fin+ings1 +ue to )aral(sis of the cer.ical s(m)athetic ner.es. !an 'e
cause+ '( com)ression on S(m)athetic #runk in !er.ical region eg Pancoast #umour. Reason it
causes VB$ is currentl( unkno2n.
Signs an+ S(m)toms* :%83P or %83#<
Samantha Richter HVLA NOTES Page E
1. %iosis :constriction of the )u)il of that e(e<
2. 8no)hthalmos :Sinking in of one e(e'all<
3. 3nhi+rosis :+iminishe+ or com)lete a'sence of secretion of s2eat< an+ flushing of the affecte+
si+e of the face.
4. Ptosis & $)silateral :+roo)ing of the u))er e(eli+ on the same si+e<
Ata4ia 9ait *isturbances
!lumsiness1 'een 'um)ing into things as the( 2alk1 'een falling o.er a lot. Nee+ to ask the )atient
a'out it e.er( .isit.
Nystagmus
Ra)i+1 rh(thmic1 re)etitious1 in.oluntar( :un2ille+< 'ack@an+@forth or c(clical mo.ements of the
e(es. N(stagmus can 'e hori;ontal1 .ertical or rotar(. $t has a .ariet( of causes inclu+ing lesions of
the la'(rinth1 .esti'ular ner.e1 cere'ellum1 an+ 'rainstem. Drug into4ications such as 2ith alcohol1
'ar'iturates1 an+ )hen(toin :Dilantin< also ma( 'e res)onsi'le.
Neurological *eficit
6acial Paraesthesia* Loss of feeling or a2areness in the face1 li)s or tongue
#ingling in the 7))er Lim's
Nee+ to ask the )atient a'out it e.er( .isit.
*iloia
Dou'le Vision
*ysart!ria
S)eech that is characteristicall( slurre+1 slo21 an+ +ifficult to )ro+uce :+ifficult to un+erstan+<. #he
)erson 2ith +(sarthria ma( also ha.e )ro'lems controlling the )itch1 lou+ness1 rh(thm1 an+ .oice
9ualities of their s)eech.
*ys!agia
Difficult( in s2allo2ing +ue to )ro'lems in muscle control.
Samantha Richter HVLA NOTES Page 1F
)BI Testing -rotocol
-rocedure
6irst e4)lain to )atient 2hat (ou are +oing an+ 2h(.
84)lain that if the( feel an(thing unusual1 such as the( feel faint or feel )ins an+ nee+les
an(2here1 for them to let (ou kno2 straight a2a( an+ (ou 2ill sto).
Stan+ in front of the )atient looking at their face an+ es)eciall( their e(es for n(stagmus.
Stan+ close enough so that (ou can catch the )atient if the( faint.
#he hea+ is mo.e+ to en+ range of mo.ements as 'elo2 for 1F secon+s.
3sk the )atient ho2 the( feel.
#he hea+ is then mo.e+ 'ack to neutral for 1F secon+s 'efore the ne4t )osition. Signs an+
S(m)toms come on +uring this )erio+ +ue to a latenc( effect.
'eated Active
1. Rotation Right
2. Rotation Left
3. 84tension
4. 84tension an+ Rotation Right
. 84tension an+ Rotation Left
'uine -assive
1. Rotation Right
2. Rotation Left
3. 84tension
4. 84tension an+ Rotation Right
. 84tension an+ Rotation Left
-ositive Test
Re)ro+uction of Signs an+=or S(m)toms in an( )osition.
Causes of *i::iness
1. S(stemic :affect the 2hole 'o+(<
2. !entral :affect the !NS<
3. Peri)heral :affect the PNS<
1 'ystemic
Medication
5()notics
3nticon.ulsants
3ntih()ertensi.es
3nalgesics
3lcohol
#ran9uillisers
3yotension
Decreases a'ilit( of 'o+( to su))l( 'loo+ to 'rain.
*iabetes
6rom h()ogl(caemia1 resulting in a +ecrease+ function of the central ner.ous s(stem.
3yot!yroidism
3n a'normal +ecrease in the )ro+uction an+ release of th(roi+ hormones.
Signs an+ S(m)toms :Ph(siolog(<*
Decrease B%R
Weight -ain 2ith no change in foo+ intake
Decrease 5eat Pro+uction intolerance to col+
5()ohi+rosis & +ecrease+ s2eating
Bra+(car+ia & relati.el( slo2 heart 'eat marke+ '( a )ulse rate 'elo2 "F ')m in an a+ult
Decrease in 3cti.it( & letharg(=slee)iness
%(4oe+ema & )uff( features
3lo)ecia & hair loss
2 Central
*emyelinating *iseases
eg %ulti)le Sclerosis :%S<
3 chronic +isease of the central ner.ous s(stem1 in 2hich there is +estruction of m(elin an+
ner.e a4ons 2ithin se.eral regions of the 'rain an+ s)inal cor+ at +ifferent times. #his results in
tem)orar(1 re)etiti.e1 or sustaine+ +isru)tions in ner.e im)ulse con+uction1 causing su++en or
)rogressi.e 2eakness in one or more lim's1 muscular s)asticit(1 n(stagmus1 fatigue1 tremors1
gait insta'ilit(1 incontinence an+ +e)ression.
