Special Issue on Spinal Manipulation to Appear in the Journal of Electromyography and Kinesiology

Christopher J. Colloca, D.C.

CEO and Founder of Neuromechanical Innovations

            At the invitation of Moshe Solomonow, PhD, MD (Hon), Editor of The Journal of Electromyography and Kinesiology, three prominent individuals in the forefront of spinal manipulation research were selected to serve as Guest Editors for a Special Issue on Spinal Manipulation appearing in the October 2012 issue of the Journal. 

Guest Editors, Chris Colloca, DC, Joel Pickar, DC, PhD, and Malik Slosberg, DC, MSc were invited to compile related papers from the worldwide spinal manipulation field.  Dr. Colloca is a Graduate Student in the PhD Kinesiology Program at Arizona State University and is also the CEO and Founder of the medical device company, Neuromechanical Innovations that manufactures the Impulse Adjusting Instruments.  Dr. Pickar is a renowned neurophysiology researcher and Professor from the Palmer Center for Chiropractic Research who has received numerous Federal Grants for his work.  Dr. Slosberg is a noted postgraduate chiropractic lecturer from Life College of Chiropractic West.  Together, they formulated an outline for paper submissions based upon the following topics: The Basis for Spinal Manipulation; Epidemiology; Clinical Research; Kinesiological Research, and Neurophysiological Research.

Through their our own personal contacts within the research community and keyword searches of the Pubmed database using ‘spinal manipulation’ together with relevant categorical terms researchers and research groups who had published on these topics were identified.   Original and review paper submissions from thirty-one individuals representing twenty-five institutions who were identified as lead researchers or department heads and who were considered authorities within a given topic on spinal manipulation. Consistent with the professional diversity of spinal manipulation research, scientists with backgrounds in chiropractic, osteopathy, physical therapy, manipulative physiotherapy, and rehabilitative medicine were sought. In addition to these professional associations, submissions were sought from individuals within the disciplines of anatomy, biomechanics, biomedical sciences, education, epidemiology, engineering, kinesiology, medicine, neurology, and public health. Eighteen paper submissions were received. Manuscripts went through the Journal’s peer-review process ultimately yielding seventeen papers included in the special issue.

When asked about how this Special Issue came to be, Dr. Colloca said, “I first met Professor Solomonow at the International Society for the Study of the Lumbar Spine (ISSLS) conference in 1999 in Kona, Hawaii.  He won the Volvo award that year in Spinal Biomechanics for his work in ligamentomuscular reflexes, so I made it a point to reach out to him and introduce myself.  Over the years at conferences, I had the opportunity to chat with him and we published a paper in the JEK in 2008.  Ultimately invited him to speak at our International Spine Research (INSPIRE) Foundation symposium that we hold in Phoenix each year.  Dr. Solomonow spoke to our group twice and got to see first-hand the chiropractic research that our group was conducting.  The idea for a special issue on chiropractic research stemmed from these discussions.  Dr. Solomonow knew well of Dr. Pickar’s excellent work in neurophysiology and he felt Joel would be an perfect candidate to assist in reviewing the many papers as a Guest Editor for this issue.  Dr. Slosberg had also reached out to Professor Solomonow to discuss some research projects that he had an interest in and in seeing how well read Malik was made a natural fit for him to participate.  Dr. Solomonow will travel to Phoenix on October 27-28, 2012 for our 10^th INSPIRE Conference where together we will debut the Special Issue where full issue reprints will be distributed to attendees.  We are very fortunate to have this opportunity to showcase spinal manipulation research in such a prestigious international publication forum.”

Published by Elsevier, The Journal of Electromyography and Kinesiology is the primary source for outstanding original articles on the study of muscle contraction and human motion through combined mechanical and electrical detection techniques. As the official publication of The International Society of Electrophysiology and Kinesiology, the journal is dedicated to publishing the best work in all areas of electromyography and kinesiology, including: control of movement, muscle fatigue, muscle and nerve properties, joint biomechanics, electrical stimulation, motion analysis, sports and exercise, measures of human performance, and rehabilitation.

            To order a copy of the Special Issue on Spinal Manipulation, contact Elsevier at http://webshop.elsevier.com. For more information on the 10^th INSPIRE Conference in Phoenix October 27-28, 2012 visit www.helpinspire.org or call toll-free 888-294-4750.

