As an instructor of chiropractic technique, I've become acutely aware of what other instructors teach people to do - and more often than not, what they teach people not to do. Differences among instructors garner more attention than agreement, for the same reason bad news is more interesting than good news.Say what I might about chiropractic technique procedures, nothing piques more interest than clashing with the views of another technique instructor. Students often tell me they already have been laboriously warned against doing just what I would have them do. Sometimes I realize I am being controversial, but other times I'm puzzled. Indeed, I frequently discover my own technique views only after learning another instructor opposes the practice or concept in question. As a person who practices no particular named technique system, this is how my self-awareness as a chiropractic clinician has evolved: I am the guy who seems to do everything the others say to avoid. Is this a problem?
Enough of these contradictions have accumulated over the years for me to list some of them. Are there other doctors out there left scratching their heads, just like me? People invested with a certain degree of cultural authority (and in the case of college technique instructors, abject power over students) should resist the temptation to "just say no" because they can. When students let me know they were admonished to not do something that makes sense to me, I advise them to politely ask, "Why not?" Frequently, there is no answer or there is an answer that doesn't stand up to scrutiny.
In the end, differences of opinion among chiropractic technique instructors flourish when the evidence is not clear and when it's not obvious practice based upon one opinion gets a better or safer outcome than practice based upon a different opinion. But I will say this: In my opinion, questionable and indefensible technique prohibitions or homilies result in easily avoidable clinical failure, frustration and despair. Here are 10 examples I have struggled with over the years.
1. Thou Shalt Not Rotate
One of the most arbitrary phenomena I have observed in chiropractic is widespread denigration of rotational prestress or line of drive in adjusting the lumbopelvic and cervical areas. By dint of constant repetition in a negative way, rotation has become a code word for presumed callous disregard for patient safety, as though the doctors deploying spinal rotation were indifferent to serious adverse outcomes such as herniated disc, cauda equina syndrome or stroke. This irrationality appears to result from the interplay of several factors:
- misinterpretation of Farfan's in vitro work demonstrating rotation and compression combined are destructive to the disk;1
- the desire to find pseudoscientific justification for the particular technique methods one already does, even lacking evidence of superiority (deploying rotation or not);
- abject dismissal, to the point of fear and loathing, of all other adjusting styles other than one's own; and
- ignorance of the literature arguing against the likelihood cervical manipulation, rotational or otherwise, produces strokes.2,3
I previously wrote an article for this column that defended side-posture manipulation in rotation.21
2. Thou Shalt Not Adjust the Spine Where It Hurts
There certainly is no guarantee that reducing chiropractic assessment procedures to the solitary thought of adjusting at spinal locations deemed to be painful or tender will obtain optimum clinical results. But it's even less likely that systematically ignoring the location(s) of pain and tenderness provocation will result in good clinical outcomes. We consistently read and hear it said that rather than focusing on patient symptoms, we should be emphasizing the "objective indicators of the vertebral subluxation complex," as though there was something more objective about a leg check or palpatory finding than simply asking the patient where it hurts. So long as the great majority of chiropractic patients identify pain as the primary purpose of seeking chiropractic care, and so long as patient-centered chiropractic is more than a catch phrase, we had best pay attention to the location of pain. It's just wrong to redirect the patient's care goal from something clinically relevant (e.g., pain reduction), toward some surrogate clinical outcome that matters more to the chiropractor, such as leg-length equality or atlas realignment.
3. Thou Shalt Not Adjust the Spine Unless There Is Evidence of "Nerve Interference"
Since chiropractors always have emphasized the concept of "nerve interference" or its equivalent, it should be noted that the consequences of a hypothetical subclinical neuropathy occurring at the histological level has been extraordinarily difficult to detect. No one has any problem diagnosing severe nerve damage since there are obvious neurological deficits: anesthesia, muscle weakness, altered deep tendon reflexes, etc. In the absence of so-called hard neurologicals, chiropractors have claimed to detect neuropathy by the presence of pain, tenderness, altered galvanic skin response, surface skin-temperature asymmetry, peculiar electromagnetic radiations and a myriad of so-called "reflexes."
Since few of these have been particularly convincing, a perennial market has been created for the proclamation of new and increasingly outlandish indicators, which has greatly enriched the world of technique systems. If anything has represented something of a chiropractic golden fleece over the years, it is the sustained effort to demonstrate "nerve interference" - that is, mild or even subclinical neuropathy that always would accompany even minor spinal dysfunctions.
