Low-amplitude Manipulation Research Articles

Intended and non-intended kinematic effects of atlanto-axial rotational high-velocity, low-amplitude techniques

IntroductionThe study of neck kinematics during high-velocity, low-amplitude manipulations of the atlanto-axial segment is essential to understanding cervical motion mechanisms and their impact and possible risk for soft-tissue injuries during treatment of spine disorders. MethodsTwenty fresh-frozen specimens were tested during manual application of an axial rotation technique. FindingsThe kinematics indicate the thrust induced motion components of approximately 1° at the treated segment around all three axes of the local embedded reference frame. Moreover, an equal amount of axial rotation motion took place at the adjacent atlanto-occipital joint. InterpretationOverall atlanto-axial motion remained below the level of slow regional mobilization of the cervical spine. These findings can be correlated to literature data concerning the limited increase in vertebral artery strain during high-velocity, low-amplitude manipulation.

Peripheral Oxidative Stress Blood Markers in Patients With Chronic Back or Neck Pain Treated With High-Velocity, Low-Amplitude Manipulation

ObjectiveThe purpose of this study was to investigate oxidative-stress parameters in individuals with chronic neck or back pain after 5 weeks of treatment with high-velocity, low-amplitude (HVLA) spinal manipulation. MethodsTwenty-three individuals aged 38.2 ± 11.7 years with nonspecific chronic neck or back pain verified by the Brazilian Portuguese version of the Chronic Pain Grade, with a sedentary lifestyle, no comorbidities, and not in adjuvant therapy, underwent treatment with HVLA chiropractic manipulation twice weekly for 5 weeks. Therapeutic procedures were carried out by an experienced chiropractor. Blood samples were assessed before and after treatment to determine the activities of the antioxidant enzymes superoxide dismutase (SOD), catalase and glutathione peroxidase (GPx), and the levels of nitric oxide metabolites and lipid hydroperoxides. These blood markers were analyzed by paired Student t test. Differences were considered statistically significant, when P was <.05. ResultsThere was no change in catalase but an increase in SOD (0.35 ± 0.03 U SOD per milligram of protein vs 0.44 ± 0.04 U SOD per milligram of protein; P < .05) and GPx (7.91 ± 0.61 nmol/min per milligram of protein vs 14.07 ± 1.07 nmol/min per milligram of protein; P < .001) activities after the treatment. The nitric oxide metabolites and the lipid hydroperoxides did not change after treatment. ConclusionHigh-velocity, low-amplitude spinal manipulation twice weekly for 5 weeks increases the SOD and GPx activities. Previous studies have shown a relationship between pain and oxidative and nitrosative parameters; thus, it is possible that changes in these enzymes might be related to the analgesic effect of HVLA spinal manipulation.

The Effect of Cervical Spine Manipulation on Postural Sway in Patients With Nonspecific Neck Pain

ObjectiveThis crossover study aimed to determine whether a single high-velocity, low-amplitude manipulation of the cervical spine would affect postural sway in adults with nonspecific neck pain. MethodsTen participants received, in random order, 7 days apart, a high-velocity, low-amplitude manipulation applied to a dysfunctional spinal segment and a passive head-movement control. Four parameters of postural sway were measured before, immediately after, and at 5 and 10 minutes after each procedure. ResultsResults showed no differences between interventions in change in any of the parameters. When changes before and immediately after each procedure were analyzed separately, only the control showed a significant change in the length of center of pressure path (an increase from median, 118 mm; interquartlie range, 93-137 mm to an increase to 132 mm; 112-147; P = .02). ConclusionThis study failed to show evidence that single manipulation of the cervical spine influenced postural sway. Given the ability of the postural control system to reweight the hierarchy of sensory information to compensate for inadequacies in any 1 component, it is possible that any improvements in the mechanisms controlling postural sway elicited by the manipulative intervention may have been concealed.

Chiropractic Care of Acute Low Back Pain and Incidental Spina Bifida Occulta: A Case Report

ObjectiveThe purpose of this case report is to describe chiropractic care of an adolescent with acute low back pain and incidental finding of spina bifida occulta managed with high-velocity low-amplitude manipulation. Clinical FeaturesA 10-year-old boy was referred for chiropractic care by his pediatrician for the management of low back pain after a fall 3 days prior. Examination and medical records revealed the patient also had spina bifida occulta at the level of L5. Intervention and OutcomeHigh-velocity low-amplitude treatment for lower back pain showed resolution of patient's pain after 6 visits. No adverse effects were reported. ConclusionAn adolescent patient with lower back pain and incidental finding of spina bifida occulta improved with a course of care that included with high-velocity low-amplitude manipulation therapy.

