Monograph B2 ~ THE ART OF PIONEER CHIROPRACTIC TECHNIC
 
   
Monograph B2 (Revised 8/25/00)

The Art of Pioneer Chiropractic Technic

--- Reflections From an Era in Which Miracles Were Taken for Granted ---

By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997

Reproduced by Chiro.Org with permission from   ACAPress

The Science of Articular Mobilization
Pioneer Chiropractic
  Emphasis Herein
  The Pioneer's Major Foes
  David Faces Goliath
  The Pioneer Era
  Educational Perspective
The Factor of Time in the Clinical Approach
Terminology
What Makes Chiropractic Unique

Articular Fixation Therapy
  Muscle Fixations
  Ligament Fixations
  Articular or Total Fixations
Underlying Biomechanical Principles
  Viscoelasticity
  Biomechanical Fatigue and Endurance
  Hysteresis
  Biomechanical Creep and Relaxation
  Posture Analysis
  Some Practical Applications
  Postadjustment Rest
  Loading Effects on Articular Cartilage
  Joint Lubrication
  The Intra-articular Synovial Tabs

The Art of Articular Correction
Background
  The Oval Posture
  Patient Positioning Objectives
Articular Planes
Table Height
Chiro-praktikos
The "Feel" of Palpation
Nerve Tracing
Type of Contact
  Contact Points and Their Options
  Securing the Contact Hand
Direction of Drive
Depth of Drive
The Articular Snap
Segmental Distraction
Timing the Thrust
"Drop-Support" Tables
Adjustive Technics
Background
Low-Velocity Technics (LVTs)
High-Velocity Technics (HVTs)
Indirect Techniques

Types of Adjustive Thrusts
Test Thrusts
Spear's Multiple-Thrust Technic
Leverage Thrusts
Recoil Thrusts
Impulse Thrusts
Body Drop Thrusts
Rotary Thrusts and Rotary Breaks
Lumbar Side-position Roll

Objective-oriented Approaches
General Adjusting
Specific Adjusting

Closing Remarks
Professional Counsel
  Nutritional and Rehabilitative Therapy
  Adjunctive Therapy
  Muscle Re-education
The Principle of Biologic Compensation
  Spinal Therapy
  Clinical Plans
Gentle-Firmness
Spondylotherapy
Reflex and Related Technics
Recruiting the Mind/body Connection

Epilog

References and Bibliography


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THE SCIENCE OF ARTICULAR MOBILIZATION

Although adjunctive procedures have been recommended in many of my texts, it should always be remembered that the adjustment is the core of chiropractic therapy. Ancillary procedures can condition tissues to receive and respond to indicated primary therapy and enhance physiologic mechanisms, but, with few exceptions, they should not be considered substitutes.

"The adjustment" refers to one or more structural and/or physiologic enhancements that improves well being, not how it is obtained. A release of an articular fixation is an adjustment. So is the temporary application of heat, a dietary supplement, an exercise to strengthen weaken muscles, a recommended change in lifestyle, etc.

This paper strives to define certain general principles that underlie almost all efficient chiropractic articular adjustive technics. A review is offered regarding depth of drive, the articular snap, segmental distraction, timing, the advantages of placing the patient's spine in an oval posture, correct table height, and patient positioning objectives. The factor of time in the clinical approach and its underlying biomechanical principles of tissue viscoelasticity, fatigue, creep, and relaxation are considered. Also reviewed are the need to visualize the loading effects on articular cartilage, joint lubrication, action of the intra-articular synovial tabs, the articular planes, the classic types of contact, contact points and their options, securing the contact hand, and the direction of drive. Then is offered a rationale on adjustive velocity, types of adjustive thrusts, objective-oriented approaches, and some closing comments.

By tradition, a professional paper should be composed in the third person. I realize that this paper will be criticized for my frequent use of the first person and elliptical sentences. So be it. My objective is to share my experiences with my colleagues as in a friendly conversation. Those whom wish to find fault in my style here are welcome to do so. At this time in my life, the critics cannot diminish my experiences. My apologies for any typos found.


Pioneer Chiropractic

During chiropractic's pioneer era, 99% of patients new to the practice did not enter a chiropractor's office at first option. A "last resort" chiropractor was chosen only after an array of traditional allopaths had been consulted whom provided little if any benefit. Could the extraordinary results of chiropractic be attributed to a placebo effect or a spontaneous remission? If so, then why did not such placebo effects or spontaneous remissions occur with these patients when under the care of "the best" --where "faith" and "psychic conditioning" must have been at their peak?

During this period, chiropractic students were taught to accept most any disorder if the best of orthodoxy had failed. "At least try" was the dictum. "What other hope does the suffering patient have?" Benefits regularly surprised the young DC. In time, surprise was replaced with wonder. And this marvel evolved to admiration. Thus the subtitle of this paper, "Reflections From an Era in Which Miracles Were Taken for Granted."

Most of these awe-inspiring phenomena could not be explained by the DC's knowledge of the basic and clinical sciences. I have seen hundreds of such instances and have no idea of cause and effect. Being a last source of hope, I just tried --if the courage was there. I sometimes felt as through I was only a stupid witness to the potential of chiropractic. And, because I could not explain it in scientific terms, I was left with only one conclusion: Many times, chiropractors must be doing the right thing for the wrong reason. I still hold this outlook, this marvel, this bewilderment, this awe.

I realize that an array of explanations can be offered. Correction of posture and its subtle influence on various systems and long tracts can be offered, but some questions remain unanswered. Resolution of IVF lesions and articular receptor deficits are described in detail, yet something unknown remains. Effects of cord stimulation or of autonomic ganglia are postulated, but important blanks in understanding still beg for resolution. Add to these enhancement of cerebrospinal fluid flow or axoplasmic circulation or the normalization of sundry spinal, somatic, visceral, and/or psychic reflexes.

