Chiropractic Technique Decisions

Technique questions on Part III are rarely about how to set up a single adjustment. They ask whether this patient should be adjusted at all, which region and procedure fit the findings, how the procedure must change for a fragile, anticoagulated, pregnant or very young patient, and what to do when something goes wrong on the table. This chapter teaches the decision behind the thrust: screening, selection, line of drive, consent and the response to an adverse event.

Section 1Indications and contraindications in the case

The indication comes first

Manipulation and mobilization are indicated for mechanical joint dysfunction: pain and restricted or aberrant motion that change with position and load, with examination findings that localize to a segment or joint (tenderness, altered end feel, restricted joint play, reproduction of the familiar pain). The best supported indications are mechanical low back and neck pain and cervicogenic headache. A Part III item often hides the real question in the indication: if the pain is constant, unchanged by movement and present at night, the problem is probably not mechanical, and the right answer is further workup, not a technique.

The decision on the day of the visit has three outcomes. Proceed when the complaint is mechanical and no contraindication applies. Modify when a relative contraindication changes how much force, which direction or which region is safe. Do not manipulate and refer when an absolute contraindication or a red flag is present. A contraindication is local or general: a metastatic deposit in T8 forbids thrusting at T8 but may still allow gentle care of an ankle, whereas a suspected vertebral artery dissection or cauda equina syndrome stops all manual care and changes the visit into an urgent referral.

Absolute and relative contraindications

An absolute contraindication means that high velocity thrust at that region carries a risk that no benefit can justify. A relative contraindication means that the risk is raised but can be managed by changing force, leverage, direction, position or technique, or by obtaining more information first. Thrust is dangerous where bone may break (fracture, tumor, infection, severe osteoporosis), where ligaments no longer hold the joint (instability), where a vessel or the cord is already damaged (dissection, aneurysm, myelopathy) and where bleeding cannot be controlled.

Osteoporosis

Osteoporosis is defined on DXA by a T score of −2.5 or lower, or clinically by any fragility fracture of the spine or hip. Stem risk factors include postmenopausal age, low body weight, smoking, alcohol excess, long term corticosteroids (5 mg prednisone or more for 3 months or longer), rheumatoid arthritis and a prior fragility fracture. Vertebral compression fractures are the most common osteoporotic fracture and many are painless; a new one typically causes sudden midthoracic or thoracolumbar pain after trivial loading (lifting a grocery bag, a cough, bending).

Modifications follow from the fracture mechanism. Osteoporotic vertebrae fail in flexion and axial compression, and ribs fail under prone posteroanterior load. Avoid prone thoracic thrusts with body weight, rib springing and forced rotation; avoid flexion based exercise such as sit ups and toe touching. Prefer instrument assisted adjusting, drop table assistance with the tension set light, gentle mobilization, supine or seated set ups with minimal leverage, soft tissue work and extension biased postural exercise.

Anticoagulation and bleeding risk

Patients on warfarin (target INR usually 2 to 3, up to 3.5 for some mechanical valves), direct oral anticoagulants (apixaban, rivaroxaban, dabigatran, edoxaban) or dual antiplatelet therapy bleed more easily into muscle, epidural space and joints. Ask about recent INR values, dose changes, easy bruising and bleeding. Spontaneous bruising, an INR above the therapeutic range or new bleeding symptoms make thrust inappropriate and call for contact with the prescriber. With stable therapy, use low force procedures, avoid sustained deep pressure and aggressive soft tissue techniques such as instrument scraping, and educate the patient to report new bruising or severe new pain, which in the spine can mean an epidural hematoma (sudden severe back pain followed by rapidly progressive weakness).

