SMT Ebook Manual

Evidence-Based Orthopedic Manual Therapy
for the Spine:

Lab-Based Mobilizations/Manipulations for
the Cervical and Lumbar Regions
Eric Jorde, PT, DPT, OCS, Cert. MDT, Cert. SMT
Alex Siyufy, PT, DPT, ATC, SCS, Cert. MDT, Cert. DN
Brent Harper, PT, DPT, DSc, PhD, OCS, CSCS, Cert. MDT, Cert. DN, FAAOMPT
Harrison Vaughan, PT, DPT, OCS, Cert. SMT, Cert. DN, Dip. Osteopractic, FAAOMPT
Spinal Manipulation & Mobilization eBook 1

Course Instructors
Eric L. Jorde, PT, DPT, OCS, Cert. MDT, Cert. SMT
Dr. Jorde is an orthopedic Physical Therapist working at the Virginia Center for Spine & Sports Therapy in
Midlothian, Virginia. Dr. Jorde earned his Bachelors of Science degree in Biology from the State University
of New York at Plattsburgh in 1998. He earned his Master of Physical Therapy degree in 2001 and a
Doctorate of Physical Therapy in 2004 from Shenandoah University.
Dr. Jorde's post graduate certifications include the following: Certification in Mechanical Diagnosis &
Therapy (McKenzie Method) in 2004, Board Certified in Orthopedics (OCS designation) by the American
Board of Physical Therapy Specialties (2006), APTA Certified Clinical Instructor (2006), Direct Access to
Physical Therapy Certification (2008), Certification in Spinal Manipulation by the Spinal Manipulation Institute of the American
Academy of Manipulative Therapy (2011).
He is an adjunct faculty member of the School of Physical Therapy and Athletic Training at Old Dominion University and taught
courses regarding spinal manipulation and Mechanical Diagnosis and Therapy. Eric is an adjunct faculty member at Radford
University Program in Physical Therapy regarding cervical spine Mechanical Diagnosis and Therapy.
Alex Siyufy DPT, ATC, SCS, Cert. MDT, Cert. DN, CPAM
Dr. Siyufy is a licensed Physical Therapist and Certified Athletic Trainer. Dr. Siyufy is currently a full-time
Assistant Professor with the Doctor of Physical Therapy program at Radford University located in Roanoke,
VA. He is a board-certified Sports Clinical Specialist (SCS), certified in the McKenzie Method of Mechanical
Diagnosis and Therapy (Cert. MDT) and holds a certification in Dry Needling (Cert. DN) from the Spinal
Manipulation Institute. Dr. Siyufy also holds a certification in Physical Agent Modalities (CPAM) from the
Physical Agent Modalities Practitioner Credentialing Agency. As a clinician, Dr. Siyufy previously directed an
Outpatient Physical Therapy clinic and served as adjunct faculty for the Old Dominion University (ODU) DPT
and Masters in Athletic Training programs. Dr. Siyufy has an active research agenda and is currently
involved in several studies in the area of manual therapy, specifically Dry Needling, Instrument Assisted Soft tissue mobilization
(IASTM) and spinal manipulative therapy.

Course Instructors
Brent Harper, PT, DPT, DSc, PhD, OCS, CSCS, Cert.MDT, Cert. DN, FAAOMPT
Dr. Harper is a licensed Physical Therapist and is presently employed as an Assistant Professor at Radford
University. He has been in practice since 1997, specializing in orthopedics and sports medicine. He has an
eclectic and extensive training background in orthopaedics and manual therapy, which includes direct
training under Ola Gimsby, Erl Pettman, and Joe Godges. Dr. Harper has been trained in various soft tissue
procedures for the treatment of pain and dysfunction in regards to myofascial pain syndromes. He has
completed extensive training in the Fascial Manipulation method. Dr. Harper is a full Fellow of the
American Academy of Orthopedic Manual Therapists. He achieved Board Certification in Orthopedics in
2003 and Re-Certification in 2012 from the American Physical Therapy Association.
Harrison N. Vaughan, PT, DPT, OCS, Cert. SMT, Cert. DN, Dip. Osteopractic, FAAOMPT
Dr. Vaughan is a physical therapist practicing at In Touch Therapy in South Hill, Virginia. Dr. Vaughan is a
graduate of the Doctor of Physical Therapy program at Old Dominion University. He is a Board Certified
Orthopaedic Clinical Specialist (OCS) and currently undergoing Fellowship training in Orthopaedic Manual
Physical Therapy from the American Academy of Manipulative Therapy. He has advanced certifications in
spinal manipulative therapy (Cert. SMT), Dry Needling (Cert. DN) and a Diploma in Osteopractic (Dip.
Osteopractic), all from the American Academy of Manipulative Therapy.
His clinical interests include the operation of manipulation and dry needling for musculoskeletal conditions
of the spine and extremities. He is a Certified Clinical Instructor through the American Physical Therapy
Association and currently the clinical coordinator for an advanced clinical internship in manual therapy at In Touch Therapy.
He is actively involved in blogging on current concepts and latest research in the field of physical therapy on the award winning
site at http://www.intouchpt.wordpress.com. You can follow him through emails or even more consistently at twitter handle:
@intouchpt

Course Agenda
Time Topic
8:00-8:45am Course Introduction
Review of Evidence based Systems
Indications/Contraindications for Manipulation
8:45am Intro to Lab techniques and effective handling techniques for performing manual therapy
9:00am Demonstration of Lumbar (L2-L5) Combined Lever (Extension/Rotation w/ body drop & mammillary
process push) Thrust Technique.
Lab Practice and feedback
10:15-10:30
Break
10:30-10:45 Review of Research / FAQ section of eBook about manipulations
10:45-12:00 Demo of Lumbar (L2-L5) Combined Lever (Extension/Rotation w/ forearm pull on sacrum/pelvis) Thrust
Technique.
12:00-1:00pm
Lunch: on your own
1:00-1:30pm General overview of safety/risks of Cervical manipulations
1:30-2:00 Demo of Cervical (C2-7) Combined Lever (Rotation/SB/side shift/local compression/extension or flexion)
Thrust Technique using Momentum with a Cradle Hold.
Mobilizations and positioning to manufacturer a barrier...then practice positioning and handling using
Gr I-IV (no thrusting)
CPR for Cervical Manipulation
2:00-2:30 Demo and Practice of Cervical (C2-7) Combined Lever (Rotation/SB/side shift/local
compression/extension or flexion) Thrust Technique using Momentum with a Chin Hold.
2:30-2:45
Break
2:45-3:30 Demo of Cervical Chin hold manipulation
3:30-4:00 Review/Practice of all techniques
4:00-4:30 Open Lab Practice

Patient vignettes (as time permits)
Concluding remarks

Course Objectives
The following course is designed to advance the skills of Physical Therapists who are treating patients through
the use of spinal manipulation and mobilization. A brief overview of the evidence based assessment systems
as it relates to the current evidence related to manual therapy will be summarized and then will be
accompanied by multiple lab sessions that will incorporate hands-on practice of specific manipulation
techniques.
This course is designed to provide individualized feedback regarding the key points of control and most
effective body mechanics in order to produce the best results. This will be achieved by having 75% hands-on
practice with the various techniques and 25% didactic instruction.
LEARNING OBJECTIVES
The Participant will be able to:
1. Discuss and review the relevant evidence based literature as it relates to

the role of spinal manipulative therapy.
2. Discuss and review the role of evidence based safety screening for spinal
manipulative therapy.
3. Perform high velocity low amplitude thrust (HVLAT) manipulation
procedures for the mid and lower Cervical spine.
4. Perform high velocity low amplitude thrust (HVLAT) manipulation
procedures for the Lumbar spine.
A combination of end range mobilizations and High velocity low amplitude thrust (HVLAT) manipulation
procedures will be instructed including the following:
1. Lumbar (L2-L5) Combined Lever Thrust Technique

(Extension/Rotation w/ body drop & mammillary process push).
2. Lumbar (L2-L5) Combined Lever Thrust Technique

(Extension/Rotation w/ forearm pull on sacrum/pelvis).
3. Cervical (C2-7) Combined Lever Thrust Technique with & without momentum (Cradle Hold)
(Rotation/SB/side shift/local compression/extension or flexion).
4. Cervical (C2-7) Combined Lever Thrust Technique with & without momentum (Chin Hold)
(Rotation/SB/side shift/local compression/extension or flexion).

Position on Thrust Joint
Manipulation Provided by
Physical Therapists
February 2009
An American Physical Therapy Association White Paper

Position on Thrust Joint Manipulation Provided by Physical Therapists.
February 2009
Introduction
The Guide to Physical Therapist Practice 1 provides the framework for describing physical therapist
practice, the patient/client management model, tests and measures, and interventions routinely used by
physical therapists (PTs). Included among the described interventions are manual therapy techniques, which
encompass mobilization/manipulation, defined as comprising a continuum of skilled passive movements to
the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small-
amplitude and high-velocity therapeutic movement.1 Central to this white paper is thrust joint
manipulation (TJM); unique compared with other manual therapy techniques due to its small-
amplitude/high velocity nature.2 Within the physical therapy profession, TJM techniques are performed only
by physical therapists, and are not to be delegated to physical therapist assistants (PTAs) or physical therapy
aides.3 Historically, TJM has been associated with physical therapist practice since the 1920s,4 and PTs have
long been involved in manipulation-related research as providers of care and as principle researchers.5,6
Despite this long history, and unlike most other physical therapy interventions, TJM for decades has been at
the center of legislative challenges that the physical therapy profession faces.7
Chiropractic organizations began opposing physical therapists performing TJM in the late 1960s, and
continue today. The APTA Orthopaedic Section was founded in 1974 to advance physical therapist practice
in the area of orthopedics.8 Twenty years later the American Academy of Orthopaedic Manual Physical
Therapists (AAOMPT) was founded to advance physical therapist practice in the area of orthopedic manual
physical therapy and to further mobilize legislative and regulatory resources. The rise in number of
challenges and the ferocity of attacks peaked in the late 1990s, when PTs were being recognized as
chiropractors chief competitors in the provision of conservative care for patients with musculoskeletal
conditions. More recently, chiropractors have noted that the physical therapist education programs shift to
the entry-level doctor of physical therapy (DPT) degree, and legislative passage of patient direct access to
physical therapy services, are elevating PTs to being their primary economic threat, now and into the
future.9 The Future of Chiropractic Revisited: 2005-2015 9 contains statements such as, The biggest
competitive threat will come from physical therapists. Physical therapists will expand their direct patient
access and restructure their educational programs so most are Doctor of Physical Therapy programs.
While the number of states facing chiropractic legislative challenges has dropped since the highs of
23 noted in 1998 and 18 in 2000, the ferocity of the attacks has not. Such opposition also has extended into
regulatory and reimbursement domains; chiropractors have initiated action at the Department of Health
and Human Services and the Veterans Health Administration to prohibit PTs from using TJM. They also
strongly opposed allowing use of the manual therapy CPT code for reimbursement to physical therapists.
Despite the evidence noting economics as the primary issue behind these challenges, opponents arguments
are always centered on the claims of TJM falling outside the scope of PT practice, lack of PT training, and
compromised patient safety.
TJM and Physical Therapist Practice: Historical and Current Overview
The history of manipulation in recorded history can be traced back to the days of Hippocrates, the
father of medicine (460-355 B.C.). There is evidence in ancient writings that Hippocrates used spinal traction
methods, and in the paper On Setting Joints by Leverage, Hippocrates describes the techniques used to
manipulate a dislocated shoulder of a wrestler.4 Five hundred years later, Galen wrote extensively on
manipulation procedures in medicine.4 The bone setters were layman who practiced manipulation in
Europe in the 1600s through the late 1800s. Friar Moulton published the text in 1656 called The Complete
Bone-Setter, and the book was later revised by Robert Turner.10 In 1871, Wharton Hood published the
book On Bone-Setting which was the first such book by an orthodox medical practitioner.11
In the United States, manipulation was first formally integrated into clinical practice by the
osteopaths. Osteopathy was founded by Andrew Still in 1874, and in 1896, the first school of osteopathy
was formed in Kirksville, Missouri.4 Osteopathy philosophy was based on the Rule of the Artery with the
premise that the body has an innate ability to heal, and with spinal manipulation to correct the structural
alignment of the spine, the blood can flow to various regions of the body to restore the bodys homeostasis
and natural healing abilities. The Osteopathic profession continues to include manipulation in its course
curricula but no longer adheres to Stills original Rule of the Artery philosophy.
Chiropractic was founded in 1895 by Daniel David Palmer, with the original chiropractic philosophy
based on the The Law of the Nerve that states that adjustment of a subluxed vertebra removes
impingement on the nerve and restores nerve flow, thus promoting healing of disease processes. 9 The
straight chiropractors continue to adhere to Palmers original subluxation theories and use spinal

adjustments as their primary means of treatment. The mixers incorporate other rehabilitative
interventions into their treatment options including physical modalities such as ultrasound and exercise.
Physical therapy evolved from traditional medicine to provide physical interventions including
manual physical therapy. The first professional physical therapy association in the United States, which was
the forerunner to the American Physical Therapy Association (APTA) was formed in 1921.12 Between 1921
and 1936, there were at least 21 articles and book reviews on manipulation in the physical therapy
literature.13 The first APTA President, Mary McMillan, wrote in the second edition of the book Massage and
Therapeutic Exercise and in a subsequent editorial14 of the four branches of physiotherapy, which she
identified as manipulation of muscle and joints, therapeutic exercise, electrotherapy, and hydrotherapy.15
This illustrates that manipulation has been part of physical therapist practice since the founding of the
profession.13
In the 1960s, several physical therapists emerged as international leaders in the practice and
instruction of manipulation. Physical therapist Freddy Kaltenborn, originally from Norway, developed what
is now known as the Nordic approach. He published his first textbook on spinal manipulation in1964.16 and
developed extensive training programs for physical therapists to specialize in manual therapy first in Norway
and then later throughout Europe and the United States. Australian physical therapist Geoffrey Maitland
published the first edition of his book Vertebral Manipulation in 1964.17 Many US physical therapists
traveled to Australia and Norway in the 1970s and 1980s to participate in long-term courses and residencies
in manual physical therapy. Residency programs were then set up by these physical therapists in the United
States to promote the teachings of Maitland and Kaltenborn. Although professional physical therapist
training includes instruction in manipulation, residency and fellowship post-professional training programs
continue to be the preferred mode of instruction to gain advanced competency in manipulation and manual
physical therapy.
Physical therapist Stanley Paris, originally from New Zealand, was awarded a scholarship early in his
career to study manipulation in Europe and the United States in 1961 and 1962.13 He later developed
numerous professional and post-professional educational programs in the United States in manual therapy
and manipulation including the formation of the University of St Augustine for Health Sciences in St
Augustine, Florida.
Documentation of manipulation being part of physical therapy practice dates back to the beginning
of the profession, and with the influence of internationally recognized leaders in manual physical therapy
plus new research findings, the practice of TJM and associated education continues to evolve.
TJM and Physical Therapist Training
Physical therapist TJM training starts in physical therapist professional education (entry-level)
programs. Entry-level program curricula design and implementation are primarily directed by A Normative
Model of Physical Therapist Professional Education: Version 2004 (Normative Model)18 and the Evaluative
Criteria For Accreditation of Educational Programs for the Preparation of Physical Therapists (Evaluative
Criteria)19 used by the Commission on Accreditation in Physical Therapy Education (CAPTE). The Normative
Model encompasses the primary content to be taught to physical therapist students and include manual
therapy techniques including mobilization/manipulation: spinal and peripheral joints, thrust and non-
thrust among the interventions to be taught.19 CAPTE is the sole organization in the United States to
accredit physical therapist education programs, passing judgment on the quality and scope of PT training.
The latest CAPTE Evaluative Criteria, effective January 1, 2006, includes a statement similar to that found in
the Normative Model: Provide physical therapy interventions to achieve patient/client goals and outcomes.
Interventions include manual therapy techniques (including mobilization/manipulation thrust and
nonthrust techniques).20 Consistent with these documents, the APTA Board of Directors adopted a position--
Minimum Required Skills of Physical Therapist Graduates at Entry-level, which lists skills that include
mobilization/manipulation thrust and non-thrust techniques.20
A group of content experts convened by the American Physical Therapy Association created the
APTA Manipulation Education Manual (MEM) to promote evidence-based practice in physical therapist
entry-level academic curricula.2 The document was written with both the academic and clinical education
communities in mind and includes recommendations for curricular content, instructional and evaluative
materials, and instructional resource lists. Built upon the MEMs framework, AAOMPT sponsors TJM courses
for academic and clinical education faculty annually.
Studies have described various ways TJM content has been integrated into physical therapist
entry-level curricula; most often it is included in required clinical science courses (e.g., musculoskeletal
track).21 This represents a shift from earlier years when the content was taught more as a standalone
required or elective course, 22 a shift consistent with the efficacy evidence supporting a multifaceted
treatment approach that includes manual therapy for musculoskeletal disorders.23 Further evidence of
TJM being incorporated successfully into entry-level education was provided by Flynn, Wainner, and Fritz.
The authors described physical therapist student use of TJM on clinical internships including the report by
students and their clinical instructors of no adverse patient events and successful treatment outcomes for

patients with low back pain.24
Besides the provided early educational training, numerous TJM professional development
opportunities exist for PTs beyond their entry-level experiences. Research reports describe the various
experiences by which graduates of physical therapist programs advance their TJM skills, including clinical
residency/fellowship training, post-professional academic programs, manual therapy certification
programs, continuing education seminars, and clinical mentorships.22 Various clinical residency and
fellowship programs are credentialed by APTA, and many of the manual therapy certification programs are
housed in educational institutions. These experiences are consistent with other medical professions as
ways to advance knowledge and clinical skills.
In summary, chiropractic claims that PTs do not receive training in TJM is unfounded. At the core of
physical therapist education and practice are movement sciences and analysis. This expertise is grounded in
anatomy, physiology, biomechanics, clinical medicine, and pathology, and it provides the knowledge base
for understanding the indications and contraindications associated with TJM techniques. This foundation
also lays the groundwork for a comprehensive patient examination scheme that will identify patients for
whom TJM is appropriate. Physical therapist students also have hundreds of hands-on psychomotor training
hours imbedded in all of the clinical science courses. This, along with the supervised clinical education
experiences, well prepares the new graduate to competently and safely utilize TJM.
TJM and Patient Safety

Chiropractors claim that manipulation provided by PTs place the public at risk for serious injury. The
following provides an overview of documented TJM patient risk from a general perspective, as well as a
more specific focus on the use of TJM by physical therapists. Cervical spine manipulation techniques pose a
risk of adverse effects that range from mild soreness to severe neurovascular injury. Adverse reactions to
cervical spine manipulation may include a temporary increase in neck pain, radiating arm pain, headache,
dizziness, impaired vision, or ringing in the ears.25 Although minor temporary adverse reactions to cervical
spine manipulation are fairly common, catastrophic complications from cervical manipulation are extremely
rare. The most catastrophic complication is vertebral artery dissection, also known as vertebral basilar
insufficiency (VBI), which is a condition characterized by occlusion or injury to the vertebral artery causing
loss of blood flow to the hindbrain. The vertebrobasilar system provides 10%-20% of the brains blood
supply, branching to many vital neural structures, including the brain stem, cerebellum, spinal cord, cranial
nerves III-XII and their nuclei, as well as portions of the cerebral cortex.26 VBI may cause dizziness,
lightheadedness, nausea, or numbness to the face, and could also result in slurred speech, nystagmus,
double vision, swallowing problems, or blurred vision. More severe cases of VBI can present as a
cerebrovascular accident (stroke) and even on occasion cause death.27
DiFabio 28 completed an extensive literature review and found reports of 177 patients (from 1925-
1997) who experienced adverse events to cervical TJM. The primary diagnosis was arterial dissection/spasm
and brain stem lesions, and 32 cases (18%) resulted in death. The majority of the injuries and deaths
occurred at the hands of a chiropractor, while PTs were involved in fewer than 2% of the injury cases, and
no deaths have been attributed to PTs providing cervical spine manipulation.28 The exact serious
complication risk from cervical spine TJM is unknown. Rivett and Milburn29 estimated an incidence of severe
neurovascular compromise within a range of 1 in 50,000 manipulations to 1 in 5 million manipulations.
Other estimates of VBI risk from cervical spine TJM have been stated as being 6 in 10 million manipulations,
or 0.00006%,30, 31 and the risk of death at 3 in 10 million manipulations.33
Serious or severe complications of lumbar spinal TJM are extremely rare.32 The most serious
potential complication from lumbar TJM is development of cauda equina syndrome. Cauda equina syndrome
is a medical emergency that should be surgically treated as soon as possible to relieve pressure on the
nerves. Cauda equina syndrome may present with urinary retention, fecal incontinence, and widespread
neurological signs and symptoms in the lower extremities that may include gait abnormality, saddle area
numbness, or a lax anal sphincter. Haldeman33, 34 reviewed the literature over a 77-year period and found
only 10 reports of cauda equina syndrome following lumbar TJM none of which were from physical
therapists performing the treatment. The risk of cauda equina syndrome from lumbar TJM has been
estimated to be less than 1 in 100 million manipulations.35, 36 The research suggests that severe adverse
responses to TJM of the cervical and lumbar spine are extremely rare. Physical therapists provide the
thorough, ongoing, patient assessment necessary to identify signs of VBI and cauda equina syndrome
throughout the examination and treatment sessions, and are aware that TJM techniques must not be used
when positive signs of these conditions are present. In such cases the PT will refer the patient to a medical
doctor.
PTs have an extremely good medicallegal track record of patient safety and the use of TJM.
According to a letter from Michael A. Scott, assistant vice president of Medical Professional Liability
Underwriting at CNA dated February 15, 2008, HPSO, the primary liability insurance carrier for physical
therapists in the United States, has confirmed that there are no higher claims losses for PTs who utilize TJM

than for those who use other types of physical therapy interventions.37 This finding is a result of sound
clinical decision-making principles and practicing within the medical model of screening for red flags,
adhering to appropriate indications and contraindications, and referring to other medical practitioners
those patients who present with conditions outside the physical therapist scope of practice.
Research Supporting the Use of Manipulation
There is a large, growing body of research evidence to support and guide the use of TJM for all
practitioners. Physical therapists are leading the effort to establish the evidenced-based framework for safe
and appropriate use of TJM in treating movement disorders. PTs also are developing and validating clinical
predication rules for determination of patient signs and symptoms that will predict dramatic clinical
improvement from TJM. (37, 38, 39) This line of research has assisted in enhancing patient outcomes and
safety in using TJM.
The highest level of evidence to support interventions is based on the recommendations of clinical
practice guidelines, systematic reviews, and meta-analysis.40 Numerous clinical practice guidelines have
recommended manipulation for the treatment of spinal disorders 41,42,43,44 with the strongest evidence
supporting the use of TJM for patients with acute low back pain without radiculopathy. The
recommendations include utilizing TJM within the first 4-6 weeks of pain onset. 41,42,43,44 The first guideline to
recommend TJM for acute low back pain was that of the United States Agency for Health Care Policy and
Research44 which ranked the evidence for manipulation higher than the evidence for any other treatment
included in the review. In 2000, Johnson and Rogers published an analysis describing the practitioners who
provided the TJM treatment used in the clinical trials that were used to develop the favorable
recommendation noted in the established guidelines.6 Of the 27 studies included in these systematic
reviews, only five (18%) studies used chiropractors to provide the manipulation, compared with 12 (44%)
studies that used PTs to provide the manipulation. The remainder of the studies used physicians and
osteopaths. More recently, PTs have completed the vast majority of quality research demonstrating t h e
effectiveness of TJM for treatment of low back pain.5,45,46,47,48
PTs also are leaders in TJM research for patients with neck pain. The neck pain clinical practice
guidelines also tend to support a multifaceted treatment approach that combines non-thrust or thrust
manipulation with specific therapeutic exercise programs.51 Recent research completed by PTs supports
the use of TJM techniques for the thoracic spine as part of the treatment for neck pain, and the
combination of specific exercise with manual physical therapy for treatment of neck pain and
headaches.39, 49, 50, 51, 52 The fact that physical therapist researchers and clinicians are leading the way in
demonstrating the effectiveness of TJM further illustrates that PTs are safe and effective providers of TJM
for treatment of spinal disorders.
Summary
Based on the coordinated, strategic chiropractic legislative activities during the past 20 years, it is clear the
chiropractic profession has established a national agenda to prevent PTs from using TJM. Their claims that
PTs are not adequately trained and that patients are at risk receiving TJM from PTs have no factual basis. The
practice of TJM by PTs is based on research evidence and is just one intervention among many used by PTs
to relieve pain and restore function.53, 54
Interestingly, the Future of Chiropractic Revisited: 2005-20159 contains numerous statements noting that PTs apply
TJM techniques. In addition, groups including the Veterans Hospital Association, US Department of Health and Human
Services, and the Virginia Board of Medicine, have concluded that TJM is in fact within physical therapists scope of
practice. This provides support for the premise that attempts to limit PTs from using TJM is based on economic
concernsnot patient safety.

