International Journal of Osteopathic Medicine (2014) xxx, xxxexxx

www.elsevier.com/ijos

RESEARCH REPORT

H-reflex responses to High-Velocity Low-

Amplitude manipulation in asymptomatic
adults
Sandro Groisman a,*, Luciano Silva a, Natalia Rocha a,
Fabrcia Hoff b, Ma
rcia Elisabeth Rodrigues a,
o Arthur Ehlers b, Leonardo Rios Diniz a
Joa

a
Brazilian Institute of Osteopathic, Rio de Janeiro, Brazil
b
Mae de Deus Hospital, Porto Alegre, Brazil

Received 15 May 2013; revised 28 March 2014; accepted 1 April 2014

KEYWORDS Abstract Background: High-Velocity Low-Amplitude (HVLA) manipulation of the

H-reflex;
Osteopathic manipula-
tion;
Osteopathic Manipula-
tive Treatment (OMT);
Somatic dysfunction;
Spinal manipulation
spine is a broadly used technique in Osteopathic Manipulative Treatment (OMT),
and studies have shown that spinal manipulation might lead to transient decrease
in motoneuronal activity assessed through Hoffmann Reflex (H-reflex) test. Howev-
er, its physiologic response is not fully understood, and there is no consensus on H-
reflex responses to spinal manipulation.
Objective: The purpose is to assess motoneuron excitability by the H-reflex test
before and after HVLA manipulation of the lumbar spine of asymptomatic adults.
Design: Prospective controlled experimental study with pre and post-intervention
measures.
Methods: The participants were first submitted to a sacrolumbar (L5-S1) control inter-
vention and after an HVLA manipulation of the same vertebral segment. H-reflex am-
plitudes were measured before and after the procedures; the participants were
positioned lying on their left side and they did not change the position during the exper-
imental procedure.
Participants: Nineteen asymptomatic adults were recruited through public advertise-
ments and referrals from healthcare professionals.
Results: There was a variation of the H-reflex amplitude; but with no systematic
change across participants. Six out of 19 participants had a decrease on H-reflex
greater than 20% after the manipulation, and no significant change in 13 participants.
Conclusion: The results hypothesize that the electrophysiological effects of HVLA
manipulation have different results among participants, and that this variability may

alves Dias 603, apt 604 e Menino Deus, 90130-061 Porto Alegre, RS, Brazil.
* Corresponding author. Rua Gonc
E-mail address: sandrogroisman@gmail.com (S. Groisman).

http://dx.doi.org/10.1016/j.ijosm.2014.04.001
1746-0689/ 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Groisman S, et al., H-reflex responses to High-Velocity Low-Amplitude manipulation in
asymptomatic adults, International Journal of Osteopathic Medicine (2014), http://dx.doi.org/10.1016/j.ijosm.2014.04.001
2 S. Groisman et al.

be due to dysfunction at the level manipulated, changes in autonomic tone and/or

technical issues delivering the technique.
2014 Elsevier Ltd. All rights reserved.

demonstrated that spinal manipulation might

Implications for clinical practice

High velocity low amplitude manipulation is
commonly used in daily practice to treat back
pain.

It is paramount to understand its physiological
effects and how it affects the body.

Our study shows evidence that the results of
this type of manipulation are variable and this
brings a need for new studies using appro-
priate samples to assess the effects of high
velocity low amplitude manipulation on so-
matic and/or neurovegetative dysfunctions.

