David I Graber, DC, DACBSP

This is the first in a series of short articles on the key factors that make up the delivery of effective high velocity low amplitude (HVLA) adjustments or manipulations. This one is on patient relaxation. Future articles will cover other elements such as adjusting the most fixated segments, specific contact points, the directional plane or line of drive, pre-thrust positioning, engagement of the restrictive barrier, speed of application, peak load amplitude and duration, depth of penetration or displacement, and post-adjustment neuromuscular, re-education and rehabilitation procedures.

The more relaxed the patient, the smoother and most efficient the adjustment. Tense patients have muscular rigidity giving resistance to any adjustive thrust. If you have ever had the experience of bouncing off a patient when delivering an HVLA adjustment, or feel like you’re adjusting a wall, you appreciate how much patient tension can be counterproductive.

Patient relaxation is needed for all 4 phases of an adjustment: the pre-adjustment phase, the set-up phase, during the adjustment, and after its delivery.

First and foremost, it’s important to recognize that your presence matters throughout all phases of the adjustment. Your head and heart need to be focused on the betterment of the patient, and you stay “in the moment”. The phrase “Patient Time Consciousness”, or PTC, was what I learned back at NYCC to describe this state of mind. It means to be fully present with the patient all the time you’re with the patient. No distractions or lapses of attention. Just being 100% with a patient is nurturing and healing for them, and for the doctor-patient relationship.  It’s essentially the Zen of chiropractic care.

Pre-adjustment, there are various strategies to ease patients’ tension, short of them having a glass of wine. Having the patient relax and breathe on the table for a few minutes, especially with a hot pack on them, is a simple and low-tech method that works great. Preliminary adjunctive therapies such as electrotherapy, mechanical massagers, intersegmental traction, etc. can also be used. There are certain manual therapy techniques that can serve as a good preliminary to an HVLA manipulation. These include Logan Basic technique, cranio-sacral therapies, SOT blocking, and myofascial release techniques. If you do rehabilitation in the office, doing exercises before the adjustment can be very helpful to reduce their tension. For those who have a massage therapist on staff, tag teaming with them is a highly desired patient option!

During the setup and positioning, it’s important to make sure patients are comfortable on the table. Are the cushions either too soft and worn, or too rigid and uncomfortable? Is the material easy to move on? Does the footrest adjust for both tall and smaller patients? Tables which have adjustable head pieces, abdominal release sections, and/or the ability to bend in multiple directions can all be utilized for patient comfort and relaxation.

Since patient comfort follows doctor comfort, your posture and positioning need to be as effortless as possible. The table must be matched and be the right height to work on a patient. Your attire should allow you to move with ease, and your footwear should give you good grounding and stability

When setting up, talk patients through the process, especially in their first few visits. Many people need to be guided through the process in a step-by-step manner, even after repeated visits. Use touch prompts and verbal instructions to get them to relax different body parts. Contract-relax PNF techniques can ease neuromuscular tension while getting to an end range joint position. All of this is to get the patient’s body to the ideal point of tissue tension, while simultaneously keeping them in the state of the most neuromuscular relaxation.

During the actual adjustment it’s critical to have a healer’s touch – gentle, firm, caring, and confident. Non-verbal cues are transmitted through your hands in a surprisingly powerful manner. Patients can feel your sense of authority, compassion, and even your mood through your contact with them. They will respond to your touch and presence. If they sense they can trust you and let down their guard, they will.

You will frequently need to coax patients’ to fully relax verbally (e.g., “let it go”, “relax”, “deep breath in and out”), and physically by pre-thrust rhythmic oscillation. This can’t be rushed as we are looking for the window of opportunity and the optimum timing to deliver the adjustive thrust or impulse.

After delivering the adjustment, reinforce the benefits that occur as a result of a successful adjustment. Both new and experienced patients are often surprised by a loud audible. Reassure them that it was a positive effect. For the patient who is sore afterwards, examine them briefly. If there’s nothing ill, ease their minds by informing them it’s not unusual and give them a mitigation strategy for home – ice, rest, stretching, etc.  Sometimes a follow-up phone call to check on them can do wonders.

Healing occurs in a parasympathetic state, so anything that can reduce their stress and induce relaxation will potentiate the effects of your adjustment. I encourage patients to take several full deep breaths at the end of their visit and throughout the day afterwards.

Finally, the more a patient understands their condition and the process of the chiropractic care, the more at ease they will be during their entire time in and out of your office. Understanding occurs on 3 levels. Intellectually, through concepts, ideas, and facts. Emotionally, by feeling comfortable in the office, cared for, and having confidence in the doctor. Viscerally, by having a gut or intrinsic sense of being in the right place with the right people.

Thank you for reading this and committing to being a better chiropractor! If you have any questions on how to better perform your adjustments, or any ideas or feedback on this article, please feel free to contact me.

About the Author:

Dr. David Graber is nationally known presenter on chiropractic technique and is a member of the ANJC board of directors. He maintains a private practice in Parsippany, NJ. He blogs on chiropractic and clinical topics at: drgraber.wordpress.com.  He can be reached at: DrDavidGraber@gmail.com.

Originally published in : NJ Chiropractor, Spring 2021

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