Instrument Adjusting Overview
The advent of using a device to assist in manipulating the spine dates back over centuries. Over the past 40 years, instrument adjusting has risen in prominence within the chiropractic profession. In fact, Instrument Adjusting has grown to become one of most commonly used chiropractic techniques in today’s practice, second only to Diversified type manual spinal manipulation (National Board of Chiropractic Examiners Survey, 2000). In this white paper, you will find important information about chiropractic instrument adjusting and the world’s fastest growing chiropractic technique, Impulse Adjusting Technique. From research to specifications, to technique summaries, this white paper will assist you in understanding and implementing instrument adjusting in your practice.
Impulse Research and Development
Bench Test Experiments Comparing Instrument Adjusting Devices
* Colloca CJ, Keller TS, Black P, Normand MC, Harrison DE, Harrison DD. Biomechanical comparison of mechanical force manually assisted chiropractic adjusting instruments. Journal of Manipulative and Physiological Therapeutics 2005; 28(6):414-22.
A 2005 study published in the Journal of Manipulative and Physiological Therapeutics compared the forces, speeds, and frequency area ratio of six commonly used chiropractic adjusting instruments including Impulse. The study reported a broader range of forces an
d a superior frequency area ratio among electromechanical adjusting instruments over traditional spring-loaded activation devices specifically favoring the Impulse Adjusting Instrument. Impulse was also found to be twice as fast as the spring-loaded activation devices examined on all settings. These findings provide a scientific rationale supporting the anecdotal reports of better results with patients by clinicians using Impulse.
OBJECTIVE: To quantify the force-time and force-delivery characteristics of six commonly used handheld chiropractic adjusting devices.
METHODS: Four spring-loaded instruments, the Activator Adjusting Instrument; Activator II Adjusting Instrument, Activator III Adjusting Instrument, and Activator IV Adjusting Instrument, and two electromechanical devices, the Harrison Handheld Adjusting Instrument and Neuromechanical Impulse Adjusting Instrument, were applied to a dynamic load cell. A total of 10 force-time histories were obtained at each of three force excursion settings (minimum to maximum) for each of the six adjusting instruments at preload of approximately 20 N.
RESULTS: The minimum-to-maximum force excursion settings for the spring-loaded mechanical adjusting instruments produced similar minimum-to-maximum peak forces that were not appreciably different for most excursion settings. The electromechanical adjusting instruments produced short duration (approximately two to four ms), with more linear minimum-to-maximum peak forces. The force-time profile of the electromechanical devices resulted in a more uniform and greater energy dynamic frequency response in comparison to the spring-loaded mechanical adjusting instruments.
CONCLUSIONS: The handheld, electromechanical instruments produced substantially larger peak forces and ranges of forces in comparison to the handheld, spring-loaded mechanical devices. The electromechanical instruments produced greater dynamic frequency area ratios than their mechanical counterparts. Knowledge of the force-time history and force-frequency response characteristics of spinal manipulative instruments may provide basic benchmarks and may assist in understanding mechanical responses in the clinical setting.
In Vivo Experiments Comparing Instrument Adjusting Devices
* Keller TS, Colloca CJ, Moore RJ, Gunzburg R, Harrison DE, Harrison DD. Threedimensional intersegmental motion validation of mechanical force spinal manipulation. Journal of Manipulative and Physiological Therapeutics 2006; 29(6):425-36.