Understanding the mechanisms of how oste-
opathic manipulative therapy works, when
properly applied, should contribute to tech-
nique selection and thus the potential to offer
better treatment to our patients.
Introduction
High-Velocity Low-Amplitude (HVLA) manipula-
tion of the spine is a widely used technique in
Osteopathic Manipulative Treatment (OMT) for
acute and chronic low-back pain.1e3 There is
moderate evidence that spinal manipulation may
reduce pain and improve function in chronic and
acute low back pain in the short term when
compared with sham spinal manipulation.4,5
However, the therapeutic mechanisms are not
thoroughly understood.6
The monosynaptic stretch reflex can play a
major role in motion restriction, and it had been
suggested that OMT could restore range of motion
by resetting the stretch receptor gain.7e10
The H-reflex is an estimate of alpha moto-
neuron (aMN) excitability and can be used to
investigate whether an intervention such as spinal
manipulation changes the H-reflex intensity by
altering the monosynaptic reflex transmission
within the spinal cord.11,12 Studies show that
patients with spinal cord injuries, and with acute
or chronic low back dysfunction have altered H-
reflex responses when compared with healthy
participants.13,14 Furthermore, Humphreys et al.15
normalize H-reflex responses.
Floman et al.16 investigated the H-reflex re-
sponses in participants with L5-S1 unilateral disc
herniation before and after lumbar spine manip-
ulation in side-lying position. At pre-manipulation
phase the H-reflex mean amplitude was signifi-
cantly lower on the side of disc herniation, and
after lumbar manipulation the H-reflex increased
significantly on the affected side while the values
on the healthy side remained unchanged.17
These findings diverge from the study of Dish-
man et al.18,19 who assessed the effects of spinal
manipulation on tibial nerve H-reflex recorded
from the gastrocnemius muscle in 17 healthy par-
ticipants. They observed the suppression of
motoneuron activity after lumbar (L5-S1) manipu-
lation; but the experimental protocol involved
changing the position of spinal manipulation and
H-reflex testing.18,19
Suter et al.17 investigated healthy participants
and patients with low back pain and observed no
significant changes in H-reflex amplitude in
healthy participants receiving manipulation to the
sacroiliac joint (SIJ) e with participants in the
same position, i.e., the participants were not
moved during the procedure. They concluded that
H-reflex responses after SIJ manipulation are sen-
sitive to movement/repositioning, and that the H-
reflex depression after manipulation documented
in previous studies were movement artifacts rather
than treatment effects. However, participants
with low back pain presented changes in motor
neuron excitability after SIJ manipulation,
because the H-reflex amplitude response
decreased 20% after treatment compared with the
measures before treatment. It is noteworthy that
the protocol used by Dishman et al.18 was L5-S1
manipulation and the protocol used by Suter
et al.17 was SIJ manipulation.
Dishman et al.18 reported the H-reflex attenu-
ation after L5-S1 spinal manipulation, where a
constant prone position was utilized during the
whole experiment. Nevertheless they changed the
direction of the applied force vectors when per-
forming the procedures. In a recent study Orakifar
et al.21 also demonstrated H-reflex attenuation
after SIJ manipulation, and they attributed it to
inhibited Ia afferents discharge.

