The Chriropractic Spinal Adjustment: Its Science and Art
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Clinical Chiropractic: Upper Body Complaints”
The following materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.
Support Chiropractic Research
Help Chiro.org support Chiropractic research.
Your donation will make a difference.
We are an Amazon Associate
We make a small commission on every purchase you make
Help us support chiropractic research with your purchases.
All of Dr. Schafer's books are now available on CDs, with all proceeds being donated
to chiropractic research. Please review the complete list of available books.
The Science of Articular Mobilization Background Articular Fixation Therapy Underlying Biomechanical Principles The Art of Articular Correction Background Adjustive Technics Types of Adjustive Thrusts Objective-Oriented Approaches Closing Remarks Professional Counsel Adjunctive Therapy The Principle of Biologic Compensation
Chapter 15: The Chriropractic Spinal Adjustment: Its Science and Art
THE SCIENCE OF ARTICULAR MOBILIZATION
Although adjunctive procedures have been recommended in this text, it should always be remembered that the articular adjustment is the core of chiropractic therapy. Ancillary procedures can condition tissues to receive and respond to articular therapy and enhance physiologic mechanisms, but, with rare exceptions, they should not be considered substitutes.
The sincere student of this manual will readily recognize that this author acknowledges the value of reflexology and numerous physiotherapeutic applications along with nutritional supplementation, counseling, "bloodless surgery," and stardardized rehabilitative procedures. Yet, as explained previously, they all stand in the shadow of the basis for and the proper administration of the chiropractic adjustment. This chapter focuses on the need for the development of our unique art.
The author has witnessed several practitioners who have turned an adjunctive tool into a primary therapy exclusively. We see this at times with acupuncture, physiotherapy, therapeutic nutrition, psychotherapy, and those who have made the upper cervical spine or sacroiliac joints their master rather than a servant of the patient. Such a limited viewpoint of the scope of chiropractic health care, unfortunately, does a disservice to the practitioner, his or her patients, and the public. The fault for this misdirection must be placed on improper training. No logical person would forsake a primary therapy for an ancillary therapy if he or she had confidence and skill in its application.
Perfection of an art is a constantly expanding process. The quest of perfection in our profession is the basis of the diligent practice of chiroprac tic –to the extent of our creative imagination. This chapter will briefly define certain general underlying principles that underlie almost all chiropractic adjustive technics. Some may be new to the reader, yet their basis is as old as chiropractic itself.
Because of tradition and not semantics, the term technic is commonly used in the profession to describe a procedure used within a manual adjustive procedure. The word technique is used relative to other procedures. Regardless, a technic or technique is only a method, one method of many, that must be adapted to the situation at hand, clinical judgment, and personal preference. This is true for those technics described in this text or within any other book or seminar.
Clinical rules are not laws. They must frequently be amended for the particular situation and the individual making the application. For example, technics must be adapted to the size, strength, and skill of the doctor; the age, sex, health status, and pain tolerance of the patient; and the type of adjusting table used. Obviously, a doctor of short height treating an obese patient on a high table will find great difficulty in applying the same contact or technic that might be applied by a tall doctor treating a lean patient on a low table. The variables that can arise are too numerous to list, and each situation must be adapted to when encountered as conditions and personal skill permit.
The Factor of Time in the Clinical Approach
To produce a therapeutic adjustment, it is first necessary to evaluate the degree of joint motions and end plays present. Whatever corrective procedure is used, remember Hooke's law: The stress applied to stretch or compress a tissue is proportional to the strain, or change in length thus produced, if the limit of elasticity of the tissue is not exceeded.
The goal of any therapy must be based on rational hypotheses. According to its founder, the primary objective of chiropractic therapy is to restore normal "tone" to the nervous system. Although some practitioners do this exclusively by "nonthrust" means (eg, the application of somatosomatic reflexes), the objectives are generally achieved by dynamic manual articular mobilization unless such a technic is contraindicated in a specific situation. Obviously, one would not apply a dynamic force over extremely porotic bone, a fracture, an abscess or a tubercular cyst, or a malignancy, for example. Nor would it be applied over acutely inflamed tissue or splinted muscles if the doctor expects the patient to return.
The author approaches the subject of chiropractic articular correction as a nonincisive surgical procedure, a chiurgical art. Correct application takes time. It takes time to assure proper patient positioning, assure that the intended line of drive is exactly parallel to a particular patient's facet design, assure that the safest and most efficient and painless point of contact is selected, and assure that the proper impulse velocity and depth have been predetermined according to the circumstances at hand (eg, patient age, size, development, individual pain threshold, underlying pathophysiologic status, etc).
Note: The author, at the age of 9, had the opportunity of watching B. J. Palmer give a student patient (my father) a side-position atlas recoil adjustment in 1939 before a group of students. The analysis of the x-ray films, palpation, re-reading the films, re-palpation, taking a con tact, and retaking the contact again and again required a period of 45 minutes before the thrust was delivered. It took B.J. this long in palpation, film interpretation, visualization, and assuring that the design of his adjustment would be correct. Granted that it was not beneath B. J. to add some theatrics for the audience whenever he could, but the experience did leave me with the impression of the need for preciseness when doing something important. This experience has always left me with a sense of confusion when I hear practitioners who hold B. J. as their ideal and speak of adjusting hundreds of patients each day.
There is no doubt that sufficient time must be taken to assure that adequate examination is made and preadjustive therapy is applied to render the tissues involved to be more receptive to the adjustment (eg, tissue plasticity, elasticity, and flexibility) and that adequate postadjustive therapy is applied to enhance the healing process (eg, neurocirculatory processes, pain control). In addition, traumatized and pathologic tissues characteristically have low endurance and high biomechanical fatigue properties. These subjects will be described further in this chapter. They form a substantial part of the scientific foundation of our art.
It also is important that the patient be allowed to rest undisturbed in a comfortable position (and draped with a sheet and light blanket to avoid chilling) for 20 30 minutes or more following an adjustment because the encouragement of physiologic normalization within viscoelastic substances takes time. This is a law of biophysics. Logic dictates that a period of postadjustive rest be allowed before the physiologic and structural demands of weight-bearing and cyclic loading are applied if optimal benefits are to be expected.
Chiropractic treatment or therapy should be differentiated from chiropractic technic, which is one form of treatment. Treatment (case management) includes the application of a primary method plus all ancillary procedures incorporated to accomplish the clinical objective. Ancillary procedures often include such procedures as meridian therapy, electrotherapy, spondylotherapy, heat, cold, nutritional supplementation, diet control, therapeutic exercise, biofeedback, supports, psychotherapy or other counseling, and other forms of justifiable therapy in the most efficient manner. The primary goals are to relieve pain, restore normal neurologic integrity, improve articular relationship and function if necessary, and to influence physiologic processes that would enhance the healing process. There are, of course, times when a usually ancillary procedure is used as a primary therapy such as in the application of cold to a burn or to reduce the swelling of a sprained joint.
Although the "adjustment" has always been the foundation of chiropractic therapeutics, few have tried to define it and most who have were met with severe criticism. A chiropractic adjustment, according to Sandoz, is a passive manual maneuver during which the three-joint complex (IVD interface and apophyseal joints) is suddenly carried beyond the normal physiologic range of movement without exceeding the boundaries of anatomical integrity. Swezey, an allopath, defines a chiropractic adjustment as the high-velocity short-arc- inducing passive movement of one articulating surface over another.
