The following is Chapter 2 from RC’s best-selling book:
“Upper Extremity Technique”

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Chapter 2:   Adjustment of Upper Extremity Joint Subluxations-Fixations

This chapter describes adjustive therapy as it applies to articular malpositions of the lateral clavicle, shoulder, elbow, wrist, and hand. Manipulations to free areas of fixation are also covered.

INTRODUCTION

From a biomechanical viewpoint, a kinematic chain extends from the cervical and upper thoracic spine to the fingertips. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles (essentially, the placement of the hands).

     Terminology: Subluxation-Fixations

The term subluxation technically refers to an incomplete or partial dislocation in which the articular surfaces have not lost contact. Partial malpositions may be extremely slight (beyond palpatory perception), yet be the focus for initiating a chain reaction in a kinematic chain that may express itself acutely in another joint or for establishing numerous adverse proprioceptive reflexes that may find expression in either the soma or viscera, or both.

In states of articular malposition (subluxation), a certain degree of fixation exists, else the malalignment would readily reduce itself during joint function because the direction of least resistance would be towards normalization (congruent surfaces). Thus, it is just as important to determine what is holding the joint in malalignment (eg, spasm, shortened ligaments, adhesions, mineral deposits, entrapped cartilage, neogenic bone, neoplasm, degenerated joint surfaces, fracture, etc) as it is to determine that a joint is subluxated-fixated to some extent.

While it is likely that some degree of fixation always accompanies a subluxation, it is also likely that a dynamic subluxation also accompanies a fixation even when the fixation is found in the joint’s position of rest. For, example:
(1) joints fixated unilaterally tend to encourage compensatory contralateral joint laxity, and (2) joints fixated bilaterally tend to encourage compensatory joint laxity in the adjacent movable joints of the kinematic chain.

It is for this reason that the site of fixation is typically asymptomatic, with symptoms expressing at the site of compensatory hypermobility where activity is likely to produce irritation and inflammation due to reduced structural support. A fixation in the elbow, for example, may exhibit as symptoms in the hand, shoulder, or cervical and/or thoracic spine, or vice versa. It is for this reason that the entire kinematic chain must be evaluated in any extremity neuromusculoskeletal disorder. Localized evaluation at the site of pain offers limited information in itself and can readily lead to false conclusions.

The term fixation, as used in chiropractic, rarely means ankylosis (complete immobility). Rather, it implies a state of reduced mobility, essentially due to soft-tissue changes, and commonly found within the range of 20%–90%. This degree of reduced mobility may be a gradual increasing resistance, as commonly encountered in passive motion against taut muscles, or normal motion up to a point that meets a firm “rubbery” motion block, as commonly found when ligament straps have shortened or a piece of dislodged cartilage serves as a barrier to motion.

     Therapy Differences

Once the possibilities of fracture and underlying pathology have been eliminated, antalgic spasm is probably the only type of fixation involved in an acute subluxation syndrome. However, with chronic subluxations, concern must be given to the mobilization of degenerated para-articular and intra-articular tissues that have lost much of their elasticity and plasticity.

Although subluxations and fixations commonly accompany each other, each requires a different therapeutic rationale. Subluxations, being bony malpositions, are usually corrected with an adjustment that employs a high-velocity thrust within a short range of motion. This can usually be accomplished instantly and only need be repeated on a subsequent office visit if the adjustment does not “hold.” Such a force, however, would usually be contraindicated with most types of soft-tissue fixations if bleeding is to be avoided, as even minute hematoma would encourage further soft-tissue fibrosis and calcification.

Thus, most fixations are treated by using a slow repetitive stretching maneuver applied (up to patient tolerance) against the resistance, which may extend through a relatively long range of motion. It may take many months (eg, frozen shoulder) to achieve the optimal results possible when the joint has been in a prolonged state of hypomobility. Both techniques require firm stabilization of adjacent joints that could possibly be adversely stressed during adjustment or mobilization maneuvers.

Other important clinical paradoxes are those of posttherapy immobilization and heat versus cold. Following the correction of an acute subluxation, short-term immobilization tends to offer the affected tissues a period of rest to promote healing and prevent further inflammation from activity. Cold would usually be indicated within the first 72 hours to reduce pain and swelling.

On the other hand, extended immobilization tends to weaken para-articular muscles (disuse atrophy), encourage circulatory stasis and the accumulation of metabolic debris, and promote shortened ligaments and stiff capsules, which would encourage the formation of soft-tissue fixation. Heat and exercise would usually be indicated to soften taut tissues and enhance circulation.

Following any manual therapy, the common procedure is to recheck joint mobility, apply any adjunctive therapy or rehabilitative procedure that would be appropriate, counsel the patient as to adverse activities, and prescribe necessary home exercises.

     Technic Differences