Treatment Principles and Procedures

CHAPTER 7
Treatment Principles and
Procedures
• Lesson Purpose

To give the student knowledge of common treatment principles

and procedures in the chiropractic setting.

• Lesson Objective
Upon completion the student will:

• Learn common treatment procedures and techniques

• Learn common stretching protocols

• Learn the principles of physiotherapeutic modalities

Cherkin, DC and Mootz, RD gave an accurate accounting of what many

in the chiropractic profession have been trying to relate to the public:

“Spinal manipulation and the profession most closely associated with

its use, chiropractic, have gained a legitimacy within the United States
healthcare system that until very recently seemed unimaginable. In
the past several decades, chiropractic has undergone a remarkable
transformation. Labeled an “unscientific cult” by organized medicine as
little as 20 years ago, chiropractic is now recognized as the principal source
of one of the few treatments of low-back pain, spinal manipulation. In the
areas of training, practice, and research, chiropractic has emerged from
the periphery of the health care system and is playing an increasingly
important role in discussions of health care policy.”1
Adapted from: AHCPR Research Report, U.S. Department of Health and Human Services, 1997.

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General Disclaimer
This chapter contains recommendations for the clinical application of
many forms of chiropractic treatment. These recommendations are
intended for educational and instructional purposes only and do not
constitute a standard of care for any specific clinical situation. These
recommendations, which may need to be updated, are intended to
be flexible. The recommendations and directives within this text should
be considered as basic and not comprehensive. One must always refer to
state and federal guidelines to assure legal compliance when educating
or applying various treatments and modalities as a chiropractic therapy
assistant. The type of treatments and their applications utilized are
dynamic, and subject to change readily over [Link] recommendations
herein would apply to all patients at all places where services are rendered.
Treatment guidelines are consistent and universal, regardless of locale,
technique, philosophy, method of reimbursement, or liability coverage
status. These guidelines are intended to provide a common framework
for patient treatment that allows for a more consistent application
and improved communication both within and outside the provider’s
practice. It is not intended to adequately train the chiropractic assistant
in all areas of skills necessary to administer physical modalities in a
chiropractic office. It is the responsibility of the doctor of chiropractic to
ensure proper education, training, and skill development for any persons
operating under his or her direction. It is not intended to review every
instrument or therapeutic device that may be used in a chiropractic
office by the doctor or assistants. It is the responsibility of the doctor to
ensure proper training and supervision for the use of all modalities.

Introduction
From the origin of chiropractic care, there have been many forms of
treatment given to the chiropractic patient with varying effects and many
are based on evidence-based research and empirical evidence. The initial
time-tested use of the chiropractic treatment has been to correct the
vertebral subluxation and help restore normal neural communication
between brain and body.11 Treatments have been adapted throughout
the years to include treatment ranging from numerous musculoskeletal
ailments (whole body) to somato-visceral ailments. Colloca, DC states
that, “…chiropractic spinal analysis has developed to focus on the
structural and functional relationships of the human frame as a basis

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 Treatment Principles and Procedures

of locating areas of dysfunction, termed subluxation, while hypotheses

have been submitted to account for purported findings.”54 Although
many early claims were empirically based and anecdotal, within the
last 40 years members of the chiropractic profession have increasingly
participated in the scientific method, utilizing proper research protocols
to attempt to substantiate these claims. Concurrently, knowledge gained
from biomedical literature and other health-related disciplines has
helped the process of dissemination of information to support several
theories now reflected in chiropractic texts.54 Chiropractic colleges and
universities are continually producing more and more graduates and
this supply has increased the demand for higher quality research. The
profession has met this challenge and continues to submit high quality
papers to reputable journals and has developed numerous research
centers in our colleges and universities.
As disease care has increased, improved diagnostics and increasingly
specialized forms of healthcare providers in the medical, osteopathic,
physical therapy, psychology and complementary health fields have
increased. There has been an increased incidence of patient dissatisfaction
due to patients falling through “cracks” in the healthcare system. To
counter this, the chiropractic profession has continually studied all the
professions to identify treatment that will aid the chiropractic adjustment
and therefore honor the patient by giving them the best treatments at our
disposal. There has been an increasing trend of combining specialties in
the healthcare paradigm, which was almost unheard of 20 years ago. The
increased demand of high quality care has caused a shift in the thought
process of individualistic care.
This chapter focuses on the specifics of the chiropractic theory and its
main forms of treatment; adjustments/manipulation, manual therapy,
soft tissue therapy, and physiotherapy. It will also teach you how to use
their combined effects to treat dysfunction and injury.
The following section is an account of treatment philosophies that are
accepted by some, but not all. As with any advancing healthcare discipline,
there are differing treatment and philosophical views within that discipline.
The intent of this section is to inform you of the variety of views within
the chiropractic profession and show that patient care and clinical outcome
supercedes any conflicting views.
Throughout history, manipulation has been a treatment technique to
improve back pain. It is commonly accepted that an English medical
doctor named Galen found evidence of spinal manipulation as treatment

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for pain while Egyptians were building the pyramids. Manuscripts have
been found signifying the use of joint manipulation within ancient
Eastern medicine as well. As we entered the 20th century, Gatterman, DC
references the founder of chiropractic, Daniel David Palmer, as concluding
after much study, that disease was due to interference with the nervous
system, primarily at the site where the spinal nerves exit the spinal foramen.11,
12
He attributed this interference to approximation of the vertebrae,
which he termed subluxation.12 Chiropractic maintains that the nervous
system plays a large role in governing the systems in the body and that
it is responsible for maintaining homeostasis within the body. Health is
seen by chiropractors as a continuously active homeostatic process that
maintains a disease-free state.11 The nervous system and the endocrine
system share an important role in maintaining equilibrium throughout
the body.11 Hans Selye spoke of homeostasis as “the body’s tendency
to maintain a steady state, despite external changes; coined physiologic
stability.”11, 13 Chiropractic philosophy is based on the concept of our own
body’s innate ability (innate intelligence) to heal itself. The philosophy
is based on the premise of the continual attempt of the body to restore
itself to normal or “ponos,” and the healing force of nature, which cures
from within or “vis medicatrix naturae.”11

Understanding Subluxation
D.D. Palmer founded a profession in 1895 on the premise of correcting
subluxations, which has grown and multiplied to allow thousands of
chiropractors to deliver quality healthcare to the public. The term
“subluxation” in medicine typically refers to an incomplete dislocation
or an operable spinal lesion that is considered unstable.14 This defi-
nition appears to be used primarily by orthopedics for mechanical
lesions. Chiropractic coins “subluxation” in more of a complex, such
as the VSC or Vertebral Subluxation Complex, whereby a “mechanism
of dis-relationship of vertebral segments and other articulations may
result in widespread functional derangement as well as disease of
various tissues.”11,15 There are 5 parts to this complex, namely spinal
kinesiopathology, neuropathophysiology, myopathology, histopathology,
and pathology (SEE FIGURE 7.A).

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 Treatment Principles and Procedures

Figure 7.a

Components of Vertebral Subluxation Complex

Kinesiopathology – Abnormal motion of the spine occurs, yielding

a sprain to the small joints of the spine. When the tissue heals, some-
times it heals incorrectly causing it to be hyper-mobile or
hypo-mobile.11, 14

Neuropathophysiology – When the joint and its surrounding

tissue heal poorly, the adjacent nerve complex can be aggravated
interfering with proper impulses from brain to body.11, 14

Myopathology – Once the nerves are aggravated, the spinal muscles

can become weakened or can spasm. At this point, adhesions can
develop. This functional abnormality will cause faulty muscle
movement patterns that can create a faulty biomechanical
movement cycle within the body.11, 14

Histopathology – When tissue undergoes prolonged injury, there

is inflammation. Adhesions and reorganization of muscular,
fascial, and ligamentous cells cause the motor unit stabilizers
(muscles and ligaments) to breakdown.11, 14

Pathology – When disease and dysfunction begin within and

around the spinal joints.11, 14

A growing segment of chiropractic prefers to use the term functional

spinal lesion to describe subluxation. This segment tends to place more
of an emphasis on biomechanical and neuromuscular correction, there-
by focusing their efforts on restoring spinal function through mani-
pulation, soft tissue therapy, and exercise rehabilitation. In the
chiropractic profession, there is the benefit of multiple view points and
research facilities which continue to identify ways to improve spinal
function and improve patient healing through persistent advancements.

The chiropractic adjustment can correct this complex, and its healing
effect is amplified with the addition of various other soft tissue and joint
treatments. Gatterman points out that many forms of manual therapy
can be employed and, at times, there are treatments more appropriate in
dealing with spinal disorders.11

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Manipulation vs. Mobilization

There are many within the healthcare community that use manipulation
and mobilization interchangeably; however, there is a definite distinction
in terms and applications. The synovial joint within the spine is where
the distinction occurs. To understand this point more clearly, look at
FIGURE 7.B. There is a normal range of motion within a diathrodial joint
where active muscular motion occurs without resistance.11 Just outside
this normal motion, there is a small range of passive motion that is not
controlled by voluntary muscles.11 At this point, motion can be given by
springing or tractioning the joint; characterizing mobilization. After this
passive range of motion, there is an “elastic barrier of resistance” that leads
into the paraphysiological space whereby the audible or cavitation occurs
and the space where manipulation is performed. Once this space is passed,
the anatomic limit of integrity is reached where tissue tearing can occur.11
Figure 7.b: Diathrodial Joint Ranges of Motion Comparison
M
Active R

O
Active R

M
Pas

RO
sive

ive
M
El

RO

er
s
as

Pas

rri
tic

Ba
Ba

tic
rri

Par
as

e
er

aph pac
El

ysio
log gic S
lo
ic S
pac hysio
ap
Anatom e Par grity
ical Inte ical Inte
grity Anatom

Manipulation is characterized by forcing the joint beyond the “elastic barrier

of resistance” producing a “cracking noise” or “cavitation.”11 The noise heard
when an adjustment or manipulation occurs and joint surfaces move apart,
resulting in a sudden diffusion of the dissolved gases from within the joint.16
Of note, manipulation does not have to have a cavitation to be successful.
The chiropractic adjustment (manipulation) utilizes short levers to which
a high-velocity thrust of controlled amplitude is directed, with the aim of
restoring mobility to individual articulations or joints.11 Mobilization takes

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 Treatment Principles and Procedures

place in the passive range of motion utilizing slow stretching motions to

help restore normal motion to the joint and is indicated within joints where
manipulation is contraindicated or would not be effective.

To summarize: Mobilization is a slower or low-velocity technique

in which the joint remains within its passive range of movement.
The treatment can be monitored and resisted by the patient,
who has final control. Manipulation is a faster or high-velocity,
light/low amplitude force technique that takes the joint beyond
the passive range, “elastic barrier of resistance,” into the para-
physiological space. The patient does not have control.

In 2003, the American Chiropractic Association released a compilation

of statistics in which manipulation techniques are used throughout the
chiropractic profession.2 (SEE FIGURE 7.C.) Descriptions of common tech-
niques are listed below. Chiropractic has many manipulation techniques
within its arsenal and those listed below are only a portion of the total;
however, they are most commonly used when the profession is reviewed.
These manipulation techniques are not inclusive of soft tissue care.

