in this video, we're going to discuss and demonstrate high-velocity, low-amplitude, or HVLA, technique for the lumbar spine. Some keys for HVLA before we begin: we want to remember that it's a direct treatment, so we're going to be positioning our dysfunctional segments into their restricted barrier. We're also going to be remembering the name of the technique: high-velocity, low-amplitude, which is a quick movement over a short distance. We don't need to make big movements in order to get the articulation that we're looking for. We're going to maximize our segmental movement by optimizing the specificity of our directed forces. So as I'm going through this technique, I'm going to be touching a few places on your back, on your pelvis, on your arms, and I'm going to be moving you around. You let me know if it's uncomfortable for you at any point, okay? All right, is it okay if we begin? All right, so I pre-diagnosed my patient with several somatic dysfunctions. So now we're going

to begin by treating our L2 dysfunction, our non-neutral dysfunction, uh, L2 flexed rotated left side left. So, can you lie on your right side facing away from me? Good. So, in this example, we're going to be positioning our patient with the posterior transverse process up or closer to the ceiling. By doing that, we're going to be using their pelvis and lower extremity to engage the lumbar spine to that segment to rotate into their restricted barrier. And then we're going to be using the torso to rotate the rest of their torso and lumbar spine into the opposite direction, further engaging the relative restricted barrier for the segment of interest. Really important, we're going to want to make sure that our table is at a good height so that when we're applying our thrust, we can relatively drop without causing too much strain on our own back. So, just going to lower just a touch, and you can experiment with what height seems to be best for you. So now we also want to have our patient

move a little bit closer to the edge of the table, so go ahead and move a little closer. Good, perfect. And they can start in this relative position with their arm under their head, acting like a pillow, and their knees slightly flexed to provide them a little bit of extra support. So now we're going to find our landmarks. We're going to start with our L2 diagnosis, which is L2 flexed, rotated left side bent left. We're going to begin by using the iliac crest here, then moving down the midline until we find L4 spinous process. Then we're going to move two spinous processes superiorly until we reach L2. So now that we're here at L2, we can monitor at either the spinous process, or we can monitor at the transverse process. This posterior, which is this left transverse process. From here, we're going to be monitoring with our left hand, and then with our right hand, we're going to grab our patient's bottom leg, and you can grab it towards

the middle of the shin or towards the ankle. I'm going to flex their legs and hips until we feel some motion at L2. And once we begin to feel some motion right at L2, then we're going to switch our hand to stabilize this top leg. And we're going to ask our patient to straighten their bottom leg. Go ahead and straighten your bottom leg. Good, good. So now that they've straightened that bottom leg, we want to maintain that bit of flexion with this top leg. And we want to tuck that foot behind their popliteal fossa on that other leg. So now here you have a choice if you want to stabilize with your thigh or if you just want to let it hang if they're balanced enough. And then you're going to go ahead and switch hands. Usually I like to make contact with a greater trochanter here, then switch hands so that now I'm monitoring with my right hand. So now I'm going to induce motion at the thorax and

lumbar vertebra above that segment by rotating the torso. So go ahead and grab my elbow. Good. So then I'm going to grab their elbow with this being a non-neutral segment. L2 flexed, rotated left side a bit left. I'm going to want to side bend to the right. So in order to segment to the right, I'm going to drag that right shoulder inferiorly. So drag it towards me until I feel movement at that L2 segment. And then I'm going to position both arms on top of each other. Then I'm going to snake my arm under their arms. So just can you lift your arms slightly. And then this contact here will be into the axilla and their upper ribs on that side. Now I can switch again my monitoring hand or I can monitor with both hands. And I'm going to release my contact if I've been making it with my thigh. And then induce rotation to the restricted barrier using the pelvis. So here if my forearm is not posterior to the greater

