Part 6

A good illustration of the value of speed may be taken from a pile of stakes bound together by a cord. If a man with a hammer desires to remove the center stake of the group, and attempts to do so with a slow pushing movement, the result is a change of position of many stakes, which adhere to the center stake and to each other. If, on the contrary, he strikes a sharp, quick blow with his hammer, meeting squarely the center of balance of the one stake, it will fly straight from its position leaving the others unmoved. This is exactly what we desire to accomplish with an adjustment. By the speed of the movement we expect to move _one_ vertebra before adhesion or the contraction of muscles or inelasticity of ligaments can diffuse the force.

Close Contact

In order to accomplish the transmitted shock it would seem wisest, at first thought, to draw back the hand and strike the vertebra sharply. On the contrary, it has been found advisable to place the hand carefully in _close_ and _immediate contact_ with the vertebra to be adjusted. Nature herself shows us the way in the delicate shock-transmitting mechanism of the tympanum.

Also the hand of the adjuster will cover much more than merely the spinous or transverse process which is used as a lever and to which it is desired to transmit the shock, unless carefully placed so that only a _small portion_ is in contact; by such a contact diffusion of the shock is prevented and its efficiency within a limited area is increased. A carpenter wishing to countersink a nail places in contact with the nail head a small instrument called a countersink, which he then strikes sharply with a hammer. The contact hand of the adjuster represents the countersink and is used by the two arms as a passive instrument for transmitting shock.

The close contact of the hand, which remains passive, renders the adjustment much less painful to the patient than it would otherwise be, and one of the prime objects in the mind of the adjuster should be the minimizing of pain inflicted, by any means which does not lessen the resulting benefit. Also any drawing back of the hand before the movement warns the patient and tends to induce involuntary muscular contraction which interferes with adjustment.

Relaxation

In an adjustment it is necessary to overcome two kinds of resistance--the passive resistance of inertia, of ligaments, or of superincumbent weight, and the active resistance of muscular contraction. It is important that both forms be minimized.

The first may be lessened through the position of the patient’s body; he is placed so that the vertebra to be adjusted is in the freest possible position. The second is reduced to the least possible quantity, amounting to no more than muscle tonus, by using two methods: (a) Oral Suggestion, and (b) Muscular Suggestion.

Oral Suggestion

Explain to the patient the need for relaxation. Make it clear to him that less force will be required if his muscles are passive. Remind him frequently of this and assume that he desires to relax. A word immediately before the adjustment often induces a temporary relaxation during which the adjustment is given. Anything which detracts the attention from the coming shock is an aid. Sometimes asking the patient to inhale and exhale slowly and deeply will sufficiently take his attention from the adjustment. Experience will teach him that he suffers less pain when relaxed and presently relaxation becomes a habit. Instructing patients to think of sleep, turning the eyeballs upward, has been effective with some.

Muscular Suggestion

This can only be given by maintaining a state of relaxation in one’s own muscles, which in itself is desirable in most cases, for reasons to be presently explained. In handling Cervical vertebrae move the head gently from side to side with your own hands relaxed as much as possible. The lazy motion suggests relaxation. Then when it is felt that the neck is thoroughly relaxed, vary the motion with a quick adjusting movement.

In Dorsal and Lumbar regions after the hands are in correct position the adjuster should pause a moment both to be sure that the direction of movement and his purpose to move are clearly fixed in his mind and to be certain that both himself and the patient are relaxed. The adjustment is given instantly and from a perfectly lax muscle, as a boxer strikes.

An added advantage is the greater amount of speed and control which may be commanded in this way. The lax arm, being in a neutral state as regards motion, can be contracted in any desired direction without loss of force or of time, whereas a taut muscle cannot further effect motion of the arm without relaxation of its antagonistic muscles, which takes time.

Muscular Control

Considerable contral over one’s own muscles is necessary in order perfectly to relax arm and shoulder muscles just before the adjustment and then to utilize a measured and determined quantity of force in a desired direction. To acquire this much practice is necessary--practice on the living subject. The desired end may be hastened, however, by acquiring the abstract property of muscular control or by developing control already gained.

Many different forms of exercise will aid in the acquisition of muscular control and the ability to relax and then to follow the relaxation with an instantaneous whiplike contraction in a given direction. The best of these is without doubt _bag-punching_. The movements employed with a punching-bag, especially the lateral quadruple movement with both elbows and both hands, tend to develop precisely the sort of control needed for correct adjusting. The beginner can do no better than to practice in this way, by which, it must be remembered, only a necessary _property_, and not by any means the exact movement, may be acquired.

