International Journal of Osteopathic Medicine 10 (2007) 42e49

www.elsevier.com/locate/ijosm

Research report

The effects of high-velocity, low-amplitude manipulation

and muscle energy technique on suboccipital tenderness
Luke Hamilton a,*, Caitlin Boswell a, Gary Fryer a,b,c
a
School of Health Sciences, Victoria University, Melbourne, Australia
b
Centre for Ageing, Rehabilitation and Exercise Science, Victoria University, Melbourne, Australia
c
A.T. Still Research Institute, Kirksville, MO, USA
Received 25 March 2007; received in revised form 15 August 2007; accepted 21 August 2007

Abstract

Background and objectives: High-velocity, low-amplitude (HVLA) manipulation and muscle energy technique (MET) are commonly
advocated by manual therapists to resolve pain and dysfunction. The aim of this controlled, single blinded study was to investigate
whether HVLA manipulation of the occipitoeatlantal (OA) joint and/or an MET stretch had an effect on pressure pain thresholds
(PPT) in the suboccipital musculature in an asymptomatic population.
Methods: Participants (N ¼ 90; mean age ¼ 23  5; 29 males and 61 females) were screened for suitability and PPT measurements
were made using a hand-held electronic algometer which was positioned centrally in the suboccipital region. Participants were ran-
domly allocated into three intervention groups and then received an HVLA thrust to cavitate the right and left OA joints, an MET
stretch applied to the suboccipital muscles bilaterally, or a sham ‘functional’ technique. Post-intervention PPT measurements were
recorded at 5 and 30 min.
Analysis: Analysis of the PPT data using a SPANOVA revealed a significant difference over time (F2,174 ¼ 8.80, P < 0.01), but no
significant difference between the groups (F2,87 ¼ 0.08, P ¼ 0.93). Within-group changes were further analysed using paired t-tests
and repeated measures ANOVA which revealed significant changes at 5 min post treatment in the HVLA (P < 0.01) and MET
groups (P < 0.01), but not in the control (P ¼ 0.35). At the 30 min interval a significant change was calculated for the MET group
(P < 0.03), but not in the HVLA (P ¼ 0.29) or control group (P ¼ 0.21).
Conclusion: Neither HVLA manipulation nor MET significantly changed the PPT of the suboccipital muscles in asymptomatic par-
ticipants. Both techniques produced greater mean increases in PPT and effect sizes compared to the control group, and investigation
of the effect of these techniques in a symptomatic population is recommended.
Ó 2007 Elsevier Ltd. All rights reserved.

Keywords: Manipulation; Stretching; Suboccipital; Muscles; Occipitoeatlantal joint; Algometry; Osteopathic medicine

1. Introduction involves the application of a fast non-forceful thrust,

which is often associated with an audible ‘pop’ or ‘crack’.1
High-velocity, low-amplitude (HVLA) manipulation MET differs from HVLA in that it is an active technique
and muscle energy technique (MET) are manual tech- requiring the patient to contribute the corrective force.2
niques advocated by osteopathic authors to restore spi- MET has been described as a valuable treatment tech-
nal range of motion and to decrease pain.1e3 HVLA nique because of the many claimed therapeutic benefits
resulting from a single procedure, including lengthening
* Corresponding author. 182 Fulham Road, Gulliver QLD 4812,
and strengthening muscles, increasing fluid mechanics
Australia. Tel.: þ61 402 908 631. and decreasing local oedema, mobilising restricted
E-mail address: [email protected] (L. Hamilton). articulations and reducing pain and disability.2,4e6 The

1746-0689/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijosm.2007.08.002
 L. Hamilton et al. / International Journal of Osteopathic Medicine 10 (2007) 42e49 43