4. Thou Shalt Not "Scissor" While Adjusting the Spine
Scissoring is another one of those code words in chiropractic that takes on the characteristic of original sin by dint of constant, automatic denunciation. One is hard-pressed to understand the denial of the use of both hands in practicing spinal manipulation - what a waste of an arm! Indeed, the countermovements of each arm in relation to the other greatly facilitates joint gapping and shearing. Lacking such countermovement, it really is much more difficult to execute moves such as the modified diversified pisiform and the modified rotary break. Grieve, in his discussion of manipulation in the mid-cervical spine, very ably describes how subtle changes in the method determine which joints are primarily affected and how they are affected.4 Taking the joint to full tension and emphasizing the contact hand (Grieve calls it the "executive hand") shears the contacted side. On the other hand, applying a slightly slower thrust to a less than fully tensioned joint, while using the contralateral hand to aggressively distract, side-flex toward and rotate the cephalad structures away from the contact hand, primarily gaps the side opposite the contact hand. That, after all, is where the audibles come from.5 In that case, the so-called stabilization hand is more the contact (executive) hand. If this is scissoring, let us make the most of it.
5. Thou Shalt Adjust the Spine Through the Plane Line of the Disc
I recently observed a chiropractic student thrusting so superiorly to inferiorly in a supine adjustment of the lower cervical spine that the patient's entire body slid inferiorly on the adjusting table. The patient winced but, mercifully, did not complain. I was about to formulate a question, but an instant later, having realized the answer, refrained from doing so. The student adjustor cast a furtive, feverish glance in my direction, hoping for and yet dreading feedback. I said, in a resigned voice, "Since you were adjusting a lower cervical, you were attempting to thrust 'in the plane line of the disc,' right?" Of course, that is what they are taught to do, although the instructors never really take this homily as literally as the hapless students who are just trying to do the right thing.
Technique homilies simply can't be questioned, let alone challenged. In the case at hand, the superior-to-inferior thrust catered to the supposed needs of a lower cervical disc indifferently slams the articular facets into one another, since they are about 70 degrees perpendicular to the disc plane. Experienced doctors, adjusting either seated or supine patients, drop their elbows when adjusting the lower cervical spine, and thus apply forces more likely to shear than compress the facets, unlike the students trying to adjust through the plane line of the disc. (I must confess I have been so far unable to reduce to practice the very provocative work of Bereznick, et al.,6 which questions the clinical relevance of line of drive in view of the frictionless nature of the skin-fascia interface.)
6. Thou Shalt Not Adjust the Spine Without Taking an X-Ray
At this time, I lack sympathy for the practice of obtaining routine X-rays of asymptomatic or minimally symptomatic patients not presenting with signs or symptoms of important pathology (i.e., "red flags"). As a corollary, I don't support taking radiographs for biomechanical analysis, as it commonly is put, to obtain listings. I say "at this time" because my position is far from intransigent and very dependent on yet another discussion on the biological hazards of low-level ionizing radiation. If it were proven beyond a reasonable doubt that X-rays pose very little biological risk, or even provide benefit (as the proponents of X-ray hormesis argue7), I would change my opinion. I believe X-rays do provide information that could have an influence on the care provided and perhaps the clinical outcome, but I don't think that point is sufficiently established to justify routine use, lacking the information needed to calculate a risk-benefit ratio.
These are the days of dueling guidelines for chiropractic radiography. Having been made aware of the intent of the Council on Chiropractic Education of Canada (CCEC) to sponsor the production of radiography guidelines, eventually resulting in several publications,8-11 a group of (largely CBP) chiropractors decided to proactively devise alternative guidelines. Their so-called PCCRP openly states their guidelines are "in direct competition/opposition to current attempts to restrict Chiropractic Radiography to 'Red Flag Only' conditions or diagnosis."12
Now that the CCEC guidelines also are published, chiropractors everywhere have lots of information to digest. I have taken my first pass through these hundreds of pages of dueling guidelines and did not come across any information or opinions that would cause me to change my "red flags only" position. I will say this: The most interesting study I have come across suggesting radiographic biomechanical analysis makes a difference is the Bakris, et al., study on upper cervical care and hypertension.13 I am happy to say the Palmer Center for Chiropractic Research currently is strategizing to repeat the study in some form so we might best be able to judge its relevance in a more comprehensive way.
