There are two important questions every chiropractor should ask, no matter what stage of your career: how safe and effective is the adjusting instrument you are using? And, is the method you are using to find a subluxation validated by research?
These two questions go straight to the heart of our integrity as a profession and are critical to building, preserving and maintaining your own practice and reputation.
Activator recently experienced the power of these questions first-hand as we sought and received approval for the use of Activator instruments in Australia. Licensure of adjusting instruments in that country is handled by the Therapeutic Goods Administration, and among their very first requests of us was for data that would show the safety and effectiveness of the Activator.
I’ve often said that research will save the day, and that maxim has proven to be true once again. Activator forwarded to the TGA a 1985 paper, funded by the U.S. National Institutes of Health (NIH), answering these specific queries. Activator passed muster with flying colors.
(Another recent newsletter, The Chiropractic Report by the Secretary General of the World Federation of Chiropractic, gives some history of The Activator Method, as well as an overview of the collected research. Read the report here:
Here in the United States and around the world, Activator bases its success on research. We recently published our eighteenth clinical trial (you can read an assortment of Activator research by visiting our website at http://www.activator.com/research/). To our knowledge, no other adjusting instrument on the market today – besides the Activator – has any clinical trials supporting effectiveness. (It is worth noting that a study about a specific instrument does not automatically apply to all other instruments. That’s something like publishing a study about a particular drug, then attempting to use it to make claims about similar drugs that were never tested. Once again, my advice is to put your faith in solid research.)
Another question posed frequently is whether research validates techniques for locating a subluxation with specific testing. The paper entitled Review of Methods Used by Chiropractors to Determine the Site for Applying Manipulation by Triano et.al. in Chiropractic and Manual Therapies 2013, 21:36 (http://www.chiromt.com/content/21/1/36) is a comprehensive evaluation of how chiropractors assess a patient and know where to manipulate. You will be quite surprised to see what is supported by the evidence and what is not.
As chiropractors, we have a tendency to run from one new piece of equipment to another, sometimes spending a great deal of money, without asking these simple questions. I hope these musings convince not only the veteran field practitioner, but also the new student, to make informed decisions on the adjusting instruments and methods of analysis they will use to determine safety and effectiveness for their own patients.
Chiropractic spinal manipulative therapy for a geriatric patient with low back pain and comorbidities of cancer, compression fractures, and osteoporosisAugust 25th, 2013
The purpose of this report is to describe the response of a geriatric patient with low back pain and a history of leukemia, multiple compression fractures, osteoporosis, and degenerative joint disease using Activator chiropractic technique.
An 83-year-old man who is the primary caretaker for his disabled wife had low back pain after lifting her into a truck. The patient had a history of leukemia, multiple compression fractures, osteoporosis, and degenerative joint disease. His Revised Oswestry Low Back Pain Disability Questionnaire was 26%, with a 10/10 pain rating at its worst on the Numeric Pain Scale. The patient presented with a left head tilt, right high shoulder, and right high ilium with anterior translation and flexion of the torso and spasm and tenderness from the lower thoracic spine to lumbar spine.
Intervention and Outcome
The patient was cared for using Activator Methods protocol. After 8 treatments, the patient was stable and remained stable for 4 months without spasm or tenderness in his spine. His Revised Oswestry score dropped to 6%, with a 4/10 Numeric Pain Scale pain rating when at its worst; and the patient reported being able to take care of his wife.
The findings of this case suggest that Activator-assisted spinal manipulative therapy had a positive effect on low back pain and function in an elderly patient with a complex clinical history.
© 2012 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
Chiropractic management of a veteran with lower back pain associated with diffuse idiopathic skeletal hypertrophy and degenerative disk diseaseAugust 23rd, 2013
The purpose of this article is to report the response of chiropractic care of a geriatric veteran with degenerative disk disease and diffuse idiopathic skeletal hyperostosis.
A 74-year-old man presented with low back pain (LBP) and loss of feeling in his lower extremities for 3 months. The LBP was of insidious onset with a 10/10 pain rating on the numeric pain scale (NPS) and history of degenerative disk disease and diffuse idiopathic skeletal hypertrophy. Oswestry questionnaire was 44% and health status questionnaire was 52%, which were below average for his age. The patient presented with antalgia and severe difficulty with ambulation and thus used a walker.