application of MET involves the voluntary contraction of motor control may play a role in the short and long-
patient muscle in a precisely controlled direction, at vary- term relief of patients.14 These proposals, however,
ing levels of intensity and against a distinctly executed would not be relevant to hypoalgesia following HVLA
counterforce which is applied by the operator.2 in asymptomatic individuals.
A small number of studies support the short-term hy- MET has been advocated as a safer alternative to
poalgesic effects of HVLA manipulation.7e10 Terret HVLA, particularly for the upper cervical spine.2,16,17
et al.7 reported an immediate rise in cutaneous pain The origins of MET are claimed to extend back to the
threshold following spinal manipulation, and noted dis- days of A.T. Still,18 the technique was developed and
tinct and progressive elevation in pain tolerance within popularised by Mitchell2 and despite many texts advo-
2 min, lasting at least 10 min post-manipulation, in com- cating the use of MET it is surprising how limited the re-
parison to the control group. Similarly, Vernon et al.8 search is with regards to its effectiveness.4e6 Of the few
found individuals suffering chronic neck pain who re- studies published to date, most have examined the effect
ceived HVLA manipulation experienced a significant of MET for increasing flexibility and range of mo-
rise (40e55%) in pressure pain thresholds (PPT) for tion.19e23 Only one study was found that examined the
all four points around the manipulated spinal segment, effect of MET on spinal pain, and this study suggested
as compared to the small change following mobilisation that MET was effective for reducing pain and disability
treatment. However, because of the small sample size in patients with low back pain.4
(n ¼ 9), the findings of this study should be treated Pressure algometry is a method of quantifying soft
with caution. tissue tenderness which has been proven to be very relia-
Fryer et al.9 reported that both HVLA and mobilisa- ble.24e27 The PPT is defined as the least stimulus inten-
tion had a significant effect on perceived tenderness over sity at which an individual perceives pain; it is the point
the thoracic spine in a group of asymptomatic partici- where the sensation of pressure turns to one of pain.24
pants. However, HVLA was less effective for increasing Sterling et al.26 found that the measurement of pain
the PPTs when compared with mobilisation, and a signif- thresholds with an electronic algometer was reliable be-
icant difference existed between the mobilisation and tween weeks (1 week period) in both asymptomatic par-
control group (P ¼ 0.01), but not between the manipula- ticipants and in participants with chronic back pain.
tion and control group (P ¼ 0.67). These findings con- Nussbaum and Downes25 recommended that the mea-
flicted with those of Cassidy et al.10 who reported that surements be taken by one examiner, because this was
a single HVLA technique was significantly more effec- more reliable than from multiple examiners.
tive in 85% of participants when compared to MET Significant regional differences in spinal PPT values
for treating neck pain. In recent systematic reviews, spi- have been reported, where the PPT increases in a caudal
nal manipulation has been recommended with some direction. Cervical segments have been determined to be
confidence to be a viable option for the treatment of the most sensitive to pressure, followed by the thoracic
both low back pain and neck pain.11,12 region and the lumbar spine.28,29 Vanderweeen et al.24
The mechanisms by which HVLA produces a hypoal- suggested this pattern might be due to the higher noci-
gesic effect are largely speculative. Melzack and Wall13 ceptor density in the cervical spine.
proposed the gate control theory, where large diameter The suboccipital region is one zone of particular clin-
myelinated neurons from mechanoreceptors modulate ical importance when assessing and treating the cervical
and inhibit the smaller diameter nociceptive neuronal in- spine.30 This triangular area inferior to the occipital
put at the spinal cord level. Joint manipulation would bone includes the posterior aspects of C1 and C2 verte-
activate mechanoreceptor afferents and may therefore brae and four small muscles: rectus capitis posterior
provide pain relief by activating this spinal gate control major, rectus capitis posterior minor (RCPMn), obli-
mechanism. Any technique that stimulates joint propri- quus capitis superior and obliquus capitis inferior.
oceptors via the production of joint movement or the The suboccipital muscles have been suggested to act
stretching of a joint capsule has been proposed to be ca- as a ‘kinesiological monitor’ for the sense of proprio-
pable of inhibiting pain.14 ception, as well as having an affect on movement of
It has also been speculated that HVLA may have the head.30 The RCPMn has been described by McPart-
a therapeutic effect by reducing zygapophyseal joint ef- land and Brodeur16 as containing a high density of
fusion and peri-articular oedema by improving the muscle spindles and therefore dysfunction at this level
drainage of flow within a joint, or by stretching of zyg- may disrupt proprioception of the head and cervical
apophyseal joint capsules to improve joint range of mo- spine. Dysfunction of the suboccipital muscles has
tion. It has been suggested that manipulative techniques been claimed to arise from any trauma that causes
play a role in descending pain control systems projecting sudden or extreme movement of the head, or simply
from higher centres such as the dorsal periaqueductal from chronic postural stresses, such as those occurring
grey (dPAG) to the spinal cord.15 Manipulation induced during slouching and the typical ‘‘chin poking’’
hypoalgesia and the improvement of proprioception and posture.16,31
44 L. Hamilton et al. / International Journal of Osteopathic Medicine 10 (2007) 42e49