Figure 7.c

Percentage of techniques used by chiropractors

• Diversified 95.9%
• Extremity Manipulating/Adjusting 95.5%
• Activator Methods 62.8%
• Gonstead 58.5%
• Cox Flexion/Distraction 58.0%
• Thompson 55.9%
• Sacro Occipital Technique [SOT] 41.3%
• Applied Kinesiology 43.2%
• NIMMO/Receptor Tonus 40.0%
• Cranial 37.3%
• Manipulative/Adjustive Instruments 34.5%
• Palmer Upper Cervical (Hole in One [HIO]) 28.8%
• Logan Basic 28.7%
• Meric 19.9%
• Pierce-Stillwagon 17.1%
Adapted from: American Chiropractic Association, Claim Solutions Work Group
Working Together to Gain Knowledge, 2003 Claims Adjuster Index (CAI)2
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 CHAPTER 7

Diversified Technique – This is a widely used type of chiropractic

manipulation/adjustment that includes most of the procedures taught
at chiropractic schools. This technique is the most commonly used of all
chiropractic techniques and is the one probably most familiar to patients.
The diversified manipulation/adjustment entails a high-velocity, low-
amplitude thrust that usually results in a cavitation of a joint. As the
name implies, the Diversified Technique can be used to treat many of
the joints in the body.2

Diversified Prone Adjustment

Extremity Manipulation/Adjusting – This is the application of a

chiropractic manipulation/adjustment to joints other than those of the
spine; i.e. shoulder, elbow, wrist/hand/finger, hip, knee, ankle/foot/toe.
Examples of conditions treated by extremity manipulation/adjustment
include: carpal tunnel syndrome, joint adhesions, gait, or posture-related
problems. 2

Extremity Wrist Adjustment

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 Treatment Principles and Procedures

Activator Method – This is a manipulation/adjustment protocol that is

accomplished by using a hand-held, spring-loaded instrument. Instead
of the manipulating/adjusting forces being delivered by hand, force is
generated with the small device that delivers a faster and lighter thrust
than can be delivered by hand. Activator can be used as a primary
treatment protocol for all patients, or a selective method for patients
who may not desire manual manipulation/adjustment or where manual
manipulation/adjustment may be contraindicated. 2

Activator Adjustment

Gonstead Technique – This is a specific chiropractic technique and is

a variation of the Diversified Technique that utilizes manipulation/ad-
justment by hand that usually results in joint cavitation. X-ray analysis,
palpation, and temperature gradient studies may be used in clinical
decision-making.2

Cox Flexion/Distraction – This is a specific chiropractic technique that

uses mechanical and hands-on manipulation/adjustment and utilizes
a special table where the spine is tractioned and flexed forward. This
technique is primarily used to treat cervical and lumbar disc herniations,
non-disc spinal disorders, and to increase mobility of spinal joints.2

Thompson Technique – This is a specific chiropractic method and is

a variation of the Diversified Technique that uses a special table with
several segments called drop pieces. These segments can be raised up a
fraction of an inch, so when the thrust is delivered, the table will drop
accordingly. The drop pieces assist the thrust while minimizing the force

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used for the manipulation/adjustment. Cavitation of the joint may or

may not occur.2

Sacro-Occipital Technique (SOT) – This is a specific chiropractic

technique that uses triangular-shaped blocks, usually placed under the
pelvis of the prone patient to treat problems identified in the low back.
Low force, slow pressure types of manipulations/adjustments may be
used to address joint problems identified in the skull. SOT may be used
as an exclusive treatment technique or as an adjunct method of patient
management.2

Sacro-Occipital Technique

Applied Kinesiology – This is an approach to chiropractic treatment in

which several specific procedures may be combined. Diversified man-
ipulative/adjusting techniques may be used with nutritional inter-
ventions, together with light massage of various points (referred to as
neurolymphatic and neurovascular points). Clinical decision-making is
often based on testing and evaluating muscle strength.2

NIMMO/Receptor Tonus – This is a specific chiropractic technique

based on the presumption that muscles are responsible for causing
abnormal joint function. NIMMO addresses muscular problems, usually
called trigger points, by applying pressure on the point(s) for variable

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 Treatment Principles and Procedures

Nimmo Technique

amounts of time (usually a few seconds) thus allowing the muscle to relax
and acquire its normal length. This procedure allows the bone(s) to which
the muscle(s) attach to move normally to restore proper joint function.2

Cranial Technique – This is not one specific chiropractic technique,

but possibly several techniques using the application of chiropractic
manipulation/adjustment to joints of the skull (similar to the SOT
technique previously mentioned). Since individual anatomy of skull
joints is different, the styles of manipulation/adjustment are different
and no cavitations occur.2

Manipulative/Adjustive Instruments – These are techniques that in-

clude the use of instruments, other than an Activator, to deliver a man-
ipulation/adjustment to the patient. Many of these procedures are used
specifically in the upper cervical region, but not all. Precision of the direct-
ion of the thrust is claimed to be the advantage of these techniques.2

Palmer Upper Cervical (H.I.O.) – This is a specific chiropractic technique

used only to manipulate/adjust joint dysfunctions in the upper cervical
spine. The theory is that treatment of this area may also address prob-
lems throughout the entire body of the patient. Usually no cavitations
occur. X-ray analysis is commonly used for making clinical decisions. 2

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Logan Basic Technique – This is a specific chiropractic technique in

which light pressure is applied to the ligamentous structures associated
with the sacrum and pelvis. Light force is concurrently applied to various
spinal levels to reduce pain/symptoms and restore muscle balance.2

Logan Basic Technique

Meric System – This is not a specific chiropractic technique, but

refers more to clinical decision-making regarding what spinal levels to
manipulate/adjust. Spinal segments are manipulated/adjusted (usually
with a diversified technique) corresponding to the nerves that supply the
area of patient symptoms.2

Pierce-Stillwagon Technique – This is a specific chiropractic technique

that uses side-posture manipulation/adjustment in the low back and
prone manipulation/adjustment in the cervical spine. X-ray analysis is
commonly used for making clinical decisions on which spinal level(s) to
manipulate/adjust.2

Pettibon Systems Adjusting – The Pettibon procedures are an advanced

and complete scientific approach to chiropractic that restore harmony,
function and biological organization to the body. The Pettibon Chiro-
practic Adjusting procedures utilize the inherent lever arms of the body
to create a mechanical advantage to stimulate the body’s righting re-
flex to cause reduction and stabilization of the Vertebral Subluxation
Complex. These procedures are accomplished manually as well as with
Pettibon Adjusting instruments. Each patient is instructed in specific in-

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 Treatment Principles and Procedures

office and at-home exercises based upon his/her structural, functional

and neurological needs.3

Chiropractic BioPhysics (C.B.P.) – Clinical Biomechanics of Posture®

a.k.a. Chiropractic Biophysics (CBP®) technique can best be characterized
as full spine and pelvis corrective/rehabilitative procedures that have a
firm foundation in the sciences of biomechanics and physics. CBP®
technique integrates Drop Table, Diversified, Toggle, and Instrument-
assisted postural MIRROR IMAGE® adjusting, postural MIRROR
IMAGE® exercises and postural MIRROR IMAGE® traction to correct
subluxations by restoring normal spinal mechanics.4
Toggle Recoil Technique – This manipulation is performed with a sud-
den shallow thrust (toggle), followed by quick withdrawal (recoil) of the
chiropractor’s hands while the patient is relaxed.

Blair Upper Cervical Technique – The Blair technique takes into ac-
count the natural asymmetries in the body and tailors the adjustment
to the specific shape of the area being treated, with a clinical objective
of achieving maximum patency of the cervical neural canal. Dermo-
thermographic and functional leg-length analysis are used as diagnostic
measures. The Blair adjustment combines a toggle thrust with a 180-
degree torque, but no recoil. The patient is side-postured on a table with
a drop headpiece.6

Direct Non-force Technique (D.N.F.T.) – This is a method of making

a chiropractic analysis by skin reflexes and a thumb contact adjustment
thrust a little deeper than skin deep. The “D” in D.N.F.T. stands for
Directional because of thrusting in a specific direction as determined by
analysis. The term, “Non-force” is used because it is non-force compared
to some chiropractic techniques. It does not cause the usual cavitations
of many chiropractic adjustments. There is also a certain amount of visu-
alization in D.N.F.T.5

Bio Energetic Synchronization Technique (B.E.S.T.) – B.E.S.T. is a

physical, yet non-forceful, energy-balancing procedure used by the
hands to reestablish the full healing potential of the body using its nat-
ural healing abilities. B.E.S.T. removes interference and/or distractions
that are demanding the attention of the healing power, thereby causing
the imbalance in the autonomic nervous system and ultimately leading
to disease.7

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 CHAPTER 7

Side-Lying Toggle Adjustment

Atlas Orthogonal Technique (A.O.T.) – Atlas Orthogonal Chiropractic

Technique is a branch of upper cervical specific chiropractic, a branch of
the healing arts which focuses on the spine’s influence on overall health.
It utilizes very minute, but supremely focused forces to correct spinal
and neck imbalances.

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 Treatment Principles and Procedures

Therapeutic Massage
Many chiropractors are licensed massage therapists or have certifications
in various forms of therapeutic massage. An increasing number of
chiropractic offices utilize contracted licensed massage therapists to aid
in the healing and completion of full recovery of the patient.

Fritz defines therapeutic massage as “a scientific art and system of

assessment, and systemic, manual application of a technique to the
superficial soft tissue of the skin, muscles, tendons, ligaments, and fascia, as
well as to the structures that lie within the superficial tissue, by means of the
hand, foot, knee, arm, elbow, and forearm. The manual technique involves
systematic application of touch, stroking (effleurage), friction, vibration,
percussion, kneading (petrissage), stretching, compression, or passive and
active joint movements within the normal physiologic range of motion. She
continues to state that, “adjunctive external applications of water, heat,
and cold are used for the purposes of establishing and maintaining good
physical condition and health by normalizing and improving muscle tone,
promoting relaxation, stimulating circulation, and producing therapeutic
effects on the respiratory and nervous systems and the subtle interactions
among all body systems.”17

The practice of massage therapy coincides well with the chiropractor’s

goal of correcting the cause of the injury or disease. Its approach should
be evaluated for what is best for the patient and should not be performed
unless the practitioner or therapist has been properly trained. Indications
and contraindications can be found in FIGURE 7.D.

Treatment Tip: Trigger points often refer pain to other areas of the
body. Becoming familiar with trigger point patterns help the therapist
pinpoint locations where the treatment will be most beneficial.

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 CHAPTER 7

Trigger Point Therapy Technique

Deep Tissue Massage

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 Treatment Principles and Procedures

Figure 7.d

Indications and Contraindications

to Therapeutic Massage17

Indications Contraindications
Back pain Acutely inflamed joints/soft tissue
Muscle spasm Suspicion of local malignancy
Orthopedic condition Phlebitis
Rheumatic conditions Lymphagitis
Nerve injuries Acute burns
Neurologic disorders Acute Dermatitis
Nervous tension/stress Osteomyelitis
Headaches Tuberculous lesions of bones
Trigger points Intra-abdominal organic disease
Radiculitis Infectious disease
Joint stiffness Advanced arteriosclerosis
Reduce post-traumatic edema Suspicion of Hematoma
Vertigo
Persistent swelling, pain, or
stiffness after a massage

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 CHAPTER 7

Ashiatsu Oriental
Bar Therapy

Hot Stone Massage

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 Treatment Principles and Procedures

Figure 7.e

Multiple Forms of Manual/Bodywork Therapy

(Not all-inclusive) 17

Integrated Approaches
Sports massage Infant massage Equine massage
Seated massage Prenatal massage Geriatric massage
Russian massage Hot Stone massage

Applied Kinesiology
Touch For Health Applied Physiology Educational Kinesiology
Three-in-one Concepts

Myofascial Approaches
Craniosacral therapy Myofascial therapy Soft tissue mobilization
Deep tissue mobilization Connective tissue massage Swedish massage
Passive Release Technique Active Release Technique

Energetic Approaches
Polarity Therapeutic touch Reiki
Zero-Balancing

Manual Lymphatic Drainage

Vodder lymphatic drainage

Neuromuscular Approaches
Neuromuscular technique Muscle energy technique Strain/counter strain
Orthobionomy Trager Myotherapy
PNF Reflexology Trigger Point Therapy

Structural Integration Approaches

Bindegewebs massage Rolfing Heller work
Looyen Pfrimmer Soma
Bowen therapy

Asian Approaches
Amma Acupressure Shiatsu
Ashiatsu Oriental Bar Therapy Jin shin do Hoshino
Tui-na Watsu Tibetan point holding
Thai Massage

Adapted and Modified from Fritz, 2nd edition, Mosby’s Fundamentals of Therapeutic Massage, 153
Box 2-1, pg 35
 CHAPTER 7

Myofascial Stretching
Chiropractic care utilizes many forms of myofascial stretch techniques
as an addition to the healing practice. According to Anderson, stretching
“relaxes your mind and tunes up your body.” Stretching tends to have
cumulative effects of reducing muscle tension, improving coordination,
increasing range of motion, prevents injury, prepares the musculoskeletal
system for activity, develops body awareness, and feels good. 10

The Stretch Reflex

The muscular system has a checks and balance system called the
“Stretch Reflex,” meaning when the muscle fibers are overstretched, a
neurological reflex occurs sending a signal to the muscle to contract
and protect against injury. This concept leads to the idea that stretching
too far will tighten the same muscles that are trying to be lengthened.
When stretching, eliminate bouncing maneuvers to avoid the stretch
reflex. When this rule is not adhered, micro-tears can occur leading to
adhesion formation, which could lead to a loss in elasticity.10 Some of
these stretches apply the rule of reciprocal inhibition, which essentially
states “when a muscle (agonist) is contracted, its opposing muscle group
(antagonist) is inhibited to allow motion of the limb to proceed. In
certain stretches, this law is used to lengthen a muscle, thereby improving
its flexibility. Below are numerous forms of stretches that can be applied
to a patient under the doctor’s orders.