Intervention and Outcome
Chiropractic care included Activator Methods protocol. Two weeks into treatment, he reported no back pain; and after 4 treatments, he was able to walk with a cane instead of a walker. The NPS decreased from a 10/10 to a 0/10, and his Revised Oswestry score decreased from 44/100 to 13.3/100. His Health Status Questionnaire score increased 25 points to 77/100, bringing him from below average for his age to above average for his age. Follow-up with the patient at approximately 1 year and 9 months showed an Oswestry score of 10/100 and a Health Status Questionnaire score of 67/100, still above average for his age.
The findings in this case study showed that Activator-assisted spinal manipulative therapy had positive subjective and objective results for LBP and ambulation in a geriatric veteran with degenerative disk disease and diffuse idiopathic skeletal hyperostosis.
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2. Nyiendo J, Hass M, Goldberg B, Sexton G. Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians. J Manipulative Physiol Ther. 2001;24(7):433–439
3. Hertzman-Miller RP, Morgenstern H, Hurwitz EL, Yu F, Adams AH, Harber P, et al. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA low-back pain study. Am J Public Health. 2002;92(10):1628–1633
4. Descarreaux M, Jean-Sebastien B, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventative spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. J Manipulative Physiol Ther. 2004;27(8):509–514
5. Lee CE, Simmonds MJ, Novy DM, Jones SC. Functional self-efficacy, perceived gait ability and perceived exertion in walking performance of individuals with low back pain. Physiother Theory Pract. 2002;2:193–203
7. Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for specific low back conditions: characterizing the literature. J Manipulative Physiol Ther. 2001;24(6):407–424
8. Green BN, Johnson CD, Lisi AJ, Tucker J. Chiropractic practice in military and veterans health care: the state of the literature. J Can Chiropr Assoc. 2009;53(3):194–204
9. Lisi AJ. Management of operation Iraqi freedom and operation enduring freedom veterans in a Veterans Health Administration chiropractic clinic: a case series. J Rehabil Res Dev. 2010;47(1):1–6
10. Dunn AS, Green BN, Gilford S. An analysis of the integration of chiropractic services within the United States military and veteran’s health care systems. J Manipulative Physiol Ther. 2009;32(9):749–757
14. Troyanovich SJ, Buettner M. A structural chiropractic approach to the management of diffuse idiopathic skeletal hyperostosis. J Manipulative Physiol Ther. 2003;26(3):202–206
15. Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic skeletal hyperostosis. Eur J Radiol. 1998;27(1):S7–S11
16. Foshang TH, Mestan MA, Riggs LJ. Diffuse idiopathic skeletal hyperostosis: a case of dysphagia. J Manipulative Physiol Ther. 2002;25(1):71–76
17. Hudson-Cook N, Tomes-Nicholson K, Breen A. A revised Oswestry disability questionnaire. In: Roland MO, Jenner JR editor. Back pain: new approaches to rehabilitation and education. New York, NY: Manchester University Press; 1989;p. 187–204
18. Vianin M. Psychometric properties and clinical usefulness of the Oswestry disability index. J Chir Med. 2008;7(4):161–163
19. Gunnar BJ, Cocchiarella L. In: AMA guide to evaluation of permanent impairment. 5th ed.. United States: American Medical Association 5 Sub edition; 2000;
20. Song X, Gan Q, Cao J, Wang Z, Rupert R. Spinal manipulation reduces pain and hyperalgesia after lumbar intervetebral foramen inflammation in the rat. J Manipulative Physiol Ther. 2006;29(1):5–13
22. Fuhr AW, Menke JM. Status of activator methods in chiropractic technique, theory, and practice. J Manipulative Physiol Ther. 2003;28:135.e1–135.e2
23. Richards GL, Thompson JS, Osterbauer PJ, Fuhr AW. Low force chiropractic care of two patients with sciatic neuropathy and lumbar disc herniation. Am J Chiropr Med. 1990;2:25–32
24. Polkinghorn BS, Colloca CJ. Treatment of symptomatic lumbar disc herniation using activator methods chiropractic technique. J Manipulative Phyiol Ther. 1998;21(3):187–196
25. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain: a meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138(11):872–881
26. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ. 1998;316:1356–1359