Few would strongly object to either of these attempts to define the purely structural effect induced; ie, if the objective is solely to mobilize a fixation or realign a subluxation. Unfortunately, such purely mechanical concepts are limited; eg, they fail to consider the induced neurologic stimulation on the cord, root, axoplasmic flow, and mechanoreceptors of the area and the local and remote "spillover," facilitation, or dampening effects of such stimuli on connected tracts and interneurons.
Besides its effect on the contents of the IVF, a vertebral segment's position in fixation is another important factor. Vertebral tilting as seen in disorders with lateral disc wedging alters the relationship of apposing articular surfaces to produce a change in the direction of compressive forces on these joints. In contrast, severe fixed rotation produces jamming compression on ipsilateral facets and contralateral facet separation. When continuous compression is applied to any joint, cartilaginous erosion followed by arthritis and its sequelae can be expected.
What Makes Chiropractic Unique
There is a trend to lump what a chiropractor does during an "adjustment" under the general category of spinal manipulative therapy (SMT). A term originated by allied health professions that was rarely seen in chiropractic literature before the late 1970s. This author is uncomfortable with such a generalization because he believes that what a chiropractor does (or should do) is far removed from the general "mobilization" and gross "manipulation" procedures commonly conducted by physiotherapists and many osteopaths. Other health-care professions typically apply passive attempts to increase a restricted gross range of movement of a joint by stretching contractures. While the descriptor SMT may be appropriate for some low-velocity extraspinal adjustive technics or the application of a stretching maneuver to improve a joint's gross range of motion, it can be argued that its use is a clear misnomer in most instances when applied to the application of scientific chiropractic during spinal therapy. The function of a robot can be explained in electrical and mechanical terms. This is not true for the human organism. Purely biomechanical or biochemical explanations will not suffice for every situation occurring in a biologic organism. More than 20 years ago, Levine had the foresight to warn those who defined the chiropractic adjustment solely in structural terms without considering the neurologic overtones involved:
"In discussing chiropractic techniques, it is only proper to note that chiropractic holds no monopoly on manipulation. Manipulation for the pur pose of setting and replacing displaced bones and joints, including spinal articulations, is one of the oldest therapeutic methods known. It has been and still is an integral part of the armamentarium of healers of all times and cultures.
"What differentiates chiropractic adjusting from orthopedic manipulations, osteopathic maneuvers, massage, zone therapy, etc? In one sentence, it is the dynamic thrust! The use of the dynamic thrust is singularly chiropractic. And it is the identifying feature of chiropractic techniques.
"However, chiropractic's rationale is hardly based on the fact that its adjustive techniques are applied with a sudden impulse of force. It is the reasons why these techniques are applied, and why they are applied in a certain manner, that distinguish chiropractic from other healing disci plines, manipulative or not. In fact, some chiropractic techniques of recent vintage are not characterized by sudden application. We are think ing of those techniques which have been named 'non-force,' though strictly speaking, the term is a misnomer. What makes them also part of chiropractic is that they are designed to serve the same purpose as the dynamic thrust, though whether they are equally efficient is a moot question."
The apophyseal joints can become fixated because of the effects of joint locking (eg, traumatic), muscle spasm, degeneration, an entrapped meniscoid or other loose body, capsular fibrosis, intra-articular "gluing" or adhesions (eg, postsynovitis, chronic rheumatoid conditions), bony ankylosis, facet tropism, etc.
Articular Fixation Therapy
Articular motion is impaired when muscles become acutely spastic or indurated from long-term contraction. The major neurologic effects are abnormal mechanoreceptor input to the CNS, foci for referred pain by compensating adjacent segmental hypermobility, and noxious somatosomatic reflexes.
Even with proper conditioning and warmup procedures, myalgic syndromes are commonly seen when treating athletes or stoic individuals because they habitually ignore the warning signals of pain. Here, the degree of impairment must be determined by the severity of spasm, the amount of induration, and the extent of functional disability. Both spastic and indurated muscles are characterized by circulatory stasis, which is essentially the effect of compressed vessels (eg, pressure, vasospasm). This leads to impaired tissue nutrition (trophic dysfunction) and the accumulation of metabolic debris. During the early stages of degeneration, palpation will often reveal tender areas that feel taut, gristly, ropy, or nodular –not unlike that of a trigger point, which they might be.
When rapid improvement of segmental mobility occurs, it is likely that a muscular fixation has been corrected. These fixations are extremely labile, variable, and dependent on local muscle tone. Because many muscle fixations are secondary, they often disappear spontaneously after a remote primary fixation in the spine has been corrected that corrects distant reflex expressions. Thus, any therapy (eg, dynamic thrust, reflex, medicinal, exercise, counseling, biofeedback, cold, heat, electrostimulation, detoxification, etc) that eases a state of excessive tension in the body appears to have a beneficial effect on muscular fixations –at least short term. This also appears true when the fixation is the result of a peripheral irritation (eg, a viscerosoma tic reflex). Such acute subluxations, however, tend to recur continually until the precipitating factor(s) is corrected.
It sometimes may appear that just examining a muscular fixation by putting the involved segments through their ROMs is enough to correct the condition, as confirmed by a patient that the area feels much better after the examination. The opposite of this also can occur; ie, too vigorous examination or too much probing in the involved area can irritate an inflammatory lesion.
A thrust directed perpendicular to the belly of the hypertonic muscle will correct the fixation or a contact can be taken on the involved segment and a thrust made that will stretch the shortened muscle. A short dynamic thrust is the most efficient approach in correcting muscular fixations. The technic selected must be adapted somewhat if the muscles involved have degenerated to a state resembling ligament fixations.
Ligament fixations (shortening restricting normal mobility), including those produced by muscular atrophy, are numerous and can be located most anywhere in the spine. They are second in importance to, yet far more prevalent than, total fixations. Ligament fixations are the only chronic fixations that will be found in many spines.
In treating taut periarticular ligaments, the recommended adjustive thrust is similar to that used for other types of fixations with essentially two differences: (1) the slack taken in the overlying tissues is less than with total fixations and even more so than with muscular fixations; (2) the depth of thrust is much shorter than that used for muscular fixations because the tissues acted on are not as elastic. Nevertheless, the amount of post-adjust ment change can be surprising yet less than that following a correction of a muscle fixation. This initially slight postadjustment improvement is optimally followed by continual slight improvement visit after visit. Slow, periodically monitored, daily stretching exercises are very beneficial.
Articular or Total Fixations
Aside from those sometimes found in the occipitoatlantal and sacroiliac joints, total articular fixations are rare. When found, they signify ankylosis or impending ankylosis. The primary concern in pseudoankylosed joints is the degenerative shortening and toughening of perivertebral ligaments and joint capsules, and likely the development of intra-articular adhesions.
The least irritation-producing type of thrust is a short, rapid, dynamic force directed against the restricted plane of motion so that the "frozen" facets are released. Avoid using more force than necessary to produce mobility. Any force applied past the point of the "normal" range of motion constitutes induced trauma to some degree. The ideal force used is that amount which is just enough to produce mobility and no more. Usually, a mild thrust followed by a moderate thrust is sufficient. An audible "click" is not necessary (and rarely produced) in a degenerated joint. Results can be appraised by an increased ROM as determined by dynamic palpation or dynamic diagnostic imaging.