A study published in the July/August, 2006 issue of the Journal of Manipulative and Physiological Therapeutics reported nearly three-fold greater vertebral motions during chiropractic adjustments delivered with the Impulse Adjusting Instrument when compared to other chiropractic adjusting instruments. The study, conducted in Adelaide, Australia at the Institute for Medical and Veterinary Science, was the first to validate just how vertebrae move during different instrument-delivered chiropractic adjustments. Activator IV Adjusting Instrument (Activator Methods International Ltd., Phoenix), the Chiropractic Adjusting Tool (CAT, J-Tech Medical Industries Inc., Salt Lake City), and the Impulse Adjusting Instrument (Neuromechanical Innovations LLC, Phoenix) were researched to see how the spine would move during each of their force settings. Substantially larger magnitude vertebral motion responses were observed for thrusts delivered with the Impulse Adjusting Instrument at most force settings and always at the high force setting. Interestingly, on the low force setting, larger magnitude vertebral accelerations were observed with Impulse compared to the spring-loaded devices despite the fact that these devices exhibit higher peak forces on the low setting. Because Impulse is twice as fast, and its near perfect half sine waveform, its efficiency is greatly improved, thereby explaining how this is possible. The Impulse Adjusting Instrument has been shown to produce chiropractic adjustments at a rate of about a hundred times faster than traditional manual type chiropractic adjustments.
OBJECTIVE: The aim of this study was to quantify and compare the 3-dimensional intersegmental motion responses produced by three commonly used chiropractic adjusting instruments.
METHODS: Six adolescent Merino sheep were examined at the Institute for Medical and Veterinary Science, Adelaide, Australia. In all animals, triaxial accelerometers were attached to intraosseous pins rigidly fixed to the L1 and L2 spinous processes under fluoroscopic guidance. Three handheld mechanical force chiropractic adjusting instruments (Chiropractic Adjusting Tool [CAT], Activator Adjusting Instrument IV [Activator IV], and the Impulse Adjusting Instrument [Impulse]) were used to randomly apply posteroanterior (PA) spinal manipulative thrusts to the spinous process of T12. Three force settings (low, medium, and high) and a fourth setting (Activator IV only) were applied in a randomized repeated measures design. Acceleration responses in adjacent segments (L1 and L2) were recorded at 5 kHz. The multiaxial intersegmental (L1-L2) acceleration and displacement response at each force setting was computed and compared among the 3 devices using a repeated measures analysis of variance (alpha = .05).
RESULTS: For all devices, intersegmental motion responses were greatest for axial, followed by PA and medial-lateral (ML) measurement axes for the data examined. Displacements ranged from 0.11 mm (ML axis, Activator IV low setting) to 1.76 mm (PA axis, Impulse high setting). Compared with the mechanical (spring) adjusting instruments (CAT, Activator IV), the electromechanical Impulse produced the most linear increase in both force and intersegmental motion response and resulted in the greatest acceleration and displacement responses (high setting). Significantly larger magnitude intersegmental motion responses were observed for Activator IV vs CAT at the medium and high settings (P < .05). Significantly larger-magnitude PA intersegmental acceleration and displacement responses were consistently observed for Impulse compared with Activator IV and CAT for the high force setting (P < .05).
CONCLUSIONS: Larger-magnitude, 3D intersegmental displacement and acceleration responses were observed for spinal manipulative thrusts delivered with Impulse at most force settings and always at the high force setting. Our results indicate that the forcetime characteristics of impulsive-type adjusting instruments significantly affects spinal motion and suggests that instruments can and should be tuned to provide optimal force delivery.
Effects of Multiple-Impulse Thrusts
* Keller TS, Colloca CJ, Moore RJ, Gunzburg R, Harrison DE. Increased multiaxial lumbar motion responses during multiple-impulse mechanical force manually assisted spinal manipulation. Chiropratic & Osteopathy 2006; 14(1):6-14.