Inflammatory arthritis

In rheumatoid arthritis, pannus and ligamentous laxity at C1 and C2 cause atlantoaxial instability, which may be silent. Before upper cervical manipulation in any patient with long standing rheumatoid arthritis, review a lateral cervical radiograph with flexion and extension views. The atlantodental interval (ADI) is normally no more than 3 mm in adults and 5 mm in children; a larger ADI, or symptoms such as occipital pain with myelopathic signs, makes upper cervical thrust absolutely contraindicated. In ankylosing spondylitis, the fused "bamboo" spine is rigid and brittle: it fractures with minimal force, often through the ankylosed disc space, and an unrecognized fracture can produce cord injury. Thrust on fused segments is contraindicated; mobile segments, the hips and soft tissues can be treated gently, and extension exercise and breathing exercise are central. During an acute flare of any inflammatory arthropathy the inflamed joint should not be thrust upon.

Down syndrome carries a risk of atlantoaxial instability from ligamentous laxity and odontoid anomalies, and the same rule applies: screen with history (neck pain, torticollis, change in gait, loss of bladder control) and imaging before considering upper cervical thrust, and prefer low force methods.

Pregnancy

Relaxin and estrogen increase ligamentous laxity, the center of gravity moves forward, lumbar lordosis increases and the sacroiliac joints and pubic symphysis take more stress. Manipulation is generally safe in an uncomplicated pregnancy when technique is modified: use pelvic or pregnancy cushions or a table with an abdominal drop so there is no pressure on the abdomen when prone; after about 20 weeks avoid prolonged supine positioning, which compresses the inferior vena cava (supine hypotensive syndrome) and should be relieved by turning her onto her left side; use side posture with minimal rotation; reduce force because joints are lax.

The red flags matter more than the technique: vaginal bleeding, leakage of fluid, regular painful contractions before term, severe abdominal pain, decreased fetal movement, and signs of preeclampsia (blood pressure of 140/90 or higher after 20 weeks, severe headache, visual disturbance, right upper quadrant pain, sudden edema of the face and hands). Any of these means same day obstetric referral; severe features need emergency care. Early pregnancy with unilateral pelvic pain and spotting suggests ectopic pregnancy, an emergency.

Children and infants

Children are not small adults. Their joints are more mobile, growth plates are vulnerable, and they cannot reliably report red flag symptoms. Forces must be scaled down dramatically: fingertip pressure for infants, low force or instrument methods for young children, and full thrust only in older adolescents. Serious pediatric mimics include leukemia (bone pain, fatigue, bruising, pallor), osteomyelitis and septic arthritis (fever, refusal to bear weight), slipped capital femoral epiphysis (an overweight adolescent with knee pain), Legg Calvé Perthes disease (a 4 to 8 year old boy with a limp), spondylolysis in young athletes, and nonaccidental trauma (injuries inconsistent with the history, multiple bruises in different stages, posterior rib fractures). Back pain in a child under 10 is uncommon and should be investigated, particularly night pain relieved by aspirin or NSAIDs, which suggests osteoid osteoma.

Section 2Spinal adjustive technique selection

What the choice depends on

No single technique is best for every patient. Part III items reward choosing a procedure that fits five variables: the region (upper cervical, lower cervical, thoracic, ribs, lumbar, sacroiliac), the finding (restricted segment, disc lesion, stenosis, facet irritation, muscle guarding), the patient's size and build relative to the doctor, the patient's tolerance and preference (fear of the cavitation sound, acute pain that makes positioning impossible), and any relative contraindication. Evidence supports manipulation and mobilization in general more than any named system, so the board rewards safe, logical selection.

The main systems

Mobilization grades and the barrier concept

Joint motion has three zones. Active range ends at the physiological barrier, passive range (joint play) continues to the elastic barrier, and the paraphysiological space lies just beyond the elastic barrier and before the anatomical barrier, where ligaments and bone stop motion. Cavitation occurs when the joint is taken quickly into the paraphysiological space and synovial pressure falls; passing the anatomical barrier causes injury. Maitland grades describe mobilization by amplitude and where in the range the movement occurs.