Amount of Force

The amount of force used in an adjustment varies so much in different spines and in different parts of the same spine that it is quite impossible to state any correct estimate of it in terms of physical units. In general the Cervicals move with least resistance, then the Dorsals, then the Lumbars, and finally the Sacrum and Ilia as hardest of all to displace or replace.

In developing additional force when it is found that the force first used on any vertebra has been insufficient to move it, remember this law: _Work equals one-half Mass times the square of the Velocity_. In other words, doubling the speed of the movement increases its effectiveness four-fold; tripling it, nine-fold.

The increase in force should never be effected by increasing the _weight_ or _pressure_ upon the patient’s body, for reasons which should be clear from a study of previous pages, but always by increasing the _speed_ of the movement.

Names Used to Describe Movements

The names herein employed to indicate certain movements, each a well-defined method of procedure for the accomplishment of some special end, are the names or descriptive terms which seem to be in the most general use at this time. Few of these movements have arrived suddenly; most of them are the result of gradual growth and evolution: so with the terms by which they are known; they have gradually become a part of the common language of the profession. Usage sanctions them, though some of them are cumbersome, unwieldy, or entirely inappropriate.

SPECIAL TECHNIC

MORIKUBO MOVE

A movement for the correction of a lateral and rotated Atlas, indicated for use only when the Atlas is recorded as R. A. or L. A. The position of the patient’s head renders the transverse process inaccessible unless it be anterior on the side from which adjustment is to be given.

Position of Patient

Place two sections of the bifid bench together so as to secure the effect of a solid bench with an upward sloping front. Have patient lying on back with back of head resting firmly on bench, chin slightly uptilted. Then turn patient’s head so that it faces sidewise and rests flatly on the side of the least prominent transverse. This exposes the anterior transverse in front of the tendons of the sterno-mastoid muscle.

Use of Hands

Stand leaning over head of bench and carefully place the pisiform bone of adjusting hand upon the tip of the transverse process, being careful to push aside the sterno-mastoid tendons if they interpose themselves between the pisiform and the process. The fingers of the adjusting hand extend downward toward the clavicle and rest lightly, very lightly, upon the patient’s neck. With the other hand firmly grip the wrist of the adjusting hand, fitting the pisiform of the upper hand into the hollow below the styloid process of the radius.

Movement

This is delivered straight downward toward the bench. It should be light and quick and the hand should not follow the process in its movement.

This movement is painful and should not be used if avoidable. When used it requires the utmost care and a careful measuring of force. Err, if at all, on the side of overcaution. The technic will be better understood after study of the more detailed description of “The Recoil”, since the position and use of hands, arms, and shoulders is much the same for both.

PISIFORM ANTERIOR CERVICAL MOVE

Indicated for rotation of a Cervical vertebra in which one transverse process is anterior to its normal position or more anterior than its fellow which may also be somewhat, though less, anterior.

Placing Patient

As for the Morikubo Move place the patient in the dorsal recumbent posture with head resting on bench and chin uptilted. Turn patient’s face slightly away from the side of the selected anterior transverse and steady the head with the free hand while palpating.

Making Contact

Palpate downward from the Atlas transverse along the posterior margin of the sterno-mastoid, dipping deeply into the neck and exploring with the tips of the first three fingers until the offending process is felt as a nodule of bone plainer to the touch than those above and below. Always reach _across_ the neck to the selected transverse; if it be the right, stand on the patient’s left and use left hand for palpating and for contact hand as well.

Having found the process, gently move aside any tissues which tend to interpose between the finger and the bone, change hands so that the palpating hand is free and the other holds the contact spot clear of interposed tissue and plainly points it out, then place pisiform bone of contact hand gently but firmly against the _front_ of the process so that a mass of bone is felt between the pisiform and the bench when downward pressure is made.

Completing Position

It will be noted here that the head is unstable and tends to rock with slight pressure or movement of the contact hand. Steady the head by placing the knee upon head of bench and against side of patient’s head, not roughly but so that the head cannot move further toward the adjuster.

Now reinforce the contact hand by gripping the wrist with the other, press slightly downward to tighten the contact and avoid slipping, and you are ready for

The Movement

which is directed sharply _downward_ toward the bench. This move rotates the vertebra around its vertical axis and puts a strain in a backward direction on the whole column at this point.

Care must be used, because the move at best is painful. It is easy to slip across the end of the transverse. Take every precaution to avoid imprisoning a muscle, nerve, or blood-vessel between the contact hand and the vertebra. Rightly used this move is valuable, perhaps most valuable of all anterior Cervical moves, but it requires nice judgment.