Many advanced states of degeneration cannot be repaired to a completely normal state, but they can, with proper treatment, be halted in their progress and considerable function can be restored. The more chronic a ligamentous- related condition, the longer adjustive therapy will be necessary. Once the asymptomatic stage occurs, maintenance care several times a year will be adequate to keep the involved joint(s) optimally mobile. Joints that are chronic ally swollen, painful, crepitant, and immobile often return with time and activity to normal or near-normal function with appropriate extended manage ment. However, radiographs may show no or little change in joint space narrowing or hypertrophic alterations. This adds credence to the hypothesis that most joint complaints are the result of joint dysfunction rather than joint disease.
Underlying Biomechanical Principles
The proper application of a chiropractic adjustment is an art: an art that must be well-founded on an understanding of the underlying biophysical and pathophysiologic processes involved with a particular patient. These factors serve in establishing the scientific basis for chiropractic adjustive therapy.
As this subject is studied, the reader should keep in mind that the biomechanical principles summarized provide a basic understanding of (1) the effects of common trauma on the spine, extrinsic or intrinsic, and (2) the effects of a spinal adjustment. A misapplied spinal adjustment is little removed from common trauma. A skillfully applied adjustment, while still a force, will have minimal traumatic effects.
All neuromusculoskeletal tissues are organic viscoelastic substances. The critical factor in viscoelastic stability involves both load and a time element. That is, a viscoelastic substance can resist a certain load for a period and then fail without the load being altered. Thus, all musculoskeletal structures have a time-dependent stability factor. This factor is usually structurally adapted to in living tissue if the time element is prolonged. We wit ness this in bone with the trabecular redesign from chronic stress according to Wolff's law. What is true for bone is true in all viscoelastic substances to variable degrees.
The combined components of viscosity and elasticity allow for relaxation and creep, and both relaxation and creep are a function of time. The viscoelastic nature of IVDs, joint capsules, articular cartilage, and other joint connective tissues therefore offers time-dependent properties such as fatigue and hysteresis. These properties vary in reaction whether a load is applied quickly with high amplitude (eg, a jerk) or slowly with low magnitude (eg, pressure fatigue failure). As the repair and regeneration capabilities of discs and cartilages are low, their fatigue life is comparatively short when subjected to repetitive loading. On failure, the result is tissue tearing.
The process of developing structure cracks when subjected to cyclic loading is called fatigue in engineering. The magnitude of the load is usually far below that of the ultimate load of the particular structure and thus well within the elastic range. The result is a summation effect in which a fatigue crack reaches a size that causes the remainder of the structure to become so weakened that the entire structure fails. In biomechanics, this factor is popularly called the time or aging factor of a structure, and the time of failure decreases as the magnitude of the load increases.
The term endurance limit refers to the least load producing a failure from structural fatigue. If healing processes are inhibited or impaired, if the body's reserves are depleted, or if the healing processes do not have adequate time to repair structural cracks in bone or cartilage, for example, a fatigue fracture occurs. Such "cracks" commonly occur microscopically in articular cartilage except in the menisci of the knee where they are frequently gross.
During the normal cyclic loading and unloading on the spine during daily activity, a viscoelastic substance shows a loss of energy in the form of heat (hysteresis). When an IVD, for instance, is subjected to repetitive cycles of loading and unloading, the shock waves directed from the feet to the head are mostly dissipated by disc hysteresis. It decreases when the load-unload cycle is prolonged (eg, constant bumping) and during old age when viscoelasticity is low.
Biomechanical Creep and Relaxation
The viscoelastic properties of a fibrocartilage such as an IVD and somewhat of articular cartilage allow creep and relaxation behavior. The greater the load, the greater the deformation and the faster the rate of creep. A degenerated disc, for example, exhibits less viscoelasticity, less creep, and less capability of attenuating shocks and vibrations uniformly over the full surfaces of the end plates. Thus, stress relaxation is the viscoelastic property of a tissue of retaining a constant deformation after a load is removed. Relaxation, popularly called "give," is a steady deformation that occurs with less force over time. This is demonstrated in a tissue being stressed at a constant magnitude where the force necessary to maintain the deformation decreases with time.
Creep is the viscoelastic property of slowly increasing deformation under a constant load. That is, there is an initial deformation followed by a slowly increasing degree of deformation. Unlike plastic behavior, creep begins even with a minimal force and the recovery is slow. Creep is exhibited in the decrease of an individual's height from many hours in the upright position owing to the phenomenon occurring in the IVDs where a constant weight has been borne for a sustained period. When a constant force is applied to viscoelastic substances such as bones, muscles, tendons, cartilage, and ligaments, the property of creep becomes apparent. When a deformation is fixed, stress relaxation becomes apparent.
Some Practical Applications
The properties of tissue relaxation, creep, and fatigue are important considerations whenever articular correction, traction, lifts, or braces are used. For example, the soft tissues involved in spinal distortion will retain some residual effects for a time after adverse forces have been removed. Thus, some means of rest and support are often necessary to allow the deformed tissues to adapt to changed conditions. This means that when certain adjustive forces, a pressure brace, or a shoe lift is applied, they should be done slowly in increments so that the degree of creep reversal obtained and the residual relaxation present can be evaluated. Monitoring is essential.
In most circumstances contributing to abnormal soft-tissue stiffness where true ankylosis has not occurred, a large degree of functional shortening is superimposed to encourage structural changes. When adjusting a vertebral or extraspinal motion unit that is obviously fibrotic, mild traction and a broad contact with mild transverse pressure held in the direction of correction for 30 60 seconds just before the corrective adjustment helps to "reverse" the established creep and elastic fiber shortening produced by gravity, hypertonicity, etc. This is usually on the side of disc or cartilage thinning or muscu lotendinous shortening. When the adjustment is delivered, it is with further palpable movement and far less discomfort to the patient than would otherwise be produced. The same firm contact following a specific adjustment appears to enhance "holding" of the correction achieved.
Office facilities for postadjustment rest offer an excellent means of providing the time factor for the soft-tissue fibers to adapt without fighting gravity and for some corrective disc imbibition.
Loading Effects on Articular Cartilage
When articular cartilage is subjected to weight bearing, deformation develops instantaneously according to the tissue's stiffness property. This initial stage of rapid deformation has a negligible matrix fluid flow, and the contour of the tissue changes but not its volume. This stage is followed by a slower time-dependent creep related to the flow of water through the matrix according to the magnitude of the load, the fiber elasticity, the quantity of surface area loaded, the uniformity of force distribution, the matrix permeability (which is low even when unloaded), the osmotic pressure of the matrix colloid, and the length of the flow path.
When load is removed during rest, stressed cartilages begin to return to their original thickness quickly at first (90%) because of the elastic recoil of the collagen fibers and then slowly after that from the absorption of water governed by the Donnan osmotic pressure of the proteoglycans in the matrix gel. This recovery by absorption is enhanced by oscillation of the unloaded joint and limited by the collagen fiber's stiffness and strength that are subjected to increasing tensile forces as the swelling develops.
Here again we see the important factor of time. Because fluid flow within a connective tissue's matrix is time dependent, cartilage response to compression depends on the magnitude of the load, the length of time the load is applied, and if the load is applied statically or cyclically. A small amount of fluid is expressed through the matrix even during a briefly applied load, and its absorption is time dependent. If a second load is applied before the matrix is fully reimbibed, as during cyclic loading, the result is incomplete recovery that summates as the cyclic loading continues.
