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NEW MEDICARE DATA SHOWING $496 MILLION ANNUALLY SPENT ON CHIROPRACTIC BY MEDICARE SPARKS BACKLASH ARTICLE IN FORBES MAGAZINE

A new article published online on April 20, 2014 in Forbes magazine, New Medicare Data Reveal Startling $496 Million Wasted On Chiropractors, was yellow journalism at its best masquerading Medicare chiropractic expenditures data as an opportunity to politically attack the chiropractic profession.


In response to the article, swift and quick responses from the ACA and ICA, among other groups and individuals addressed the shortcomings of the article. From our own perspective at Neuromechanical Innovations, the points raised in the article can each be individually addressed and it is our hope that our responses with data may be helpful to you in discussing any questions that you may receive from patients or other health care professionals.


Motive.

First, consider the motivation for the Forbes article. The author, Steven Salzberg, took an interest in taking shots at chiropractors after learning about chiropractors’ anti-vaccination beliefs. He’ is a co-founder of the influenza virus sequencing project – there’s his rub. It’s not the first biased article that he’s written about chiropractic.

Biased Statements.

His clearly biased arguments in the article include:


“A huge amount of money is spent on the highly dubious practice known as chiropractic.” Yet, we have good evidence that chiropractic interventions are cost-effective (1;2).


“They (chiropractors) primarily treat back pain, but they claim to treat a wide range of other conditions, which some of them believe are related to mis-alignments of the spine, called subluxations. This belief has no scientific basis.” However, citing the very principles that Salzberg criticizes, chiropractors don’t aim to treat any conditions, rather, administer care to the spine in patients whom happen to suffer a variety of symptoms. Indeed, there is a scientific basis and rationale for applying care to the spine. Furthermore, the prevalence of patients with non-musculoskeletal symptoms that pay visits to chiropractors are indeed a small minority of overall visits (3).


“The entire field was invented out of thin air by D.D. Palmer in 1895, and later popularized by his son. In his book-length expose Chiropractic Abuse: An Insider’s Lament, chiropractor Preston Long lists “20 things most chiropractors won’t tell you…” Yet, the field was “invented” out of sound deductive principles and the profession has licensure in all 50 states and many countries throughout the world (4). Millions of satisfied patients drive the demand for chiropractic services (5). As further evidence for bias, Preston Long is a man whom earns his living as a plaintiff’s expert in legal cases against chiropractors (I know, I’ve been against him on the defense side).


“Chiropractic manipulation can cause a stroke, by causing a tear in the major artery running through the neck.” Yet, the highest level of evidence available to us, case-control studies, demonstrate the low association of veterbal artery dissection associated with chiropractic care (6), and it is more likely that those suffering adverse events associated with chiropractic care are seeking care for symptoms associated with a dissection (headache, neck pain) as opposed to a cause and effect relationship (7). In fact, stroke has been found to be just as likely in association to one’s family physician as to one’s chiropractor (8). To put it into perspective, are visits to one’s family doctor a concern as a risk factor for stroke? Of course not.


It’s our hope that this information and cited literature is useful to you in responding to this unsubstantiated and biased attack on chiropractic.

References


(1) Hurwitz EL. Epidemiology: Spinal manipulation utilization. J Electromyogr Kinesiol 2012 Jan 28.

(2) Hurwitz EL, Carragee EJ, van d, V, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008 Feb 15;33(4 Suppl):S123-S152.

(3) Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med 2007 Jun;13(5):491-512.

(4) Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002 Feb 5;136(3):216-27.

(5) Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998 Oct 8;339(15):1021-9.

(6) Cassidy JD, Bronfort G, Hartvigsen J. Should we abandon cervical spine manipulation for mechanical neck pain? No. BMJ 2012;344:e3680.

(7) Kawchuk GN, Jhangri GS, Hurwitz EL, Wynd S, Haldeman S, Hill MD. The relation between the spatial distribution of vertebral artery compromise and exposure to cervical manipulation. J Neurol 2008 Mar;255(3):371-7.

(8) Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976 ) 2008 Feb 15;33(4 Suppl):S176-S183.

SPECIFICITY, CONTROLLED FORCE, AND EASE OF APPLICATION ATTRACT CHIROPRACTORS TO PEDIATRIC INSTRUMENT ADJUSTING

By Christopher J. Colloca, D.C.
CEO & Founder - Neuromechanical Innovations

Why Peds?