Definitions of Mobilization & Manipulation
Different healthcare professions and authorities have described mobilization and manipulation in a variety of
definitions. Some professions have several authoritative bodies that have refined their definition over the
course of time. The following is a collection of definitions relating to mobilization and manipulation.
Oxford English Dictionary:

Manipulation: to handle, deal skillfully with, manage craftily
Geoffrey Maitland, PT
Manipulation: This term is used in two distinct ways:
1. It can be used loosely to refer to any kind of 'passive movement' used in examination or
treatment.
2. In a restricted definition, it is used to mean a small-amplitude rapid movement (not necessarily

performed at the limit of a range of movement), which the patient cannot prevent taking place.
Mobilization: This is another passive movement' but its rhythm and grade are such that the patient cannot
prevent its being performed. (Maitland, G. (1986) Vertebral Manipulation, 5th edition (Glossary))
James Cyriax, MD
Manipulation: Simply defined as a passive movement at a joint with a therapeutic purpose, using the
hands.Cyriax, James, M.D., Textbook of Orthopaedic Medicine, Vol. I Bailliere Tindal, 6th Edition, 1975, pg. 701
George Grieve, FCSP, DipTP

Manipulation: an accurately localized, single, quick and decisive movement of small amplitude, following
careful positioning of the patient. It is not necessarily energetic and is complete before the patient can stop
it.Grieve, G. (1981), Common Vertebral Joint Problems (pg 378)

Geoff Maitland, PT
Manipulation: A grade V manipulation is a high velocity short amplitude thrusting movement near or at the
limit of abnormal movement, outside the control of the patient. (Maitland, G (1986) Vertebral Manipulation, 5th edition pg3)
John Mennell, MD
Manipulation is a manual procedure to treat joint dysfunction (Mennell, J. (1960) Back Pain (pg 29))
Stanley Paris, PT, PhD

Manipulation: the skilled passive movement to a joint (Paris, S. (1979) JAPTA, 49 (8))
Phillip Greenman, DO described the state of manipulation:

"There is a wide and varying range of techniques that now fall under manipulation, or spinal
manipulotherapy, and if one picks up various textbooks on the subject, one notes whole different systems.
They vary from mild mobilization or from very slight movements to various forms of massage, to gross
nonspecific movements using femurs and shoulders and so on, to minute specific kinds of adjusting
techniques which put a specific contact on either a transverse or spinous process and give a very short,
sharp thrust. So there is a great variation in techniques by people who claim to be spinal manipulators, and
a generalization can never be made from a single qualified practitioner to the entire field of manipulation.
Nevertheless, all of manipulation is often dismissed on the basis of one technique" (Greenman, PE. 1978 Manipulative
therapy in relation to total healthcare. In: Korr. The Neurological Mechanisms in Manipulative Therapy. Plenum Press, London. (Pg 83))
Boissonnault et al (JOSPT 2004) defined manipulation:

For the purposes of this survey, the term joint manipulation was defined as small-amplitude/high-velocity
therapeutic movement. Although contrary to the Guides definition of mobilization/manipulation, the authors
made the decision to link joint manipulation with this more specific definition based on the assumption that
most physical therapists conventionally equate the term with this specific intervention.

International Federation of Orthopedic Manipulative Therapists (IFOMPT)
Manual Therapy Techniques
Skilled hand movements intended to produce any or all of the following effects: improve tissue
extensibility; increase range of motion of the joint complex; mobilise or manipulate soft tissues and joints;
induce relaxation; change muscle function; modulate pain; and reduce soft tissue swelling, inflammation
or movement restriction.
Mobilisation
A manual therapy technique comprising a continuum of skilled passive movements to the joint complex
that are applied at varying speeds and amplitudes, that may include a small-amplitude/high velocity
therapeutic movement (manipulation) with the intent to restore optimal motion, function, and/or to
reduce pain.
Manipulation
A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit with
the intent to restore optimal motion, function, and/or to reduce pain.

Anatomical limit: Active and passive motion occurs within the range of motion of the joint
complex and not beyond the joints anatomic limit. (http://www.ifompt.com/Educational+Standards/SC+Glossary.html)
DASP AAOMPT 1998. Adopted Orthopaedic Section APTA 2000.

Manipulation / Mobilization: the skilled passive movement to a joint and or the related soft tissues at varying
speeds and amplitudes including a small amplitude, high velocity therapeutic movement
Dorland's Illustrated Medical Dictionary, 28th Ed.

Mobilization: The process of making a fixed part or stored substance mobile, as by separating a part from
surrounding structures to make it accessible for an operative procedure or by causing release into the
circulation for body use of a substance stored in the body.

Stanley Paris, PT, PhD
Manipulation vs. Mobilization: The term "mobilization" is identical in meaning with the word "manipulation".
They are interchangeable. Mobilization has been the more common term in the United States due to physical
therapists wishing to avoid the word "manipulation" which has to some an implied association with
chiropractic. While that might have been true it is no longer the case. In medical journals they refer to
manipulation and recognize our role in it. (Spinal Manipulative Therapy, Clinical Orthopaedics and Related Research, S.V. Paris, #179, Oct. 1983.)
Guide to Physical Therapist Practice American Physical Therapy Association (1999)

Manipulation: A skilled passive hand movement that usually is performed with small amplitude at a high
velocity.
Manual therapy techniques: A broad group of skilled hand movements, including but not limited to
mobilization and manipulation, used by the physical therapist to mobilize or manipulate soft tissues and joints
for the purpose of modulating pain; increasing range of motion; reducing or eliminating soft tissue swelling,
inflammation, or restriction; inducing relaxation; improving contractile and non-contractile tissue extensibility;
and improving pulmonary function.
Mobilization: A skilled passive hand movement that can be performed with variable amplitudes at variable
speeds. Manipulation is one type of mobilization. Appendix 1-3 Guide to Physical Therapist Practice American Physical Therapy Association 1999, 1997 by the American
Physical Therapy Association (APTA). Revised July 1999. American Physical Therapy Association. For more information about other APTA publications, contact APTA, 1111 North Fairfax Street, Alexandria, VA 22314-1488, or
access APTA's Resource Catalog online via APTA's Web site, [URL=http://www.apta.org/res_cat.]www.apta.org/res_cat.[/URL] [Publication order no. P-139] ISBN 1-887759-16-6
Guide to Physical Therapist Practice American Physical Therapy Association (July 2000)
Orthopedic Section of APTA, AAOMPT & APTA agreed to a revised definition of manipulation and mobilization
for the use in the Guide to Physical Therapy Practice
Mobilization/Manipulation: a manual therapy technique comprised of a continuum of skilled passive

movements to joints and /or related soft tissues that are applied at varying speeds and amplitudes, including a
small amplitude/high velocity therapeutic movement. (http://guidetoptpractice.apta.org/content/1.body.epub)

Virginia Board of Medicine Department of Health Professions: Study Task Force Spinal
Manipulation in Physical Therapy (1999)
Definitions provided by the Virginia Physical Therapy Association & American Physical Therapy
Association are as follows:
Manual Therapy: A broad group of skilled hand movements, including but not limited to mobilization and
manipulation, used by the physical therapist to mobilize or manipulate soft tissues and joints for the purpose
of modulating pain; increasing range of motion; reducing or eliminating soft tissue swelling, inflammation or
restriction; inducing relaxation; improving contractile or non-contractile tissue extensibility; and improving
pulmonary function. Manual therapy techniques include connective tissue massage, joint mobilization and
manipulation, manual lymphatic drainage, manual traction, passive range of motion, soft tissue mobilization
and manipulation, and therapeutic massage
Spinal Care: A generic term that describes no specific intervention, philosophy or methodology. In contrast,
the Guide to Physical Therapist Practice describes the "disablement model" and defines "impairment,"
"functional limitation," and "disability." These are terms that can be applied to any human condition including
those that involve the spine.
Mobilization: A skilled passive hand movement that can be performed with variable amplitudes at variable
speeds.
Manipulation: A skilled passive hand movement that usually is performed with small amplitude at a high
velocity.
When applied to treatment of spine dysfunction, manual therapy techniques are often termed manual spinal
care or manual spinal therapy. The terms spinal mobilization or spinal manipulation may be used depending
on the intervention performed.
Definitions provided by the Virginia Chiropractic Association are as follows:

Spinal Manipulation: Passive movement of short amplitude and high-velocity which moves the joint into the
paraphysiologic range. This is accompanied by cavitation or gapping of the joint that results in an intrasynovial
vacuum phenomenon thought to involve gas separating from fluid.
Spinal Mobilization: Passive movements within physiological joint range of motion without cavitation or the
popping sound inherent to manipulation.
http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Manipulation/VAStudyofSpinalManipulation.pdf

Maitland Spinal Manipulation & Mobilization
Geoffrey Maitland was a significant influence in the Maitland Mobilization/Manipulation

world of physical therapy and manual therapy Grading Scale
during the twentieth century. Maitland developed
an extensive clinical examination and assessment
system using the patients comparable signs and
symptoms to develop an effective treatment plan
for the patients condition. Maitland developed a
system of categorizing mobilizations, joint signs,
and movement diagrams for the application of a
manual therapy intervention.
This system was initially developed in the 1950s by

Maitland and has continued to evolve over time
with the influence of his faculty and is currently
known as the Maitland-Australian Approach. The
focus of the MAPS approach is on the management
of neuromusculoskeletal conditions. Maitlands
initial evaluation, assessment and manual therapy
techniques were influenced in the early 1960s
when he received an award from a special studies
fund which allowed him to travel internationally to
work with other thought leaders in manual
therapy. Maitland visited and studied with many
osteopaths, chiropractors, medical doctors, and
physical therapists which included such notable
figures in manual therapy such as James Cyriax and
Gregory P. Grieve. Maitland published his first
edition of Vertebral Manipulation in 1964, a work
that is currently in its eight edition as of 2013.
The purpose of this section is to provide a very

brief summary of key concepts in Maitlands
system as they apply to mobilization/manipulation.
The clinician is encouraged to read Maitlands
Vertebral Manipulation, 8th Edition for a more
thorough description of the MAPS evaluation and
treatment paradigm.

Maitland Spinal Manipulation & Mobilization
Maitland Mobilization/Manipulation Rate
of Application
Maitland Grade V Manipulation (Thrust)

The clinician determines a segment of interests The clinician will perform a flexion PIVM until the
using Maitlands evaluation process which is segment of interest initiates movement. The
beyond the intent of this eBook. Again, the clinician then holds the patients cervical spine in
clinician is encouraged to read Maitlands Vertebral flexion and initiates a right rotation PIVM away
Manipulation, 8th Edition for a more thorough from the targeted joint and the clinician stops
description of the MAPS evaluation and treatment when movement is felt at the applicator hand. The
paradigm. clinician maintains the first and second PIVM
positions and initiates a third PIVM into left side
This example describes the creation of a barrier bending towards the targeted joint. The clinician
and HVLAT targeting a mid-cervical right facet.
maintains all three PIVM positions at an end range
The clinician may use a variety of hand holds, but position and may make some minor adjustments to
commonly a chin hold (also called a chin cradle)
ensure a barrier is manufactured. Application of a
technique is used for a manipulation using the
high velocity, low amplitude movement into right
Maitland system. The clinician applies the chin rotation towards the opposite orbit is applied using
hold using his left hand. The clinicians right hand
both hands and clinicians trunk.
contacts the articular pillar of the targeted
segment along the anterolateral aspect of the 2nd
digit MCP joint. Broad contact with the right hand
is more comfortable and the 1st digit rests on the
patients jaw.

UK Osteopathic Manipulative Treatment (OMT)
The philosophy and practice of osteopathic countries focuses on musculoskeletal system and
medicine was developed by Andrew Taylor Still, they are not licensed to prescribe medications or
MD in 1874 in reaction to what he felt were perform surgeries. Some foreign schools such as
frequently harmful or dangerous medical practices the British School of Osteopathy allow other
of the late 1800s. Dr. Still founded the first school healthcare professionals such as physical therapist,
of osteopathic medicine in Kirksville, MO in 1892. chiropractors, or medical doctor to become
Dr. Stills research and clinical observations formed competent in manual therapy to attain a
his belief that the musculoskeletal system played a certificate, masters degree or doctorate in
vital role in health and disease and that physicians osteopathy.
should focus on treating the whole patient and not
However, US trained osteopaths physicians are
just the disease. Dr. Still was considered a pioneer
licensed to practice the entire scope of modern
of the wellness concept and incorporated this
medicine which includes surgery, prescribing
focus on the patient as whole into the curriculum
medication, ability to practice any medical specialty
of his medical school of osteopathy.
and perform osteopathic manual treatment. The
Osteopathic medical practice and philosophy is Osteopathic International Alliance has a country
practiced throughout the world, but the profession guide with details of registration and practice rights
has evolved into two branches consisting of non- and the International Osteopathic Association has a
physician manual medicine osteopaths and full list of all accredited osteopathic colleges. "Directories".
Osteopathic International Alliance. Retrieved27 July 2012.
scope of medical practice osteopathic physicians.
Non-physician osteopaths and physician Osteopathic manual technique classification has
osteopaths function as distinct and separate evolved over time as the profession of osteopathy
professions in their respective countries. However, has evolved. Classification of osteopathic manual
non-physician osteopaths and physician osteopaths techniques was separated into three general
both refer to themselves as a DO which causes categories consisting of soft tissue, articulation and
some confusion amongst the public and other thrust at the turn of the twentieth century.
healthcare providers. US trained physician However, this classification of manual therapy was
osteopaths attain a Doctorate of Osteopathic too narrow and hindered communication between
Medicine and many foreign trained non-physician professionals. The British School of Osteopathy
trained osteopaths attain a Diploma of Osteopathy. (BSO) formed a team of teachers to develop a more
The non-physician scope of practice varies greatly accurate and extensive classification of manual
between regulatory bodies and countries. In techniques in the 1970s. This classification has
Australia, the UK, and New Zealand the non- been amended several times, but remains
physician manual medicine osteopaths are relatively intact and valid (Hartman 1997).
regulated by statute and practice requires
registration with the relevant regulatory authority.
The practice of non-physician osteopaths in foreign
UK Osteopathic Treatment Classification: Low Velocity Stress Technique Category
Hartman (1997) describes three main groups of

osteopathic techniques as described by the BSO.
There are some limitations in classifying techniques
and overlapping of techniques between
classification groups exists. The three primary
classification groups include the rhythmic
techniques, thrust techniques and low velocity
stress techniques.
Rhythmic Technique Category
Thrust Techniques (HVLA)
One of the primary foci of this eBook and course is

on high velocity low amplitude thrust procedures
and will examine this category of osteopathic
manual therapy in more detail. Readers with more
Thrust Technique Category interest in this area or other areas pertaining to
osteopathy are advised to read Dr. Laurie
Hartmans text the Handbook of Osteopathic
Technique, Third Edition (1997).
Hartmans (1997) text describes the thrust

techniques as follows: Thrust techniques can be
defined as a technique using a single application of
force using high velocity and low amplitude. The
objective of the technique is to direct forces to a
specific point, area or structure. It is not usually
necessary to perform thrust techniques at the end
of a range of movement. By combining many
components, a barrier is formed which is at a
cumulative end-of-range rather than at an
anatomical end of range. If sufficient speed can be
attained, the inertia of the tissues can form enough
resistance to permit efficient thrust procedures.
They will reach a target tissue or structure without momentum prior to the application of a HVLAT.
reaching the end of range of the joint. This is much The application of the HVALT is initiated from a
less potentially traumatic and uncomfortable, and static resting point at the manufactured barrier.
allows a chance to use this category of technique in Greenman (2005) writes that the impulse tries to
a wider range of patients. It is accepted that not all achieve movement amplitude of 3mm in the
practitioners can achieve this ideal of ultra-rapid affected joint. Usually, this technique is applied
acceleration and very controlled braking force. very close to the target joint or tissue. However, a
Inevitably some thrust techniques will be of a lower long lever or thrust from a more distant site can be
or intermediate velocity, but the aim of minimal used as an alternative or a combination of short
amplitude remains consistent. A force short of and long levers can be applied in this technique.
adequate joint separation is not going to be
This technique is very similar in nature to a
traumatic; an excessive force or amplitude is
Maitland grade V thrust technique. A Maitland
potentially dangerous. Hartman (1997) continued
grade V thrust technique uses no or very little
his description of HVLA: Traditional manipulation
derotation which prevents to operator from using
is performed at the end-of-range, and then by the
momentum for the application of a thrust.
application of overpressure beyond the point of
Maitland uses a series of PIVMs to lock out the
control of the patient. Well-controlled osteopathic
segments above and below in order to apply the
thrust technique is not usually performed in this
thrust to the segment of interest. This osteopathic
way. The act of inducing multiple components
technique does not lock out segments, but
produces a point of useful tension that is short of
combines the use of multiple levers in order to
the end of anatomical range. The thrust is
create a barrier to focus forces at the segment of
performed in a chosen direction while the
interest.
secondary components are maintained by the
operator control to make the barrier available. The Combined Lever & Thrust Using Momentum
same amplitude of the primary lever applied
without the secondary component would not be This thrust technique is very similar to the
effective. It is, therefore, the understanding and combined lever and thrust. The operator
control of these secondary components which introduces the use of momentum in this technique
make the osteopathic approach different from for several purposes:
manipulation as it is usually defined.
1. Patient may find the combined lever &
Combined Lever & Thrust thrust positioning uncomfortable or
threatening.
This thrust technique utilizes a combination of 2. Operator may find difficulty producing
primary, secondary and tertiary levers to sufficient acceleration from a static
manufacture a barrier for the application of a position.
HVLAT. The operator uses very little derotation or

3. Momentum can be used near optimal stipulates that the movement of one vertebra in
barrier position in order to fine tune one direction reduces its movement in all other
directions (Greenman, 2005). This kind of
a barrier prior applying HVLAT.
technique is usually more comfortable for the
4. Momentum enables increased force patient because the barrier is built up closely to the
to be applied when absolutely middle position of the joint.
necessary.
Non Lever & Thrust
5. Allows a smaller operator to use
momentum on a larger patient in order to According to Hartman (1997) this technique is
produce sufficient acceleration and force. usually more often used by chiropractors but some
osteopaths or physical therapists find it useful in
Minimal Lever & Thrust
certain circumstances. The purpose of this thrust
Hartman (1997) states that this technique can be technique is to apply a force directly to a bone or
further divided into two broad subdivisions. The joint in order to release a blocked facet or break a
first subdivision consists of a true use of minimal fixation. Often, local compression at the target site
levers prior to the application of a thrust. Hartman is used by the operator instead of combined levers.
feels that this is the most difficult thrust technique According to Greenman (2005) this compression
to master by most clinicians. This technique emphasizes that the building up of tension is the
requires an extremely rapid acceleration using the precondition for applying an impulse or thrust.
least number of combined levers followed by a Usually a very fast impulse is necessary so that the
rapid and controlled deceleration. Some clinicians applied force is not dispersed in other tissues and
feel that the sudden deceleration produces the loses its intensity (Hartman, 1997).
primary energy during this type of manipulation.
Non Lever & Thrust Using Momentum
The purpose of using this technique includes:
This technique is similar to the aforementioned
1. Break a fixation before other tissues technique with the addition of a small oscillation
deform under pressure and limit the applied to joint of interest prior to the HVLAT. This
operators ability to perform the HVLAT. can allow some operators to generate the proper
2. Patient may find the combined lever and acceleration for the thrust technique to be
thrust positioning uncomfortable or effective.
threatening.
The second and more common method of minimal

lever and thrust is to use several components to
reduce the amplitude of the individual movements
as much as possible. This positioning or use of
combined levers follows Fryettes III law which
Kinematics of Spinal Manipulation (HVLAT)
What do we mean by "High Velocity"? Cervical Thrust Amplitude
Cervical HVLAT Force
Cervical High Velocity Thrust
Cervical HVLAT Cavitation
Pre-Thrust Cervical ROM
Cervical De-Rotation ROM prior to HVLAT

Thoracic HVLAT Pre-Load
1= peak pre-load force. 4= peak HVLAT Force
Cervical HVLAT Summary
Thoracic HVLAT Force
Thoracic Vertebrae Movement
Thoracic High Velocity Thrust
Lumbar High Velocity Thrust

Accuracy of Lumbar HVLAT Lumbar HVLAT Cavitation
What is the pop associated with HVLAT?