Joint lubrication is another factor to consider. The complex lubrication system of human joints far exceeds that of similarly designed man-made bearings. Much of this is due to (1) the renewable coating of glycoprotein molecules that blanket the surface of articular cartilage, (2) the ingress and egress of fluid from the cartilage's matrix, (3) the porosity and elasticity of cartilage that also allow fluid imbibition and discharge during load compression and relief, and (4) the unique folding and sliding action of interarticular synovial folds during movement.
The Intra-articular Synovial Tabs
The faces of the posterior articular facets of the spine are covered by tough hyaline cartilage and separated by meniscus-like tabs of synovium originating from the synovial lining of each joint. They allow a degree of extra shock-absorbing and pressure-absorbing protection for the articular cartilage. The tabs normally glide in and out of the joint during motion but are sometimes nipped during joint jamming (eg, in forced extension). The resulting swelling and hypertrophy from chronic inflammation of the tabs disrupt normal articular glide and establish a state of chronic apophysitis leading to the features of spondylosis. An acutely "locked" joint due to tab dislocation can mimic the features of IVD rupture.
THE ART OF ARTICULAR CORRECTION
The two most important instruments for a chiropractic adjuster are his or her hands and a well-designed adjusting table. Some graduates in recent years appear to have not been taught the useful applications of either. The following recommended procedures regarding the art of articular correction are based on the biomechanical principles just described: the properties of connective tissue viscoelasticity, fatigue, hysteresis, creep, relaxation, lubrication, and the effects of loading.
Seven cardinal rules are suggested for the application of any adjustive technic. They concern (1) preadjustment tissue relaxation, (2) preadjustment patient positioning, (3) directing the impulse drive carefully in line with the facets' plane of articulation, (4) applying the active contact on the strongest logical point of the segment, (5) using the mechanical advantage of leverage, (6) applying segmental distraction before the thrust, and (7) timing the thrust.
The well-designed adjusting tables available today contain a multitude of potential adjustments to help achieve these goals. It is unfortunate that many DCs practice for years with little knowledge of why these many position and tension variables are available or when they should be used. This section will attempt to solve this apparently widespread mystery.
The Oval Posture
Adequate adjusting tables are primarily designed to position the patient's spine in an "oval posture" (mild flexion). This is because it is difficult to open thoracolumbar foramina and facets if the table does not have an abdominal support that can be arched. It also avoids postural compression of the discs, permits free movement at the posterior articular processes, reduces muscular tension, and enhances the corrective forces of a properly applied adjustment. Without an abdominal support that can be lowered and released of tension, it would be contraindicated to adjust a pregnant woman in the prone position. Today, a large number of other optional mechanical adjustments and automatic mobilization devices have been incorporated that enhance the application of chiropractic technics. Some distract from this goal, however, and these will be described later in this chapter.
Patient Positioning Objectives
Ideal patient positioning on an adjusting table is that position which best encourages spontaneous release of the segment being treated if such were possible. This often requires the use of padded wedge-shaped cushions and/or various alterations in treatment table adjustment. The objective is to enlist the forces of gravity and reduce compressive forces on the involved facets.
If it is found that segmental lateral bending to the left is blocked, for example, it takes far less effort to make a correction if the patient can be placed in a position of lateral bending to the left before applying the corrective thrust. The same is true for flexion, extension, and rotational fixations. This is easily achieved by (a) table positioning (eg, raising or lowering the abdominal piece, (b) increasing or releasing the spring tension), (c) patient position (prone, supine, lateral-recumbent), (d) positioning the patient with your stabilizing hand, and/or (e) using wedged-shaped pillows in various positions under a patient's shoulder, hip, or both.
Some modern adjusting tables provide for horizontal shifting positions. In such a manner, proper positioning can conduct a large portion of the correction because it encourages motion (through both extrinsic and intrinsic mechanisms) toward the direction desired. Proper preadjustment positioning inducing motion up to the point of "block" can therefore add leverage and the benefits of soft-tissue tensile forces. For this reason, a rotary technic delivered at the end of passive rotation is far less traumatizing to the patient than a recoil adjustment with the patient in the neutral position.
With proper patient positioning, half the adjustment is accomplished and only a minimal additional applied force by the physician is necessary to complete the release. Here are four common examples:
1. A thoracic vertebra is fixed in flexion. The patient is placed prone, the headpiece of the table is raised, tension is released from the thoracicabdominal support, and the front aspect of the pelvic-thigh support is lowered –all which add gravitation force encouraging thoracic extension (flattening). Special care must be taken, however, not to induce a degree of extension that would produce jamming of the facets to be released. Thus, specific positioning will be a matter of compromise and clinical judgment of the situation (primarily, the degree of habitual thoracic kyphosis).
2. A thoracic vertebra is fixed in extension. The patient is placed prone, the headpiece of the table is lowered, the thoracic-abdominal support is raised and tension is increased, and the front end of the pelvic-thigh support is raised all which add gravitation force encouraging thoracic flexion (hyperkyphosis).
3. A thoracic vertebra is fixed in posterior rotation on the right. The patient is placed prone with a wedge-shaped cushion inserted under the patient's left shoulder girdle and upper thorax to encourage thoracic rotation toward the posterior on the left. If the patient's thoracic spine as a whole presents with a distinct kyphosis, the thoracic-abdominal support is made level with moderate tension. If the patient's thoracic spine as a whole is unusually flat, the thoracic-abdominal support and pelvic-thigh supports are adjusted to induce a moderate kyphosis, and spring tension is increased. Various other positioning modifications and a hip wedge may be helpful depending on the individual design of the patient's thoracic scoliosis, if one exists.
4. A thoracic vertebra is fixed in lateral flexion to the right. The patient is carefully placed in the right lateral recumbent position, with the contralateral side of involvement upward. The headpiece of the table is raised, the thoracic-abdominal support is lowered and its tension is reduced, and the front aspect of the pelvic-thigh support is raised all which add gravitational force encouraging the area involved to laterally flex to the left (curve toward the floor).
The author has seen practitioners who use the same table position on every patient adjusted despite the type of subluxation present. All mechanical adjustments on the table have been locked in the same position for years. This also has limited the doctor's potential. By using various positions and spring tensions available to place the patient in a comfortable position best affording spontaneous release, the adjustment will be more efficient and almost painless. It seems strange that a doctor would spend $5000 on a fine piece of equipment and use only $1000 of its capabilities.
Planes of Articulation
It is almost certain that every DC has seen another chiropractor delivering a thoracic adjustment with the line of drive directed toward the floor. Such a line of drive is contrary to all the biomechanical and anatomical factors involved. Besides being inefficient, it is highly painful to the patient. The fault lies in failure to visualize the design and position of the structures beneath the contact hand. Knowledge and vision are the keys for mastering any art.
A line of drive directed exactly parallel to the plane of articulation is the most mechanically efficient and induces the least amount of articular injury (and related patient discomfort). Because the midthoracic facets face almost straight toward the anterior, the adjustive impulse must be directed as parallel to the spine as is possible; ie, headward, minimally downward. Granted, this is an awkward position, but the more downward impulse, the more articular jamming will be induced, encouraging articular bruise and the subsequent development of an inflammatory reaction leading to adhesion develop ment in the weeks or months ahead. Keep in mind that the superior articular processes of the subjacent segment extend somewhat upward like rabbit ears. They would be easily fractured by a sharp force directed anteriorly if not for the stability provided by the rib cage.