Chiropractic pediatrics has become a growing interest within the profession. After all, Complementary and Alternative Medicine utilization by the pediatric population is increasing (1;2). Studies in the Journal of Pediatrics (2) have discussed the growing utilization rate of chiropractic services among pediatric patients. Citing a 1998 JAMA study (3) of $4 Billion spent on chiropractic care in the United States, $1 Billion was spent on chiropractic care of children, and nearly half of the expenditures were paid out of pocket. Indeed, kids need chiropractic care too and pediatric instrument adjusting provides a unique and efficient treatment approach in chiropractic care delivery.


Pediatric Training of the DC

Technique applications for the pediatric population can be subcategorized into newborns (0-3 mos), infants (3-18 mos.), toddlers (18 – 36 mos.), children (3 – 12 yrs.), and adolescents (12-18 yrs.) Different strategies for pediatric chiropractic techniques must be considered based upon the musculoskeletal and neural development of the particular age group. These include variations in both physical examination and assessment as well as treatment application.


Technique Considerations in Chiropractic Pediatrics

First, consider the motivation for the Forbes article. The author, Steven Salzberg, took an interest in taking shots at chiropractors after learning about chiropractors’ anti-vaccination beliefs. He’ is a co-founder of the influenza virus sequencing project – there’s his rub. It’s not the first biased article that he’s written about chiropractic.


While other groups advocate motion palpation as an assessment tool, intra- and inter-examiner reliability studies have seriously questioned their clinical utility. The Impulse Adjusting System® thus advocates alternative objective measures in the physical examination of pediatric patients including postural evaluation, global range of motion, functional tests and static palpation. Dysfunctional responses are revealing of chiropractic subluxation driving the Impulsive [1] adjustment indicators.


How Can I Be Specific In Contacting Tiny Bones?

The speed of an Impulse® adjustment has been found to be on the order of 100x faster than a manual adjustment(7;8). The extreme speed of the Impulse® devices allows the adjustment to occur before the muscles tighten up and resist the adjustment, which is commonplace during adjusting set-ups that require rotation and tensioning during the tissue pull.


Manual chiropractic techniques advocate making contact points using bony prominences of the hands, including the pisiform or fingertips. Considering the small size of the spine in infants and toddlers, this calls into question the specificity of manually applied chiropractic techniques. A study by Perle (4) found that the hamate was actually the contact point among those attempting to use their pisiform. Another study that examined the surface area over which segmental contacts are delivered determined that an area as large as 4-6x is utilized during manual thrusts (5) . Considering the small size of pediatric bones, it’s unlikely that manual techniques are able to target the joints that they intend. Impulse® adjusting offers a solution by providing a small 1 cm2 tip for use as the contact point, thereby increasing the specificity of adjustments.


How Much Force is Appropriate for the Pediatric Patient?

From a medicolegal perspective, consideration of the force application during chiropractic adjustments to pediatric patients are second only to failure to diagnosis in commonality amongst litigious claims. Recent allegations in Australia have included an alleged fractured dens following manual chiropractic interventions and rib fractures in an infant receiving care with an Activator device (6) . A recent review of the literature was undertaken to study and ascertain the ligamentous strains to attempt to arrive at appropriate forces to use when adjusting the pediatric spine. As the search for improved practice measures continues, the Impulse Adjusting System® offers new coursework for managing the pediatric patient with all new analysis and adjusting protocols for instrument adjusting.

The Impulse Adjusting® Solution for Pediatrics

Consistent Force Application With Every Adjustment.

Incorporation of the Impulse Adjusting Instrument® for care of pediatric patients provides a sound benefit of a consistent known force with each and every adjustment delivery. Knowing the applied force provides benefits to the patients of receiving consistent care that is known to be within the physiologic range and definitively below any threshold for iatrogenic injury. This certainty alone is a deciding factor for many DCs in adopting instrument adjusting for pediatric patients. The low force setting of the Impulse and Impulse iQ instruments are approximately 25% less force than the spring loaded instruments in the market (7).

Extreme Speed Benefits of Instrument Adjusting.

The speed of an Impulse® adjustment has been found to be on the order of 100x faster than a manual adjustment(7;8). The extreme speed of the Impulse® devices allows the adjustment to occur before the muscles tighten up and resist the adjustment, which is commonplace during adjusting set-ups that require rotation and tensioning during the tissue pull.

