Validation of clinical practice by research

Back Pain Breakthrough

Natural Lower Back Pain Cure and Treatment

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Responsibility for the scientific credence that can be afforded osteopathic medicine rests largely within its own discipline. The osteo-pa thic profession is obligated to question the value of teaching unsubstantiated doctrines, except within their historical perspective. Students and the profession should be encouraged to engage in active research. Research is needed both to establish the clinical efficacy of osteopathic therapeutic intervention and to elaborate the biological basis and physiological mechanisms that underlie the osteopathic principles of practice. Patient satisfaction is also an important measure of the quality of care. i If there is to be a commitment to research, where should the osteopathic profession focus its research funds and activities?

WHY UNDERTAKE RESEARCH?

Given the financial constraints placed upon health expenditure and the increasing pressure upon third party payers to rationalize and limit costs, one can expect that health professionals will be required to demonstrate efficacy of treatment. It will no longer be acceptable to claim that therapy is beneficial solely because individual patients report improvement after treahnent. The challenge is to demonstrate that symptom improvement is a direct outcome of specific intervention rather than natural recovery and that this intervention is more effective, and cost-effective, than marketplace competitors. Bogduk2 argues that research is not an indulgence of academics but constitutes the basis of best practice and quality assurance.

Various osteopathic authors have acknowledged the need for research and the importance of continuing to search for new knowledge.'-5 he need for research should be indisputable, but where should the osteo-pathic profession's resources be concentrated? Bogduk and Mercer* express a view that it is more valuable to demonstrate the efficacy of a therapy before one explores its mechanism. They suggest there may be limited value in utilizing scarce resources researching the underlying mechanisms of a therapy that may eventually be shown to be ineffective.

It would also be reasonable for a profession to hold the view that there is a place for both therapeutic trials and continuing research to explore the biological basis and physiological mechanisms that underpin osteopathic treatment. However, it should be recognized that even if we had a clear understanding of the biological and physiological mechanisms underlying all osteopathic therapeutic interventions, this in itself would not prove that their use would produce a positive clinical outcome. Only properly conducted clinical trials can legitimize a therapy by demonstrating positive outcomes from therapeutic intervention.

WHERE SHOULD RESEARCH BE FOCUSED?

Research effort should be directed towards designing and implementing effective therapeutic trials that could demonstrate the efficacy or otherwise of therapeutic interventions'" Validation of osteopathic practice by outcome studies could be a way forward. Management of patients utilizing outcome measures has the benefit of establishing baselines, documenting progress and assisting in quality assurance?

Osteopathic practice is diverse. Individual practitioners, depending upon their style of practice and interests, treat a wide variety of different complaints. Osteopaths see and treat a significant number of patients presenting with spinal pain.8-9 Outcome studies on patients presenting with spinal pain and disability are an obvious area for osteopathic research. Despite this fact, there is a paucity of osteopathic outcome studies.

Various authors"^" highlight the point that there are significant difficulties associated with clinical research in the osteopathic area. Stoddard11 emphasizes that clinical research in osteopathy is hampered by the complexity and diversity of the presenting problems and the difficulties associated with patient allocation to syndrome groups that vary constantly over time. However, similar problems associated with clinical research exist for other disciplines practising manual therapies. Despite the difficulties, other disciplines are participating in an increasing number of research projects.

PATIENT CLASSIFICATION

A possible spectrum of research designs would include conventional and unconventional group designs, ethnomethodological designs and single case studies.12 Each research method has advantages and limitations, with varying applicability, differing ranges of validity and ethical constraints, and will generate differing sets of data. Which approach would be most useful for outcome studies in osteopathic medicine? The nature of the research question should guide the selection of research design.

One of the major problems associated with clinical trials related to spinal pain lies in the area of diagnosis.13 The aetiology of most low back pain is imknown,14 with the pathological or structural diagnosis uncertain in 80-90% of patients presenting with disabling back pain. l5-17 Assessment procedures used may not be able to diagnose the pathology involved or may be incorrectly interpreted.'8 Problems associated with poor inter-observer reliability for clinical findings further confound the picture.

Palpatory findings are integral to the establishment of an osteopathic diagnosis. For pal-patory diagnosis to be useful for classification purposes, good inter-examiner reliability needs to be demonstrated. It is well documented that there is poor inter-observer reliability for palpatory findings without pain provocation. 19 3" For these reasons, current osteopathic diagnostic labels caiU1ot be used effectively in clinical trials of spinal pain and disability, and an alternative means of classification needs to be identified.