It is of questionable clinical value to the patient to release a fixation only to set the stage for another in the future. When it is necessary to stretch the anterior longitudinal ligament and widen the IVD space anteriorly, it is recommended that this be done by patient positioning and to release the fixed facets with a force that is parallel to their plane of articulation. In this era of increasing malpractice claims, it is wise to give patient safety and comfort an extraordinary priority over a loss of a few ounces of mechanical efficiency.
The plane of articulation of an individual patient's particular involved segment must be considered. Textbook descriptions are based on population averages and do not consider the factors of individual genetic design or the effects of unique trauma and osseous erosion from long-term postural imbalance. Adapt to the situation at hand, not a textbook illustration.
It has often been taught that the ideal adjusting table height is 18 inches for an adjuster of average stature. Of course, other variables would be the thickness of the patient and the type of adjustment to be given. If the table is too high, a mechanical disadvantage occurs. If too low, overstress on the adjuster's spine results when several patients must be treated.
To be more accurate, table height should be adjusted so that when the patient is positioned prone, the doctor's fists just touch the patient's thoracic apex when the doctor's arms are relaxed. This means that recumbent patient height when would be a few inches below the doctor's flexed wrists. This space difference is essential to allow for full extension of the elbows when the adjustive impulse is applied. The patient must be positioned low enough that the doctor can position his shoulders, if necessary, parallel to the patient's shoulders and that a line of dive can be achieved in line with the apophyseal planes.
Unfortunately, many modern adjusting tables have so much machinery at their base that the minimal surface height is far higher than the ideal. If the patient is positioned too high, it is impossible to deliver an efficient painless adjustment –even if the DC stands on his toes. Toe standing is soon disregarded after the fourth or fifth patient because of fatigue. The solution to a high table is to have a platform of necessary height on each side of the adjusting table. This is rarely used, however, and one reason we hear people complain of painful chiropractic adjustments.
A word to the wise: never buy an adjusting table that you have not been adjusted on by someone whose height and build is similar to yours.
Type of Contact
The type of contact used is optional in most situations. The broadest contact that is efficient should be used, because the force will be directed through a larger surface area. A force applied by a fairly open palm against the skin is perceived by the patient far differently than a force applied by a pointed finger against the skin. Thus, a palm-heel, thenar, or knife-edge (edge of the hand) contact produces less patient discomfort than a pisiform or thumb contact. There are times, however, when a pisiform or thumb contact on a spinous process is necessary to get the job done quickly and efficiently.
Contact Points and Their Options
All contact points are optional at some time. For example, if the site of contact is to be on a thoracic transverse process, the use of a pisiform, the nar, palm heel, or thumb contact could all meet the same objective, essentially depending on doctor-patient positions and the segmental position of fixation. Thus, the choice of selecting a transverse process, a spinous process, or a lamina contact is a matter of clinical judgment. A mobilizing force directed against any of these structures will induce articular separation, tissue stretching, and the effected segmental motion. One type of contact may be more efficient and less painful to the patient than another, depending on the situation at hand.
Most classic adjustive technics apply contact on the spinous process or transverse process for greater leverage. Whenever possible, a laminal contact would allow the force to be directed against the strongest aspect of the posterior portion of the vertebra. Some leverage is lost with a laminal contact, but added safety is gained. Unless cautiously applied, a transverse process contact holds the inherent danger of the contact slipping laterally, which can easily result in rib injury. A medial transverse or laminal contact is less painful to the patient than a spinous contact because of the padding afforded by the intervening musculature). Again, a broad contact (eg, knife- edge, hand heel), although less specific, is less painful to the patient than a contact applied with a smaller surface area (eg, thumb, pisiform, adjusting gun).
Securing the Contact Hand
Precautions should always be taken when applying an adjustment to avoid slipping and pounding because both can bruise the patient, induce unnecessary pain, and result in an inefficient correction attempt. The patient's skin should be drawn taut in the direction of drive. Slipping results from not having the contact point properly anchored or perspiration from the patient's skin has not been removed. Pounding is generally produced by making an adjust ment when the contact is lifted from the patient's skin just before applying the adjustive force or delivering a recoil adjustment when the elbows are not completely relaxed.
Direction of Drive
Once motion restrictions have been found, the joint is usually adjusted with the force directed into the restriction. This is best achieved in most situations by adjusting with the contract on the opposite side of the fixation because more motion with less force can be accomplished by using a long lever arm. In any joint exhibiting fixation, it is often necessary to adjust in more than one direction if more than one plane of motion is restricted or blocked. Proper stance allows the line of drive to be delivered in the most efficient direction. The direction of drive should be against (through) the fixation, in the direction of blocked mobility, and in line with the articular plane. As in any generality, there are a few exceptions to this rule but space does not allow their explanation here.
The basic principle is that movement of the segment being adjusted is determined by the direction of drive and the plane of articulation. To have a better understanding of this, let us take as an example a midthoracic vertebra whose apophyseal joints have a plane of articulation almost at a 45* angle. A P-A force directed against both transverse processes will move the segment anteriorly and superiorly. A P-A force directed against the right transverse process will rotate the vertebra in a counterclockwise direction (anterosuperiorly on the right, posteroinferiorly on the left). A P-A force applied against the left transverse process will rotate the segment in a clockwise direction (anterosuperiorly on the left, posteroinferiorly on the right). If the contact is taken on the left side of the spinous process and a force is delivered toward 2 o'clock, the vertebra will rotate in a counterclockwise direction, and vice versa if the contact is applied against the contralateral side of the spinous process.
A spinous process contact taken in the midline or a double transverse contact will flex the vertebra if a P-A force is delivered and the subjacent segment is stabilized. However, if the superior segment is stabilized and the inferior segment is forced to extend, the same intersegmental motion is achieved. Once the mechanical principles behind this concept are grasped, there need be little argument in the effectiveness of one technic over another. Likewise, a P-A thrust against a right transverse process or a thrust against the left side of the spinous process will both rotate the vertebra in a counterclockwise direction. The choice of contact is solely a matter of clinical judgment and personal preference. The direction of drive, however, is not optional if the best mechanical advantage is to be assured. The direction of drive is determined by the site of fixation and the plane of articulation.
Depth of Drive
The depth of drive also must be accurate. It is taught in some books and professional papers that it should be to the anatomical limit, but this is not always true. Adjusting a strong ligament fixation immediately to the anatomical limit may rupture degenerated tissues –resulting in the development of even tougher scar tissue. The object here would be to progressively stretch but not rupture the shortened fibers. Again, this takes time for adaptation.
The opposite side of the coin also should be recognized. To mobilize further after a fixation has been released will produce a new defensive contraction and therefore predispose the development of a new fixation.
The Articular Snap
Spinal adjustments often involve the breaking of the synovial seal of the apophyseal joints, resulting in an audible "snap." While some feel this is of little significance, most authorities feel that breaking the joint seal permits an increase in mobility (particularly that not under voluntary control) from 15–20 minutes –allowing the segment to normalize its position and functional relationships. Unsuccessful manipulation resulting in increased pain rarely produce an audible joint release, while successful adjustments usually produce an immediate sense of relief (though some pain and spasm may remain), a reduction in palpable hypertonicity, and an improvement in joint motion, and are typically followed by a gradual reduction in symptoms.
A vertical axis extension (distraction) or separation of joint surfaces and elongation of shortened soft tissues should be a component of every adjustive thrust so that articular pressure is reduced to a minimum at the moment of joint movement. In this manner, articular friction with its accompanying trauma and pain will be reduced and taut tissues contributing to the fixation will be stretched. Instruction in adding intersegmental traction to all adjustive procedures was a fundamental principle in pioneer chiropractic.