Ease of Use in Sometimes Difficult Times

Ease of use is obviously another benefit to Impulse® adjusting for pediatrics. The ability to quickly get in to deliver the adjustment and out again is appreciated by clinicians who work with kids who are many times fussy, uncomfortable, squirming or crying at the time of care.

References


(1) Adams D, Dagenais S, Clifford T, Baydala L, King WJ, Hervas-Malo M, et al. Complementary and alternative medicine use by pediatric specialty outpatients. Pediatrics 2013 Feb;131(2):225-32.

(2) Kemper KJ. Holistic pediatrics = good medicine. Pediatrics 2000 Jan;105(1 Pt 3):214-8.

(3) Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA 1998 Sep 2;280(9):788-94.

(4) Perle SM, Kawchuk GN. Pressures generated during spinal manipulation and their association with hand anatomy. J Manipulative Physiol Ther 2005 May;28(4):e1-e7.

(5) Herzog W, Kats M, Symons B. The effective forces transmitted by high-speed, low-amplitude thoracic manipulation. Spine 2001 Oct 1;26(19):2105-10.

(6) Wilson PM, Greiner MV, Duma EM. Posterior rib fractures in a young infant who received chiropractic care. Pediatrics 2012 Nov;130(5):e1359-e1362.

(7) Colloca CJ, Keller TS, Black P, Normand MC, Harrison DE, Harrison DD. Comparison of mechanical force of manually assisted chiropractic adjusting instruments. J Manipulative Physiol Ther 2005 Jul;28(6):414-22.

(8) Keller TS, Colloca CJ, Moore RJ, Gunzburg R, Harrison DE, Harrison DD. Three-dimensional intersegmental motion validation of mechanical force spinal manipulation. J Manip Physiol Ther 2006;in press.

ACTIVATOR FARES WORSE THAN MANUAL MANIPULATION IN NEW LARGE SCALE RCT STUDY

Results from a recent NIH Funded large scale randomized controlled clinical trial (RCT) were presented in Orlando in March, 2014 at the Association of Chiropractic Colleges Research Agenda Conferencecomparing manual spinal manipulation with Activator Methods type care and usual medical care. The manual thrust manipulation group received side posture HVLA to regions identified by palpation standard in chiropractic practice. The mechanically-assisted manipulation group received care by a certified Activator Methods practitioner using the Activator IV Instrument and using palpation and the Activator Method of leg length analysis. For the usual medical care group, care consisted of advice and over-the-counter analgesic and NSAID medications by a medical physician board certified in physical medicine and rehabilitation according to current clinical guidelines for the management of non-specific LBP in primary care practice.


The 107 subjects in the study were randomized to each of the three groups and received care 2x per week in the manipulation group and 3x per week in the medical care group. Outcome measures included Oswestry low back pain disability index and numeric pain rating scale and were taken at baseline, 4 weeks, three months and six months. The study reported significantly greater reductions in Oswestry scores (physical function) and pain scores in the manual manipulation group over the Activator Methods group at 4 weeks. Significant differences in pain scores favoring manual manipulation over Activator Methods treatment and usual medical care were also found at follow-up. The abstract of the study can be found below and the study is currently in review for publication in the scientific literature.


Indeed, this study is unique and important for several reasons. First, it is the largest RCT ever conducted that included comparisons of Activator treatment and Manual manipulation and in fact, to our knowledge the first study that has ever shown superiority of one technique over another. Second, unique to this study was the fact that the Activator practitioners actually did the Activator “Method” of leg length analysis for clinical decision making. Among previous RCTs done involving an “Activator” almost all used standard Diversified measures to locate the segment to treat, and not the Activator “Method” of isolation tests and challenges. Indeed, the poor showing of the Activator group may be due to the fact that the Activator Method didn’t properly identify the correct target area for treatment. Activator methods dubious technique procedures have been criticized for their reliability and validity (1-4). Of course, it’s also possible that the Activator IV instrument itself wasn’t effective due to its smaller force than lumbar manual manipulation. Whatever the case, this study takes the wind out of the sails for proponents of the technique.