The Quebec Task Force'3 recognized the lack of uniformity in diagnostic terminology used for spinal disorders and proposed a classification that does not depend upon pathological entities but reflects the clinical presentations encountered in practice. A modified form of this classification can be utilized for conducting research. This classification system can be used by all clinicians, regardless of discipline, to categorize patients with spinal pain in the clinical setting and links patient symptomatology with duration of symptoms and working status (Table A.7.1). The Quebec Task Force classification consists of 11 categories with classification based upon historical markers and clinical and paraclinical examinations. Some

Table A. 7.1. Classification of activity-related spinal disorders (Quebec Task Force13)

Classification

10 11

Symptoms

Duration of symptoms from onset

Pain without radiation Pain + radiation to extremity, proximally Pain + radiation to extremity, distally Pain + radiation to upper/lower limb + neurological signs

Presumptive compression of a spinal nerve root on a simple roentgenogram (i.e. spinal instability or fracture) Compression of a spinal root confirmed by: —specific imaging techniques (i.e. CAT, myelography or MRI) —other diagnostic techniques (e.g.

electromyography, venography) Spinal stenosis

Post-surgical status, 1-6 months after intervention Post-surgical status, > 6 months after intervention

9.1 Asymptomatic

9.2 Symptomatic Chronic pain syndrome Other diagnoses a ( < 7 days) b (7 days-7 weeks) c (> 7 weeks)

Working status at time of evaluation

categories are further subdivided by stage, i.e. acute, subacute and chronic, and whether the patient is able to work.

A number of authors have suggested different methods of classification31-12. DeRosa and Porterfield,: modified the Quebec Task Force classification for spinal pain, making it more appropriate for physical therapy diagnosis (Table A.7.2).

Categorizing patients using the Quebec Task Force or a similar system of classification enables outcome studies to be performed on groups of patients with spinal pain without the need for a specific osteopathic or mechanical diagnosis. This does not obviate the need for the practitioner to undertake a full and thorough assessment of each patient but does allow classification of patients into groups for the purpose of research. This form of classification removes the obstacles to research associated with a lack of standardization and validation of diagnostic terminology in spinal disorders.

Table A.7.2 Modified physical therapy diagnosis classification (DeRosa and Porterfield32)

Category Definition

1 Back pain without radiation

2 Back pain with referral to extremity, proximally

3 Back pain with referral to extremity, distally

4 Extremity pain greater than back pain

5 Back pain with radiation and neurological signs

6 Post-surgical status ( <6 months or > 6 months)

7 Chronic pain syndrome

More recently, the Quebec Task Force33 published a similar classification for whiplash-associated disorders. This classification of whiplash 'provides categories that are jointly exhaustive and mutually exclusive, clinically meaningful, stand the test of common sense, and are "user friendly" to investigators, clinicians, and patients'. A classification system exists that would also allow outcome studies on 'whiplash' patients to be undertaken.

MEASURING OUTCOMES

Consideration needs to be given as to what instruments might be used to measure patient outcomes arising from osteopathic intervention. The process of selecting appropriate measuring instruments can be broken down into three stages:

• The researcher must identify what he or she wishes to measure, e.g. spinal pain and disability.

• What is to be measured must be defined in quantifiable terms, e.g. the intensity of pain suffered by the patient and the impact the pain and disability have upon the patient's activities of daily living.

• Selection of appropriate data collection and recording instruments that will give reliable and valid results.

While patient records are easily accessible to the practitioner, there are problems associated with this form of data collection for the purpose of outcomes assessment. Recording in patient records lacks standardization and is often incomplete, and what is recorded may not reflect what has actually occurred.}.! Practitioners also record physical examination findings, but the large variability in normal values and poor inter-examiner agreement limit the use of such tests in research.

A variety of easily used tools have been developed that allow practitioners to assess specific outcomes resulting from therapeutic interventions. Leibenson and Yeomans7 have identified eight categories of available outcome approaches (Table A.7.3).

As the range of questionnaires and pain rating scales is diverse, researchers must be confident that they have selected the most appropriate measurement tools for their clinical trials. A different approach and rating instrument would be selected for assessment of chronic spinal pain, with the possibility of a strong affective component, as compared with acute spinal pain. Clinicians undertaking research must be cognizant of both the advantages and disadvantages of individual outcome assessment instruments. Once the most appropriate measurement tool has been selected, it should be used throughout the period of the study. Different scales and questionnaires are not interchangeable.

