THE ART OF ARTICULAR CORRECTION
The three most important instruments for chiropractors are
their minds, hands, and a well-designed adjusting table. Many
graduates in recent years have not been taught the optimal
applications of the latter.
The following suggested procedures regarding the art of
articular correction are based on established biomechanical
principles. They are not new. They are the approach of pioneer
chiropractic in which they may have been applied unknowingly, but
they were applied in their methodology.
Nine cardinal rules are suggested for the application of any
efficient articular adjustive technic. They concern: (1)
preadjustment tissue relaxation; (2) preadjustment patient
positioning; (3) directing the impulse drive in line with the
facets' plane of articulation; (4) applying the active contact
firmly on the strongest logical point of the segment; (5) using
the mechanical advantage of leverage; (6) applying segmental
articular distraction before the thrust; (7) timing the thrust;
(8) using supportive therapy when indicated; and (9) allowing for
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. The following sections
will attempt to solve this apparently widespread mystery.
The Oval Posture
Adequate adjusting tables are primarily designed to position
the patient's thoracic spine in an "oval posture" (mild flexion).
This is sometimes called a prone "C" posture. This position is
necessary because it is difficult to open thoracolumbar foramina
and facets of a patient positioned prone if the table does not
have an abdominal support that can be arched (tented). It also
avoids postural compression of the discs, permits freer movement
at the posterior articular processes, reduces muscle tension, and
enhances the corrective forces of a properly applied articular
Without an abdominal support that can be lowered, released of
tension, and pillowed, 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 "innovations" distract from this
goal, however, and these will be described later.
Firth offered the following comments on the oval posture:
"Without an abdominal support [that can be slightly raised],
it is impossible to open any foramina. The oval posture has
(1) avoids postural compression of the discs,
(2) permits free movement at the articular surfaces,
(3) removes muscular tension, and
(4) makes adjustments more corrective."
--Firth's Technic Notes, 1944.
Patient Positioning Objectives
The 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.
The more that can be achieved by gravity and body weight, the
less force required in the adjustive thrust.
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 (1) table positioning (eg, raising or
lowering the abdominal piece; (2) increasing or releasing the
spring tension); (3) patient position (prone, supine,
lateral-recumbent); (4) positioning the patient with your
stabilizing hand; and/or (5) using wedged-shaped pillows in
various positions under a patient's shoulders, hips, 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 a static
corrective force 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, at least half the adjustment
is accomplished, and only a minimal additional applied force by
the physician is necessary to complete the release. Here are four
A thoracic vertebra is fixed in
flexion. The patient is placed prone, the headpiece of
the table is raised, tension is released from the
thoracic-abdominal support, and the front aspect of the
pelvic-thigh support is lowered -- all which adds mild
gravitational 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 judgement of the situation (primarily,
the degree of habitual thoracic kyphosis).
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
flexion support is raised -- all which adds gravitational force,
encouraging mild thoracic flexion (slight hyperkyphosis).
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
has a distinct kyphosis, the thoracic-abdominal support, with
moderate tension, is lightly lowered, but not to the point of
jamming facets. If the patient's thoracic spine as a whole is
unusually flat, the thoracic-abdominal support and pelvic-thigh
supports are raised to induce a slight 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, kyphosis, or flattening, if
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 the 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 of which adds mild gravitational force, encouraging
the area involved to laterally flex to the left (to curve toward
I know of practitioners who use the same table position on
every patient adjusted despite the type of subluxation/fixation
present. All mechanical table adjustments have been locked in the
same position for years. This limits the doctor's potential. By
using various positions and spring tensions available to place
the patient in a comfortable position of relief and one that best
affords almost spontaneous release, the adjustment will be more
efficient and painless. It seems strange that a doctor would
spend $5,000 on a fine piece of equipment and use only $1,000
worth of its capabilities.
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 biomechanical and anatomical factors involved. Besides
being structurally 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 visualization are major 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 thoracic facets normally face obliquely
toward the anterior when the patient's spine is in an oval
posture, the adjustive impulse must be directed as parallel to
the articular planes 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 development 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
could be easily fractured by a sharp force directed anteriorly if
not for the stability provided by the rib cage. It is of no
clinical value to the patient to release a fixation only to set
the stage for another in the future by adjustive abuse.
