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Literature Review: HVLA in Entry Level Physical Therapist Training

Grace Blankenhagen

Manipulation can be a threatening term. When manipulation is mentioned, most

people automatically think of chiropractors or cracking someones spine. In truth,

many different disciplines participate in the art of manipulation, especially (actually

PTs, by percentage, do less than DCs) physical therapists (PTs). In physical

therapy, the preferred term to refer to manipulation is a high velocity low amplitude

(HVLA) mobilization or grade 5 mobilizations. This skill is taught to mostall entry-

level PTs, and can be perfected with post-graduate education and certification in

manual therapy. There are many common musculoskeletal ailments treated by PTs

that can benefit from HVLA mobilizations, including adhesive capsulitis, ulnar

abduction (What is ulnar abduction? Not a common term), and lateral ankle sprains.

High velocity low amplitude mobilizations are a common practice in some outpatient

orthopaedic physical therapy clinics and is a necessary skill to be taught to all entry-

level practitioners.

One of the impairments physical therapists treat often with manual therapy is

primary adhesive capsulitis, or frozen shoulder. About 2-5% of the general

population is affected by adhesive capsulitis, which makes it very common in PT

practice1. The etiology behind primary adhesive capsulitis is currently unknown2. In a

study performed by Johnson et al3, it was determined that HVLA mobilizations were

more effective in restoring internal and external rotation of the affected shoulder than

traditional therapy consisting of exercise and massage alone. With insurance


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companies pushing for fewer visits allowed for patients, it is important for the PT to

perform the most effective techniques available to decrease patient pain efficiently

and effectively.

Another common ailment seen in PT practice are lateral elbow injuries.

According to Windsor4, it is reported that 7.4% of industrial workers and 40-50% of

tennis players in the United States are at some time affected by lateral epicondyle

pain. In the same study, it is stated that modalities and non-thrust techniques do not

work well to restore range of motion in an elbow with an abducted ulna 4. There is

one thrust technique that when performed correctly, works to restore near full range

of motion in the elbow of the sufferer4. This also falls under the importance of

efficiency when treating patients. It can save them time, for the patient as well as the

physical therapist. Performing HVLA to treat this condition would prevent the patient

from having to be referred back to the doctor and possibly referred out for an ailment

that could be treated by an entry level physical therapist with basic knowledge in

manual therapy.

Although the most effective technique for treating certain conditions is HVLA

mobilization, other methods of treatment can be successful as well. For example, in

a study focusing on lateral ankle sprains, which is a very common diagnosis, it was

determined that both HVLA mobilization treatment and non-thrust techniques

combined with myofascial release were successful treatments 1 month after 4 weeks

of therapy5. The manual therapy itself was able to improve weight bearing and

mobility of the ankle/foot complex, both with and without HVLA mobilizations5. In

another study relating to shoulder adhesive capsulitis comparing high- and low-
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grade mobilization techniques, similar results were achieved, in that both improved

external rotation and abduction range of motion in a similar time frame6. From this

information, it can be assumed that practicing PTs are capable of treating lateral

ankle sprains without HVLA mobilizations, and the same with adhesive capsulitis if

necessary. However, it may take longer, which unfortunately is not a luxury most

patients/therapists have due to insurance restrictions.

Lateral ankle sprains also can come with another condition, called cuboid

syndrome, which can accompany up to 4% of complaints of foot pain in athletes, and

up to 17% of ballet dancers7. Cuboid syndrome is hard to diagnose, but easy to treat

with HVLA. In a study performed by Jennings and Davies7, 7 patient athletes were

diagnosed and treated for cuboid syndrome with the cuboid thrust manipulation

technique. Of those 7, all of them experienced near full relief following one

manipulation, and only 2 patients returned for a second manipulation to resolve all

symptoms7. If the treating therapist is able to recognize the cluster of signs that point

to cuboid syndrome, the ailment can be treated quite easily with a manipulation.

Having training for the entry level therapists on this condition and learning how to

perform the manipulation in an entry level program could save a large amount of the

athletic population from dealing with pain and prevent a further loss of playing time

from a condition that can be treated quickly with one or two manipulations.

In conclusion, it is found that high velocity low amplitude mobilizations are the

most successful treatments a physical therapist can use when dealing with limited

range of motion in various joints. Although a practicing PT can achieve the same

benefits with less aggressive techniques, it takes more time and is not always as
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effective at restoring range of motion as HVLA techniques. In the current fast- paced

world, efficiency is everything. Insurance companies are covering fewer and fewer

treatments, and it is imperative PTs perform successful treatments in the short time

they are allotted. Therefore, it is in the patients and physical therapists best

interests to include high velocity low amplitude mobilization techniques in the entry-

level PT programs.

Works Cited

1. Hsu JE, Okechukwu AA, Warrender WJ, Abboud JA. Current review of adhesive
capsulitis. J Shou Elbo Surg. April 2011;20(3):502-514. doi:
http://dx.doi.org/10.1016/j.jse.2010.08.023

2. Theresa C, Hannafin JA. Adhesive capsulitis. Tech Shld & Elbo Surg. March
2014;15(1):2-7. doi: 10.1097/BTE.0000000000000015

3. Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior
versus posterior glide joint mobilization on external rotation range of motion in
patients with shoulder adhesive capsulitis. J Orth & Spor Phys Ther. March
2007;37(3):88-99. doi: 10.2519/jospt.2007.2307

4. Windsor B. High-velocity thrust technique for traumatic onset lateral elbow pain. J
Man & Manip Ther. 2006;14(1):37-47. doi: 10.1179/106698106790820845

5. Truyols- Domnguez S, Salom-Moreno J, Abian-Vicen J, Cleland JA, Fernndez-


De-Las-Peas C. Efficacy of thrust and nonthrust manipulation and exercise with
or without the addition of myofascial therapy for the management of acute
inversion ankle sprain: A randomized clinical trial. J Orth & Spor Phys Ther. May
2013;43(5):300-309. doi: 10.2519/jospt.2013.4467

6. Vermeulen HM, Rozing PM, Obermann WR, le Cessie S, Vlieland TPMV.


Comparison of high-grade and low-grade mobilization techniques in the
management of adhesive capsulitis of the shoulder: Randomized controlled trial.
Phys Ther. March 2006;86(3). Available at:
http://ptjournal.apta.org/content/86/3/355.short. Accessed on July 5, 2016.
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7. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle


sprains: A case series. J Orth & Spor Phys Ther. July 2005;35(7):309-415. doi:
10.2519/jospt.2005.35.7.409

PTH 661 Manual Therapy I EBM Literature Review Paper 2016

Student: Grace Blankenhagen Faculty Initials: JTZ

Scoring Criteria
1. Clearly describes the clinical question or purpose 1/1
2. Provides brief description of materials reviewed 1/1
3. Provides synopsis of conclusions/discussion 2/2
4. Assessed the quality of the evidence provided 1/1
5. Identifies why article(s) is/are appealing/interesting 1/1
6. Clinical implications (relevance to practice?) 2/2
7. Grammar/spelling/punctuation 1/1
8. Clarity, organization, conciseness 1/1
Total Score 10 /10

Percent Score 100%

Additional Feedback: Grace, you did a great job with scouring the literature and
finding strong evidence for mobilizations and manipulations. You will need this
type of evidence in clinical practice when questioned by other healthcare
providers or if outcomes dont turn out positively. Stay current in the literature
and I feel you will be an outstanding PT one day! Dr. Zipple