Minimal Lever Osteo-Articular Adjustment Technique

Daryl Herbert DO

Daryl Herbert

Information about Daryl Herbert

Daryl Herbert has 30 years experience as an osteopath and 26 years experience of teaching Advanced Spinal Manipulation. His friendly and clear style is appreciated by all manual therapists in teaching spinal manipulation techniques. This course will provide you with skills, tips and tricks that will give you the knowledge, practical exercises that will allow you to develop your own style and will enable you to get more optimum manipulation results in clinical practice

Please have a look here for further informations.

or find his course:
Osteoartikuläre Adjustierungen der Brust- und Lendenwirbelsäule mit „minimalem Hebel“
Datum: 06., 07. & 08.07.2018
Dozent: Daryl Herbert D.O., United Kingdom
Kurssprache: Englisch
Kursgebühr: 335,00 Euro (für Osteopathieschüler) und 380,00 Euro (für Osteopathen)
Kursort: SKOM, Wandalenweg 14-20, 20097 Hamburg

An Explanation of the Concepts and Benefits of Osteopathic Minimal Lever osteoArticular Adjustment Technique

This is a specific style of adjustment or impulse technique designed to cavitate a single Spinal Apophyseal Facet Joint.

It is based on good foundations, of Handling, Operator Posture & Stance, then focusing and targeting a specific vertebral segment accurately, choosing a primary lever direction (the primary lever is the direction of the impulse, which usually initiates the start of technique. Try to choose a sliding direction for the particular facet joint. Sliding is ‘more physiological’ less effort required, gapping is ‘less physiological’ more effort required but very appropriate in certain situations). The Primary Lever is kept minimal by the use of adding multiple small Secondary Levers and summating their affects to reduce the amplitude of the Primary Lever direction. Finally the Impulse for this style of technique is kept gentle but positive and the amplitude of the impulse is kept very small. Due to the combination of small multiple secondary components, which are summated (added) together, this controls and minimizes the amplitude of the Primary Lever direction and controls to a minimum any torsion involved in the technique. More importantly this keeps the technique in what is described as the neutral arc or mid range of the joints movement. Thus avoiding working at the Physiological or Anatomical “End of Range’ of the joints movement, also avoids working at the ‘lesion’ position for the joint. The therapist creates or manufactures a barrier in the neutral arc or mid range making the technique safe, but gentle, soft, comfortable, controlled and accurate. When a small impulse is applied here a change is made without excessively forcing the barrier. A cavitation sound may or may not be felt or heard but due to the small impulse and effort being put into the joint its function will be altered and normal function will be restored, maybe in one session or more gradually over a small number of sessions. Only one or maybe two small impulses are attempted and no further repetition, not forced and change can still be achieved. If there is no cavitation with the impulse then as the tension or barrier point is in the neutral arc or mid range point then the technique is still completely safe.

Patients are set up into a basic but formalized position avoiding any torsion, avoiding generalized locking of the whole spine or locking of the region being worked on. The Operator will move into the appropriate position maintaining good close & comfortable contact, using optimum handling, posture & feet position.

Using ‘Directional Compression’ from the Operators body & hands/arms the ‘chosen’ segment is targeted accurately using a compressing non-torsional sinking movement into the patient, focusing to the single segment whilst adjacent segments above and below are ‘free’ & not involved. Directional compression is similar to pre-loading but even more beneficial and helpful. Pre-loading is the effort put into the technique to produce tissue tension, compaction of fluid within the soft tissues. It is non torsional, added gradually in ‘layers’. Directional Compression has the advantage of directing the above effort to the chosen joint increasing accuracy and specificity.

The Primary Lever is then chosen, usually to slide the facet surfaces, although it can be a gapping and the amplitude of the Primary Lever at the specific chosen segment is tested. It is then backed off. Then some of the 1st chosen Secondary Lever is introduced and kept, the Primary Lever is then retested. If the 1st Chosen Secondary Lever is helpful the amplitude of the Primary will be less. The Primary is then taken off and the Secondary kept. Then some of the 2nd Chosen Secondary Lever is introduced and the Primary Lever is retested. If the Primary Lever amplitude is less, this is good. The Primary Lever is backed off and then some of the 3rd Chosen Primary Lever is introduced. The Primary Lever is again re tested and should be further reduced. This process/routine is further continued until the primary lever is firm and stops. This is the barrier.

