The Somatic Connection  |   May 2018
Cervical HVLA Used as Single Intervention Improves Motion and Strength
Author Notes
  • Western University of Health Sciences-College of Osteopathic Medicine, Pomona, California 
Article Information
The Somatic Connection   |   May 2018
Cervical HVLA Used as Single Intervention Improves Motion and Strength
The Journal of the American Osteopathic Association, May 2018, Vol. 118, 346-348. doi:
The Journal of the American Osteopathic Association, May 2018, Vol. 118, 346-348. doi:
Galindez-Ibarbengoetxea X, Setuain I, Andersen LL, et al. Effects of cervical high-velocity low-amplitude techniques on range of motion, strength performance, and cardiovascular outcomes: a review. J Altern Complement Med. 2017;23(9):667-675. 
Osteopathic physicians have the ability to provide an individualized and unique approach to patients with a variety of chief complaints.1 Despite the efficacy of this approach recorded in the osteopathic literature, meta-analyses and systematic reviews continue to exclude osteopathic research based solely on the study design. The profession needs to be cognizant of this ongoing issue, which diminishes the impact of osteopathic manipulative medicine. 
Cervical high-velocity, low-amplitude (HVLA) is one of the most common techniques used by foreign-trained osteopaths, osteopathic physicians, physiotherapists, and chiropractors. Most research related to HVLA has been in relationship to neck pain or adverse effects after cervical HVLA. This gap in the literature led an international group of researchers to perform a systematic review of randomized controlled trials (RCTs) looking at the isolated effect of cervical HVLA on various conditions, including strength, spine and temporomandibular joint mobility, and the cardiovascular system, with no restriction on the outcomes measured. The researchers excluded studies that used a multimodal approach because, they argued, these studies lacked specificity in the effect size outcomes. Yet, they did not evaluate the effect size of all the included studies for specific outcomes. 
The systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the Cochrane Back Review Group criteria. The authors conducted an electronic database literature search for English-language RCTs published in peer-reviewed scholarly journals from January 2000 to August 2016. Of 2145 articles initially assessed, 11 met the inclusion criteria, in which symptomatic and asymptomatic patients of any age or sex received cervical HVLA as the only intervention. The comparisons included inactive controls, sham, manual contact, quiet rest, or other placebo. The researchers excluded studies that used instrumentation, co-interventions, or comparisons with exercise, medication, patient education, or manipulation outside of the cervical spine. Studies that used a preparatory soft tissue massage were also excluded. 
These exclusion criteria eliminated all US-based RCTs of osteopathic manipulative treatment (OMT), including the sole osteopathic RCT that demonstrated how a single cervical HVLA OMT procedure could be a reasonable and effective alternative to an injectable nonsteroidal anti-inflammatory drug in the emergency department for patients with acute neck pain.2 There is no explanation for the decision to exclude studies that used medication as a comparison group. Included articles had a low risk of bias, and effect sizes were calculated. However, the authors did not critique the quality of the methods in these articles. 
This systematic review found that symptomatic patients had a large effect size after cervical HVLA for increased range of motion (d>0.80) and pain-free handgrip strength (d=0.78). This finding is consistent with Licciardone's landmark study that found that patients with higher baseline low back pain and dysfunction had more significant improvement after OMT.3 
Although the authors concluded that stronger evidence-based studies are needed regarding cervical HVLA, it is unlikely that the osteopathic medical profession will participate in this endeavor because OMT research is conscientiously designed using instrumentation, co-interventions, and comparisons (eg, exercise, medication, patient education, manipulation). Although maintaining this approach is pragmatic, as it lends itself to better external validity, it provides researchers outside the profession with a reason to exclude OMT studies from consideration, as with the American College of Physicians’ clinical practice guidelines regarding nonpharmacologic treatments for patients with low back pain.4-6 There is therefore a need for OMT RCTs with specific outcome measures related to each technique modality to better discern which techniques have the greatest effect and what the combined effect is compared with individual procedures. 
Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014;15:286. [CrossRef] [PubMed]
McReynolds TM, Sheridan BJ. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. J Am Osteopath Assoc. 2005;105(2):57-68. [PubMed]
Licciardone JC, Gatchel RJ, Aryal S. Targeting patient subgroups with chronic low back pain for osteopathic manipulative treatment: responder analyses from a randomized controlled trial. J Am Osteopath Assoc. 2016;116(3):156-168. [CrossRef] [PubMed]
Chou R, Deyo R, Friedly Jet al.   Noninvasive Treatments for Low Back Pain. Comparative Effectiveness Review No. 169. AHRQ publication No. 16-EHC004-EF. Rockville, MD: Agency for Healthcare Research and Quality; February 2016.
Licciardone JC, Gatchel RJ. Nonpharmacologic therapies for low back pain [letter]. Ann Intern Med. 2017;167(8):606. [CrossRef] [PubMed]
Chou R. Nonpharmacologic therapies for low back pain [letter]. Ann Intern Med. 2017;167(8):66-67. [CrossRef] [PubMed]