We frequently see results that are intellectually incredulous and are left only with the feeling we have glimpsed but a small tip of an iceberg of potentialities. Much has been learned. Yet so very much remains a mystery. Benefits to hundreds of thousands of patients after the best of traditional approaches has failed cannot be ignored or casually dismissed as a spontaneous healing or a placebo effect. Will these mysteries ever be answered? Not unless mental ruts are escaped.

Note:   As an aside, I think some are too eager to degrade the "placebo" effect. If a placebo benefits a patient, eases suffering and improves one's lifestyle, I'd apply it at any opportunity. My patients are not interested in my choice of methodology --only whether it will help achieve mutually agreeable goals. Here again, this just reflects that I'm patient oriented.

Were pioneer chiropractors clinically naïve? Certainly. All physicians of past ages were when compared to those with having the knowledge of today. Were they effective? Many more times than not by applying, through experience or intuition, an efficient modus operandi for the times. At one period, not a single state licensed a chiropractor. Now, all states and many foreign countries do. This was not a gift. It was well earned, often by great personal sacrifice --sacrifices that have been trudged by the avaricious, the pseudointellectuals, and the philosophically deluded.

Chiropractic became firmly established in the 1920s--mid-1930s: impetus initially followed excellent results during the great flu epidemic after World War I. Before the discovery of antibiotics in the 1940s, many found chiropractic the treatment of choice for pneumonia.

Up to the mid-1960s, most chiropractors considered themselves as in general family practice, treating such complaints as headaches, sinusitis, indigestion, colds, pharyngitis, myalgia, neuritis, hypertension, arthritis, common childhood infections, allergies, etc. Both the NCA and ICA published a large variety of "health tracts," describing chiropractic management of common visceral dysfunctions. There was little desire to exclusively treat acute sprains or strains, and rarely was the topic mentioned in chiropractic literature. On occasion, a DC would gain fame in treating race car drivers, a professional baseball or hockey team, etc. However, this was rare and looked upon by colleagues as that doctor's hobby.

The 1930s was the era of the great depression. About a third of one's practice could not afford the DC's $1--$3 office fee. A dollar a day was considered a good wage for manual labor. This was commonly accepted for reimbursement was made by community love and respect. "Poor people get sick too." If a person could not work, his family did not eat. This was an era in which results had to be achieved quickly and cheaply if a doctor's reputation was to be established. It invariably was.

This was the time in which house calls were made during blizzards, often without payment, and the threat of jail for practicing medicine without a license hung like a dark cloud over every DC. These were the DCs that built chiropractic's heritage. Today, their dedication and sacrifices have been forgotten or ignored and replaced by too many preoccupied with "marketing" gimmicks. So sad.


Emphasis Herein

Were the technics described herein practiced by all pioneer chiropractors? No. As in any profession, some were highly skilled, some possessed moderate skills, and a few exhibited poor skills. Nonthinkers would only do or apply what their chosen mentor approved. Also, as in any profession, some tabled their knowledge to accommodate the time demands of a high-volume practice.

The approaches presented here represent the methodology of the "Cream of the crop." It were these that spurred the profession to its current main-stream position in society despite mammoth antichiropractic forces.

     The Pioneer's Major Foes

Few living today can appreciate the gigantic obstacles overcome that were built from both within and without. The majority of obstacles within were those constructed by B. J. Palmer who personally lobbied state legislatures against chiropractors being licensed as doctors of chiropractic; lobbied that chiropractors do not diagnose, only analyze (via the neurocalometer instrument, a surface-heat detection device that must be leased from him); lobbied that any chiropractor who adjusted any patient's below the axis and other than when laterally recumbent was a fraud, and lobbied that the use of physiologic modalities perfected by chiropractors, long before there was a profession called physiotherapy, was not chiropractic.

B. J. Palmer's philosophy even denied the existence of an autonomic nervous system, and his ADIO (above down, inside out) presupposition ignored the body's complex sensory system. He viewed the nervous system as a one-way street and employed a "foot-on-a-hose" analogy to describe nerve compression, though his father emphasized nerve irritation at the intervertebral foramen (IVF). On the younger Palmer's side were money from the first radio station west of the Mississippi River and blind devotion by his disciples. Those that dared challenge his dogma were labeled unprincipled, chiropracTOIDS, or medipractors. He fought against expanding Palmer Chiropractic School's 18-month (3 years of 6 months) curriculum to his death in the early 1960s.

It is my belief that if the profession had divided itself in the 1920s into two professions, those following the basic philosophy of D. D. Palmer and those of B. J. Palmer, both professions would be further advanced today.

     David Faces Goliath

"If you think it's tough now, wait until the opposition arrives."

Of course, the pioneers' other major foe (externally) was political medicine who controlled many powerful politicians, media editors, influential columnists, state health-related agencies, insurance companies, etc. Chiropractic was a minority profession and B. J. Palmer's power to divide the profession (AMA supported according to "Wilk case" discovery) added to its weakness in combating the formidable forces of political medicine.

     The Pioneer Era

Were pioneer chiropractors those that practiced between 1896 and 1926? No, in this author's opinion. I define the pioneer era of chiropractic to extend from the late 1800s to the very early 1970s. Once most states had licensed chiropractors, once many insurance companies and state workers compensation boards recognized chiropractic care, once the federal government included chiropractic under Medicare, professional focus, and rightfully so, shifted to scientific verification. Here the art of chiropractic took a secondary role. Unfortunately, some believe even more so than the subjugation of manipulative arts within osteopathy.

Following is a July 2000 comment made by Richard Gillespie, DC, a member of the Board of Texas Chiropractic Examiners. It is in response to my thoughts on developing this monograph.

"It sounds like this is a topic that needs to be addressed. I'd love to see you do it if you have the 'want to--can do'. I am on the Part IV test committee for NBCE, and I see future docs give tremendous exams with proper DX and then look totally bewildered on the adjusting technique stations! No one knows how to adjust any more!"