In relation to spinal pain and disability, there is evidence that appropriately designed questionnaires have at least equal scientific validity to practitioner measurements.""'6 Specific questionnaires can measure a patient's presenting level of pain and disability and be used to reflect changes in that pain and disability after treatment and over time. The Oswestry Low Back Pain Disability Questionnaire37--<9 and the Roland-Morris Low Back Pain Disability Questionnaire4" have been shown in randomized controlled trials to have validity and reliability in measuring results for patients with back pain. Vernon and Mior41 demonstrated a high degree of test-retest reliability and internal consistency for the Neck Disability Index. This index was modified from the Oswestry Low Back Pain Disability Questionnaire.

Of the large number of scales available to measure functional disability and impairment in back pain patients, the most widely accepted are the Roland, Oswestry, Million and Waddell scales.42 These scales have been demonstrated to reliably detect changes in the level of disability and impairment over time and are reproducible and acceptable to patients.

The subjective sensation of pain can be self-rated by patients using a number of different measures. The most commonly used include the visual analogue scale, numerical rating scale and the verbal rating scale. With the

Table A.7.3 Outcome approaches. (Adapted from Leibenson and Yeomans7)

Category based on assessment goals 1. Pain level

2. Region/condition-specific disability questionnaires —LBP — Neck —Headache

Outcomes assessment instrument

3. General health

4. Psychometrics

5. Patient satisfaction

6. Job dissatisfaction

7. General disability

1. Numerical pain scale (NPS)

2. Visual analogue scale (VAS)

3. McGill/Melzack Pain Questionnaire

4. Oswestry Low Back Pain Disability Questionnaire

5. Roland-Morris Low Back Pain Disability Questionnaire

6. Dallas Pain Questionnaire

8. Neck Disability Index (NDI)

9. Headache Disability Index (HDI)

10. Dartmouth COOP charts

11. Health Status Questionnaire 2.0

13. Health Status Questionnaire (HSQ) 20

15. Waddell's Non-organic LBP signs

16. Modified Zung Questionnaire

17. Modified Somatic Perception Questionnaire

18. Beck's Depression Scale

19. Fear Avoidance Beliefs Questionnaire

21. Patient Satisfaction Questionnaire

22. Visit specific Questionnaire

23. Chiropractic Satisfaction Questionnaire

24. APGAR

25. Vermont Disability Questionnaire

26. Vermont Disability Questionnaire — brief form

27. Functional Assessment Screening Questionnaire

28. Fear Avoidance Beliefs Questionnaire

8. Job demands

29. Job Demands Questionnaire visual analogue scale (Fig. A.7.1), the patient records the level of pain by making a single perpendicular line along the 100 mm scale. This can be repeated at second and subsequent visits. The researcher measures the pain level for all visits by measuring from the left end of the 100 mm line. As the line is 100 mm long, all measurements can be expressed as a percentage. However, even with this simple scale, experience has demonstrated that patients need oral reinforcement and supervision in addition to written instructions in case they use a circle or a cross to indicate level of pain rather than a perpendicular line. Such responses would render the rating imprecise and invalid. Modifications to refine use of the visual analogue scale to include pain level at present, average pain grade and worst pain grade have been suggested.43 If applied in a clinical setting, it is recommended that the scale be used every 2 weeks.44

The numerical rating scale is similar to the visual analogue scale but offers the patient more defined pain categories to mark. The

100 mm

No pain I-

Excruciating pain

Fig. A.7.1 Visual analogue scale.

No pain

0 1

2

3 4 5

6

7

8

9

Excruciating pain

Fig. A.7.2 Numerical rating scale.

Not noticeable

Just noticeable

Very weak

Weak

Mild

Moderate

Strong

Very strong

Intense

Very intense

Severe

Excruciating

Fig. A.7.3 Twelve-point verbal rating scale.

Fig. A.7.3 Twelve-point verbal rating scale.

patient is asked to rate the severity of pain by marking one box on the scale in Figure A.7.2.

With the verbal rating scale, the patient must select an adjective, from a standardized list, that best describes the pain. There are many verbal rating scales with the level of pain severity being represented in the questionnaire varying from as few as 4 to 14 (Fig. A.7.3).