It has been proposed that the suboccipital muscles are student and teaching body at Victoria University. Partic-
a causative factor in both cervicogenic neck pain and ipants were required to sign consent forms and provide
headache and in addition may become atrophic further information in a questionnaire regarding the presence
complicating the pain syndrome.16,32e35 The RCPMn of cervical spine problems and other recurrent health
has been found to be continuous with the posterior at- risks. Participants were excluded if they had received up-
lanto-occiptal membrane, which is intimately related per cervical spine manipulation in the previous three
to the dura mater.16,32 This relationship is important as days, had any cervical spine pathology, were long-term
the RCPMn prevents crimping of the dura at the occipi- cortico-steroid users, or had vertebro-basilar insuffi-
toeatlantal junction when the head is extended. Chronic ciency, as these contraindicated the use of HVLA.1 Par-
postural stress has been proposed to cause hypertonicity ticipants who experienced chronic headaches were also
of the suboccipital musculature, leading to tension being excluded from the study. The Victoria University Human
transmitted to the pain sensitive dura resulting in chronic Research Ethics Committee granted ethics approval for
headaches.16,32 Hallgren et al.36 examined patients with the study.
chronic headaches and neck pain using MRI and found
that some individuals exhibited replacement of suboccipi- 2.2. Measures
tal skeletal muscle with fatty tissue. This may result in a re-
duction of muscle spindle and golgi tendon organ density, 2.2.1. Pressure pain thresholds
with a decrease in proprioceptive information transmit- The PPTs were measured using a hand-held electronic
ted to the central nervous system, which may result in algometer (Somedic algometer II, Sweden) consisting of
postural destabilisation. It may also be possible that a pressure transducer and an output screen that measured
proprioceptive changes could lead to a reduction in the and displayed the pressure and the rate of applied pres-
mechano-receptive gating effect at cord level, and as a re- sure. The algometer was calibrated before the testing be-
sult be a contributing factor to neck pain. While cervical gan. Participants were requested to lie prone on a bench
proprioception is recognised as an essential component in with their head in the face hole. The head end of the bench
maintaining balance, adequate treatment of the region is was angled approximately 30 towards the floor to expose
imperative, especially when treating the elderly commu- the suboccipital region adequately and allow the re-
nity. Research investigating the suboccipital region and searcher to palpate a tender point in the area between
what effects manual treatment may have on a potential the occiput and the C2 spinous process. A midline point
problematic area is therefore warranted. between the occiput and C2 was chosen as the location
To date, no studies have examined the effect of HVLA for PPT measurement as both are prominent landmarks
manipulation or MET on suboccipital tenderness. The lit- therefore enabling the procedure to be repeatable. Fur-
tle research into HVLA has focused on the mid to lower thermore, it was considered an appropriate point of mea-
cervical spine, with emphasis on different techniques surement as it lies in close proximity to the OA joint, the
applied to this area and what effects they have had on de- suboccipital muscles span the region, and according to
creasing pain and increasing the range of motion.8,10,26,35 pain maps by Dreyfuss et al.37 the site of measurement is
Similarly, MET is commonly advocated by authors of located within the C0eC1 zone of pain referral. The mea-
manual therapy for treatment of somatic dysfunction surement procedure was based on the procedures used by
and muscle pain, although limited research exists into Fryer et al.9 The PPT was measured with the transducer of
the effects of MET on pain and tenderness.4e6 Manual the algometer positioned centrally and at 90 to the site to
techniques have been reported to lower spinal PPT in be measured in the suboccipital region (Fig. 1). Pressure
an asymptomatic population.9 The aim of this study was applied at 30 kPa/s. When the pressure being applied
was to investigate whether HVLA manipulation of the oc- changed to a sensation of pain, the participants were in-
cipitoeatlantal joint or an MET stretch to the suboccipi- structed to press a button on an extended hand-held device
tal region had an effect on PPTs in the suboccipital linked to the algometer. As the button was depressed the
musculature within an asymptomatic population. on-screen counter froze and an audible beep alerted the re-
searcher to arrest the force that was being applied. The
reading (when the button was pressed) was displayed on
2. Methods the screen of the algometer and was recorded. Three
PPT measurements were performed with a 20-s break be-
2.1. Participants tween each to calculate the mean PPT score at three sepa-
rate time intervals; an initial, at 5 min and at 30 min.
Ninety participants (29 males, 61 females, mean
age ¼ 23 years  5) were recruited and randomly allo- 2.2.2. Pilot reliability
cated into either a control group (n ¼ 25) or experimen- To assess the test-retest reliability of the examiner us-
tal groups which were divided into HVLA (n ¼ 35) and ing the algometer, a pilot study was conducted prior to
MET (n ¼ 30). All participants were recruited from the the main study. Three measurements of PPT were
 L. Hamilton et al. / International Journal of Osteopathic Medicine 10 (2007) 42e49 45