Tumours of Brain or 'inal Cord
'ei:ures
)BI
-ost5traumatic )ertigo Concussion
( -eri!eral
Benign -ositional )ertigo 1B-)2
3 'alance +isor+er that results in the su++en onset of +i;;iness1 s)inning1 or .ertigo 2hen mo.ing
the hea+.
Meniere *isease
3 +isease is +ue to +(sfunction of the semi@circular canals :en+ol(m)hatic sac< in the inner ear & eg
'lockage of cochlear a9ue+uct. !ome on in attacks1 2here the )atient 2ill 'e ill for a cou)le of
+a(s 'efore resol.ing an+ not a constant )ro'lem.
#hree !ar+inal Signs*
1. Recurrent .ertigo=+i;;iness
2. #innitus
3. Deafness
>ther s(m)toms inclu+e nausea1 .omiting1 an+ a'normal e(e mo.ements.
Cervical 'ine *ysfunction
!er.icogenic Di;;iness
,abyrint!itis
$nflammation of the la'(rinth1 the s(stem of intercommunicating canals an+ ca.ities 2ithin the
inner ear res)onsi'le for sensing 'alance. La'(rinthitis ma( 'e accom)anie+ '( the su++en onset of
a feeling of .ertigo triggere+ '( hea+ or 'o+( mo.ement together 2ith feelings of nausea an+
malaise. $t is +ue to +i.erse causes inclu+ing .iral an+ 'acterial infections.
)estibuloto4ic Medication
%e+ication that is to4ic to the .esti'ular :'alance< )ortion of the ear.
Reference* Wen+( 3s)ienall1 A!linical #esting for !er.ical %echanical Disor+ers that cause
$schemic Vertigo1B Dournal of >rtho)ae+ic an+ S)ort Ph(sical #hera)(1 No.em'er 1EJE.
Cervical Instability
Anatomy
Alar ,igaments
#he alar ligaments are strong1 roun+e+ cor+s1 2hich arise one on either si+e of the u))er )art of the
o+ontoi+ )rocess1 an+1 )assing o'li9uel( su)erior an+ lateral1 are inserte+ into the rough +e)ressions
on the me+ial si+es of the con+(les of the occi)ital 'one. #he alar ligaments limit rotation of the
cranium an+ therefore recei.e the name of c!eck ligaments; $t also limits contralateral
si+e'en+ing.
Transverse Atlantal ,igament
#he trans.erse ligament of the atlas is a thick1 strong 'an+1 2hich arches across the ring of the atlas1
an+ retains the o+ontoi+ )rocess in contact 2ith the anterior arch. $t is conca.e in front1 con.e4
'ehin+1 'roa+er an+ thicker in the mi++le than at the en+s1 an+ firml( attache+ on either si+e to a
small tu'ercle on the me+ial surface of the lateral mass of the atlas. #he 2hole ligament1 2ith its
su)erior an+ inferior running fi'res1 is name+ the cruciate ligament of t!e atlas;
Atlantodental Interval
#he atlanto+ental $nter.al is the +istance 'et2een*
#he most anterior )oint of the +ens of the a4is=!2
#he )osterior as)ect of the anterior arch of the altas=!1
3tlantoa4ial insta'ilit( is in+icate+ '( an 3tlanto+ental $nter.al greater than*
3+ults* 2.@3.F mm
!hil+ren* 4.@.F mm
Diagnose+ '( lateral ra+iogra)hs of the cer.ical s)ine in fle4ion1 neutral an+ e4tension )ositions.
'igns and 'ymtoms
+ Cardinal 'igns and 'ymtoms
,oss of Balance & in relation to hea+ mo.ement
<acial ,i -araest!esia & re)ro+uce+ '( neck mo.ements
,imb -araest!esia & 'ilateral or 9ua+rilateral
& constant or re)ro+uce+ '( neck mo.ements
& shoul+ ask the )atient e.er( .isit in histor( as can change
Nystagmus & )ro+uce+ '( neck mo.ements
%t!er 'igns and 'ymtoms
Neck -ain
,imitations of Neck Movement
Torticollis
3 2r(neck1 a contracte+ state of the cer.ical muscles1 )ro+ucing t2isting of the neck an+ an
unnatural )osition of the hea+.
Neurological 'ymtoms
1. 5ea+ache
2. Di;;iness
3. #innitus
4. D(s)hagia
Neurological 'igns
1. 5()errefle4ia
2. 3ta4ia=-ait Distur'ances
3. S)asticit( & a s)astic state or con+ition es)eciall( muscular h()ertonicit( 2ith increase+ ten+on
refle4es
4. Paresis & slight or )artial )aral(sis
Tests
Transverse Atlantal ,igament 'tress Test Modified '!ar5-urser Test
-rocedure
5a.e )atient sitting 2ith hea+ an+ neck rela4e+ in semi@fle4e+ )osition.
Stan+ to the right of the )atient.