The pop associated with HVLAT is theorized to be
joint cavitation.
When a joints volume is increased, pressure

decreases and cavitation occurs with consequent
release of energy as noise. (Cyriax 1975)
This rapid increase in joint volume in combination

with decreased pressure below the partial pressure
of CO2 results in gas coming out of solution. This
phenomenon is known as tribonucleation.
Joint Space Following HVLAT & Cavitation
Force of Lumbar & SIJ HVLAT

Does Cavitation Impact Treatment

Outcome?
Applied Physics of HVLAT Application

Clinicians need to apply different levels of force
during a manipulative procedure to the spine
depending on the spinal region being treated. The
cervical spine requires much less force than the
thoracic and lumbar spine in order to achieve the
treatment effect desired by the clinician. However,
the clinician can decide how to develop the force
needed to perform a proper HVLAT.
Cavitation Refractory Period

The time period needed for gas following joint
cavitation to be reabsorbed into solution. Joint
cavitation is not possible during this time period.
The literature states 15-30 minutes average
refractory period length. (Brodeur (1995), Sandoz (1969),
Mierau (1998), Unsworth (1971)

Force applied to the spine during a manipulative force for a spinal manipulation. A controlled
procedure is a product of mass and acceleration sudden or abrupt stop during a spinal manipulation
used during the thrust. Therefore, the clinician produces a negative acceleration rate. This is most
may opt to use more speed or acceleration during commonly used in the osteopathic techniques
a manipulation to produce a desired force applied using momentum or minimal lever and thrust
to the spinal segment of interest. Conversely, the technique. This sudden controlled stop produces a
clinician has the option to use a lower rate of very high deceleration (or negative acceleration)
acceleration and will need to use more mass during rate and must be combined with a very small
the manipulation procedure or the clinician may amount of mass during the procedure.
use an equal amount of acceleration and mass
The clinician should consider these factors when
during the manipulation.
applying a high velocity low amplitude force to a
These modifiable factors may assist a smaller spinal segment. Many variables are involved when
clinician attempting to perform a lumbar spine using a manipulative procedure and the clinician
manipulation on a larger patient. Specifically, the should err on the side of less force to produce the
smaller clinician does not possess enough body desirable treatment effect and to avoid an adverse
weight to use a large amount of mass during the event.
procedure to generate adequate force. Therefore,
the smaller clinician can produce the proper force Modifiable Aspects of HVLAT Thrust
by taking advantage of a higher acceleration rate in
order to achieve the proper force required for the
technique.
Generally, a cervical manipulation using a chin hold

will not allow a clinician to develop as much speed
or acceleration compared to a cradle hold
technique. This impacts the clinicians ability to Duration: HVLAT occurs between 80-200
produce the proper force for a manipulation. A milliseconds which is a wide variation in speed, but
chin hold technique will use more mass and less can be a significant factor in the particular
acceleration compared to a cradle hold technique. technique chosen. The speed of the thrust is
However, a cradle hold technique is more versatile inversely related to the amount of mass applied in
in that the clinician may choose to use either more order to achieve the proper amount of force.
mass, more acceleration, or choose to use equal
mass and acceleration to produce the proper force
Plane: A HVLAT force will be applied at a 90
for the manipulation technique. degree angle to a joint in order to produce joint
gapping. Another option for a clinician is to apply a
The clinician may also use negative acceleration or thrust in the plane of the joint in order to produce
deceleration to develop the proper amount of a sliding movement within the target joint.

Compression: This can be used as a secondary Levers: The primary lever in a technique is usually
lever in order to increase tissue resistance prior to a sliding or gapping force applied to the target
application of a HVLAT. Some clinicians will use joint. The primary lever can also be called the
traction as a secondary lever when creating a principle force or executive force in a manipulation
barrier. Traction and compression both have a technique. Sliding techniques generally require
similar effect in increasing tissue resistance when less force than gapping techniques to produce the
used as a secondary lever. desired treatment effect.
Amplitude: The amount of de-rotation prior to a Secondary and tertiary levers allow the clinician to
thrust determines the amount of amplitude decrease the amount of primary lever force
involved in a HVLAT. Techniques using momentum needed for a technique. The amount of application
have larger amplitude than combined lever of secondary and tertiary levers is dependent on
techniques. The degree of amplitude positively patient comfort, the technique chosen, and the
correlates to the peak acceleration of a thrust. purpose or indication for the procedure.
However, the clinician should take care to keep the
Abrupt Stop: The rate at which a technique is
amplitude to a minimum. Larger amplitudes during
stopped plays a factor on the forces and
HVLAT can be associated with adverse events such
physiological effects on the targeted tissue as
as soreness or possible tissue injury.
mentioned early in this section. A very sudden
Force: The target tissue is an important stop in a thrust technique produces a very large
consideration when deciding how much force is deceleration force and should be coupled with a
needed for a particular technique. The cervical very low mass to produce the desired force.
spine requires much less force than thoracic and
Onset: The onset of acceleration can be modified
lumbar spinal regions. Patient size and
for a particular technique and has a similar effect
morphology may play a factor in the minimal
as the abrupt stop. Technique type may be a
proper dose of force for a technique.
primary variable in the onset of acceleration to
The clinician should attempt to use the least produce the proper amount of force. A combined
amount of force needed to produce the desired lever and thrust procedure involves a very small
treatment of effect. Proper use of combined levers amplitude and would require a faster onset speed
or focusing during barrier manufacturing will help to produce the desired acceleration.
the clinician become more specific in the
application of his/her force. Excessive use of force Respiration: The use of respiration can be used as
is not an alternative for proper technique and is a secondary or tertiary lever in thoracic or lumbar
more likely to lead to an adverse event and/or techniques. The clinician may use inhalation or
tissue injury and should be avoided. exhalation to produce increased tissue resistance
or patient relaxation in order to perform a
technique with minimal force.
Principles of Creating a Pre-HVLAT Barrier
The purpose in creating a pre-HVLAT barrier is to describe some common definitions of joint
focus the force to a specific spinal segment. This barriers.
focusing of forces following a manufactured barrier
is intended to exclude adjacent spinal segments
from the thrust and allow the clinician to use the
least amount of force required to achieve the
desired treatment effect.
Several terms are used for the creation of a pre-

HVLAT barrier and these terms are similar in
nature, but are not synonymous. The most
common term used to describe the creation of a
barrier is locking. The term locking for creating a
barrier is a misnomer in that the spine is not truly
being locked up, but tissues are placed in a position
of tension to allow forces to be directed at a target
tissue. Other terms to create a barrier include
terms such as PIVM (to the target segment),
manufacturing, focusing, tissue wind-up, taking up
tissue slack and tensioning.
Two different terms for locking have been

described by Hartman (1997) and other authors
which are physiological locking and ligamentous
locking. Physiological locking implies a facet joint
apposition that allows the clinician to direct forces
at the specified tissue target. Ligamentous locking
implies that the clinician applies progressive tissue
tensioning that allows the clinician to direct forces
at the specified tissue target. However, a
combination of both types of locking is used by
most clinicians to manufacture a barrier for a
HVLAT.
Several definitions of barriers exist which can cause

some miscommunication between practitioners
within a profession or between professions that
utilize spinal manipulation. The figures below

Most schools of thought take Fryettes Laws into

consideration when creating a barrier for a
manipulative thrust. Clinicians should have a good
understanding of these principles in order to
Utilizing Type III movement in pre-HVLAT barrier
properly manipulate or mobilize the spine.
creation allows the clinician to direct the forces to
These principles are not true laws and Type I and II the target of interest using the least amount of
movements have come under scrutiny in the force needed to produce a treatment effect. This
literature. These principles provide some valuable also allows the clinician to avoid over utilizing any
insight into barrier creation in different areas of the one cardinal plane of motion and thrust beyond
spine. Type III motion is especially pertinent in the anatomical barrier which could lead to an
developing a barrier or locking maneuvers. adverse reaction or injury.
The following graphs demonstrate how using a

combination of levers can help distribute or
dissipate a thrusting force. This allows the clinician All three diagrams utilize a combination of levers to
to use less total range of motion in the primary create a barrier prior to a HVLAT and each diagram
lever vector by taking up tension in other planes of maybe appropriate for a particular manipulation
spinal motion. procedure. The different categories of spinal
manipulation described by the osteopaths can be
found in each of these graphs. The clinician needs
to properly assess the patient to determine the
proper manipulative procedure or if the patient is a
candidate for manipulation. However, the third
graph using the most levers is thought to provide a
more comfortable positioning for the patient and
least likely to over use any one plane of spinal
motion.
Clinical Insights for Manufacture Pre-

HVLAT Barrier
Choose the appropriate:
Hold (chin, cradle or combined for cervical

spine)
Posture (diagonal, parallel or pulling)
Technique (sliding techniques are safer and
more comfortable)
Building the barrier will allow the clinician
to get good tissue dialogue. This will allow
the clinician to obtain tissue change and will
lead to more a more comfortable patient
position and successful outcome.
The use of multiple levers to create a tissue barrier

is described as the addition of several individual
levers together. In actuality, it is the simultaneous
combination of levers in various amounts that
produces a multi-planar movement.
The spine typically requires 3-4 final priming

impulses to develop this proper tissue dialogue and
set the target segment for a thrust manipulation.
The priming impulses, or mini-thrusts, will come The clinician should notice less primary
automatically as the barrier is built. Priming will lever amplitude (Fryettes III law).
allow for slight variations and balance of all the
Add tertiary levers
components. This allows the clinician to assess the
patient response prior to the thrust and "feel" the Re-test the primary lever amplitude
proper primary lever. Meaning, there are The clinician should notice less primary
abnormalities and facet tropism (asymmetry) in the lever amplitude (Fryettes III law).
spine that the clinician must take into account for Perform 3-4 primes or mini-thrusts to fine
differences in morphology and adjust the plane of tune barrier prior to thrust in the direction
the thrust. of the primary lever without losing
secondary & tertiary levers.
The clinician will combine the components or
levers together as a whole, instead of individually. Big points to Factor into Building a Barrier
This allows the clinician to take up tension sooner
Continuously test the primary component
and will be more comfortable for the patient. This
after adding secondary and tertiary levers.
will also allow the maneuver to become more
automatic for the clinician as the operator The 'order' that the clinician adds secondary
becomes more unconsciously competent in their and tertiary components may have to be
psychomotor skills. adjusted in order to obtain good tissue
dialogue and to find the crispest barrier
As the clinician adds components and can feel a A firm (not hard) stop point is the barrier
crisp barrier (which allows the clinician to know the Thrust requires alignment of the joint facet
manipulative technique will work), provide a very in the primary component direction
fast thrust with a very rapid thrust followed by an (knowledge of anatomy, but also feel).
abrupt stop in the direction of the primary lever You must get to 97%, and then only have a
without losing your secondary & tertiary levers. small amplitude primary force left to apply
during the thrust.
Be confident and comfortable. The more relaxed
the clinician, the more relaxed the patient will be Building the barrier can be broken down
during the technique. Excessive force is not a also by remembering:
substitute for a lack of skill!!!
Focus to the target segment
Steps to Building a Tissue Barrier
Focus using components, but also
Decide on the primary component and test compression (global and local
levers/components)
this lever at the target segment level.
Create local tissue tension using all of these
Add secondary component(s)
components
Re-test the primary lever amplitude

We are creating our OWN barrier.
Component technique is aimed to create a

resistance/manufactured barrier
The manufactured barrier will change the
tissue behavior at the actual barrier
This leads to close packing of the joint and
NOT closed packed position of the joint.

Risks & Adverse Events in Spinal Manipulation
Adverse Events in Manual Therapy

As with any healthcare procedure, there are certain
adverse events which may arise during a physical
therapy intervention. This has been especially
analyzed for interventions directed at the upper
cervical spine, particularly utilizing high-velocity,
low-amplitude thrusts with rotation (Ernst E. 2007). The most common complications are minor,
Historically speaking, the majority of the scrutiny transient impairments. These begin within 4 hours
has been directed at chiropractors due to their and should resolve within 24 hours. They can be
routine use of manipulation, while other local pain/discomfort, headache, fatigue, tiredness,
healthcare professionals use it more sparingly. radiating pain, paresthesia, dizziness, nausea,
However, with the increased usage of manipulation stiffness, hot skin and fainting. These adverse
by physical therapists, one has to come to suspect events are non-serious & the patients function
that adverse events will occur and critical remains intact and the consequences are short
evaluation of physical therapists utilizing high- term & contained.
velocity, low-amplitude thrusts will surely come.
Less common complications can be substantive
The risk of major adverse events with manual reversible or Moderate adverse event. Moderate
therapy has been shown to be low, but a recent adverse events are described the same as major
systematic review found around half of the manual adverse events with only difference of moderate to
therapy patients may experience minor to severe intensity in major group. These
moderate adverse events after treatment that complications include, but are not limited to:
occur within 24 hours and resolve within 72 hours fractures, black out, breathing difficulties, loss or
(Carnes 2010). This also correlates with previous reduced bladder/bowel control, medium/long term
findings (Senstad et al, 1996a,b; Leboeuf-Yde et al loss of movement, medium/long term increase in
1997; Barreett and Breen, 2000; Cagnie et al pain, disc injuries (herniation/prolapse),
2004p, Rubinstein et al 2007). dislocations, muscle strain, cervical myelopathy,
The classifications for adverse events are typically costovertebral strains and separations.
categorized in the literature per Carnes & The most rare of the adverse events include
Underwood 2010, which are defined as minor, serious complications and are described as Major
moderate & major. or non-reversible impairments. These can include
cerebrovascular accidents, spinal cord compression
and caudal equina syndrome. Some types of
manipulation of the neck have been associated
with injuries to the arteries in the neck leading to,

or contributing to, serious complications, including Arterial dissection and HVLAT
stroke and/or death.
The risk of arterial dissection is by far the most
Physical therapists should be cognizant that serious (Rivett DA. 2004) adverse event and the
adverse events (Minor) are common, but mostly actual risk of dissection is unknown. However, best
transient and can occur after multiple types of estimates show risk of stroke from cervical thrust
manual therapy. Adverse events are not confined manipulations to be as follows:
to manipulation and may occur even after
examination, routine manual therapy and exercise
prescription. Notably, Carnes 2010 recent
systematic review defined manual therapy as: any
technique administered manually, using touch, by a
practitioner for therapeutic purposes. Therefore,
unlike the other aforementioned studies, Carnes et
al did not limit search results to just spinal
manipulative therapy but could include any manual
therapy intervention from soft tissue massage to
passive/active mobilization and manipulation.
Moreover, a randomized control trial by Paanalahti
Risk & Incidence of Death Associated with
et al 2014 found no difference between treatment
Manipulation
arms of several manual therapy interventions
concerning the occurrence of adverse events and
no serious adverse events were reported.
Risk of Injury with Manual Therapy
The risk of injury is very rare and is not definitely

established, but may also be under reported in the
literature. Given the negative opinion of
manipulation by medical practitioners resulting in
inaccurate reporting, the adversarial nature of
litigation, and latency of symptomology after Adverse Events in the Cervical Spine
treatments, understanding the epidemiology is
A recent systematic review by Carlesso 2010 found
very limited and extremely difficult to develop
no strong evidence linking the occurrence of
effective screening tools.
serious adverse events with the use of cervical
manipulation or mobilization in adults with neck
pain. However, this study only used a 48 hour
follow-up following cervical manipulation. Dunning
et al 2012 study participated did not report any reported a primary adverse event following
adverse events while comparing upper cervical and thoracic spine manipulation to be increased pain,
upper thoracic thrust manipulation versus non followed by numbness/autonomic, & then followed
thrust mobilization in patients with mechanical by rib fracture.
neck pain.
In a randomized control trial examining thoracic
Furthermore, two of the largest randomized manipulation versus mobilization for chronic neck
control trials to date comparing the effectiveness pain, Suvarnnato et al 2013 did not report an
of cervical HVLA thrust manipulation and cervical adverse event in either participant group.
non-thrust manipulation demonstrated no serious Additionally, Cleland et al 2007 showed no
neurovascular adverse events out of any of the significant difference between numbers of adverse
participants. Hurwitz et al 2002, in a randomized events experienced by subjects in the non-thrust
control trial utilizing 336 patients, showed the and thrust mobilization/manipulation groups and
manipulation group only had transient minor no serious complications for any of the subjects in
discomfort over the mobilization group and no either group.
serious neurovascular adverse events. Leaver et al
Adverse Events in the Lumbar Spine
2010 reported common minor adverse events and
no major adverse events following manipulation. The risk of injury or adverse events in the lumbar
Leavers study did not demonstrate a significant spine and sacro-iliac joint following manipulation is
difference between groups. reported to be rare. The most serious effect is
cauda equina syndrome with risk of 1 in per several
Adverse Events in the Thoracic Spine
million (Haldeman 1992). The risk of making a
The risk of injury following thoracic spine lumbar spine herniated disc worse is 1 in 1 million
manipulation has not been studied as thoroughly (Assendelft 1996) to 3.7 million (Oliphant 2004).
as the cervical spine. Oppenheim 2005 presented
In a recent randomized control trial, Cook et al
3 cases of adverse events following thoracic spine
2013 reported no adverse events in either group
manipulation, including T4-5 vertebral collapse
comparing early use of thrust manipulation versus
with cord compression, T4 vertebral fracture with
non-thrust manipulation on 149 subjects. Similarly,
cord compression and T3 vertebral fracture with
Hondras et al 2009 reported no serious adverse
cord compression. Two of the three cases had a
events while comparing two types of spinal
history of cancer and the other adverse event was
manipulation on subacute and chronic low back
a result of an epidural tumor. Adams and Sim 1998
pain.

Cervical Fracture Screening

Cervical Myelopathy Screening

Cervical Instability Screening
Due to ethical and legal ramifications, it is wise to in differential diagnosis (Cook et al 2005). In fact,
consider clearing the upper cervical spine recent systematic review (Hutting 2013) showed
ligaments/membranes on every patient (Meadows that only the atlanto-axial membrane and tectorial
1999) prior to performing manual therapy. This is membrane tests showed the best diagnostic
prudent practice despite the evidence that cervical accuracy. However, neither test has been
spine instability is difficult to diagnose and confirmed or validated as a pretreatment screen
clinicians have few valid, reliable clinical tests to aid for manual therapy.