     Educational Perspective

Most of us have witnessed practitioners who have turned an adjunctive tool into a primary therapy exclusively. We see this at times with acupuncture, physiotherapy, therapeutic nutrition, psychotherapy, herbology, and those who have made one region of the spine their master rather than a servant. Such a limited viewpoint of the scope of chiropractic health care, unfortunately, does a disservice to the profession, the practitioner, his or her patients, and the public.

The fault for this misdirection must be placed on inadequate or shunted training. No logical person would forsake a primary therapy for an ancillary therapy if he or she had confidence and skill in its application. Articular therapy is no exception.

This paper briefly defines certain general underlying principles that underlie almost all chiropractic adjustive technics proved by time and patients' joy. Some may be new to the reader, yet their basis is as old as chiropractic itself.


The Factor of Time in the Clinical Approach

To produce an effective articular adjustment, it is first necessary today to evaluate the degree of joint motions and end plays present if possible. Whatever corrective procedure is used, Hooke's law should be remembered: 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.

Adjustive 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, a tubercular cyst, a fusion, or a malignancy, for example; nor would it be applied over acutely inflamed tissue or splinted muscles if the doctor expects the patient to continue the treatment plan.

I approach the subject of chiropractic articular correction as a nonincisive surgical procedure, a "chiurgical" art. Astute application takes time. It takes time (1--3 minutes) to assure proper patient positioning, conditioning, assure that the intended line of drive is 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, table design, etc.).

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 and pain control). In addition, traumatized and pathologic connective tissues characteristically have poor nutrition, low endurance, and high biomechanical fatigue properties. These considerations form a substantial part of the scientific foundation of our art.

Neuromusculoskeletal tissues are organic viscoelastic substances. The critical factor in viscoelastic stability involves both load and a time element; ie, a viscoelastic substance can resist a certain load for a period and then fail without the load being altered. All musculoskeletal structures, thus, have a time-dependent stability factor, which is usually structurally adapted to in living tissue if the time element is prolonged. We witness this in bone with the trabeculae redesign from chronic overstress according to Wolff's law. What is true for bone is true in all viscoelastic substance to a variable degree.


Below are some pioneer thoughts:

"Regularity of adjustments is necessary. Each adjustment has a certain 'survival' value that decreases with time. They have a commutative value, and the adjusting is only complete when a correction has been made." "...Rest after an adjustment is of distinct value. This gives the discs a chance to remain expanded for a greater length of time. Rest, even without adjustments, is corrective, for even the slightest expansion is helpful when considering the fact that a single nerve fiber is about 1/200th of an inch in diameter."
--Firth's Technic Notes, 1944.


Terminology

Because of tradition and not semantics, the term technic was commonly used in the profession to describe a procedure utilized within a manual adjustive procedure. The word technique was used relative to other procedures. Regardless, a technic or technique is only a method, one method of many, options 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.

Chiropractic treatment or therapy should be differentiated from chiropractic technic, which is one form of treatment. Treatment (case management) often includes the application of a primary method plus all ancillary (supportive, adjuvant) procedures incorporated to accomplish the clinical objective. Procedures in chiropractic often include articular therapy, myotherapy, meridian therapy, electrotherapy, spondylotherapy, heat, cold, traction, nutritional supplementation, diet control, therapeutic exercise, biofeedback, supports, magnetics, psychotherapy (including therapeutic suggestion and psychoneuroimmunologic enhancement) or other forms of counseling, and other forms of justifiable therapy in the most efficient manner.

Conservative treatment is that designed to avoid radical measures or procedures; rational treatment, that based on knowledge of the disorder and the action of the remedies applied; empiric treatment, any means by which experience has proved to be beneficial; prophylactic (preventive) treatment, that designed to prevent occurrence of a disease/dysfunction; and palliative treatment, designed to relieve pain and distress without an attempt to cure (usually applied to strength-reducing factors).

The primary goals are to relieve direct/indirect causes of pain (a physiologic signal), enhance neurocirculatory integrity, improve articular relationship and function if necessary, influence other physiologic processes that would augment the healing process, and minimize disability as far as possible. There are, of course, times when a usually ancillary procedure is used as a primary therapy such as in the application of coolness to a burn or initially to reduce the swelling of a sprained joint.

The term adjustment simply means to alter current status or to fix or fit; to bring into correct relationship, to regulate, conform or adapt; Almost any thing, thought, process, level, habit, lifestyle, etc, may be adjusted.

Although the articular "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 attacking the boundaries of anatomical integrity. Swezey, an allopath, defined a dynamic chiropractic adjustment as the high-velocity short-arc inducing passive movement of one articulating surface across another.

Few would strongly object to either of these limited attempts to define the purely structural effect induced; ie, if the objective is solely to mobilize a fixation or reposition a subluxation. Unfortunately, such purely mechanical concepts are limited; eg, most importantly 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 intervertebral foramina (IVFs), 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, arthritis followed by erosion and exostosis and its sequelae can be expected. Contralateral foramina elongation can equally produce noxious effects by the increased tensile forces upon foraminal contents, especially if adhesions have formed between bone and sheaths.


What Makes Chiropractic Unique?

There is a trend to lump what a chiropractor does during an articular "adjustment" under the general category of spinal manipulative therapy (SMT). This is a term originated by allied health professions that was rarely seen in chiropractic literature before the late 1970s. I am uncomfortable with such a generalization because I believe that what a chiropractor does (or should do) is far removed from the manipulation procedures commonly taught to physiotherapists and many osteopaths. Other health-care professions typically apply little more than passive attempts to increase a restricted gross range of movement of a joint by stretching contractures. Dr. Roy Hildebrant dropped the traditional term "adjustment" for "manipulation" as the first editor of the JMPT, and the term, unfortunately, became generally accepted.

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 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. Today's purely mechanical or neurochemical explanations will not suffice for every situation occurring in or by a biologic organism.