• Ballistic stretching – This form of stretching uses the momentum of

a moving body or a limb in an attempt to force it beyond its normal
range of motion. This is stretching, or “warming up,” by bouncing
into (or out of) a stretched position, using the stretched muscles as
a spring which pulls you out of the stretched position (e.g. bouncing
down repeatedly to touch your toes). It does not allow your muscles
to adjust to, or relax in the stretched position. It may instead cause
them to tighten up by repeatedly activating the stretch reflex.9 This
stretch is not typically used in the chiropractic setting. This form of
stretch is rarely used in the clinical setting.

• Dynamic stretching – This type of stretch, according to Kurz,

“involves moving parts of your body and gradually increasing reach,
speed of movement, or both.” Do not confuse dynamic stretching
with ballistic stretching. Dynamic stretching consists of controlled
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 Treatment Principles and Procedures

leg and arm swings that take you (gently) to the limits of your range
of motion. Ballistic stretches involve trying to force a part of the
body beyond its range of motion. In dynamic stretches, there are
no bounces or “jerky” motions. An example of dynamic stretching
would be slow, controlled leg swings, arm swings, or torso twists.9, 9b
Dynamic stretching can be used to warm-up for an active or aerobic
workout.9

• Active stretching – Also referred to as static-active stretching, an

active stretch is one where you assume a position and then hold it
there with no assistance other than using the strength of your agonist
muscles. For example, bringing your leg up high and then holding
it there without anything (other than your leg muscles, themselves)
to keep the leg in that extended position. The tension of the agonists
in an active stretch helps to relax the muscles being stretched (the
antagonists) by reciprocal inhibition.9 Active stretching increases
active flexibility and strengthens the agonistic muscles. Many of the
movements (or stretches) found in various forms of yoga are active
stretches.9

• Passive (or relaxed) stretching – Also referred to as relaxed stretch-

ing, and as static-passive stretching, a passive stretch is one where
you assume a position
and hold it with some
other part of your
body, or with the as-
sistance of a partner or
some other apparatus.
For example, bringing
your leg up high and
then holding it there
with your hand. The
splits are an example
of a passive stretch (in
this case the floor is the
“apparatus” that you
use to maintain your
extended position).9

Passive Hamstring Stretch

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 CHAPTER 7

• Isometric stretching – Isometric stretching is a type of static

stretching (meaning it does not use motion) which involves
the resistance of muscle groups through isometric contractions
(tensing) of the stretched muscles. The use of isometric stretching is
one of the fastest ways to develop increased static-passive flexibility
and is much more effective than either passive stretching or active
stretching alone. Isometric stretches also help to develop strength in
the tensed muscles (which helps to develop static-active flexibility),
and seems to decrease the amount of pain usually associated with
stretching. The most common ways to provide the needed resistance
for an isometric stretch are to apply resistance manually to one’s own
limbs, to have a partner apply the resistance, or to use an apparatus
such as a wall (or the floor) to provide resistance. An example of
manual resistance would be holding onto the ball of your foot to
keep it from flexing while you are using the muscles of your calf to
try and straighten your instep so that the toes are pointed.9
The proper way to perform an isometric stretch is as follows:

1. Assume the position of a passive stretch for the desired muscle.9

2. Next, tense the stretched muscle for 7-15 seconds (resisting against
some force that will not move, like the floor or a partner).9

3. Finally, relax the muscle for at least 20 seconds.9

Treatment Tip:
Remind the patient to BREATHE during stretching. If the patient
holds his/her breath, he or she is less likely to relax into the stretch
and receive the full benefit of the treatment.

• PNF stretching – PNF is an acronym for proprioceptive neuromuscu-

lar facilitation. It is a technique of combining passive stretching and
isometric stretching in order to achieve maximum static flexibility.
PNF was initially developed as a method of rehabilitating stroke
victims. PNF refers to any of several post-isometric relaxation
stretching techniques in which a muscle group is passively stretched,
then contracts isometrically against resistance while in the stretched
position, and then is passively stretched again through the resulting

156
 Treatment Principles and Procedures

increased range of motion. PNF stretching usually employs the use

of a partner to provide resistance against the isometric contraction
and then later to passively take the joint through its increased
range of motion. It may be performed, however, without a partner,
although it is usually more effective with a partner’s assistance.9 Most
PNF stretching techniques employ isometric agonist contraction/
relaxation where the stretched muscles are contracted isometrically
and then relaxed. The most common PNF stretching techniques are:
Contract-Relax, Contract-Relax-Contract, Hold-Relax-Swing.9

PNF Stretch of Levator Scapulae

The proper way to perform a PNF stretch:9

1. Assume the position of a stretch for the desired muscle.
2. Tense the stretched muscle for 7-15 seconds (resisting against
some force that will not move, like the floor or a partner).
3. Relax the muscle for 2-3 seconds.
4. Stretch the muscle to the next taut point and hold for
7-15 seconds.
5. Perform this sequence 3 times. Relax approximately 20 seconds
between sequences.

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 CHAPTER 7

PNF stretching techniques take advantage of the sudden “vulnerability”

of the muscle and its increased range of motion by using the period of
time immediately following the isometric contraction to train the stretch
receptors to get used to this new, increased range of muscle length.9
Chiropractic principles focus on the overall function of the locomotor
system. This understanding has created a spotlight to rehabilitate the
muscles that attach directly to the spine and pelvis or have effect on the
function of the appendicular skeleton. By expanding this focus to include
stretching techniques of the lower extremity and upper extremities, chiro-
practic physicians stabilize and strengthen the core muscles of the spine
more effectively, thereby improving their performance. In the following
pages there are many examples of stretching “setups” that show many
of the muscles that attach to the spine or effect its function. Multiple
types of stretching techniques can be applied to these setups to improve
flexibility with varied results. Consult your supervising physician on
his/her preferred method to apply in the clinical setting and for which
conditions the various stretches are most helpful.

Caution:
When performed poorly or with the wrong condition,
stretches can be very harmful to a patient. These setups are for
demonstration only and are not intended to teach how to perform
the stretch, merely to demonstrate typical techniques used
within the chiropractic setting. Please refer to a text designed for
stretching instruction as well as your supervising physician.

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 Treatment Principles and Procedures

Stretching

Anterior Scalene stretch

Suboccipital Muscle stretch

Levator Scapulae stretch

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 CHAPTER 7

Stretching

Upper Trapezius stretch

Rhomboid and Posterior Shoulder Capsule stretch

(Example 1 – Lying)

Rhomboid and Posterior Shoulder Capsule stretch

(Example 2 – Sitting)

160
Pectoralis Major stretch
 Treatment Principles and Procedures

Stretching

Pectoralis Minor stretch

(Note: Rolled up towel has been placed lengthwise
down the spine to improve the stretch)

Lumbar Spine Erector stretch

(Example 1 – Forearm on knees)

Lumbar Spine Erector stretch

(Example 2 – Isolating sacrum with forearm support)

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 CHAPTER 7

Stretching

Hamstring stretch

Gastrocnemius stretch

Illiotibial Band (ITB) and

Tensor Fascia Latae (TFL) stretch
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 Treatment Principles and Procedures

Stretching

Two-joint Adductor Muscle stretch

One-joint Adductor muscle stretch

Piriformis stretch
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 CHAPTER 7

Stretching

Illiopsoas Muscle stretch

(Example 1 – Supine)

Illiopsoas Muscle stretch

(Example 2 – Prone)

Illiopsoas Muscle stretch

(Example 3 – Side-Lying)
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 Treatment Principles and Procedures

Stretching

Quadriceps Muscle stretch

(Example 1 – Supine)

Quadriceps Muscle stretch

(Example 2 – Prone)

Quadriceps Muscle stretch

(Example 3 – Side-Lying) 165
 CHAPTER 7

Principles and Procedures of

Physiotherapeutic Modalities
Introduction

The most common reason a patient will seek the care of a chiropractic
physician, or any other physician, is pain. Pain is a physiological and
emotional experience that interferes with normal functioning. One of
the most beneficial services a chiropractor or chiropractic assistant can
provide is to help alleviate or reduce the amount of pain that a patient is
experiencing.

The second most common reason a patient will enter your office is for
the correction of a dysfunction. Simply put, dysfunction means that
the patient’s body is not performing in a normal, healthy manner. This
becomes a problem when the patient is unable to carry out his/her normal
activities of daily living. Correction of musculoskeletal dysfunction is one
of the areas of healthcare in which the chiropractic profession excels.

Although the primary treatment unique to the chiropractic profession is

the spinal adjustment, many chiropractic offices also utilize a variety of
physical therapeutic modalities. The use of these modalities is to enhance
the effects of, and compliment the use of the chiropractic adjustment.

Modalities are used in the chiropractic office as an adjunct to the hands-

on adjustment or other treatment administered by the doctor. In most
cases, the modality will be applied by the doctor or by an assistant under
the direction and supervision of the doctor. Generally, the assistant is not
authorized to administer therapy without the direction of the doctor.
Refer to individual state laws for direction.

The therapy modality should be selected on the basis of desired effect,

safety, and practicality of application. The beneficial effects of many types
of modalities overlap. For example, a patient may benefit from application
of ultrasound, interferential, high-volt, moist heat, or cold packs. In some
cases a combination of therapies will be most beneficial. The choice of
modalities to be used is the discretion of the doctor. Different doctors may
treat the same condition differently. This situation is where the doctor’s
training and specific experience with a condition leads to multiple ways to
treat a particular condition.

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 Treatment Principles and Procedures

A primary importance in the application of all therapies, is patient safety.

Although the contraindications for most forms of physical therapy
modalities are few, they are important. Also important, is learning how to
apply the modalities safely.

This manual is designed to present generally agreed-upon practices

relating to the use of the modalities commonly used in chiropractic
offices. It is expected that there may be situations in which your individual
doctor may have reason to direct you to use or apply selected modalities
in a manner different from that presented here. If there are questions or
conflicts between the material presented in this overview and the policies
of your office, the treating doctor of chiropractic should be consulted.

A wide array of references were consulted in preparation for this manual.

Although there are generally agreed-upon principles and practices concern-
ing the selection and application of therapeutic physical modalities, there
are also areas of varying opinions. Many uses of these modalities have been
common for many years, and are generally thought to be safe and effective,
but have not been subjected to rigorous scientific study. The selection and
application of any therapy, including those reviewed here, is always best de-
termined by sound clinical judgment by a qualified, licensed clinician.

It is paramount to place emphasis at the cellular level and its response to

injury when first understanding the process and application of modalities.
The body’s innate ability to heal is often facilitated by creating an environment
to heal. For example, when a smoker develops bronchitis, it is important to
remove the aggravating substance so the surrounding environment or lung
tissue in this case has a chance to heal optimally. With regard to mechanical,
electrical, or thermal modalities, practitioners strive to facilitate the body’s
natural physiologic healing response to provide the body with the best
environment possible to repair itself.18, 20, 53

Starkey defines an application as being “therapeutic” when an external

stress is applied to the body and is conducive to the healing process of the
injury in its current state of healing.18 The key to modality application
is timing and when applied at the wrong time, recovery may be stalled
or slowed.18

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 CHAPTER 7

Physiologic stress can be identified when a particular chemical,

mechanical, or emotional force is placed on the body or at the cellular
level. There are negative and positive results of physiologic stress and the
body responds accordingly. Starkey states that when stress is placed on a
cell, it reacts in one of three ways: 1) it adapts to stress, 2) it is altered but
recovers, 3) it dies.18

A researcher in 1900, Hans Selye, coined the principle, General Adapt-

ation Syndrome (G.A.S.), which essentially states that the body has a
particular mechanism for handling stress.13 He outlined three stages of
stress response:

1) Alarm stage – This stage is the body’s fight-or-flight response to

an initial change in the body’s natural equilibrium. This is where
the body mobilizes its defense forces to combat the aggressor or the
stressor. For example, when the body’s limbs are chilled, the body
will redirect blood to the affected areas.13,18

2) Resistance stage – This is thought to be the lengthiest stage when

the body’s reactive process slows and the natural adaptive process
continues to create equilibrium within the somatic tissue.13,18

3) Exhaustion stage -This is the stage in which the stressors overcome

the physiologic response of the body and the body begins to falter,
and injury such as overuse or trauma occurs.13,18

With regards to acute or chronic musculoskeletal injury, the G.A.S.

principle is imperative to understand the body’s soft tissues response
to being overloaded from a single trauma or event as well as repetitive
forces placed on a tissue. When these processes occur, the healing process
begins.