A 2012 Systematic Review on the clinical effectiveness of the Activator Adjusting Instrument (REF) in the treatment of musculoskeletal disorders identified only 8 clinical studies, none of which were randomized clinical trials. The review reported that it is unfortunate that most of the clinical trials investigating Activator’s effectiveness were only pilot studies involving between 8 and 92 patients and typically involving only one or two treating doctors with a limited post-study follow-up. The authors further noted, “Moreover, not all studies were adequately controlled with respect to both subject and examiner blinding, with 5 of the studies being assigned a “0” out of 5. An additional limitation was that all but one study failed to either strategize or adjust for relevant baseline characteristics. Due to the lack of long-term follow-up care and the use of a single treatment intervention, contamination and co-intervention grading had to be assumed in 4 of the 8 studies which may have further influenced the overall quality of these studies. A further limitation was that 7 of the 8 studies utilized a previously established patient base as study subjects, thus introducing the possible confounding factors of treatment expectancy and type II errors.” Considering the lack of quality evidence to support the Activator Method, the current study, being a large scale RCT demonstrating negative outcomes raises serious concern for support of the use of Activator. Considering that some third-party payers will not currently reimburse for Activator treatments due to concerns of lack of effectiveness, this study may only lead to further abandonment of this technique and intervention.


This is among the many reasons why we have prospectively taken the time to research the forces and speeds of manual adjustments and have created an instrument that can produce similar forces to manual manipulation. We’ve shown that these instrument delivered forces to the spine can create the same intersegmental motions as manual manipulation (Colloca et al., Clinical Biomechanics, 2006). In Impulse Adjusting Technique®, we advocate using PART findings for our analysis, the most reliable and valid measures to determine where to apply treatment. Currently, there are four RCTs underway in different parts of the World investigating the effects of Impulse delivered treatment on various functional and health outcomes.


Schneider MJ et al. A Comparison of Spinal Manipulation Methods and Usual Medical Care for Low Back Pain: A Randomized Clinical Trial. Proceedings of the 2014 ACC RAC Conference, Orlando, Florida, March 20-22, 2014.

ABSTRACT


Background Context: Low back pain (LBP) is one of the most common conditions seen in primary care and physical medicine practice. Manual thrust manipulation is a common treatment for LBP. Mechanical-assisted manipulation devices are being promoted as safe and effective alternatives to manual manipulation, but these claims have yet to be substantiated. In addition, there is still some question about the use of spinal manipulation in acute episodes of LBP, as compared to the use of over-the-counter medications and advise to stay active (usual medical care).


Purpose: This study was designed to explore two key issues: 1) the comparative effectiveness of manual versus mechanical types of spinal manipulation; and 2) the comparative effectiveness of spinal manipulation versus usual medical care.


Study Design/Setting: Randomized, controlled clinical trial (Funding Source: NIH/NCCAM Grant # R00AT004196) conducted at a University-affiliated Center for Integrative Medicine.


Patient Sample: 107 adults with a new onset of LBP within the past 12 weeks.


Outcome Measures: Oswestry low back pain disability index and numeric pain rating scale.


Methods: Subjects were randomized to one of three treatment groups: 1) Manual-Thrust Manipulation (MTM); 2) Mechanical-Assisted Manipulation (MAM); and 3) Usual Medical Care (UMC). Subjects in the two manipulation groups were treated twice a week for four weeks, and subjects in the UMC group were seen three times over four weeks. Outcome measures were captured at baseline, four weeks, three months and six months.


Results: Subjects in the MTM group achieved significantly greater reductions in Oswestry scores at four weeks compared with MAM (-8.1, p=0.009) and UMC (-6.5, p=0.032). The MTM subjects also had greater reductions in Numeric Pain Ratings scores at four weeks compared with MAM (-1.4, p=0.002) and UMC (-1.7, p<0.001). Significant differences in pain scores, in MTM versus MAM and UMC, were also found (with p=0.05 and p=0.04) in the repeated measures model. No adverse events were reported in any group.


Conclusions: MTM provides greater immediate reductions in self-reported disability and pain scores as compared to UMC or MAM.

References

(1) Troyanovich SJ, Harrison DD, Harrison DE. Motion palpation: it's time to accept the evidence. J Manipulative Physiol Ther 1998 Oct;21(8):568-71.

(2) Schneider M, Homonai R, Moreland B, Delitto A. Interexaminer reliability of the prone leg length analysis procedure. J Manipulative Physiol Ther 2007 Sep;30(7):514-21..