Linking CSM to VBI: Currently Referred to (CSM) has been directed to VBI (Grant 1987, 1988;
as Cervical Artery Dysfunction (CAD) Drueger & Okazaki 1980, Terret 1987, Dvorak,
1985, Hurwitz 1996, Assendelft 1996, De Fabio
The safety of spinal manipulation, particularly in 1999, Haldeman 1999, Haldeman 2002 in Spine & J
the cervical spine, has been an issue of significant Neurol, Malone 2002, Ernst 2002, Haneline 2005,
debate since 1907, when the first adverse event Jones 2015) complications of manual therapy
was reported (Rivett 2006). Arguably, the most treatment to the internal carotid artery (ICA) have
concerning of adverse event to the therapists with been reported (Ernst E. 2004, Taylor AJ 2005,
regard to cervical spine manual therapy for Haldeman 2002, Beatty 1977, Hamman G 1993,
decades has been vertebrobasilar insufficiency Lyness 1974, Peters 1995) and have been
(VBI). Even though the substantial investigations recognized by physical therapists to make an
on adverse events of cervical spine manipulation immediate medical referral (Willet GM 2001).
Additionally, strokes have been shown to involve than controls to have seen a chiropractor within 30
ICA more than often than VBI (Hart 1983 Haneline days of stroke. Additionally, Rothwell et al found
2003, Schievink 1993, Lee 2006). Therefore, in light that patients younger than 45 years old were 5
of contemporary evidence and thought, we now times more likely than controls to visit a
know that limiting concern to only VBI in the chiropractor within 1 week of stroke.
cervical spine is limited knowledge and poor clinical
In 2008, Cassidy et al mirrored Rothwell et al
reasoning.. Kerry & Taylor (Kerry 2006 & 2008)
design but added a case-crossover design to allow
propose a revision of the nomenclature and
cases to serve as their own controls. They
suggests using the term cervical artery dysfunction
examined not only chiropractor visits, but also
(CAD). CAD considers all of the potential arterial
primary care visits within 30 days of a stroke with
dysfunctions of the cervico-cranial vasculature,
analysis of more than 100 million person-years of
including vertebrobasilar insufficiency. It looks at
data. Cassidy et al 2008 found no evidence of
the risk that has always been present from a global
excess risk of vertebrobasilar stroke associated
haemodynamic perspective and not just one
with cervical spine manipulation as compared to
structure or pathology as in the past. CAD can be
primary medical physician care within 24 hours of a
defined as:
visit. Nevertheless, there was an increased
the completeness of the arterial anatomy (i.e. the association between chiropractic visits and
vertebrobasilar system, the internal carotid vertebrobasilar artery stroke in patients younger
arteries, and the circle of willis), and the range of than 45 years of age, but no associated in
pathologies that the manual therapist may individuals 45 years of age or older. Additionally, a
encounter (e.g. local dissection, atherosclerotic strong association was found between visits to
events, vessel injury, non-ischaemic events, primary care physicians and chiropractors,
ischemic events). especially for visits involving neck pain or
headache.
To date, CAD has since been recognized in thirty-
seven journal articles and distinctly in the A more recent study by Whedon 2014 echoes
International Framework for Examination of the Cassidy et al 2008 finding among Medicare B
Cervical Region for potential of Cervical Arterial beneficiaries aged 66 to 99 years with neck pain,
Dysfunction prior to Orthopedic Manual Therapy chiropractic cervical spine manipulation is unlikely
Intervention (Rushton A et al 2012). to cause a stroke and incidence of vertebrobasilar
stroke was extremely low. Additionally, Chung et al
The strongest evidence for likelihood of
2014 found no epidemiological studies to support
vertebrobasilar stroke after visits to chiropractor
the hypothesis that cervical spine manipulation is
comes from two case control designs. Smith et al
associated with an increased risk of internal carotid
concluded that spinal manipulation is an
artery dissection.
independent risk factor for vertebral artery
dissection and patients were six times more likely

The understanding of the relationship between VBI of total cases whilst 61% were spontaneous and
and stroke has evolved tremendously over the 39% were associated with other trivial trauma.
years and now it is not seen as a direct causal link,
Specifically, 68 activities have been implicated in
but likely that initial symptoms of an arterial
the development of CAD (Rome 1999). Playing golf
dissection is reason for the patient to seek out
(Yamada 2013), playing tennis (Josien 1992),
medical care. It is likely that patients are seeking
sneezing (Gutowski 1992), yoga (Hanus 1977 &
care for headache and neck pain as a result of a
Nagler 1973), vomiting (Kumar 1998), backing out
spontaneous event already in progress (Miley
of the driveway (Senter 1982, Sherman 1981),
2008, Triano & Kawchuk 2006, Thomas 2011, Marx
visiting the hairdresser (Foye 2002), and painting
2009, Symonds & Westaway 2001, Murphy 2010)
the ceiling (Okawara 1974, Sullivan 1982) have
and not necessarily due to cervical thrust
been associated with CAD.
manipulation (Carlesso 2010, Cassidy 2008,
Murphy 2010, Herzog 2012, Thomas 2013). It has been found that 10-20% of the population
has normal anatomical variations. These anomalies
The potential risks of thrust manipulation to the
can be found in the course of the vertebral artery
cervical spine, although rare, do exist and clinicians
in cervical foramen and size (hypoplasia is diameter
should take responsibility to inform patients about
of 2 mm or less). Theoretically, anomalies of the
the risks and any adverse events that may occur
vertebral artery may alter hemodynamics,
from the intervention. There are no existing valid
therefore increasing turbulence and may
tests for screening and information must be
predispose the patient to aneurysms and increase
incorporated into our clinical reasoning processes
the risk of a cerebrovascular accident.
to detect risk. We must embrace the uncertainty in
this clinical area and allow patients to make Clinicians cannot screen for these anomalies as
informed choices. they are not able to be picked up by extrinsic or
intrinsic factors. It is known to occur in certain
Spontaneous arterial dissection
individuals and appears to be considered by some
Cervical spine manipulation has bee suggested as a to be due to connective tissue abnormalities and
possible trigger in the formation of CAD, especially can occur during innocuous day to day movements.
to the vertebral artery. However, the vertebral The pathogenesis behind such events continues to
artery can be disrupted in many ways and in many remain unknown but could be due to inherent
areas. An abrupt head movement through a vessel wall weakness linked to connective tissue
manipulative procedure is not the only mechanical abnormalities (Caplan 2004, Pelkonen 2003,
trigger that could possibly cause a dissection. Even Benninger 2004).
day to day activities can cause spontaneous arterial
Can we prevent adverse events?
dissection. In fact, an analysis of CAD by Haneline
et al 2005 showed manipulation only included 9% Several guidelines have been in use for several
years to aid in screening patients at risk for
neuromuscular complications following manual tunica adventitia to generate neck pain and
therapy, but the utility of the guidelines are headache.
constantly being challenged.
The clinician must understand that a vascular event
Haldeman et al 2002: is a potentially serious disorder, albeit extremely
uncommon and rare enough where analysis of over
We were unable to recognize characteristics from a
100 million person-years did not detect the
patients history or examination that would
relationship (Cassidy 2008). The clinician should
indicate increased risk of CVA following CSM.
always use sound clinical reasoning behind an
These complications appear to be unpredictable,
intervention. That is, are the symptoms arising
and should be considered as inherent and
from a mechanical or non-mechanical origin?
idiosyncratic
The authors of this manuscript recommend
Concluded that risks associated with CSM are
investigating the possibility of vascular insufficiency
inherent and the occurrence of serious
from two dimensions in an individual with
complications appears to be unpredictable.
headache and neck pain from a differential
Puentedura 2013 demonstrated: diagnosis standpoint: intrinsic and extrinsic factors.
44.8% of 134 adverse events in the literature Intrinsic disorders:

between 1950 and 2010 could be prevented by
Factors related to pathology of the artery itself and
ruling out red flags and contraindications,
will narrow the lumen. This includes conditions like
performing a thorough examination and using
atherosclerosis, aneurysms, thrombosis, and
sound clinical reasoning. However, this study also
emboli. In other words, processes involved in a
found that 10.4% of deaths were unpreventable
spontaneous arterial dissection.
suggesting an inherent risk of cervical thrust
manipulation.
Vascular Insufficiency
There have been cases in the literature where a
patient develops a vertebral dissection even
without having headache and neck pain (Haldeman
2002, Lee 2006). Even though it is currently Extrinsic disorders:
accepted that symptomology of headache and neck
Extrinsic disorders include the encroachment of the
pain may be a spontaneous dissection in progress,
artery by external structures. This includes
even though low, there is an underlying risk for
osteophytes, bony anomalies, muscular
manipulation. Another assumption in these cases
entrapment, fibrous bands, nerve entrapment and
is that an underlying condition was present but was
excessive mechanical forces. In other words,
not providing nociceptive afferent input from the
processes involved in a mechanical arterial
dissection.
Even though it has been shown that pre- patient. The aforementioned risk factors have not
manipulative screening through cardiovascular risk been shown to be related to arterial dissection
factors (Haldeman 1999, 2002), the use of 5 Ds pathologies directly, but they are strongly
and 3 Ns (Kerry 2005) is not sufficient to identify correlated with major vascular pathologies of
individuals at risk for stroke following hypertension, stroke and athelesclerosis. This can
manipulation. It is of relative importance to then provide adequate information on a type of
provide a clinical profile to assist in making an procedure and if the patient needs further medical
informed judgment about the overall investigation.
cardiovascular and cerebrovascular health of a
INTRINSIC EXAMINATION OPTIONS was proved to be appropriate in a recent case

series of three neuromusculoskeletal presentations
Blood Pressure (Taylor & Kerry 2013).
IFOMPTs recent seminal consensus document by Nevertheless, you should use blood pressure
Rushton et al 2012 (Section 5.1) details one of the findings in context with the whole patient
key recommendations of incorporating blood presentation. Sound clinical reasoning should not
pressure testing into risk assessment prior to only incorporate resting blood pressure, but risk
treatment. factors such as hypertension and how well it is
managed.
Moreover, APTAs Guide to Physical Therapist
Practice (2001- Cranial Nerves
http://guidetoptpractice.apta.org/) & Frese
et al 2011 guide therapists to perform a systems IFOMPTs recent seminal consensus document by
review including: Rushton et al 2012 (Section 5.3) details one of the
key recommendations of incorporating cranial
Heart rate and BP are measured to assess aerobic nerve testing into risk assessment for
function and circulation, these measures can assist neurovascular conditions prior to treatment.
the physical therapist in identifying cardiovascular Cranial nerve assessment should include:
or pulmonary problems that might affect prognosis
and intervention or require referral to another CN II, III, IV, VI (6 Cardinal fields or H test)
practitioner. Eye exam (general eye/eyelid symmetry,
pupil size/shape, pupil reaction to light)
A definitive threshold of blood pressure value has
not been determined. Meaning, we do not know if A modification from Kerry & Taylor 2008, the
it is safe to manipulate an individual with clinician can appreciate the subjective
150/70mmHg with less risk than an individual with manifestations of the 5 Ds, 3 Ns are correlated
170/85mmHg. However, blood pressure testing with cranial nerve testing.

Auscultation for bruits

Answer = No.
It is impractical to palpate the vertebral arteries
due to the inaccessible anatomy and small The current data on screening before
diameter, but the clinician could use simple manipulation by placing the head and neck in
palpation to the common and internal carotid extension and rotation suggest that this test is not
arteries to assess for a pathological pulse quality capable of screening out the patients at risk
and turbulence assessment. Using a stethoscope, (Haldeman 2002)
listen for bruit which is the unusual sound that
blood makes when it rushes past an obstruction, The neck extension-rotation test has not been
called turbulent flow. shown to be a valid screening tool for either a
vertebral artery tear or reflexogenic vertebral
artery spasm (Cote 1999)
Extrinsic Examination Options
The current pathophysiological, clinical,
Do pre-manipulation procedures reduce the epidemiological, and ethical evidence suggests that
risk of adverse events? the extension-rotation tests have very limited
clinical validity and that using their potentially

misleading results may lead to patient anxiety and Vertebral artery syndrome or VBI is defined as a
clinical confusion (Cote 1999) transient, partial, or complete occlusion of a
branch of the vertebrobasilar arterial system
The answer is no, but some experts state that resulting in ischaemia or infarct in the brainstem,
clinicians should still perform the test.
spinal cord or cerebellum (Rivett 2005). Signs and
Regarding screening procedures, we propose that symptoms may be numerous, but are traditionally
at least the sustained pre-manipulative position for known as the "5 D's, 3 N's" (Coman 1986) and "A
VBI be included (Carlesso & Rivett 2011) for Ataxia". These include dizziness, diplopia,
dysarthria, dysphagia, drop attacks, nystagmus,
Positioning the patient in the pre-manipulative nausea, numbness and ataxia. It is now known that
test position prior to a manipulation is good adherence just to these classical signs/symptoms is
practice to evaluate patient comfort and to enable incomplete and presentations of vertebrobasilar
evaluation of their response (Rushton A 2012) dysfunction is not always in line with the classical
picture (Kerry & Taylor 2006, Kerry et al 2008).
The simulated manipulation position (pre-
manipulative hold) is also recommended if Even though the internal carotid arteries provide
manipulation is the proposed treatment (Rivett et 80-89% while the vertebral arteries contribute 11-
a 2006) 20% of cerebral blood flow, most of the concerns
for manual therapists are the vertebral arteries due
Vertebral basilar Insufficiency (VBI) Test
to the anatomical course through cervical column.
The VBI test has been used by manual therapists The vertebrobasilar system provides blood flow to
for decades to assist in screening for CAD the hindbrain and has a close relationship from C6
conditions. The test involves a passive maneuver to the occiput. The passage of the vertebral artery
while patient is lying supine while clinician takes and the posterior vascular anatomy can be divided
the cervical spine in ipsilateral rotation, lateral into 4 zones.
flexion and extension in order to hypothetically Zone 1 forms the region of the vertebral artery as it
stretch the contralateral vertebral artery as it transcends from the subclavian artery and ascend
tethers around C1-2. The examiner then holds the within the transverse foramina of the 6th cervical
position for 10-30 seconds and then repeats on the vertebrae. It runs in the angle between the anterior
other side. The patient is observed throughout the scalenes and longus colli muscles.
test while observing for signs and symptoms that
are consistent with a positive vertebral artery test Zone 2 forms the region of the vertebral artery as it
(Magee 2008). If the test is positive, it is an travels vertically through the foramina
absolute contraindication to thrust joint transversaria of the upper six cervical vertebrae. It
manipulation (Barker 2000). has close relationship to two bony structures at
this location, the uncinate process of the vertebral

body and the superior articular process of the anatomical course of the vertebral artery and
zygapophyseal joint. vulnerability at fixation points described above
could potentially affect blood flow and be a
Zone 3 forms from the superior aspect of C2
concern for physical therapist. This has been the
foramen to the dura. The vertebral artery passes
foundational premise of using cervical movements
through the foramen transversarium of C1 and
to assess patency of the arterial structure. The VBI
makes a sharp turn horizontally across C1. The 2nd
test has withstood the test of time, but now it is
and 3rd zones of the vertebral artery are fixed
apparent the construct validity and effectiveness as
within the foramina transversaria, therefore, it
a screen has suffered under the scrutiny of recent
must move whenever the transverse processes
evidence.
move. This motion is the greatest at the atlanto-
axial level during rotation. In addition, the vessels Even though the VBI test is continuously taught in
are "tethered" at various points along zone 3 entry level physical therapy programs, it continues
including C2 transverse foramina, C1 transverse to be challenged and questioned as an objective
foramina and atlantooccipital membrane (Johnson clinical test. Due to the poor sensitivity (Cote 1996,
et al 2000, Macchi et al 1996, Kerry & Taylor 2006). Rivett 2000, Kerry 2003, Kerry 2006, Hutting 2013),
Therefore, the tortuous course of the vertebral the chance of false negatives is overly high (Dvorak
artery in zone 3 correlates with location frequently 1985, Haldeman 2002) and ability to predict the
injured (Frunkin and Baloh 1990, George and absence of arterial pathology is poor. There is clear
Laurian 1987, Sim et al 1993, Sullivan 1992). evidence that the provocative tests may produce
both false positives and false negative findings.
Zone 4 forms from the dura into the cranium. This
Clinicians cannot definitely rule out VBI due to the
is where the vertebral artery enters the foramen
lack of supporting available tests (Childs 2005) or
magnum to join the contralateral vertebral artery
use symptom aggravation as a valid assessment to
and form the basilar artery and feeds into the
rule out VBI (DiFabio 1999).
Circle of Willis.
There have been case reports of patients having
The course of the vertebral artery is not concrete,
adverse events after a manipulation procedure
meaning, there is marked variability in
even with the absence of a positive test (Rivett
vertebrobasilar anatomy. The vulnerability of
1998, Westaway 2003). This type of response
individuals at risk for VBI within these anomalies is
disputes the clinical reasoning of performing a
unknown (Guiffre and Sherkat 1999, Macchi 1996,
manual intervention if the test is negative showing
Johnson 2000). The VBI test purposely
poor ability to rule out a condition. Additionally,
compromises blood flow from the vertebral artery
other end range procedures have been
circulation (Arnold 2004). The vertebral artery is
implemented to show changes in blood flow to the
stretched during rotation, whilst the internal
vertebral and internal carotid arteries (Magarey
carotid artery is stretched during extension more
2004, Rivett 2006, Herzog et al 2012, Thomas et al
so than rotation (Rivett 1999, Scheel 2000). The
2013)
As previously mentioned, the assertion behind Additionally, it can be a natural assumption to
using the VBI test is to examine vertebrobasilar speculate that additional strains to the vertebral
dysfunction arising from potential disruption in artery are encountered during CSM compared to
blood flow. However, the validity behind this other therapeutic procedures to the cervical spine.
rationale is flawed considering blood flow studies Supplementing the blood flow argument, a case
during the VBI test are inconclusive and conflicting. can be made that the stretch and strain on the
Using doppler sonography, several studies have vertebral artery occurs to a degree that it can
demonstrated a reduction in contralateral blood result in damage to the vertebral artery. In fact,
flow during rotation (Arnold et al 2004, Li et al mean failure strains of vertebral arteries have been
1999, Licht et al 1998, Mitchell 2003, Mitchell reported previously to be 58% on average (Symons
2004, Rossitti & Volkmann 1995) while others have et al 2002).
shown no change in blood flow. (Bowler et al 2011,
Even though researchers are unable to assess VA
Haynes & Milne 2001, Thiel et al 1994, Weingart &
strains in vivo due to obvious reasons, Herzog et al
Bischoff 1992, Zaina et al 2003) Moreover, recent
2012 examined vertebral artery strain on 12 human
study by Thomas et al 2013 found no changes of
cadavers. A total of 3034 segment strains were
blood flow using MRI with non-manipulative
obtained during spinal manipulative therapy and
procedures, such as end-range rotation, upper
2380 segment strains were obtained during full
cervical rotation or strong distraction. Even though
ROM testing. The spinal manipulative therapy was
tested on healthy individuals, conclusion stated
performed with high-speed, low-amplitude thrusts
that positions using enduring neck rotation and
while range of motion testing was performed in
distraction do not appear to be more hazardous to
flexion, extension, rotation and lateral bending.
cerebral circulation than more segmentally
The mean strains for three vertebral segments for
localized techniques (Thomas et al 2013).
the ROM testing were 3.3% (1.0-14.5%), 4.9% (1.3-
In fact, it has been shown that asymptomatic 12.7%) and 12.2% (3.6-22.9%) compared to
individuals have a decrease in blood flow without corresponding levels for the SMT group at 0.9% (0-
signs and symptoms that lead to a positive VBI test. 4.3%), 1.4% (0-4.6%) and 3.8% (0-12.6%). Both
This absolutely questions the validity of the test as groups are clearly below the mechanical failure
a screening tool. It is hypothesized that the rate of the vertebral artery as found by Symons et
decrease in blood flow is a natural phenomenon al 2002, but interesting enough, the range of
and due to the compensatory nature of the four motion testing group had the largest value at
vessels (left and right vertebral arteries, left and 22.9%. The largest value of 22.9% strain in range of
right internal carotid arteries), a decrease of blood motion group represents about 39% of the total
flow in one vessel will subsequent have an failure strain compared to the largest value of
increased flow in the other three vessels (Thomas 12.6% strain in the spinal manipulation group,
2014). which only represents about 21% of the total
failure strain; almost half the strain on the
vertebral artery. The authors found that the
maximal strain values for the range of motion at the routine practice of performing this test, a
each segment was always greater than the medicolegal argument is significantly challenged.
corresponding strain values for the spinal Even though the test has been shown to have
manipulative segment (Herzog et al 2012), moderate specificity (Hutting et al 2013), one has
suggesting that spinal manipulation imposes less to wonder why placing a mechanical load on the
stretch than typical range of motion activities that vascular system in a patient who has high risk and
occur day to day (Wuest et al 2010, Herzog et al suspicion of cervical vascular involvement that
2012). could possibly do more harm is the most
appropriate assessment? The actual performance
This same group of researchers performed very
of a biomechanics test may enable a spontaneous
similar methodology examining the internal carotid
event to occur more readily. This correlates with
artery (ICA) during range of motion testing and
the vascular strain findings of Herzog et al 2012 &
spinal manipulative therapy (Herzog 2012). A total
Symons 2002). It is prudent to acknowledge the
of 1080 strain measurements were obtained during
latest data on haemodynamics, risk factors,
spinal manipulative therapy and 864 segment
pathophysiology and vascular clinical presentations
strains were obtained during range of motion
rather than placing importance on one test. It is
testing. Compared to 58% mean failure rate of the
essential that clinicians are aware of the limitations
vertebral artery (Symons et al 2002), the mean
gained from this test and it should be taken in
failure rate of the ICA was 59% (+/- 16%). Even
context with other findings to make a sound clinical
though the maximal ICA strain is quite large during
decision.
ROM testing and SMT, the results echo previous
findings in the vertebral artery showing that Several authors have taken to the literature to
maximal ICA strains for the ROM testing were express discontinuity of the vertebral artery test:
significantly greater than the corresponding
Prudence would dictate that if a suspicion of VBI
maximal strains for the SMT group. In fact, the
exists, based on the patients history, then end range
mean of all maximal ICA strains obtained during
provocative testing should be avoided; the physical
SMT was 28% of that measured during the ROM therapist should refer these patients to the
testing. It can be concluded that ICA strains during appropriate medical practitioner (Childs et al 2005)
SMT is much smaller than what can be expected
during day to day activities (Herzog et al 2012). ...Its purpose is not to screen for a vertebral artery
tear. (Cote 1999)
Even though the VBI test was first described by
...provocative testing is very unlikely to provide any
DeKlyne over 75 years ago and commonly used in
useful additional diagnostic information and
past 30 years (Grant 1996), it has never been linked
to a clinical prediction rule, performed without ...if there is a strong likelihood of VAD, provocative
adequate subjective history taking or provided as a premanipulative tests should not be performed...
guideline in isolation (Margarey 2004). With the (Thiel & Rix 2005)
substantial amount of evidence weighing against
...We recommend that it is inappropriate to perform arterial dissection based on current available
the VBI if significant signs are present during the evidence, prevalence rates for adverse events, and
patient history... (Cook & Hegedus 2008) intervention type.
Reliance solely on objective clinical tests, i.e. so called Based on objective findings, the current literature
vertebral artery tests which have poor validity and
provides modest screening tools for cervical
reliabilityshould be avoided (Kerry R & Taylor AJ
fracture, cervical myelopathy and cervical
2006)
instability but extrinsic examination options for
It can be concluded based on blood flow studies cervical artery dysfunction is lacking. The use of
(Bowler et al 2011, Haynes & Milne 2001, Thiel et doppler velocimetry is not yet reasonable to use in
al 1994, Weingart & Bischoff 1992, Zaina et al clinical practice and not cost efficient to use
2003, Thomas 2013), vertebral artery (Wuest et al magnetic resonance angiography. For now, it is
2010, Herzog et al 2012) and internal artery prudent to acknowledge the lack of validity of
(Herzog et al 2012) vascular strain studies, the mechanical testing through provocative positional
construct validity of the vertebral artery test is testing and focus on an indirect assessment
incomparably lacking. Additionally, the lack of through vascular profiling. The clinician has to
psychometric properties to have the ability of weigh the potential risk of proceeding with spinal
ruling in or ruling out a vertebrobasilar event (Cote manipulation, or mobilization at that, based on
et al 1996, Rivett et al 2000, Kerry et al 2003, Kerry limitations and uncertainties.
2006, Dvorak 1985, Haldeman 2002, DiFabio 1999)
The purpose of the previous material is to provide
or provide any useful additional diagnostic
treating clinicians a subset of predictor variables.
information (Thiel & Rix 2005), it is judicious to
(Subjective & Objective data) that will assist the
know that this test is not an appropriate screen
clinician in attempting to identify those who are
and should be avoided. Our current understanding
and who are not spinal manipulation, or
of the global haemodynamic perspective in CAD
mobilization, candidates for manual therapy to the
and not just one structure or pathology as
cervical spine. It should provide the clinician a risk
proposed for the validity behind the vertebral
to benefit ratio in clinical decision making when
artery test further minimizes the judgment of
dealing with uncertainties. This not only includes
utilizing this procedure in clinical practice.
cervical artery dysfunction, but cervical fracture,
Based on subjective findings of known co- cervical myelopathy and cervical instability.
morbidities and presenting symptomology, the
clinician should use strong clinical reasoning skills
for differential diagnosis. The subjective findings
are less frank in the differential diagnosis of a
cervical artery dysfunction compared to other
contraindications. The clinician then has to weigh
the potential risk for mechanical or spontaneous
HVLAT Indications
General Principles
The goal of manipulation is intended to normalize the function of the neuromuscular system. This can occur
through one or a combination of the following: range of motion restrictions, pain modulation, reflex changes,
neuro-endocrine effects & neurophysiological effects on the central nervous system.