Please cite this article in press as: Groisman S, et al., H-reflex responses to High-Velocity Low-Amplitude manipulation in
asymptomatic adults, International Journal of Osteopathic Medicine (2014), http://dx.doi.org/10.1016/j.ijosm.2014.04.001
H-reflex responses to High-Velocity Low-Amplitude manipulation
Current literature shows controversial results
in the measurement of the H-reflex before and
after spinal manipulation, and this is mainly
because of different methodologies. Therefore
the present study intends to investigate H-reflex
responses to HVLA manipulation of L5-S1 verte-
bral segment in healthy participants, without
changes in the body position between spinal
manipulation and H-reflex measurement, i.e., the
participants remained lying on their left side
throughout the procedures.
Methods
Participants
Healthy participants with no history of low back
pain within the last 3 months, no radiculopathy or
neuropathy of the lower limbs, or other musculo-
skeletal disorders were eligible to participate in
the study. They were recruited through public
advertisements and referrals from healthcare
professionals. All participants signed an informed
consent and the study was approved by the Medi-
cal Ethics Committee of the Ma e de Deus hospital
under the number: 209/08.
Exclusion criteria: neoplasm, lower limbs sur-
gery; manipulative treatment of the foot, ankle
and/or lumbar spine within the last 4 months. All
participants were submitted to neurological ex-
amination (dermatomes, muscle function and deep
tendon reflexes) to exclude participants with rad-
iculopathy or peripheral neuropathy.
Experimental protocol
The procedures were delivered with the partici-
pants lying on their left side on a treatment table.
Every participant received the following protocol:
1) control intervention, 2) HVLA lumbar manipu-
lation of the right L5-S1 joint; and 3) measurement
of H-reflex response before and after intervention.
Measurement of the H-reflex
H-reflex was measured in milivolts (mv) before and
after the lumbar manipulation and control inter-
vention using the standard methodology. To stim-
ulate the tibial nerve, the electrical stimulator
was placed on the participants skin centrally
within the popliteal fossa between the biceps
femoris and semimembranosus tendons. Surface
electrodes with a 1-cm active diameter were
wrapped with an elastic bandage for better skin/
Please cite this article in press as: Groisman S, et al., H-reflex responses to High-Velocity Low-Amplitude manipulation in
asymptomatic adults, International Journal of Osteopathic Medicine (2014), http://dx.doi.org/10.1016/j.ijosm.2014.04.001
3
electrode contact. Before attaching the recording
electrodes, the skin was shaved and cleansed with
alcohol. The electrodes were placed approxi-
mately 2 cm to the distal end of the medial and
lateral gastrocnemius and superior to the Achilles
tendon to measure the H-reflex response.22
The optimal stimulation voltage was individually
determined by performing stimulations of
increasing intensity from 0 to 100 V in 2-volt in-
crements. The Hmax recruitment curve was
generated by increasing stimulus intensity until a
maximal H-wave and minimal M-wave response
was reached, where M-wave is the response of the
muscle in relation to electric stimulation. Ten H-
reflex amplitude measurements were recorded
before and after spinal manipulation and control
intervention.23
The EMG signal was bandpass filtered
(10 Hze10 kHz) and amplified using the Synergy N-
EP Biolink EMG system. The evoked EMG responses
were collected using an analog-to-digital con-
verter (12-bit resolution) interfaced to a computer
and the sampling rate was 5 kHz per channel. The
deliverance of the peripheral nerve stimulus was
controlled through the computers digital output
port interface. The Synergy software was used for
data acquisition and the EMG amplitudes of H-re-
flex responses were detected and stored in a data
output file for statistical analysis.
Participants were asked not to talk and to keep
their head, arms, and lower extremities relaxed
during the experimental to minimize changes in H-
reflex response because of muscle contraction,
change in joint position, or tonic reflexes. The
whole procedure lasted 10 min.
Spinal manipulation and control
intervention
Participants laid on their left side; the control
intervention was performed first and then the
HVLA spinal manipulation. Both were performed
by a 5th year osteopathic medicine student. A
control intervention was performed by placing the
hands on the right L5-S1 joint and taking up the
joint slack and no manipulative thrust was per-
formed. For the High-Velocity Low-Amplitude
(HVLA) manipulation, the clinician manually con-
tacted the tissues overlying the lumbar zyg-
apophyseal joint, tension was increased with a
rotation force, pelvis and lumbar spine were
rotated towards the practitioner until motion was
palpated at the L5-S1 segment. The participants
upper body was rotated away from the practi-
tioner until a sense of tension was palpated at the
4 S. Groisman et al.
Table 1 Characteristics of participants.
Total n 19
Age, years 31  5
Male sex 12 (63%)
Height, cm 174  6,5
Weight, Kg 74  10
Values in mean  SD or n (%).
L5-S1 segment; the leg of the participant during
the procedure remained extended. The direction
of thrust was towards the table accompanied by
pelvic rotation. The achievement of a cavitation
was not recorded.24
Data analysis
Data were analyzed using SPSS version 17.0, sta-
tistical software package. The dependent vari-
ables were H-reflex expressed in milivolts (mv)
using median and percentile (25the75th).
The assumptions for the use of parametric sta-
tistics were not satisfied for H-reflex average
amplitude, based on the analysis of skewness and
kurtosis to compare pre-intervention and post-
intervention. Therefore, nonparametric analysis
was necessary. The immediate changes (H-reflex
response) before and after manipulation was
compared using median and the Wilcoxon test for
paired samples, with a significance level of 0.05.
The distribution of results are presented as median
and percentile (25the75th).
Results
Data from one participant was excluded from the
analysis because it was not possible to acquire
both M-wave and H-reflex data. Nineteen (19)
remaining participants were analyzed (12 males,
63.2%), the mean age was 30.8  5.5 years, weight
73.8  10.3 kg, height 171  6.5 cm (Table 1).
The median H-reflex of all 19 participants
demonstrated no statistically significant changes
after receiving lumbar manipulation. Table 2
shows the median results (25th75th percentile)
before and after manipulation. Fig. 1 shows me-
dian and percentile 25the75th of the H-reflex
amplitude before and after spinal manipulation
and control intervention; there were no significant
differences.
Six out of 19 participants showed a decrease
greater than 20% in the H-reflex amplitude imme-
diately after manipulation e concurring with the
Please cite this article in press as: Groisman S, et al., H-reflex responses to High-Velocity Low-Amplitude manipulation in
asymptomatic adults, International Journal of Osteopathic Medicine (2014), http://dx.doi.org/10.1016/j.ijosm.2014.04.001
Table 2 Data electroneurograph.
Hoffmann Pre Post p-Value
reflex
amplitude
Hmax, mV 2.8 (1.9e4.5) 2.5 (1.3e3.8) p 0.432
(LM)
Hmax, mV 2.7 (1.9e3.5) 2.8 (1.5e4.1) p 0.752
(CI)
Hmax, mV 5.4 (3.5e7.0) 2.8 (2.2e4.5) p 0.002
(PSD)
Abbreviations: Hmax, Maximun Hoffmann reflex amplitud;
Pre, pre lumbar manipulation; Post, post lumbar manipula-
tion; CI, control intervention; LM, lumbar manipulation;
PSD, participants showed a depression of the H-reflex.
Values in median (25th75th percentile). p-Values, com-
parisons by Wilcoxon signed rank test.
percentage found by Suter et al.17 When these 6
participants were evaluated separately the H-re-
flex median amplitude (25the75th percentile)
dropped from 5.4 mv (3.5e7.0) before manipula-
tion to 2.8 mv (2.2e4.5) after manipulation, with
statistical significance (p 0.002). Moreover, the
same group of 6 participants showed no statisti-
cally significant change before and after the con-
trol intervention (Fig. 2).
Discussion
Previous studies have shown an attenuation of the
H-reflex in healthy volunteers after HVLA manip-
ulation of the lumbosacral joint L5-S1, and the
authors attributed the results to a possible aMN
inhibition caused by zygapophyseal joint disten-
sion.25 The present study has demonstrated
changes only in 6 out of 19 participants, and there
was no randomization of the order of the in-
terventions; because HVLA manipulation before
the control intervention could modify the H-reflex
response.
Indahl et al.,7 using a porcine model, reported
that distension of the zygapophyseal joint by in-
jection of physiologic saline solution reduced the
amplitudes of motor unit action potentials recor-
ded from the paraspinal musculature.
Based on these physiological effects, Dishman
et al. assessed H-reflex in healthy participants
before and after L5-S1 manipulation and observed
attenuation after manipulation.18 However, others
authors did not observe H-reflex attenuation in
healthy participants receiving spinal manipulation
when H-reflex testing and manipulation were
H-reflex responses to High-Velocity Low-Amplitude manipulation 5