More than 30 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 purpose 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 reason these techniques are applied and why they are applied in a certain manner that distinguish chiropractic from other healing disciplines, manipulative or not. In fact, some chiropractic techniques of recent vintage are not characterized by sudden application. We are thinking 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."



ARTICULAR FIXATION THERAPY

Early chiropractic pioneers were not exposed to "fixation" theory. They just understood that if a vertebral segment was malpositioned (subluxated), something was causing it to be "stuck" there else it would spontaneously reduce.

The fixation theory first entered chiropractic through the studies of Cheal at Lincoln Chiropractic College and Vladef of Detroit. In their analyses, Both Cheal and Vladef compared full-spine films taken in the standing and sitting posture to determine which segments moved and which did not (fixation) with this change in carriage. Although this method was crude, it did apply a spark to the question: Why did some spinal segments adapt to postural changes while others did not? Later, Henri Gillet of Belgium briefly studied with Cheal and Vladef and introduced the art of motion palpation. Since then, L. J. Faye and associates have advanced this theory further but not to an all-encompassing finale.

After being in practice for about 2 years, I became disillusioned with some acquired expectations. Mainly, patients were discarding their canes, crutches, and wheelchairs. Many quickly became quickly pain free, enjoyed greater function, and happily returned to what they described as their normal "healthy" lifestyle. Yet, follow-up static x-ray films invariably showed no significant change in vertebral position. Then why did patient complaints resolve? Searching for an answer to this clinical dilemma led me to forego the "bone out of place" theory for that of the "fixation" theory. A theory, however, is just that. I hold all my theories lightly until a better one arises.

A brief description of fixation theory is presented below

     Muscle Fixations

Articular motion is impaired when periarticular muscles (local or regional) become acutely spastic or indurated from long-term contraction. The major neurologic effects are thought to be abnormal mechanoreceptor input to the CNS, foci for referred pain by compensating adjacent segmental hypermobility, and noxious somatosomatic reflexes.

Even with proper conditioning and warm-up 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, changes in soft-tissue texture (eg, 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, direct pressure, vasospasm, stasis). This leads to impaired tissue nutrition (trophic dysfunction) and the accumulation of metabolic debris. During the early stages of degeneration, palpation often reveals tender areas that feel taut, gristly, ropy, or nodular --not unlike that of some trigger points, 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 to a primary lesion in the neurologic chain, they often disappear spontaneously after a remote primary fixation has been released that corrects distant reflex expressions.

Thus, any therapy (eg, dynamic thrust, reflex, appropriate 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 minor muscular fixations --at least short term. This also appears true when the fixation is the result of a peripheral irritation (eg, a viscerosomatic 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 can also 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 often correct the fixation or a contact can be taken on the involved bony segment and a thrust made that will stretch the shortened muscle. A short dynamic thrust appears to be an efficient approach in correcting acute local muscle fixations. The technic selected must be adapted somewhat if the muscles involved have degenerated to a state resembling ligament fixations. Supportive therapies should always be considered.

     Ligament Fixations

Ligament fixations (shortening restricting normal mobility), including those produced by scarred or degenerated muscle, are numerous and can be located most anywhere in or near joints. They are second in importance to, yet far more prevalent than, total fixations. Ligament fixations may be the only chronic fixations found in many elderly spines or those with a history of severe joint trauma.

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 postadjustment 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, progressive, periodically monitored, daily stretching exercises are highly beneficial.

     Articular or Total Fixations

Aside from those sometimes found in the occipitoatlantal and sacroiliac joints, total articular fixations are not common. When found, they signify ankylosis or impending fusion. The primary concern in pseudoankylosed joints is the degenerative shortening and toughening of perivertebral ligaments and joint capsules and possibly the development of intra-articular adhesions.

One should always keep in mind that local symptoms arise contralateral to a unilateral fixation because fixation forces unusual hypermobility on the adjacent mobile segment(s) in the kinematic chain.

The least irritation-producing type of thrust is a short, rapid, dynamic force directed against the restricted plane of motion so that the "semifrozen" facets are released. Avoid using more force than necessary to produce mobility. Any force applied much past the point of the current physiologic 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 test thrust followed by a moderate thrust is sufficient. An audible release "click" is not necessary (and rarely produced) in a degenerated joint). Results can be appraised by symptom relief and possibly by an increased ROM as determined by dynamic palpation or dynamic diagnostic imaging (stress films).

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 ligament-related condition, the longer adjustive therapy will be necessary. Once the asymptomatic stage occurs, maintenance care several times a year will often be adequate to keep the involved joint(s) optimally mobile.

Joints that are chronically swollen, painful, crepitate, or immobile often return with time and activity to near-normal function with appropriate management. However, static radiographs may show no or little change in joint space narrowing or hypertrophic alterations. This adds credence to Mennell's 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: a talent that should be well-founded on an understanding of the underlying biophysical and pathophysiologic processes involved with a particular patient at a particular time. These factors serve in establishing the scientific basis for chiropractic adjustive therapy. However, it does no good for the suffering patient to argue the potential effects of an adjustive trust on the viscoelastic properties of connective tissue. Such didactics require resolution by research scientists, not clinicians.

Chiropractic pioneers has little knowledge of articular and perivertebral viscoelasticity, biomechanical fatigue, hysteresis, creep, relaxation, articular loading principles, joint lubrication, etc. The information just was not available. However, they did appreciate the importance of adjusting table design and height, patient positioning, and postadjustment rest wherein today's knowledge was frequently applied inadvertently. Thus, while scientific data were not available, most of our current knowledge was satisfied in the alert pioneer's methodology. This should become clear as this paper unfolds.

The general effects of these now understood principles are briefly described below. As this subject is studied, the reader should keep in mind that the biomechanics 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, whether it was applied in the 1920s or today. A misapplied spinal adjustment is little removed from common trauma. A skillfully applied adjustment, while still a force, will have minimal traumatic effects.