Three-dimensional chiropractor-patient contact loads during side posture lumbar spinal manipulation: a pilot study

Abstract Background Patients with low back pain often seek chiropractic care and more than ninety percent of Chiropractors use lumbar side posture manipulation for the treatment of low back pain. During this procedure chiropractors deliver forces by means of hand contact on the patient in a side lying position. The objective of this pilot study was to report on the three-dimensional forces at the hand contact between the chiropractor and the simulated patient (asymptomatic volunteers) during side posture lumbar high velocity low amplitude adjustments. Methods In 2005, two licensed chiropractors delivered spinal manipulations to the lumbar spines of the participants. A three-dimensional force transducer (Model # Mini-45, ATI-Industrial Automation, Apex, North Carolina) was used to measure the three-dimensional loads. The force-time histories were analyzed for preloads, peak loads, duration of thrusts to peak load, duration of thrust for completion, rate of loading, and magnitudes of the three forces and the resultant total force delivered by the chiropractor. Results The two chiropractors delivered a total of 14 thrusts to the five asymptomatic volunteers. Normal force (Fz) is the dominating force, followed by inferior-superior force (Fx). The lateral force (Fy) occurred in both directions. Conclusions This study reports on the three dimensional load (three forces and the total resultant force) characteristics of chiropractor-patient hand contact while delivering a chiropractic high velocity low amplitude (HVLA) manipulation in a side lying position.

Kinematics of the upper cervical spine during high velocity-low amplitude manipulation. Analysis of intra- and inter-operator reliability for pre-manipulation positioning and impulse displacements

To date, kinematics data analyzing continuous 3D motion of upper cervical spine (UCS) manipulation is lacking. This in vitro study aims at investigating inter- and intra-operator reliability of kinematics during high velocity low amplitude manipulation of the UCS.Three fresh specimens were used. Restricted dissection was realized to attach technical clusters to each bone (skull to C2). Motion data was obtained using an optoelectronic system during manipulation. Kinematics data were integrated into specific-subject 3D models to provide anatomical motion representation during thrust manipulation. The reliability of manipulation kinematics was assessed for three practitioners performing two sessions of three repetitions on two separate days.For pre-manipulation positioning, average UCS ROM (SD) were 10° (5°), 22° (5°) and 14° (4°) for lateral bending, axial rotation and flexion–extension, respectively. For the impulse phase, average axial rotation magnitude ranged from 7° to 12°. Reliability analysis showed average RMS up to 8° for pre-manipulation positioning and up to 5° for the impulse phase.As compared to physiological ROM, this study supports the limited angular displacement during manipulation for UCS motion components, especially for axial rotation. Kinematics reliability confirms intra- and inter-operator consistency although pre-manipulation positioning reliability is slightly lower between practitioners and sessions.

Global and regional kinematics of the cervical spine during upper cervical spine manipulation: A reliability analysis of 3D motion data

Studies reporting spine kinematics during cervical manipulation are usually related to continuous global head–trunk motion or discrete angular displacements for pre-positioning. To date, segmental data analyzing continuous kinematics of cervical manipulation is lacking. The objective of this study was to investigate upper cervical spine (UCS) manipulation in vitro. This paper reports an inter- and intra-rater reliability analysis of kinematics during high velocity low amplitude manipulation of the UCS. Integration of kinematics into specific-subject 3D models has been processed as well for providing anatomical motion representation during thrust manipulation.Three unembalmed specimens were included in the study. Restricted dissection was realized to attach technical clusters to each bone of interest (skull, C1–C4 and sternum). During manipulation, bone motion data was computed using an optoelectronic system. The reliability of manipulation kinematics was assessed for three experimented practitioners performing two trials of 3 repetitions on two separate days.During UCS manipulation, average global head–trunk motion ROM (±SD) were 14 ± 5°, 35 ± 7° and 14 ± 8° for lateral bending, axial rotation and flexion-extension, respectively. For regional ROM (C0–C2), amplitudes were 10 ± 5°, 30 ± 5° and 16 ± 4° for the same respective motions. Concerning the reliability, mean RMS ranged from 1° to 4° and from 3° to 6° for intra- and inter-rater comparisons, respectively.The present results confirm the limited angular displacement during manipulation either for global head–trunk or for UCS motion components, especially for axial rotation. Additionally, kinematics variability was low confirming intra- and inter-practitioners consistency of UCS manipulation achievement.