Timing the Thrust
Somewhere at some time somebody taught another DC that the best time to deliver the thrust is at the end of patient exhalation. This erroneous idea has spread throughout the country like an epidemic to infect hundreds of DCs to the detriment of their patients. The advice, "Take a deep breath, and then let it out" is poor counsel if the adjustment is delivered at the end of exhalation. Patients soon learn of the doctor's tricks and consciously apply muscle-splinting mechanisms. Nobody likes their lungs to be shockingly over deflated.
Relaxed exhalation is a passive mechanism. Inhalation is not. At the end of relaxed exhalation, respiratory muscles prepare to contact by increasing their tone. Thus, the best time to deliver the thrust is immediately after the beginning of exhalation. The effect on the patient's lungs, then, is only to increase the rate of normal passive exhalation. If the thrust is made at the end of exhalation, forced exhalation results and the effect is a sharp automatic protective contraction of the diaphragm, thoracic muscles, and paraspinal musculature. The latter is likely to return the segment immediately to its abnormal but habitual positioning. Such poor timing is painful to the patient, and patients who suffer unanticipated pain are not inclined to refer their friends, relatives, and neighbors for such abuse.
Nobody enjoys unpleasant surprises. It is always wise to carefully explain to patients new to the practice before they are placed on the adjusting table exactly what you are going to do, why you are going to do it, how you are going to do it, and what sensations they may feel during this "operation." In this manner, there are no surprises, no shocks to one's expectations. The adjuster need not tell the patient how to breathe. The patient knows how. All the adjuster has to do is to feel the patient's thorax rise and fall as the contact is taken to time the thrust properly. A more efficient adjustment will be achieved, and the patient will feel little discomfort and no surprise.
Adjusting tables that produce a loud mechanical "crack" when the adjust ment is delivered are not recommended for three reasons: (1) no biomechanical principle justifies their use, (2) the "gunshot" noise frightens many patients, and (3) the noise prevents patients from personally sensing the deep articular release that so often accompanies an adjustment. This latter factor destroys the psychologic value of having the patient feel that something has moved in their spine.
One's preference in technic can be clinically justified as long as biophy sical and physiologic principles are followed. In health care, however, we are not dealing with purely mechanical principles. We are dealing with patients, sensitive human beings, who are often already in pain and we should not wish to induce any more discomfort during a correction than is necessary.
Thrust technics applied to an articulation can be divided into two categories: low-velocity technics (LVTs) and high-velocity technics (HVTs), and each has various subdivisions depending on the joint being treated, its structural-functional state, and the primary and secondary objectives to be obtained. The term adjustment velocity refers to the speed at which the adjustive force is delivered. In either low-velocity or high-velocity technics:
The force applied may be low, medium, or high.
The duration of the force may be brisk or sustained.
The amplitude (distance of articular motion) may be short, medium, or long.
The direction of the force may be straight or curving and/or perpendicular, parallel, or oblique to the articular plane.
Overlying soft-tissue tension may be mild, medium, or strong.
Primary or secondary leverage may be applied early, synchronized, or late.
Contralateral stabilization may or may not be necessary.
Thrust onset may be slow, medium, or abrupt.
Fixations may be produced by perivertebral fascial adhesions, ligamentous contractures, IVD dehydration, fibrosed muscle tissue, spondylosis, or meningeal sclerosis and perivertebral or intra-articular adhesions. An excessively forceful dynamic thrust to these conditions may result in increased mobility by stretching shortened tissues and breaking adhesions, but there is always some danger of osseous avulsion or tearing of meninges as scar tissue has a much higher tensile strength than osseous or nerve tissue. Because of this, progressive therapy may have to be extended over several weeks or months.
Low-Velocity Technics (LVTs)
The category of low-velocity adjustments contains applications that apply slow stretching, pulling, compression, or pushing forces. Sustained or rhythmic manual traction or compression and procedures to obtain proprioceptive neuromuscular facilitation (PNF) are typical examples. Many leverage techniques (eg, Cox technic) advocated to reduce IVD protrusions and functional spondylolisthesis can be placed in this category.
High-Velocity Technics (HVTs)
The category of high-velocity adjustments holds the applications of classic dynamic-thrust (direct, rotary, or leverage) chiropractic adjustment technics that are applied to a vertebra's transverse or spinous process or a lamina, with various degrees of counterleverage and/or contralateral stabilization. Contact pressure is usually firm, if the underlying tissues are not acutely painful, when the contact is to be maintained at a specific point and the thrust delivered in a precise direction.
A dynamic thrust against a point of articular resistance is an effective method of imposing the force necessary to produce adequate mobility to initiate the recovery process. Especially when leverage is applied before the application of a corrective impulse, considerable skill and caution are necessary to avoid iatrogenic trauma. The same is true if motion beyond the physiologic limit (eg, overextension, overflexion) is used.
A dynamic thrust will start a momentary myotactic stretch reflex even faster than a slow stretch, via the low-threshold stretch circuit, but, if delivered properly, a dynamic thrust will also excite the higher threshold Golgi tendon apparatus that will initiate the inverse myotatic reflex to cause the contracted muscle to give way suddenly (clasp-knife reflex). By holding a finger near a colleague's contact hand while a dynamic adjustment is given to a patient, the quick contraction followed by relaxation of the underlying musculature can be sensed. This phenomenon, autogenic inhibition, has many applications in correcting muscular fixations and relaxing splinted muscles.
The objective of almost all HVTs is to release instantly the fixated articulation (increase joint mobility). How this is executed has not been specifically determined because more is involved than the application of a mechanical force against a resistance. The most common theories are:
The mobilization of fixated articular surfaces.
The relaxation of perivertebral musculature. While a high-velocity force that suddenly stretches muscles spindles in primary muscle spasm will increase the spasm, the same force applied to a segment when its related muscles are in secondary or protective spasm produces relaxation if the impulse succeeds in removing the focal stimulus for the reflex.
The shock-like effect on the CNS. Shock-like forces
(1) are known to have a normalizing effect on noxious self-sustaining CNS reflexes;
(2) are stimulative to the neurons involved, resulting in increased short-term neural and related endocrine activity; and
(3) set up postural and muscle-tone-normalizing cerebellar influences via the long ascending and descending tracts.
Manual mobilization and thrust techniques are direct approaches to relieving articular fixations. Indirect functional approaches are often used when the cause for fixation has been determined to be essentially muscular in origin or when any form of direct force would be contraindicated. Within the category of indirect approaches fall many manual light-touch cutaneous reflex techniques, meridian therapy, trigger-point therapy, electrotherapy, transverse massage, traction, therapeutic vibration, isometric and isotonic contraction, etc. It is theorized that these procedures produce much of their effects because of their influence on the gamma-loop system and/or by the superiority of mechanoreceptor input on nociceptive input.
Types of Adjustive Thrusts
Test thrusts are mild preliminary thrusts applied before an actual corrective thrust is delivered. They have a twofold purpose: first, to acquaint the adjuster with the structural resistance present and patient response to the pressure applied; second, to acquaint the patient with what to expect.
The term leverage move refers to the use of counterpressure or contralateral stabilization. It is applied to prevent the loss of applied force, secure the most work with the least amount of energy expenditure, and concentrate the movement or force at the directed point of contact. Visualize! Only enough counterpressure is used to balance the force of the adjustive thrust. This thrust is the most commonly applied thrust used in chiropractic.