A 2006 study published in the journal Chiropractic and Osteopathy determined that multiple-impulse chiropractic adjustments can create up to 25 percent more vertebral movement than single chiropractic thrusts. This study represents the first biomechanical investigation of the effect of multiple-impulse thrusts on vertebral motions. Using the Impulse® device the first thrust was compared to a series of consecutive thrusts delivered six times per second (6 Hz) to the spinous processes of sheep. Using high-tech tri-axial accelerometers, the intersegmental motions of the vertebrae were able to be measured and compared between the initial thrust and subsequent thrusts. The research revealed a general trend toward maximizing vertebral motions typically anywhere between the third and
BACKGROUND: Spinal manipulation has been found to create demonstrable segmental and intersegmental spinal motions thought to be biomechanically related to its mechanisms. In the case of impulsive-type instrument device comparisons, significant differences in the force-time characteristics and concomitant motion responses of spinal manipulative instruments have been reported, but studies investigating the response to multiple thrusts (multiple impulse trains) have not been conducted. The purpose of this study was to determine multi-axial segmental and intersegmental motion responses of ovine lumbar vertebrae to single impulse and multiple impulse spinal manipulative thrusts (SMTs).
METHODS: Fifteen adolescent Merino sheep were examined. Tri-axial accelerometers were attached to intraosseous pins rigidly fixed to the L1 and L2 lumbar spinous processes under fluoroscopic guidance while the animals were anesthetized. A handheld electromechanical chiropractic adjusting instrument (Impulse) was used to apply single and repeated force impulses (13 total over a 2.5 second time interval) at three different force settings (low, medium, and high) along the posteroanterior axis of the T12 spinous process. Axial (AX), posteroanterior (PA), and medial-lateral (ML) acceleration responses in adjacent segments (L1, L2) were recorded at a rate of 5000 samples per second. Peak-peak segmental accelerations (L1, L2) and intersegmental acceleration transfer (L1-L2) for each axis and each force setting were computed from the acceleration-time recordings. The initial acceleration response for a single thrust and the maximum acceleration response observed during the 12 multiple impulse trains were compared using a paired observations t-test (POTT, alpha = .05).
RESULTS: Segmental and intersegmental acceleration responses mirrored the peak force magnitude produced by the Impulse Adjusting Instrument. Accelerations were greatest for AX and PA measurement axes. Compared to the initial impulse acceleration response, subsequent multiple SMT impulses were found to produce significantly greater (3 percent to 25 percent, P < 0.005) AX, PA and ML segmental and intersegmental acceleration responses. Increases in segmental motion responses were greatest for the low force setting (18 percent-26 percent), followed by the medium (5 percent-26 percent) and high (3 percent-26 percent) settings. Adjacent segment (L1) motion responses were maximized following the application of several multiple SMT impulses.
CONCLUSION: Knowledge of the vertebral motion responses produced by impulsetype, instrument-based adjusting instruments provide biomechanical benchmarks that support the clinical rationale for patient treatment. Our results indicate that impulse-type adjusting instruments that deliver multiple impulse SMTs significantly increase multiaxial spinal motion.
The Impulse Adjusting Instruments Specifications
Over the past five years, more than 6,000 chiropractic offices, in all 50 States and more than 40 countries around the world have incorporated the Impulse and Impulse iQ Adjusting Instruments into their practice. Here are some important specifications about the Impulsefamily of chiropractic adjusting instruments.
*Areas of the body to be treated with Impulse and Impulse iQ Adjusting Instruments, and the clinical utility and effectiveness of treatment are determined by the clinical judgment of the licensed health care provider administering care under their scope of practice.
The Impulse and Impulse iQ Adjusting Instruments both have three distinct force settings (low, medium, and high) that are achieved by means of the three-position switch located just above the handle grip. Selection of the appropriate force setting is essential for safety and achieving the best results with patients. Prior to applying the instrument to the patient, first thrust into your own hand to get a feel for the thrust that the chosen force setting produces. Below are some general guidelines. Setting Switch Position Typical Use Force () Force (Pound
|Setting||Switch||Typical Use On||Force||Force|
|Occiput, TMJ, Upper Cervical Spine, Pediatric|
|or Geriatric Patients, Excessively Tender Areas|
|Lower Cervical, Thoracic, Lumbar|
|High||Up||Lumbar Spine, Sacrum, Sacroiliac Joint, Hip||400||90|
Prior to adjusting, pressing too hard into a patient can reduce the amount of bone movement that will occur, while conversely, not pressing hard enough will cause the force to be absorbed by the soft-tissues rather than the target vertebra. Research has shown that about 20 Newtons of preload is utilized by chiropractors performing manual adjustments (Herzog et al., Spine 2001;26(19):210510) . Impulseand Impulse iQ are equipped with a 20 Newton spring in the nosepiece of the instrument that is
ideal for just the right amount of tissue compression (tissue pull) prior to thrusting. You’ll notice when you preload the instrument, the red LED adjacent to the force-adjustment switch will turn green signaling that appropriate preload has been achieved. Note that the instrument will not fire unless the stylus is preloaded.