The Primary Lever is now introduced as a small impulse only, whilst maintaining all the components as previously described. Furthermore do not back off from the barrier. Impulses are often difficult to just initiate from nothing, so we will often make the end of the technique a little dynamic and make ‘mini’ impulses, which in themselves can achieve a release as the tension ‘self-builds’ in the patients own tissues, whilst holding the barrier and the technique firm. A slightly more positive impulse can be used, maybe required to achieve cavitation.

Impulse techniques as above are not easy to learn but are extremely safe when applied optimally, constant training is required to obtain good and expert skills to develop this safe and controlled approach.

The Difference compared to Long Lever or what is also known as Combined Lever!

Generally speaking Long Lever is very torsional, using locking of the spine to the relevant joint, usually at the point of the lesion, which can be painful or at the physiological and or anatomical end of range. Sometimes extra components are introduced but to help with locking not to reduce torsion. In Long Lever the impulse is also usually large. The same can be said for Combined Lever, which is the same, but extra components are added in the technique but it is usually once again torsional and painful. Since the locking position is at end of range then a large and often too forceful impulse can definitely cause damage & pain.

The Difference between HVLA & Minimal Lever Techniques
Some definitions:

The term HVLA comes from the 2002 textbook “Chiropractic Technique” by Peterson and Bergmann, described on p 99.  They use HVLA to describe “the adjustive thrust” of the
Clinician.  They state the HVLA thrust “is a ballistic force of controlled velocity, depth and direction”.

High Velocity Low Amplitude (HVLA) thrust procedures take place when the practitioner applies a rapid thrust that is accompanied by a “popping” or “cracking” sound. The aim of these manipulation techniques is to achieve joint cavitation.

HVLA is a general type of manipulative treatment that involves a quick thrust over a short distance through what is termed a pathologic barrier. The movement is within a joint’s normal range of motion and does not exceed the anatomic barrier or range of motion. With proper positioning of the patient, high-velocity-low-amplitude requires very little force and can be specifically targeted to spinal segments. The goal of the treatment is restoration of joint play or a desirable gap between articulating surfaces.

Generally regarding HVLA techniques, most practitioners and teachers who say they are using this style do so, but really do not control the amplitude of all the ‘amplitude related components and factors’ that are involved in adjustment techniques. HVLA techniques are still torsional and stressing and uncomfortable to the patients and certainly are nearer to the end of range, anatomical or physiological, of the joints movement and not at the mid range and finally less accurate to single specific Apophyseal facet joints.

Minimal Lever is similar and yet quite different because it is a lot more specific in its formulation. The technique is set up as described as above, the focus point and barrier is built up, using pre-loading and directional compression. The focus point/barrier is mid range in the primary lever movement direction. All the multiple secondary levers are small and mid range, the impulse amplitude is very small, made with small repetitive ‘mini’ impulse like movements. Due to the pre-load and directional compression focusing accurately to the joint, choosing to slide or gap the joint in order to achieve a possible cavitation, the bodies own tissues self build the tension whilst maintaining all the components static and just increasing the compressions or translation movements, or as the same (non increasing) repeated small mini impulses are made.

Therefore Minimal Lever is not aggressive, not torsional, not locking, not end of range (with respect to the primary lever or secondary lever directions), not fast (although if faster speed is needed or required, it can be) and often liked by many patients. Minimal Lever is more comfortable, more relaxing, positive, controlled, accurate, effective, efficient and generally well received by patients. Finally it is a safer technique in experienced and trained hands and many contra-indications become less absolute or only relative due to the above explanations. Although this does not mean that contra-indications should be excluded, diluted or ignored!

Minimal Lever is an integral part of osteopathy and is one of many specific therapeutic techniques entrenched from our origins and continuously developing through the years. It has reached a point now where it can still grow and develop further as we learn and know more and are able to research further.

My descriptions and ideas as above are based on over twenty years of teaching and clinical experience, including learning from and being mentored by Prof L Hartman DO PhD, author of the Handbook of Osteopathic Technique.

Book Reference:
L Hartman, Handbook of Osteopathic Technique
P Greenman Principles of Manual Medicine

David W. Evans, BSc(Hons)Ost,a and Alan C. Breen, DC, PhDb (2006)

Why do spinal manipulation techniques take the form they do? Towards a general model of spinal manipulation David W. Evans* Research Centre, British School of Osteopathy, London SE1 1JE, UK (March 2009)

What is ‘manipulation’? A reappraisal. David W Evans and Nicholas Lucas December 2009

Mechanisms And Effects of Spinal High-Veolcity, Low-Amplitude Thrust Manipulation: Previous Theories. David W. Evans, BSc (Hons) Ost August 1, 2001

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