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 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 planes of articulation of an individual patient's
particularly involved motion unit must be considered. Textbook
descriptions are based on population averages and do not consider
the factors of individual genetic design or the affects of unique
trauma and osseous erosion from long-term postural imbalance.
Adapt to the situation at hand as viewed on film, not a textbook
illustration. Expect the unexpected.
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, size, 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
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 size of the patient and the type of
adjustment to be given. If the table is too high, a mechanical
disadvantage for the adjuster occurs. If too low, overstress on
the adjuster's spine results when several patients must be
treated. Possibly this is why so many DCs complain of a chronic
To be more accurate, table height should be adjusted so that
when the patient is in a prone position the doctor's fists just
touch the patient's thoracic apex when the doctor's arms are
relaxed. This means that the patient's recumbent height 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 drive 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 it is one reason we hear people complain of painful
I personally used a hylo for thoracic adjustments and
spondylotherapy. For side-position adjustments, supine cervical
adjustments, and extraspinal adjustments, I used a lower and
wider vinyl covered "lounge chair," whose upper third titled
upward about 30 degrees.
A word to the wise: never buy an adjusting table that you have not been adjusted on by someone whose height and build are
similar to yours.
Chiro-praktikos (Handv Efficiency)
Perfection of an art is a constantly expanding process. The
quest of perfection in our profession is the basis of the
diligent practice of chiropractic to the full extent of our
knowledge, clinical skills, and creative imagination.
This paper is not a "Technic Course." I will not describe
segmental listings for each vertebra, the occiput, or the pelvic
bones; or modifications of the sundry optional technics when the
patient is in the supine, prone, sitting, or lateral recumbent
positions. These should be well known to the general readership
of this paper. If not. The reader is referred to the classic:
Janse J, Houser RH, Wells BF: Chiropractic Principles and
Technic, Chicago, National College of Chiropractic, 1947. I
also do not address extremity adjusting as this subject is
covered in detail in my many textbooks, and "Books on Disks."
These books and disks describe, and often attempt to
illustrate in one still photograph, adjustment mechanics.
However, understanding the fundamental mechanics alone falls far
short of the mark. Such guidelines cannot describe what is
"felt." My emphasis herein will be on basic principles neglected
in standard textbooks plus the skillful application of the
mechanics with finesse. An impossible task?
Actually, the arts of palpation and the chiropractic
adjustment cannot be taught, just piloted. How does one teach an
art? What does an experienced artist say to the student of
classical music or realistic painting say when asked, "Please
teach me to play (or paint) as you do."
Here is this author's dilemma in challenging the basic topics
of this paper. Better say nothing than attempt the impossible?
Or, do the best I can in hopes that a candle will be lit in an
area of darkness that will inspire a life-long quest? How is the
finesse of skill and discretion developed except by
motivated practice, practice, and more practice? I have opted for
Complicating the development of adjustive finesse is the need
for persevering motivation, one's genetic disposition and
talents, and, likely, refined intuitive faculties. These cannot
be conveyed from one to another. Thus, despite a student's best
intentions, some will progress far, some a little, and some would
be better off in another career.
A mechanical instrument can be easily designed that is
programmed to deliver the correct direction of drive, the ideal
depth of drive, the appropriate velocity of force, etc. However,
the clinical results of such a machine will never approach the
results of chiro-praktikos (hand efficiency).
The "Feel" of Palpation
As a chiropractic student, our Freshman II class was
instructed to practice the art of palpation because Technic I was
to be taught in the following semester. We were instructed to
determine the location of a needle progressively overlaid with
sheets of "onion-skin" paper. It was suggested we practice this
at least 15 minutes each day, 5 days a week. During the first day
of Technic I, the instructor asked how many students had done
this exercise. All raised their hand, but mine foolishly shot up
abruptly with pride. I was asked to stand before the class and
demonstrate my skill with six overlays. When finished, the
instructor, Dr. John Alton, said, "Not bad!"