The classic recoil thrust is applied against a spinous process or lamina with a pisiform contact. After the contact has been accurately taken and secured, the correct stance must be assured and the elbows must be completely relaxed. At the beginning of patient exhalation, the adjuster's extensor muscles of the arms and pectorals are suddenly and simultaneously contracted.
As the elbows are in line on the same plane, this spasmodic-like contraction adducts the elbows and produces the thrust. So the force of the adjustment will not go in the opposite direction (ie, toward the ceiling), the adjuster must contract his abdominal, thoracic, and neck muscles at the same time the force is delivered. This posture maintains a rigid trunk, and the adjuster's body weight will concentrate the force on the spinous process being adjusted. Visualize!
The force of the adjustment should be applied equally with both arms at the same instant after the adjuster positions the trunk so that the force of the adjustment will be applied in a straight line from the episternal notch to the point of contact. The proper position, therefore, is to have the episternal notch directly over the point of contact. Another factor of importance is for the adjuster to position the elbows at right angles to the line of drive and bent only to the extent that allows the entire force of the adjustment to be delivered in a short, swift manner. Immediately after the adjustment is delivered, the adjuster's hands should "recoil" away from the patient's spine.
A thoracolumbar recoil adjustment delivered to a patient in the prone position should not be applied on a hard-surfaced table. Injury to the patient's chest or abdomen may result because of the velocity and force associated with this type of thrust. The table should have a spring support in which the tension is relaxed, yet there must be resistance under the thighs and upper thorax of the patient.
An impulse thrust is the application of a short sharp force without recoil. The hands adopt a preset tension in the line of drive, and the impulse is characterized by a high-velocity low-depth thrust.
Body Drop Thrusts
A body-drop thrust is usually associated with Willard Carver's technic. The adjuster centers trunk weight over the contact hand(s) and raises the body between the shoulders using straight arms. The adjuster's trunk is then allowed to drop to apply a short sharp impulse, and the force is delivered through the straight arms (elbows locked). Visualize! This method is not to be confused with that of dropping the body by bending the knees as is occasionally used in lumbar side-posture adjusting. The Carver body drop must be used cautiously with children, the elderly, osteoporotics, etc. Less forceful tech nics are usually more applicable in these cases.
Spear's Multiple-Thrust Technic
The objective of multiple-depth thrusts is to permit a gradual increase in force, prolong the relief on compressed discs and articular cartilage, allow time to compensate for the applied force, and permit the application of a force that can be equal to or greater than that used in a single thrust, thus reducing patient discomfort.
A specific example of a multiple-thrust technic would be the application of Leo Spears' double-transverse contact, which is applied to the spine with thenar contacts in a deep, low-velocity, alternating, rhythmic fashion to obtain patient relaxation and to stretch perispinal and intersegmental adhesions and other taut tissues before more specific spinal therapy. It has been described as a continuous "down light, down medium, down heavy" multiple thrust in which each nonjerky thrust (without relaxing the pressure between the multiple thrusts) applies progressive pressure after tissue adaptation. These progressively increasing forces must be made in a smooth steady manner so that patient relaxation will not be disturbed to the point of producing perivertebral contraction. Visualize what is occurring and why.
This full-spine technic, applied from T1 to the sacrum, is extremely beneficial in spinal cord diseases (eg, acute poliomyelitis) and situations where either cerebrospinal or axoplasmic fluid flow has been restricted or requires enhancement. Although this "stretching-milking" technic is not designed to reduce severe subluxations, numerous secondary muscles fixations will be gently removed and frequent articular snaps will be felt and heard after the technic has been applied to the thoracolumbar spine for a minute or two. This is also an excellent initial technic to use in conditioning the spine preparatory to a more forceful technic. This technic has a direct effect on axoplasmic flow, IVF contents, the costal vertebral articulations, and CSF circulation. It has an indirect effect of massaging ("pumping" or "milking") the lungs, mediastinum, heart, and upper-abdominal viscera.
Rotary Trusts and Rotary Breaks
A rotary thrust, with accompanying joint distraction, is administered to correct either local or area rotatory fixations. The direction of drive is clockwise or counterclockwise and parallel to the plane of articulation. Visualize! A rotary break is the addition of a force to open thinned disk space on the contralateral side of rotation fixation. The technic is commonly applied in the cervical area with the patient supine or prone or in the lumbar position with the patient in the lateral recumbent position (eg, "million-dollar roll").
Most chiropractic adjustive technics have the common objectives of freeing restricted mobility and releasing impinged or stretched nerves or vessels passing within the IVFs. Added factors are the expansion or compression of deformed IVDs, the elongation of shortened tendons and ligaments, the release of adhesions, and the enhancement of cerebrospinal and axoplasmic fluid circulation.
It can be generally stated that joints and nerves become painful only when nociceptors are stretched, compressed, or chemically irritated. In adjusting acute lesions, proper analysis consists of the localization of fixations as well as the determination that these conditions produce the nociceptive input experienced by the patient in pain.
General (regional) adjusting means nonspecific adjustments applied in different regions of the spine. General adjustments are usually applied in postural distortions (eg, scoliosis, lordosis, kyphosis) to affect groups of vertebrae, muscles, and ligaments rather than specific segments. It is good procedure to apply a general adjustment to relax the patient before administering specific adjustments (eg, Spears multiple-thrust technic).
Specific adjusting means to deliver an adjustment to a specific vertebrae to alter specific biomechanics and symptomatology.
The biomechanical objective in specific chiropractic adjustments is to restore motion throughout the active, passive, and paraphysiologic range of motion. Because of the dynamic forces involved, such techniques must carefully consider the exact geometric plane of articulation (normal or abnormal), asymmetry, the force magnitude to be applied, the direction of force, torque, coupling mechanisms, the state of the holding elements (eg, spastic muscles, articular fixations, stiffness and dampening factors), the integrity of the check ligaments (eg, stretched, shortened), and any underlying pathologic processes (eg, infectious, neoplastic, sclerotic, arthrotic, osteoporotic) of the structures directly or indirectly involved.
As local tissue temperature, architecture, density, elasticity, flexibility, plasticity, nutrition, etc, are variables affecting the material properties of tissues, these factors must be considered also. The application of any clinical procedure without consideration of the cause-and-effect forces anticipated is not within the confines of scientific chiropractic.
In the study of neurology, Meltzer's law of contrary innervation states: All living functions are continually controlled by two opposite forces –augmentation or action on the one hand and inhibition on the other. There is a similar maxim concerning biomechanical adaptation in articular lesions: If there is local segmental hypermobility without a history of overt trauma (eg, severe sprain resulting in instability), there is also the causative site of primary fixation. In joint disorders, there is invariably hypomobility in one area and compensatory hypermobility in another. Whenever possibly, the body will adapt to (compensate for) both normal and abnormal change.
Comprehensive therapy cannot be restricted to the doctor's office environment. Healing and its encouragement is an ongoing process. To enhance rehabilitation, nutritional counsel and prescribed home exercises, for example, have been shown to be beneficial in many musculoskeletal, neurologic, circulatory, hormonal, and visceral disorders. When spastic areas of partial fixations do not release adequately or conventional methods only offer temporary relief, a comprehensive nutritional evaluation should be made. Potential effects of occupational or emotional stresses should be deeply explored also.