     Viscoelasticity

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 witness this in bone with the trabeculae redesign from chronic stress according to Wolff's law. What is true for bone is true in all viscoelastic substances to variable degrees.

     Biomechanical Fatigue and Endurance

The combined components of viscosity and elasticity allow relaxation and creep, and both are a function of time. The viscoelastic nature of intervertebral discs ((IVDs) 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 dynamic thrust) or slowly with a low magnitude (eg, pressure fatigue failure [eg, simple weight bearing]). 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 microfissures, tearing, and increased vulnerability.

The limit of tissue endurance is the least load produceing 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 fissures in bone or cartilage, for example, multiple small fatigue fractures commonly occur in articular cartilage and related connective tissue.

     Hysteresis

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 or posttrauma when viscoelasticity is poor.

     Biomechanical Creep and Relaxation

The viscoelastic properties of a fibrocartilage such as an IVD and to a lesser degree 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.

Stress relaxation is thus the viscoelastic property of a tissue to retain a constant deformation after a load is removed. Relaxation, popularly called "give," is a steady deformation occurring with less force over time. It 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.

Spinal 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 weigh has been borne for a sustained period. When a constant force is applied to viscoelastic substances such as bone, muscles, tendons, cartilage, and ligaments, the property of creep becomes apparent. When a deformation is fixed, stress relaxation becomes apparent.

     Posture Analysis

One of the first things a pioneer chiropractor did during a physical examination was to view the patient's posture from the back and side with a plumb line to determine any degree of scoliosis, abnormal thoracic kyphosis, abnormal cervical or lumbar lordosis, and of pelvic tilt or sway. Bilateral weight scales were also used. It was commonly taught that major spinal concerns would likely be found at apices of curves and at transition points. We now recognize that it is also at these areas where viscoelastic properties are likely to be the most overstressed.

     Some Practical Applications

The biomechanical properties of tissue relaxation, creep, and fatigue are especially important considerations whenever articular correction, traction, lifts, or braces are used. For example, soft tissues involved in spinal distortion retain some residual effects for a time after adverse forces have been removed. Thus, some means of rest and support are usually 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 are applied, they should be done slowly, in progressive increments, so that the degree of creep reversal obtained and the residual relaxation present can be evaluated.

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 overtly fibrotic, mild but firm manual traction and a broad contact with mild transverse pressure held in the direction of correction for 30--60 seconds just before the corrective thrust helps to "reverse" the established creep and elastic fiber shortening produced by gravity, hypertonicity, overstress, etc. This is usually on the side of disc or cartilage thinning or musculotendinous shortening.

When the articular adjustment is delivered, it is with further palpable movement and far less discomfort to the patient than would otherwise be produced. The same mild but firm contact of a pioneer following a specific adjustment appeared to enhance "holding" of the correction achieved because of inadvertently applying our current knowledge of the properties of connective tissue.

     Postadjustment Rest

It 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 minutes or more following an adjustment because the encouragement of physiologic normalization within viscoelastic substances takes time. This is application of a law of biophysics, and 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. Thus, facilities for quiet, private postadjustment (positional, stimulative) rest offer an excellent means of providing the time factor for soft-tissue fibers to adapt without fighting gravity and for some corrective disc imbibition.

Postadjustment rest was thought mandatory in quality pioneer chiropractic; an important rule often overlooked today. Pioneer chiropractors believed that widespread systemic changes were taking place throughout the patient's body after an adjustment, and this required time for neuroresynchronization and recuperation of homeostatic reserves.

     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 fluid 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 articular load is decreased during rest, overstressed cartilages begin to return to their original thickness --quickly at first (90%) because of the elastic recoil of 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 collagen fiber stiffness and strength that are subjected to increasing tensile forces as the swelling develops.

Again we see the important factor of time as considered by pioneers in their use of positioning, traction, and rest. 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, again, 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.

The above general principles advocating posttherapy rest have served as a foundation for my frequent criticism against volume-oriented stop-watch "cafeteria-like" clinics. Those inclined to heed this advice will be rewarded by far greater clinical efficacy.

     Joint Lubrication

Joint lubrication is another factor to consider and visualize during adjustive therapy. The complex lubrication system of human joints far exceeds that of similarly designed manmade 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 allows 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 that originate 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 stressful 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 spondylosis. An acutely "locked" joint due to tab dislocation can easily mimic the features of intervertebral disc protrusion.



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.


Background

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 posttherapy rest.

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 adjustment.

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 several purposes:
(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 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 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).

  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 flexion support is raised -- all which adds gravitational force, encouraging mild thoracic flexion (slight 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 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 existing.

  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 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 the floor).

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.


Articular Planes

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.


Table Height

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 permit.

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 lumbosacral disorder.

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 chiropractic adjustments.

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 the latter.

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?


Nerve Tracing

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 palpation:

"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.

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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:

  1. Pisiform. A quarter circle drawn over the fleshy part of the hand anterior to the pisiform bone.

  2. Edge contact. Upon the abductor tendon of the little finger, about 2/3rds the distance from the pisiform bone.

  3. Thumbpad contact.

  4. 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.

  5. Palmer surface of the fifth metacarpal bone.

  6. Heel of the hand.

  7. Palmar surfaces of the fingers.

  8. 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 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 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 gun).

     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 restricted.

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 spinous process.

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 articulations.

"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


Segmental Distraction

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 overdeflated.

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 passive exhalation.

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 painful surprise.

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 the Unknown

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.


"Drop-Support" Tables

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 clowns."

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."



ADJUSTIVE TECHNICS


Background

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.

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 reflex.

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 strike.


Indirect Techniques

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 theory).

Near the end of this paper, reflex technics used in pioneer chiropractic will be described.



TYPES OF ADJUSTIVE THRUSTS


Test 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 multiple thrust:

"(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 patient.


Leverage Thrusts

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 chiropractic.

"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.


Recoil Thrusts

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 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 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.