He then pulled a hair from my scalp and asked another student
to remove the needle, add two more sheets of paper, and lay the
hair anywhere under the sheets once the instructor's back and my
back were turned. After several minutes of agonizing
embarrassment, I had no clue whatsoever. Then the instructor
quickly swept his fingers over the top sheet, isolated the
location of the hair, and traced its curl with a pencil. Upon
lifting the sheets, I was amazed that his perception was perfect.
He looked at me, smiled, and said, "Practice, Dick, practice."
There is so much more to soft-tissue palpation, for instance,
besides locating a spastic muscle, a thickened tendon, or a
degree of fibrosis. First is surface and contour inspection. Then
to be determined are skin temperature, texture, degree of
moistness or dryness, depth of subcutaneous fat, effect of
fascial restraints between skin and muscle, etc. There's muscle
texture, tone, rebound after pressure, pliability, smoothness or
striations of fibrosis, state of adjacent lymph nodes, subtle
pulsations, etc. Whenever an abnormality arises, the question
begins, "Why?" and can this "Why" be corrected if beneficial or
at least its progress halted?
The common methods chiropractic pioneers used in determining
the site of a vertebral subluxation were posture analysis, static
bony palpation, palpation of perivertebral soft-tissue tone and
texture, relating a patient's signs and symptoms to appropriate
spinal level, local temperature, and nerve tracing.
Pioneer literature offered a caveat to static bony
"There are six factors that can mislead in palpation: (1)
bent spinous processes, (2) irregularities and exostoses on
spinous processes, (3) aponeuroses make some spinous processes
palpate from 1/2 to 3/4th inch thick, (4) bifurcations that
cannot be palpated, (5) bifurcations of cervical vertebrae not in
the midline, and (6) bifurcations with unequal prongs." --Firth's
Technic Notes, 1944.
As few modern graduates have any knowledge of nerve tracing, a
brief description is given below.
There may be a condition that would cause tenderness if
pressure would be exerted but no abnormal sensation will be felt
if there is no induced pressure. It is upon this fact that nerve
tracing is based. Nerve tracing is the palpable act of following
the course of tenderness over nerves irritated or impinged that
will often assist in locating the focus of pain, tenderness, or
headache. It is a diagnostic art that was used more in pioneer
chiropractic than any other healing art.
Nerve tracing is thus the art of following by palpation a
tender nerve from its spinal origin to some inflammatory or
pathologic lesion or zone or the act of tracing a tender nerve
from an inflammatory zone to its spinal IVF. A nerve may be
traced if it is tender and situated at a point where it may be
reached while palpating. To be traced, it is necessary that the
nerve be hypersensitive regardless of cause.
As mentioned, nerve tracing as an analytical procedure is a
technique once widely practiced by pioneer chiropractors.
Although it has fallen into disuse in recent decades (like
outlining the borders of organs through percussion), the art has
merit. Firth, Janse, Harper and others mentioned the importance
of nerve tracing in their writings on spinal analysis. More
recently, Kirby, using the early works of Gregory as reference,
offers a brief explanation of the methodology, of which the
following has been adapted.
Method of holding the palpating
finger. It is necessary in nerve tracing to perform deep
palpation by considerable pressure to elicit tenderness along the
nerve pathway and thus determine its course. To avoid finger
fatigue during such continuous deep pressure, place the index
finger on the top surface of the middle finger for support and
the thumb against the under surface of the middle finger to
support the bottom of the palpating middle finger.
Method of following a nerve. Once
a sensitive point along a nerve pathway is found by digital
exploration, palpation is continued along the anticipated course
of the nerve. If tenderness is lost, pressure is applied above or
below the expected course by palpating in a half-moon direction.
The nonactive hand may hold a skin pencil that can be used to
mark the course of tenderness.
Unpalpable nerve pathways. If a
tender nerve passes under a bone or thick muscle where tenderness
cannot be elicited, the examiner must try to anticipate its route
and pick it up past the obstruction where the nerve will again be
elicited by tenderness. This is common when a nerve passes under
the scapula or clavicle and the pathway must be reaffirmed.