If physiotherapy is to be employed, whatever modality selected should be chosen for its specific indications. Modalities are often helpful in normalizing continuous motor nerve firing, in dislodging collections of metabolic debris, and in improving circulation, drainage, and cellular nutrition. The intensity used in electrotherapy should be maintained below the threshold of pain to prevent a protective reflex contraction of the involved musculature.
Stretching, heat (superficial or deep), cryotherapy, muscle stimulation, ultrasound, galvanism, high-volt therapy, interferential current, pulsating vibration, ultraviolet radiation, and various types of therapeutic massage have proved themselves effective under certain conditions for a wide range of disorders.
The basic goals of rehabilitation therapy are shown in Table 15.1.
Table 15.1. Basic Functional Goals in Rehabilitative TherapyFunction Dysfunction Primary Therapy Strength Weakness Exercises against resistance Physiologic elasticity Spasticity Thermotherapy, ultrasound, autosuggestion, biofeedback therapy, postural correction, relaxing exercises Contraction/Relaxation Spasm Pain relief, "gate" blockage techniques, relaxing exercises, heat Normal tone Tension Relaxing exercises, hydrotherapy, bio- feedback, hypnotherapy, psychotherapy Physical elasticity Contracture Stretching exercises, joint mobilization, ultrasound, thermotherapy Coordination Incoordination Strengthening and relaxation exercises, coordination training and practice.
Rehabilitative exercise should be conducted with sufficient warmup, frequency, duration, and intensity, and these factors must be based on the individual patient's current, often changing, functional and biomechanical status and need. Thus, explicit instruction, demonstration, motivational encouragement, and patient monitoring are often basic factors in arriving at a long-range successful outcome.
Many chronic musculoskeletal disorders seen in a chiropractic office present with two underlying periarticular muscle-?ligament conditions: one or more muscle groups that are in a weakened state and a shortened and spastic condition of their antagonists, or vice versa. It is presumed that this functional imbalance, which leads to both physiologic and biomechanical overstress, is one frequent cause of many articular disorders. Thus, adjunctive therapy in articular disorders directed to the involved joint(s) is often helpful in correcting this imbalance by strengthening certain muscles and ligaments, and stretching others. If not, the effects of primary therapy are likely to be effective only during the short term and recurrence of some problem (either locally or somewhere else in the kinematic chain) can usually be expected.
According to Starling's law, a normal long muscle is a strong muscle; a normal short muscle is a comparatively weak muscle. Thus, any type of therapy tending to elongate an abnormally shortened muscle will be clinically indicated in most cases. How this is accomplished is not as important as its being accomplished in the most efficient and painless manner.
The Principle of Biologic Compensation
One of the basic laws of physics is that every action has a reaction. This law must be held foremost during health care.
The body is a dynamic adaptable organism. DCs who approach health care as spinal engineers often fail to appreciate this point.
Personal Case History #1. In the early 1960s, several months of cluster headaches were experienced. The painful attacks were frequent and excruciating to the degree that banging my head against a wall was tried sometimes in an attempt to change the agonizing pattern. Adjustments from a colleague had only slight effect, and a MD's morphine was of no help once an attack had started. A suicidal attitude was developing when someone suggested I visit a chiropractor he knew who practiced in a small town several miles away. I arranged an appointment, introduced myself, offered my history, and mentioned that x-ray films had shown an atlas posterior on the right ever since I was in chiropractic college. His findings agreed with this listing. I visited him once a week. After 3 weeks, his adjustments had increased the interval between attacks, but they did not stop the attacks. He then asked me if I had his permission to try something different. I agreed, and he then adjusted my atlas further posterior on the right. I have never suffered a cluster headache since then.
This was his explanation: "The body is a dynamic adaptable organism. Evidently, you suffered some type of upper-cervical stress in early childhood, or possibly from a forceps delivery, that left you with a chronic subluxation: atlas rotated posterior on the right. As the years went by, your body adapted to this malposition. Recently, however, something occurred to reduce this malposition which set up a new situation that was highly inflammatory. Although your listing remained posterior on the right, it was less than what your body had adapted. The adjustment resolving your problem just returned the atlas to its habitual, well-adapted position –the setting your body had been accustomed to for over 30 years. For you, a certain atlas position of posterior on the right can be said to be your normal."
Personal Case History #2. It has always been impossible for me to stand erect and flex forward and touch my toes with my fingertips. On seeing this one time during my childhood, a gym teacher pushed my upper back downward at the end of active forward flexion –an act that left me with low-back pain for several days. It also was extremely difficult to do a simple forward somersault roll. I was told that I had "stiff joints" and tight hamstrings. These physical inabilities were frequently the cause of personal embarrassment and ridicule because I could not do what other children could do easily.
It was not until late in my junior year at Lincoln Chiropractic College that the answer was found –when students of spinal roentgenography had full-spine films taken and analyzed by the instructor. Earl Rich, who later became the father of chiropractic cineroentgenography, was my x-ray instructor. He pointed out that I had an unusual lumbar spine in that the articulations resembled those of the thoracic spine. This allowed a greater degree of lumbar rotation than "normal" but far less anterior flexion mobility.
Guidelines. The lesson in this is that textbook explanations or teachers' opinions should be the doctor's servants and not his master. Textbook descriptions, including those described in this book, are based on average, typical findings. Yet, no particular patient will meet these criteria. Each patient presents with unique characteristics. This fact must be forefront when analyzing the results on any laboratory, neurologic, or orthopedic test. The effects are facts, but the reason(s) why the effects occur in a particular patient is often only an assumption based on a list of preconceived "causes."
The human intellect is out of its league when it tries to compete with the highly complex unconscious "intelligence" that directs the multimillion integrating, coordinating, synergistic, facilitating and dampening mechanisms occurring each moment of one's life. Unnecessary failures occur in health care when the doctor works in opposition to an individual's unique biologic needs and capabilities; ie, in preferring to follow prejudgments, peer pressure, and current theory to the detriment of the patient.
Clinical Plans It is easy to fall into the mental trap of viewing pain, swelling, inflammation, joint restriction, etc, as abnormal reactions. Yet any widely recognized resource on pathology will tell us they are not. They are normal reactions to abnormal situations. They exist for a reason and only manifest when certain physiologic mechanisms can function. They are also diagnostic signals. Thus, it is the wise doctor who uses his eyes, ears, and senses of touch and smell to answer the question: "What is the patient's body trying to tell me?" Once the answer to this question is found, it is then that the doctor's intellect can be rightfully used to devise a constructive plan of action –a plan that is in harmony with the patient's unique nature and status.
Nutritional and Rehabilitative Therapy
The same principle is true in therapeutic nutrition and rehabilitation. Counsel and therapy must be designed for the patient and the conditions at hand. The problem is to decide what is "normal" for a particular individual and work to achieve this goal –keeping in mind that what may be normal for a particular patient may not be what we were taught in college or a textbook of what constitutes "normal."
It is for this reason that a person who has lived on little else than rice or beans for many years will become ill if immediately placed on what we call in America a "healthy balanced diet." We have seen in recent years the stupidity of medical "expert" counsel on television during the 1970s encouraging everybody to "get out and jog a mile or two every day." The result was been thousands of fatigue fractures, heel spurs, damaged knees and IVDs, heart attacks, and strokes. One should never tell a sedentary patient to jog who is not accustomed even to long walks. If a change in life-style is to be made, it must be made in increments – slow enough that biologic adaptation mechanisms can conform. When stretch would be beneficial, stretch; don't tear.
There are only two sorts of doctors: those who practice with their brains and those who practice with their tongues. – Sir William Osler