Why What Happens Before the Adjustment Might Matter More Than the Adjustment Itself
- Dr. Lucas Marchand
- Apr 4
- 7 min read
By Dr. Lucas Marchand, DC — MyChiro Mobile Chiropractic, Sioux Falls, SD
I've been adjusting spines in Sioux Falls for nearly a decade. I've worked on farmers from Harrisburg with backs that feel like knotted fence wire, office workers from Brandon who've spent years folded over laptops, and athletes from Tea whose hips are so locked up they've forgotten what full range of motion feels like. And in that time, I've come to believe something that sounds almost too simple to be worth saying: the order in which you do things matters enormously.
Not just clinically. Physiologically. Neurologically. And — maybe most importantly — in the way a patient walks out of a visit feeling like something real happened to them. Because in healthcare, perception and outcome are not as separate as we'd like to pretend.
The Problem with Leading with the Pop
There's a mythology around the chiropractic adjustment. The cavitation — that audible release when a joint is mobilized — carries a kind of cultural weight that most other manual therapies don't. Patients come in having watched YouTube videos of it. They've described it to their friends. Some of them are nervous about it. Some of them are specifically there for it.
And for years, I watched colleagues walk a patient in, do a thirty-second assessment, and go straight to the table. Adjust the cervical spine, adjust the lumbar, maybe throw in a thoracic roll, send them on their way.
It works. Sometimes. But I kept asking myself a question I couldn't shake: works compared to what?
What the Tissue Is Doing Before You Ever Touch the Joint
When a patient presents with restricted motion, pain, and guarding — whether from an acute strain, a chronic postural issue, or the kind of accumulated mechanical wear that comes from driving a combine for thirty years — the joint restriction is rarely the whole story. Surrounding musculature is in a protective state. Tone is elevated. The nervous system is, in a very real sense, braced.
You can adjust into that bracing. Clinicians do it every day. But you're working against a system that hasn't been given a reason to relax yet.
This is what I kept coming back to: what if you gave it a reason first?
Building the Protocol From the Ground Up
What I've arrived at — after years of iteration on my own patients here in Sioux Falls — is a three-stage sequence that I now consider my clinical foundation. It isn't revolutionary. The individual components have existed in manual therapy for decades. But the sequence, and the reasoning behind it, is something worth laying out explicitly.
Stage One: Soft Tissue Work — Earning the Right to Move the Joint
The first thing I do with almost every patient is address the soft tissue. Depending on the presentation, that might mean ischemic compression on active trigger points, instrument-assisted work, effleurage along the paraspinal musculature, or percussion therapy using a massage gun to drive mechanical vibration into hypertonic tissue.
The goal isn't relaxation for its own sake. The goal is neurological permission.
When you apply sustained pressure to a trigger point, or when percussion disrupts the local twitch response in an overactive muscle, you're doing something specific: you're interfering with the feedback loop that keeps that tissue contracted. The Golgi tendon organs, the muscle spindles, the Type III and IV afferents — they're all part of a system that's been running a particular pattern. Soft tissue work interrupts that pattern.
By the time I finish this stage, the patient's tissue is genuinely different than when they walked in. Warmer. Less guarded. More responsive. I haven't touched a joint yet, and they already feel better. That matters.
This is also the stage where I'm building trust. A patient who has experienced your hands for five minutes before you ask them to let you manipulate their cervical spine is a different patient than one who walked in thirty seconds ago.
Stage Two: PNF and PIR Stretching — Using the Nervous System Against Itself
Post-Isometric Relaxation and Proprioceptive Neuromuscular Facilitation are techniques most people associate with physical therapy. Chiropractors don't always claim them loudly. They should.
The principle is elegant: you ask a muscle to contract isometrically against resistance, then release, then take it into a lengthened position. What you're exploiting is a predictable neurological response — the autogenic inhibition that follows a sustained contraction. The Golgi tendon organ fires, the alpha motor neuron quiets down, and you get a window of reduced tone during which the muscle can be moved further than it normally would allow.
After soft tissue work has already reduced baseline tone, this window opens wider.
