by Steve Agocs, DC, K. Jeffrey Miller, DC, DABCO, and Steve Troyanovich, DC
Care of the extremities, including extravertebral adjusting, can be traced back to the founder of Chiropractic, D.D. Palmer, and many other Chiropractic pioneers. Extremity care is part of almost every major technique system in Chiropractic, and extremity adjusting enjoyed a major resurgence in the profession in the 1970s and 1980s. In addition to spinal adjusting, extremity care is at the core of the Chiropractic profession, and it is a legacy not to be soon forgotten.
In the 1910 text The Chiropractor’s Adjuster, the founder of Chiropractic, D.D. Palmer, wrote: “Chiropractic is not a system of healing. Chiropractors do not treat disease; they do not manipulate the spinal column. Chiropractors adjust any or all of the 300 joints of the body, more particularly those of the spinal column.”1
Although Chiropractic extremity adjusting can be traced back to the founder and many early practitioners, extremity care has taken a back seat to spinal-pelvic adjusting. In fact, some suggest extremity adjusting is not and should not be a part of Chiropractic. In recent history, Chiropractors in Michigan and New Jersey have battled to maintain extremity care in their scope of practice, making this a timely and relevant topic as other states revise their own scope of practice laws. This writing is intended to remind the reader of the role extremity care has played in the profession and to urge the continuation of what is truly a legacy.
Manipulation in History and Chiropractic
Chiropractors were not the first group to manipulate the extremities. Virtually every culture that has existed has employed some form of manipulative art or “bonesetting” tradition. The earliest written records of Asia, Egypt, and Greece all clearly document manipulation traditions, as do drawings and artwork from ancient cultures. In Western culture, manipulation survived throughout the Middle Ages and Renaissance periods. It was largely a peasant practice, passed down from master to apprentice.2
As people from all over the world immigrated to the United States, they brought these traditions with them. Prior to the last quarter of the nineteenth century, there were no formal schools or professional organizations for these practitioners. The skills were practiced by independent-minded individuals throughout the American frontier, and some of the early art of Chiropractic can be traced to these bonesetters.
Since its inception, the Chiropractic profession has been focused on the spine, with extravertebral adjusting taking secondary importance. The focus, though secondary, does not reduce the effectiveness and importance of extremity care.
The earliest of Palmer’s theories dealt with the human body as a machine. Palmer theorized that the human body was like a fine watch. If all of the parts of the watch were in perfect alignment, there would be little or no friction and the watch would function normally.3 By analogy, if the parts of the human frame were in perfect alignment, friction and inflammation would be kept in check and the human body could function normally. Naturally, in this analogy of alignment, friction and inflammation would extend to the joints of the extremities.
The Chiropractor’s Adjuster, Palmer wrote, “I emphatically affirm, as I did 13 years ago, that about 95% of diseases are caused by displaced vertebrae; the other 5%, including corns and bunions, come from luxated joints other than those of the backbone”4 (p. 100). This quote echoes Palmer’s early statements regarding the role of extremity adjusting in Chiropractic and links it to Palmer’s analogy of a watch and the human body.
Many of Palmer’s writings about extremity adjusting focused on the feet. Corns and bunions were mentioned numerous times. Hard manual labor, walking long distances, and the poor quality of shoes were the likely culprits here. Palmer practiced in the Midwest, where farming provided the majority of jobs. Transportation was limited, resulting in walking relatively long distances by today’s standards.
Most shoes in the late 1800s were still made with straight lasts for women and girls. Only shoes for men and boys were made specifically for the right and left feet. Shoes for women and children had to mold to the wearer’s feet, a process that was aided when the shoes were wet (Curator of the Arabia Steamboat Museum, personal communication with K.J. Miller, October 2009). This leaves little wonder why corns, bunions, subluxations, and other conditions of the feet were common and a concern of Palmer’s. In 1910, Palmer wrote: “I have never found it beneath my dignity to do anything to relieve human suffering. The relief given bunions and corns by adjusting is proof positive that subluxated joints do cause disease” (p. 322). And, also, “Why adjust in the lumbar for displacements in the joints of the foot?”4 (p. 322).