The Healing Process

Once the injury occurs, the healing process of the tissue begins. There
are three phases in injury repair, and while each phase has a distinct role
in healing, the phases themselves overlap each other. Therefore they have
no exact beginning or end. These three stages correspond with the three
R’s during treatment (Reduce, Restore, and Rebuild/remodel).

168
 Treatment Principles and Procedures

Phase 1: The Inflammatory Response Phase begins as soon as an in-

jury occurs, and as a rule lasts for 2-4 days. The common signs of this
stage include inflammation characterized by swelling, redness, point
tenderness, and increased temperature. The body’s aim here is to iso-
late the damage and to protect the area from additional harm.18, 20

Phase 2: The Repair Phase ensues a few hours after an injury, and can
last from two to four weeks. During this phase, the body removes the
waste created by the inflammation process and begins to form scar
tissue at the injury location. This early gelatinous scar tissue is fairly
weak and is layered randomly throughout the injured tissue.18, 20

Phase 3: The Remodeling Phase can last for years, depending on the
injury. During this phase, the body reorganizes the adhesive tissue
into a design or pattern that favors the original tissue and therefore
improves the strength of the scar tissue. The new and improved scar
tissue is rarely as strong and pliable as the tissue prior to injury.18, 20

Many of our healing physiologic processes are impeded by: length

of injury or trauma; excess edema or swelling; faulty blood supply;
infection; muscle atrophy or weakness; overall deconditioned health;
nutrition; and age.

Goals of Modality Use During the Healing Process

During each phase of the healing process, therapeutic modalities are bene-
ficial in helping to encourage proper and efficient healing. When applying
a modality, it is important to know what the goal of the treatment is and
make sure it corresponds with the current phase of healing.

In the Inflammatory Response Phase, the goal of utilizing physiothera-

peutic modalities is to reduce swelling and help control pain. A stan-
dard principle in the healthcare community is the R.I.C.E. principle
which should be applied to the injured site once it occurs. The acronym
of R.I.C.E. stands for rest, ice, compress, and elevate. Modalities used
during this phase include acute frequency settings in or with electrical
stimulation, low-power laser, ultrasound, and range of motion exercises.
These modalities combined with thermal therapies such as ice or heat
are quite effective.

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 CHAPTER 7

Figure 7.f

The R.I.C.E. Principle

Rest helps to protect the area from further injury and allows
the body to focus on healing.

Ice (Cryotherapy) helps to reduce swelling and provides an

analgesic effect on the injured tissue. (Using heat during this
phase can actually delay the healing process by increasing swelling
in the area.)

Compression and Elevation help to decrease swelling.

Electrical Stimulation and Low-Power Lasers help to decrease

pain.

Ultrasound helps to stimulate cells and encourages healing.

Range of Motion Exercises help with lymphatic draining and can

help reduce swelling and stiffness.

During the Repair Phase, much of the swelling and inflammation has
subsided and the goal is to help the body clean up the injury site and
begin to form scar tissue. Common modalities during this phase include
heat or ice, compression, various frequencies of electrical stimulation,
low-powered laser, and exercises (SEE FIGURE 7.F).53

170
 Treatment Principles and Procedures

Figure 7.g

Repair Phase Modalities

Heat (Thermotherapy) is applied in this phase after most of the
swelling has subsided. Hydrocollator packs, paraffin, and warm
whirlpool help to increase circulation and decrease pain.
Ice (Cryotherapy) may still be common in this phase if
swelling is persistent or if thermotherapy creates a reoccurrence
of inflammation.
Compression can still be used at this stage to help remove toxins
and fluid from the area.
Electrical stimulation can be used for pain control, increasing
circulation, reducing spasms, and in certain settings create
muscle-pumping actions to aid in waste removal.
Low-powered lasers can help decrease trigger points and speed up
the healing process.
Range of Motion and Strengthening exercises should be progressing
in this phase to prevent atrophy and restore mobility.

During the Remodeling Phase, the importance is to return to normal activ-

ity. Goals include helping to properly align scar tissue and increasing the
load capabilities and flexibility of the new tissue, as well as increasing the
strength and symmetry of the surrounding musculature. Some common
modalities include ultrasound, shortwave and microwave diathermy,
electrical stimulation, and progressive exercise rehabilitation.20
Figure 7.h
Remodeling Phase Modalities
Ultrasound and Diathermy help promote healing by increasing
the flow of healthy blood and assisting in waste removal. This
treatment is used less frequently in this stage.
Electrical Stimulation can help with pain but is also used for
increasing muscle strength and range of motion.
Exercise is vital in this stage to return full range of motion,
increase flexibility, and most importantly to help align and
strengthen the scar tissue and surrounding tissue by progressing
the load capabilities of the injured area.
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 CHAPTER 7

Pain Control with Modalities

Pain sensations warn us that a tissue is being injured or has already been
injured. Pain helps us modulate activity and is reduced when modalities
are applied. Pain is activated by various nerve fibers such as nociceptors,
that when stimulated cause impulses to be sent to the brain where pain is
perceived.18

Acute pain control using modalities attempts to restore the body’s homeo-
stasis by providing an optimal environment to heal. Once the inflamma-
tory cascade subsides, and the mechanical and chemical stimulation of the
nociceptors subsides, pain is usually eliminated. Modalities are also used to
trick or mask pain impulses to disrupt the pain process. Chronic pain is
much more complicated and less understood. The effectiveness of mod-
alities is more limited in chronic pain. However, there are applications to
help increase range of motion, flexibility, blood flow, and increased
strengthening of de-conditioned tissues.18

Pain Scales

Pain scales are often used to assess the need for various modalities. Pain
scales are used to describe a patient’s level of pain. Since pain is subjective,
the experience of pain is different and pain scales can provide a means for
the patient to better describe the pain and label its severity.18 Pain scales also
create a baseline that allow patients and clinicians to see the progress that
is being made. There are various kinds of pain scales commonly used that
may include:
Visual Analog Scale (VAS) make use of a line that is labeled “No Pain” on
one end and “Severe Pain” on the other. Patients mark where they think
their pain falls on that line.
Example: (No Pain) 1-------10 (Severe Pain)

Pain charts allow patients to mark where their pain is on a draw-

ing of the body. Many use different symbols or colors to describe
types of pain (e.g. burning, tingling, and aching).

Numeric pain scales tell patients to rate their pain on a scale

from 1 to 10, with 10 being the worst pain they could imagine.
This is basically the same principle as using the VAS, but it does
not require a graphical response.

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 Treatment Principles and Procedures

Scientific Principles of Therapeutic Modalities

A large portion of the modalities used in the rehabilitation setting fall
into two categories: electromagnetic and acoustic. While these two
classes use different forms of energy to create physiological effects on
body tissue, both depend on frequency and wavelength to achieve their
desired effect.20, 21

Frequency is the number of cycles or wave oscillations that occur

in 1 second. The unit used to express frequency is Hertz (HZ). One
Hertz is the same as one cycle per second.

Wavelength is the distance from one point on a wave to the same

point in the following wave.
Figure 7.i

Shorter Wavelength

Frequency
(faster)

Longer Wavelength

Frequency
(slower)

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 CHAPTER 7

Frequency and Wavelength have an inverse relationship

(SEE FIGURE 7.I).
– A higher frequency means a shorter wavelength.
– A lower frequency means a longer wavelength.

The frequency and wavelength are determined by radiant energy

in electromagnetic modalities and by sound waves in acoustic
modalities.

Electrical Stimulation
Electricity Basics

Many of the modalities used in the chiropractic setting require the use
of an electrical current passing through the affected tissue to create a
desired therapeutic effect on the body. The equipment must modify
the current it receives from the outlet and transform it. To understand
how the electrical modalities are used on the body, it is important to
understand some basics of electricity.

An electrical current is the movement of electrons, or negatively

charged particles, from a higher potential to a lower potential. The force
produced by this movement is called voltage (V) and the rate at which
the current moves is called an ampere (A). A watt is the unit used to
measure electrical power. This power is determined by multiplying
voltage (force) by amperes (current amount).53 There are three types of
currents used in electrotherapeutic modalities that can produce an effect
on tissues.

Direct Current has an uninterrupted flow of electrons from the

negative to the positive pole. Direct currents flow in one direction
only. An example of direct current is the electricity from a common
flashlight battery.53

Alternating Current has an uninterrupted flow of electricity that

alternates the direction that it moves. The current changes directions
when the poles are reversed. An example of alternating current is the
electricity from a household wall outlet.53

174
 Treatment Principles and Procedures

Pulsed Current occurs when the applied current is interrupted in-

tentionally to achieve a specific therapeutic effect. These pulses can
be direct or alternating currents. The pulsation can range from very
slow to very rapid and this variation is expressed as the pulse rate. 53

Electrical currents can create three types of physiological responses

when applied to tissue. These responses are thermal, physiologic, and/or
chemical. All tissue rises in temperature when an electrical current passes
through it.18 The higher the resistance of the tissue, the greater the heat
response.18 Electrical currents can also produce a muscle contraction
and alter pain impulses at the nerve level. It is also possible that some
forms of direct current will affect the tissue chemically.

Alterations in Current Related to Treatment Regimens

When using electrical stimulation, it is important to know the various

fact-ors that can influence an electrical current and how these factors
can affect the body. By understanding these factors, the parameters of the
treatment can be altered to create the desired physiological effect. Below
are seven basic points to note when thinking about treatment regimens.

1) One of the first parameters to be determined is whether to use a mono-

phasic (direct) or biphasic (alternating) current. Biphasic currents
are much more efficient at creating muscle contractions. Monophasic
currents are considered to be more effective at reducing edema.20,30

2) For an electrical current to create a physiological effect on muscle or

nerve tissues, it must cause depolarization. Depolarization occurs
when a chemical, thermal, or mechanical stimulus is strong enough
to cause a nerve cell or muscle cell membrane to react or initiate a
dicharge of stimuli. This reaction could be an impulse along the nerve
or a contraction of muscle fibers. When using electrical stimulation,
the current must be strong enough to cause depolarization of the
desired tissue.20, 21

3) Impedance refers to how much a body tissue resists the passage

of an electrical current. Electrical currents like to travel through
the path of least resistance. In the body, the best conductors are
the tissues with the highest water content. Bone, fat, tendons, and

175
 CHAPTER 7

skin are considered poor conductors, while muscle and blood are
much more efficient. Nerves are good electrical conductors but
are surrounded by fat and fibrous sheaths, which impede flow.
Tissues with high impedance mean more current must be used to
create depolarization.18
4) The frequency, or the number of pulses per second, of a current
will determine the amount and length of tissue contractions. A high-
er frequency is used to increase muscle tension since there is very
little rest time between pulses. In contrast, a lower frequency can be
used as a muscle pump and for edema reduction.53 (SEE FIGURE 7.I.)
5) The intensity, or strength, of a current determines the depth the
current reaches. The higher the intensity, the deeper the current
reaches into the tissue.18
6) The duration of a current is the length of time a wavelength lasts. By
increasing the duration of a stimulus, more tissue fibers will be re-
cruited and the effects of the current will be spread over a larger area.18
7) The polarity of a current can determine the effect of electrical
stimulation. The polarity can be positive or negative. With bi-
phasic (alternating) currents, the polarity constantly changes and
cannotbe altered. However, with monophasic (direct) currents,
the polarity can be determined and set according to the desired goal
of the treatment. There are several effects of polarity to remember
when choosing polarity. Chemical changes might occur, it may
change the pH of the tissue, tissue is stimulated, and there is an
increased ability to move ions into a damaged tissue. A concept
noted in modality use with regards to polarity is ease of excitation.
This concept describes how efficient polarity is at stimulating
a muscle contraction. In general, a negative current flow pro-
duces a more comfortable contraction and uses a lower intensity
than a positive current flow. The direction of current flow is
considered important in instances when trying to replicate the
normal flow of electrons in the body. The negative electrode is
placed distally to the injured site and the positive electrode should
be placed proximally.18, 20

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 Treatment Principles and Procedures

Clinical Application of Electrical Stimulation

Basic Guidelines for Set-Up

Electrical stimulation is primarily used in the chiropractic setting to create

a desired physiological effect on the body. While many modalities used
are plugged into an outlet, the fact that they require electricity to operate
does not identify them as electrical stimulation. The types considered
to be electrical stimulators are those that pass an electrical signal
through the body. There are many forms of electrical stimulation including
high-volt stimulation, low-volt galvanic, interferential stimulation,

Electrical Stimulation Pads

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 CHAPTER 7

Russian stimulation, microcurrent, and T.E.N.S. units.18 Some of the

known uses of electrical stimulation are pain control, edema control,
muscle re-education, fracture healing, tendon and ligament healing,
and wound healing.20 Before starting a treatment, it is important to
identify the goals of the treatment and make sure the type of electrical
stimulation and the treatment settings are appropriate. The following
are general guidelines for setting up each treatment of electrical
stimulation.18, 45, 46
1) Check the leads and wires to make sure there are no frayed
or damaged wires and that the outlet and wires are properly
connected.
2) Clean the area to ensure proper contact with the skin by using an
appropriate alcohol based solution.