27. Luoma K, Riihimäki H, Luukkonen R, Raininko R, Viikari_Juntura E, Lamminen A. Low back pain in relation to lumbar disc degeneration. Spine. 2000;25(4):487–492
28. Coppes MH, Marani E, Thomeer RTWM, Groen GJ. Innervation of “painful” lumbar discs. Spine. 1997;22:2342–2350
29. Olmarker K, Blomquist J, Stromberg J, Nannmark U, Thomsen P, Rydevik B. Inflammatogenic properties of nucleus pulposus. Spine. 1995;20:665–669
30. Kline CM. The language of disc disorders. J Am Chiropr Assoc. 2004;42(11):8–15
31. Brodke DS, Ritter SM. Nonoperative management of low back pain and lumbar disc degeneration. J Bone Joint Surg Am. 2004;86-A(8):1810–1818
32. Holton KF, Denard PJ, Yoo JU, Kado DM, Barrett-Connor E, Marshall LM. Diffuse idiopathic skeletal hyperostosis and its relation to back pain among older men: the MrOS study. Semin Arthritis Rheum. 2011;41(2):131–138
33. Rothschild BM. Diffuse idiopathic skeletal hyperostosis. Compr Ther. 1988;14(2):65
34. Fahrer H, Barandum R, Gerber NJ, Friederich NF, Burkhardt B, Weisman MH. Pelvic manifestations of diffuse idiopathic skeletal hyperostosis (DISH): are they clinically relevant?. Rheumatol Int. 1989;8(6):257–261
35. Schlapbach P, Beyeler C, Gerber NJ, van der Linden D, Burgi U, Fuchs WA, et al. Diffuse idiopathic skeletal hyperostosis (DISH) of the spine: a cause of back pain? A controlled study. Br J Rheumatol. 1989;28(4):299–303
37. Symons BP, Herzog W, Leonard T, Nguyen H. Reflex responses associated with activator treatment. J Manipulative Physiol Ther. 2000;23(3):155–159
38. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine. 1997;22:2128–2156
39. Boos N, Weissback S, Rohrback H, Weiler C, Spratt KF, Nerlich AG. Classification of age-related changes in lumbar intervertebral discs. Spine. 2002;27(23):2631–2644
40. Alcantara J, Plaugher G, Elbert RA, Cherachanko D, Konlande JE, Casselman AM. Chiropractic care of a geriatric patient with an acute fracture-subluxation of the eighth thoracic vertebra. J Manipulative Physiol Ther. 2004;27:e4
41. Haas M, Groupp E, Muench J, Kraemer D, Brummel-Smith K, Sharma R, et al. Chronic disease self-management program for low back pain in the elderly. J Manipulative Physiol Ther. 2005;28(4):228–237
42. Johnson I. Low force chiropractic adjustment and post-isometric muscle relaxation for the ageing cervical spine: a case study and literature review. BJC. 2002;5(3):50–59
43. Roberts JA, Wolfe T. Chiropractic spinal manipulative therapy for a geriatric patient with low back pain with comorbidities of cancer, compression fractures, and osteoporosis. J Chiro Med. 2012;11(1):16–23
44. Dunn AS, Towle J, McBrearty P, Fleeson SM. Chiropractic consultation requests in the veterans affairs health care system: demographic characteristics of the initial 100 patients at the Western New York Medical Center. J Manipulative Physiol Ther. 2006;29(6):448–454
45. Armstrong B, Levesque O, Perlin JB, Rick C, Schectman G. Reinventing Veterans Health Administration: focus on primary care. J Health Care Management. 2005;50(6):399–408
© 2012 National University of Health Sciences. Published by Elsevier Inc. All rights reserved
Clinical effectiveness of the Activator adjusting instrument in the management of musculoskeletal disorders: a systematic review of the literatureAugust 13th, 2013
Tiffany Huggins, BA(Hons), BEd, DC, Ana Luburic Boras, BA, DC, Brian J. Gleberzon, DC, MHSc*, Mara Popescu, BA, DC,
Lianna A. Bahry, BKin, DC
Objective: The purpose of this study was to conduct a systematic review of the literature investigating clinical outcomes involving the use of the Activator Adjusting Instrument (AAI) or Activator Methods Chiropractic Technique (AMCT).
Methods: A literature synthesis was performed on the available research and electronic databases, along with hand-searching of journals and reference tracking for any studies that investigated the AAI in terms of clinical effectiveness. Studies that met the inclusion criteria were evaluated using an instrument that assessed their methodological quality.
Results: Eight articles met the inclusion criteria. Overall, the AAI provided comparable clinically meaningful benefits to patients when compared to high-velocity, low-amplitude (HVLA) manual manipulation or trigger point therapy for patients with acute and chronic spinal pain, temporomandibular joint (TMJ) dysfunction and trigger points of the trapezius muscles.