Method of tracing nerves from the
spine. Standard paraspinal palpation is performed, but
then the palpation continues along the nerve pathway step-by-step
until the pathologic zone is reached. Sometimes nerve pressure
upon the tender nerve tract may relieve the tenderness or numb it
to the degree that it cannot be traced further. For that reason,
it may be difficult to retrace a nerve at this time from its
spinal origin to the periphery.
Method of tracing nerves to the
spine. First, the tender point along the nerve pathway
near the inflammatory area should be elicited, but avoid deep
palpation over the actual tender zone of the affected area.
Palpation should be made a short distance toward the spinal
origin of the nerve supply. If pressure on the nerve numbs its
sensitivity, only the distal portion of the nerve will be
affected. Deep pressure along the nerve pathway will sometimes
relieve pain or at least afford temporary relief. This is often a
palliative aid but a diagnostic obstacle.
Dual routes. It is often found
that the nerve will branch, and the tender pathway can be traced
to two different points of the spinal column. This is most likely
because multiple organs are involved or because a nerve supply
from different segments of the spine are given off to the same
pathologic zone that has become involved.
Locating tender points along the nerve
pathway. It is important to realize that as the nerve is
traced from its spinal origin to the region of some pathologic
zone, or vice versa, certain points along the nerve pathway may
prove more tender than others. These points, similar to trigger
points or acute acupoints, should be marked. Pressure along the
nerve may excite a sharp and decisive pain in the pathologic
area. This site also should be marked and noted.
Tracing of the peripheral nerve
rami. Nerves and their branches that innervate internal
viscera cannot be directly traced because they are too deep to be
palpated. How then in such a condition can one elicit information
that will help to correctly determine the location of the
etiologic spinal lesion? The explanation is that if a deep nerve
is sensitive or tender, usually its superficial branches are
equally hypersensitive. Thus, if we cannot trace a nerve to the
end site of a trunk or cavity of the organ, it may be possible to
trace a peripheral branch of the same nerve back to its spinal
origin. Needless to say, an alert working knowledge of neurology
is essential for this particular work. If the peripheral nerve
branches can be traced to the proper point or locality of the
spinal lesion, then a helpful tool of analysis is at hand.
Not all nerve pathways follow the course shown in anatomy
textbooks. Some deviate and wander somewhat wildly along their
classic course. Any surgeon will confirm this. In these cases, by
palpating in a fantail manner, tenderness may be found and nerve
tracing may then proceed as normal. Gregory felt that when a
major nerve is tender at all, it is tender throughout its entire
length. Consequently, any tender major nerve will likely be
tender near its spinal origin.
Gregory illustrated these wandering nerves by describing a
patient with pain over the right hypochondriac region when a full
breath was drawn. He expected to locate the tender zone and trace
it from this region back to the spine following the intercostal
nerves. For the first few inches, this was true; then suddenly
the tender pathway took an upward direction through the axillary
region to the front of the shoulder, under the clavicle, and back
to the origin at C6 on the same side as the tender zone.
Master the art of nerve tracing, and you will have acquired
another important diagnostic tool. A well is not an ocean. Seek
as many confirmatory signs as possible.
Type of Contact
The type of contact used in applying a chiropractic articular
adjustment 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. For example, 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 low radial
side of forefinger contact produces less patient discomfort than
a pisiform or thumb contact. There are times, however, when a
pisiform or thumb contract on a spinous process is necessary to
get the job done quickly and efficiently.
There are eight classic contact points described by Firth:
Pisiform. A quarter circle drawn
over the fleshy part of the hand anterior to the pisiform
Edge contact. Upon the abductor
tendon of the little finger, about 2/3rds the distance from the
Thenar. Extends from the first
metacarpophalangeal articulation of the thumb to the middle of
the middle of the heel of the hand. It is the fleshy part of the
palmar surface of the hand overlying the first metacarpal bone.
Palmer surface of the fifth metacarpal
Heel of the hand.
Palmar surfaces of the fingers.
Radial side of the forefinger.
The author's favorite contacts, if applicable.
a. Cervical, patient supine. Contact #8.
b. Thoracic, patient prone, general, double Contact #4 or crossed #2.
c. Thoracic, patient prone, specific, Contact #1.
d. Lumbar, patient laterally recumbent, Contact #1.
e. C7--T3, patient prone, Contact #3.
f. First rib, patient prone or supine, Contact #8.