3) Make sure all controls are in the off or zero position before applying
electrodes.

4) Electrodes must be properly inspected before application. If using

rubber electrodes, make sure to apply water, conductive gel or a wet
sponge to improve the electrical contact with the patient. If using self-
sticking gel electrodes, inspect them for damage or wear. There are
certain qualities that electrode pads have that can affect current flow.
• Electrical current depth increases as electrode spacing increases.
• Smaller electrodes have a greater current density then larger
electrodes.

5) Set the necessary parameters (frequency, mode, duration, etc.) before

starting the treatment as determined by the overseeing chiropractic
physician.

Caution:
Patients should never feel the sensation of hot pins and needles
or major discomfort during electrical stimulation. Many
patients have a “no pain, no gain” mentality and believe more
stimulation is better. If the treatment is too strong or painful,
the patient will not relax for the benefits of the treatment or
worse, they could receive a skin burn.

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 Treatment Principles and Procedures

High-volt vs. Low-volt Stimulation

Both high-volt and low-volt stimulators use a direct current that flows in
only one direction. In both of these units the desired polarity (positive
or negative) must be determined for each treatment. Each type of stim-
ulator has various treatments it is commonly used for. 18, 20
Pulsed high-volt stimulation is commonly used for muscle re-education,
nerve stimulation, edema reduction, and pain control.18, 31
Pulsed low-voltage stimulation can be used in applications similar to
pulsed high-volt stimulation.
Continuous low-voltage stimulation can be very effective in changing
the pH of the area under the electrode pads, increasing blood
flow, and for transportations. There is a risk with continuous low-
voltage stimulation of severe skin complications and even burns.
Continuous low-voltage stimulation is most commonly used for
iontophoresis.18, 22, 23

Interferential Stimulation
Interferential stimulation is a widely used form of electrical stimulation
that uses alternating currents. It involves the use of two different channels
of electrical stimulation that intersect with each other. When the two
currents meet, they create a third current that can penetrate tissues with
very little resistance. Interferential stimulation is used for pain control,
muscle contractions, and edema reduction.53, 46

Single Channel Direct Current

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 CHAPTER 7

When setting up interferential stimulation, the placement of the electrodes

is very important. For the treatment to work properly, the two channels
must criss-cross over the desired treatment area. The pads should be
set up in a square pattern to maximize the interference of the two
currents and produce the best results.18 This pattern is termed quad-
polar interferential.

2 Channels Interferential Quad-polar

Treatment Tip:
Altering the vector setting on most interferential stimulation
settings rotates the angle of interference and in turn creates a larger
treatment area.

Premodulated currents are similar to interferential currents but use

only one channel and are often used when four pads cannot be used
because of the size or shape of the treatment area. In premodulated
stimulation, the desired treatment area should be located between the
electrodes. This setup can also be referred to as bipolar. Premodulated
current means the interferential current is created within the generator,
whereas quad-polar interferential current is formed by criss-crossing
the pads.18, 20 (SEE FIGURE 7.J.)

Russian Stimulation, Microcurrent, and T.E.N.S. Units

There are several other forms of electrical stimulation used frequently in
the chiropractic rehabilitation setting. Each has unique properties that
can be useful in producing certain therapeutic effects in the body.

180
 Treatment Principles and Procedures

1 Channel Premodulated Bipolar

Figure 7.j

Interferential vs. Premodulated

Pad Placement
Quad-polar Pad Placement
Channel 1 Channel 2

Target Area

Channel 2
Channel 1
Premodulated Pad Placement

Channel 1

Target Area

Channel 1

181
 CHAPTER 7

Russian stimulation is an alternating current that is used to create a

strong muscle contraction. It can be very effective in muscle reedu-
cation, muscle strengthening, prevention of muscle atrophy, and
spasm reduction. Since Russian stimulation forces a muscle con-
traction, there may be some discomfort with treatment but the
intensity should not be intolerable.18,27,28

A) For spasm reduction, the contractions should be more frequent in

order to create muscle fatigue. For example, a setting of 10 seconds
ON, 10 seconds OFF will provide little time for the muscle to relax
and may help reduce spasm by creating muscle fatigue.

B) For muscle strengthening and reeducation, the contractions should

be farther apart. A setting of 10 seconds ON and 50 seconds OFF is
commonly used when strengthening is the desired goal.

Treatment Tip:
Russian stimulation can be very effective in reducing the amount
of atrophy in muscles that weaken very quickly after injury, such
as the Vastus Medialis Obliques (VMO) in the knee.

C) During Russian stimulation, typically one channel is used and the

electrodes should be placed near both the origin and insertion of
the targeted muscle group in order to get the most effective
contractions.20 There are setups labeled co-contraction and reciprocal;
however, the individual machine owner’s manual should be consulted
for these techniques.

182
 Treatment Principles and Procedures

Russian Stimulation relaxed

Russian Stimulation contracted

Russian Stimulation Russian Stimulation

Co-contraction relaxed Co-contraction contracted

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 CHAPTER 7

Russian Stimulation Reciprocal setup

Microcurrent Stimulation
Microcurrent stimulation or low intensity stimulation, is often used
when the goal is to promote healing. It is used for the stimulation of
bone formation in fractures, the acceleration of wound healing, and also
to increase the rate of the healing process in injured tissues. The patient
often feels no sensation with microcurrent stimulation. The electrode
pads should be placed so that the current runs through the injured tissue
site.18, 23

T.E.N.S. Unit

Transcutaneous Electrical Nerve Stimulation (T.E.N.S.) units are

small, battery-powered electrical stimulation devices that may be carried
or worn by the patient. Like office-based units, the T.E.N.S. units must
be operated in a specific manner to be safe and effective. Most T.E.N.S.
units have adjustments to vary the frequency, pulse duration, intensity,
or other signal characteristics.18 The prescribing doctor of chiropractic

184
 Treatment Principles and Procedures

should determine the proper settings, and the patient should be instructed
carefully in how to apply the therapy. Precautions need to be taken to
avoid skin irritation and prevent dependency on the unit. Instructions
should include proper unit settings, placement of electrodes, and care of
unit and electrodes. T.E.N.S. units are primarily used for pain relief only
by masking the pain and releasing the body’s natural pain mediators;
enkephalins and endorphins. The patient should be educated to realize
that the primary effect is to reduce pain and this should be differentiated
from the other more therapeutic forms of electrical stimulation.20

Indications and Contraindications for Electrical Stimulation

There are many indications for the use of electrical stimulation. For each
treatment, it is important to determine what the goal of the treatment
is and if those goals are consistent with the indications for using the
machine as well as the contraindications. FIGURE 7.K includes a list of
indications and contraindications.
Figure 7.k

Indications and Contraindications for

Electrical Stimulation 18,20
Indications for Electrical Stimulation
Acute or chronic pain
Increased circulation
Muscle strengthening
Re-education/prevention of atrophy
Tissue/fracture healing
Muscle spasms

Contraindication for Electrical Stimulation

Cancer
Carotid Sinus abnormalities
Pacemakers
Defibrillators
Near the heart
Trans cerebrally (through the head)
Areas of impaired sensations
(Diabetes, neuropathy)
Open wounds
Directly over metal implants

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 CHAPTER 7

Iontophoresis vs. Phonophoresis

Iontophoresis and phonophoresis are both used to drive specific medi-
cations into a desired tissue. However, while the treatments may sound
similar, the method behind their effectiveness is different. Iontophoresis
is the use of a direct electrical current to drive ions into the body.
Phonophoresis uses acoustic energy, or sound waves, to drive molecules
through the skin into the tissues.18

Iontophoresis
Ion Transfer Basics with Iontophoresis

An ion is a positively or negatively charged particle. Ions want to move

towards the opposite polarity. Therefore, positively charged ions will
move towards a negative electrode and negatively charged ions will move
towards a positive electrode.20, 18 Iontophoresis is beneficial because it
allows patients to receive topical medications with a certain charge and
drives them into the skin by using an electrical current. Once these
charged ions are introduced through one electrode they will travel
through the body to the opposite electrode. This allows medication to
be delivered to site-specific locations in the body. Some uses of these
charged medications include decreasing inflammation, reducing pain,
healing tendonitis, and encourages wound healing.18, 20

Iontophoresis Equipment and Treatment

The use of iontophoresis requires a specific, low-voltage, direct current

machine, electrodes capable of holding the medication, and an ionized
solution. The machine used should deliver a continuous direct current
that maintains a constant voltage output. The key in iontophoresis is
that the machine adjusts to the changes in tissue impedance which
reduces the risk of burns.18 Machines called iontophoresors are most
commonly used because they adjust their amperage according to the
amount of impedance to ensure a constant output. The single most
common problem associated with iontophoresis is the possibility of a
chemical burn that usually occurs as a result of the direct current itself,
and not because of the ion being used in treatment.20, 53

186
 Treatment Principles and Procedures

• Recommended current amplitudes used for iontophoresis range

between 3 and 5 µamp.
• Recommended treatment durations range between 10 and 20
minutes, with 15 minutes being average.
• During this 15 minute treatment, the patient should be comfortable
with no reported or visible signs of pain or burning.
• The therapist should check the patient’s skin every 3-5 minutes
during treatment for signs of skin irritation.
• Since skin impedance usually decreases during the treatment, it may
be necessary to decrease current intensity to avoid pain or burning.
The electrode pads most commonly used in iontophoresis have a special
area that holds the medication. The electrode that houses the medication
is considered to be the active electrode and should be placed over the
desired tissue.18 The second electrode is called the dispersive electrode
and should contain some form of a conductive agent such as water or
gel.18 The lead placed on each electrode is determined by the polarity of
the medication.

A) If a solution has a positive ion charge then the positive electrode

lead attaches to the active electrode.
B) If a solution has a negative ion charge then the negative electrode
lead attaches to the active electrode.

There are many different ion solutions that are commonly used in
iontophoresis.18 Each one has unique characteristics that create certain
physiological effects on the target tissue. It is important to know the
ion charge and indications for each solution so that the most beneficial
treatment is administered with as few side effects as possible.20 A physician
must prescribe most of these medications before they can be used.
Two commonly used medications are Dexamethasone and Lidocaine.
This treatment should only be used under the direction of a healthcare
practitioner licensed to administer medication. This treatment is usually
seen in a chiropractic setting where a medical doctor, nurse practitioner, or
physician’s assistant prescribes the treatment. Defer to the owner’s manual
for specific medications that could be used.
A) Dexamethasone is a negatively charged solution that is used with
conditions including tendonitis, epicondylitis, plantar fasciitis,
and other inflammatory conditions.18

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 CHAPTER 7

B) Lidocaine is a positively charged solution that may be used to

treat acute inflammation such as bursitis and tendonitis, and may
also create an analgesic effect.18 (As a safety check, be sure to ask
about any allergies before administering medication.)

Indications and Contraindications

With all iontophoresis treatments, care must be taken to ensure proper

application to avoid skin irritations and possible skin or tissue burns.
When used properly, iontophoresis can be an effective way to treat an
area without the use of injections or oral medications that have a systemic
(versus localized) effect. The patient should feel a tingling and possibly
itchy sensation, but should not feel pain, burning, or any other dis-
comfort. There are many indications and contraindications for the use
of iontophoresis. Before applying any ion solution, the patient must be
questioned about any known reactions to medication (SEE FIGURE 7.L).

Phonophoresis
Phonophoresis differs from iontophoresis in that it uses acoustic energy,
or sound waves, to drive molecules through the skin into the tissues.
Ultrasound opens pathways that allow the medication to be absorbed
easily through the skin.18, 52 The treatment does not have the risk of
burns as much as iontophoresis. The advantage of phonophoresis is its
noninvasive nature, compared to injections, and it is safer than oral medi-
cation because its medication bypasses the liver.18 The application of
phonophoresis is consistent with ultrasound application. Please see the
section in this chapter on ultrasound for specific application techniques.
SEE FIGURE 7.M for a list of indications and contraindications. As with
iontophoresis, prior to applying medication solution, the patient must
be questioned about any known reactions to medication.