Conclusion: This systematic review of 8 clinical trials involving the use of the AAI found reported benefits to patients with a spinal pain and trigger points, although the clinical trials reviewed suffered from many methodological limitations, including small sample size, relatively brief follow-up period and lack of control or sham treatment groups.
(JCCA 2012; 56(1):49–57)
With the notable exception of the manual Diversified technique, which involves high velocity and low amplitude (HVLA) thrusting spinal manipulative therapy (SMT) (also commonly referred to as spinal adjustments), the therapeutic intervention most commonly used for patient care by chiropractors is instrumented-adjusting using the Activator Adjusting Instrument (AAI). According to the 2005 National Board of Chiropractic Examiner’s (NBCE) Job Analysis1 51.2% of American chiropractors report using the AAI for patient care, although this data does not differentiate between those practitioners who use the AAI only (often as a substitute for HVLA manipulation) from those practitioners who use the Activator Methods Chiropractic Technique (AMCT), a technique system that involves a group of specialized diagnostic procedures during prone leg length checking.2 [The 2005 NBCE Job Analysis is the most recent source of information on the rates of use of different technique systems by chiropractor since the NBCE’s Practice Analysis of Chiropractic 2010 did not capture this data]. The 1993 NBCE Job Analysis3 reported roughly 40% of Canadian chiropractors use an AAI, although more recent estimates range from 31.4%4 to 22%.5 A survey of British chiropractors reported 82% of respondents indicated they use an AAI, although only 2% of them stated they used it as their primary treatment methods and the NBCE 19947 reported that 72.7% and 54.3% of Australian and New Zealand chiropractors, respectively, used an AAI.
In 2001, Cooperstein et al.8 and Gatterman et al.9 published companion articles that sought to characterize the literature with respect to chiropractic technique procedures for various low back conditions and rate the effectiveness of specific chiropractic procedures for low back conditions, respectively. These systematic reviews reported that the widest base of evidential support existed for side posture HVLA manipulations and a panel of experts ascribed a value of 9.3/10 with respect to clinical effectiveness for acute low back pain and 8.1/10 for chronic low back; by contrast, instrumented-adjusting was only allocated a score of 3.7/10 for acute low back pain and 1.6/10 for chronic low back pain.9 This led Cooperstein et al. to assert: “These considerations suggest that those researchers attempting to validate the appropriateness of their favored methods had best focus more on the type of research they do- more on outcomes and less on peripheral matters such as modeling and the reliability of diagnostic
A review of the literature conducted in 2001 found that the number of retrievable articles from the peer-reviewed literature on AMCT (n = 21) was second only to the number of retrievable articles on Upper Cervical techniques (n = 28).10 [It should be noted that the developers of Chiropractic BioPhysics/Clinical Biomechanics of Posture have also been very prolific with respect to publishing in the peer-reviewed literature, but many of those studies principally focused on mathematical modeling of the spine.11,12].
Since that time, investigations of AAI and AMCT have continued at an impressive rate. That being said, many of these published articles have investigated the mechanical properties of the AAI, the reliability and validity of prone leg length checking and the reliability and validity of diagnostic tests unique to AMCT (isolation, stress and pressure tests). Despite Cooperstein et al’s admonishment a decade earlier, relatively few studies have investigated the clinical effectiveness of the AAI. For example, the 2001 review of the literature cited above10 found only 6 case studies, 2 case series and 2 clinical trials involving AAI or AMCT. A textbook chapter devoted to describing AMCT published in 200413 found only one additional clinical trial published between 2001 and 2004. Moreover a DVD14 listing all published studies on the AAI or AMCT [distributed by Activator Methods Inc to attendees of the 2011 Association of Chiropractic Colleges and Research Agenda Conference (ACC-RAC)] had only one incomplete additional clinical trial, indicating a continued under-representation of studies of this nature. Even so, notwithstanding the relative paucity of clinical investigations, advocates of the AAI and AMCT continue to extol its clinical value and usefulness.13,14
The purpose of this study was to conduct a systematic review of the literature investigating clinical outcomes involving the use of the AAI or AMCT. A brief narrative review of each article that met the inclusion criteria is also provided.
This study was approved by the Ethics Review Board of the Canadian Memorial Chiropractic College.