7. Thou Shalt Not Manipulate
What's in a word, you say? In this case, lots. For many in chiropractic, manipulation is another one of those code words supposed to rile up patriotic fervor among those flying the flag of "the adjustment." Does anyone really think instructors at osteopathic or physical therapy colleges teach their students to use the long levers of the spine and a lot of rotation, paying no attention to what spinal level is contacted, to crack the back at random? As someone fortunate enough to have had many opportunities to hear talks and attend workshops conducted by nonchiropractic manual therapists, I must attest to the absurdity of this stereotype.
As for the "pop-and-pray technique," it's my opinion one is just as likely to encounter this boorish method in chiropractic as out of it. Admittedly, words change their meaning. The founders and pioneers of chiropractic might have found some value in contrasting the spinal "adjustment" with spinal "manipulation" as an important element of achieving professional identity and cohesion, but today's operational definition of manipulation usually characterizes it as a high-velocity, low-amplitude (HVLA) thrust. In other words, manipulation refers to the biomechanical properties of a type of (usually) manual therapy, whether performed by chiropractors or nonchiropractors.
8. Thou Shalt Not Seek Audibles
I have been so perplexed by the denigration of the "audible" - the cavitation event that usually accompanies a competent high-velocity, low-amplitude thrust - that I once wrote an entire column about it, somewhat facetiously.14 The point, of course, is not that all adjustments must he HVLA, but rather that successful HVLA thrusts tend to cavitate. I am aware of at least one article to the contrary,15 but nonetheless, I would never seek the care of a manual therapist who actually thought the production of audibles was somehow incidental to the clinical outcome. As evidence-based as I try to be, I simply can't accept the results of this particular study, any more than I would a published study claiming to have detected cold fusion or perpetual motion. The audible is the signature of a manual thrust that is accelerated and well-enough timed to gain substantial access to the paraphysiological joint space. Although it might seem convenient in a particular time and place for someone to declare, "I am interested in the correction, not the pop," I would not trust a manual therapist who really thought that way. It's my opinion that any experienced clinician or patient can tell the difference between a clean thrust that moves a joint well, as compared with an adjustment that just "doesn't go."
9. Thou Shalt Not Adjust Secondaries or Compensations
Many, if not most, of the technique systems posit some sort of primary subluxation.16 Other spinal problems (symptomatic or not) would be seen as "secondaries" or "compensations." The primary subluxations are the focus of care, whereas the compensatory subluxations are thought to resolve upon the successful correction of the primaries. Some techniques place more emphasis on contrasting primaries from secondaries than others, and some don't seem to feel the need at all. Logan felt that although subluxations could occur anywhere, all would be self-resolving provided the primary sacral subluxation was corrected.17
Some of the upper-cervical practitioners adopted a similar position, emphasizing atlas in much the same way Logan did the sacrum, but with an important difference: The upper cervical specialists declined to even use the term subluxation for these associated spinal problems.18 B.J. Palmer introduced the concept of the primacy of the atlas, and to a lesser extent, the axis subluxation.19 Personally, I think it very difficult to distinguish would-be primary spinal problems from so-called secondaries; and furthermore, I think the risk of failing to address an important spinal area of concern (thinking it secondary or compensatory) exceeds the risk involved in adjusting a spinal area that might have been better seen as purely discretionary.
10. Thou Shalt Use Tissue Pull
It's reasonable to attempt displacing intervening soft tissue (some would say remove tissue slack) to get one's hand closer to the intended bony contact under the skin. It's also reasonable to define the direction of tissue pull - generally in the same direction as the intended thrust will follow. The problems that arise have to do with variation in patients' skin elasticity. Suppose, for example, the T7 transverse processes are the target for a double-hypothenar (Carver-bridge) style intervention. The principle of tissue pull requires the adjustor place the hypothenar contacts somewhat caudal to the target and then slide up to the T7 level to attain the segmental contact point. Since some patients will have very elastic skin and others relatively inelastic skin, it's not clear from which start point the adjustor should begin the inferior-to-superior tissue pull. Locating the T7 target is challenging enough without complicating the matter by contacting the spine inferior to it and then tugging the skin some unknown amount so as to wind up exactly on T7. It's possible to work the hypothenar contacts into the skin at the location of the intended target, a procedure that might be called "tissue burrowing." It's reasonable to assume this would ensure greater accuracy in attaining the intended target.20
I think it would be interesting to reinvent all of chiropractic technique as we know it without having to pay lip service to all that has come before. Far from ignoring or discrediting this profession's technique developers and innovators, this would provide them their just historical due. I am quite certain most of them would be horrified that their contemporary followers had petrified their techniques, separated from research and literally cast in stone. I guess I would call for a paradigm shift, were not for the fact that Thomas Kuhn, having tried to explain how paradigms shift, has himself become a cliché since each technique system believes itself to be something of a new paradigm.