Contact Points and Their Options
All contact points are usually optional. For example, if the
site of contact is to be on a thoracic transverse process root,
the use of a pisiform, thenar, palm-heel or thumb contact could
all meet the same objective, essentially depending on
doctor-patient positions, the segmental position of fixation, and
degree of associated spasticity. Thus, the choice of selecting a
transverse process root or a spinous process 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, although one
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 lamina contact (recommended) at the root of a
transverse process 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
Unless cautiously applied, a transverse process contact holds
the inherent danger of the contact slipping laterally, which can
easily result in rib injury. A transverse or laminal contact is
less painful to the patient than a spinous contact because of the
padding afforded by the intervening soft tissues. A broad contact
(eg, knife-edge, heel of hand) although less specific, is less
painful to the patient than a contact applied with a smaller
surface area (eg, thumb, pisiform, or forceful adjusting
Securing the Contact Hand
Precautions should always be taken when applying an adjustment
to avoid slipping and pounding, as 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
adjustment 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 articular 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
contact 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
Proper stance allows the line of drive to be delivered
in the most efficient direction. Again, 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 here 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 typical midthoracic vertebra where the apophyseal
joints have a plane of articulation almost at a 45 degree 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
A spinous process contact applied 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 these concepts 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 an oblique 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.
At T10 and below, the hands should be brought very close
together when using double thenar or pisiform contacts to apply
the force on the mammillary processes rather than the weak
transverse processes found in this region.
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, the contour of the spine, and
the plane of articulation.
Depth of Drive
Besides patient positioning, the type of contact selected, and
direction of drive, the depth of drive also must be accurate. It
is sometimes taught that it should be to the anatomical limit,
but this is not often true. Adjusting a strong ligament fixation
immediately to the anatomical limit may rupture degenerated or
brittle tissues --resulting in the development of even tougher
scar tissue. The object is to progressively stretch but not
rupture shortened fibers. Adaptation takes time.
The opposite should also be recognized. A brisk attempt to
mobilize further after a fixation has been released will produce
a new defensive contraction and inflammation, and therefore
predispose the development of a new fixation. Excessive
unconditioned mobilization is not beneficial; it is trauma.
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, many 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 as much as possible if post-adjustment
rest is allowed.
Unsuccessful manipulation resulting in increased pain rarely
produces an audible joint release, while successful adjustments
usually produce an immediate sense of relief (though some mild
discomfort and spasm may remain). A reduction in palpable
hypertonicity and an improvement in joint motion are typically
followed by a gradual reduction in related symptoms.
Below are some historic comments:
"The 'pop' or 'snap' heard when adjusting the spine is due
to the breaking of the fluidic attraction between articular surfaces. The fact that a vertebra pops is not proof of an adjustment; it only proves that movement has occurred.
"The articular surfaces may be separated a slight distance
without popping, and this degree of separation is dependent upon
the size of the articular surfaces. The cervical articular
surfaces are barely 1/4th inch in diameter; therefore, they
produce a pop easier than the articular surfaces in the lumbar
area, which measure about 3/4th inch in diameter.
"In the cervical and lumbar regions, only four pops are possible
for each vertebra: one for each of the four articular surfaces.
In the thoracic region, however, there are ten such pops possible
for each vertebra: one for each of the four articular surfaces,
the two costotransverse articulations, and the four demi-facet
"If a pop occurs and a correct adjustment has been given, there
is a greater amount of correction made than if the vertebra has
not popped. " --Firth's Technic Notes, 1944
An axial extension (distraction) or separation of joint
surfaces and elongation of shortened soft tissues should be a
prior component of every adjustive thrust. Articular pressure is
thus 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, and it's still valid.
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 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 extremely poor counsel if the adjustment is delivered at
the end of exhalation. Patients soon learn the doctor's tricks
and consciously apply muscle splinting mechanisms just before the
thrust is delivered. Nobody likes their lungs to be shockingly
Relaxed exhalation is a passive mechanism; inhalation is not.