Proposed Mechanisms for Manual Therapy
Treatment Effect
Proposed Mechanisms of Manual Therapy (Bialosky et al 2009)
Mechanical, Neurophysiological & Placebo Effect
Proposed Pain Neuroscience Model
Gifford 1998. Pain, the Tissues and the Nervous System:

A conceptual model. Physiotherapy

Effectiveness of Manipulation vs. Mobilization
Dunning et al. Upper cervical and upper thoracic thrust manipulation versus non-thrust mobilization in
patients with mechanical neck pain: a multicenter randomized clinical trial. (Dunning et al. J Orthop Sports Phys Ther.
2012;42(1):5-18)
Manipulation > Mobilization (short-term treatment effect)
Cleland et al. Short-term effects of thrust versus non-thrust mobilization/manipulation directed at the thoracic
spine in patients with neck pain. (Cleland et al Phys Ther 2007;87(4):431-40)
Cassidy JD et al. The immediate effect of manipulation versus mobilization on pain and range of motion in the
cervical spine: a randomized controlled trial. (Cassidy JD et al JMPT 1992;15(9):5705)
Leaver et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck
pain. (Lever et al. Arch Phys Med Rehabil. 2010;91(9):1313-8)
Manipulation = Mobilization (no conclusive difference)
Hurwitz et al. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients with Neck Pain:
Clinical Outcomes From the UCLA Neck-Pain Study. (Hurwitz et al. Am J Public Health. 2002;92(10):1634-41)
Gross A et al. Manipulation or mobilization for neck pain. (Cochrane Database Syst Review2010(1):CD004249)
Cook C, Learn K, Showalter C, Kabbaz V, OHalloran B. Early use of thrust manipulation versus non-thrust
manipulation: A randomized clinical trial. (Manual Ther. 2013(18):191-198)

Clinical Guidelines for Spinal Pain
Fourteen LBP guidelines since 2004 have recommended spinal manipulation for conservative management.
These recommendations recognize the most effective and robust indications of manipulation to lumbar spine
are for acute low back pain. Weaker evidence exists for manipulation in the sub-acute and chronic patient
population.
European: NICE Guidelines.

National Institute for Health and Care Excellence. Early management of persistent non-specific low back pain.
May 2009.
"Considering offering a course of manual therapy, including spinal manipulation, comprising up to a

maximum of nine sessions over a period of up to twelve weeks."
European: Guidelines for Acute Nonspecific Low Back Pain
European Guidelines for the management of acute nonspecific low back pain in primary care. (van Tulder et al. Euro Spine J.
2006;2:S169-91)
"Consider (referral for) spinal manipulation for patients who are failing to return to normal activities"
American: Family Physician Guidelines
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of
Physicians and the American Pain Society. (Chou et al. Annals of Internal Medicine. 2007;147(7):148-91)
Recommendation 7: For patients who do not improve with self-care options, clinicians should consider
the addition of non-pharmacologic therapy with proven benefits for acute low back pain, spinal
manipulation; for chronic or subacute low back pain, intensive acupuncture, massage therapy, spinal
manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation,
moderate-quality evidence)
Willem J, Assendelft W, Morton S, Yu E, Suttorp M, Shekelle P. Spinal manipulative therapy for low back pain.
A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138(11):871-881.
"Willem et al notes that all national guidelines on the management of low back pain include spinal
manipulation."

Clinical Guidelines for Spinal Pain
UK BEAM Trial
UK BEAM Trial (United Kingdom Back Pain Exercise and Manipulation) randomized trial: cost effectiveness of
physical treatments for back pain in primary care. Brit Med J. 2004:329-1381.
"Concluded that spinal manipulation over a 12 week period produced statistically significant benefits
relative to best care in General Practice at both 3 and 12 months. SMT is a cost effective addition to "best
care" for back pain in general practice. Manipulation alone probably gives better value for money than
manipulation followed by exercise."
Senna MK, Mechaly SA. 2011. Spine 36(18):1427-37.
"SMT is effective for the treatment of chronic non-specific LBP"

Manipulation Clinical Prediction Rules
Clinical Prediction Rules:
Clinical prediction rules are mathematical tools that are intended to guide clinicians in their everyday decision
making. (Adams et al BMJ 2012;344:d8312)
Haskins et al. Clinical prediction rules in the physiotherapy management of low back pain: A systematic review.
Man Ther. 2012 Feb:17(1):9-21.
"Current body of evidence does not enable confident direct clinical application of any of the CPRs"
Stanton et al. Critical appraisal of clinical prediction rules that aim to optimize treatment selection for
musculoskeletal conditions. Phys Ther. 2010;90(6):843-854.
"There is little evidence that CPRs can be used to predict effects of treatment for musculoskeletal
conditions". "Validation of these rules is imperative to allow clinical application"
May S et al. Prescriptive clinical prediction rules in back pain research: a systematic review. J Man Manip
There. 2009;17(1): 36-45.
"Most need further evaluation before they can be applied clinically...most did not pass the lowest level of
evidence hierarchy". "Manipulation CPRs evidence to date for its clinical utility is limited and
contradictory".
Beneciuk JM et al. Clinical prediction rules for physical therapy interventions: a systematic review. Phys Ther.
2009;89(2):114-124.
"10 included CPRs were poor to moderate quality but most lacked validation studies"



Manipulation & Mobilization Safety/Risk Analysis
Analyze the risk by considering the risk:benefit ratio.

Do the benefits must outweigh the risks?
Rule out all sinister disorders & exclude red flags.
Would you mobilize, but not manipulate?

Why, is mobilization safer?
Risk profile of mobilization remains unknown.
Manual therapy should be based on a prescription.

Prescription depends on clinical reasoning &
findings.
Absolute Contraindication:
Clinician would not use a thrust technique or mobilization.
Relative Contraindication:
Clinician may use a thrust technique or mobilization with caution and sound clinical reasoning.
Precaution:
Clinician may use a thrust technique or mobilization, but should screen for possible underlying
pathology that would place a patient in the relative or absolute contraindication category. The patient
may need a referral to physician depending on the findings of the clinical screen.


Clinical Decision Making (Clinical Reasoning):
1. Exclude Red Flags

2. Determine influence of Yellow Flags
3. Identify a mechanical diagnosis through a presence of a derangement & treatable lesion/joint
4. Risk: Benefit Ratio
5. Patient Preference
6. Decide upon your appropriate intervention

Lab: Combined Levers Mobilizations & High
Velocity Low Amplitude Thrust (HVLAT) Procedures
Cervical Mobilizations & HVLAT Procedures:

Cervical (C2-7) Combined Lever Rotary HVLAT & Non-Thrust (cradle hold)
Cervical (C2-7) Combined Lever Rotary HVLAT & Non-Thrust (chin hold)
Thoracic HVLAT Procedure:

Thoracic (T1-9) Combined Lever HVLAT
Lumbar Mobilizations & HVLAT Procedures:

Lumbar (L2-S1) Combined Lever Thrust & Non-Thrust
Lumbar (L2-S1) Combined Lever Thrust & Non-Thrust

Cervical (C2-C7) Combined Lever HVLAT:
Rotatory Thrust using a Cradle Hold
HVLAT Technique: -Flexion of the cervical spine (lifting the patients head
off of the pillow) can assist as a secondary lever in
Cervical (C2-7) Combined Lever Thrust treatment of lower cervical segment
Rotatory thrust using a cradle hold Clinician Positioning:
Levers: Rotation/Side-shift/SB/local
compression/extension or flexion.
Type of Technique:
-Sliding technique using minimal combined levers.
-NOT a ligamentous locking technique.
-NOT a gapping technique.
-Momentum during the application of the HVLAT.
-Levers are combined to focus forces on the segment of
interest without over utilizing any one lever during the
thrust.
-All levers are applied within the normal anatomical
range of motion (not at end range).
Target of HVLAT:
Sliding force applied to the facet on concave side of
cervical spine (short lever hand). -Treatment table elevated in order for the apex of the
patients head to be at the height of the clinicians belt
buckle.
-Diagonal (fencer's) stance at the head of the treatment
Patient Positioning: table.
-LE on short lever side: placed more posteriorly,
hip in slight internal rotation, heel slightly off
the floor, knee slightly flexed, and pelvis open in
direction of thrust.
-LE on long lever side: hip slightly flexed with
neutral rotation, slight knee flexion, and foot
flat on ground.
-Upright spinal posture and avoid excessive
cervical flexion.
-Elbows stay adducted along clinicians trunk and 70-90
degrees of flexion.
-Wrist maintained in a neutral position in regards to
flex/ext & rad/ulnar deviation.
Clinician Contact (hand placement):

-Supine lying with cervical spine in neutral with head
lying on a pillow.

process). First digit of the short lever hand rests
along the mandible of the patient.
-Non-thrusting hand (long lever)
-Marked offset from the short lever hand
and entire hand rests over the
posterolateral occiput above the ear with
firm yet gentle pressure in order to assist
manufacturing the barrier and application
of the HVLAT.
Manufacturing a Barrier for HVLAT:
Initial hand contact should be smooth & gentle yet firm Primary lever:
in order to gain patient confidence. -Rotation away side short lever side.
The degree of supination & pronation of the short lever -Start with 30-45 of pre-rotation.
wrist/forearm & long lever wrist/forearm will be
inversely related (i.e. as the short lever wrist pronates -Rotation will be the primary lever
as the long lever wrist supinates). utilized during HVLAT once all other
-The long & short lever hands work in concert combined levers have been used to
together or as mirror images of each other manufacture a barrier.
during the thrust. Secondary Lever(s):
-This technique does NOT use a stable hand and -Side-shift away from short lever side
movement hand as described in some
mobilization techniques. -achieved by the clinician moving his
trunk and using his lower extremities.
Side-shift is not produced by clinicians
upper extremities alone.
-Side-bend towards short lever side
-achieved by the clinician pivoting or
using lower extremities to move the
patients cervical spine. Side-bend is
not produced by the clinicians upper
extremities alone.
-Side bend should produce a fulcrum
effect over the 2nd digit of the clinicians
short lever hand in order to focus forces
on the segment of interest.
Tertiary Lever(s):
-P/A Extension and abduction of 2nd digit at
local segment
-Thrusting hand (short lever or applicator)
-Compression (local and global)
-Entire hand contacts patients cervical spine, but
focus pressure of hand contact to the radial -Traction
aspect of proximal phalanx of the 2nd digit on
target segment. -Flexion / Extension of cervical spine
-The target segment should be contacted along
the posterolateral articular pillar (not transverse

-Lower mandible (C4-7)
Clinical Tidbits:
-Your short lever hand should have full control of the skull
-A common mistake is not providing enough side-shifting, this

lever can be powerful.
-Keep your short lever hand posterior-laterally over articular

pillar vs more anteriorly as this is on the transverse processes,
which is more painful and less "contact" with the vertebrae.
-Remember the primary lever during the thrust is into

rotation, but you can also glide downwardly into the pillow.
Introduce the primary lever and add

secondary/tertiary levers to help amplify and focus
the primary lever. The order in which secondary &
tertiary levers are applied is not predetermined.
Patient presentation may change which levers are
applied, how much of each lever is utilized, and the
order of which lever is applied.
Combining multiple levers to find a barrier is the
primary purpose without over utilizing any one
lever during the HVLAT.
Manufacture a barrier and determine if it is crisp
and firm (not at end range). This should take
continuous reassessment or testing of all
combined levers simultaneously using mini-thrusts
in order to fine tune the barrier prior to the
application of the HVLAT.
The apex of the patients head should be in midline
when all combined levers have been applied to
produce a barrier prior to applying a thrust.
Application of HVLAT:
At the 'moment of truth' prior to the application of
the HVLAT, use slight compression of 2nd digit to
focus force, perform a slight de-rotation without
losing all combined levers.
Apply a short, sharp thrust (HVLAT) in the direction
of the primary lever without losing the secondary
levers.
The arc of rotation (the primary lever) is towards
the:
- Zygoma (C2-3)
- Angle of jaw (C3-4)
Rotatory Thrust using a Chin Hold
HVLAT Technique: -Supine lying with cervical spine in neutral with head
lying on a pillow.
C2-7 Combined Lever Thrust
-Flexion of the cervical spine (lifting the patients head
Rotatory thrust using a chin hold off of the pillow) can assist as a secondary lever in
treatment of lower cervical segment
Levers: Rotation/Side-shift/SB/local
compression/extension or flexion
Type of Technique: Clinician Positioning:

-Sliding technique using minimal combined levers to create a
barrier.
interest without over utilizing any one lever.
-All levers are applied within the normal anatomical range of
motion (not at end range).
Target of HVLAT:
Sliding force applied to the facet on concave side of cervical
spine (short lever hand).
-Treatment table elevated in order for the apex of the
Patient Positioning: patients head to be approximately the height of the
clinicians hip.
-Clinician stands slightly offset (towards the corner of
the plinth) of the patient in order to align the clinicians
axilla of the short lever side with the midline of the
patients head.
-Diagonal (fencer's) stance at the head of the treatment
table.
the floor, hip is flexed ~30-40, knee flexed
~30-40, and pelvis open in direction of thrust.
neutral rotation, slight knee flexion, and foot
flat on ground.
cervical flexion.
-Note that although the clinician has assumed a
flexed hip posture, the clinician is not flexed at
the spine.
Clinician Contact (hand placement):

Spinal Manipulation & Mobilization eBook Page 70
Initial hand contact should be smooth & gentle yet firm Proper contact as described above should allow
in order to gain patient confidence. the clinician to control the patients head and
cervical spine.
-The long & short lever hands/forearms work in
concert together or as mirror images of each
other during the thrust.
-This technique does NOT use a stable hand and
movement hand as described in some
mobilization techniques.
-Thrusting hand (short lever or applicator)

-Entire hand contacts patients cervical spine, but
focus pressure of hand contact to the radial
aspect of proximal phalanx of the 2nd digit on
target segment.
-The target segment should be contacted along
the posterolateral articular pillar (not transverse
process).
-First digit of the short lever hand rests along the
-Non-thrusting hand (long lever or chin hold hand) mandible of the patient.
-Place the long levers forearm close the pillow -The clinicians short lever wrist should be in 90
next to the patients head. Gently rotate the of extension, elbow ~90 flexion & shoulder will
patients cervical spine ~45 towards the long be slightly flexed/abducted.
lever in order to allow the side of the patients
zygoma to rest on the clinicians forearm.
-The long lever hand should be able to reach Manufacturing a Barrier for HVLAT:
the side of the patients mandible and chin. The
hand contact for the long lever is applied
through the palmer surface of the 4th & 5th digit
onto the patients chin. Primary lever:
-Note that the hand should not -Rotation away side short lever side.
interfere with the patients ability to
breathe or cause the patient to feel -Start with 30-45 of pre-rotation.
claustrophobic.
-Rotation will be the primary lever
-The clinician flexes at the hip in order for the utilized during HVLAT once all other
anterior arm to contact the apex of the combined levers have been used to
patients head. manufacture a barrier.
-Three Points of Contact for the chin hold: Secondary Lever(s):
1. The 4th & 5th digits contact the -Side-shift away from short lever side
patients chin
-Side-shift is achieved by movement of
2. The forearm contacts the patients the clinician trunk & lower extremities.
zygoma Side-shift is not only produced by
clinicians upper extremities.
3. The clinicians anterior arm contacts
the patients apex of the head. -Side-bend towards short lever side
-Achieved by the clinician pivoting or combined levers simultaneously using mini-thrusts

using lower extremities to move the in order to fine tune the barrier prior to the
patients cervical spine. Side-bend is application of the HVLAT.
not only produced by the clinicians
upper extremities. The apex of the patients head should be in midline
when all combined levers have been applied to
-Side bend should producenda fulcrum produce a barrier prior to applying a thrust.
effect over the clinicians 2 digit on
the short lever hand in order to focus Application of HVLAT:
forces on the segment of interest.
At the 'moment of truth' prior to the application of
Tertiary Lever(s): the HVLAT, use slight compression of 2nd digit to
focus force, perform a slight de-rotation without
-P/A Extension and abduction of 2nd digit at losing all combined levers.
local segment
The HVLAT using a chin hold comes from a
-Compression (local and global) combination of:
-Traction -Short lever hand pronation thrust into rotation
-Flexion / Extension of cervical spine. w/o losing combined levers
-Supination of the long lever hand without
losing combined levers.
-Adduction of the long lever shoulder towards
the trunk.
Flapping a chicken wing
of the primary lever without losing the secondary
and tertiary levers.
The arc of rotation (the primary lever) is towards
the:
- Zygoma (C2-3)
- Angle of jaw (C3-4)
-Lower mandible (C4-7)
Clinical Tidbits:
Introduce the primary lever and add -Your thrusting hand should have full control of the skull
secondary/tertiary levers to help amplify and focus
the primary lever.
-A common mistake is not providing enough side-shifting, this
The order in which secondary & tertiary levers are lever can be powerful.
applied is not predetermined.
Patient presentation may change which levers are -Keep your short lever hand posterior-laterally over articular
applied, how much of each lever is utilized, and the pillar vs more anteriorly as this is on the transverse processes,
order of which lever is applied. which is more painful and less "contact" with the vertebrae.
Combining multiple levers to find a barrier is the
primary purpose without over utilizing any one
lever during the HVLAT. -Remember the primary lever to manipulate is rotation, but
you can also glide downwardly into the pillow.
Manufacture a barrier and determine if it is crisp
continuous reassessment or testing of all
Lumbar (L2-S1) Combined Lever HVLAT:
Extension/Rotation with Mammillary Process P/A thrust & Body Drop
HVLAT Technique: Patients pelvis should be 6-10 inches from the edge of
the plinth. Pelvis should be perpendicular to plinth at
Lumbar (L2-S1) Combined Lever Thrust this point in the patient positioning.
-Extension/Rotation with Body Drop &

Mammillary Process P/A Thrust
Type of Technique:
Sliding technique using combined levers.
interest without over utilizing any one lever. Lower leg: hip in slight flexion, knee extended, ankle in
neutral position. Lateral malleolus should be resting at
-All levers are applied within the normal anatomical the edge of the plinth.
Upper leg: hip and knee flexed in order to allow the
ankle/foot to contact & hook the lower leg at the
Target of HVLAT: popliteal space.
Sliding force applied to the facet on up-side of lumbar
spine (short lever hand). Lumbar spine initially placed in a neutral position or
slight extension.
Patient Positioning: The clinician gently grasps the patients humerus that is
lying on the plinth with one hand and places the
opposite hand on the scapula. The clinician pulls the
humerus and pushes the scapula into protraction in
order to produce thoracic and lumbar rotation.
-Spinal rotation during patient position is not

meant to lock the spine or achieve end range
rotation.
-This position should feel comfortable to the

The purpose of this initial patient position is provide a patient and feel quite stable (i.e. patient does
stable patient position in order to combine different not feel like he/she will roll and fall off the
levers in order to manufacture a barrier for the plinth).
application of a HVLAT.
Patient is placed in a lateral recumbent position (facet Patient Positioning: Upper Extremities:
of interest on the upside). Pillow(s) as needed in order
to maintain a neutral cervical spine. Three commonly used UE positions:

UE positioning depends on patient comfort,

clinician comfort, positioning needed to create
a barrier, clinician or patient size & other Manufacturing a Barrier for HVLAT:
variables.
Introduce the primary lever and add secondary/tertiary
UE Position #1: levers to help amplify and focus the primary lever.
Underside shoulder flexed to 90/elbow flexed 90. The order in which secondary & tertiary levers are
applied is not predetermined.
Opposite shoulder in neutral/elbow flexed 60-100
Patient presentation may change which levers are
applied, how much of each lever is utilized, and the
order of which lever is applied.
Combining multiple levers available to create a barrier is
the primary purpose without over utilizing any one
lever during the HVLAT.
-4 lumbar spine positions
-3 UE positions
UE Position #2: -3 Downside LE positions
-5 Upside LE positions
Patient places each hand on opposite shoulder which
allows elbows to be stacked on top of each other or Manufacture a barrier and determine if it is crisp
forms a V shape. continuous reassessment or testing of all
combined levers simultaneously using mini-thrusts
in order to fine tune the barrier prior to the
application of the HVLAT.
Primary lever:
Lumbar Rotation:
If pelvis is angled towards the floor at a ~45
angle then most of the clinicians body drop
using a long lever will produce a rotation force.
UE Position #3:
Short lever P/A thrust at the mammillary
process will produce a rotation force.
Patient stacks hand on top of each other along the
costochondral junction of ribs 7-10 on the upside of the
thorax. Secondary/Tertiary Levers:

Lumbar spine: Four Positions

1. Neutral Lumbar spine
2. Extension of Lumbar Spine Downside Lower Extremity: Three Positions

1. Downside LE in Neutral (ankle at edge
of plinth)
3. Flexion of Lumbar Spine
2. Downside LE placed in Extension
4. Side-Bend of Lumbar Spine
3. Downside LE placed in Flexion

Upside Lower Extremity: Five Positions
1. Upside LE in Neutral with Body Drop

Hip flexed/knee flexed/hip 3. Upside LE off edge of plinth
adducted/foot hooked onto lower leg
popliteal fossa Hip Adduction/Knee extension/hip
flexion ~30-40 (LE off the edge of
Allows for the use of a long lever (body plinth in a position similar to a sciatic
drop with thigh to thigh contact) for the nerve tensioning position).
primary lever of rotation
Produces side bending towards the
plinth side facet.
Minimal use of long lever in this
position for HVLAT
2. Upside LE in FADIR position

Hip Adduction/Hip flexion/Hip IR/Knee
flexion (LS side-bending towards upside
facet)
Produces side bending towards upside
facet 4. Upside LE between clinicians LEs
Loss of long lever for HVLAT Hip flexion/hip adduction/knee flexion.
Upside LE secured between legs of
clinician and the clinician uses his/her

thighs to apply femoral compression to
the patients LE.
Produces lumbar flexion
Useful for patients with excessive
lordosis
Loss of long lever for HVLAT
Treatment table elevated in order for the edge of the

plinth to be at the height of the clinicians knee.
The clinician assumes a diagonal (fencer's) stance on the
side of plinth with the patient facing the clinician.
Clinician should be facing the head of the table.
neutral rotation, slight knee flexion, foot flat on
5. Upside LE in sciatic nerve tension ground and parallel to treatment plinth.
position between clinicians LEs
Produces lumbar flexion and side-bend cervical flexion.
towards upside facet
The clinician will place their non-thrusting hand one of
Useful in patients with excessive the following areas depending on the patients UE
lordosis and hypermobility to create a placement:
barrier for HVLAT
-Anterior deltoid of the patients upside
Loss of long lever for HVLAT shoulder (UE placement #1)
-Patients hand which is resting on their upside
shoulder (UE placement #2)
-Patients hands which are stacked on their
upside costochondral junction (UE placement
#3).
The clinician places the thrusting hand (short lever)
onto the patients lumbar spine:
Clinician Positioning & Contact:

HVLAT Application:
Gently roll patient towards the edge of the
plinth. At the 'moment of truth' prior to the application of
Note the patient is rolled under the the HVLAT, perform a slight de-rotation without
clinician. The clinician is NOT losing all combined levers.
attempting to excessively lean over the The HVLAT using a short and long lever comes from
patient. a combination of:
The patients pelvis should be at a ~45 angle -Use of non-thrust hand to control patients
towards the floor. trunk.
The clinician places their rear thigh onto the -Short lever hand thrust using hypothenar
patient upside thigh. eminence contact on mammillary process
Note that the clinicians vastus lateralis towards the plinth.
muscle should be in contact with the -However, this thrusting angle may vary
patients vastus lateralis. from patient to patient due to patient
The patients ASIS & the clinicians ASIS should facet joint morphology or barrier
be in close proximity as well. produced by the combined levers. The
thrust is a rotation force into the
The clinician places the short lever hand (thrusting manufactured barrier and not a
hand) just lateral to the spinous process of the segment predetermined direction.
of interest. The clinician is attempting to contact the
mammillary process of the superior articular process. -Long lever: body drop with rear LE using a
contact of clinician/patient consisting of thigh
-Short lever contact is the hypothenar to thigh & ASIS to ASIS contact.
eminence (not just the pisiform)
-Front foot is facing head of the bed & is
-Short lever hand is parallel to the spine. flexed.
-Rear foot is off the ground or heel is off
the ground.
-Body drop is performed by collapsing
the front leg and dropping onto the rear
foot. This will produce a rotation force
if the pelvis is angled at ~45 towards
the floor.
The knee on the front leg should not
contact the table during the body drop
if the foot is placed facing the head of
the bed.