Choosing by region

Upper cervical (occiput to C2): motion is mostly flexion and extension at the occipitoatlantal joint and rotation at the atlantoaxial joint. Use low amplitude, carefully localized procedures with minimal rotation, and always clear instability and vascular history first. Lower cervical (C3 to C7): rotary and lateral break set ups follow the facet plane, which faces up and back at about 45 degrees; keep end range rotation and extension modest and localize with lateral flexion. Supine set ups allow the doctor to monitor the patient's face. Thoracic: prone posteroanterior thrusts (bilateral thenar, crossed bilateral pisiform, hypothenar to transverse process), the supine anterior thoracic (patient's arms crossed, doctor's hand under the segment, body drop through the patient's elbows), and seated or standing lifts for the upper thoracics. Ribs: costovertebral and costotransverse contacts with a gentle impulse; avoid in osteoporosis. Lumbar: side posture (lumbar roll) with contact on the spinous (push or pull) or mammillary process, using rotation to lock segments above and below; flexion distraction; drop table. Sacroiliac and pelvis: side posture ilium and sacral moves, drop table, SOT blocking.

The key safety idea in lumbar side posture is localization by locking: flexing the upper leg and rotating the trunk to bring tension to the target segment so the thrust acts there and does not spread into adjacent levels. In an acute disc herniation, side posture with heavy rotation and flexion may increase intradiscal stress, so many clinicians begin with flexion distraction or prone extension biased mobilization and progress to gentle side posture once leg pain centralizes.

Size, tolerance and preference

For a patient much larger than the doctor, drop pieces, flexion distraction and instruments replace long lever side posture. A patient who braces against the cavitation sound needs low force or mobilization, and preference is a legitimate reason to choose; fused levels are not thrust, and segments adjacent to a fusion are treated gently.

Section 3Extremity adjustive technique

Principles that apply to every joint

Extremity manipulation follows the same sequence as spinal work: establish a mechanical indication, clear fracture, dislocation, infection, tumor and instability, then identify the restricted motion and choose the glide that restores it. Joint play (the small accessory motions such as glides, distraction and spin that a patient cannot produce voluntarily) is assessed with the joint in its loose packed (resting) position, where the capsule is most lax. Manipulation is usually delivered from loose packed toward the restricted direction; the close packed position (maximal congruence, capsule taut) is used for stability testing and avoided for mobilization. When the whole capsule is involved, motion is lost in the joint's capsular pattern, which points to arthritis or capsulitis rather than a single ligament or muscle problem.

Capsular patterns worth knowing: glenohumeral, external rotation then abduction then internal rotation; hip, internal rotation, flexion and abduction; knee and elbow, flexion more than extension; talocrural, plantar flexion more than dorsiflexion; first MTP, extension more than flexion.

Shoulder

The glenohumeral joint is a convex humeral head on a shallow concave glenoid, so the humeral head glides opposite to the direction the shaft moves (Section 4). Restricted abduction is treated with inferior glide; restricted flexion and internal rotation with posterior glide; restricted extension and external rotation with anterior glide, which is avoided in a patient with anterior instability or a history of anterior dislocation. In adhesive capsulitis (frozen shoulder, most common in women aged 40 to 60 and in diabetics), passive external rotation is lost first and most; the freezing phase is painful and calls for gentle grade I and II mobilization, while the frozen and thawing phases tolerate end range grade III and IV glides and long axis distraction. Acute acromioclavicular separations of grade III or higher are not manipulated.

Before treating a painful shoulder, consider what does not belong in a chiropractic office: a proximal humerus fracture in an older patient after a fall, an unreduced posterior dislocation (arm locked in internal rotation, often after a seizure or electric shock), a full thickness rotator cuff tear with a positive drop arm test and true weakness, and referred pain from the heart, the lung apex (Pancoast tumor with Horner syndrome), the diaphragm and gallbladder (right shoulder), the spleen (left shoulder, Kehr sign) or a cervical radiculopathy.

Elbow and forearm

The elbow comprises the humeroulnar hinge, the radiohumeral joint and the proximal radioulnar joint, which share one capsule. Common procedures are humeroulnar long axis distraction, medial and lateral gapping (often written as ulnar adduction or abduction listings) and radial head glides. Restricted pronation and supination often reflect a radial head that will not glide: a posterior radial head listing is common after a fall on the outstretched hand with pronation, while an anterior radial head is associated with forceful supination.