At the end of relaxed exhalation, respiratory muscles prepare to
contract by increasing their tone. Thus, the best time to deliver
the thrust is after the beginning of exhalation. The effect on
the patient's lungs, then, is only to increase the rate of normal
The adjuster need not tell the patient how to breathe. The
patient knows how. All the adjuster has to do is feel the
patient's thoracic cage 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
If the thrust is made at the end of exhalation, forced
overexhalation results and the effect is a sharp, automatic,
protective contraction of the diaphragm, costothoracic muscles,
and perispinal musculature. The latter are likely to return the
segment immediately to its abnormal but habitual position. 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.
Information Dissolves Fear of
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; what
sensations they may feel during this "closed surgical procedure";
and what benefits they should look for as the day progresses. In
this manner, there are no surprises and no shocks to one's
expectations. This explanation builds a logically designed image
within the patient's mind so that the patient's psyche is working
with you, not in a contrary fashion.
Drum rolls, trumpets, flashing lights, or "gunshot" theatrics
have no place in a clinical atmosphere. A colleague recently
remarked, "Those who set a circus stage soon become known as
Adjusting tables designed to produce a loud "crack" when the
adjustment is delivered are firmly not recommended for three
reasons: no proved biomechanical principle justifies their use,
the "gunshot" noise frightens most patients, and the extraneous
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 changed. For many patients,
this is a positive affirmation. There is nothing wrong in
combining physical benefits with mental reinforcement. It used to
be called "good bed-side manner."
One's preference in technic can be clinically justified as
long as biophysical and physiologic principles are followed. In
health care, however, we are not coping 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 velocity 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.
The force applied may be low, medium, or high.
The duration of the force may be brisk or prolonged.
The amplitude (distance of articular motion) may be short, medium, or long.
Overlying soft-tissue tension may be mild, medium, or strong.
Primary or secondary leverage may be applied early or synchronized
Thrust onset may be slow, medium, or abrupt.
Articular fixations may be produced by such restricting factors as perivertebral fascial adhesions, ligamentous contractures, IVD dehydration, fibrosed muscle tissue, spondylosis, meningeal sclerosis and adhesions, etc. 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 weak meninge attachments as scar tissue has a much higher tensile strength than osseous tissue or nerve sheaths. Because of this, therapy may have to rarely progress over several weeks, possibly 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-distraction techniques
advocated to reduce intervertebral disc 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, recoil, rotary,
or leverage) chiropractic adjustment technics that are applied to
a vertebra's transverse root or spinous process 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
--which is common.
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, excessive
rotation) is appropriate.
A dynamic thrust starts 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 initiates
the inverse myotatic reflex to cause associated contracted muscle
fibers 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 muscle can be sensed. This
phenomenon, autogenic inhibition, has many applications in
correcting muscle fixations and relaxing splinted muscles.
The objective of almost all HVTs is to release instantly, to
some degree, 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. Common theories are:
The mobilization of fixated articular surfaces. 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.
The relaxation of the 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
The shock-like effect on the CNS. Shock-like forces (1) are known to have a normalizing
effect on noxious self-sustaining 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 of the cord. These benefits are
also products of spondylotherapy.
A HVT is the most stimulative adjustment. It is not a common
push or is it a shove or punch. It resembles a controlled hammer
Manual mobilization and thrust techniques are direct
approaches to relieving articular fixations. Indirect functional
approaches are often used when the cause of fixation has been
determined to be essentially muscular in origin or when any form
of manipulation would be contraindicated.
Within this category fall many manual light-touch cutaneous
reflex techniques, meridian acupressure therapy, 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 (Gate
Near the end of this paper, reflex technics used in pioneer
chiropractic will be described.
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 the doctor's finesse.
Surprise lowers a patient's pain threshold.
Spear's Multiple-thrust Technic
The major 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 summing force that can be
equal to or greater than that used in a single thrust, thus
reducing patient discomfort.
A classic example of a multiple-thrust technic would be the
application of Leo Spears' double-transverse contact, which is
applied to the spine with bilateral 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 diagonal "down light, down
medium, down heavy" multiple thrust in which each non-jerky
thrust (without relaxing the pressure between the multiple
thrusts) applies progressive pressure after a moment for 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.