Apply a short, sharp thrust (HVLAT) in the direction of

the primary lever without losing control of the patients
trunk (non-thrust hand) & without losing the
secondary/tertiary levers.
Approximately 60% of HVLAT force is produced by the
short lever & 40% is produced by the long lever.
The long lever thrust (body drop) must be performed a
fraction of second prior to the short lever thrust in
order to ensure that the forces culminate at the same
time at the segment of interest.
Clinical Tidbits:
At the moment of HVLAT, ensure that the clinicians
trunk is erect and flexed over the patient.
Oscillation of the patients thoracic and lumbar spine
will help to fine tune the combined levers in order to
find a crisp barrier.
This is a momentum technique and not an end range
technique. Some de-rotation has to occur just prior to
the application of the HVLAT.
The force applied through the use of a body drop must
be applied a fraction of a second prior to the application
of the short lever thrust. This may take some practice in
order to master this motor skill. This ensures that the
short & long lever forces culminate at the segment of
interest at the same moment.

Extension/Rotation with Forearm Pull on Sacrum/Pelvis & Body Drop
HVLAT Technique: Patients pelvis should be 6-10 inches from the edge of
the plinth. Pelvis should be perpendicular to plinth at
Lumbar (L2-S1) Combined Lever Thrust this point in the patient positioning.
-Extension/Rotation with forearm pull on

sacrum/pelvis & body drop
Type of Technique:
-Sliding technique using minimal combined levers to
create a barrier.
Lower leg: hip in slight flexion, knee extended, ankle in
-Levers are combined to focus forces on the segment of neutral position. Lateral malleolus should be resting at
the edge of the plinth.
-All levers are applied within the normal anatomical
range of motion (not at end range). Upper leg: hip and knee flexed in order to allow the
Target of HVLAT: ankle/foot to contact & hook the lower leg at the
popliteal space.
Sliding force applied to the facet on up-side of lumbar
spine (short lever hand).
Lumbar spine initially placed in a neutral position or
Patient Positioning: slight extension.
The clinician gently grasps the patients humerus that is

lying on the plinth with one hand and places the
opposite hand on the scapula. The clinician pulls the
humerus and pushes the scapula into protraction in
order to produce thoracic and lumbar rotation.
-Spinal rotation during patient position is not

meant to lock the spine or achieve end range
rotation.
The purpose of this initial patient position is provide a
stable patient position in order to combine different -This position should feel comfortable to the
levers in order to manufacture a barrier for the patient and feel quite stable (i.e. patient does
application of a HVLAT. not feel like he/she will roll and fall off the
plinth).
Patient is placed in a lateral recumbent position (facet
of interest on the upside). Pillow(s) as needed in order
to maintain a neutral cervical spine. Primary lever:
Lumbar Rotation:
If pelvis is angled towards the floor at a ~45
angle then most of the clinicians body drop

using the short lever and body drop will -Forearm is pronated to allow anterior forearm
produce a rotation force. to contact ribs & allow for the clinicians hand
to apply local compression to the segment of
interest.
-GH joint is slightly flexed & positioned in IR.
The clinician places the thrusting UE (short lever) or
forearm onto the patients ilium (ala of the ilium on
gluteal side)/sacrum:
-Forearm is slightly pronated in order for
contact to occur along the ulnar & anterior
aspect of the forearm.
-Care is taken to avoid compression onto the
sciatic nerve.
Short lever (forearm contact along -Short lever hand can be used to provide
ilium/sacrum) P/A thrust will produce a rotation compression to segment of interest.
force.
-GH joint and arm are maintained in a neutral
Secondary/Tertiary Levers: position.
-Side bending of lumbar/thoracic spine -Elbow is flexed ~70-90
-Compression using clinicians body weight
-Local compression using short &/or long lever UE
-Body drop

Treatment table elevated in order for the patients
upside ASIS to level with the clinicians short lever side
ASIS when the pelvis is rolled towards the edge of the
plinth.
-LE on long lever side: hip slightly flexed with Gently roll patient towards the edge of the
neutral rotation, slight knee flexion, foot flat on plinth.
ground and parallel to treatment plinth.
Note the patient is rolled under the
-Upright spinal posture and avoid excessive clinician. The clinician is NOT
cervical flexion. attempting to excessively lean over the
patient.
Long Lever UE:
The patients pelvis should be at a ~45 angle
-Slides between the patients humerus and ribs. towards the floor.
-Distal ulnar aspect forearm contacts patients The clinician places their rear thigh onto the
anterior shoulder & axilla. patient upside thigh.
The patients ASIS & the clinicians ASIS should forces culminate at the same time at the
be in close proximity or touching. segment of interest.
HVLAT Application:
At the 'moment of truth' prior to the application of Clinical Tidbits:
the HVLAT, perform a slight de-rotation without
losing all combined levers. Several mini-thrusts Compression of patient using the clinicians body weight
prior to HVLAT will help to adjust all combined is a powerful component to this technique. This cannot
levers to produce a crisp barrier. occur it the clinicians and patients ASIS are not
touching or very close proximity to each other.
The HVLAT using a short and long lever comes from
a combination of: Ensure that short lever elbow remains close to the
operators trunk at the time of HVLAT.
-Use of more superior UE to control patients
trunk, provides compression/traction & side At the moment of HVLAT, ensure that the clinicians
bending. trunk is erect and flexed over the patient.
-Short lever UE thrust using forearm contact on Oscillation of the patients thoracic and lumbar spine
the sacrum/ilium towards the plinth. will help to fine tune the combined levers in order to
-However, this thrusting angle may vary
from patient to patient due to patient This is a momentum technique and not an end range
facet joint morphology or barrier technique. Some de-rotation has to occur just prior to
produced by the combined levers. The the application of the HVLAT.
thrust is a rotation force into the
manufactured barrier and not a
predetermined direction.
-Long lever: body drop with rear LE using a
contact of clinician/patient consisting of ASIS to
ASIS contact and UE contacting thoracic
region/shoulder.
-Front foot is facing head of the bed & is
flexed.
-Rear foot is off the ground or heel is off
the ground.
-Body drop is performed by collapsing
the front leg and dropping onto the rear
foot. This will produce a rotation force
if the pelvis is angled at ~45 towards
the floor.
contact the table during the body drop
if the foot is placed facing the head of
the bed.
of the primary lever without losing control of the
patients trunk (non-thrust hand) & without losing
the secondary/tertiary levers.
-Approximately 60% of HVLAT force is produced
by the short lever & 40% is produced by the
long lever.
-The long lever thrust (body drop) must be
performed a fraction of second prior to the
short lever thrust in order to ensure that the
Thoracic (T1-9) Combined Lever HVLAT:
Supine Mid Thoracic A/P thrust with Body Drop
HVLAT Technique: Patient is placed in a supine position. Pillow(s) as

needed in order to maintain a neutral cervical spine.
Thoracic Combined Lever Thrust
Patients trunk should be 6-10 inches from the edge of
-Mid Thoracic traction/ extension using an A/P the plinth. The clinician performs handling & technique
thrust with body drop on this side of the plinth.
Type of Technique:
Sliding technique. Minimal combined levers.
NOT a ligamentous locking technique.
NOT a gapping technique.
Momentum used prior to the application of the HVLAT.
Levers are combined to focus forces on the segment of
All levers are applied within the normal anatomical
Patient flexes his/her knee 45 & hip 45 on the
opposite side from the clinician. The lower extremity
Target of HVLAT: closer to the clinician can remain in a neutral and
comfortable position for the patient.
Sliding force applied to bilateral thoracic facets
Lumbar spine initially placed in a neutral position.
Patient Positioning: Patient places each hand on opposite shoulder which

allows elbows to be stacked on top of each other or
forms a V shape. The patients elbow that is opposite
of the clinician must be placed more superiorly.
Placement of a rolled towel between the patients chest
and UEs (hugging the rolled towel) may be necessary in
order to avoid forces from the clinicians thrust being
delivered into the glenohumeral joints via horizontal
adduction.
Primary lever:
Thoracic traction & extension (A/P force):
Secondary Levers:
The purpose of this initial patient position is provide a -Side bending of thoracic spine
stable patient position in order to combine different -Compression using clinicians body weight
levers in order to manufacture a barrier for the
application of a HVLAT. -Side shift (through lateral compression by bringing
patients elbows towards the clinician)
-Flexion (pulling patients elbows down in order to focus The clinician reaches over the patient and uses his/her
forces of the clinicians short lever hand) short lever forearm to contact the patients opposite
thorax & flank region (broad area of contact increases
-Local compression into treatment plinth patient comfort & confidence). The patient is gently
rolled towards the clinician in order to allow the
-Body drop clinician to place his/her short lever hand at the level of
interest. The opposite hand may help roll the patient by
contacting both olecranon processes (elbows are in a
stacked position).
Tertiary Levers:
Short Lever UE:
Short lever hand:
Several hand positions are available to the clinician.
-Side-bend through radial deviation The hand position used by the practitioner will depend
-Rotation by pronation upon patient morphology, comfort of the clinician,
comfort of the patient and contact needed to
-Caudal traction (by pulling down) manufacture a proper barrier for a HVLAT.
-P/A extension of wrist (at target segment)

-Open hand contact:

Treatment table elevated in order for the plinth to be
level with the clinicians mid-thigh.
hip in slight internal rotation, heel slightly off -Wrist & fingers are parallel with
the floor, knee slightly flexed, and pelvis open in patients spine. The patients spinous
direction of thrust. process lies between the clinicians
-LE on long lever side: hip slightly flexed with pisiform & tuberosity of the scaphoid.
neutral rotation, slight knee flexion, foot flat on
ground and parallel to treatment plinth.
-Closed fist contact:
cervical flexion.
-Wrist is placed in ulnar deviation with hand in a

fist position (2-5 MCP, PIP, DIP joints placed in
90 of flexion & 1st digit adducted). The
patients spinous processes should contact or lie
between the hypothenar eminence/2-5 DIP
joints & the thenar eminence. The patients
spinous process should contact the clinicians
proximal phalanx of the thumb.
-Partially closed fist contact:

region on the patients stacked elbows. The

non-thrust hand is utilized to keep the elbows in
place as a secondary lever.
Clinician maintains an upright spinal
posture and avoids excessively flexing
cervical spine.
Care must be taken that the patients
elbows do not contact the clinicians
xiphoid process or sternum during the
thrust. This could cause injury to the
-Wrist is placed in ulnar deviation with hand in a clinician.
fist position (2-5 MCP joints placed in 0
extension. st2-5 PIP & DIP joints placed in 90 of
flexion & 1 digit adducted). The patients
spinous processes should contact or lie HVLAT Application:
between the hypothenar eminence/2-5 DIP
joints & the thenar eminence. The patients At the 'moment of truth' prior to the application of
spinous process should contact the clinicians the HVLAT, perform a slight de-compression of the
proximal phalanx of the thumb. thoracic spine without losing all combined levers.
Several mini-thrusts prior to HVLAT will help to
-Pistol grip contact: adjust all combined levers to produce a crisp
barrier.
-Wrist is placedndin ulnar deviation with hand in a

fist position (2 digit MCP, PIP & DIP joints
placed in 0 of extension. 3-5 MCP joints placed
in 90 of flexion, 3-5 PIP & DIP joints placed in
90 of flexion & 1st digit abducted). The
patients spinous processes should contact or lie The HVLAT using a short and long lever comes from
between the hypothenar eminence/2-5 DIP a combination of:
joints & the thenar eminence.
-Long lever: body drop
Once the segment of interest is located and the hand
contact is selected the patient is rolled back into a -Front foot is facing head of the bed & is
supine position. As the clinician rolls the patient onto flexed.
the short lever hand the clinician pulls his/her short -Rear foot is off the ground or heel is off
lever inferiorly towards the patients sacrum. This will the ground.
provide slight extension & traction of the thoracic spine
and decrease the normal amount of thoracic kyphosis. -Body drop is performed by collapsing
The patients thorax and flank region should lie on the the front leg and dropping onto the rear
clinicians forearm when rolled back onto the table in a foot.
supine position.
Long Lever (Clinicians upper abdominal region & UE): contact the table during the body drop
-The clinician pulls down on the patients if the foot is placed facing the head of
stacked elbows in order to focus tension the bed.
under the short lever hand. Once this has -Short Lever Hand:
focusing of pressure has been accomplished,
the clinician places his/her upper abdominal
If needed, the short lever hand may

provide tertiary levers during the HVALT
that include:
-Wrist extension
-Wrist pronation
-Wrist ulnar or radial deviation
of the primary lever without losing control of the
patients trunk (non-thrust hand) & without losing
the secondary/tertiary levers.
The angle of the primary thrust should be directed
at the target segment at a 60 angle in the plane of
the thoracic facets.
However, this thrusting angle may vary from
patient to patient due to patient facet joint
morphology or barrier produced by the combined
levers. The thrust is a traction/extension force into
the manufactured barrier and not a predetermined
direction.
Clinical Tidbits:
Compression of patient using the clinicians body weight
is a powerful component to this technique. This cannot
occur it the clinicians and patients ASIS are not
touching or very close proximity to each other.
Ensure that short lever elbow remains close to the
operators trunk at the time of HVLAT.
At the moment of HVLAT, ensure that the clinicians
trunk is erect and flexed over the patient.
Oscillation of the patients thoracic and lumbar spine
will help to fine tune the combined levers in order to
This is a momentum technique and not an end range
technique. Some de-rotation has to occur just prior to
the application of the HVLAT.

References
APTA Position Statement on Thrust Joint Manipulation Provided by Physical
Therapists
1. Guide to Physical Therapist Practice. Revised 2nd ed. Alexandria, Va: American Physical Therapy Association; 2003.
2. APTA Manipulation Education Manual for Physical Therapist Professional Degree Programs. Alexandria, Va: American Physical Therapy
Association; 2004.
3. American Physical Therapy Association. Procedural Interventions Exclusively Performed by Physical Therapists (HOD P06-00-30-36).
American Physical Therapy Association; 2000. Available at
http://www.apta.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=25681. Accessed on
January 23, 2009.
4. Paris SV. A History of Manipulative Therapy. JMMT. 2000;8(2):66-77.
5. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal
manipulation: a validation study. Ann Intern Med. 2004;141:920-8.
6. Johnson D, Rogers M. Spinal manipulation [letter]. Phys Ther. 2000;80(8):820-823.
7. Huijbregts P.Chiropractic legal challenges to the physical therapy scope of practice: anybody else taking the ethical high ground?
[editorial].
8. JMMT. 2007;15(2):6980.
9. Paris, SV, APTA Orthopaedic Section Bulletin, 1974, p. 7,
10. Institute of Alternative Futures. The Future of Chiropractic Revisited, 2005-2015. Alexandria, Va: Institute of Alternative Futures; January
2005. Available at http://www.altfutures.com/docs/FutureofChiropracticRevisited.pdf Accessed on January 23, 2009.
11. Paris SV, Loubert PV. Foundations of Clinical Orthopaedics. St. Augustine, Fl: Institute Press; 1990.
12. Hood W. On the so-called bone-setting. Its nature and results. Lancet. 1871:1:336-4, 441-3.
13. Healing the Generations: A History of Physical Therapy and the American Physical Therapy Association. Alexandria, Va: American Physical
Therapy Association; 1995:70-72.
14. Paris SV. 2006 37th Mary McMillan Lecture: In the best interest of the patient. Phys Ther. 86(11):1541-1553.
15. McMillan M. Change of name [editorial]. P. T. Review. 1925b;5(4):3-4.
16. McMillan M. Massage and Therapeutic Practice. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1925.
17. Kaltenborn FM. The Spine Basic Evaluation and Mobilization Techniques. Oslo, Norway: Olaf Norlis Bokhandel; 1964.
18. Maitland GD. Vertebral Manipulation. London: Butterworth; 1964.
19. American Physical Therapy Association. A Normative Model of Physical Therapist Professional Education: Version 2004. Alexandria, Va:
American Physical Therapy Association, 2004.
20. Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Educational Programs for the
Preparation of Physical Therapists. Alexandria, Va: Commission on Accreditation in Physical Therapy Education; 2007.
21. American Physical Therapy Association. Minimum Required Skills of Physical Therapist Graduates at Entry-level (BOD G11-05-20-49).
American Physical Therapy Association; 2005. Available at
http://www.apta.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=53569. Accessed on
January 26, 2009.
22. Boissonnault W, Bryan JM, Fox K. Manipulation curricula in physical therapist professional degree programs. J Orthop Sports Phys Ther.
23. 2004:34(4):171-181.
24. Bryan JM, McClune LD, Romito S, Stetts DM, Finstuen K. Spinal mobilization curricula in professional physical therapy education
programs. J Phys Ther Edu. 2007;11(2):11-15.
25. Jull G, Trott P, Potter H, et al. A randomized controlled trial of physiotherapy management for cervicogenic headache. Spine. 2002;27:
1835- 1843.
26. Flynn TW, Fritz JM, Wainner RS. Spinal manipulation in physical therapist professional degree education: a model for Tteaching and
integration into clinical practice. JOSPT. 2006;36(8):577-587.
27. Hurwitz EL, Morgenstern H, Vassilaki M, Lu-May C. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA
neck pain study. Spine. 2005;30(13): 1477-1484.
28. Rivett DA. The vertebral artery and vertebrobasilar insufficiency. In: Bouling JD, Jull GA. Greives Modern Manual Therapy, The Vertebral
Column. Third ed. London: Elsevier Churchill Livingstone, 2004:257-273.
29. Magarey ME, Rebbeck T, Coughlan B, Grimmer K, Rivett DA, Refshauge K. Pre-manipulative testing of the cervical spine review, revision
and new clinical guidelines. Manual Therapy. 2004;9:95-108.
30. DiFabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999;79(1):50-65.
31. Rivett DA, Milburn P. A prospective study of complications of cervical spine manipulation. J Manual Manipulative Ther. 1996;4:166-170.
32. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after
cervical trauma and spinal manipulation. Spine. 1999;24: 785-94.
33. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: a systematic review of the
literature. Spine. 1996;21:1746-1760.
34. Bronfort G, Haas M, Evans R L, Bouter LM. (2004). Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a
systematic review and best evidence synthesis. Spine J, 4(3), 335-356.
References
35. Danish Institute for Health Technology Assessment. Low Back Pain: Frequency, Management and Prevention from a Health Technology
Perspective. Copenhagen, Denmark: National Board of Health; 2000.
36. http://www.gacguidelines.ca
37. Haldeman S, Rubinstein SM. Cauda Equina Syndrome in patients undergoing manipulation of the lumbar spine. Spine. 1992;17(12):1469-
1473.
38. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract.
1996;42(5):475-480.
39. Shekelle P G, Adams AH, Chassin M R, Hurwitz E L, Brook RH. Spinal manipulation for low-back pain. [see comments]. Ann Internal Med.
117(7): 590-8, 1992.
40. Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to identify patients with low back pain most likely to respond to spinal
manipulation: a validation study. Ann Internal Med. 2004;141(12): 922-928.
41. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. Development of a clinical prediction rule for guiding treatment of a subgroup of
patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther. 2007;87(1):9-23.
42. Tseng YL, Wang WTF, Chen WY, Hou Tj, Chen TC, Lieu FK. Predictors for the immediate responders to cervical manipulation in patients
with neck pain. Manual Ther. 2006;11:306-315.
43. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. Second ed.
Edinburgh: Churchill Livingstone, 2000.
44. Hutchinson A, Waddell G, Feder G, et al. Clinical Guidelines for the Management of Acute Low Back Pain. London: Royal College of
General Practitioners, 1996 (updates 1999, 2001).
45. 42 Accident Compensation Corporation. New Zealand Acute Low Back Pain Guide. Wellington, NZ: Accident Compensation Corporation,
2004. Available at http://www.nzgg.org.nz/guidelines/0072/acc1038_col.pdf. Accessed on January 26, 2009.
46. Department of Defense /VA Low Back Pain Guidelines. Falls Church, Va: Department of Defense, 1999. Available at
www.cs.amedd.army.mil
47. Bigos S, Bowyer O, Braen G. Acute low back problems in adults. Clinical Practice
48. Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US
Department of Health and Human Services, 1994.
49. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term
improvement with spinal manipulation. Spine. 2002;27:2835-2843.
50. Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in
individuals with low back pain. Arch Phys Med Rehabil. 2003;84:1057-1060.
51. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term
improvement with spinal manipulation. Spine. 2002;27:2835-43
52. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/subacute nonspecific
low back pain. Results of a randomized clinical trial. Spine. 31(6):623-631.
53. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. A Cochrane review of manipulation and mobilization for mechanical
neck disorders. Spine. 2004;29(14):1541-1548.
54. Jull G, Trott P, Potter H, Zito G, Niere K, Emberson J, Marschner I, Richardson C. A randomized controlled trial of physiotherapy
management for cervicogenic headache. Spine. 2002;27:1835-43.
55. Haldeman S, Carroll L, Cassidy D, Schubert J, Nygren A. The Bone and Joint Decade 20002010 Task Force on Neck Pain and Its Associated
Disorders, SPINE 33 (4S), 2008
56. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G. 2004 A Cochrane review of manipulation and mobilization for
mechanical neck disorders. Spine 29(14):1541-1548.
57. Olson KA. Presidents message: History is on our side. Articulations. 2005;11(2):1-3,8.
58. Olson KA. Manual Physical Therapy of the Spine. St Louis: Saunders, Elsevier, 2009.
Cervical Risks & Effects