I think of it as a two-step unlock. The soft tissue work reduces the lock's resistance. The PNF/PIR stretching is the actual turn of the key. By the end of this stage, I have joints that are moving through a fuller range of motion, surrounded by musculature that has been neurologically reset — not just mechanically pushed aside.
Why This Changes What Comes Next
A restricted lumbar segment surrounded by hypertonic paraspinals requires more force to mobilize than that same segment after it's been properly prepared. More force means more patient apprehension. More apprehension means more bracing. More bracing means more force required. It's a cycle that degrades the quality of the adjustment and the patient's experience of it simultaneously.
Break the cycle at the start, and the adjustment that follows is a different procedure entirely.
Stage Three: The Chiropractic Adjustment — Arriving at the Right Moment
By the time I position a patient for an adjustment at the end of this sequence, a few things are true that weren't true when they walked through my van doors fifteen minutes earlier.
The periarticular musculature has lower tone. The joint itself is moving through a fuller range. The patient has experienced two prior interventions that felt good and communicated competence. And the neurological environment surrounding the target segment is primed — not braced.
The adjustment, in this context, is not the thing that overcomes the body's resistance. It's the thing that completes a process the body has already been guided toward.
The cavitation, when it comes, is cleaner. The force required is lower. And the therapeutic effect — whatever the exact mechanism turns out to be, and researchers are still genuinely debating this — is occurring in tissue that's been set up to receive it.
Patients in Sioux Falls and the surrounding communities — Brandon, Tea, Harrisburg, Renner — present with the same constellation of issues I see everywhere: lower back restriction, upper cervical tension, hip flexor tightness from hours in a cab or a car or a desk chair. This protocol meets all of it.
The Perceived Value Problem Nobody Wants to Talk About
Here is something I've learned to say plainly: perceived value is not a dirty concept in clinical care. It is, in fact, downstream of actual value — and pretending otherwise leaves patients worse off.
A patient who receives three distinct, recognizable, explainable interventions in a single visit — soft tissue work, therapeutic stretching, and a spinal adjustment — leaves understanding what happened to them. They can describe it to their spouse. They can connect what you did to how they feel. That connection is not an illusion. It's clinical comprehension, and clinical comprehension drives compliance, return visits, and the kind of word-of-mouth that sustains a practice in a mid-sized market like Sioux Falls better than any advertising ever will.
I have over 100 five-star reviews from patients across the Sioux Falls metro. When I read them carefully, a theme emerges that has nothing to do with whether a specific spinal segment moved the right number of millimeters. It's that people felt cared for. They felt like something thorough happened. They felt like the provider understood what their body needed and addressed it systematically.
That's not separate from good clinical outcomes. That's part of what a good clinical outcome looks like.
When to Break the Protocol
No sequence survives contact with every patient unchanged.
A patient presenting with active inflammation — a lumbar disc event in the first 48 hours, for instance — gets a different soft tissue approach or none at all. Percussion over acutely inflamed tissue is contraindicated and, frankly, cruel. A hypermobile patient with connective tissue laxity doesn't need aggressive PIR stretching; she needs stability work, and the adjustment, if indicated, is delivered with more care and less amplitude.
The protocol is a scaffold. The clinical judgment is in knowing when the scaffold needs to be modified — when effleurage replaces percussion, when PNF is swapped for active range of motion, when the adjustment itself is deferred in favor of more preparatory work.
What doesn't change is the underlying logic: you earn the adjustment. You don't start with it.
A Note on Where This Happens
I do all of this out of a fully equipped Ford Transit — a mobile clinic that comes to patients in Sioux Falls, Brandon, Tea, Harrisburg, and Renner. The van carries the same tools I'd have in any clinic: an adjusting table, percussion devices, the hands I've been developing for a decade.
The setting changes. The protocol doesn't.
If you've been managing chronic low back pain, cervicogenic headaches, hip restriction, or the kind of shoulder and neck tension that accumulates quietly over years, the question isn't whether manual therapy can help. The research on that is reasonably clear. The question is whether the sequencing is right — whether the person treating you understands that what happens before the adjustment is part of the treatment, not just the warm-up.
In my experience, that sequencing makes the difference between a patient who feels temporarily better and one who understands why they feel better — and comes back to stay that way.
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