Electromyographic Biofeedback 18, 20

Biofeedback Basics and Clinical Applications

Biofeedback is gained through the use of an electrical instrument that

provides information related to certain actions in the body. There are
several kinds of biofeedback frequently used; however, electromyo-
graphic biofeedback is most common in the therapeutic rehabilitation

188
 Treatment Principles and Procedures

Figure 7.l

Indications and Contraindications for Iontophoresis 18,20

Indications for Iontophoresis Use
Inflammation from conditions such as: tendonitis, bursitis, epicondylitis,
plantar fasciitis
Edema Scar tissue Creation of an
analgesic effect
Contraindications for Iontophoresis Use
Cancer Carotid Sinus Pacemakers
Defibrillators abnormalities Trans cerebrally
Areas of impaired sensations Near the heart (across the head)
(Diabetes, neuropathy) Open wounds Directly over metal
Known allergy to ion Skin burns implants
being introduced Areas around eyes, Skin hypersensitivity
Infection skull, genitals Pregnancy

Figure 7.m

Indications and Contraindications for Phonophoresis 18,20

Indications for Phonophoresis
Inflammation from conditions such as: tendonitis, bursitis, epicondylitis,
plantar fasciitis
Edema Scar tissue Creation of an
analgesic effect
Contraindications for Phonophoresis
Cancer Carotid Sinus Areas of impaired
Over the thorax with abnormalities sensations (Diabetes,
pacemakers Skin hypersensitivity neuropathy)
Over thorax with Areas around eyes, Areas of deep vein
defibrillators skull, or genitals thrombosis
Over a fracture site Pregnancy when Trans cerebrally
prior to healing used over pelvic or (across the head)
Over the heart lumbar areas Known allergy to ion
Infection being introduced
Directly over metal
implants Open wounds Skin burns

189
 CHAPTER 7

setting. Biofeedback works by measuring an action and providing

feedback through either visual or auditory signals that allows the
patient to see the performance of the desired tissue and tries to make
changes or corrections.18 The benefit of biofeedback is that performance
changes can be seen immediately, creating positive reinforcement and
encourages the patient’s progress. There are many clinical applications
of electromyographic biofeedback.20

Muscle reeducation is the most common use of biofeedback in the

therapeutic rehabilitation setting. It is used to regain muscle control or
to teach a particular muscle or muscle group to contract.20 It is com-
monly used in muscles where atrophy has occurred after an injury,
such as the Vastus Medialis Oblique (VMO) of the leg after many knee
injuries. Along with biofeedback, the patient or therapist should try to
facilitate muscle movement by stroking or tapping the desired muscle
while looking at the muscle for a reaction.
Relaxation of muscle guarding and the reduction of pain are also
helped by biofeedback. The biofeedback equipment can be used to help
the patient learn how to relax a muscle that is guarded. This muscle
guarding often increases pain so by teaching the muscles to relax, the
patient’s pain level may be decreased.20

Equipment and Treatment Techniques

Electromyographic biofeedback units use the electrical activity created
by a muscle contraction to produce a readout of the strength of the
muscle contraction. As a contraction increases, the unit will show an
increase in the amount of electrical activity. The units use electrodes
placed at the target site to pick up this electrical activity. Biofeedback
units generally provide either a visual or auditory feedback to represent
the amount of electrical activity detected at a muscle site. Visual feed-
back units typically show electrical activity as a line traveling across a
screen, a series of lights, a bar graph, a digital number, or as a meter
with a moving needle. Audio feedback units use some form of beeping,
clicking, or a tone that decreases and increases as electrical activity
changes.20 (SEE FIGURE 7.N for indications and contraindications.)

190
 Treatment Principles and Procedures

Figure 7.n

Indications and Contraindications for

Electromyographic Biofeedback 18,20
Indications
Facilitate muscle contractions
Muscle re-education
Decrease spasm and muscle guarding
Promote relaxation
Contraindications
Joint being ill-prepared for excessive tension or range of motion
If muscle contraction may damage skin graft or underlying tissue

Diathermy
Shortwave and Microwave Diathermy

Diathermy is the use of high frequency electromagnetic energy to gen-

erate heat in body tissue.18 The body resists the passage of the electro-
magnetic energy and this resistance generates heat in the tissues. Dia-
thermy is considered to be a thermal modality because it causes high
frequency vibration of molecules in the body that can result in deep
heating of targeted tissue sites.18 There are two kinds of diathermy
modalities: shortwave and microwave. Both use a high frequency and
shortwave electromagnetic current to create the desired physiological
effects. In general, shortwave diathermy is considered safer than micro-
wave diathermy.18

Shortwave diathermy can be either continuous or pulsed. Continuous

shortwave diathermy creates a deep heat while pulsed shortwave
diathermy can have thermal and non-thermal effects. There are two
methods of application for shortwave diathermy.18

1) The capacitor technique creates an electromagnetic field by placing

the tissue between two electrodes and using the patient as part of the
circuit.
2) The induction technique creates a magnetic field around the tissue by
using either a coil or drum. With the induction technique, the patient
is not part of the circuit.

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 CHAPTER 7

Microwave diathermy units use a higher frequency and shorter

wavelength than shortwave diathermy, creating a strong electromagnetic
field. Microwave diathermy does not penetrate fat layers very well so it
is best used in areas with low adipose tissue such as the hand and foot.18
Clinical Applications of Diathermy
There are many various applications of diathermy that have been
found to be therapeutic in treating different injuries in the body. These
treatments fall into both the thermal and non-thermal aspect of care;
however, the thermal uses are more common. Diathermy applications
produce many of the same effects as ultrasound treatments but are more
efficient in treating a larger target area.18
A Some thermal uses of diathermy include muscle relaxation, pain
reduction, increased circulation, decreased inflammation, and re-
duced stiffness.
B) The non-thermal benefits include wound and tissue healing, and
edema reduction.
Indications and Contraindications
When setting up diathermy treatments, it is important to know which
method of application is most beneficial in creating the desired physio-
logical effect. Precaution should be taken to keep perspiration from
gathering so as to prevent hot spots. Also, metal jewelry and metal im-
plants should not be near the treatment area in order to avoid burns.20
Therapists who are pregnant should distance themselves from microwave
diathermy units because there could be an increased risk of miscarriage.
(SEE FIGURE 7.O for indications and contraindications for diathermy.)

Figure 7.o
Indication and Contraindications for Diathermy 18,20
Indications
Sub-acute and chronic Pain reduction Increased circulation
musculoskeletal injuries Improved range of Trigger point reduction
Muscle relaxation motion Wound healing
Contraindications
Areas of reduced sensitivity Acute musculoskeletal Near metal, pacemakers
Fluid filled areas or organs injuries Malignancies
Intrauterine devices Pregnancy Areas of joint effusion
Near the eyes Ischemic areas

192
 Treatment Principles and Procedures

Cryotherapy and Thermotherapy

Cryotherapy
Basics of Heat Transfer

Heat transfer is the movement of thermal energy across a temperature

gradient. This transfer is applicable to both heat and cold modalities.20
Heat travels from warmer areas to cooler areas; therefore, heat transfer
works in both directions. When using a heat therapy, the heat from the
modality is transferred to the body tissue, making the tissue warmer.
When using cold therapy, the heat from the body is transferred to the
modality, making the body tissue colder.20 This heat transfer can create a
change in circulation, muscle spasm, and pain. There are three methods
of heat transfer: conduction, convection, and radiation.

A) Conduction occurs when there is direct contact between the body

and a heat or coldsource. Hydrocollator packs, cold packs, ice
massage, and paraffin baths are examples of conduction.

B) Convection is when air or water particles move across the body and
create temperature changes such as a hot or cold whirlpool.

C) Radiation is the transfer of heat energy from a warmer source to

a cooler source with no physical contact or transference medium
being used. Examples include infrared lamps and lasers.

Physiological Injury Response

Cryotherapy is the use of cold modalities to create a decrease in tissue

temperatures in the body. This cooling is primarily superficial and is
most commonly used in acute and sub-acute injuries. There are many
physiological responses of the body when cold therapies are applied.
Here are three of the most common responses:

1) One of the greatest benefits of cold therapy is its analgesic

effect. It helps to reduce pain sensations by changing the sensation
signal that the nerves are conducting.

193
 CHAPTER 7

2) When cold is initially applied to an area, the tissue responds with

vasoconstriction. This reduces further inflammation and damage
after an injury by slowing blood flow.

3) Cold treatments also decrease cellular metabolism and the

accumulation of edema.

Clinical Applications of Cryotherapy

The ability of cryotherapy to reduce edema and pain make it one of

the most frequently used modalities for acute injuries. The cold mod-
ality methods are typically used for
at least 72 hours after an injury and
most treatments are at least 15 min-
utes long in order to achieve analges-
ic effects. With each cold therapy,
the body will go through a progress-
ion of sensations. Typically there is
the sensation of cold, which may be
uncomfortable, which is followed
by stinging, burning or aching, and
then numbness.

Several forms of cold therapy involve

using some form of ice or frozen
gel packs applied to the patient.
These therapies should be applied
until numbness is achieved in order
to create the most therapeutic results.
With each of these treatments, the
patient should be in a comfortable
relaxed position and, if possible, the
treatment area should be elevated to
further reduce swelling. These appli-
cations include ice massage, cold
hydrocollator or frozen gel packs,
and ice bags. When applying these
ice treatments, it is important that
the patient never has direct contact
with the cold pack. Cryotherapy-Contused Muscle

194
 Treatment Principles and Procedures

Ice Cup used with Ice Massage

Some of the most intense and effective uses of cryotherapy involve

immersing the treatment area in cold water and using either a cold whirl-
pool or an ice bucket.18 Typically, ice is added into the water until the
temperature is 50 to 60°F. Cold whirlpools have the added benefit of
water flow, which has a massaging and vibrating effect. Contrast baths
that alternate hot and cold whirlpools are also beneficial for treatment
in sub-acute injuries.

Ice Massage Tip:

To avoid water running everywhere, place a piece of plastic wrap
over the ice cup to catch the water. A little lotion on the skin reduces
friction.

Home Use Tip:

Patients can create an ice cup at home by freezing water in a paper
cup. When it is frozen, rip off the top half of the paper and
use the bottom half to hold on to the ice.

There are a few other methods of cryotherapy often used in the thera-
peutic rehabilitation setting. The Cryo-Cuff combines cold and com-
pression and is beneficial with acute injuries and after surgery.18 Cold
sprays are often used to help reduce muscle spasm by reducing pain and
allowing the muscle to be stretched or to relax. Application of cold with
electrical stimulation increases the benefits of both applications. SEE
FIGURE 7.P for a sample form that can be given to the patient for cryo-
therapy at home.

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 CHAPTER 7

Home Instruction Tip:

For sub-acute conditions and for patients that are sensitive to
extreme cold, a very positive effect can be attained by using gel
packs that have been chilled in the refrigerator rather than the
freezer. Instruct the patient to use repeated applications of ten
minutes on the affected area followed by thirty minutes without
the pack to allow the gel pack to re-chill. This can be very helpful
for pain control and muscle spasm. This protocol is tolerated
better by patients and is more effective than a single application
of a frozen gel pack.

Figure 7.p

Sample Patient “Take Home” Instruction Sheet

PROPER USE OF ICE PACKS
• Ice should ALWAYS be used for all new injuries for at least the
first 24-72 hours.
• By doing this, your swelling will be reduced which is one of the
causes of pain.
• The ice pack should be kept in the freezer and available for any
bumps, sprains, or strains.
• The pack will last a long time if you do not bend and crease it.

DIRECTIONS:
• Lay the ice pack directly on the area for 20 minutes—no longer.
Remove ice for 1-2 hours (this allows the skin to return to
normal temperature) and then repeat at same interval.
• A wet paper towel conducts the ice better.
• If ice-sensitive, use a thin dry towel.

CONTRAINDICATIONS FOR ICE:

• Impaired circulation • Suspected fractures
• Bleeding in joint (note by • Cold allergy or
discolored and swollen joints.) hypersensitivity
• Uncovered open wounds • Anesthetized skin

196
 Treatment Principles and Procedures

Thermotherapy
Physiological Injury Response

Thermotherapy is the use of superficial heating that is most commonly

used in sub-acute and chronic conditions to reduce pain and relax muscle
tissues.18 Heat increases the dilation of blood vessels which improves
circulation and encourages the removal of waste at the injury site. Care
must be used with heat therapies not to increase swelling and edema.20
Thermotherapy is usually not used until the sub-acute or chronic stages
and after the majority of edema has been reduced.