59. Adams G, Sim J. A survey of UK manual therapists practice of and attitudes towards manipulation and it complications. Physiotherapy
Research International 1998;3:206-227.
60. Arnold M, Bousser MG (2005). Carotid and vertebral dissection. Practical Neurology 5:100-109.
61. Arnold C, Bourassa R, Langer T and Stoneham G. Doppler studies evaluating the effect of a physical therapy screening protocol on
vertebral artery blood flow. Man Ther. 2004; 9:1321.
62. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract
1996;42:475-80.
63. Barker S, Kesson M, Ashmore J, Turner G, Conway J and Stevens D. Professional issue. Guidance for premanipulative testing of the
cervical spine. Man Ther. 2000; 5:3740.
64. Barrett AJ, Breen AC. Adverse effects of spinal manipulation. Journal of the Royal Society of Medicine 2000;93(5):2589.
65. Beatty RA. Dissecting hematoma of the internal carotid artery following chiropractic cervical manipulation. J Trauma 1977;17:248-9.
66. Benninger DH, Geogiadis D, Kremer C. Mechanisms of ischemic infarct in spontaneous carotid dissection. Stroke 2004;35:4825.

References
67. Bowler N, Shamley D, Davies R. The effect of a simulated manipulation position on internal carotid and vertebral artery blood flow in
healthy individuals. Man Ther. 2011 Feb;16(1):8793.
68. Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side effects of spinal manipulation and can these side effects be predicted?
Manual Therapy 2004;9 (3):1516.
69. Caplan LR, Biousse V. Cervicocranial arterial dissections. J Neuroophthalmol 2004; 24: 299305
70. Carlesso LC, et al. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in
adults: a systematic review. Man Ther.2010;15(5):434-444.
71. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Man Ther
2010(15):355-363
72. Carnes D, Mullinger B, Underwood M. Defining adverse events in manual therapies: a modified Delphi consensus study. Manual Therapy
2010;15(1):26.
73. Carey P. A report on the occurrence of cerebral vascular accidents in chiropractic practice. J Can Chiropract Assoc 1993;37:104-6
74. Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiorpractic care: results of a population-based case-controls and
case-control study. Spine (Phila Pa 1976) 2008;33:S176-183.
75. Cattrysse E, Swinkels RA, Oostendorp RA, Duquet W. Upper cervical instability: are clinical tests reliable? Man Ther. 1997;2(2):91-97.
76. Cheeks & Ross. Pre-manipulative testing for upper cervical ligament integrity and/or fracture: Case Report. Physical Therapy. 2008.
77. Childs JD, Flynn TW, Fritz JM, Piva SR, Whitman JM, Wainner RS and Greenman PE. Screening for vertebrobasilar insufficiency in patients
with neck pain: manual therapy decisionmaking in the presence of uncertainty. J Orthop Sports Phys Ther. 2005; 35:3006.
78. Chung CL, Cote P, Stern P, LEsperance G. The Association between cervical spine manipulation and carotid artery dissection: a systematic
review of the literature. J Manipulative Physiol Ther. 2014.
79. Cleland JA, Glynn P, Whitman JM, Eberhart SL, MacDonald C, Childs JD. Short-term effects of thrust versus non thrust
mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Phys Ther. 2007;87(4):431-
440.
80. Coman WB. Dizziness related to ENT conditions. In: Grieve GP, editor. Modern Manual Therapy of the Vertebral Column. Edinburgh, UK:
Churchill Livingstone; 1986.
81. Cook C, Brismee JM, Fleming R, et al (2005). Identifiers suggestive of clinical cervical spine instability: a Delphi study of physical therapists.
Physical Therapy 85(9):895-906.
82. Cook C, Learn K, Showalter C, Kabbaz V, OHalloran B. Early use of thrust manipulation versus non-thrust manipulation: A randomized
clinical trial. Manual Ther. 2013(18):191-198.
83. Cook C, Brown C, Isaacs R, et al. Clustered clinical findings for diagnosis of cervical spine myelopathy J Man Manip Ther. 2010 Dec; 18(4):
175180.
84. Cook CE, Hegedus E, Pietrobon R, Goode A . A pragmatic neurological screen for patients with suspected cord compressive myelopathy.
Phys Ther. 2007 Sep; 87(9):1233-42.
85. Cook, Hegedus 2008. Orthopedic Physical Examination Tests. Prentice Hall.
86. Cote, Pierre. Screening for stroke: let's show some maturity. Editorial. J Can Chiropr Assoc 1999; 43(2)
87. Cote P, Kreitz BG, Cassidy JD, Thiel H. The validity of the extension rotation test as a clinical screening procedure before neck
manipulation: a secondary analysis. J Manipulative Physiol Ther.1996;19:159164.
88. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999; 79:5065.
89. Dobbs A. Manual Therapy assessement of cervical instability. Orthopaedic Physical Therapy Clinics of North America. 2001;10:431-454.
90. Dunnning JR, Cleland JA, Waldrop MA, Arnot C, Young I, Turner M, Sigurdsson G. Upper Cervical and Upper Thoracic Thrust Manipulation
Versus Nonthrust Mobilization in Patients with Mechanical Neck Pain: A Multicenter Randomized Clinical Trial. JOSPT. 2012;42(1)5-18.
91. Dvorak J, Orelli F. How dangerous is manipulation to the cervical spine? Case report and results of a survey. Manual Med. 1985;2:14
92. Ernst E. Adverse effects of spinal manipulation: A systematic review. J R Soc Med 2007;100:330-338
93. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Review 2004;9:5-15
94. Foye P.M., Najar M.P., Camme A.A. Pain, dizziness, and central nervous system blood flow in cervical extension: vascular correlations to
beauty parlor stroke syndrome and salon sink radiculopathy. Am J Phys Med Rehabil. 2002;81(6):395399.
95. Frese EM, Fick A, Sadowsky HS. Blood Pressure Measurement Guidelines for Physical Therapists. Cardiopulmonary Physical Therapy
Journal 2011;22(2):5-12.
96. Frumkin L and Baloh RW (1990): Wallenbergs syndrome following neck manipulation. Neurology 40: 611615.
97. George B and Laurian C (1987): Vertebrobasilar ishaemia with thrombosis of the vertebral artery: two cases with embolism. Journal of
Neurology, Neurosurgery and Psychiatry 45: 9193.
98. Gibbons P, Tehan P (2005). Manipulation Of The Spine, Thorax And Pelvis: An Osteopathic Perspective, 2nd Edn, Churchill Livingstone.
99. Grant R. Vertebral Artery Testing the Australian Association protocol after 6 years; Manual Therapy; 1996; 1; 149153.
100. Grieve's Modern Manual Therapy. 3rd ed. Edinburgh, UK: Churchill Livingstone; 2005.
101. Gutowski NJ, Murphy RP, Beal DJ. Unilateral upper cervical posterior spinal artery syndrome following sneezing. J Neurol Neurosurg
Psychiatry 1992;55:841-3
102. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipating neck movements causing vertebrobasilar artery dissection after
cervical trauma and spinal manipulation. Spine 1999;24:785-94.

References
103. Haldeman S, Rubinstein SM. Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. Spine (Phila Pa 1976)
1992;17:1469-73.
104. Haldeman S, Cary P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience.
CMAJ. 2001; 165:905-6
105. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy:
a review of sixty-four cases after cervical spine manipulation. Spine (Phila Pa 1976). 2002;27:49-55.
106. Haneline MT, Lewkovich GN . An analysis of the etiology of cervical artery dissections: 1994 to 2003. J Manipulative Physiol Ther. 2005
Oct; 28(8):617-22.
107. Haneline M, Lewkovich G (2004). Identification of internal carotid artery dissection in chiropractic practice. J Can Chiropr Assoc 48(3):206-
10.
108. Haneline MT, Croft AC, Frishberg BM. Association of internal carotid artery dissection and chiropractic manipulation. Neurologist. 2003
Jan; 9(1):35-44.
109. Hamann G, Haass A, Kujat C, et al. Cervicocephalic artery dissections due to chiropractic manipulations. Lancet 1993;341:764-5.
110. Hanus SH, Homer TD, Harter DH. Verebral artery occlusion complication yoga exercises. Arch Neurol 1977;34:574-5.
111. Harrop JS, Hanna A, Silva MT, Sharan A. Neurological manifestations of cervical spondylosis: an overview of signs, symptoms, and
pathophysiology. Neurosurgery. 2007 Jan; 60(1 Supp1 1):S14-20.
112. Hart RG, Easton JD. Dissections of cervical and cerebral arteries. Neurol Clin. 1983 Feb; 1(1):155-82.
113. Haynes MJ, Milne N. Color Duplex sonographic findings in human vertebral arteries during cervical rotation. J Clin Ultrasound.
2001;29:1424
114. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prevalence of and screening for
serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009 Oct;60(10):3072-
80.
115. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal
manipulation. J Electromyogr Kinsiol. 2012;22(5):740-6.
116. Herzog W, Tang C, Leonard T. Internal carotid artery strains during high-speed, low-amplitude spinal manipulations of the neck. Journal
of Manipulative and Physiological Therapeutics. 2012.
117. Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A randomized controlled trial comparing 2 types of spinal manipulation and
minimal conservative medical care for adults 55 years and older with subacute and chronic low back pain. J Manipulative Physiol Ther.
2009;32(5):330-43.
118. Hurwitz EL et al. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine. 1996;21(15):1746-1759)
119. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A Randomized Trial of Chiropractic Manipulation and Mobilization
for Patients with Neck Pain: Clinical Outcomes from the UCLA Neck-Pain Study. Am J Public Health. 2002; 92(10): 1634-1641.
120. Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, ScholtenPeeters GG. Diagnostic accuracy of premanipulative
vertebrobasilar insufficiency tests: a systematic review. Man Ther2013;18(3):177182.
121. Hutting N et al. Diagnostic Accuracy of Upper Cervical Spine Instability Tests: A Systematic Review. Phys Ther. 2013(19);9:
122. Johnson CP, How T, Scraggs M, West CR and Burns J (2000): A biomechanical study of the human vertebral artery with implications for
fatal arterial injury. Forensic Science International 109: 169182.
123. Josien E. Extracranial vertebral artery dissection: nine cases. J Neurol 1992;239:327-30.
124. Kaale BR, Krakenes J, Albrektsen G, Wester K. Clinical assessment techniques for detecting ligament and membrane injuries in the upper
cervical spine region - a comparison with MRI results. Man Ther.2013(13):397-403.
125. Kaperonis EA, Liapis CD, Kakisis JD, Dimitroulis D, Papavassiliou VG. Inflammation and atherosclerosis. Eur J Endovasc Surg 2006; 31: 386
393.
126. Kerry R & TaylorA . Arterial pathology and cervicocranial pain differential diagnosis for manual therapists and medical practitioners.
International Musculoskeletal Medicine. 2008(30);2: 70-77.
127. Kerry R, Taylor AJ. Cervical Arterial Dysfunction: Knowledge and Reasoning for Manual Physical Therapists. JOSPT. 2009;29(5): 378-387
128. Kerry R, Taylor AJ, Mitchell J, McCarthy C, Brew J. Manual Therapy and Cervical Arterial Dysfunction, Directions for the Future: A Clinical
Perspective. JMMT. 16(1): 2008;39-48
129. Kerry R & Taylor AJ. Cervical artery dysfunction assessment and manual therapy. Manual Therapy. 2006(1);243-253.
130. Kerry R, Taylor AJ, Mitchell JM, et al (2008). Cervical arterial dysfunction and manual therapy: A critical literature review to inform
professional practice. Manual Therapy 13(4):278-288.
131. Kerry R, Rushton A. Decision theory in physical therapy. World Confederation for Physical Therapy 14th International Congress.
Barcelona, Spain: 2003.
132. Kerry R, Taylor AJ. Cervical artery dysfunction assessment and manual therapy. Man Ther.2006;11:243253.
133. Kougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiopractic practice: Part II. Treatment to the upper neck and the rate of
cerebrovascular incidents. J Manipulative Physiol Ther 1996;19:563-9.
134. Kumar S.D., Kumar V., Kaye W. Bilateral internal carotid artery dissection from vomiting. Am J Emerg Med. 1998;16(7):669670.
135. Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, Refshauge KM. A Randomized Controlled Trial Comparing Manipulation
with Mobilization for Recent Onset Neck Pain. Arch Phys Med Rehabil. 2010;91: 1313-1318.
136. Leboeuf-Yde C, Hennius B, Rudberg E, Leufvenmark P, Thunman M. Side effects of chiropractic treatment: a prospective study. Journal of
Manipulative & Physiological Therapeutics 1997;20(8):5115.
References
137. Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology.
2006 28;67(10);1809-12.
138. Li YK, Zhang YK, Lu CM, Zhong SZ. Changes and implications of the blood flow velocity of the vertebral artery during rotation and
extension of the head. J Manip Physiol Ther. 1999;22:9195.
139. Licht PB, Christensen HW, Hjgaard P, HilundCarlsen PF. Triplex ultrasound of vertebral artery flow during cervical rotation. J Manip
Physiol Ther. 1998;21:2731.
140. Lyness SS, Wagman AD. Neurological deficit following cervical manipulation. Surg Neurol 1974;2:121-4.
141. Macchi C, Giannelli F, Cecchi F, Gulisano M, Pacini P, Corcos L, Catini C and Brizzi E (1996): The inner diameter of human intracranial
vertebral artery by color doppler method. Italian Journal of Anatomy and Embryology 101: 8187
142. Magee DJ. Orthopaedic Physical Assessment. Elsevier Health Sciences. 2008
143. Magarey ME, Rebbeck T, Coughlan B, Grimmer K, Rivett DA and Refshauge K. Premanipulative testing of the cervical spine review,
revision and new clinical guidelines. Man Ther. 2004; 9:95-108.
144. Marx P et al. Manipulative treatment for the cervical spine and stroke. Forester Neurol Psychiatr. 2009;77(2):83-90.
145. Meadows J. Orthopedic Differential Diagnosis in Physical Therapy: A Case Study Approach. New York, NY: McGraw-Hill;1999.
146. Meadows J. The Sharp-Purser Test: A Useful Clinical Tool or an Exercise in Futility and Risk? JMMT. 1998;6(2):97-100
147. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically
important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012 Nov 6;184(16):E867-76.
148. Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM . Does cervical manipulative therapy cause vertebral artery dissection and
stroke? Neurologist. 2008 Jan; 14(1):66-73
149. Mintken et al. Upper cervical ligament testing in a patient with Os Odontoideum presenting with CGH. Resident's case problem. JOSPT.
2008.
150. Mitchell J. Changes in vertebral artery blood flow following normal rotation of the cervical spine. J Manip Physiol Ther. 2003;26:347351.
151. Mitchell J, Keene D, Dyson C, Harvey L, Pruvey C, Phillips R. Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency
test, associated with a measurable change in intracranial vertebral artery blood flow? Man Ther. 2004;9:220227.
152. Murphy DR. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic
profession? Chiropr Osteopat. 2010;18:22.
153. Nagler W. Vertebral artery obstruction by hyperextension of the neck: Report of three cases. Arch Pays Med Rehabil 1973;54:237-40.
154. Okawara S, Nibbelink D. Vertebral artery occlusion following hyperextension and rotation of the head. Stroke 1974;5:640-2.
155. Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J
Manipulative Physiol Ther. 20014;27(3):197-210.
156. Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications following spinal manipulation. The Spine Journal. 2005(5)660-667.
157. Osmotherly PG et al. The anterior shear and distraction tests for craniocervical instability. An evaluation using magnetic resonance
imaging. Man Ther. 2012 Oct;17(5):416-21.
158. Paanalahti et al.: Adverse events after manual therapy among patients seeking care for neck and/or back pain: a randomized controlled
trial. BMC Musculoskeletal Disorders 2014 15:77.
159. Pelkonen O, Tikkakoski T, Leinonen S. Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course, and
prognosis. Neuroradiology 2003;45:717.
160. Peters M, Bohl J, Thomke F, et al. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology.
1995;45:2284-6.
161. Puentedura EM et al. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed
appropriately? A review of 134 case reports. JMMT. 2012. 20(2):66-74.
162. Rivett DA. Adverse effects of cervical manipulative therapy. In: Boyling JD, Jull GA, editors. Grieves modern manual therapy of the
vertebral column. 3rd ed. Edinburgh: Churchill Livingstone; 2004. p. 53349
163. Rivet DA. Adverse events and the vertebral artery: can they be averted? Man Ther. 2006 Nov; 11(4):241-2)
164. Rivett DA. Adverse events and the vertebral artery: can they be averted? Man Ther. 2006 Nov; 11(4):241-2)
165. Rivett DA. The vertebral artery and vertebrobasilar insufficiency. In: Boyling J, Jull G, editors.
166. Rivett DA, Sharples KJ, Milburn PD. Effect of premanipulative tests on vertebral artery and internal carotid artery blood flow: a pilot
study. J Manipul Physiol Ther 1999; 22: 368375.
167. Rivett DA, Sharples KJ, Millburn PD. Vertebral artery blood flow during premanipulative testing of the cervical spine. 2000.
168. Rivett DA, Milburn PD, Chapple C. Negative premanipulative vertebral artery testing despite complete occlusion: a case of false
negativity? Manual Therapy. 1998;3(2):1027.
169. Rivett D, Shirley D, Magarey M, Refshauge KM. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of
Cervical Spine Disorders, 2006. Melbourne, Australia: Australian Physiotherapy Association, Musculoskeletal Physiotherapy Australia;
2006.
170. Roman M, Brown C, Richardson W, Isaacs, R, Howes C, Cook C. The development of a clinical decision making algorithm for detection of
osteoporotic vertebral compression fracture or wedge deformity. J Man Manip Ther. 2010 Mar; 18(1): 4449.
171. Rome P. Perspectives: an overview of comparative considerations of cerebrovascular accidents. Chirpr J Aust. 1999;29:87102.
172. Ross R. Atherosclerosis an inflammatory disease. N Engl J Med 1999; 340: 115126.
173. Ross, Michael and Cheeks, John. Undetected Hangman's Fracture in a Patient Referred for Physical Therapy for the Treatment of Neck
Pain Following Trauma. Phys Ther. 2008;88:98-104.
References
174. Rossitti S, Volkmann R. Changes of blood flow velocity indicating mechanical compression of the vertebral arteries during rotation of the
head in the normal human measured with transcranial Doppler sonography. Arquivos de NeuroPsiquiatria. 1995;53:2633.
175. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001;32:1054-
60.
176. Rubinstein SM, Peerdeman SM, van Tulder MW, Riphagen I, Haldeman S . A systematic review of the risk factors for cervical artery
dissection. Stroke. 2005 Jul; 36(7):1575-80
177. Rubeinstein SM. Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?
J Manipulative Physiol Ther. 2008;31:461-4.
178. Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder ME. The benefits outweigh the risks for patients
undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. Journal of Manipulative & Physiological
Therapeutics 2007;30(6):40818
179. Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International Framework for Examination of the Cervical Region for potential of
Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention. Man Ther. 2013.
180. Scheel P, Ruge C, Schoning M. Flow velocity and flow volume measurements in the extraranial carotid and vertebral arteries inhealthy
adults: reference data and the effects of age. Ultrasound Med Biol 2000; 26: 12611266
181. Schievink W.I., Mokri B., Whisnant J.P. Internal carotid artery dissection in a community. Rochester, Minnesota, 1987-1992. Stroke.
1993;24(11):16781680.
182. Senstad O, Leboeuf-Yde C, Borchgrevink C. Predictors of side effects to spinal manipulative therapy. Journal of Manipulative &
Physiological Therapeutics 1996a;19(7):4415.
183. Senstad O, Leboeuf-Yde C, Borchgrevink C. Side-effects of chiropractic spinal manipulation: types frequency, discomfort and course.
Scandinavian Journal of Primary Health Care 1996b;14(1):503.
184. Senter HJ, Sarwar M. Nontraumatic dissecting aneurysm of the vertebral artery: Case report. J Neurosurg 1982;56:128-30.
185. Sherman DG, Hart RG, EAston JD. Abrupt change in head position and cerebral infarction. Stroke 1981;12:2-6.
186. Sim E, Schwarz N, BiowskiFasching I and Biowski P (1993): Colourcoded Duplex sonography of vertebral arteries: 11 cases of blunt
cervical injury. Acta Orthopaedica Scandinavica 64: 133137.
187. Sullivan EC (1992): Brainstem stroke syndromes from cervical adjustments: report on five cases. Journal of Chiropractic Research and
Clinical Investigations 8: 1216
188. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.
Neurology 2003;60:1424-8.
189. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001
Oct 17;286(15):1841-8.
190. Sullivan E. Prestroke screening prior to the cervical adjustment. Dig Chriopract Econ 1988;30:64-9.
191. Suvarnnato T, Puntumetakul R, Kaber D, Boucaut R, Boonphakob Y, Arayawichanon P, Chatchawan U. The effects of thoracic
manipulation versus mobilization for chronic neck pain: a randomized controlled trial pilot study. J Phys Ther Sci. 2013;25(7):855-871.
192. Symons & Westaway. Virchows Triad and spinal manipulative therapy of the cervical spine. J Can Chiropr Assoc. 2001;45(4):225-231.
193. Symons B, Leonard TR, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative
Physiol There 2002;25:50410.
194. Taylor AJ, Kerry R. Neck pain and headache as a result of internal carotid artery dissection: Implications for clinicians. Man Ther
2005;10:73-77
195. Taylor AJ, Kerry R. The vertebral artery test. Manual Therapy 2005b;10(4):2978
196. Taylor AJ, Kerry R. Vascular profiling: should manual therapists take blood pressure? Man Ther. 2013;18(4);351-3.
197. Thiel H, Rix G. Is it time to stop functional premanipulative testing of the cervical spine? Manual Therapy 2005;10(2):14854.
198. Thiel H, Wallace K, Donat J, YongHing K. Effect of various head and neck positions on vertebral artery blood flow. Clin Biomech.
1994;9:105110.
199. Thomas LC, Rivett DA, Attia JR, et al (2011). Risk factors and clinical features of craniocervical arterial dissection. Manual Therapy
16(4):351-356.
200. Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of Selected Manual Therapy Interventions for Mechanical Neck Pain on
Vertebral and Internal Carotid Arterial Blood Flow and Cerebral Inflow. Physical Therapy. 2013; 93(11): 15631574.
201. Thomas LC, McLeod LR, Osmotherly PG, Rivett DA. The effect of endrange cervical rotation on vertebral and internal carotid arterial
blood flow and cerebral inflow: A sub analysis of an MRI study. Man Ther. 2014 Nov 29. pii: S1356689X(14)002331.
202. Thomas LC, Rivett DA, Parsons M, Levi C. Risk factors, radiological features, and infarct topography of craniocervical arterial dissection.
Int J Stroke. 2014 Dec;9(8): 1073-82.
203. Triano JJ, Kawchuk G, eds. Current Concepts: Spinal Manipulation and Cervical Arterial Incidents. Clive, IA: NCMIC; 2006.
204. Vickers & Zollman. The manipulative therapies: osteopathy and chiorpactic. BMJ 1999; 1176-to 1179
205. Weingart JR, Bischoff HP. Doppler sonography of the vertebral artery with regard to head positions appropriate to manual medicine.
Manuelle Medizin. 1992;30:6265.
206. Westaway MD, Stratford P, Symons B. False negative extension/rotation premanipulative screening on a patient with an atrocity and
hypoplastic vertebral artery. Manual Therapy 2003;8:1207.
207. Willet GM, Wachholtz NA. A Patient With Internal Carotid Artery Dissection. Phys Ther. 2001;91(8):1266-1274.