Fig. 1. PPT measurement. Fig. 3. Experimental technique (MET).

amount of rotation and side-bending leverage, and

performed on 20 participants who were not involved in
a thrust was delivered to the joint, as described by Gib-
the main study at the time intervals of interest (initial,
bons and Tehan1 (Fig. 2).
5 min and 30 min). The average measure Intraclass Cor-
Those participants allocated to the MET treatment
relation Coefficient (ICC) was 0.96, indicating high re-
group received an MET stretch to the suboccipital and
peatability for the PPT measurement. The precision of
trapezius muscles on both the left and right sides. The
the measurement procedure is estimated by the standard
practitioner made contact with the base of the occiput
error of measurement (SEM) of the mean differences be-
using one hand, while the other hand stabilised the
tween intervals.38 The initial e 5 min mean difference
shoulder. The head and neck were positioned in flexion
was 7 kPa (SEM ¼ 9.64 kPa) and the initial e 30 min
and slight lateral bending to the opposite side until the
mean difference was 11 kPa (SEM ¼ 11.60 kPa), so the
participant reported a stretching sensation in the suboc-
absolute error range of the measurement procedure
cipital region. The participant was instructed to gently
was considered to be 9.64 kPa and 11.60 kPa.
push their head back against the practitioners’ resistance
2.2.3. Intervention for 3e5 s, followed by a period of approximately 5 s of
The HVLA treatment group received two HVLA relaxation.39 The practitioner repeated this procedure,
thrusts, one delivered to both the right and left occipi- so that three applications of ‘contractionerelaxation’
toeatlantal joints (C0/1).1 The participant lay supine were performed on the muscles of each side (Fig. 3).
on a bench and a registered osteopath contacted the pos- A modified, sham ‘‘functional technique’’ was utilised
terior aspect of the occiput or the posterior arch of the as a control treatment. Pain thresholds may be influ-
atlas, positioned the head and neck using a small enced by the expectation of a treatment effect and so

Fig. 2. Experimental technique (HVLA). Fig. 4. Control.