Radial head subluxation (pulled elbow, nursemaid's elbow) is the classic pediatric extremity question: a child of 1 to 4 years whose arm was pulled while extended and pronated, who then holds the arm slightly flexed and pronated against the body and refuses to use it, with no swelling or deformity. The annular ligament has slipped over the radial head. Reduction by hyperpronation (slightly more successful) or by supination followed by full flexion with the thumb over the radial head usually produces a click and return of use within minutes. If there was a fall, swelling, bruising or point tenderness, obtain radiographs first; a supracondylar fracture (posterior fat pad sign, risk to the brachial artery and median nerve) must not be manipulated.

Wrist and hand

At the radiocarpal joint the convex proximal carpal row moves on the concave radius, so a restriction of wrist flexion is treated with a dorsal glide of the carpals and a restriction of extension with a volar glide. Individual carpals are mobilized with a thumb contact on the displaced bone; after a fall on the outstretched, extended wrist the lunate classically shifts volarly (anterior) and the capitate dorsally.

Two wrist injuries must never be adjusted. A scaphoid fracture follows a fall on an outstretched hand with tenderness in the anatomical snuffbox; initial radiographs can be negative, so the wrist is immobilized in a thumb spica and imaged again in 10 to 14 days (or by MRI), because a missed fracture can progress to avascular necrosis of the proximal pole and nonunion. A lunate or perilunate dislocation shows the "spilled teacup" lunate on the lateral film and may compress the median nerve; it needs urgent orthopedic reduction.

Hip

The femoral head is convex in the concave acetabulum, so restricted flexion and internal rotation call for a posterior glide and restricted extension and external rotation an anterior glide. Long axis distraction (traction through the leg with gentle oscillation or a thrust, the hip in its resting position) is the workhorse for hip osteoarthritis, in which manual therapy combined with exercise improves pain and function; hip osteoarthritis presents in older adults with groin pain, morning stiffness under an hour and loss of internal rotation.

Do not manipulate a hip until the dangerous diagnoses are cleared: slipped capital femoral epiphysis (overweight adolescent, groin, thigh or knee pain, obligatory external rotation with hip flexion, frog leg lateral film), avascular necrosis (corticosteroids, alcohol, sickle cell disease), a femoral neck stress fracture in a runner (groin pain with impact, especially in a female athlete with low energy availability; tension side fractures on the superior neck are surgical emergencies) and a septic joint (fever, refusal to bear weight).

Knee

The concave tibial plateau moves on the convex femoral condyles, so in open chain the tibia glides in the same direction as the leg moves: an anterior tibial glide restores extension and a posterior tibial glide restores flexion. The proximal tibiofibular joint is mobilized anteriorly or posteriorly (a posterior fibular head listing is common after ankle inversion sprains, because inversion pulls the fibula downward and alters fibular mechanics); because the common fibular nerve winds around the fibular neck, contact is broad and force moderate. The patella is mobilized in superior, inferior, medial and lateral directions; inferior patellar glide is required for knee flexion and is often restricted after immobilization.

Apply the Ottawa knee rule after acute trauma: radiographs are needed if the patient is 55 or older, has isolated patellar tenderness, has tenderness at the fibular head, cannot flex to 90 degrees, or cannot bear weight for four steps both immediately and at examination. A locked knee (cannot fully extend) after a twist suggests a displaced bucket handle meniscal tear and needs orthopedic referral, not manipulation.

Ankle and foot

At the talocrural joint the convex talus rolls within the concave mortise, so restricted dorsiflexion is treated with a posterior glide of the talus (or long axis distraction with a thrust), and restricted plantar flexion with an anterior glide. After a lateral (inversion) ankle sprain, the talus commonly remains anteriorly displaced and dorsiflexion stays limited for weeks, which impairs squatting, stair descent and running; posterior talar glide plus calf flexibility and balance training speeds recovery. The subtalar joint is mobilized into inversion and eversion with calcaneal contacts. Cuboid syndrome produces lateral midfoot pain after an inversion sprain or repetitive plantar flexion (dancers); the cuboid is displaced plantarly and is treated with the cuboid whip or a cuboid squeeze, a thrust that moves it dorsally. The navicular is mobilized dorsally, and the first metatarsophalangeal joint is mobilized with a dorsal glide of the proximal phalanx to restore extension in hallux limitus.