Clinical Applications of Thermotherapy

As with cryotherapy, many forms of thermotherapy involve applying

some form of heat to the affected area. Hydrocollator packs kept at around
170°F and wrapped in protective pads apply a moist heat that helps to
stimulate the circulatory response.18 Paraffin baths, where the patient
dips the treatment area in melted paraffin, are often used for problems of
the hands and feet.20 Heat application, along with electrical stimulation
increases the benefits of both applications. Never allow direct contact
with the patient’s skin to the hydrocollator pack; doing so can result in
burns. Warm whirlpools help to reduce muscle spasm, increase range
of motion, and have the added benefit of the circulating water which
creates a massaging effect. The warm whirlpool should be between 100°-
110°F. Infrared lamps and fluid therapy units use dry heat to increase
tissue temperature and reduce pain.18 SEE FIGURE 7.Q for indications and
contraindications. SEE FIGURE 7.R for a sample form that can be given to
the patient for heat therapy at home.

Moist Heat Pack

Hydrocollator and Pads
197
 CHAPTER 7

Figure 7.q

Indications and Contraindications for Heat Therapy 18,20

Indications
Pain Sub-acute edema and contusions
Sub-acute sprains and strains Decreased range of motion
Muscle guarding and spasm Trigger points
Sub acute and chronic inflammation

Contraindications
Acute conditions Peripheralvascular disease
Impaired circulation Poor thermal regulation
Neuropathy
Use caution with elderly or frail patients or those with conditions
such as diabetes

Figure 7.r

Sample Patient “Take Home” Instruction Sheet

PROPER USE OF HEAT PACKS

• Moist heat packs should be applied only at your chiropractor’s
instruction because of the adverse effects that can occur.
Example: Heat will produce too much swelling into an acute area
(i.e. joint), which may feel good initially, but will cause more
pain later.
DIRECTIONS:
• Make sure that you use moist heat and never dry heat.
• Use about 3-6 layers of towel as a medium between the heat
pack and skin. If you have to lie on your back make sure to have
additional toweling.
• Use pack for 20 minutes and then remove, 1 hour later repeat
procedure.
• Never fall asleep on heat pack.
• Most offices carry moist heat packs. Inquire for information.

Contraindications for Heat:

• Acute conditions • Peripheral vascular disease
• Impaired circulation • Poor thermal regulation
• Neuropathy
198
 Treatment Principles and Procedures

Caution:
Make sure patients clearly comprehend the instructions regarding
use of heat, and repeat them back to you. Often patients are
tempted to overuse heat due to its comforting sensation which
can increase the inflammatory response. An example statement
is: “That heat felt so good, I slept with it on.”

Therapeutic Ultrasound
Acoustic Physics and Components of Ultrasound Machines

Ultrasound is the use of acoustic energy at a high frequency that produces

both thermal and non-thermal physiological effects. Ultrasound is a
commonly used modality that can have both diagnostic and therapeutic
effects. In the chiropractic setting, ultrasound is primarily used for its
therapeutic effects. 53

Inside the sound-head of an ultrasound unit is a crystal that converts

electrical energy into acoustic energy.18 Ultrasound is beneficial, due to the
manipulation of sound waves that creates vibration of the molecules of
the tissue being treated. Most of the waves in an ultrasound are longitudi-
nal. Because of this, they are able to travel through liquids and solids.53
This means that the energy created by the molecular vibrations of the
tissue travels in the same direction as the sound wave. This allows the ultra-
sound waves to travel deeper into the soft tissue. The depth this sound
wave will penetrate is determined by the frequency of the wave.18, 50
This frequency is measured in megahertz (MHz). In the body, higher
frequency waves are absorbed more quickly than lower frequency ones.

There are several different factors that must be determined before

performing a therapeutic ultrasound treatment, in order to achieve the
desired physiological effects. The parameters must be set to achieve the
desired depth of penetration, intensity of treatment, and whether the
wave is continuous or pulsed.53, 50

A) The frequency of an ultrasound application determines the depth

the treatment will penetrate. Most ultrasound machines give the
option of using a 1 MHz or 3 MHz frequency. The 1 MHz setting

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 CHAPTER 7

is considered to be a deeper heat and the 3 MHz setting is a more

superficial heat.53

B) The type of sound wave needed should also be determined

before starting an ultrasound treatment. This wave can be either
continuous or pulsed. A continuous ultrasound treatment means
that the ultrasound is always generating energy. This treatment
produces thermal effects. A pulsed ultrasound setting means that
the ultrasound is only producing sound waves for a percentage
of the time. This treatment creates mainly non-thermal effects
in the tissue that are most commonly used to facilitate soft tissue
healing.53

C) The intensity of the ultrasound is the volume of energy that is

being delivered to the area. This is often expressed as watts per
square centimeter (W/cm2). Intensity determines how much heat
is produced. The higher the intensity, the more heat the patient
should feel. The intensity should always be at a level where a
warming sensation is felt but no pain or burning is reported by
the patient.53

Physiological Effects of Ultrasound

The physiological effects of ultrasound on a treatment area will largely

depend on whether the goal of the treatment is thermal or non-thermal.

The thermal effects of ultrasound are typically produced by a continuous

wave. The benefits from this treatment are mainly a result of heating the
tissue. The common therapeutic effects of continuous ultrasound
include: 18

– Increase of blood flow

– Reduction of stiffness and spasm
– Increase in flexibility of tendon and joint capsules
– Decrease of pain

200
 Treatment Principles and Procedures

The non-thermal effects of ultrasound are produced by a pulsed wave.

There is little heating with pulsed ultrasound waves but the physiological
effects are created by the mechanical movement that the pulsed wave
creates in the tissue. These effects can include: 18

– Increased cell permeability to ions beneficial

in healing
– Tissue regeneration
– Collagen synthesis
– Increased blood flow
– Reduction of edema

Ultrasound Treatment Techniques

There are some general guidelines that apply when performing an
ultrasound. The type of injury and treatment goals will determine the
specific parameters of each treatment, but all ultrasound applications
have several things in common. Some form of a coupling agent must
be used in order to ensure the ultrasound energy is transmitted to the
patient and is not impeded when passing from the sound head to the
patient. The most common forms of coupling agents are water and
water-soluble gels.53

A) Water is used when the area being treated has many bony promi-
nences or uneven surfaces such as the hands and feet. The body part
and the ultrasound head should be immersed in a bucket or tub
of water and there should be a slight gap between the soundhead
and the patient. 20

Underwater Ultrasound Technique

201
 CHAPTER 7

B) A water-soluble gel is most commonly used for ultrasound treat-

ments. Make sure there is enough gel to allow good contact and lub-
rication between the sound head and patient. Be careful not to use
too much gel, because air pockets can be created. 20

C) The ultrasound head should be in constant motion in order to pre-

vent hot spots from forming. An overlapping circular motion is most
commonly used in order to provide uniform treatment of an area.
The treatment area should be around 2 to 3 times larger than the
the soundhead diameter for full effectiveness. 18

Gel and Ultrasound Heads

D) The sound head should remain in contact with the skin at all times.
If there is an air gap while the ultrasound is turned on, it could
result in damage to the crystal located in the sound-head. When
performing underwater ultrasound, there should be a gap between
the soundhead and patient but water should always fill this gap. 20

202
 Treatment Principles and Procedures

Ultrasound Treatment

Treatment Tip:
Using a little extra pressure on the soundhead while using
gel not only ensures good contact with the skin but allows
the wand to act as a massage head.
Precaution:
Avoid using ultrasound over any bony prominence, such as
the spinous processes of the spine. There is little soft tissue
coverage and this creates a risk of periosteal burns.

Clinical Applications for Therapeutic Ultrasound

Ultrasound is a commonly used modality that can be very effective in

treating a wide variety of conditions. The application of ultrasound is
used for both its thermal and non-thermal benefits. Following are some
of the various clinical uses of ultrasound. (SEE FIGURE 7.S for indications
and contraindications.)

203
 CHAPTER 7

Use 1) Continuous and pulsed ultrasound can be used to promote

soft-tissue healing in acute injuries by accelerating the
inflammatory response phase. Ultrasound helps to speed
up the inflammation process and promote faster healing.
During the repair phase of healing, ultrasound helps to
increase cell permeability and encourage the body to begin
producing scar tissue. 20, 50

Use 2) Ultrasound can also be used to increase mobility of scar

tissue that can limit range of motion. Scar tissue is made up
of collagen fibers, and the thermal effects of continuous
ultrasound works well to increase the flexibility of these
collagen fibers. 18

Use 3) Patients suffering from chronic inflammation conditions

such as tendonosis and bursitis benefit from ultrasound
because it increases blood flow which promotes healing and
the reduction of pain. 18

Use 4) Ultrasound can be used to assess stress fractures because of

its ability to aggravate the periosteum of the bone. To assess
for a stress fracture, use a continuous setting and gradually
increase the intensity to 2.0 W/cm2. If the patient has a
feeling of pressure, bruising, or aching during the treatment
there may be a stress fracture. This technique is mentioned for
historical purposes; however, it is a technique of questionable
reliability and could result in creating a periosteal burn.

Use 5) Other theorized but unproven clinical applications of ultra-

sound include absorption of calcium deposits, treatment of
plantar warts, and bone healing.

Ultrasound Combined with Other Modalities

Ultrasound is commonly combined with other therapeutic modalities
such as heat, cold, and electrical stimulation. When using ultrasound in
combination with other modalities, it is important to know what works
well together and what treatments may interfere with each other.

Combo 1) When using an ultrasound unit for thermal effects, a hot

pack before the ultrasound treatment may increase the
204
 Treatment Principles and Procedures

tissue temperature and decrease the amount of time needed

to achieve the desired effects with the ultrasound.
Combo 2) Cold therapy and ultrasound may be used together to try
to reduce pain and increase healing in the acute phase of an
injury. When using ultrasound and ice, it is most effective to
use the non-thermal setting of ultrasound so that the cold
of the ice and the heat of the ultrasound do not interfere
with one another.

Combo 3) Electrical stimulation and ultrasound are often used in

combination with one another. One reason for this is that
the beneficial effects of each modality, such as pain reduction
and increased blood flow, can be combined into one treat-
ment. Another common use is for the treatment of trigger
points. When used together, the soundhead will produce a
contraction over trigger points and can help to fatigue the
muscle and therefore reduce pain and spasm. 18
Figure 7.s

Indications and
Contraindications for
Ultrasound 18,20
Indications
Acute injuries (pulsed)
Sub-acute or chronic injuries (pulsed
or continuous)
Scar tissue
Buristis/tendonitis/tendonosis
Plantar warts
Contraindications
Areas of decreased sensation
Areas of decreased circulation
Growth plates in children
Acute injuries (continuous)
Open wounds or infection
Therapy Bay Setup for Combo Modality Over the eyes or genitals
Use caution with continuous
ultrasound over bony prominences
and other areas sensitive to heat.

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 CHAPTER 7

Light Therapy (Lasers)

Basics of Light Therapy

The term laser stands for light amplification of stimulated emissions

of radiation. Light energy is made up of particles called photons.53 The
action of these photons is what creates the therapeutic benefits of lasers.
There are three main qualities that make laser light different from other
forms of light. These qualities are monochromaticity, coherence, and
collimation. They allow the laser to focus a very precise, uniform beam
at a specific target. 53

A) Monochromaticity is when all the photons have a uniform

wavelength and color. 53
B) Coherence is when all the photons have the same wavelength and
all of the light waves are in phase with each other.53
C) Collimation is when there is little divergence of the photons as the
light travels through space. This lack of divergence creates a beam
of light.53

Types of Lasers

There are many variations of lasers that are used for many different
purposes including medical, industrial, and military. The kinds of
lasers used most commonly in the chiropractic setting are considered
to be low-level lasers (cold lasers) that do not produce heat, but instead
create photochemical effects in the body. Helium neon and gallium
arsenide lasers are the two main kinds of lasers used in low-level laser
therapy.53 The helium neon (HeNe) laser is a gas laser with a continuous
wavelength, the effects of which are mainly superficial at between 2-10
mm.53 The gallium arsenide (GaAs) lasers use a pulsed wave and have
effects that reach a depth between 1-5 cm.53

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 Treatment Principles and Procedures

Clinical Application of Lasers

The beneficial physiological effects of lasers are believed to occur at the

cellular level. Most of the benefits of lasers are thought to come from
an acceleration of collagen synthesis, an increase in vascularization, and
from its anti-inflammatory interactions. 53 Low-level lasers are most
commonly used for wound healing, pain reduction, reducing scar tissue,
and edema reduction.
Lasers are very commonly used for wound healing because of their ability
to destroy bacteria, increase tensile strength of collagen, and improve
circulation at the wound site. This effect helps to shorten healing times
and reduce infection.18 When lasers are used for wound healing, the
amount of scar tissue is decreased. The scar tissue that is formed has
more tensile strength and more flexibility. Low-level laser therapy helps
with pain reduction by altering the nerve impulses.18 It can be used for
both acute and chronic pain. Lasers can be used for treating edema and
inflammation because they interrupt the production of chemicals that
produce inflammation in the body, such as histamines. (SEE FIGURE 7.T
for indications and contraindications.)