References
208. Whedon JM, Song Y, Mackenzie TA, Phillips RB, Lukovits TG, Lurie JD. Risk of stroke after chiropractic spinal manipulation in Medicare B
Beneficiaries Aged 66 to 99 years with neck pain. Journal of Manipulative and Physiological Therapeutics. 2014; in press.
209. Wuest S, Symons B, Leonard T, Herzog W. Preliminary Report: Biomechanics of Vertebral Artery Segments C1-6 During Cervical Spinal
Manipulation. Journal of Manipulative and Physiological Therapeutics. 2010;33(4): 273-278.
210. Uitvlugt & Indenbaum. Clinical assessment of atlantoaxial instability using the Sharp-Purser test. Arthritis Rheum. 1988;31(7):918-22.
211. Yamada SM, Goto Y, Murakami M, Hoya K, Matsuno A. Vertebral Artery Dissection Caused by swinging a golf club: A Case Report and
Literature Review. Clin J Sport Med. 2013(19).
212. Zaina C, Grant R, Johnson C, Dansie B, Taylor J, Spyropolous P. The effect of cervical rotation on blood flow in the contralateral vertebral
artery. Man Ther. 2003;8:103109.
General References
213. Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms--a systematic review. Man Ther. 2004;9(3):134-143.
214. Bakker, M., & Miller, J. (2004). Does an audible release improve the outcome of a chiropractic adjustment?. The Journal of the Canadian
Chiropractic Association, 48(3), 237.
215. Beffa, R., & Mathews, R. (2004). Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation
sounds. Journal of manipulative and physiological therapeutics, 27(2), 118-122.
216. Bialosky, J. E., Bishop, M. D., Robinson, M. E., & George, S. Z. (2010). The relationship of the audible pop to hypoalgesia associated with
high-velocity, low-amplitude thrust manipulation: a secondary analysis of an experimental study in pain-free participants. Journal of
manipulative and physiological therapeutics, 33(2), 117-124.
217. Bialosky, J. E., Simon, C. B., Bishop, M. D., & George, S. Z. (2012). Basis for spinal manipulative therapy: a physical therapist
perspective. Journal of Electromyography and Kinesiology, 22(5), 643-647.
218. Brennan, G. P., Fritz, J. M., Hunter, S. J., Thackeray, A., Delitto, A., & Erhard, R. E. (2006). Identifying subgroups of patients with
acute/subacute nonspecific low back pain: results of a randomized clinical trial. Spine, 31(6), 623-631.
219. Cascioli, V., Corr, P., & Till, A. G. (2003). An investigation into the production of intra-articular gas bubbles and increase in joint space in
the zygapophyseal joints of the cervical spine in asymptomatic subjects after spinal manipulation.Journal of manipulative and
physiological therapeutics, 26(6), 356-364.
220. Cleland, J. A., Flynn, T. W., Childs, J. D., & Eberhart, S. (2007). The audible pop from thoracic spine thrust manipulation and its relation to
short-term outcomes in patients with neck pain. Journal of Manual & Manipulative Therapy,15(3), 143-154.
221. Conway, P. J. W., Herzog, W., Zhang, Y., Hasler, E. M., & Ladly, K. (1993). Forces required to cause cavitation during spinal manipulation of
the thoracic spine. Clinical Biomechanics, 8(4), 210-214.
222. Cramer, G. D., Ross, K., Pocius, J., Cantu, J. A., Laptook, E., Fergus, M., ... & Raju, P. K. (2011). Evaluating the relationship among cavitation,
zygapophyseal joint gapping, and spinal manipulation: an exploratory case series. Journal of manipulative and physiological
therapeutics, 34(1), 2-14.
223. Cramer, G. D., Ross, K., Raju, P. K., Cambron, J., Cantu, J. A., Bora, P., ... & Gregerson, D. (2012). Quantification of cavitation and gapping
of lumbar zygapophyseal joints during spinal manipulative therapy. Journal of manipulative and physiological therapeutics, 35(8), 614-
621.
224. Delitto, A., Erhard, R. E., & Bowling, R. W. (1995). A treatment-based classification approach to low back syndrome: identifying and
staging patients for conservative treatment. Physical Therapy, 75(6), 470-485.
225. Deyo, R. A., & Diehl, A. K. (1988). Cancer as a cause of back pain. Journal of general internal medicine, 3(3), 230-238.
226. Dhillon, M. S., Bali, K., & Prabhakar, S. (2012). Differences among mechanoreceptors in healthy and injured anterior cruciate ligaments
and their clinical importance. Muscles, Ligaments and Tendons Journal, 2(1), 38.
227. Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W., de Vet, H. C., ... & Maher, C. G. (2013). Red flags to screen for
malignancy and fracture in patients with low back pain: systematic review. BMJ, 347, f7095.
228. Dunning, J. R., Cleland, J. A., Waldrop, M. A., Arnot, C., Young, I., Turner, M., & Sigurdsson, G. (2012). Upper cervical and upper thoracic
thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. journal
of orthopaedic & sports physical therapy, 42(1), 5-18.
229. Dunning, J., Mourad, F., Barbero, M., Leoni, D., Cescon, C., & Butts, R. (2013). Bilateral and multiple cavitation sounds during upper
cervical thrust manipulation. BMC musculoskeletal disorders, 14(1), 24.
230. Evans, D. W., & Lucas, N. (2010). What is manipulation? A reappraisal.Manual therapy, 15(3), 286-291.
231. Fernndez-Carnero, J., Cleland, J. A., & Arbizu, R. L. T. (2011). Examination of motor and hypoalgesic effects of cervical vs thoracic spine
manipulation in patients with lateral epicondylalgia: a clinical trial. Journal of manipulative and physiological therapeutics, 34(7), 432-440.
232. Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., ... & Allison, S. (2002). A clinical prediction rule for classifying patients
with low back pain who demonstrate short-term improvement with spinal manipulation. Spine,27(24), 2835-2843.
233. Flynn, T. W., Fritz, J. M., Wainner, R. S., & Whitman, J. M. (2003). The audible pop is not necessary for successful spinal high-velocity
thrust manipulation in individuals with low back pain. Archives of physical medicine and rehabilitation,84(7), 1057-1060.
234. Flynn, T. W., Childs, J. D., & Fritz, J. M. (2006). The audible pop from high-velocity thrust manipulation and outcome in individuals with
low back pain.Journal of manipulative and physiological therapeutics, 29(1), 40-45.
235. Flynn, T. W. (2006). There's more than one way to manipulate a spine. Journal of Orthopaedic & Sports Physical Therapy, 36(4), 198-199.
236. Gal J, Herzog W, Kawchuk G, Conway PJ, Zhang YT. Movements of vertebrae during manipulative thrusts to unembalmed human
cadavers. J Manipulative Physiol Ther.1997;20(1):3040.
References
237. George, S. Z., Bishop, M. D., Bialosky, J. E., Zeppieri, G., & Robinson, M. E. (2006). Immediate effects of spinal manipulation on thermal
pain sensitivity: an experimental study. BMC Musculoskeletal disorders, 7(1), 68.
238. Goodman, Snyder. Differential Diagnosis for Physical Therapists: Screening for Referral, 5th Edition. W.B. Saunders Company, 2013.
239. Hartman, L. (1996). Handbook of osteopathic technique. Nelson Thornes.
240. Hefford C. McKenzie classification of mechanical spinal pain: Profile of syndromes and directions of preference. Manual Therapy (2007),
doi:10.1016/j.math.2006.08.005
241. Henschke, N., Maher, C. G., Refshauge, K. M., Herbert, R. D., Cumming, R. G., Bleasel, J., ... & McAuley, J. H. (2009). Prevalence of and
screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis & Rheumatism,
60(10), 3072-3080.
242. Herzog, W. (1991). Biomechanical studies of spinal manipulative therapy. The Journal of the Canadian Chiropractic Association, 35(3),
156.
243. Herzog, W., Kats, M., & Symons, B. (2001). The effective forces transmitted by high-speed, low-amplitude thoracic
manipulation. Spine, 26(19), 2105-2110.
244. Herzog, W., Leonard, T. R., Symons, B., Tang, C., & Wuest, S. (2012). Vertebral artery strains during high-speed, low amplitude cervical
spinal manipulation. Journal of Electromyography and Kinesiology, 22(5), 740-746.
245. Hicks, G. E., Fritz, J. M., Delitto, A., & McGill, S. M. (2005). Preliminary development of a clinical prediction rule for determining which
patients with low back pain will respond to a stabilization exercise program. Archives of physical medicine and rehabilitation, 86(9), 1753-
1762.
246. Kawchuk, G. N., Herzog, W., & Hasler, E. M. (1992). Forces generated during spinal manipulative therapy of the cervical spine: a pilot
study. Journal of manipulative and physiological therapeutics, 15(5), 275-278.
247. Lantz, C. A., Klein, G., Chen, J., Mannion, A., Solinger, A. B., & Dvorak, J. (2003). A reassessment of normal cervical range of
motion. Spine, 28(12), 1249-1257.
248. Lurie, J. D. (2005). What diagnostic tests are useful for low back pain?. Best Practice & Research Clinical Rheumatology, 19(4), 557-575.
249. Ngan, J. M., Chow, D. H., & Holmes, A. D. (2005). The kinematics and intra-and inter-therapist consistencies of lower cervical rotational
manipulation. Medical engineering & physics, 27(5), 395-401.
250. Reggars, J. W. (1996). THE MANIPULATIVE CRACK: Frequecy Analysis.Australasian Chiropractic & Osteopathy, 5(2), 39.
251. Reggars, J. W. (1998). The therapeutic benefit of the audible release associated with spinal manipulative therapy: a critical review of the
literature.Australasian Chiropractic & Osteopathy, 7(2), 80.
252. Ross, J. K., Bereznick, D. E., & McGill, S. M. (2004). Determining cavitation location during lumbar and thoracic spinal manipulation: is
spinal manipulation accurate and specific?. Spine, 29(13), 1452-1457.
253. Rubinstein, S. M., & van Tulder, M. (2008). A best-evidence review of diagnostic procedures for neck and low-back pain. Best Practice &
Research Clinical Rheumatology, 22(3), 471-482.
254. Salem, W., & Klein, P. (2013). In vivo 3D kinematics of the cervical spine segments during pre-manipulative positioning at the C4/C5
level. Manual therapy, 18(4), 321-326.
255. Sandoz, R. (1969). The significance of the manipulative crack and of other articular noises. Ann Swiss Chiro Assoc, 4, 47-68.
256. Sauerland et al. (2004) Reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-analysis. Arch
Orthop Trauma Surg. 124:123-128.
257. Sillevis, R., & Cleland, J. (2011). Immediate effects of the audible pop from a thoracic spine thrust manipulation on the autonomic nervous
system and pain: a secondary analysis of a randomized clinical trial. Journal of manipulative and physiological therapeutics, 34(1), 37-45.
258. Symons, B., Wuest, S., Leonard, T., & Herzog, W. (2012). Biomechanical characterization of cervical spinal manipulation in living subjects
and cadavers.Journal of Electromyography and Kinesiology, 22(5), 747-751.
259. Tramr, M. R., Moore, R. A., Reynolds, D. J. M., & McQuay, H. J. (2000). Quantitative estimation of rare adverse events which follow a
biological progression: a new model applied to chronic NSAID use. Pain, 85(1), 169-182.
260. Triano, J. J. (1992). Studies on the biomechanical effect of a spinal adjustment.Journal of manipulative and physiological
therapeutics, 15(1), 71.
261. Triano, J. J., & Schultz, A. B. (1993). Motions of the head and thorax during neck manipulations. Journal of manipulative and physiological
therapeutics,17(9), 573-583.
262. Triano, J. J. (2001). Biomechanics of spinal manipulative therapy. The Spine Journal, 1(2), 121-130.
263.Unsworth, A., Dowson, D., & Wright, V. (1971). 'Cracking joints'. A bioengineering study of cavitation in the metacarpophalangeal
joint. Annals of the rheumatic diseases, 30(4), 348.
Indications: Cervical Spine

264.Bronfort G et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine.
2001;26(7)788-99.
265.Bronfort G et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a
randomized trial. Ann Intern Med. 2012;156:1-10
266.Jull G et al. A randomized control trial of exercise and manipulative therapy for cervicogenic headache.
Spine.200227(17):1835-43.
267.Gross AR, et al. Manipulation and mobilization for mechanical neck disorders. Cochrane Database Syst Rev.
2004;(1):CD004249
268.Tseng YL, et al. Predictors for the immediate responders to cervical manipulation in patients with neck pain. Man Ther.
2006(4):306-15.
References
269.Martinez-Segurra R, et al. Immediate effects of neck pain and active range of motion after a single cervical high-velocity
low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized control trial. J Manipulative
Physiol Ther. 2006;29(7):511-7.
270.Vernon H, et al. Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in
randomized control trials. J Manipulative Physiol Ther. 2007;30(3):215=27
271.Puentedura EJ, et al. Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute
neck pain: a randomized control trial. J Orthop Sports Phys Ther. 2011;41(4):208-20.
272.Puentedura EJ, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from
thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther. 2012;42(7):577-92.
Indications: Thoracic Spine
273.Young JL, et al. Thoracic manipulation vs mobilization in patients with mechanical neck pain: a systematic review. Journal of
Manual and Manipulative Therapy. 2014;(3):141-153
274.Cross KM, et al. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients
with mechanical neck pain: a systematic review. JOSPT. 2011; 9:633-42
275.Karas S, Olson Hunt MJ. A randomized clinical trial to compare the immediate effects of seated thoracic manipulation and
targeted supine thoracic manipulation on cervical spine flexion range of motion and pain. J Man Manip Ther. 2014
May;22(2):108-14
276.Cleland JA et al. Immediate effects of thoracic manipulation to patients with neck pain: a randomized clinical trial. Manual
Ther. 2005;10(2):127-135
277.Cleland JA et al. Short-term effects of thrust versus non-thrust mobilization/manipulation directed at the thoracic spine in
patient with neck pain: a randomized clinical trial. Phys Ther. Apr 2007;87(4):431-440.
278.Cleland JA, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain:
use of thoracic spine manipulation, exercise, and patient education. Phys Ther. Jan 2007;87(1):9-23.
279.Cleland JA, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic
spine thrust manipulation and a general cervical range of motion exercise: a multi-center randomized control trial. Phys
Ther. Sept 2010;90(9):1239-1250.
280.Walser RF et al. The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: A
systematic review and meta-analysis of randomized clinical trials. 17. 2009;4(237-246).
281.Fernandez-de-las-Penas et al. Changes in neck pain and active range of motion after a single thoracic spine manipulation in
subjects presenting with mechanical neck pain: a case series. J Manipulative Physiol Ther. May 2007;30(4):312-320.
282.Gonzales-Iglesias J et al. Inclusion of thoracic spine thrust manipulation into an electro-therapy/thermal program for the
management of patients with acute mechanical neck pain: a randomized clinical trial. Man Ther. June 2009;14(3):306-313.
283.Gonzalez-Iglesias J et al. Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical
trial. J Orthop Sports Phys Ther. Jan 2009;39)1):20-27.
284.Krauss J, et al. The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of
motion: a randomized clinical trial. J Man Manip Ther. 2008;16(2):93-99.
285. Vanti, C et al. Manual Therapy for non-specific thoracic pain in adults: Review of the literature. Journal of Back and
Musculoskeletal Rehabilitation. 2008: 143-152

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Evidence-Based Orthopedic Manual Therapy

for the Spine:

Eric Jorde, PT, DPT, OCS, Cert. MDT, Cert. SMT

Alex Siyufy, PT, DPT, ATC, SCS, Cert. MDT, Cert. DN

Spinal Manipulation & Mobilization eBook 1

Spinal Manipulation & Mobilization eBook 2

Spinal Manipulation & Mobilization eBook 3

3:30-4:00 Review/Practice of all techniques

4:00-4:30 Open Lab Practice

Spinal Manipulation & Mobilization eBook 4

The Participant will be able to:

1. Discuss and review the relevant evidence based literature as it relates to

1. Lumbar (L2-L5) Combined Lever Thrust Technique

2. Lumbar (L2-L5) Combined Lever Thrust Technique

Spinal Manipulation & Mobilization eBook 5

An American Physical Therapy Association White Paper

Spinal Manipulation & Mobilization eBook 6

TJM and Physical Therapist Practice: Historical and Current Overview

Spinal Manipulation & Mobilization eBook 8

Spinal Manipulation & Mobilization eBook 10

TJM and Patient Safety

Spinal Manipulation & Mobilization eBook 12

Research Supporting the Use of Manipulation

concernsnot patient safety.

Spinal Manipulation & Mobilization eBook 14

Oxford English Dictionary:

2. In a restricted definition, it is used to mean a small-amplitude rapid movement (not necessarily

George Grieve, FCSP, DipTP

Spinal Manipulation & Mobilization eBook 15

Stanley Paris, PT, PhD

Phillip Greenman, DO described the state of manipulation:

Boissonnault et al (JOSPT 2004) defined manipulation:

Spinal Manipulation & Mobilization eBook 16

DASP AAOMPT 1998. Adopted Orthopaedic Section APTA 2000.

Dorland's Illustrated Medical Dictionary, 28th Ed.

Spinal Manipulation & Mobilization eBook 17

Guide to Physical Therapist Practice American Physical Therapy Association (1999)

Mobilization/Manipulation: a manual therapy technique comprised of a continuum of skilled passive

Spinal Manipulation & Mobilization eBook 18

Definitions provided by the Virginia Chiropractic Association are as follows:

Spinal Manipulation & Mobilization eBook 19

Geoffrey Maitland was a significant influence in the Maitland Mobilization/Manipulation

This system was initially developed in the 1950s by

The purpose of this section is to provide a very

Spinal Manipulation & Mobilization eBook 20

Maitland Grade V Manipulation (Thrust)

Spinal Manipulation & Mobilization eBook 21

UK Osteopathic Treatment Classification: Low Velocity Stress Technique Category

Hartman (1997) describes three main groups of

Rhythmic Technique Category

Thrust Techniques (HVLA)

One of the primary foci of this eBook and course is

Hartmans (1997) text describes the thrust

Spinal Manipulation & Mobilization eBook 24

The second and more common method of minimal

What do we mean by "High Velocity"? Cervical Thrust Amplitude

Cervical HVLAT Force

Cervical High Velocity Thrust

Cervical HVLAT Cavitation

Pre-Thrust Cervical ROM

Cervical De-Rotation ROM prior to HVLAT

Spinal Manipulation & Mobilization eBook 26

Thoracic HVLAT Pre-Load