The following electronic databases were searched from their earliest date of publication to April 2010: ICL, MANTIS, and AMED. CINHAHL and MEDLINE were searched through EBSCO publishing. The following key terms were used: “Activator Adjusting,” “Activator Technique,” “Neck pain,” Low back pain,” “Mechanical manipulation,” “Mechanically assisted device” and “Instrument assisted manipulation.”) The initial search strategy was then further refined by using the following MeSH terms: chiropractic*, therapy*, joint dysfunction* and cervical vertebrae*. References were also used from citations found in papers that were included after reviewing the inclusion and exclusion criteria for each. Citations from specific articles (reference tracking) were then researched independently through selected databases followed by hand searching throughout the periodicals.
Several inclusion/exclusion criteria were used to select studies eligible for this review. Inclusion criteria were as follows: studies must involve more than one subject; treatments must have been administered by a qualified chiropractor; papers were written in English; were published between January 1980 and March 2010; prospective or retrospective studies including RCTs, controlled clinical/quasi-experimental trials, cohort, case control and case series; studies using some type of outcome measure for determining the effect of chiropractic care [i.e. Visual Analogue Scale (VAS), Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Oswestry Disability Index (ODI), McGill Pain Questionnaire, range of motion, algometer/goniometer devices]; published in peer-reviewed journal and; only studies involving human subjects.
Subject age, sex, demographic, and pain type and duration were not consistent among studies and were therefore not utilized as inclusion criteria in this review. Manuscripts from conference proceedings or abstracts of studies were not included in this review since the criteria for inclusion in a conference proceeding is often much less stringent than the criteria used for inclusion in peerreviewed indexed journals. Using these inclusion criteria, eight articles qualified for review.
Instrument Used to Review Eligible Articles
The articles selected for review were evaluated using an instrument developed by Sackett (see Table 1).15
Four authors (TH, ALB, MP, LB) independently reviewed the studies meeting the inclusion criteria. The data from all included articles were recorded onto a data extraction sheet by the authors as part of the review. The authors checked and edited all entries for accuracy and consistency. Recorded data included study authors and quality score, details of the study design, sample, interventions, outcome measures, and main results/conclusions of the study. These four authors met on April 5th, 2010 to compare their graded scores. Any discrepancies of scores between the authors were settled via discussion until consensus was reached.
The initial search strategy yielded 283 hits when using the search terms “Instrument and Manipulation.” Many articles found that discussed instrumentation other than an AAI or discussed unrelated topics such as historical development of the Activator, diagnostic testing used by AMCT practitioners or other non-clinical issues. Once refined to “Mechanically Assisted Manipulation” 51 articles were found. Of these 51 articles, only eight met our inclusion criteria.16–23 After methodological quality assessment of each article using the grading instrument, papers were allocated scores out of a possible 50 points (Table 2). Articles are listed in descending order of their score using the Sackett criteria; in the event two or more articles had the same score, they were arranged alphabetically (Table 3).
Table 1 Instrument Categories Used to Grade Articles for this Review
When assessed in terms of clinical effectiveness, AAI and manual manipulation were both found to result in equally statistically significant patient outcomes, although the differences between the use of these two treatment interventions was not statistically significant. Studies investigating the use of AAI only reported that it conveyed clinically meaningful benefits to patients.
Instrumented-Adjusting in Chiropractic
Instrumented adjusting has grown in popularity since the time Solon Langworthy first developed a table mounted percussive device in the early 19th century.24 Along with the AAI other chiropractic technique systems have developed adjusting instruments. There are a number of instrumented Upper Cervical techniques that involve cervical adjusting devices that are handheld, floor-mounted or table-mounted.25 Other notable examples include the Integrator associated with Torque Release Technique26 and a floor mounted device used by CBP practitioners.27 An internet search for “instrumented-adjusting devices
in chiropractor” found a device called an “Impulse Adjusting Instrument” developed by NeuroMechanical Innovations, 28 and a device called the “Pro-Adjustor”29 has recently been demonstrated at chiropractic trade shows over the past few years (for example, the 2011 World Federation of Chiropractic conference in Rio de Janeiro, Brazil and the 2010 Canadian Chiropractic Conference in Toronto, Ontario, Canada).