Single vs. Multiple Thrusts
Impulse and Impulse iQ are equipped with an electronic trigger that interfaces with an internal optical sensor that enables you to perform single or multiple pulse thrusts for accomplishing the chiropractic adjustment. After preloading the stylus, the red LED will turn green indicating that proper preload has been achieved. Pulling the trigger once
and immediately releasing it causes the instrument to thrust once. Pulling the trigger and holding it causes the instruments to enter the multiple pulse mode. In the multiple pulse mode, the Impulse Adjusting Instrument will thrust 12 times in a row over 2 seconds (6Hz). You can release the trigger at any you feel is clinically indicated allowing you to perform number of thrusts you desire ranging from 1-12. With the Impulse iQ Adjusting Instrument, multiple thrust rate is determined from data obtained from the acceleration response of the initial thrust. The computer algorithm inside the instrument processes and analyzes the data and in turn sets the pulse train rate ranging from 4-12 Hz. As the area is being adjusted during Impulse iQ’s multiplethrust mode, the thrust rate may stay the same, increase, or decrease dependent upon the acceleration response. Audible (beep) indicators assist the clinician in understanding the responses.
Generally speaking, one thrust is recommended for articular adjusting with new patients, whereas the multiple pulse mode is commonly used for excessively fixated segments or for neuromuscular applications. Our research has shown that multiple pulses with the Impulse Adjusting Instrument® can increase the vertebral motions by 25 percent. Thus, in areas you desire to create greater mobility, engaging the multiple pulse mode will enable you to create more vertebral motion than is capable with a single thrust. Please note that applying more than 12 thrusts on a segmental contact point is contraindicated. Always re-check the clinical indicators that necessitated administration of the device in the first place prior to delivering more than one cycle (12 thrusts). Over adjusting is more work for the doctor, can cause excessive soreness for the patient, as well as can shorten the lifespan of the instrument.
Single vs. Dual Syluses
Single stylus applications include chiropractic adjustment of body rotation subluxations or subluxations with lateral flexion dysfunction components. In essence, Impulsive thrusts utilizing the Single stylus application provide axial rotation motions coupled with lateral flexion and posteroanterior motion of the functional spinal unit, as the single stylus contact unilaterally on the side of the spine.
Cervical and Lumbar Dual Styluses can be interchanged with the single stylus thereby contacting on both sides of the spinous process simultaneously. Application of the Dual stylus is used for accomplishing greater control during multiple thrusts and for instances desiring greater posteroanterior directed forces. Dual styluses are often used in addressing hypolordosis or kyphotic spinal configurations or retrolisthesis subluxations.
Impulse iQ Adjusting Instrument Specifications
The Impulse iQ Adjusting Instrument has an sensor embedded in the nose piece of the instrument to precisely measure accleration responses. The sensor is connected to a computer microprocessor that controls the functionality of the device. When Impulse iQ is applied to the musculoskeletal structures of the body (spine and extremity joints) the instrument measures the acceleration response simultaneously during the chiropractic adjustment.
Generally speaking, two basic variables are assessed during the adjustment:
1. the displacement for the given force (peak acceleration response) and;
2. the speed or frequency at which the spine moved (peak-to-peak acceleration response duration).