Fig. 1 Changes in Hmax after the administration of a side-posture HLVA manipulation comparing nineteen partic-
ipants Values in median (25the75th percentile). Abbreviations: Hmax, Maximun Hoffmann reflex amplitude; Pre, pre
manipulation; Post, post manipulation; Manipulation, experimental procedure; Sham control procedure.

performed in the same position, i.e., the participant
was not moved during the procedure.20 Thus, these
authors concluded that H-reflex responses to
manipulation are sensitive to movement/reposi-
tioning, and that the H-reflex depressions following
manipulation documented in previous studies were
movement artifacts, with subsequent distension of
the z-joint capsule, rather than treatment effects.17
However, unlike the work of Dishman et al., who
applied a manipulation to the lumbosacral joint,
Cramer et al. applied the manipulation to the SIJ,
instead of lumbosacral joint.26 This methodological
difference hinders the comparison between the
studies because the sensory innervation of the
sacroiliac and lumbosacral joints are distinct. In the
L5-S1 region the zygapophyseal joint, ligaments and
monoarticular muscles receive sensory and motor
inputs mainly from the L5 root e the main compo-
nent of the tibial nerve, and the SIJ receives sensory
inputs from the L2-S3 roots.27,28
To minimize movement artifacts, Dishman
et al. performed an L5-S1 manipulation and the
measurement of the H-reflex in the same body
position. They observed an attenuation of moto-
neuronal activity, and they suggest that the
manipulation caused the H-reflex attenuation.20

Fig. 2 Changes in Hmax after the administration of a side-posture HLVA manipulation comparing six of the nineteen
participants that demonstrated attenuation in H-reflex median (H-reflex attenuation >20%) Values in median
(25th75th percentile). p-Values, comparisons by Wilcoxon test. Abbreviations: Hmax, Maximun Hoffmann reflex
amplitude; Pre, pre manipulation; Post, post manipulation.