Firth listed five advantages for applying a corrective
"(1) permits a gradual increase of force, (2) prolongs the
release of compressed discs, (3) permits time to compensate for
force [loading], (4) makes adjustments more corrective, and (5)
permits use of forces equal to or greater than that used in a
single thrust. There also is much less discomfort to the
patient." --Firth's Technic Notes, 1944.
I have found that this spinal technic, applied from T1 to the
sacrum, is extremely beneficial in many 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 muscle
and articular 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.
The technic apparently has a direct effect on axoplasmic flow,
intervertebral foramen contents, the costovertebral
articulations, and cerebrospinal fluid (CSF) circulation. It has
an indirect effect of massaging (pumping) the lungs, mediastinum,
heart, and upper-abdominal viscera. In many instances, it is the
only technic applicable to the geriatric or severely debilitated
The term leverage move refers to the use of counter pressure
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 counter
pressure is used to balance the force of the adjustive thrust.
Leverage thrusts are the most commonly applied technic used in
"The use of counterpressure in a leverage move (1) prevents
loss of force applied, (2) secures the most work with the least
amount of effort, and (3) concentrates the movement or force at
the desired point." --Firth's Technic Notes, 1944.
The classic recoil thrust is applied against a spinous process
or lamina with a pisiform contact. After the contact has been
accurately placed and secured, the correct stance must be assured
and the elbows must be completely relaxed. At patient
midexhalation, the adjuster's extensor muscles of the arms and
pectorals are suddenly and simultaneously contracted. As the
elbows are in line with each other and in the same plane, this
spasmodic-like contraction adducts the elbows and produces the
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 maintains a rigid trunk, and the
adjuster's body weight will concentrate the force on the spinous
process being adjusted.
Visualize! Mentally picture the underlying tissues and their
pathophysiologic state. Then image the when, where, and why of
what you are going to do.
The force of a recoil 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 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, percussive 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 surface 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
moderately relaxed, yet there must be resistance under the
patient's thighs and upper thorax. Alert the patient that they
will perceive a painless "jolt" during the procedure.
Pioneer literature went into great detail describing the nail
hand, nail point, nail head, hammer hand, hammer head, zone
modifications, spinous listings, stance, nail head anchoring, and
delivery related to specific recoil adjusting.
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
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 his body between the shoulders using straight
arms. The adjuster's trunk is then allowed to drop to apply a
short, sharp impulse. The force is delivered through the straight
arms (elbows locked). This method is not to be confused with that
of dropping the body by bending the knees as is used in lumbar
The Carver body drop will invariably be contraindicated with
children, the elderly, osteoporotics, etc. Less forceful technics
are customarily more applicable in these cases. The only times I
have found a "drop" applicable is in the upper thoracic region of
professional athletes, weight lifters, etc, exhibiting greatly
Rotary Thrusts and Rotary Breaks
A rotary thrust (release), with accompanying joint
distraction, is administered to correct either local or area
rotary fixations. The direction of drive is clockwise or
counterclockwise and parallel to the plane of articulation.
A rotary release 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 area with the patient
in the lateral recumbent position (eg, modified "osteopathic
million dollar roll" described below).
Lumbar Side-position Roll
In delivering a lumbar rotary thrust with the patient in the
lateral recumbent position, most all DCs and DOs have the patient
flex the upward knee and the adjuster's knee in placed in the
popliteal fossa of the patient's flexed limb. DOs apply their
knee pressure toward the floor to rotate the patient's pelvis.
Skilled DCs do not. They apply pressure more caudally (traction)
to open the ipsilateral lumbar facets, thus allowing easy
mobilization. Proper patient positioning, traction, contact, and
direction, amplitude, and depth of force are the keys to artful
application. And again, gentle-firmness.
It is almost impossible to deliver this adjustment efficiently
on a hylo because of its height and narrow width. With a large
obese patient, don't even think of it.
Again for emphasis, most chiropractic adjustive technics have
the common objectives of freeing restricted mobility and
releasing impinged or stretched IVF contents. Added factors are
the expansion or compression of deformed IVDs, the elongation of
shortened tendons and ligaments, the release of adhesions, the
enhancement of cerebrospinal and axoplasmic fluid circulation,
and, sometimes, a physical shock to the cord.