There is evidence that tissue tenderness is also measurable. The American College of Rheumatology recommends a five-grade classification of tenderness (Box A.7.1).45

Box A.7.1 Standardized palpation of tenderness (Wolfe et al 1990"5)

Using 4 kg of pressure (enough to blanch the tip of the thumbnail if you pressed on a table):

Grade 0 No tenderness

Grade I Tenderness with no physical response

Grade II Tenderness with grimace and/or flinch

Grade III Tenderness with withdrawal (+ jump sign)

Grade IV Withdrawal to non-noxious stimuli

CONCLUSION

There is a strong desire amongst the osteopathic profession to see effective clinical research undertaken. Establishing the effectiveness of osteopathic treatment was rated highly in a study of responses from a group of osteopathic professionals.46 Structured questionnaires and pain rating scales have been shown to be valid and reliable research instruments to evaluate the efficacy of any given therapy in altering pain and disability. Standardized patient classification systems are available for patients with spinal pain which remove problems associated with use of diagnostic labels. The use of standardized classification systems would enable comparison of efficacy of treatment between professions and of therapeutic approaches within a profession.

REFERENCES

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2 Bogduk N 1995 Editorial. Scientific monograph of the Quebec Task Force on whiplash-associated disorders. Spine 20(8S) : 8-9

3 Moor D 1992 Aspects of clinical research in osteopathy. Australian Journal of Osteopathy ">(1): 6-14

4 Ward R C 1993 Myofascial release concepts. In: Basmajian J V, Nyberg R (eds) Rational manual therapies. Williams and Wilkins, Baltimore, ch 10, p 223-241

5 Spaltro K 1984 Northup and Jokl speeches round out research conference. The DO 24: 81-82

6 Bogduk N, Mercer S 1995 Selection and application of treatment In: Refshauge K, Gass E (eds) Musculoskeletal plnvsiotherapy, 1st edn. Butterworth Heiimemann, Oxford, ch 7, p 169-181

7 Leibenson , Yeonians S 1997 Outcomes assessment in musculoskeletal medicine. Manual Therapy 2(2): 67-74

8 Jamison J R 1991 Osteopathy in Australia: a survey of osteopaths recognized by the Australian Osteopathic Association. Australian Journal of Osteopathy 3(2): 3-11

9 Burton A K 1981 Back pa in in osteopathic practice. Rheumatology and Rehabilitation

10 Keating J C, Seville J, Meeker W C, Lonczac R S, Quitoriano L A, Dydo M, Leibel D P 1990 Intrasubject experimental designs in osteopathic medicine: applications in clinical practice. In: Beal M C (ed) The principles of palpatory diagnosis and manipulative technique. American Academy of Osteopathy, Newark, p 205-214

11 Stoddard A 1969 Manual of osteopathic practice. Hutchinson Medical Publications, London, p 281-282

12 Aldridge D 1988 Single-case research designs. Complementary Medical Research 3(1): 37-46

13 Quebec Task Force 1987 Scientific approach to the assessment and management of activity-related spinal disorders. Spine 12(7S): 16-21

14 Schultz A B, Warwick D N, Berkson M H, Nachemson A L 197') Mechanical properties of human lumbar spine motion segments. Journal of Biomedical Engineering 101: 46-52

15 Gass E M 1995 The challenging role for physiotherapy in chromic musculoskeletal disorders. Jn: Refshauge K, Gass E (eds) Musculoskeletal physiotherapy Butterworth Heinemarm, Oxford, ch 9, p 206-217

16 Nachemson A L 1982 The natural course of low back pain In: White A A, Gordon S C (eds) American Academy of Orthopaedic Surgeons symposium on idiopathic low back pain. Mosbv, St Louis, p 45-51

17 Dillane J B, Fry J, Kalton G 1966 Acute back syndrome - a study from general practice. British Medical Journal 2: 82-84

18 DonTigny R L 1985 Function and pathomechanics of the sacroiliac joint. Physical Therapy 65: 35-43

19 Goruiella C, Paris 5, Kutner M 1982 Reliability in evaluating passive intervertebral motion. Physical Therapy 62: 436-444

20 Matyas T A, Bach T M 1985 11ie reliability of selected techruques in clinical arthrometrics. Australian Journal of Physiotherapy 31: 175-199

21 Mior S A, King R 5, McGregor M, Bernard M 1985 lntra-and inter-examiner reliability of motion palpation in the cervical spine. Journal of the Canadian Chiropractic Association 29: 195-198

22 Love R M, Brodeur R R 1987 Inter- and intraexaminer reliability of motion palpation for the thoracolumbar spine. Journal of Manipulative and Physiological Therapeutics 10: 1-4