Please cite this article in press as: Groisman S, et al., H-reflex responses to High-Velocity Low-Amplitude manipulation in
asymptomatic adults, International Journal of Osteopathic Medicine (2014), http://dx.doi.org/10.1016/j.ijosm.2014.04.001
6 S. Groisman et al.
In the present study, the lumbosacral HVLA was
performed in the same body position as the mea-
surement of the H-reflex. Compared with previous
authors, H-reflex attenuation was demonstrated
only in 6 out of 19 participants. It is possible that
these results are due to pre-synaptic inhibition or
other synaptic processes within the spinal cord.
A proposed after-effects mechanism would
explain these outcomes, i.e. after HVLA manipula-
tion, a post-activation depression phenomenon
occurred which was triggered by the mechanical
strain of the ligament-muscular system of the spine,
subsequently inhibiting the alpha motoneuron ac-
tivity.29 Mechanical strain associated with the
application of an HVLA could change the mechanical
and neural properties of the muscle spindle.
The mechanoreceptors and free nerve endings
in the annulus fibrosus, zygapophyseal joint
capsule and ligaments of the spine are potentially
involved as are the group Ib, III and IV muscle af-
ferents from receptive fields within and near the
facet join capsule. Mechanical stimulation (i.e.
through HVLA manipulation) might inhibit aMN and
stimulate gamma motoneurons (gMN) as well as
the sympathetic nervous system.30,31
The absence of cavitation during HVLA manip-
ulation, or to cavitation occurring in a spinal
segment above L4/L5, could account for those
participants who did not demonstrate attenuation
of the H-reflex in the present study. This variable
was not assessed because the physiological
response with or without cavitation was not our
objective.
Gibbons & Tehan25 describe cavitation as the
aim of HVLA manipulation, and Bereznick33 et al.
define cavitation as a result of a drop in the in-
ternal joint pressure without an increase in the
size of the joint space and gas.
Gas is found inside the joint and is reabsorbed
into the synovial fluid within 15e30 min e this
period is known as the refractory period. Widening
of lumbar zygapophyseal joints post manipulation
has been demonstrated by magnetic resonance
imaging following lumbar osteopathic manipula-
tion.26 It could be the combination of cavitation
with distension of the joint capsule generating
changes in the stimulation of the motoneurons.
A limitation of the current study stems from the
use of the gastrocnemius muscle H-reflex as an index
of motoneuronal excitability of the lumbar spine.
The authors chose this technique because the L4/5
nerve root forms the tibial nerve, and the use of
healthy participants. Thus, it is not possible to
extrapolate the results to patients suffering from low
back pain. In addition, there was not any cavitation
during the HVLA manipulation for all participants.
Please cite this article in press as: Groisman S, et al., H-reflex responses to High-Velocity Low-Amplitude manipulation in
asymptomatic adults, International Journal of Osteopathic Medicine (2014), http://dx.doi.org/10.1016/j.ijosm.2014.04.001
Future studies should investigate the H-reflex
changes in symptomatic participants and poten-
tially measure the autonomic nervous system var-
iables to assess their relationship to the H-reflex.
Conclusion
The present study provides preliminary data on
the short-term effects of HVLA manipulation on
the H-reflex. The findings suggest that the
response to manipulation varies and depends on
the individual; because it changes in some but not
in all participants. The results support the hy-
pothesis that H-reflex attenuation differs be-
tween people.
Future studies on neurophysiologic effects of
lumbar manipulation should consider the presence of
somatic and autonomic dysfunction in order to
investigate the H-reflex variations between
participants.
Authors contributions
Natalia Rocha, Sandro Groisman, Luciano Silva,
Fabrcia Hofff, Marcia Rodrigues conceived the
idea for the study, contributed to the design and
planning of the research.
All authors were involved in data collection.
Sandro Groisman, Luciano Silva and Fabrcia
Hofff analyzed the data. Joa o A Ehlers, Sandro
Groisman, Luciano Silva and Leonardo Diniz were
involved in H-reflex collection.
Sandro Groisman, Luciano Silva, Fabrcia Hofff
wrote the first draft of the manuscript and coor-
dinated funding for the project. Leonardo Diniz
revised the final manuscript after Journal review.
All authors edited and approved the final
version of the manuscript.
All authors were involved in literature search,
figures, study design, data analysis, data
interpretation.
Conflicts of interest statement
None declared.
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asymptomatic adults, International Journal of Osteopathic Medicine (2014), http://dx.doi.org/10.1016/j.ijosm.2014.04.001
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