LAST FINGER CONTACT

This movement differs from the preceding one in two important particulars; the contact hand must be so selected with relation to the side of vertebra adjusted that the fingers will extend upward toward the patient’s head, and the opposing hand supports the head instead of reinforcing the contact hand.

Placing Patient

As for preceding move. The head will remain in this position only until the contact is made, after which it will be raised by the supporting hand until a tight contact is felt and the neck muscles drawn fairly taut.

Making Contact

Palpate with left hand if standing on patient’s left to adjust a right, anterior subluxation. Find the offending anterior transverse, draw tissues away with middle finger of palpating hand, change to middle finger of free hand which marks and holds the point of contact. Now place (with care) the base of the little finger of the hand which was used for palpating, at a point just below the condyle of the last metacarpal and a little to the palmar side, in direct contact with the front of the transverse. The last finger will be flexed toward the radial side and a shallow depression thus left for the contact.

Completing Position

Hold contact lightly and slip the free hand under the patient’s head, which faces slightly toward the adjuster. Raise the head, bending the neck away from the adjusting hand and toward patient’s chest until it is felt that the contact is secure and that further movement would put the neck upon a strain. You are ready for

The Movement

which is delivered entirely with contact hand, downward and toward the back of the neck. The delivery is difficult because the force arm is flexed at the elbow and the position awkward. Practice, however, will soon render one adept.

Uses

For rotated vertebrae which have one transverse anterior to the other, Cervicals only. This move gives a slightly less advantageous force angle than the preceding, but is less likely to be painful.

SECOND METACARPAL CONTACT

Position of Patient

Place patient supine on bench so that his head extends beyond the end of bench and is supported by the upraised knee of the palpater. Stand at head of bench so as to face patient’s feet.

Use of Hands

Differing from their use in the preceding moves the hands are so placed that the adjusting hand for a right, anterior subluxation will be right hand, for a left anterior the left hand. The opposite hand supports the head after contact is made.

Making Contact

Contact point on hand is second metacarpal at the end of the condyle, or second metacarpo-phalangeal joint. This is placed in front of the offending transverse, the head having been rotated away from that side and other tissues drawn carefully aside from the bone. The back of the hand is downward toward the clavicle, fingers semi-flexed on palm, thumb resting on jaw.

Supporting Head

The following position is the correct one for supporting the head in all Cervical adjustments delivered in the above position of patient and adjuster.

Cup the supporting hand slightly and fit the patient’s ear into the cupped palm. Let fingers extend toward the base and back of the neck, the finger position varying according to the amount of rotation of the head so that the fingers are in all cases directly _under_ the head weight. The wrist then flexes on the hand, and wrist and forearm are brought up across the patient’s forehead so that a force delivered from the opposite side cannot cause the head to roll or move upon the supporting hand. After placing both hands draw the head so that the chin is tilted upward until it is felt that contact is snug and tight. This supporting position is invaluable and much neglected by adjusters, who might save themselves much annoyance and many failures by its constant use. In the study of succeeding Cervical moves refer to this description frequently. We shall call it the Hook Support, because the arm and hand resemble a hook which grasps the under side of the head and curves over the upper.

Movement

This is delivered entirely with contact hand and in a direction as much posterior as can be achieved without slipping past the end of the process. If the head is sufficiently rotated away from the contact side the angle of force is better than with a straight lateral adjustment, which it somewhat resembles, but not so good for anteriors as either of the two preceding moves. It is chiefly useful when the other two fail.

OCCIPITO--ATLANTAL MOVE

To move an Atlas so disposed that its one side is posterior while the whole vertebra is laterally displaced in the same direction; to move, for instance, an Atlas R. P.

Have patient lying on back in position C with head projecting beyond bench and supported by adjuster’s knee.

Placing of Hands

Place the first three fingers of one hand under the most laterally prominent transverse so as to hold it firm, first placing the first finger carefully just behind and against the end of that transverse and then reinforcing it with the second and third fingers, slightly tensed, and resting their tips on the lamina close underneath the occipital bone.

Next place the other hand so that the thumb rests firmly upon the patient’s jaw and the first finger extends backward along the lower margin of the occipital bone.

To complete the position rotate the head gently toward the side of the laterally prominent Atlas, until it rests, face toward the side, and is supported by the three fingers of the one hand and the heel and wrist of the same hand. It will be noted that when the head is rotated the first finger of supporting hand slips to a position directly upon the tip of the transverse process and the other two take its place against the posterior aspect of the tip of the transverse. The Atlas now rests with its intertransverse line almost vertically upward from supporting fingers, which hold it against further rotation.