Instrumented adjusting is thought to convey multiple benefits to both patients and practitioners.2,30–33 From the perspective of the patient, benefits conveyed by instrumented-adjusting include: the management of patients with osteoporotic bone fragility;2,31–33 for children; for patients who are fearful of manipulative procedures that result in joint cavitation (i.e “cracking”); for extremity adjusting; to (theoretically) achieve greater joint specificity2,30 and; it can be used for patients who wish not be physically touched (perhaps they have been physically or sexually abused, for example).30 To date, no experimental
or clinical evidence exists that the use of instrumented adjusting demonstrates a better safety profile compared to manual manipulation with respect to serious adverse events (i.e stroke) in patients with identified or unidentified vascular risk factors, since manual manipulation has not been conclusively linked to the incidence of stroke at all.34
From the perspective of the practitioner, instrumented adjusting can be used in cases of doctor injuries (disabilities of the hand, wrist, elbow or shoulder, for example) and it can used to compensate for anthropomorphic differences between a small doctor and a large patient.2,30 Lastly, AAI conveys benefits to the research community since it can be used as a “sham” procedure by setting it to “0” since even set to “0” the AAI will still produce an audible sound.2
Currently, instrumented-adjusting is permitted for use by chiropractors in all Canadian, American, British and Australian jurisdictions,5 although that has not always been the case. As recently as 2004, Saskatchewan prohibited its members from instrumented adjusting. The reasonableness of this standard of practice was raised in an article by one the authors of this review (BG) in an article published in 2002;30 this spawned a heated exchange of letters to the editor.35–37 Contemporaneously, the Chiropractic Association of Saskatchewan (CAS) struck a Committee to evaluate the literature on the efficacy, safety, usage and educational requirements for chiropractic practice relative to AAI [or mechanical adjusting devices (MAD) as it was termed in that report38,39]. Overall, the majority of the Committee members (4–2) concluded that, while all of the studies it reviewed were flawed to varying degrees and the literature was generally weak, the evidence supported the statement that AAI procedures were as effective as manual HVLA procedures in producing clinical benefits and biological change.38 The Committee reached consensus (5–1) that AAI procedures are widely used for spine related and extremity conditions, is safe and has no more risk than do manual HVLA procedures (majority opinion 4–2).39 Lastly, the Committee reached consensus (5–1) that there was no evidence with respect to educational requirement to form any conclusions.39
General Weaknesses of Studies Reviewed
Irrespective of the wide utilization rates among chiropractors, and despite the plethora of practical benefits to patients and practitioners championed by its proponents, this study found only 8 clinical trials that sought to determine the clinical effectiveness of the AAI, the form of instrumented-adjusting with the most publication in the peer-reviewed journals. None of the clinical trials reviewed here were randomized clinical trials; that is, none of them included a control (no-treatment) group or a sham treatment group or included patients without any clinical symptoms at all. In general, examiners in the studies reviewed in this article were seasoned practitioners well acquainted with AAI use or with AMCT as well as the other treatment modality option employed (i.e. spinal manipulation, trigger point therapy). All the studies used small study populations, ranging from 8 to 92 subjects. 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.
This systematic review of 8 clinical trials involving the use of the AAI found reported benefits to patients with spinal pain and trigger points, although these results were not statistically significantly different when compared to the use of HVLA manual manipulation or trigger point therapy.
Given the wide use and clinical utility of the AAI, it is unfortunate that most of the clinical trials investigating its 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. That said, there does exist case studies, case series, clinical trials and now this systematic review that suggests patients do experience positive and clinically meaningful benefits when treated for spinal pain and trigger points
using an AAI. Clinically meaningful improvements were documented in patients with acute and chronic low back or SIJ pain, acute and subacute neck pain, TMJ disorders and trigger points in the trapezius muscle.
Further studies ought to include a larger patient base using a placebo or sham group and a no-treatment group, better randomization and blinding protocols and longerterm post-intervention follow-up in order to more definitively assess the benefits of AAI treatment.
1 National Board of Chiropractic Examiners. Job Analysis of Chiropractic: a project report, survey analysis and summary of the practice of chiropractic within the United States. Greeley, Colorado, USA. National Board of Chiropractic Examiners; 2005.
2 Cooperstein R, Gleberzon BJ. Activator Methods Chiropractic Technique. In: Technique Systems in Chiropractic. Cooperstein R, Gleberzon BJ (editors). Churchill-Livingston. 2004; 65–75.
3 National Board of Chiropractic Examiners. Job Analysis of Chiropractic: a project report, survey analysis and summary of the practice of chiropractic within Canada. Greeley, Colorado, USA. National Board of Chiropractic Examiners; 1993.
4 Kopansky-Giles D, Papadopoulos C. Canadian Chiropractic Resource Databank (CCRD). A profile of Canadian chiropractors. J Can Chiro Assoc. 1997; 41(3):155–191.