23 Boline P D, Keating J C, Brist J, Denver G 1988 Interexaminer reliability of palpatory evaluation of the lumbar spine. American Journal of Chiropractic Medicine 1: 5-11

24 Keating J C, Bergmenn T F, Jacobs G E, Finer B A, Lawson K 1990 Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality. Journal of Manipulative and Physiological Therapeutics 13:463-470

25 Van Duersen L LJ M, Patijn J, Ocklnnysen A L, Vortman B J 1990 The value of some clinical tests of the sacroiliac joint. Manual Medicine 5: 96-99

26 Harvey D, Byfield D 1991 Preliminary shidies with a mechanical model for the evaluation of spinal motion palpation. Clinical Biomechanics 6: 79-82

27 Panzer D M 1992The reliability of lumbar motion palpation. Journal of Manipulative and Physiological Therapeutics 15(8): 518-524

28 Lewit K, Liebenson C 1993 Palpation - problems and implications. Journal of Manipulative and Physiological Therapeutics 16(9): 586-590

29 Nyberg R 1993 Manipulation: definition, types, application. Ln: Basmajian J V, Nyberg R (eds) Rational manual therapies. Williams and Wilkins, Baltimore, ch 3, p 22-47

30 Laslett M, Williams M 1995 11ie reliability of selected pain provocation tests for sacro-iliac joint pathology. In: Leeming A, Mooney V, Dorman T, Snijders C (eds) The integrated function of the lumbar spine and sacroiliac joint. ECO, Rotterdam, p 485-498

31 Deyo R A 1987 Clunical concepts in regional musculoskeletal illness. Grime and Stratton, London, p 25-50

32 DeRosa C P, Porterfield J A 1992 A physical therapy model for the treatment of low back pain Physical Therapy 72(4): 261-269

33 Quebec Task Force 1995 Scientific monograph of the Quebec Task Force on whiplash-associated disorders: redefining "whiplash" and its management. Spine 20(8S): 10-73

34 Fowkes F G R 1982 Medical audit cycle . Medical Education 16(4): 228-238

35 McDowell I, Newell C 1987 Measuring health: a guide to rating scales and questionnaires. Oxford Press, New York.

36 Deyo R 1988 Measuring the functional status of patients with low back pain. Archives of Physical Medicine and Rehabilitation 69: 1044-1053

37 Fairbanks J, Davies j, Couper J, O'Brien J 1980 The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy 66: 271-272

38 Meade T W, Dyer S, Browne W, Townsend J, Frank A O 1990 Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. British Medical Journal 300: 1431-1437

39 Hsieh C J Phillips R B, Adams A H, Pope M H 1992 functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 15(1): 4-9

40 Roland M, Morris R 1983 A study of the natural history of back pain. Part 1: development of a reliable and sensitive measure of disability in low-back pain. Spine 8: 141-144

41 Vernon H, Mior S 1991 The Neck Disability Index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 14(7): 409-415

42 Kopec J A 1995 Functional disability scales for back pain. Spine 20(17): 1943-1949

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44 Deyo R A, Cherkin DC, Franklin C, Nichols J C 1992 Low back pain (forms 6.1 to 6.4, Octobcr 1992). Health Outcomes Institute, Bloomington, MN