Figure 7.t

Indications and Contraindications for Light Therapy 18, 53

Indications
Wound healing
Pain reduction
Inflammation reduction
Bone healing
Scar tissue

Contraindications
Cancerous growths
Pregnancy
Application over or into the eyes

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 CHAPTER 7

Cervical and Lumbar Traction

Introduction

Traction is the application of a longitudinal force applied to the spine

and its adjacent structures, to separate the vertebra from each other.
These traction forces can be applied by mechanical, manual, or gravita-
tional forces.18, 20 When combined with active exercise rehabilitation
exercises, traction therapy can provide great relief to the patient for a va-
riety of conditions. In this section, we will focus our attention on mech-
anical distraction techniques.

Traction Principles

Traction’s effectiveness is directly related to the body part, the position

of the patient, the force, the duration of the traction, and the angle of
pull.18, 19 Starkey states, “to distract a vertebra, the force of the applied
traction must be sufficient to overcome the sum of resistance of the
weight of the body part being treated, the tension of the surrounding soft
tissues, the force of friction between the patient and the table, and the
force of gravity.”18 Traction should be applied to hypo-mobile segments
only when appropriate. The use of traction on hyper-mobile or loose
segments is contraindicated because of the increased chance of tissue
tearing, plastic deformation of tissue, dislocation or other potentially
permanent undesired sequela. Traction can be applied to the cervical or
lumbar spine.

Physiologic Effect of Traction

When traction provides the application of a longitudinal force to

the spine, a separation between spinal segments produces several
physiological effects.18, 20, 57, 58
1) Separation encourages overall spinal movement and movement
between the individual segments of the spine.

2) One of the largest effects of spinal traction is its ability to help with
disc injuries and disc pain. It is theorized that the space created
between spinal segments decreases the amount of pressure on the

208
 Treatment Principles and Procedures

discs and creates space for any bulging discs to return to a more
“normal” state.

3) The distraction of the discs allows for healthy movement of fluid

in and out of the joint space.

4) Spinal traction can help to restore normal length and function of

the ligaments along the spinal column.

5) In addition to taking pressure off of the disc space, traction takes

pressure away from the facet joints where cartilage and synovial tis-
sue often become compressed or impinged. By separating the facet
joints, practitioners can remove pressure from the structures that
are often the primary pain generators.

6) Nerve irritation is often created by pressure from bulging discs, in-

flamed and degenerated facet joints, spinal stenosis, and bone spurs.
This pressure often causes numbness, tingling, weakness, and pain.
When this irritation is removed, imflammation decreases and the
nerve function can be restored by the pressure reduction.

Forms of Traction
There are many forms of traction, including: manual; continuous (sus-
tained); intermittent; and spinal decompressive traction. Manual traction
is the practitioner’s application of a force to the spine to passively dis-
tract the vertebra.18 Continuous traction uses a device, such as a weight
and pulley system, over-the-door traction unit, or some form of pneumatic
unit. Pneumatic units utilize a sustained pull to distract the vertebra seg-
ments and apply a tension that does not alter over time until the treatment
is over.18 Intermittent traction can be applied by the practitioner or a
mechanical device which has a cycle of “On/Off” whereby the “On”
cycle causes the distraction, and the “Off” cycle allows the segments and
surrounding soft tissue to relax.18

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 CHAPTER 7

Manual Traction

Spinal decompression is a variation on conventional traction, and is

having a great deal of success due to its ability to reduce the amount
of muscle guarding that often decreases the effectiveness of traditional
traction. The motor head of the table is computer controlled and util-
izes intervals of distraction and relaxation that gradually builds tension
to prevent the surrounding musculature from tightening or fighting
the pull of the machine. This gradual increase in pull is more effect-
ive at a lower weight, but also reduces patient discomfort during and
after treatment. SEE FIGURE 7.U for indications and contraindications for
spinal traction. 55,56,57,58

Prone Lumbar Traction Setup

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 Treatment Principles and Procedures

Figure 7.u

Indications and Contraindications for Traction 18, 20

Indications
Degenerative disc disease Degenerative joint disease
Herniated discs Facet joint inflammation
Nerve root compression Muscle spasm

Contraindications
Primary or metastatic Aortic aneurysm
malignancy Gross hemorrhoids
Cord compression Osteoporosis
Infectious disease of spine Vertebral fractures
Cardiovascular disease Acute injury
Severe arthritis Unstable spine
Pregnancy Certain shoulder injuries
Active peptic ulcers (prone position)
Hernia

Treatment Tip:
In order to avoid discomfort after decompression, allow the
patient’s body to “recompress” before they get off the table. If
a patient stands too quickly, he or she might feel like his/her
back “catches” or that everything that was stretched jams back
together upon standing. One way to help is to keep the patient on
the table a few minutes and have the patient perform isometric
abdominal squeezes and buttock squeezes to stabilize the spine.

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 CHAPTER 7

Treatment Setup

Applying traction to a patient with a warranted spinal condition can be

highly beneficial; however, caution must be taken. The most common
mistakes made during the application of long axis traction are setting
the wrong poundage, the wrong time, and/or the wrong angle of pull.
Correct angle of pull and tension applied to the spine is imperative
when using traction. There are many brands of traction and spinal
decompression devices available, and exact poundage and angle of pull
varies among machines. The manufacturer’s manual should be consulted
prior to any application to ensure safety. There are some basics of setup
that are universal and will be reviewed. 18, 20

1) Make sure the patient has been asked about any

contraindications.
2) Identify the patient’s body weight.
3) Remove all forms of metal, necklaces, earrings, umbilical rings, or
apparel that could interfere with procedure.
4) Lay the proper harness configuration or cervical mechanism on the
table conducive to the patient positions ordered by the clinician.
5) Lay the patient supine, prone, or on his/her side, with proper
pillow supports for comfort.
6) Make sure all the pieces of the machine are intact and in good
working order.
7) For cervical or lumbar traction, set the table height for the proper
angle of pull specific to the patient’s condition.
8) Place the safety switch in the patient’s hands and explain its purpose.
9) Explain the purpose of the treatment and what the patient should
expect.
10) Reset and “zero out” the machine.
11) Set the controls or presets in accordance with the clinician’s orders.
12) With lumbar traction/decompression, unlock the table in accord-
ance with the manufacturer’s recommendations.

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 Treatment Principles and Procedures

Caution:
Any increase in back pain, leg pain, arm pain, headache, dizziness,
or change in skin color is a “Red Flag” and treatment should cease
immediately.

13) During the treatment, check on the patient to ascertain his/her

comfort.
14) Lumbar traction: When the session is complete, lock the table,
gently pull the rope loose, take off the harness, allow the patient
to lie there for a minute to re-compress, have the patient perform
isometric abdominal and gluteal contractions to stabilize the
segment. Then have the patient turn to his/her side while exhaling,
and push himself/herself upright to a seated position, prior to
standing.

Supine Lumbar Traction Setup

Note:
To be effective, the pull should be at least a quarter of the
patient’s body weight. The majority of lumbar treatments
use a force of 65 to 200 pounds. Cervical traction typically
pulls at a rate between 10 and 30 pounds. Manufacturers
and clinician’s discretion are required for exact poundage.

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 CHAPTER 7

15) Cervical traction: When the session is complete, gently release

the rope, loosen the head harness and neck unit. Allow the
patient to lie there for one minute to re-compress and have the
patient perform gentle isometric neck retractions to stabilize the
segment. Help the patient up from the unit.

Intersegmental Traction

Intersegmental traction (IST) uses a system of rollers to create a wave-

like motion to the spinal segments. This motion helps to gently stretch
the ligaments and muscles of the spinal column and creates better
movement of the individual spinal segments. This treatment is very
relaxing for patients and can increase mobility and reduce stiffness.

Intersegmental traction is one of the most widely used modalities com-

mon to the chiropractic practice. The rollers are designed to successively
tilt each vertebra to induce movement between the spinal segments.
This repetitive action increases the pumping action of the discs known
as imbibition. This pumping action is responsible for the infusion and
expulsion of extraspinal fluid from the spinal discs. Imbibition allows
nutrient-rich fluid to enter the disc and toxic laden fluid to be expressed
from the disc as a result of the variations in pressure.
Application

Depending upon the design of the particular table, the patient is

instructed to sit either in the center or at the lower end of the table. They
will lie back until they are properly positioned with the roller area of the
table beneath his/her spine.

The timer is adjusted to the pre-determined setting, usually 5-20

minutes. The unit is then activated and the therapist adjusts the height
of the rollers. The setting should be high enough to obtain the intended
rocker-action effect but low enough to avoid patient discomfort.

In addition to inducing imbibition into the spinal discs, the unit acts to
repetitively separate and distract the facet joints as the rollers activate
each spinal segment. The rollers are shaped to apply a therapeutic
kneading pressure to the paraspinal muscles to reduce edema, reduce
adhesions, and stimulate lymphatic circulation.

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 Treatment Principles and Procedures

Some intersegmental traction units also incorporate infrared heat that

can be applied to the patient’s back during treatment. Some clinics
combine electro-stimulation with intersegmental traction by applying
the electrical stimulation pads prior to positioning the patient on the
intersegmental traction table.
SEE FIGURE 7.V for indications and contraindications for intersegmental
traction.

Intersegmental Traction

Figure 7.v

Indications and Contraindications for IST

Indications
Muscle stiffness Ligament stiffness
Joint hypo-mobility Osteoarthritis
(minimal to moderate)
Contraindications
Acute inflammation Osteoporosis
Spinal fractures (moderate-severe)
Joint instability Spinal cancers
Pregnancy

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 CHAPTER 7

Other Common Chiropractic Modalities

There are a number of other modalities that are commonly used in the
chiropractic rehabilitation setting. Most of these use some form of vibra-
tion, percussion, or massage to create their desired effect.

Vibration Massage Tool (Jeanie Rub)

Devices that create a vibration are good for reducing superficial muscle
tightness and increasing circulation to the desired area. These are often
handheld massagers that are used both in the clinic and at home. The
Jeanie Rub is an example of a device that uses vibration. Other handheld
massagers use tapotement, or percussion, to provide a deeper massaging
action. This deep tapping action also helps with muscle tightness,
Figure 7.w

Indications and Contraindications

for Handheld Massagers
Indications
Muscle spasms Muscle stiffness
Trigger points Myofascial release
Increasing circulation

Contraindications
Fractures Acute inflammation
Open wounds Cancers
Increased symptomatology

216
 Treatment Principles and Procedures

trigger point, myofascial release, and increased circulation. Devices that

use this form of therapy include Jeanie Rub, G5 massagers, The
Thumper, Arthrostim, and percussors (SEE FIGURE 7.W for indications
and contraindications).

Safety Precautions
The goal of therapeutic modalities is to decrease healing time, reduce
pain, and encourage wellness. To provide the safest environment for
this to occur, certain safety precautions should be followed.
1) Chiropractic therapy is guided by patient comfort. Listen to the
patient when he/she says something is uncomfortable or does
not feel right, and adjust the treatment as necessary.

2) All equipment should be inspected regularly for damage to cords

and wires. The machines should receive maintenance or be cali-
brated according to the recommendation of the manufacturer,
typically once per year.
Caution:
Electrodes need to be replaced regularly as their ability to
distribute electrical current fails over time. Always use caution
when using “disposable” or “single use” electrodes. Follow the
manufacturer’s instructions closely.

3) All therapists should be properly trained on the function and

application of each modality. It is important to understand the
goal of each treatment and to only apply those therapies that will
be beneficial to the patient.
4) The chiropractic physician will prescribe the therapeutic
modalities that they deem are most beneficial for the patient,
based on the patient’s condition and goals of care. Only those
modalities prescribed should be applied to the patient.

5) It is advisable for a staff member or doctor to “test” each modality

on a regular basis by having it applied to themselves. This will
reveal any abnormalities or subtle changes in function that might
not be recognized by patients.

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 CHAPTER 7

218