In the Beginning
Chiropractic began with Palmer’s adjustment of Harvey Lillard. This also marked the beginning of the Palmer School. From this beginning in 18965 (not 1895, as legend goes), the school was run by Palmer, who espoused a philosophy of adjusting any subluxated joint in the body.
The Palmer School of Chiropractic taught extravertebral adjusting. In 1910, the Palmers wrote: “Were we to know of a dislocated shoulder, hip, or of any one of the 52 articulations of the vertebral column being luxated…and did not replace the dislocation…it would show to our patients and students that we were not doing our duty and were criminally negligent”4 (p. 78).
The Palmers studied and wrote of bone-setting techniques for the extremities. They were also acutely aware of the techniques of various European bonesetters as well as techniques from New England. Palmer mentions the Sweet family of “natural bone-setters” as well as others in his 1910 text4 (p. 543).
While Palmer wrote about the importance of adjusting the extraspinal joints, there is no record of Palmer’s specific extremity approach. The earliest written record of a systematic approach to extremity adjusting in Chiropractic comes from Palmer’s first rival, Dr. Solon Langworthy. Langworthy and his co-authors, Minora Paxson and Oakley Smith, published the first textbook on Chiropractic, Modernized Chiropractic, in 1906. The book contains detailed instruction in extremity adjusting and was used in the curriculum of the American School of Chiropractic, located in Cedar Rapids, Iowa6 (p. 257-272).
Palmer’s son, Bartlett Joshua (“B.J.”) Palmer, took over the operations of the Palmer School of Chiropractic in 1906.7 From 1906 until 1924, B.J. was inarguably the most influential leader in Chiropractic. While his influence waned after 1924, B.J.’s opinions continued to exert themselves in the profession through his leadership of the Palmer School of Chiropractic until his death in 1961.
In 1907, B.J. and his cohorts in the Universal Chiropractors Association helped defend his friend and colleague Shegetaro Morikubo in a landmark trial held in LaCrosse. The Wisconsin case was the first successful defense of Chiropractic as a separate and distinct profession from osteopathy and the practice of medicine. The defense was based partly on the premise that Chiropractors were exclusively engaged in reducing vertebral subluxations. This is in stark contrast to Palmer’s initial teachings of “all of the 300 joints of the body.”8
Following the trial and for the next few decades, thousands of trials ensued for Chiropractors accused of practicing medicine or osteopathy without a license. The defense always fell back to the precedent set by the Morikubo ruling of 1907.
B.J. maintained the spine-only philosophy in the Palmer School and used his influence to attempt to exert the philosophy on the profession. In the early 1930s, B.J. narrowed his focus even further by almost exclusively limiting Chiropractic adjusting to the upper cervical spine. In 1956, B.J. relaxed his upper cervical stance by allowing full-spine adjusting in the clinic and classroom of the Palmer School.9 Extremity adjusting, however, remained in exclusion.
Langworthy and Others
While the control and philosophy of the Palmer School changed over the years, the influence of the profession’s largest institution and its leader did not prevent other Chiropractic practitioners from carrying the flag for extremity care in Chiropractic.
Solon Langworthy led the way. Langworthy was an osteopath who received his diploma in Chiropractic from the Palmer School of Chiropractic and Cure in 1901. Langworthy founded the American School of Chiropractic and Nature Cure, the first real rival to Palmer’s school, in 1903. Langworthy co-authored the first textbook on Chiropractic, Modernized Chiropractic, along with two other early graduates of Palmer’s school, Minora Paxson and Oakley Smith.10
Modernized Chiropractic was published in 1906 as two volumes. Volume II contains specific descriptions and photographs for adjustments of the clavicle, hand, fibula, scaphoid, cuboid, tarsals and metatarsals, calcaneus, talus, cuneiforms, metacarpals, and phalanges. On page 271-272, the authors wrote:
The idea which we have been advancing in regard to the foot is not that disease in the foot (and perchance subluxation of the bones of the foot themselves), is not in many instances the result of subluxations of the spine or pelvis. We know from many cases of trouble in the foot successfully treated by adjustments given to the spine and pelvis, that such is many times the case.
