Today’s OMM question involves a 35-year-old woman with pain radiating down from the bottom of her skull toward her lower neck. How would you set up for HVLA to the occipitoatlantal joint in this patient?
A 35-year-old woman presents to your clinic for one week of moderately severe pain radiating down from the bottom of her skull toward her lower neck. She has no numbness, tingling, photophobia or back pain. She has no family or personal history of osteoporosis or rheumatoid arthritis. Her temperature is 37 ºC (98.6 ºF), pulse is 66/min, respirations are 12/min, blood pressure is 118/75 mmHg. Physical examination of the occipitoatlantal joint shows a deep right sulcus which evens out with the left sulcus upon extension. Her friend sees an osteopathic physician who recommended HVLA techniques to her. How would you set up for HVLA to the occipitoatlantal joint in this patient?
A. Position her in neutral, with your 2nd MCP joint against her right posterior occiput
B. Position her in flexion, with your 2nd MCP joint against her left posterior occiput
C. Position her in flexion, with your 2nd MCP joint against her right posterior occiput
D. Position her in extension, with your 2nd MCP joint against her right posterior occiput
E. Position her in extension, with your 2nd MCP joint against her left posterior occiput
Scroll down for the correct answer!
The correct answer to today’s OMM Question is…
C. Position her in flexion, with your 2nd MCP joint against her right posterior occiput
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
The incorrect answers to today’s OMM Question are…
A. Position her in neutral, with your 2nd MCP joint against her right posterior occiput
Since her OA joint is E SL RR, you should place her joint in slight flexion with left rotation and slight right sidebending. This is the correct side for setup but does not include the slight flexion component.
B. Position her in flexion, with your 2nd MCP joint against her left posterior occiput
Since her OA joint is E SL RR, you should place her joint in slight flexion with left rotation and slight right sidebending. This correctly includes flexion but is the wrong side for setup.
D. Position her in extension, with your 2nd MCP joint against her right posterior occiput
Since her OA joint is E SL RR, you should place her joint in slight flexion with left rotation and slight right sidebending. This is the correct side for setup, but she should be flexed rather than extended.
E. Position her in extension, with your 2nd MCP joint against her left posterior occiput
Since her OA joint is E SL RR, you should place her joint in slight flexion with left rotation and slight right sidebending. This represents her somatic dysfunction and would be correct if she had the opposite findings.
Main Explanation
Rotation and sidebending always go in opposite directions at the OA joint, so you can diagnose both of these motions by only testing one of them. Use the depth of the sulci to determine the rotation (the deeper sulcus is the side of rotation), and the translation of the joint to determine sidebending (e.g. easier leftward translation means sidebent right). Flexion/extension (or neutral) is determined by which motion causes the sulci to even out.
HVLA is a direct technique in which you take a patient to their barrier and then provide a low amplitude thrust directly into the barrier. Like muscle energy, patients should be set up directly opposite of their somatic dysfunction (freedom of motion). Be very careful to only extend the occipitoatlantal joint and not involve the lower cervical spine. Remember contraindications to HVLA of the cervical spine, such as osteoporosis, previous fracture to the area, severe or longstanding rheumatoid arthritis, Down syndrome.
Major Takeaway
Once you have established the diagnosis, take the patient to their barrier by positioning directly opposite of their somatic dysfunction, then perform a low amplitude thrust through the barrier. For patients with a flexed dysfunction, remember to only extend at the occipitoatlantal joint and not involve the lower cervical spine.
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