As previously stated, the clinical judgment of the operator to determine if treatment with Impulse iQ is indicated, or successful is to be made independently from the functionality of the device itself. Clinical indicators indicating the need for treatment and its dosage always take precedence over the audible indicators of the device. Treatment can be ceased at any time by simply releasing the trigger of the device. The determination of medical necessity of treatment including treatment dosage is always the responsibility of the clinician and not the device.
Multiple thrust rate is determined from data obtained from the acceleration response of the initial thrust. The computer algorithm inside the instrument processes and analyzes the data and in turn sets the pulse train rate ranging from 4-12 Hz. As the area is being adjusted during Impulse iQ’s multiple-thrust mode, the thrust rate may stay the same, increase, or decrease dependent upon the acceleration response. Audible (beep) indicators assist the clinician in understanding the responses.
Figure 1 provides the three audible indicator categories (single beep, double beep, and no beep). A single beep indicates that the acceleration response has been maximized. A double beep indicates that the acceleration response has not yet been maximized. No beep indicates that no significant change in acceleration response has been sensed. In the figures below, you will find the Impulse iQ Adjusting Instrument audible indicators and clinical decision making with consideration to other variables that may influence the treatment
Single Beep. If the instrument beeps once after the adjustment, this indicates that maximum mobility has been reached for pulse train (Figure 2). Indeed, it is recommended that the clinical indicators that necessitated the treatment be re-assessed prior to further clinical decision making.
Double Beep. If the instrument beeps twice after the adjustment, this indicates that maximum mobility has not been reached for pulse train (Figure 3). Of course, it is recommended that the clinical indicators that necessitated the treatment be re-assessed prior to fu
rther clinical decision making. It is recommended that special consideration is also given to insure that the contact as correct with consistent preload throughout the adjustment.
No Beep. If the instrument does not beep after the adjustment, this indicates that no significant improvement in acceleration response has been detected. In this instance, the clinical indicators that necessitated the treatment must be re-assessed prior to further clinical decision making (Figure 4). Consideration should be given to insure proper segmental contact point, line of drive (adjustment vector), or if area is not receptive to change.
Instrument Adjusting and Medicare
Medicare’s coverage of chiropractic services can be found in the Centers for Medicare & Medicaid Services Carriers Manual, Part 3, Chapter II Coverage and Limitations (2251) found online at http://www.cms.hhs.gov.
“Coverage of Chiropractic Services”
“2251.1 Manual Manipulation. – Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself. …”
Medicare does not “approve” any specific chiropractic adjusting device, rather, states that the thrust of chiropractic adjusting instruments must be controlled manually. The force of the Impulse Adjusting Instrument® is controlled manually by means of a threeposition force selection switch. In fact, new research has demonstrated a greater range of forces for electromechanical devices over their spring-loaded counterparts (Colloca et al. J Manipulative Physiol Ther, July/August, 2005).