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CONTENTS

Section 1 Cervical and cervicothoracic spine

1.1 Atlanto-occipital joint CO-Cl: contact point on occiput

1.2 Atlanto-occipital j oint CO-Cl: contact point on atlas

1.3 Atlantoaxial joint Cl-2: chin hold

1.4 Atlantoaxial joint Cl-2: cradle hold

1.5 Cervical spine C2-7: up-slope gliding; chin hold; patient supine

1.6 Cervical spine C2-7: up-slope gliding; cradle hold; patient supine

1.7 Cervical spine C2-7: up-slope gliding; cradle hold; patient supine; reversed primary and secondary leverage

1.8 Cervical spine c2-7: up-slope gliding; patient sitting; operator standing in front

1.9 Cervical spine C2-7: up-slope gliding; patient sitting; operator standing to the side

1.10 Cervical spine C2-7: down-slope gliding; chin hold; patient supine

1.11 Cervical spine C2-7: down-slope gliding; cradle hold; patient supine

1.12 Cervical spine C2-7: down-slope gliding; patient sitting; operator standing to the side

1.13 Cervicothoracic spine C7-T3: rotation gliding; patient prone; operator at side of couch

1.14 Cervicothoracic spine C7-T3: rotation gliding; patient prone; operator at head of couch

1.15 Cervicothoracic spine C7-T3: sidebending gliding; patient sitting

1.16 Cervicothoracic spine C7-T3: sidebending gliding; patient side-lying

Section 2 Thoracic spine and rib cage

2.1 Thoracic spine T4-9: extension gliding; patient sitting

2.2 Thoracic spine T4-9: flexion gliding; patient supine

2.3 Thoracic spine T4-9: rotation gliding; patient supine

2.4 Thoracic spine T4-9: rotation gliding; patient prone; short lever technique

2.5 Ribs Rl-3: patient prone

2.6 Ribs R4-10: patient supine

2.7 Ribs R4-10: patient prone

2.8 Ribs R4-10: patient sitting

Section 3 Lumbar and thoracolumbar spine

3.1 Thoracolumbar spine T10-L2: neutral positioning; patient side-lying

3.2 Thoracolumbar spine T10-L2: flexion positioning; patient side-lying

3.3 Lumbar spine L1-5: neutral positioning; patient side-lying

3.4 Lumbar spine L1-5: flexion positioning; patient side-lying

3.5 Lumbar spine L1-5: neutral positioning; patient sitting

3.6 Lumbosacral joint L5-S1: patient side-lying

Introduction

Part B includes 30 manipulative techniques applied to the spine from the atlanto-occipital to the lumbosacral joint. All techniques are described using a variable height manipulation couch.

This part of the book relates to specific high-velocity, low-amplitude (HVLA) techniques applied to spinal joints. HVLA techniques are also known by a number of different names, e.g. adjustment, high-velocity thrust, mobilization with impulse, grade V mobilization. Despite the different nomenclature, the common feature in techniques of this type is that they are designed to achieve a joint cavitation (pop or cracking sound) within synovial joints of the spine and periphery. The cause of the popping or cracking sound is open to some speculation.

Information gained from a thorough history, clinical examination and segmental analysis will direct the practitioner towards any possible somatic dysfunction and/or pathology. The use of HVLA techniques is dependent on a diagnosis of somatic dysfunction.

Somatic dysfunction is identified by the A-R-T-T of diagnosis:

• T - relates to tissue texture changes

• T -relates to tissue tenderness.

The manual is designed in a format that presents a standardized approach to each region of the spine. If the instructions are followed conscientiously the novice manipulator will be well placed to achieve a positive outcome from the procedure. The nature of manipulative practice is such that there are many different ways to achieve joint cavitation at any given spinal segment. Many clinicians achieve extremely high levels of expertise and competence in the use of HVLA techniques. This is the result of many years of individual clinical experience and practice.

This manual is designed to be a safe and effective starting point upon which practitioners can build basic and then more refined technical skills. No text can teach the subtle nuances of HVLA techniques. For example, the sense of appropriate pre-thrust tension is difficult to describe and acquire. Extensive practice under the supervision of skilled and experienced clinicians is strongly recommended.

This text lays out the primary and secondary joint leverages required to facilitate effective localization of forces to a specific segment of the spine prior to application of the thrust. If the instructions are followed, the resultant thrust is likely to achieve joint gliding and cavitation with the use of minimal force. The joint to be thrust should not be locked by facet apposition, but remain free so that the practitioner can direct a gliding thrust along the joint plane. Appropriate pre-thrust tension is then developed by positioning the joint towards the limit of its available range and not at its anatomical barrier.

Techniques are described using facet apposition locking. In broad terms, facet apposition locking uses combinations of sidebending and rotation. An understanding of the biomechanics associated with coupled movements of the spine in different postures allows the operator to decide on optimal leverages. While rotation and sidebending are the principal leverages used, the more experienced manipulator may include elements of flexion, extension, translation, compression or traction to enhance localization of forces and patient comfort.

Patient relaxation is an essential prerequisite for effective HVLA techniques. This may be facilitated by the use of respiration and other distraction methods.

After making a diagnosis of somatic dysfunction and prior to proceeding with a thrust, it is recommended that the following checklist be used for each of the techniques described in this section:

• Have I excluded all contraindications?

• Have I explained to the patient what I am going to do?

• Do I have informed consent?

• Is the patient well positioned and comfortable?

• Am I in a comfortable and balanced position?

• Do I need to modify any pre-thrust physical or biomechanical factors?

• Have I achieved appropriate pre-thrust tissue tension?

• Am I relaxed and confident to proceed?

• Is the patient relaxed and willing for me to proceed?

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Section 1

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