Firth taught that Lincoln College's technic observed three
major principles of adjusting that, if properly observed, will
result in much less discomfort to the patient. These were the
oval posture, counterpressure during a leverage move, and use of
the prespecific "multiple thrust."
It can be generally stated that tissues become painful only
when nociceptors are stretched, compressed, or chemically
irritated. Prior to adjusting spinal lesions, proper analysis
must consider the localization of fixations, the integrity of
perivertebral soft tissues, any degree of osteoporosis or other
contraindicating pathology exhibited, as well as the
prognostication that these conditions are producing the
nociceptive input or dysfunction experienced by the patient in
pain or distress.
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 has been described that it is good procedure to apply a
general adjustment (eg, Spears multiple-thrust technic) to relax
the patient and condition spinal soft-tissues before
administering specific articular adjustments. It also acquaints
the patient to your "touch" to afford maximal patient relaxation.
Specific adjusting means to deliver a force to a specific
vertebrae to improve its biomechanics and related processes.
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
geometric plane of articulation (normal or abnormal), asymmetry,
the force magnitude to be applied, the direction of force,
mobility 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 contraindicated
pathologic processes (eg, infectious, neoplastic, sclerotic,
arthrotic, osteoporotic) of the structures directly or indirectly
As local tissue temperature, architecture, density,
elasticity, flexibility, plasticity, nutrition, etc, are
variables affecting the material properties of tissues, these
factors must be considered. The application of any clinical
procedure without consideration of the cause-and-effect forces
anticipated is not within the confines of scientific
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
focal trauma (eg, severe sprain resulting in overt 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 (usually at the first
mobile link in the kinematic chain}. Whenever possibly, the body
will adapt to (compensate for) both normal and abnormal change
Overt nutritional concerns did not become a part of mainstream
pioneer chiropractic until the 1930s. However, it added another
factor in which political medicine could ridicule DCs. The AMA's
claim of "Three balanced meals a day are sufficient" continued to
We now acknowledge that 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 lifestyle evaluation should be made. Potential
effects of occupational, social, ethnic, or emotional habits and
stresses should be deeply explored also.
Nutritional and Rehabilitative Therapy
The same principle is true in therapeutic nutrition and
rehabilitation. Counsel and therapy must be designed for the
individual patient and the conditions at hand. The problem is to
decide what is "normal" for a particular individual, who is
always unique, 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
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. If you have caused pain, you have torn. If
you have caused undue pain, you have not mastered the art of
Most pioneer chiropractors were eclectic and empiric (ie,
diversified). They selected an appropriate style from many
options and used knowledge based on personal experience. If they
were introduced to a new product or approach that gave plausible
promise, they would try it. Almost nothing was considered beneath
their dignity if it promised patient benefit and was legal and
However, because of this thirst for "something better," the
pioneers sometimes became vulnerable to the claims of
manufacturers of useless machines, salesmen of dubious
instruments, promoters of useless technics, and itinerant
peddlers of fanatic-dogmatic philosophies. Yet, this search
developed many modalities used today long before the vocation of
physiotherapy was established. Typical examples include traction
and stretching, spondylotherapy, galvanism, electrostimulation,
vibropercussion, ultraviolet radiation, infrared heat, myotherapy
by goading, heel/sole lifts, and extremity taping. The list is
History shows that the AMA established the profession of
physiotherapy as an alternative to chiropractic, for only with
the former they could maintain control (ie, physiotherapy by
We are aware today that 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 for
muscle disorders should always be maintained below the threshold
of discomfort to prevent a protective reflex contraction of
Stretching, traction, spondylotherapy, heat (superficial or
deep), cryotherapy, muscle stimulation, reflexology, ultrasound,
galvanism, high-volt therapy, low-frequency currents,
interferential current, pulsating vibration, reflex therapy,
ultraviolet radiation, hydrotherapy, and various types of
therapeutic massage have proven themselves effective under
certain conditions for a wide range of disorders. The basic goals
of rehabilitation therapy are shown in Table 1.
Table 1. Basic Functional Goals in Modern Rehabilitative Therapy