Impulse Adjusting Technique Outline
CMS Requirements and PART Documentation
P – Pain
• location, quality, intensity, and tenderness (by palpation)
• qualitative via palpation
• quantitative via algometry
A – Asymmetry
• asymmetry assessed by observation
• leg length inequality
• antalgia or scoliosis
• muscle asymmetries
• gait abnormalities
R – Restriction or ROM
• restriction or ROM decrease
• active ROM
• passive ROM
• orthopaedic tests
T – Tone, Texture, Temperature
• changes in soft tissues
• spasm/hyperactivity of muscles
• muscle inhibition
• color change
Five Step Lumbopelvic Analysis and Adjusting Procedures
1. Bilateral Nachlas Test
2. Unilateral Nachlas Test
3. Hip Rotation Tests
4. Lower Extremity Muscle Compression Tests and Adjustments
5. Suprapelvic Evaluation (Quadratus Lumborum) and Adjustments
• Sacroiliac Joint Adjustment
• External Hip Rotation Dysfunction
• Internal Hip Rotation Dysfunction
• Lateral Hamstring Hyperactivity Instrument
• Differential Diagnosis: Referred vs. Radicular Symptoms
• Lumbar Compression Test
• Analysis and Adjustment
• Mamillary Process Contacts
• Dual Stylus Contacts
• Multifidus Atrophy Assessment
• Thoracic Compression Test
• Thoracic Spine Adjustment
• Thoracic Transverse Process Adjustment
• Thoracic Posterior Rib Adjustment
• Thoracic Dual Stylus Adjustment
• Anterior Rib Adjustment
• Cervical Zygapopyseal Joint Referred Pain Patterns
• Cervical Spine Kinematics
• Analysis and Adjustment
• Occiput – Single Stylus
• Occiput – Dual Stylus
• C1 Transverse Process Contact
• C2 Spinous Contact
• Cervical Rotation Test
• C2 Transverse Process Contact
• C2 Dual Stylus Contact
• Cervical Lateral Flexion Test
• Lower Cervical (C3-C7) Transverse Process Contact
• Lower Cervical (C3-C7) Dual Stylus Contact
• Muscle Adjustments
• Scalene Adjustment
• Upper Trapezius Adjustment
• Levator Scapula Adjustment
• Splenius Test and Adjustment
Temporomandibular Joint (TMJ)
• Active TMJ Range of Motion Exam
• Passive TMJ Range of Motion Exam
• TMJ Adjustment
• Posterior-Superior TMJ Adjustment
• Anterior TMJ Adjustment
• Posterior TMJ Adjustment
• Superior TMJ
• Lateral TMJ Adjustment
• Plantar Fascitis
• Achilles Tendonitis
• Inversion Ankle Sprain
• Eversion Ankle Sprain
• Instep (Dorsal Ankle) Pain
• Posterior Knee Pain
• Posterolateral Knee Pain
• Anterior Knee Pain
• Lateral Knee Pain
• Medial Knee Pain
• Differential Diagnosis: Hip
• Posterior Hip Pain
• Posterior Trochanter
• Lateral Hip Pain
• Anterior Hip Pain
• Scapulothoracic Joint
• Rotator Cuff
• Acromioclavicular (AC) Joint Seperation
• Sternoclavicular Joint
• Lateral Epicondylitis
• Medial Epicondylitis
Wrist and Hand
• Carpal Tunnel Syndrome
• Wrist Pain
• Thumb Pain
Certification in Instrument Adjusting
A postgraduate Certification in Instrument Adjusting is available from Neuromechanical Innovations. The examination is administered at The Impulse Adjusting Technique seminars in most major cities in the USA and abroad. Seminar listings can be found online at www.neuromechanical.com.
To be eligible to sit for the Instrument Adjusting Certification examination, you must be a doctor of chiropractic or a student currently enrolled in a CCE accredited chiropractic college. You must also have attended one prior Impulse
Adjusting Technique seminar to have received prior training on the Instrument Adjusting protocols. *Students who sit for the examination and successfully pass may not use the designated “Certified Instrument Adjuster” status until they provide proof of graduation from Chiropractic College.
The Instrument Adjusting Certification examination consists of a written and practical assessment to determine your knowledge of the subject matter. The written examination consists of multiple choice and true false questions. You must score 80 percent on the written examination to be eligible for the practical examination. The practical examination will pair you with a patient as the examiner determines your practical knowledge of using the Impulse Adjusting Technique analysis and Instrument Adjusting protocols (analysis procedures, segmental contact points, lines of drive, force settings, etc.).
The examination content will consist of chiropractic analysis and instrument adjustment techniques. Contained within this course study guide in the pages that follow you will find testable material for the examination. This information is based upon knowledge about the Impulse Adjusting Instrument and Impulse Adjusting Technique.
Please reference your Impulse Adjusting Technique seminar notes for details about segmental contact points, lines of drive, and combination adjustments for the most common conditions that are covered. This is all testable material.
Good luck in your studies.
This research was provided by Neuromechanical Innovations.