(3) Haas M, Peterson D, Hoyer D, Ross G. Muscle testing response to provocative vertebral challenge and spinal manipulation: a randomized controlled trial of construct validity. J Manipulative Physiol Ther 1994 Mar;17(3):141-8..

(4) Haas M, Peterson D, Panzer D, Rothman EH, Solomon S, Krein R, et al. Reactivity of leg alignment to articular pressure testing: evaluation of a diagnostic test using a randomized crossover clinical trial approach. J Manipulative Physiol Ther 1993 May;16(4):220-7.

COLLOCA PRESENTS BIOMECHANICS RESEARCH IN BARCELONA, SPAIN

BARCELONA, Spain - Christopher J. Colloca, D.C. presented his team's original biomechanics research at the 12th Annual Conference of the International Society for the Advancement of Spinal Surgery (ISASS) in Barcelona, Spain on March 22, 2012. The research is a culmination of the work of a multi-disciplinary research team that he assembled combining his specialty as a chiropractor and biomechanist together with the expertise of orthopedic spine surgeons, biomedical engineers, and histopathologists, from Australia, Belgium, Canada, and the USA. The paper being accepted for platform presentation at the prestigious orthopedic conference is further testimony to the success of the collaboration.


The paper entitled, Quantifying Biomechanical Alterations of Cervical Disc Degeneration: An in vivo Spinal Stiffness Assessment Methodology, presented the team's first results of its inquiry to the cervical spine at the Adelaide Centre for Spinal Research (ACSR) in (Adelaide) Australia. In the study a validated degenerated disc model in sheep was used to determine if differences in spinal stiffness existed between normal and degenerated cervical spine discs. This research provides the unique opportunity to examine spine biomechanics in living subjects, as opposed to ex vivo studies conducted on cadaveric specimens. Significant differences in spinal stiffness were observed in animals with cervical disc degeneration with the examiner blinded to the subject groups. The work is currently being prepared for journal submission.

The group's previous research has focused on the lumbar spine where their instrumentation was validated and numerous clinical conditions have been examined. Lumbar disc degeneration, muscle hyperactivity, ligament injury, spondylolysis, the effects of an interspinous implant have all been compared to normal conditions and published in a variety of scientific journals such as Clinical Biomechanics, European Spine Journal, The Journal of Electromyography and Kinesiology, The Journal of Biomechanics, and Spine among others. Concerning his research, Dr. Colloca stated, "I wanted to have our research presented at the very highest level medical scientific conferences so we could receive constructive criticism prior to publication. It's helpful for the chiropractic profession to have the technology that we're developing stand up to the scrutiny of the medical community. That's how you do it in the medical device arena."


The ability to objectively quantify spinal motions is of great interest to not only chiropractors, but to anyone who examines the spine. Dr. Colloca explained, "For years, chiropractors and physical therapists have used motion palpation during clinical assessments of their patients. The problem, however, is that our own kinesthetic senses aren't good enough to detect normal from abnormal, which is why the reliability studies are so poor with the qualitative motion palpationtechniques. Using a sensor mounted inline with a stylus, using an instrument we can probe the spine and quantify its stiffness using numbers that are reliable and valid. I think that this truly will be thefuture of physical examination not only in chiropractic, but across healthcare disciplines from PT to Orthopedics." The research was generously supported by the International Spine ResearchFoundation (INSPIRE) through grants from CBP Non-profit, Inc., and The William M. Harris Family Foundation.


For further details visit www.helpinspire.org. Citation: Colloca CJ, Gunzburg R, Szpalski M, Freeman BJ, Afifi M, Moore RJ. Quantifying biomechanical alterations of cervical disc degeneration: an in vivo spinal stiffness assessment methodology. 12th Annual Meeting of the International Society for the Advancement of Spine Surgery (ISASS). Barcelona, Spain, March 20-23, 2012:46.


THE IMPORTANCE OF THE HIPS

By James W. Gudgel, DC, RPT
Lead Instructor, Neuromechanical Innovations
Clinic Director, Chiro-Plus
Redwood Falls, MN


Part of our “5-Point Pelvic Analysis” is the evaluation of internal and external rotation of the hips (femero-acetabular joints). There is good reason for this. Researchers and clinicians have found that sacroiliac joint motion is inherently related to hip motion. Scholtes et al, Clinical Biomechanics, 2008:24, found that hip rotation is often unilaterally reduced in patients with low back pain. Flynn et al, in Spine, December, 2002, found that patients with low back pain who also had reduced hip rotation did not respond as well to spinal manipulative therapy.