5 Watkins T, Saranchuk R. Analysis of the relationship between educational programming at the Canadian Memorial Chiropractic College and the professional practice of its graduates. J Can Chiro Assoc. 2000; 44(4):230–244.
6 Read DT, Wilson FJH, Gemmell HA. Activator as a therapeutic instrument: Survey of usage and opinions amongst members of the British Chiropractic Association. Clin Chiropr. 2006; 9(2):70–75
7 National Board of Chiropractic Examiners. Job Analysis of Chiropractic: a project report, survey analysis and summary of the practice of chiropractic within the United States. Greeley, Colorado, USA. National Board of Chiropractic Examiners; 1994.
8 Cooperstein R, Perle SM, Gatterman MI et al. Chiropractic technique procedures for specific low back conditions: Characterizing the literature. J Manipulative Physiol Ther. 2001; 24(6):407–411.
9 Gatterman MI, Cooperstein R, Lantz C et al. Rating specific chiropractic techniques procedures for common low back conditions. J Manipulative Physiol Ther. 2001; 24(7):449–456.
10 Gleberzon BJ. Chiropractic Name Techniques: A review of the literature. JCCA. 2001; 45(2):86–99
11 Oakley PA, Harrison DD, Harrison DE, Haas JW. Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. JCCA. 2005; 9(4):270–296.
12 Cooperstein R, Perle SM, Gleberzon BJ, Peterson DH. Flawed trials, flawed analysis: Why CBP should avoid rating itself (Editorial). JCCA. 2006; 50(2):97–102.
13 Activator Methods Research DVD. Undated. Available upon request.
14 Activator Methods (r). www.activator.com. Accessed May 11, 2011.
15 Sackett DC, Williams MC, Rosenbery JA. Evidence Based Medicine: What is it and what it isn’t. BMJ. 1996; 312:71–72.
16 Gemmel H, Allen A. Relative immediate effects of ischemic compression and Activator trigger point therapy on active upper trapezius trigger points: a randomized trial. Clin Chiropr. 2008; 11(1):175–181.
17 Y urkiw D, Mior S. Comparison of two chiropractic techniques on pain and lateral flexion in neck pain patients: a pilot study. Chiro Tech. 1996; 8:155–162.
18 DeVocht JW, Long CR, Zeitler DF et al. Chiropractic technique of temporomandibular disorders using the Activator Adjusting Instrument: a prospective case series. J Manipulative Physiol Ther. 2003; 26(7):421–425.
19 Osterbauer PJ, Kenneth F, Boear DE et al. Treatment and biomechanical assessment of patients with chronic sacroiliac joint syndrome. J Manipulative Physiol Ther. 1993; 16(2):82–89.
20 Wood TG, Colloca CJ. Matthews R. A pilot randomized clinical trial on the relative effect of Instrumental (MFMA) Versus Manual (HVLA) Manipulation in the treatment of cervical spine dysfunction. J Manipulative Physio Ther. 2001; 24(4):260–271.
21 Gemmell HA, Jacobsen BH. The immediate effect of Activator Vs Meric Adjustment on acute low back pain: a randomized controlled study. J Manipulative Physio Ther. 1995; 18(7):453–456.
22 Schneider MJ, Brach J, Irrgang JJ et al. Mechanical Vs Manual Manipulation for low back pain: an observational cohort study. J Manipulative Physiol Ther. 2010; 33(3):193–200.
23 Shearer KA, Colloca CJ, White HL. A randomized clinical trial of Manual Versus Mechanical Forces Manipulation in the treatment of sacroiliac joint syndrome. J Manipulative Physiol Ther. 2005; 28(7):493–501.
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The diagnostic performance of vertebral displacement measurements derived from ultrasonic indentation in an in vivo model of degenerative disc diseaseAugust 11th, 2013
Reference: Kawchuk GN, Kaigle AM, Holm SH, Rod Fauvel O, Ekstrom L, Hansson T. The diagnostic performance of vertebral displacement measurements derived from ultrasonic indentation in an in vivo model of degenerative disc disease. Spine 2001 (Jun 15); 26(12): 1348-55
Abstract STUDY DESIGN: The diagnostic performance of a newly described variable was assessed in an in vivo model of disc degeneration using a split-pair experimental design.
OBJECTIVE: To determine if vertebral displacement measures generated from ultrasonic indentation could distinguish between experimental and control groups of animals.
