Where To Give An Adjustment

Since the beginning of our education, we chiropractors have been taught many methods to locate where to make an adjustment. Sometimes it seems that if you get 10 chiropractors together, you get 10 different ways of finding where to apply an adjustment. The methods often contradict each other.

 

Several researchers have looked at the research evidence for various methods of chiropractic analysis and have rated their reliability. 1 -4  Those that showed good evidence of reliability were designated as favorable, and those that did not have adequate evidence were rated as unfavorable.

The following methods were found favorable:

• Pain Provocation
• Posture: antalgia, kyphosis, lordosis, scoliosis
• Stiffness as determined by instrument
• Static palpation for major anatomical landmarks
• Motion palpation with pain
• Manual muscle testing for strength
• Range of motion
• Skin rolling Surface EMG for Flexion-relaxation phenomenon in lumbar region
• Motion palpation to localize the site of care
• Stiffness by joint springing or overpressure testing

 

The following were found unfavorable:

• Manual muscle testing for non-pathologic altered function
• Para-spinal skin temperature to locate the site of care
• Surface EMG for site of care
• Radiographic imaging for localizing the site of care

 

For daily visits, most chiropractors use some sort of functional examination protocols. These include postural analysis, segmental alignment or position, range of motion, reactive muscle testing, kinetic palpation, and provocative testing. The chart below shows a brief summary of each, along with their strengths and weaknesses.

 

 

FUNCTIONAL JOINT EXAMINATION METHODS (Order of Least to Most Invasive)

METHOD	RATIONALE	STRENGTHS	WEAKNESSES
Positional and Postural	~Misalignment creates joint and connective tissue stress	~Assesses muscle imbalance and tightness ~Positional dyskinesia demonstrated	~Difficult to assess anomalies ~Alignment doesn’t correlate     with kinetic disturbance ~Doesn’t identify unstable joints
ROM	~Altered instantaneous axis of rotation	~Easy to implement ~Quick screen ~Demonstrative to patient	~Assesses quantity but not quality of motion ~Global, not-specific
Reactive Muscle Testing (Active MMT, Passive Reflex Testing)	~Mechanoreceptor dysfunction	~Neurological indicator of joint stress ~Indicates neurological dysfunction ~Very demonstrative to patient	~Secondary indicator ~Poor validity and reliability ~Can’t gauge prognosis ~Highly skill dependent with questionable accuracy and reliability
Motion Palpation (Joint Play Testing)	~Connective, muscular, and articular tissue restrictions prevent normal arthokinematics	~Primary indicator ~Can assess quality of motion ~Can differentiate between acute and chronic conditions ~Can identify unstable joints ~Can monitor progress ~Can offer prognosis information	~Labor intensive ~Highly skill dependent requiring extensive practice ~Modest to good intra-examiner reliability; fair to moderate inter-examiner reliability ~Best used in combination with other exam methods rather than as a stand-alone
Provocative Testing	~Pain on testing indicates articular tissue irritation or inflammation	~Most literature evidence support ~Demonstrative to patient ~Can be integrated with orthopedic exam (overpressure) and joint play end feel analysis	~Narrow scope of assessment (pain only)

The practice of locating where to adjust currently remains as much or more art than science. Deliberate practice in any chosen method is necessary to become proficient. With more research we can get even better.

 

About the Author

Dr. David Graber is the chairperson of the ANJC Council on Technique and Clinical Excellence. He maintains a private practice in Parsippany, NJ. He can be reached at: DrDavidGraber@gmail.com.

1. Triano JJ, Budgell B, Bagnulo A, et al, Review of methods used by chiropractors to determine the site for applying manipulation. Chiro & Man Ther, 2013;21:36
2. Cooperstein R, Young M, Haneline M. Interexaminer reliability of cervical motion palpation using continuous measures and rater confidence levels. J Can Chiropr Assoc. 2013;57(2):156-64.
3. Cooperstein, Robert & Young, Morgan. (2016). The reliability of spinal motion palpation determination of the location of the stiffest spinal site is influenced by confidence ratings: A secondary analysis of three studies. Chiropractic & Manual Therapies. 24. 10.1186/s12998-016-0131-x.
4. Holt, Kelly et al. Interexaminer Reliability of Seated Motion Palpation for the Stiffest Spinal Site. Journal of Manipulative & Physiological Therapeutics. Oct. 2018

where to give an adjustment