But we say emphatically that when the primary cause in the shape of a subluxation exists in the foot itself, that it is logical and scientific to make direct correction of these conditions and that it is extremely illogical, unscientific, and anti-modern not to do so.6
In addition to Langworthy and his associates, hundreds of other Chiropractic technique developers included extremity care in their systems. Diversified Technique began as a “proto-technique” of “non-Palmer” adjustments used by many Chiropractors who refused to fall into step with B.J.’s upper cervical philosophy.11
In 1947, National College of Chiropractic published Chiropractic Principles and Technique, accepted as the “textbook” on Diversified techniques. Janse et al.’s book contains adjustments of the spine as well as the extremities, viscera, and cranium, contrary to the “spine-only” focus that the Palmer School embraced.12
Other technique developers who branched out from the spine with their instruction of adjusting extremities included Leo Spears (Spear’s Painless System), Major Bertrand DeJarnette (Sacro-Occipital Technique), Clarence Gonstead (Gonstead Chiropractic Technique), Hugh Logan (Logan Basic), and Raymond Nimmo (Receptor Tonus Technique). Many other shorter-lived techniques instructed doctors in extraspinal adjusting, as evidence by the myriad books and manuals one may find from the 1920s and onward in a Chiropractic library.
A common link among these techniques is the premise that the extremities were being addressed to influence the spine. This was achieved through heel lifts, braces of various types, or direct adjustment.
In the late 1940s and early 1950s, Monte Greenawalt noticed that patients he referred to a podiatrist returned with increased lower-back pain. The patients had been fitted with rigid orthotics. He concluded that if the orthotic’s effect on the feet could influence the spine in a negative manner, it was logical that they may also affect the spine in a positive manner.
Greenawalt also felt that part of the orthotic problem stemmed from the rigid materials used by the podiatrist. So began a process of tinkering with flexible materials to develop an orthotic that would enhance spinal care. The resulting product of Greenawalt’s experimentation was called the Spinal Pelvic Stabilizer, and in 1952 he founded Foot Levelers, Inc. to market his product to other Chiropractors.
Greenawalt’s invention was initially met with great criticism. In 2002, Greenawalt, reflecting on his career and invention, said, “In the early years, my ideas and work were scoffed at by some of the best minds of the time. Today, all the major Chiropractic techniques recognize that stabilization of the feet is an integral part of care and recommend orthotics with foot imbalances.”13
Another development in the 1950s was the publishing of Athletic and Industrial Injuries of the Ankle and Foot in 1958 by August Schultz. Schultz later published The Shoulder, Arm and Hand Syndrome in 1969 and The Knee, Femur and Pelvis in 1979. Like Greenawalt, Schultz was an inventor. His first book included an order form for products he invented, including the Schultz Shinsplint Easer, Schultz Elbow Easer, and the Schultz Osgood-Schlatter Support.
In the 1970s and 1980s, extremity adjusting as a standalone procedure seemed to really come into its own. D.D. Stierwalt published Extremity Adjusting in 1975.14 Kim Christensen published the Illustrated Manual of Common Extremity Adjustments in 198015, and in 1981, Kevin Hearon published, What You Should Know About Extremity Adjusting.16 That same year, Motion Palpation Institute founder Leonard Faye published Motion Palpation and Manipulation of the Extremities.17
In 1982, R.C. Shafer wrote Chiropractic Management of Sports and Recreational Injuries.18 In 1985, National College of Chiropractic published the States Manual of Spinal, Pelvic and Extravertebral Techniques, largely thought of as the modern “Diversified textbook.”19
These authors and instructors were looking at the extremities beyond their relationship to the spine. The concept of a subluxation was quickly moving away from a “bone out of place and nerve pressure.” Recognition of the extremities as part of a complex biomechanical and neurological model was coming to light. Investigations into movement, the gait cycle, exercise physiology, and how Chiropractic plays a role in athletics showed that healthy extremity function went far beyond a sore elbow or a fallen arch, and the effects were wide-ranging.