46 L. Hamilton et al. / International Journal of Osteopathic Medicine 10 (2007) 42e49

the sham treatment was designed to control for a placebo Table 2

effect. Participants were informed that they were to be Mean differences (SD), P values (t-tests) and effect sizes (Cohen’s d )
treated with an osteopathic functional technique which Mean differences P Effect
involved subtle positioning of the upper neck, which (SD) value size (d )
was held for 30 s, but no ‘position of ease’2 or barrier preHVLA-HVLA-5 39.37 (76.07) <0.01* 0.52a
was engaged, in order to keep the technique inert preHVLA-HVLA-30 15.89 (87.50) 0.29 0.18
preMET-MET-5 42.03 (62.37) <0.01* 0.67a
(Fig. 4). preMET-MET-30 30.00 (69.53) <0.03* 0.43a
preControl-Control-5 15.88 (83.62) 0.35 0.19
2.3. Procedure preControl-Control-30 16.12 (62.49) 0.21 0.26
*Significant at P  0.05.
a
Three researchers were involved in the study: Re- Indicates medium effect size.
searcher 1 explained the testing procedure and recorded
SD ¼ 76.07), but the standard deviations were also large
the pressure values, whilst Researcher 2 used the algo-
(Table 2). A smaller mean change was noted for the con-
meter to measure the PPTs, and Researcher 3 (a regis-
trol group (15.88 kPa, SD ¼ 83.62) over this time period.
tered osteopath) performed the treatment. Researchers
A modest mean change occurred between the initial to
1 and 2 were blinded to the group allocation of partici-
30 min post treatment interval in the MET group
pants during the testing procedure.
(30 kPa, SD ¼ 69.53), but smaller changes were observed
Participants entered a testing room and the initial PPT
within the HVLA (15.89 kPa, SD ¼ 83.62) and control
was recorded as described earlier. The participants were
groups (16.12 kPa, SD ¼ 62.49) (Fig. 5).
directed to another room where they were randomly allo-
Analysis with SPANOVA revealed a significant dif-
cated into the treatment or control group via a lottery
ference over time for the entire cohort (F2,174 ¼ 8.80,
draw procedure by Researcher 3. After receiving the allo-
P < 0.01), but there was no significant difference be-
cated treatment intervention, the participants were asked
tween the treatment groups (F2,87 ¼ 0.08, P ¼ 0.93).
to return to the original testing room and the PPT mea-
Post-hoc analysis of within-group PPT changes using re-
surements were recorded again by Researchers 1 and 2.
peated measures ANOVA for each group revealed sig-
The participants were asked to return to the room
nificant differences in the MET and HVLA groups
30 min later for a third measurement of PPT.
(F2,58 ¼ 5.89, P ¼ 0.01 and F2,68 ¼ 4.86, P ¼ 0.01, re-
spectively), but not the control group (F2,48 ¼ 0.73,
2.4. Statistical analysis
P ¼ 0.49). Further analysis of the time period using
paired t-tests revealed a significant increase in both the
Data was collated in Microsoft Excel and analysed us-
HVLA (P < 0.01) and MET groups (P < 0.01), but not
ing the statistical package SPSS Version 11. The pre-,
the control (P ¼ 0.35). A significant change was also
post-5 and post-30 mean PPT measurements were ana-
found for the MET group at 30 min (P < 0.03), but
lysed for differences over time and between groups with
not for the HVLA (P ¼ 0.29) or control group
a SPANOVA. Paired t-tests and repeated measures
(P ¼ 0.21). Medium within-group effect sizes were calcu-
ANOVA were used for further analysis of within-group
lated for the HVLA group at 5 min (d ¼ 0.52) and in the
changes. The within-group effect size (Cohen’s d ) was cal-
MET group at both the 5 and 30 min intervals (d ¼ 0.67
culated for each pair and can be interpreted as small
(d ¼ 0.2), medium (d ¼ 0.5) or large (d ¼ 0.8).40 Statistical
significance was set at alpha 0.05. 140

120
3. Results
100
PPT (kPa)

Mean PPT values are shown in Table 1. A relatively 80

large mean difference in PPT occurred between the ini-
tial and 5 min interval for both the MET (42.03 kPa, 60
SD ¼ 62.37) and HVLA groups (39.37 kPa,
40
Table 1
Mean (SD) PPT values (kPa) 20

Initial PPT Post-PPT Post-PPT

0
measurements measurements measurements MET HVLA Control
(5 min) (30 min)
Group
HVLA 358.69 (132.12) 398.06 (133.51) 374.58 (127.50)
Mean Difference - 5 minutes Mean Difference - 30 minutes
MET 340.63 (166.94) 382.s67 (158.29) 370.63 (182.17)
Control 352.56 (155.76) 368.44 (208.16) 368.68 (192.62)
Fig. 5. Mean PPT changes.
 L. Hamilton et al. / International Journal of Osteopathic Medicine 10 (2007) 42e49 47