H-reflex responses to High-Velocity Low-Amplitude manipulation in asymptomatic adults

BackgroundHigh-Velocity Low-Amplitude (HVLA) manipulation of the 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. However, its physiologic response is not fully understood, and there is no consensus on H-reflex responses to spinal manipulation. ObjectiveThe purpose is to assess motoneuron excitability by the H-reflex test before and after HVLA manipulation of the lumbar spine of asymptomatic adults. DesignProspective controlled experimental study with pre and post-intervention measures. MethodsThe participants were first submitted to a sacrolumbar (L5-S1) control intervention and after an HVLA manipulation of the same vertebral segment. H-reflex amplitudes 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 experimental procedure. ParticipantsNineteen asymptomatic adults were recruited through public advertisements and referrals from healthcare professionals. ResultsThere 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. ConclusionThe results hypothesize that the electrophysiological effects of HVLA manipulation have different results among participants, and that this variability may be due to dysfunction at the level manipulated, changes in autonomic tone and/or technical issues delivering the technique.

Immediate Effects of Bilateral Sacroiliac Joint Manipulation on Plantar Pressure Distribution in Asymptomatic Participants

To investigate the immediate effects of manipulation of bilateral sacroiliac joints (SIJs) on the plantar pressure distribution in asymptomatic participants in the standing position. Randomized, controlled, double-blind clinical trial. Sixty-two asymptomatic men and women (mean age, 20.66±2.56 years) randomly assigned to 2 groups. The experimental group underwent mobilization without tension of the hips in the supine position and high-velocity, low-amplitude manipulation in the SIJs bilaterally. The control group underwent only mobilization, without tension of the hips in supine position. Pre- and postintervention outcomes measured by an assessor blinded to the treatment allocation of the participants included a baropodometric analysis performed by using a force platform. Baseline between-group differences were examined with a Kolmogorov-Smirnov test. A chi-square test was used for categorical data. Analysis of covariance (ANCOVA) was used to assess differences between groups, with the preintervention value as covariant (95% confidence level). At baseline, no variables significantly differed between groups. Baropodometric analysis showed statistically significant differences in the location of the maximum pressure point in the experimental group (p=0.028). Pre- and postintervention analysis with ANCOVA showed statistically significant differences between both groups in the left hindfoot load percentage (interaction p=0.0259; ANCOVA p=0.0277), right foot load percentage (ANCOVA p=0.0380), and surface of the right forefoot (interaction p=0.0038). There was also a significant effect in the variables that analyze the entire foot (left foot: surface [interaction p=0.0452], percentage of load [ANCOVA p=0.0295]) and between both groups (right foot: weight [interaction p=0.0070; ANCOVA p=0.0296]). Sacroiliac joint manipulation applied bilaterally in asymptomatic persons resulted in immediate changes in load distribution on plantar support in the standing position. Study limitations and suggestions for future studies are discussed.

Staging the use of teaching aids in the development of manipulation skill

Skill development in manual therapies is influenced by a number of factors. The effects of the training program organization, mentor coaching, feedback in various forms, and electromechanical training aids are factors that have been studied. A significant gap exists in understanding when teaching aids might be most effective within a defined curriculum structure. This project used the ratio of instructional theory and laboratory practice to define the learning context. An electromechanical training aid (Dynadjust™) was introduced at different stages (year 2 and year 4) of training for high-velocity, low-amplitude (HVLA) manipulation. Learners were assigned to either the Aid group or the NoAid group. Independent assessment of skill was evaluated before and after 6 weeks by means of recording force–time profiles of HVLA performance. Repeated measures analysis of variance (ANOVA) evaluated change scores in the force amplitude and rate of rise in force. Program features were dominated by a low ratio of laboratory practice to didactic foundational education components. Use of the aid was not associated with any measurable gains for participants when used in year 2. Later participation in year 4 suggested enhanced development in rate of rise for force (p<0.0597) and for peak force (p<0.0303). Careful attention should be given to the sequencing of content and laboratory work in designing curricula for training programs. For programs using lower ratios of laboratory contact hours, teaching aids to augment practice may result in better performance gains when introduced later than if added early in the curriculum.

