You are sitting in a class or seminar watching one the world's best adjusters demonstrate adjustment after adjustment, and you're wondering to yourself, “how does he or she do that”?
Hopefully, some explanation of determination and application of what adjustment to deliver was communicated. Often, what’s happening inside the person providing the adjustment doesn’t get discussed at the seminars or college adjusting labs.
The Motion Palpation Institute has become very transparent, and hopefully, progressive over the years in this concept. We take pride in studying and then trying to explain what makes the best adjusters in the world. Of course, every person who delivers an adjustment has nuances and things that are unique to that person performing the adjustment.
There are some variables that we cannot control, such as height, limb length, hand size, body type, coordination, and mass. However, over the years of observing and studying the best adjusters in the world, certain traits are universal to all good or great adjusters. I realize most great adjusters/manipulators are DC's, but I've also seen many PT’s who were quite amazing at manipulation as well.
We would like to outline some of the universal and common traits all master manipulators have that are coachable and trainable. There are very few excuses for not becoming a master of manipulation. Of course, there are going to be exceptions to every rule, and there are some physical limitations that we have seen over the years that would limit one's ability to become great at joint manipulation.
However, for the most part, anyone that is willing to put in the time can become very good, if not excellent at joint manipulation. Hand size, mass, and height are not factors at all in being able to adjust the spine and extremities. This has been proven time and time again by very small, and slight DC's and PT’s, many of whom are better manipulators of the joint system than their larger, heavier counterparts.
So what is it that makes a master manipulator of the joint system?
First, the best adjusters on the planet are also the best palpators of the joint system. This skill is probably the hardest to gain confidence and mastery. Palpation takes a lot of time and effort and is the most time-consuming of the skills. However, this is the foundation of a great adjuster.
The inter and intra-rater reliability research proponents will always ridicule joint palpation. As Karel Lewitt said, “the problem with joint palpation is not it’s reliability; it's that people will not take the time to get good at it.” The Motion Palpation Institute was founded upon the dynamic assessment of the joint system that was started by Dr. Henri Gillet and continued and refined by Dr. Leonard Faye.
The Motion Palpation Institute demonstrates a systematic approach to joint palpation that builds on redundancy to make joint palpation more reproducible for you. However, becoming competent and skillful with your joint palpation is difficult and takes years of practice. Palpation is also the least dynamic and sexy of the skills that will make you a great adjuster. Becoming great at joint palpation is very much like becoming great at any sport. The best quarterbacks in the NFL enjoy throwing the deep outs and difficult throws, but the great quarterbacks in NFL spent much time in the film room and working with their receivers before what you see on TV on Sunday afternoons. The hours of grit and grind behind the scenes that set people up for success and being great at joint palpation sets you up for success as an adjuster.
Skills of the trade:
All great joint manipulators understand force generation. They realize that force is equal to mass times acceleration, and the one reproducible and trainable aspect of that equation is the acceleration aspect.
If you can learn to set a joint up at end range and accelerate quickly through the 1/8th inch of paraphysiological space, then you are going to be very proficient at adjusting. What allows you to master the acceleration component of the force equation?
Your setup is crucial to the success of your adjustment. Your palpation determines your setup. For example, if you're trying to achieve extension and right lateral flexion in the cervicothoracic spine, you would be unsuccessful in restoring that motion along those axis‘ of rotation if you place the patient face down on a table. The very position of the patient prone creates flexion along the cervicothoracic joint axis’. It would be challenging to create enough lateral flexion in this position as well to achieve motion in the extension and lateral flexion planes.
However, it would be easy to achieve extension and right lateral flexion in the seated position. In this position, you can place the patient's head and neck in a stable environment (broad hands and torso support) and move the cervicothoracic junction into extension and right lateral flexion.
Again, your setup is crucial to success, and palpation of the joint system is essential in choosing and achieving the correct setup. If your setup does not allow for motion along the joint axis’ that is restricted and is challenging to get to the end range of that joint, then adjusting becomes very forceful and uncomfortable.
Acceleration/Speed. How do you train speed?
Speed starts with your ability to choose a setup that creates stability within you and your patient. Balance and stability allow you to relax. The relax-contract phenomenon is critical and being fast and being able to feel the joint restriction with your setup and contact. Let me repeat the contract-relax phenomenon is extremely important in being a great adjuster. Being able to relax requires stability. This can be passive stability at times, such as a side posture kick adjustment using a dorsiflexed foot/ankle to allow your knee to rest against the table.
Most of the time, stability comes from your body position and being athletic. Let’s again use a seated cervical adjustment in this example. Once you have determined what the joint complex is lacking through palpation, then your off-hand becomes a source of stabilization. This off-hand covers as much surface area as possible to help guide the patient’s cervical spine into the axis’ of restriction and to create comfort.
You must ensure your contact hand is also relaxed and resting in the middle of the restriction. The contact is a fulcrum, and the final force transducer in the chain. It is NOT the initiator or the driver of the adjustment!! Our contact cannot create motion in a joint that is not already there in the setup.
Our external force determines none of the movement or gapping at the joint level. Our force/speed is the final push or gapping force into the paraphysiologic space…nothing more. To create this relax-contract phenomenon, then we need to be stable and athletic. In this case, we support the head and cervical spine with wide and relaxed hands. Then we stabilize the head further with our torso or shoulder resting against the head. Finally, we are bent at the waist (taking a bow), and 80% of our weight is on the outside leg. This position allows us our final point of support, our stable outside leg.
With all these points of stability, we can now relax our shoulders, forearms, and hands. Now that all of this is relaxed, we can use our relaxed contact hand to move the cervical spine in small motions along with the end ranges of restriction that we achieved at setup.
We call this the chiropractic waggle, like the golf waggle, which allows us to 1) relax further and 2) feel the restriction and end range. Once we relax, we can initiate tremendous speed from the ground up. We stiffen the core through building up intra-abdominal pressure (think the kiap of the martial artist), which allows us to build up a very quick and explosive, yet shallow, bilateral pectoralis contraction, which sends all that ground reaction force through the stiffened core and into the end of the fingers. This creates a quick impulse that will gap the joint in the paraphysiologic space.
Think of being in a defensive athletic position or a fighting position and being relaxed and throwing a quick jab. Jabs are a much greater motion, but you get the visual and the feel. Another way to think about and train this is to hold an 8-pound medicine ball with cables or resistance bands attached to your hands. Now impulse with both hands into the ball.
Now we can start to train feel and speed. To be fast in this situation, we have to be stable (so we don’t drop the ball) and relaxed (to generate speed). There are many different ways to train speed (resistance bands, exercise balls), but nothing beats seeing patients. For ways to see training ideas, please visit the MPI YouTube channel.
Once we learn how to impulse, relax-contract-relax, or thrust, then the next step is not to use it. What?!? Not every patient will want osseous manipulation, or they may be too acutely inflamed. The next level of clinical expertise when using manipulation is to know when and who to use it on. Develop tremendous power and then use it only when you need to…that, however, is a topic for another day.
Corey Campbell, DC
Motion Palpation Institute
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