Impulse Thrusts

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 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 side-posture adjusting.

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 hypertrophied rhomboids.


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. Visualize!

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.



OBJECTIVE-ORIENTED APPROACHES

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 Adjusting

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

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 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. The application of any clinical procedure without consideration of the cause-and-effect forces anticipated is not within the confines of scientific chiropractic.



CLOSING REMARKS

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 (physiologic, postural).


Professional Counsel

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 the 1970s.

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 "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. If you have caused pain, you have torn. If you have caused undue pain, you have not mastered the art of chiropractic.

     Adjunctive Therapy

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 ethical.

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 almost endless.

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 prescription).

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 involved musculature.

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

Function

Strength

Physiologic elasticity



Contraction/Relaxation


Normal tone


Physical elasticity


Coordination
Dysfunction

Weakness

Spasticity



Spasm


Tension


Contracture


Incoordination
Therapy

Exercises against resistance

Thermotherapy, ultrasound, autosuggestion,
   biofeedback therapy, postural correction,
   relaxing exercises

Pain relief, "gate" blockage techniques, relaxing
   exercises, heat

Relaxing exercises, hydrotherapy, biofeedback,
   hypnotherapy, psychotherapy

Stretching exercises, joint mobilization, ultrasound,
   thermotherapy

Strengthening and relaxation exercises,    coordination training and practice

Note: While the above therapies are considered modern, all but ultrasound, biofeedback, and "gate" blockage techniques were available in the 1920s in a more unrefined form.


     Muscle Re-education

Over the years, it has been shown that rehabilitative exercise should be conducted with sufficient warm-up, 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. However, full patient compliance is an ideal rarely obtained.

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 neurologic or 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. Most of the intrinsic muscles of the spine are short muscles. Regardless, 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.

     Spinal Therapy

The body is a dynamic highly adaptable organism. DCs who approach health care as spinal engineers often fail to appreciate this point.

Personal History #1. In early 1962, several months of cluster headaches were experienced concomitant with poisoning from a common print shop chemical. The painful attacks were frequent and excruciating to the degree that banging my head against a wall was sometimes tried in an attempt to change the agonizing pattern. Adjustments from a colleague had only momentary 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 pioneer chiropractor that 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 palpation 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 headache of any type since. Nor was I ill with anything until 1992, 30 years later, when I was diagnosed as having inoperable prostate cancer.

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 30 years or more. For you, a certain atlas position of posterior on the right can be said to be your normal."

Personal 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 so 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 paper, are based on average, typical findings. Yet, no particular patient will meet all these criteria. Each patient presents with unique characteristics. Expect the unexpected.

This fact must be forefront when analyzing the results on any laboratory data, neurologic sign, or orthopedic test. The effects are facts, but the reason(s) the effects occur in a particular patient is often only an assumption based on a list of preconceived "causes." A mental rut can be a shallow grave for rational thinking.

The human intellect may be out of its league when it tries to compete with the highly complex unconscious "intelligence" that appears to direct the multimillion integrating, coordinating, synergistic, facilitating and dampening mechanisms occurring each moment of one's life. I believe that unnecessary failures occur in health care when the doctor works in opposition to an individual's unique biologic design, needs, and capabilities; ie, in preferring to follow prejudgments, peer pressure, current theory fads, or philosophic dogmatism to the detriment of the patient. I'm a pragmatist who insists on doing his own thinking. All do not agree with my opinion, however.

I once asked an upper-cervical specialist how he would define himself. "I'm a spinal engineer," he said. "Would you 'realign' the atlas if you determined it was out of alignment in an apparently happy, healthy, symptom-free patient?" I asked. "Absolutely," he replied. "That would be unethical according to the ACA," I said. "I'm not an ACA member," he replied, "I correct the atlas misalignment, the subluxation --the silent killer."

"Would you ever purposefully 'subluxate' an atlas even if you knew it might benefit the patient?" I asked. "Never," he said. "Would you realign an atlas even if it may cause harm to the patient?" I asked. "Certainly," he replied, "My job is to align the articulations in a manner and to a position I was taught to be structurally ideal. Patient benefit is not my concern. It's a hopeful secondary benefit. I don't diagnosis. I don't treat a patient's complaints. I'm not a physician. I'm a principled spinal engineer." "Do you hold yourself out as a health-care provider when you bill the patient or insurance company?" I asked. "Of course," he replied, "What does that have to do with anything?"

The viewpoint expressed by the doctor above is obviously bizarre and not that of the rational upper-cervical specialist. I offer it here only to portray how hypnotized some become to absurdities. They have allowed another to enter their head and do their thinking. A tyrant sits on their inner throne.

There are only two sorts of doctors: those who practice with their brains and those who practice with their tongues. --Sir William Osler


     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 (noxious) 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 at a certain moment in time.

I ask, rather, I beg: Approach every patient as unique, every chiropractic articular adjustment as a closed surgical procedure. Take your time. Do it right.


Gentle-Firmness

If I had to define the most important factor between a good adjuster and a poor adjuster it would be gentle-firmness. However, exactly what I mean by this is impossible for me to convey with words on a page. It's an action-feeling --a tactile sense acquired before the adjustment, during the adjustment, and after the adjustment --data that cannot be conveyed by an adjusting instrument other than the hands.

Gentleness implies "Do no harm." If the adjustment traumatizes, the adjuster then become part of the problem rather then its solution. It may be microtrauma, but trauma no less with all its consequences. Firmness infers controlled assertiveness, not aggressiveness. It is a product of acquired self-confident finesse.

Excessive gentleness just results in "fiddlin" with the joint(s). Nothing clinically is accomplished. It's a half-hearted attempt usually founded on the adjuster's poor confidence. Because some minor cavitation might be heard or felt, the procedure is rationalized erroneously as being corrective. On the other hand, excessive firmness (aggressiveness) borders on brutality, where the thrust cracks against the anatomical limit of mobility.