Effect of Chiropractic Manipulation on Vertical Jump Height in Young Female Athletes with Talocrural Joint Dysfunction: A Single-Blind Randomized Clinical Pilot Trial

ObjectiveThe main objective of this pilot study was to explore the effect of chiropractic high-velocity, low-amplitude (HVLA) manipulation on vertical jump height in young female athletes with talocrural joint dysfunction. MethodsThis was a randomized assessor-blind clinical pilot trial. Twenty-two female handball players with talocrural joint dysfunction were randomized to receive either HVLA manipulation (n = 11) or sham treatment (n = 11) once a week during a 3-week period. The main outcome was change in vertical jump height from baseline to follow-up within and between groups after 3 weeks. ResultsNineteen athletes completed the study. After 3 weeks, the group receiving HVLA manipulation (n = 11) had a statistically significant mean (SD) improvement in vertical jump height of 1.07 (1.23) cm (P = .017). The sham treatment group (n = 8) improved their vertical jump height by 0.59 (2.03) cm (P = .436). The between groups' change was 0.47 cm (95% confidence interval, −1.31 to 2.26; P = .571) in favor of the group receiving HVLA manipulation. Blinding and sham procedures were feasible, and there were no reported adverse events. ConclusionThe results of this pilot study show that a larger-scale study is feasible. Preliminary results suggest that chiropractic HVLA manipulation may increase vertical jump height in young female athletes with talocrural joint dysfunction. However, the clinical result in favor of HVLA manipulation compared with sham treatment needs statistical confirmation in a larger randomized clinical trial.

Three-dimensional chiropractor-patient contact loads during side posture lumbar spinal manipulation: a pilot study

Patients with low back pain often seek chiropractic care and more than ninety percent of Chiropractors use lumbar side posture manipulation for the treatment of low back pain. During this procedure chiropractors deliver forces by means of hand contact on the patient in a side lying position. The objective of this pilot study was to report on the three-dimensional forces at the hand contact between the chiropractor and the simulated patient (asymptomatic volunteers) during side posture lumbar high velocity low amplitude adjustments. In 2005, two licensed chiropractors delivered spinal manipulations to the lumbar spines of the participants. A three-dimensional force transducer (Model # Mini-45, ATI-Industrial Automation, Apex, North Carolina) was used to measure the three-dimensional loads. The force-time histories were analyzed for preloads, peak loads, duration of thrusts to peak load, duration of thrust for completion, rate of loading, and magnitudes of the three forces and the resultant total force delivered by the chiropractor. The two chiropractors delivered a total of 14 thrusts to the five asymptomatic volunteers. Normal force (Fz) is the dominating force, followed by inferior-superior force (Fx). The lateral force (Fy) occurred in both directions. This study reports on the three dimensional load (three forces and the total resultant force) characteristics of chiropractor-patient hand contact while delivering a chiropractic high velocity low amplitude (HVLA) manipulation in a side lying position.

Osteopathic Manipulative Treatment in Tarsal Somatic Dysfunction: A Case Study

The authors present a case of a 24-year-old woman with left foot pain that began after an inversion injury obtained while running. The pain minimally improved with nonsteroidal anti-inflammatory medications. Clinical examination revealed a relatively normal foot with palpable changes in the bony structures at the midfoot consistent with a tarsal subluxation. Cuboid reduction was performed using high-velocity, low-amplitude manipulation, after which the patient reported immediate and near-complete pain relief. The authors also review mechanisms of injury, clinical findings, and treatment modalities for patients with tarsal subluxation.