trochanter or to the s i joint. I can shift it so that I make good contact in the posterior pelvis here, and then I'm going to rotate until I feel tension right here at this segment to the restricted barrier. So now when I'm doing this, if I'm meeting my restricted barrier right here and my general force vector through my arm is still horizontal, what I can do is I can maintain this restricted barrier but roll my patient slightly towards me. So now that changes my force vector to be more inferior, that makes a little bit easier to thrust. Now that I'm at this restricted barrier, I'm going to ask my patient to take a few breaths in and out, and as they exhale, I'm going to take up the slack until I meet the maximum restricted barrier. And then at that point, I'll apply a quick but short thrust using my forearm down through the pelvis while stabilizing at this shoulder. In doing that, I'm going to be accentuating that twist right through the segment. So go ahead and take a

breath in, and then out, and then here. I'm taking up some slack, and then one more time, breath in. Now here at the end of exhalation, I'm going to throw. So go ahead and breathe out. Good. And then good. Then I'm going to return my patient back to a neutral position and reassess for somatic dysfunction. So go ahead and uh sit up facing this wall here. Good. So now starting from iliac crests, I'm going to find L4, move up to L2, move lateral to L2 transverse processes, and the left rotation of L2 seems to have improved. Can you go ahead and flex forward, and then come back up, and stick out your chest. Good. And that looks relatively symmetrical to me. Good. So for our next example, we're going to be treating a group curve L3 to L5 neutral rotated left side bent right. So now we're going to be focusing on treating the apex of that curve L4. So again, we're going to have our patient lie on the right side. So go ahead and

line your right side, and we're going to make sure again that our table is at a good height, and that our patient is at a good distance from the edge of the table. Just move slightly to the edge of the table, perfect, that's fine. And now again, we're going to find our landmarks. So, iliac crests moving down to the spinous process of L4. Then we're going to move a little bit lateral to find the transverse process where you can monitor at the spinous process. Then we're going to grab that bottom leg. Here, we're going to flex the hips and knees slightly until we feel engagement right at that segment. As soon as we feel movement, then we're good. Then go ahead and straighten out that bottom leg. Good, perfect. We're going to take this top leg without losing that flexion and engagement, and we're going to just tuck it behind the popliteal fossa here. Then we're going to switch hands, and then we're going to ask our patient to grab our arm. Go ahead and grab my

elbow. So now here because our dysfunction is l4 neutral rotated left side, but right, we're going to want to side bend her to the barrier, which is cybering to the left. So we're going to accomplish that by stepping towards the head and lifting her shoulder up towards her head, which is going to induce relative side bending at our restricted segment to the left. Then we're going to take this arm. We're just going to place it right on their other arm, roll them back for stability. And then can you lift this arm just slightly? We're going to tuck our arm underneath their axilla. Good. And on their upper ribs. And then from here, now that we're in a stable position, we can monitor with our other hand, monitor with both hands if you like, and then use our forearm behind the pelvis and then induce rotation to the restricted barrier. So I'm rotating that l4 to the right. And then from here, if my force vector is still too horizontal, I can roll them towards the edge of the table.

to create more of a vertical force vector, and then I can go through my breath cycles. At the end of the second breath, I'm going to apply a quick but short thrust through the restricted barrier. So go ahead and take a breath in and out, and I'm going to take up the slack. Let that pelvis fall, and then again deep breath in and then out. At the end of the breath, a quick drop down and then back up, and then I would return my patient back to a neutral position and reassess for somatic dysfunction.

OMT: HVLA - Lumbar Spine (Lumbar Roll - Lateral Recumbent; Rotation Emphasis)

Osteopathic Clinical Skills is a channel dedicated to discussing and exploring Osteopathic Clinical Skills concepts for medical students, residents, and clinicians and presenting them in an easy to understand manner.

Throughout the videos in this channel, we explore principles of physical diagnosis and Osteopathic Manipulative Treatment (OMT).

These videos are not intended as a complete source of physical diagnosis or OMT instruction.

Instead, it should be treated as a supplement to independent learning using primary physical diagnosis and Osteopathic Manipulation instructional resources. Clinical skills are best learned and developed with support from faculty in the context of a complete Osteopathic Medical School Curriculum.