They said, “When the hips are stuck, address them first. Releasing the hip takes the load off of the lower back.” Allum and Honnegger reported in Experimental Brain Research, 1998, “Unilaterally reduced or altered hip motion produces rotation of the trunk. This excites lumbar joint receptors triggering muscular contractions to counter the rotary forces and provide stability.” Ford, in Advance for Physical Therapy and Rehab Medicine, May 16, 2011, said, “What makes discs bulge are the joints dictating the misaligned position of the vertebrae. It follows that if you take away the mechanical twist of the spine, you take away the disc bulge.” Cibulka et al, Spine, 23:9, found that patients with low back pain and evidence of sacroiliac joint dysfunction often had unilaterally reduced hip internal rotation.



When there is a decrease in hip internal rotation, the possible cause could be inhibited (short, tight, tender, and resistant to stretch – Headley, Advance for Physical Therapists, Feb 9, 2009) external rotator muscles. The gluteus maximus is the most powerful external rotator (and extensor) of the hip but it is often inhibited and weakened from years of SI joint fixation (Hungerford et al, Spine, 2003:38). This weakness can be observed when the patient is asked to perform a one-legged supine bridge maneuver (McGill, Low Back Disorders, 2002). It is also evident during Dr. Major DeJarnnette’s prone hip extension test (a.k.a. “Sacral Cup” tests) when there is an SI lesion on that side. And when the maximus is weak, the 6 deep external rotators are forced to work harder to produce the necessary external rotation and hip extension that is part of normal gait. Muscles that are “over-loaded”, or forced to work in a manner that they are not accustomed to, will become inhibited. For example, have you ever performed a lot of heavy resistance biceps curls during an exercise session? Did you notice how painful and difficult it was to straighten your elbows the next day? The biceps muscles and tendons were overloaded and strained, and became inhibitied. Thus, often the loss of hip internal rotation that we see is muscular induced.


But sometimes it is due to advanced osteoarthritis of the hip. Mcknas et al, Scandivanian Journal of Medicine and Science in Sports, April, 2010, stated that OA of the hip may start in the deep external rotator tendons and then proceed to the joint. In patients with OA of the hip, there were more tendon ruptures with scar tissue, increased amounts of GAGs and calcium deposits, and lack of distinct inflammatory changes as seen in tendinosis of other areas of the body, especially the internal obturator tendon (one of the deep 6 hip external rotators).


I recommend that the “5-Point Pelvic Analysis” that we’ve developed in the Impulse Adjusting System® to be performed on every patient, regardless of their complaints or symptoms, including young children who are just beginning to walk. With this technique you can evaluate the sacroiliac joints, and hips to assess the pelvis and further differentially diagnose sacroiliac joint versus lumbar problems.


Further, adjusting of the primary subluxations in these areas is complimented by adjustments of the compensatory or causative hip joint dysfunctions while allowing you to reset the lower extremity muscles that have been receiving the hyperactive message being sent to them. In all, this thorough approach has proven value to me and to the thousands of doctors who have adopted the Impulse Adjusting Techniques. Give it a try for yourself and let us know your feedback.



"Top 10 Benefits of Instrument Adjusting" by Christopher J. Colloca, DC, PhD


What are the benefits of instrument adjusting? Do you have a list I can see and download?

Yes we do! Instrument Adjusting has grown to become one of the most commonly used techniques in today’s chiropractic practice, second only to Diversified type manual spinal manipulation (National Board of Chiropractic Examiners Survey, 2000).


From ease of use to added patient safety, adjusting instruments provide a new dimension to chiropractic practice. Likewise, instrument adjusting has expanded the range of conditions and patients that can now be more easily managed with chiropractic care. Read more below and download the article.

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"Top 10 Benefits of Instrument Adjusting" by Christopher J. Colloca, DC, PhD

So, why all the buzz about instrument adjusting? Here are the top ten most popular reasons why you should incorporate Instrument adjusting into your practice.

#10. Mechanical Advantage

Adjusting instruments were developed to provide a mechanical advantage for more efficient chiropractic adjustments. Biomechanically speaking, adjustments are delivered to move the bones of the spine. If there were a way to move vertebra the same amount as manually, but with less force, would you be interested?


