In the annals of chiropractic history and literature, and in the imagination of the public, there is one manual adjusting technique that can produce a wide range of responses, both from patients and casual observers. Experiencing the benefits of the technique can stir appreciation and relief in a patient, but watching the technique being done can evoke curiosity and sometimes, anxiety. Application varies widely, and yet it is a hallmark of chiropractic, portraying the ultimate trust and compliance necessary in the doctor-patient encounter.
Yes, it goes by many names, but the clinical definition has evolved to its present name: the high-velocity, low-amplitude (HVLA) manipulation.
For the rare uninitiated, simply put, the HVLA adjusting technique is accomplished by putting a malaligned joint into a stretched position and giving it a quick "thrust." There is often an audible "release" – the "cracking" sound so often mentioned by patients.
I would venture to say every chiropractic college in the world teaches this technique and every student is required to learn it. But not every DC uses it, and that's because HVLA is rather challenging to master. Learning the technique requires balance, leverage and some strength. The very label, "high-velocity, low-amplitude" connotes speed, yet control.
Myth #1: All DCs Can Do It
In my opinion, the first myth of the HVLA technique is promulgated by the marketing material of many chiropractic schools. I have read educational brochures that suggest this technique, when used for adjusting the lower back, can be learned by any student using crafty leverage and some kind of special positioning of the patient, even if the student is 5 feet tall and missing an arm.
Bless our schools, since they give students the opportunity to learn many effective techniques, but the athletic demands of the HVLA should not be minimized.
Imagine being a flamingo, standing on one leg, using a toilet plunger. That's close to what it is like to perform a lumbar (lower back) HVLA adjustment, with the patient lying on their side.
Not every chiropractor wants to struggle with a 300 lb. male patient precariously balanced on a skinny treatment table. So, other techniques using drop, traction, mechanical instruments, etc., are used instead, and thankfully these offer alternatives to the HVLA.
It has been said female chiropractors often have problems using the HVLA technique when adjusting the lower back with the patient in a side-posture position. This is true and false. As already noted, it has nothing to do with being female, but instead is related to upper-body strength, height and agility.
Perhaps it is politically incorrect to point out that many ladies do not have as much upper-body strength as males and consequently might be disadvantaged in that regard. But that never stopped Dr. Wendy, who was about 5 feet, 2 inches tall and weighed about nothing. I watched her, with surprising adroitness, adjust a big guy's lumbar spine while he was lying on his side.
She kicked off her high heels, raised up her leg and stuck her foot on the man's knee, and then, like kick-starting an old Harley Sportster, she torqued his low back with flair and flurry. He got off the table with a big smile on his face, amused and feeling better.
Myth #2: It's Never Painful
Another myth surrounding the HVLA technique is that it is painless when done by a skilled chiropractor. All DCs know this is false. No matter what part of the spine is treated, this technique can hurt like a punch in the kidneys.
Sure, most of the time, it is robust, but measured. But then ... well, sometimes it just hurts, and that's another reason DCs may refuse to use it. Even the best and most proficient adjuster among us will admit they occasionally hurt people a little or (hopefully) not a lot.
Often, I will explain to a patient that the HVLA technique I am about to use may be uncomfortable, and their reply may be, "Do what you have to do." It makes me feel like a dentist about to pull a tooth. The patient simply wants to get better, and will tolerate what they think is the cure.
So, over the years, I have done what most of my colleagues have done, and that is to learn alternative techniques to the HVLA that will give the same outcomes, without hurting the patient.
Myth #3: We Talk to Our Patients About It
There is no myth about the phrase "high-velocity, low-amplitude" in practical clinical jargon. In my opinion, none of us practicing DCs would ever utter the phrase.
When I talk to patients about treatment, the words I use never include "velocity" (like a speeding bullet), or "amplitude" (like "turn it up!"). That sounds much too scary. In fact, if I told the patient I was going to perform a "low-velocity, high-amplitude" manipulation, what would they picture it looking like?
Fortunately, there's a place and time for HVLA and many other manipulative techniques we utilize in practice.
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