This trend continued with the founding of the Council on Extremity Adjusting in 1995. The council offers a 105-hour post-graduate program on extremity care leading to a certification as a Chiropractic Extremity Practitioner, and post-graduate education in extremity care remains popular in the Chiropractic profession.
Despite rather humble beginnings in the late nineteenth century, by the mid-1990s evaluation and adjusting of extremity conditions were part of the core curriculum of every Chiropractic college, and they remain so today. Recent evaluation of the websites of all 16 Chiropractic educational institutions that are members of the Association of Chiropractic Colleges confirms extremity care in their curricula. With few exceptions, extremity care is within the scope of licensed Chiropractors in almost every state and country where Chiropractors practice.
A 2003 survey included in the Job Analysis of Chiropractic 2005 showed that 95.4% of respondents used extremity adjusting techniques in their practices. The survey also showed 69.3% of Chiropractors use heel lifts and 81.8% use foot orthotics in their practices.20 Extremity care in Chiropractic has a long, rich history, and it is a history that continues to be written.
1 Palmer, D.D. (1910). The Chiropractor’s adjuster, the science, art, and philosophy of Chiropractic. Portland, OR: Portland Printing House, 228.
2 Breasted, J.H. (1930). The Edwin Smith Surgical Papyrus, Volume 1: Hieroglyphic Transliteration, Translation, and Commentary. Chicago, IL: University of Chicago Press, 303-304.
3 Palmer, D.D. (1899). The key to Chiropractic work. The Chiropractic, No. 26, 1.
4 Palmer, D.D. (1910). The Chiropractor’s Adjuster. Davenport, IA: D.D. Palmer, 100.
5 Palmer, D.D. (1897). Deaf seventeen years. The Chiropractic, 17(3).
6] Smith, O., Langworthy, S.M., & Paxson, M. (1906). Modernized Chiropractic (Vol. II). Cedar Rapids, IA: S.M. Langworthy, 257-272.
7 Troyanovich, S.J. & Keating, J.C. (2005). Wisconsin versus Chiropractic: The trials at LaCrosse and the birth of a Chiropractic champion. Chiropractic History, 25(2), 37-45.
8 Rehm, W.S. (1986). Legally defensible: Chiropractic in the courtroom and after 1907. Chiropractic History, 6, 50-55.
9 Himes, H.M. (Speaker). (1956). Policy talk delivered to the PSC student body.
10 Troyanovich, S.J. & Gibbons, R.W. (2003). Finding Langworthy: The last years of a Chiropractic pioneer. Chiropractic History, 23, 9-17.
11 Cooperstein, R. (1995). Diversified technique: Core of Chiropractic or ‘just another technique system?’. Journal of Chiropractic Humanities, 5(1), 50-55.
12 Janse, J., Houser, R.H., & Wells, B.F. (1947). Chiropractic principles and technic. Chicago, IL: National College of Chiropractic.
13 Greenawalt, M.H. Introduction. In: Hyland, J.K. (2002). Spinal pelvic stabilization: A practical approach to orthotic application. Roanoke, VA: Foot Levelers, Inc.
14 Stierwalt, D.D. (1975). Extremity adjusting. Davenport, IA: D.D. Stierwalt.
15 Christensen, K.D. (1980). Illustrated manual of common extremity adjustments.
16 Hearon, K.G. (1981). What you should know about extremity adjusting (5th ed.). K.G. Hearon.
17 Faye, L.J. (1981). Motion palpation and manipulation of the extremities. Huntington Beach, CA: Motion Palpation Institute.
18 Shafer, R.C. (1982). Chiropractic management of sports and recreational injuries. Baltimore, MD: Williams & Wilkins.
19 Kirk, C.R., Lawrence, D.J., & Valvo, N.L. (Eds.). (1985). States manual of spinal, pelvic and extravertebral techniques (2nd ed.). Lombard, IL: National College of Chiropractic.
20 Christensen, M.G. (2005). Job analysis of Chiropractic 2005. Greeley, CO: National Board of Chiropractic Examiners, 135.