The ideal finesse is to apply just enough force to be below the patient's discomfort threshold yet be strong enough to mobilize the articulation(s) as far as possible at a particular moment in time (pathophysiologic stage) without insulting the lesion.

With this said, I'm sure that the "fiddlers" will continue to rationalize their "fiddlin" and the brutes will continue with their pounding--and brag to their colleagues of their awe-inspiring mastery of technic. Thus the criticisms of diversified (eclectic) technic. [Dear Lord, have pity on the artless and their patients.]


Spondylotherapy

The objective of pioneer objective was not just to reposition a subluxation or mobilize a fixated articulation, it was often used to stimulate the underlying spinal cord and adjacent ganglia whether a subluxation/fixation exhibited or not (eg, general adjusting, Meric).

"An adjustment has two effects --stimulation and correction. It must be noted, however, that excessive [prolonged] stimulation will produce depression." "...Percussion done in the upper thoracic region stimulates and causes contraction of the blood vessels serving the cranium and its contents. This procedure should be contraindicated in cases with high blood pressure. Percussion done in the lower thoracic region stimulates and causes dilation of the blood vessels supplying the viscera." --Firth's Technic notes, 1944.

Thus above we see a crude application of spondylotherapy. Early pioneers often applied stimulation by either several short brisk nonspecific thrusts or placing a clenched fist over the segment and striking it several times with the other closed fist. Today, it is generally applied by electromechanical vibropercussion.


I have found spondylotherapy to be my most important modality.
A brief explanation can be found at:
http://acapress.com/Monograph_A3.shtml



Reflex and Related Technics

As Aquarian Age technic and its refinement into Logan Basic Technic require specialized instruction, I will not attempt to describe them here. I will, however, describe several reflex technics that were taught in many pioneer chiropractic colleges with the major exception being the Palmer School of Chiropractic. Some of these technics are still in use; some have been discarded by substitution. Efficiency is judged by personal experience. Aside from the Oculocardic Technic, the below technics are considered experimental.

  1. Thumb and Finger (T&F) Technic.

    The purpose of this technic, developed by a Dr. Dillon, is to determine the best direction of thrust to relieve perivertebral pain and tenderness. For example, a tender site is located in muscles lateral to the vertebral column. A vertebra is selected in this region and pressure applied by thumb and finger on the spinous process of this vertebra in varying directions to find a direction in which when pressure is applied to the spinous process relief from pain or tenderness is achieved.

    Once this direction has been determined, pressure is maintained until sufficient relaxation of the musculature exhibits. Following the relaxation of spasticity, a leverage or recoil adjustment is made on an optional contact point with the direction of drive as that determined to relieve the pain and tenderness.

  2. Key Vertebra (K-V) Technic

    The purpose of this technic is to relieve tender areas on the surface of the body (contributory) that did not have a recent history of trauma. The key vertebra was C3. Tender perispinal and peripheral areas on the body are isolated and marked with a skin pencil. Pressure is applied on the spinous process or lamina of C3 in varying directions until a sensitive area marked is somewhat relieved.

    Once this direction for relief is determined, C3 is manually vibrated lightly several times for 5--15 seconds in the direction previously determined to provide relief. These bouts of vibration are separated by "test" pressures over a marked tender area until tenderness has been eliminated or greatly reduced. The procedure is repeated for remaining sites of tenderness, usually starting with the most acute site and progressing to less sensitive sites.

    The Damon and Damon Technic is a modification in which tender sites are not marked and no test procedures are used. The lamina of C3 is vibrated at a point 1/2 inch lateral to the spinous process and 1/4 inch cephalad. Ten 3--5 second bouts of vibration were used.

  3. Focal Myospasm Technic.

    The goal of this reflex is to relieve focal muscle spasms (eg, trigger-like points) lateral to the spine before or after articular adjustment of a medially adjacent vertebra or its perivertebral tissues (eg, muscle fixation).

    A sensitive myospasm is found, characterized as a small, firm, deep knot of hypersensitive muscle. It may be located anywhere from the suboccipital area to the iliac musculature. Firm thumbtip pressure just below the patient's pain threshold is directed medially. The knot and its hypersensitivity should be relieved in 30--60 seconds. The contact is held for several additional seconds to assure resolution.

  4. Three-Phase Gluteal Technic.

    This reflex consists of three successive contact phases designed primarily for the relief of pain in acute sacroiliac and lumbosacral syndromes.

    a. With the patient prone, the doctor stands on the opposite side of involvement facing obliquely cephalad. The thumbpad of the doctor's lateral hand is placed against the side of the L5 spinous process opposite the side of involvement, and steady pressure is directed laterally toward the side of involvement. The doctor's other thumbpad (medial hand) is placed over the sciatic notch on the side of involvement and directed ventromedially. These firm nonpainful pressures are applied simultaneously with both thumbs for about a minute.

    b. The second phase immediately follows this 1-minute duration. The L5 spinous process contact pressure remains the same. The notch contact is replaced with a thumbpad contact against the tensor fascia lata at a point midway between the iliac crest and greater trochanter. Here, pressure is directed medially. And again, these firm nonpainful pressures are applied simultaneously with both thumbs for about a minute.

    c. The third phase immediately follows the 1-minute duration of the second phase. Again, the L5 spinous process contact pressure remains the same. The fascia lata contact is replaced with a thumbpad contact just below the midpoint of the gluteal rim. Pressure is directed anterosuperiorly. Again, these firm nonpainful pressures are applied simultaneously with both thumbs for 1 minute.

  5. Perineal Technic.

    The goal of this technic is to reduce regionalized perivertebral tension and pain. With the patient supine, the doctor (usually sitting, facing obliquely cephalad) places the tip of his/her flexed thumb (medial hand) against the center of the patient's perineum, the thumb is then straightened, and moderate pressure is directed obliquely ventral and cephalad.