5a.e the )atient fle4 their hea+ an+ neck for2ar+.
!heck if there is an onset of the signs an+ s(m)toms. $f not1 the test is halte+ there an+
consi+ere+ negati.e. $f so1 continue 2ith the remaining ste)s.
5a.e (our right arm cra+ling the )atient/s forehea+.
Sta'ili;e s)inous )rocess an+ .erte'ral arch of a4is :!2< 2ith thum' an+ in+e4 finger.
#ranslate occi)ut an+ atlas :!1< )osteriorl( '( a))l(ing )ressure 2ith (our right arm.
-ositive Test
When all of the follo2ing occurs*
>nset of Signs an+ S(m)toms 2ith 5ea+ an+ Neck 6le4ion
Re+uction of Signs an+ S(m)toms 2ith Posterior #ranslation of >cci)ut an+ 3tlas on 34is
Pal)a'le h()ermo'ilit( of anterior=)osterior translation
Alar ,igaments 'tress Tests
-rocedure 1
8nsure hea+ is straight an+ neutral
Sta'ilise s)inous )rocess an+ .erte'ral arch of a4is :!2< 2ith #hum' an+ $n+e4 6inger
Passi.el( rotate hea+ to left an+ right
Pal)ate for 2hen mo.ement of !2 s)inous )rocess 'egins.
-ositive Test
>nset of Signs an+ S(m)toms an+=or
3 range of )assi.e rotation greater than 3FO at the 7))er !er.ical Segments
-rocedure 2
8nsure hea+ is straight an+ neutral
Sta'ilise s)inous )rocess an+ .erte'ral arch of a4is :!2< 2ith thum' an+ in+e4 finger
Passi.el( si+e 'en+ hea+ to left an+ right
Pal)ate for 2hen !2 s)inous )rocess 'egins to rotate to o))osite si+e.
Re)eat 2ith neck in fle4ion an+ e4tension
Re)eat all three )ositions in su)ine 2ith )atient hea+ an+ neck 'e(on+ 'ench
-ositive Test
>nset of Signs an+ S(m)toms an+=or
3n increase+ range of )assi.e si+e'en+ing in all )ositions of Neutral1 6le4ion an+ 84tension
Samantha Richter HVLA NOTES Page 1"
,ocking
Cervical and Cervicot!oracic 'ine
Tec!ni$ue
N
o;
Tec!ni$ue ,ocking Tye
1.1 3> ?oint1 !hin 5ol+1
Patient Su)ine
No locking1
>cci)ital !on+(le 3nterior -li+e #hrust
1.3 33 ?oint1 !hin 5ol+1
Patient Su)ine
No locking1
Rotation #hrust
1. !er.ical1
7)@slo)e -li+e1
!hin 5ol+1
Patient Su)ine
6acet 3))osition Locking & #()e 1 %o.ement
1O Rotation1 2O Si+e'en+ing1
Lock +o2n to 'ut not ?oint of ca.itation1
#hrust on Su)erior Verte'ra
1." !er.ical1
7)@slo)e -li+e1
!ra+le 5ol+1
Patient Su)ine
1.1F !er.ical1
Do2n@slo)e -li+e1
!hin 5ol+1
Patient Su)ine
1O Si+e'en+ing1 2O Rotation1
1.12 !er.ical1
Do2n@slo)e -li+e1
Patient Sitting
1.13 !er.icothoracic1
Rotation -li+e1
Patient Prone1
6rom Si+e of Patient
#hrust on $nferior Verte'ral S)inous Process
Rotation -li+e1
Patient Prone1
6rom 5ea+ of !ouch
#hrust on $nferior Verte'ral #rans.erse Process
Si+e'en+ing -li+e1
Patient Sitting
#hrust on Su)erior Verte'ral S)inous Process
1.1" !er.icothoracic1
Si+e'en+ing -li+e1
Patient Si+e@l(ing
#hrust on Su)erior Verte'ral S)inous Process
T!oracic
Tec!ni$ue
N
o;
2.1 #horacic1
84tension -li+e1
Patient Sitting
No locking1
Ligamentous %(ofascial #ension1
#hrust on $nferior Verte'ral S)inous Process
2.2 #horacic1
6le4ion -li+e1
Patient Su)ine
No locking1
Ligamentous %(ofascial #ension1
#hrust on $nferior Verte'ral #rans.erse Process
,umbar and T!oracolumbar
Tec!ni$ue
N
o;
3.1 #horacolum'ar1
Rotation -li+e1
Patient Si+e@l(ing an+
Neutral Position
Lock +o2n an+ u) to 'ut not ?oint of ca.itation1
#hrust on Lo2er Le.er
3.2 #horacolum'ar1
Rotation -li+e1
6le4ion Position
3.3 Lum'ar1
Rotation -li+e1
Neutral Position
3.4 Lum'ar1
Rotation -li+e1
6le4ion Position
3." Lum'osacral1
Rotation -li+e1
Neutral Position
Lock +o2n 'ut not ?oint of ca.itation1

HVLA Safety

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Samantha Richter HVLA NOTES Page 1

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