Newton’s Second Law is force equals mass times acceleration. Adjusting instruments take advantage of the acceleration part of the equation in providing large accelerations with a substantially smaller mass. In contrast, to achieve force, manual adjustments require the use of more mass (weight) due to our physical limitations in achieving accelerations. Increasing the speed component of chiropractic thrusts has been found to be associated with the elicitation of neuromuscular reflexes thought to be related to the mechanisms underlying successful treatments. Instrument adjustment speed also allows you to deliver the thrust faster than the patient’s natural tendency to tighten up and resist the adjustment.


Stress is another consideration among the mechanical advantages of instrument adjusting. In continuum mechanics, stress is a measure of the average amount of force exerted per unit area, where stress equals force divided by area. When we contact the spine with our hand, the surface area over which the force is produced is relatively large compared to the stylus of an adjusting instrument. Adjusting instruments achieve an appreciable stress to the spine, while keeping forces relatively low due to their small contact area with the patient. By having such a small surface area contact, less force is required to achieve the same stresses that are imparted to the spine with manual adjustments. Appreciating the concept of stress together with the understanding of the high accelerations achieved with instrument adjusting, it’s easy to understand how studies have shown that the same amount of intersegmental bone movement can be achieved with instrument adjusting as manual techniques.

#9. Safety

Chiropractic adjustments are extremely safe. Still, there are instances where you may have a concern of manually adjusting a particular patient. You may not want to provide higher forces of manual adjustments to an elderly patient with osteoporosis. Maybe you don’t want to impart rotatory cervical spine adjustments to a patient with dizziness or signs of cerebrovascular disease. Low force instrument adjusting techniques can be delivered in the prone neutral position, thus enabling you to administer care with peace of mind in situations where you may otherwise feel uncomfortable applying manual techniques.

#8. Easy Incorporation into Your Existing Technique

The National Board survey cited above also revealed that the average chiropractor uses about five different chiropractic techniques in combination in their practice. Instrument adjusting can be easily incorporated into your existing technique. You may want to adjust the upper cervical spine and TMJ of a headache patient with an instrument, yet perform manual methods on their thoracic and lumbar spine.

#7. Evidence-Based Care

Studies have found instrument adjusting to be equivalent to manual adjusting techniques. In a number of clinical trials, instrument adjusting fared just as well as manual adjusting in reducing pain and improving function in pain patients seeking chiropractic care. Ongoing research into the basic science and clinical study of instrument adjusting has quantified vertebral motions, electromyographic responses, and neurophysiological responses associated with instrument adjusting.

#6. Increase Your Range of Patients

Instrument adjusting allows you to care for a broader range of patients. The low force setting makes adjustments easier to provide pediatric adjusting, as well as provides a quick and effective method to manage children.

#5. Expand Your Range of Services

Not treating plantar fasciitis in patients’ feet? Avoiding concentrating on the spine and extremity adjusting, patients with anterior rib pain, TMJ dysfunction, shoulder problems, etc.? Incorporating instrument adjusting into your practice allows you to care for a broader range of conditions and will create a buzz among your patients!

#4. Add Technology to Your Practice

Adding instrument adjusting to your practice gives your practice a feeling of technology in this technological age. Explain to your patients that the adjusting instrument you are about to use is not only much faster than you can adjust them manually with your hands, but also that you can target just the right areas specifically with the tip of the stylus. Your patients will be impressed with your choice to stay current with the times by adding technology to help them heal!

#3. Easier on Your Patient

Because of the extreme speed and lower forces generated with instrument adjusting, the adjustments are easier on the patient. This equates with less side effects, such as muscle soreness, and increased pain during or after treatment. Adjustments that are easier on the patient increase patient satisfaction, compliance and patients’ willingness to refer others.

#2. Speed up Your Adjusting Time

If we could achieve the same or better clinical results while speeding up your patient treatment time, you would be more efficient with both yours and your patient’s time. Instrument adjusting, when done properly, is fast and effective. Care for more patients each day in less time.

#1. Easier on You

Instrument adjusting may prolong your practice career. Instrument adjusting is easier on you, and with the new technology, you can stop beating yourself up. Not only are instrument delivered adjustments usually performed with the table in a higher position, allowing you to stand up instead of bend over, you also don’t need to generate high forces with your own body, since the instrument does the work for you. Decrease the risk of injuring yourself and prolong your practice career with instrument adjusting.

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