    With the perineal pressure sustained, the doctor's free hand (lateral), palm upward, is inserted under the patient and palpation is made for relaxation of the predetermined perivertebral tension and pain. Once optimal relaxation has been achieved, the technic concludes.

  6. Suboccipital Technic.

    This reflex technic is used primarily for the reduction of suboccipital tension headaches. With the patient prone and the headrest lowered, the doctor assumes an oblique cephalad sitting position on either side of the patient's cervical spine.

    A pisiform contact of the doctor's hand nearest the patient (medial) is placed against the superior aspect of the patient's vertebra prominens. The doctor's free hand (lateral) applies axial tension (palm heel) on the patient's occiput, causing the upper cervical area to flex. The doctor's thumb and forefinger are then moved to behind the patient's mastoid processes, and pressure against the vertebra prominens is relaxed. Contact is held until palpable suboccipital tension is relieved.

  7. Piriformis Technic.

    The goal of this reflex technic is to relieve piriformis muscle spasm. The patient is placed prone, with the abdominal and pelvic supports moderately tented.

    The doctor inserts a gloved index finger into the patient's rectum and applies moderate pressure, just below patient's pain threshold, on the side of involvement along the anterolateral aspect of the sacral apex for a duration of 1--2 minutes. The spasm should abate within this time.

  8. Perianal Technic.

    This technic is often used to quiet severe muscle spasms and visceral (autonomic) hyperactivity. The patient is placed relaxed prone, with the pelvic support raised moderately. The anal circle is viewed as a cross section of the body. Moderate middle finger pressure is placed on the anal circle (site clock for contact point) corresponding to the site of the organ being treated; eg, heart, 1:30; liver, 9:00; spleen, 3:00; stomach, low 12:00; rectum, 5:00; urogenital, 6:00; etc.

    With this contact held, sites of perispinal tenderness or spasm are lightly massaged with the middle finger of the free hand. Typical session duration is about 5 minutes. Excellent results have been achieved with migraine, hypertension, petite mal, anxiety states, and PMS. Why? Completely beyond my comprehension. Because the anus is so richly innervated, an effect similar as that achieved in Logan Basic reflexes may be evoked. A Dr. Watkns published several papers on this technic in the JNCA (1950s).

  9. Oculocardic Technic.

    With the eyelids closed, pressure upon the eyeballs normally causes moderate cardiac inhibition, slowing pulse rate from 5--10 beats. In paroxysmal tachycardia and sometimes with persistent hiccoughs, it may be possible to slow the rate by ocular pressure or direct vagal pressure. If ocular pressure accelerates heart rate, the reflex is said to be inverted. The cause of inversion is unknown to the author.

    Besides the above, many pioneer chiropractors utilized reflex technics developed by osteopaths (eg, Chapman's reflexes), naturopaths, and naprapaths. If interested, please refer to the literature of these professions.


  10. Recruiting the Mind/body Connection

    A colleague recently asked how I recruited a patient's subconscious faculties to be in harmony with my case management plan. If we consider a patient more than flesh and bone, then it would be logical to have both psychic and physical forces working toward the same goal. Below is my response. It is one broad example similar to that used in pioneer chiropractic. The labels have changed with time; the process has not.

    "By the time the physician (any type) has spurred an in-depth history, gathered facts from appropriate physical, neuro, ortho, lab, and radiated imaging studies, he/she should have a working logical perception of the patient's pathophysiologic status. This is what I call my basic 'clinical image.' As I further examine the patient (eg, palpate an acute area), I form a mental image of what is under my fingertips; ie, current state of fascia, muscles, tendons, ligaments, vessels, nerves, and bone --healthy function vs dysfunctional/pathologic processes.

    "I'm thus refining my mental picture --my image. If, for example, a patient may say, "It hurts when I turn this way but not that way, Doc," I ask myself "Why?" The dialogue continues with many questions, many "Whys." My image becomes clearer, more detailed. The patient may say, "I've sprained this several times like this before." "No you haven't," I reply. "The first time you sprained healthy ligaments. The succeeding times you also tore poorly nourished scar tissue." This, again, refines my image of what actually is beneath my fingertips. I see this in my "mind's eye" just as I would view an illustration in a book.

    "The same thing occurs with my adjustments. I visualize how things are, what I'm going to do in detail, why I am going to do it, what the patient will likely "feel," and what my logical incremental expectations are. I then explain this in lay terms to the patient --actually transferring my mental image to the patient's mind. If logical in substance and sequence to the patient, it will be accepted. Nothing I do will be a surprise to the patient. The doctor and patient are in harmony, en rapport. This, in general, is how I engage the Mind/Body connection.

    "The patient has thus been exposed to multisensory communication --my words, the tone of my voice, my emphasis, my touch, my gestures, my sincerity, my gentle-firmness --all unpretentiously expressing deductively from my image. If doctor-patient rapport has been firmly established and I have the patient's optimal attention, a mind/body template has been created --like an artist visualizing a painting from start to finish on blank canvas before he grasps the first brush or a sculptor envisioning a figure within a crude block of marble before he chips away the excess."

    For further study, the reader is referred to the many hundreds of noteworthy university studies regarding psychoneuroimmunology. Your interest will be well rewarded.



    EPILOG

    I am neither scientist nor scholar. I am a clinician. My priority concern has never been what other chiropractors did or thought. I have no interest in self-serving dogmatic chiropractic philosophy. I did not develop textbooks to benefit my colleagues. I developed them to benefit their patients. I am and always have been 100% patient oriented.

    It is my belief that to approach chiropractic by a strict mechanical viewpoint is to yield a cesspool of often confusing/contradictory inhumane data. Alert health care cannot be practiced solely from the head. Alert health care cannot be practiced solely from the heart. Alert health care must be practiced from both cultured places simultaneously, in harmony.

    I hope these notes and recollections will benefit your patients. If so, this, likely my last paper, has not been in vain. So mote it be. --RCS


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