I sent a prepress version of this article to my technique comrade-in-arms, Dr. Brian Gleberzon, who teaches technique at the Canadian Memorial Chiropractic College, maintains a private practice of chiropractic, and is co-author of our book Technique Systems in Chiropractic (Elsevier, publishers). I thought it worthwhile to include, with his permission, his brief response:
"As you may guess, although there may be some resistance and faces made, generally most DCs here at CMCC would have no arguments with most of this. I adjust the painful segment; I adjust 'secondaries'; I (and my patients) like hearing the pop; I thrust P-A through the joints (having been shown the error of my previous ways [see reference #6)], and probably scissor the C/T spine when I adjust it; and I definitely introduce rotation when I adjust the neck. (I try to keep it at a minimum because it just seems less brutal.)"
- Quon JA, Cassidy JD, O'Connor SM, Kirkaldy-Willis WH. Lumbar intervertebral disc herniation: treatment by rotational manipulation. J Manipulative Physiol Ther, 1989;12(3):220-7.
- Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine, 2008;33(4 Suppl):S176-83.
- Boyle E, Cote P, Grier AR, Cassidy JD. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine, 2008;33(4 Suppl):S170-5.
- Grieve G. Common Vertebral Joint Problems, 2nd ed. New York: Churchill Livingstone; 1988.
- Reggars JW, Pollard HP. Analysis of zygapophyseal joint cracking during chiropractic manipulation. J Manipulative Physiol Ther, 1995;18(2):65-71.
- Bereznick DE, Ross JK, McGill SM. The frictional properties at the thoracic skin-fascia interface: implications in spine manipulation. Clin Biomech (Bristol, Avon), 2002;17(4):297-303.
- Oakley PA, Harrison DD, Harrison DE, Haas JW. On "phantom risks" associated with diagnostic ionizing radiation: evidence in support of revising radiography standards and regulations in chiropractic. J Can Chiropr Assoc, 2005;49(4):264-9.
- Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther, 2008;31(1):33-88.
- Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints in adults-an evidence-based approach-part 2: upper extremity disorders. J Manipulative Physiol Ther, 2008;31(1):2-32.
- Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults - an evidence-based approach. Part 1. Lower extremity disorders. J Manipulative Physiol Ther, 2007;30(9):684-717.
- Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults - an evidence-based approach: introduction. J Manipulative Physiol Ther, 2007;30(9):617-83.
- Bakris G, Dickholtz M, Sr., Meyer PM, et al. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. J Hum Hypertens, 2007;21(5):347-52.
- Cooperstein R. "In Defense of the Audible." Dynamic Chiropractic, May 6, 1996.
- Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil, 2003;84(7):1057-60.
- Cooperstein R, Gleberzon BJ. "Toward a Taxonomy of Subluxation-Equivalents." Topic Clin Chiropractic 2001;8(1):49-60.
- Logan HB. Textbook of Logan Basic Methods. St. Louis: 1950.
- Palmer BJ. The Upper Cervical Specific; The Adjustment Specific; and The Exposition of The Cause of All Disease. Davenport, Iowa: Palmer School of Chiropractic, 1934.
- Dye AA. The Evolution of Chiropractic - Its Discovery and Development. Richmond Hill, NY: Richmond Hall, Inc., 1939.
- Cooperstein R. "Adjustive Technique Scheme: A Fresh Look." J Am Chiropractic Assoc 2007;44(2):15-9.
- Cooperstein R. "Would You Believe a $50 Roll?" Dynamic Chiropractic, May 31, 1997.
Click here for previous articles by Robert Cooperstein, MA, DC.