Clear fracture with the Ottawa ankle and foot rules, which have sensitivity close to 100 percent for significant fractures: ankle films are needed for pain in the malleolar zone with bone tenderness at the posterior edge or tip of either malleolus (the distal 6 cm) or inability to bear weight for four steps both immediately and at examination; foot films for midfoot pain with tenderness at the base of the fifth metatarsal or the navicular, or the same weight bearing failure. Also exclude a high ankle (syndesmotic) sprain (pain with the squeeze or external rotation test), a Maisonneuve fracture (proximal fibular fracture with medial ankle injury) and an Achilles rupture (positive Thompson squeeze test).

Section 4Skeletal biomechanics applied to technique

Why biomechanics decides the thrust

A thrust is effective and safe when it moves a restricted joint in a direction its surfaces allow with no more force than needed. Facet orientation, coupled motion and arthrokinematics (the convex concave rule) supply the direction; listings record what was found and corrected.

Facet planes and the line of drive

Facet orientation is described by two angles: the angle to the transverse (horizontal) plane, seen from the side, and the angle to the coronal (frontal) plane, seen from above. The orientation determines the motions each region favors and therefore the line of drive, which should run along the facet plane so the joint surfaces glide rather than jam.

Coupled motion

Coupling is the consistent association of one motion with another about a different axis. In the lower cervical spine (C2 to C7), lateral flexion is coupled with rotation to the same side: bending to the right turns the vertebral bodies to the right and the spinous processes to the left. A cervical set up therefore combines lateral flexion with rotation rather than relying on excessive rotation. In the upper cervical spine, lateral flexion at the occipitoatlantal joint is coupled with slight rotation to the opposite side, and rotation at C1 and C2 is accompanied by slight vertical translation as the biconvex facets ride over each other.

In the thoracic spine coupling is variable; the upper thoracics behave like the cervical spine (same side), while mid and lower patterns differ between individuals and with posture. In the lumbar spine coupling is small and inconsistent between studies; the commonly taught pattern is that in neutral, lateral flexion is accompanied by rotation of the vertebral bodies to the opposite side (bodies toward the convexity), while in flexion the coupling may become same side. The osteopathic summary is Fryette's laws:

• Type I (neutral mechanics): with the spine in neutral, side bending and rotation occur to opposite sides, across a group of vertebrae. This is the pattern of a scoliotic curve: the bodies rotate toward the convexity and the spinous processes toward the concavity.
• Type II (nonneutral mechanics): with the spine flexed or extended, side bending and rotation occur to the same side, at a single segment. Isolated segmental restrictions follow this pattern.
• Type III: introducing motion in one plane reduces available motion in the other planes. This is the basis of locking: flexion and rotation are used to tighten the segments above and below so the thrust acts only at the target.

Joint play and end feel

Joint play is examined passively at the end of active range and in the resting position: the clinician stabilizes one bone and moves the other through small glides and distraction. Restricted, painful joint play at a segment that reproduces the complaint is the main indication for adjusting it. The quality of resistance at end range, the end feel, adds information.

The convex concave rule

Joint surfaces move by rolling (new points on one surface meet new points on the other), gliding (one point slides across new points) and spinning (rotation about a fixed axis). When a convex surface moves on a fixed concave surface, it rolls in the direction of the bone's movement but glides in the opposite direction; otherwise the head would roll off the socket. When a concave surface moves on a fixed convex surface, roll and glide occur in the same direction. Mobilization restores the glide component, so the rule tells you which direction to push.

Segmental listings

A listing records the position or motion fault of a segment so the doctor can choose a contact and line of drive and so another clinician can understand the record. Two families are tested. Static (positional) listings, used in Gonstead and many diversified systems, describe where the vertebra has moved relative to the one below. Motion (fixation) listings, from motion palpation, describe which motion is restricted, for example "T6 restricted in right rotation" or "L4 to L5 left lateral flexion fixation." Both must be readable.