SUMMARY OF BACKGROUND DATA: Few procedures are available that noninvasively assess subcutaneous vertebral mechanics. Information from such a procedure would be of value in determining potential clinical relevance of spinal mechanics with respect to low back pain.
METHODS: Eight adolescent pigs underwent endplate perforation surgery to initiate lumbar disc degeneration. After 4 months of recovery, these and eight age-matched controls were assessed by ultrasonic indentation, a noninvasive procedure that quantifies vertebral displacements in the plane of loading-indentation. Each animal then received a facetectomy and was reindented at the same location as confirmed by ultrasonic imaging. Discal materials were removed postmortem for analysis.
RESULTS: Degenerative discs exhibited morphologic changes consistent with early degenerative disc disease. Prefacetectomy comparison of vertebral displacement measures between control and experimental animals resulted in sensitivity, specificity, and diagnostic accuracy values of 75.0%, 83.3%, and 77%, respectively. After facetectomy these values increased to 87.5%, 83.3%, and 85%, respectively. These measures of diagnostic performance were comparable or superior to those of existing clinical techniques (invasive or otherwise) used to assess degenerative conditions of the spine.
CONCLUSIONS: The results of this study suggest that noninvasive measures of vertebral displacement are clinically significant and possess the additional advantages of being objective and noninvasive.
Reference: James W. DeVocht, DC, PhD, Joel G. Pickar, DC, PhD, and David G. Wilder, PhD
ABSTRACT: Objective: To examine the effect of spinal manipulation on electromyographic (EMG) activity in areas of localized tight muscle bundles of the low back.
Methods: Surface EMG activity was collected from 16 participants in 2 chiropractic offices during the 5 to 10 minutes of the treatment protocol. Electrodes were placed over the 2 sites of greatest paraspinal muscle tension as determined by manual palpation. Spinal manipulation was administered to 8 participants using Activator protocol; the other 8 were treated using Diversified protocol.
Results: Electromyographic activity decreased by at least 25% after treatment in 24 of the 31 sites that were monitored. There was less than 25% change at 3 sites and more than 25% increase at 4 sites. Multiple distinct increases and decreases were observed in many data plots.
Conclusions: The results of this study indicate that manipulation induces a virtually immediate change, usually a reduction, in resting EMG levels in at least some patients with low back pain and tight paraspinal muscle bundles. In some cases, EMG activity increased during the treatment protocol and then usually, but not always, decreased to a level lower than the pretreatment level. (J Manipulative Physiol Ther 2005;28:465Q471)
Key Indexing Terms: Chiropractic, Electromyography, Manipulation, Spinal
Diagnostic Accuracy of the Clinical Examination in Identifying the Level of Herniation in Patients with SciaticaAugust 11th, 2013
Reference: Mark J. Hancock, PhD; Bart Koes, PhD; Raymond Ostelo, PhD; Wilco Peul, PhD. Spine Journal 15 May 2011 Volume 36 – Issue 11 – p E712–E719
ABSTRACT: Objective: To investigate the ability of the neurological examination to identify the specific level of a disc herniation in patients with sciatica and confirmed disc herniation.
Summary of Background Data: Tests included in a neurological examination theoretically provide accurate diagnostic information about the level of the herniated disc. However, there is currently very little evidence about the diagnostic accuracy of individual tests or combinations of tests.
Methods: The study included 283 patients with sciatica and confirmed disc herniation from a previous randomized controlled trial. The reference test for the current study was the MRI scan, reported for level of disc herniation. Index tests investigated were a neurologist’s overall impression of the level of disc herniation, individual neurological tests (e.g., sensation testing) and multiple test findings (i.e., the number of positive tests). The index tests were performed blinded to the MRI results. The diagnostic accuracy of the index tests in predicting herniations at the lower three lumbar discs was investigated using area under the curve (AUC), sensitivity and specificity.
Results: None of the individual neurological tests from the clinical examination were highly accurate for identifying the level of disc herniation (AUC < 0.75). The outcome of multiple test findings was slightly more accurate but did not produce high sensitivity and specificity. The dermatomal pain location was generally the most informative individual neurological test. The overall suspected level of disc herniation rated by the neurologist after a full examination of the patient was more accurate than individual tests. At L4/5 and L5/S1 herniations the AUC for neurologist ratings was 0.79 and 0.80 respectively.
Conclusions: The current study did not find evidence to support the accuracy of individual tests from the neurological examination in identifying the level of disc herniation demonstrated on MRI. A neurologist’s overall impression was moderately accurate in identifying the level of disc herniation.