and d ¼ 0.43, respectively). The effect sizes were small at and mobilisation had a significant improvement on
both intervals for the control group (d ¼ 0.19 and PPTs in the thoracic spine of asymptomatic participants.
d ¼ 0.26) and in the HVLA group at 30 min (d ¼ 0.18). Other studies have reported improvements in PPT fol-
The composition of the three treatment groups was lowing mid to lower cervical spine manipulation in
similar with regards to the maleefemale ratio (MET ¼ a symptomatic population.8,10 The results of the present
8:22, HVLA ¼ 13:22 and control ¼ 8:17). No significant study show similar trends to that of Terret et al.7 who
difference was calculated between the ages of participants observed a progressive elevation in pain tolerance fol-
within the groups (F2,87 ¼ 0.07, P ¼ 0.94) or between the lowing thoracic spinal manipulation, and noted a distinct
pre-treatment PPT values (F2,87 ¼ 0.12, P ¼ 0.89). increase at 2 min which lasted for at least 10 min post-
manipulation. In the present study, a ‘peak’ cannot be
4. Discussion identified because PPT measurements were only re-
corded at 5 and 30 min post-manipulation.
Manipulation of the occipitoeatlantal joint and It may appear from the present study that MET has
MET to the cervical spine and cervical musculature little effect on pain levels, but in the clinical setting most
are commonly advocated techniques in the osteopathic treatments are applied more than once and to symptom-
field.1e3,10 In the present study, modest mean PPT in- atic patients. Wilson et al.4 used multiple applications of
creases following the MET and HVLA interventions MET over eight weeks for patients suffering with acute
were noted (42.03 & 39.37 kPa, respectively), whereas low back pain, whereby application of MET in combi-
only a small increase occurred in the control group nation with neuromuscular re-education and resistance
(15.88 kPa). However, these differences were not signif- training was more effective than the re-education and
icant when analysed using a SPANOVA. On further training alone for reducing pain levels. Although the
analysis, using the less robust paired t-tests, the increases present study is useful for examining and comparing
following HVLA and MET were significant at 5 min the effects of individual techniques, it does not accu-
(P < 0.01), but were not significant in the control group rately represent treatment in a clinical setting, and fur-
(P ¼ 0.35). Medium effect sizes were also calculated for ther research is recommended using a symptomatic
HVLA and MET treatment groups (d ¼ 0.52 and population and including multiple treatments.
d ¼ 0.67) at this interval. Despite the significant t-tests, The dPAG has been proposed in the descending con-
it cannot be concluded that HVLA or MET had a hypo- trol of nociception.41 Manipulative techniques may pro-
algesic effect on suboccipital tenderness, because of the vide an adequate stimulus to activate descending pain
non-significant SPANOVA. These findings, however, control systems projecting from the dPAG to the spinal
suggest that HVLA and MET may have some effect, cord. A strong correlation was reported between hypo-
and further research using a symptomatic population algesia and sympatho-excitation (r ¼ 0.82) following
is recommended. spinal manipulation, suggesting the dPAG had been ac-
The trends observed following the treatment inter- tivated.15 In addition, Sterling et al.42 proposed that ma-
ventions appeared to be short lived. At the 30 min retest, nipulation of the cervical spine had a hypoalgesic effect
the PPT was not significantly different from the initial specific to mechanical nociception, an excitatory effect
measure for the HVLA group (P ¼ 0.29). The relatively on sympathetic nervous system activity and also an
large standard deviation (SD  87.5) may be a contribut- effect on motor activity. A central structure may be
ing factor as to why a significant difference was not responsible for the initial effects of HVLA. Another
found at 30 min when compared to the baseline. A sig- study found that plasma ß-endorphins were released fol-
nificant pre-post change and a medium effect size were lowing spinal manipulation; heart rate, blood pressure
calculated in the MET group at 30 min, but this increase and anxiety levels were monitored and controlled to
was smaller than the change at 5 min post treatment. establish that the release of endorphins was not stress
All of the participants had some degree of osteopathic induced.43 Recent studies have examined mobilisation
education and it was possible that some participants were of the knee in both humans and animals and demon-
aware of the sham nature of the control group. The con- strated widespread hypoalgesia, further suggesting the
trol treatment was a modified functional technique where involvement of central mechanisms.44,45 In the animal
no motion barriers were engaged, and, given the leverages model, knee mobilisation of an experimentally induced
are normally very subtle, the researchers believe it is un- hyperalgesic joint has produced hypoalgesia which re-
likely that participants would have been aware of the mained unaffected by spinal blockade of GABA and
sham, but no follow up study was conducted to determine opioid receptors, supporting the role of descending in-
this. The small mean changes of the control groups (15.88, hibitory centres that use serotonin and noradrenaline.46
16.12, and 0.24 kPa, respectively) and the respective small The reliability pilot study demonstrated that the PPT
effect sizes suggest little placebo effect. measurement procedure appeared to be highly repeatable
The results from the present study differ from previ- (ICC ¼ 0.96), which was similar to a previous study that
ous research by Fryer et al.9 who found that HVLA used the same algometer (ICC ¼ 0.93).9 However, there
48 L. Hamilton et al. / International Journal of Osteopathic Medicine 10 (2007) 42e49

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