Spinal High-Velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain

A randomized, double-blinded, placebo-controlled, parallel trial with 3 arms. To investigate in acute nonspecific low back pain (LBP) the effectiveness of spinal high-velocity low-amplitude (HVLA) manipulation compared with the nonsteroidal anti-inflammatory drug diclofenac and with placebo. LBP is an important economical factor in all industrialized countries. Few studies have evaluated the effectiveness of spinal manipulation in comparison to nonsteroidal anti-inflammatory drugs or placebo regarding satisfaction and function of the patient, off-work time, and rescue medication. A total of 101 patients with acute LBP (for <48 hr) were recruited from 5 outpatient practices, exclusion criteria were numerous and strict. The subjects were randomized to 3 groups: (1) spinal manipulation and placebo-diclofenac; (2) sham manipulation and diclofenac; (3) sham manipulation and placebo-diclofenac. Outcomes registered by a second and blinded investigator included self-rated physical disability, function (SF-12), off-work time, and rescue medication between baseline and 12 weeks after randomization. Thirty-seven subjects received spinal manipulation, 38 diclofenac, and 25 no active treatment. The placebo group with a high number of dropouts for unsustainable pain was closed praecox. Comparing the 2 active arms with the placebo group the intervention groups were significantly superior to the control group. Ninety subjects were analyzed in the collective intention to treat. Comparing the 2 intervention groups, the manipulation group was significantly better than the diclofenac group (Mann-Whitney test: P = 0.0134). No adverse effects or harm was registered. In a subgroup of patients with acute nonspecific LBP, spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo.

The immediate effects of pre-event high velocity low amplitude manipulation on sit and reach flexibility, acceleration and velocity speed in rugby union

The immediate effects of pre-event high velocity low amplitude manipulation on sit and reach flexibility, acceleration and velocity speed in rugby union

Effect of High-Velocity, Low-Amplitude Treatment on Superoxide Dismutase and Glutathione Peroxidase Activities in Erythrocytes From Men With Neck Pain

ObjectiveThis study investigates the analgesic effect of high-velocity, low-amplitude (HVLA) manipulation and antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx) in erythrocytes of men with neck pain. MethodsTwenty-two men with neck pain of mechanical origin who were aged 20 to 50 years, were nonsmokers, had a sedentary lifestyle, had no comorbidities, and were not in adjuvant therapy underwent 6 sessions of HVLA chiropractic manipulation 3 times a week for 2 weeks. Patients were treated by the same chiropractor and under the same conditions. Blood samples were collected before the beginning of the treatment and at the end of the third and last session. Erythrocytes were separated from blood and then processed to determine SOD and GPx activities. The quadruple visual scale and the Neck Disability Index were used to demonstrate the analgesic effect of treatment. The results were analyzed by repeated-measures analysis of variance followed by Bonferroni posttest. Differences were considered significant when P was less than .05. ResultsDespite the tendency to reduction in SOD and increase in GPx activities, there was no significant change after the treatment. ConclusionHigh-velocity, low-amplitude treatment for 6 sessions in men with neck pain did not affect systemic SOD and GPx activities. Despite the absence of significant changes, this study is important because it is the first to investigate the activities of SOD and GPx in patients with neck pain treated with HVLA spinal manipulation.

Conservative chiropractic management of urinary incontinence using applied kinesiology: a retrospective case-series report

ObjectiveThe purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI). Clinical FeaturesTwenty-one case files of patients 13 to 90 years of age with UI from a chiropractic clinic were reviewed. The patients had a 4-month to 49-year history of UI and associated muscle dysfunction and low back and/or pelvic pain. Eighteen wore an incontinence pad throughout the day and night at the time of their appointments because of unpredictable UI. Intervention and OutcomePatients were evaluated for muscle impairments in the lumbar spine, pelvis, and pelvic floor and low back and/or hip pain. Positive manual muscle test results of the pelvis, lumbar spine muscles, and pelvic floor muscles were the most common findings. Lumbosacral dysfunction was found in 13 of the cases with pain provocation tests (applied kinesiology sensorimotor challenge); in 8 cases, this sensorimotor challenge was absent. Chiropractic manipulative therapy and soft tissue treatment addressed the soft tissue and articular dysfunctions. Chiropractic manipulative therapy involved high-velocity, low-amplitude manipulation; Cox flexion distraction manipulation; and/or use of a percussion instrument for the treatment of myofascial trigger points. Urinary incontinence symptoms resolved in 10 patients, considerably improved in 7 cases, and slightly improved in 4 cases. Periodic follow-up examinations for the past 6 years, and no less than 2 years, indicate that for each participant in this case-series report, the improvements of UI remained stable. ConclusionThe patients reported in this retrospective case series showed improvement in UI symptoms that persisted over time.