In the Gonstead system a lumbar or thoracic listing usually starts with P (the vertebral body has moved posterior), followed by R or L (the side toward which the spinous process has rotated) and then S or I, which describes lateral flexion (the disc wedge) on the side of spinous rotation. A PRS listing means posterior body, spinous rotated right, and the right side superior (disc wedge open on the right); it is corrected with a contact on the right side of the spinous and a line of drive posterior to anterior, right to left and superior to inferior. A PLI listing is posterior, spinous left, left side inferior.

Atlas listings describe its laterality and the position of the anterior tubercle: ASR (anterior superior right) means the atlas has shifted right and its anterior arch is superior; the classic atlas listings combine A or P, S or I, and R or L. Pelvic listings describe the innominate (ilium) relative to the sacrum:

Section 5Safety, consent and adverse events

Screening before cervical manipulation

Serious adverse events after cervical manipulation are rare, and the most feared is stroke from cervical artery dissection (vertebral or internal carotid). Population studies show that patients with vertebrobasilar stroke are about as likely to have seen a primary care physician as a chiropractor beforehand, suggesting that many dissections are already under way and cause the pain that brings the patient in; the clinician must recognize one before treating it as mechanical neck pain.

Screening relies on history, not provocative positioning tests. Rotation and extension tests (such as the DeKleyn, Hautant, George and Maigne tests) have poor sensitivity and cannot clear a patient; a negative test does not make thrust safe. Ask about:

• Pain character: sudden, severe, unusual neck pain or headache, especially "worst ever" or different from previous episodes, often unilateral and occipital (vertebral) or anterolateral neck, face and eye (carotid).
• Recent trauma, even minor (sports, a sudden head turn, a fall, a motor vehicle collision) in the preceding days or weeks.
• Posterior circulation symptoms, the classic "5 Ds and 3 Ns": dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, numbness (often facial or perioral) and nystagmus, plus ataxia.
• Carotid signs: ipsilateral Horner syndrome (ptosis, miosis), pulsatile tinnitus, transient monocular vision loss, contralateral weakness or speech disturbance.
• Risk factors: connective tissue disorders (Ehlers Danlos, Marfan, fibromuscular dysplasia), recent infection, migraine with aura, uncontrolled hypertension, prior dissection.

Also screen for upper cervical instability (rheumatoid arthritis, Down syndrome, recent trauma, steroid use; symptoms such as a sensation of the head being heavy, lump in the throat, bilateral paresthesia) and for myelopathy (clumsy hands, gait change, Hoffmann sign, hyperreflexia), both of which forbid cervical thrust until imaging and specialist assessment.

Adverse events: expected and serious

Informed consent

Consent is a process, not a signature. A valid consent requires a competent patient (or a parent or legal guardian for a minor, or a legally authorized representative), voluntary agreement and adequate disclosure of: the diagnosis or clinical impression, the nature and purpose of the proposed procedure, its material risks (common minor ones and rare serious ones, including stroke for cervical manipulation), the expected benefits, reasonable alternatives including no treatment, and the likely consequences of declining. Most jurisdictions judge disclosure by the reasonable patient standard: what a reasonable person in the patient's position would want to know. The patient must have the chance to ask questions and may withdraw consent at any time, including on the table. Consent should be renewed when the plan changes, for example when a new region or a new procedure is added. Use a trained interpreter when needed.

Documenting the procedure

The record must let another clinician reproduce the visit and let a reviewer judge necessity. Use a SOAP structure. The objective findings that justify a spinal adjustment are often summarized with PART: Pain and tenderness, Asymmetry or misalignment, Range of motion abnormality and Tissue tone, texture and temperature change; two of the four, one of which must be asymmetry or range of motion, are commonly required to document a subluxation for payment purposes. For each procedure record the region and segment, the technique and patient position, the side and line of drive, the patient's immediate response, any adverse event and its management, the advice given, and the plan with goals tied to outcome measures (such as the Neck Disability Index or Oswestry Disability Index). Never alter a record after the fact; corrections are made as dated, initialed addenda with the original left legible.

Words worth knowing