Movement

When the neck muscles have been thoroughly relaxed by slight and gentle movement, throw the upper elbow sharply away from your body, which has the effect of transmitting force through the thumb to the jaw and sharply rotating the head still further, loosening its articulation with the now firmly held Atlas. The condyloid joints thus loosened tend to settle into their proper relations, the weight of the head causing it to slip downward--laterally upon the Atlas.

Uses

This is really a movement of the head rather than of the Atlas and is an easy movement when practicable. It requires complete relaxation and will often fail. It is probable that many apparent Atlas subluxations are really subluxations of the head upon that bone which leave Atlas and Axis in normal relation. This move is most used to loosen the Atlas when it resists ordinary adjustments.

“THE BREAK” No. 1

(Lateral Cervical Move)

The principle involved in this and the three succeeding moves is the same. The contact is made with the end of the laterally prominent transverse process of a Cervical vertebra other than the Atlas, and the movement is directed entirely from side to side. It is to be used only for lateral and not for rotary or anterior or posterior subluxations, a point to be remembered as it is just as easy to produce as to correct subluxation with this move.

Position

Have patient lying on back in position C, with head projecting beyond bench and supported by adjuster’s knee. Following a record previously made count downward to a subluxated vertebra and palpate both transverses with the two hands at once to find if one is prominent laterally, remembering that the record indicates merely the position of the spinous process.

Having found the laterally prominent transverse, place the tip of the finger of the corresponding hand on the spinous of the subluxated vertebra; that is, if a right subluxation, use right hand and if a left, use left hand. Then draw the hand around until the middle of the proximal phalanx of the first finger rests against the end of the transverse. The tip of the finger will be freed from the spinous by this movement.

Hold the adjusting hand tense, edgewise to the neck, fingers together and pointing downward. The thumb may rest against the patient’s jaw or may be free; the essential thing is the snug contact of the first finger against the transverse.

Movement

With the hand in position and the head supported by the Hook Support, bend the head laterally, keeping the face upward, until it is felt that further movement would strain the muscles.

Deliver the movement in a straight lateral direction, quickly and entirely with the contact hand.

“THE BREAK” No. 2

For the Atlas only, and for straight lateral displacement of that vertebra.

Position and Contact

Position of patient’s head and of supporting hand exactly as in using Break No. 1. Contact is made with the end of the Atlas transverse on the laterally prominent side. Contact point on hand is second metacarpo-phalangeal joint, or rather, the condyle of the second metacarpal.

Movement

As for Break No. 1.

“THE BREAK” No. 3

Position

Have patient sitting erect on bench or stool and stand before him. For a right subluxation use left hand and for a left, right hand. Contact point is the middle of the proximal phalanx of the first finger and the fingers reach backward and downward, thumb upward so as to be out of the way.

Movement

Force _should_ be applied entirely with the contact hand to avoid the possibility that movement of the head may bring about movement of some other vertebra than the desired one. But in practice the force is usually divided between the head and the vertebra. The Hook Support cannot be used in this position.

Uses

The use of this position for the Break avoids the necessity for the patient to lie down again in a new position after having Dorsals and Lumbars adjusted. It is extremely convenient. But on the other hand it is undeniably harder for the patient to relax his muscles when sitting up with head flexed sidewise and a sense of lost equilibrium than when lying down. The Break No. 1 will be found the better for the average case.

“THE BREAK” No. 4

Position

Same as Break No. 3 except that adjuster stands behind patient and rests the thumb upon the base of the neck posteriorly while the fingers extend downward and forward toward the clavicle. As with No. 3, the supporting hand rests against the opposite side of the head and forces it sidewise to tighten the contact.

Movement

Properly, a quick lateral movement of contact hand while the head is firmly held by the opposing hand.

NOTE: “The Break” is unfortunately named and it would be well if some less suggestive term were generally substituted.

THE ROTARY No. 1

For the correction of rotation only, and usable in the Cervicals from 2 to 7 inclusive.

Philosophy of the Rotary

A study of the Cervical articulations will make it clear that if a force be applied laterally to the spinous process the probable result will be a _rotation_ of the vertebra, which swings one articular process back from its fellow but leaves the other in close, but modified, contact. Thus the spinous process may appear to the left while the left articular process is fitted firmly against that of the adjacent vertebra, while those on the right are separated. Similar rotation, modified only by the difference in shape of the vertebrae, occurs in the Lumbar region.

A movement applied to the spinous process might correct this condition or might complicate it according to the manner of application. But the _most direct line_ of force for correction is along a line which would pierce the separated articular processes almost in an antero-posterior direction. The Rotary approaches this very closely. It is a setting forward of the articular process against its fellow by applying a movement directly to the transverse process, which lies very close to the articular process.