Chiropractic management of pediatric plantar fasciitis: a case report

ObjectiveThe purpose of this report is to present the case of a 10-year-old football player with bilateral plantar fasciitis who improved with a multimodal conservative approach using chiropractic treatment. Clinical FeaturesThe patient presented with bilateral plantar heel pain at the origin of the plantar fascia with a duration of 3 weeks. Intervention and OutcomeTreatment was provided for 6 visits over a 6-week period. Chiropractic care consisted of manipulative therapy, soft tissue therapy, and home rehabilitation exercises. The soft tissue technique (Graston Technique) was performed to the origin of the plantar fascia and the triceps surae bilaterally. High-velocity, low-amplitude manipulation was applied to the restricted ankle mortise joint. After 6 treatments, the patient reported resolution of foot pain bilaterally and improvements in activities of daily livings. Three months later, the patient reported no further complications and the absence of pain. ConclusionThis patient with bilateral plantar fasciitis improved after a course of a multimodal treatment approach using chiropractic manipulation and soft tissue therapy in addition to exercise and stretching therapies.

The Effect of Lumbosacral Manipulation on Corticospinal and Spinal Reflex Excitability on Asymptomatic Participants

ObjectiveThe aim of the study was to examine the effects of a high-velocity, low-amplitude (HVLA) manipulation to the lumbosacral joint on corticospinal excitability, as measured by motor evoked potentials (MEPs) using transcranial magnetic stimulation, and spinal reflex excitability, as measured by the Hoffman reflex (H-reflex). MethodsIn a randomized, controlled, crossover design, 14 asymptomatic volunteers (mean age, 23 ± 5.4 years; 10 men; 4 women) were measured for MEPs and H-reflexes immediately before and after a randomly allocated intervention. The interventions consisted of HVLA applied bilaterally to the lumbosacral joint and a control intervention. Participants returned a week later, and the same procedures were performed using the other intervention. Data for H-reflex and MEP amplitudes were normalized to the M-wave maximum amplitude and analyzed using 2-way analysis of variance with repeated measures. ResultsA significant interaction of treatment by time was found for MEP (F1,13 = 4.87, P = .04), and post hoc analyses showed that the MEP/M-wave maximum ratio decreased significantly in the HVLA treatment (P = .02; effect size, 0.68). For H-reflex, there was a significant effect of time (F1,13 = 8.186, P = .01) and treatment and time interaction (F1,13 = 9.05, P = .01), with post hoc analyses showing that H-reflexes were significantly reduced after the HVLA manipulation (P = .004; effect size, 0.94). There were no significant changes in MEP latency or silent period duration. ConclusionAn HVLA manipulation applied to the lumbosacral joint produced a significant decrease in corticospinal and spinal reflex excitability, and no significant change occurred after the control intervention. The changes in H-reflexes were larger than those in MEPs, suggesting a greater degree of inhibition at the level of the spinal cord.

Chiropractic care of a patient with thoracic outlet syndrome and arrhythmia

Objective The purpose of this article is to describe a case report and discuss a possible anatomical explanation of the occurrence of arrhythmias in patients with thoracic outlet syndrome (TOS). Clinical Features A 60-year-old man experienced arrhythmia when he turned his head to the left and had these symptoms for 7 years. The patient attributed his symptoms to TOS. The arrhythmia was triggered while performing an Adson test during the clinical evaluation. Intervention and Outcome The Grostic procedure as a measure of analysis of the biomechanical relationship of C1 to C0 and the lower cervical spine was performed. According to this analysis, the patient had a right laterality malposition of the atlas. High-velocity, low-amplitude manipulations (adjustments) were applied. The patient's symptoms improved after one visit and demonstrated resolution upon evaluation at the third visit. In the year following the initial presentation, he has had minor recurrent short-lived episodes of arrhythmia that abated with the atlas manipulation/adjustment. Conclusion There is a paucity of published reports describing the management of patients with arrhythmias through manipulative methods. This appears to be the first case that describes the successful amelioration of an arrhythmia associated with TOS using chiropractic adjustment of the atlas vertebra as the sole intervention.