The Impulsive Adjustment: State-of-the-Art Technology Enables Spine Monitoring Simultaneously During Treatment

VIEW PRINT VERSION

 Christopher J. Colloca, D.C.

CEO and Founder of Neuromechanical Innovations

A ISO 13485 Certified Medical Device manufacturer of the Impulse® family of adjusting instruments, based in Chandler, Arizona.

Prominent Spine Researcher and Reviewer

He can be reached at DrC100@aol.com or at www.neuromechanical.com

INTRODUCTION

            Inherent in the definition of chiropractic adjustment is the need to identify abnormal mobility and/or alignment and the introduction of specifically applied forces intended to reduce or correct the dysfunction.  Inasmuch, over a decade ago, I placed my research focus into developing technology geared towards  the ability to quantify spinal displacements and monitor spinal motion responses during chiropractic adjustments.  With this agenda, I assembled an international research team to examine the biomechanical characteristics of various spinal pathologies and their relationship to spinal motion. Born out of this research was a validated non-invasive spinal stiffness assessment methodology that compared our methods to a gold-standard intersegmental motion technique that we published in 2009 in the journal, Spine (Colloca et al. 2009). Forces that are relatively large in magnitude, but act for a very short time (much less than the natural period of oscillation), are called impulsive.

Quantifying Spinal Pathology

Segmental instability and pathology of the spine are believed to produce abnormal patterns of motion and forces, which may play a significant role in the etiology of musculoskeletal disorders (Nachemson 1985).  The ability to quantify in vivo spine segment motion (displacement) and stiffness (force/deformation) in response to forces is thus considered to be of clinical significance in terms of both diagnosis and treatment of spinal disorders. Moreover, knowledge of spine segment motion patterns, forces and stiffness is also of fundamental interest to understanding the postural, time-dependent and dynamic response of the spine, the role of spinal implants in mechanical load sharing, and the response of the extremities (appendicular skeleton) and spine (axial skeleton) to externally applied forces such as chiropractic adjustments (Keller et al. 2002).    

            The mechanical and physiologic response of the spine to PA forces is dependent upon many factors, including the intensity, direction, duration and frequency of the applied force. Of these factors, the frequency-response and frequency-dependent stiffness characteristics of the spine to PA dynamic loading is perhaps the least well understood. The dynamic PA frequency-dependent stiffness behavior of the human spine reflects the fact that the spine is a viscoelastic structure, albeit generally more elastic than viscous.  Different structures (ligaments, cartilage, bone, tendons, muscle) will exhibit varying degrees of time-dependent and frequency-dependent viscoelastic behavior.  Consequently, the overall structural/vibration response of the spine is modulated by both the architecture or structural organization of component tissues as well as load sharing provided by adjacent structures (e.g. rib cage, sternum, pelvis).  When such factors are combined with other considerations such as spinal curvature, the net effect is a complex structure-frequency-dependent mechanical behavior.

Structural Frequency Response Functions

            The general approach for determining the dynamic response of a man-made or biologic structure consists of simultaneously measuring an excitation or input signal (typically force) and response or output signal (displacement, velocity or acceleration) in the time domain and analyzing them in the frequency domain.  Two principal types of frequency response transfer functions can be determined: a ratio of like parameters such as the ratio of the force transmitted to the disturbing force (transmissibility), or a ratio of two dissimilar parameters such as the ratio of the disturbing force to the velocity transmitted (mechanical impedance). Frequency response functions, together with identification of the resonant frequencies associated with the vibration, provide important information concerning the mechanical behavior of the structure.  For example, when the spine is dynamically loaded along the PA direction a lower impedance value implies that the intervertebral joints are easier to excite and capable of greater mobility and storage of larger amounts of energy, whereas the opposite holds for transmissibility (Kazarian 1972).  A variety of mechanical vibration “transfer functions” can be defined for various excitation (input) and response (output) signals (Table 1).

Table 1. Dynamic Frequency Response Transfer Functions

Name	Transfer Function
Accelerance	acceleration/force (kg-1)
Effective Mass	force/acceleration (kg)
Mobility	velocity/force (m/Ns)
Impedance	force/velocity (Ns/m)
Compliance	deformation/force (m/N)
Stiffness	force/deformation (N/m)

            A very fast and efficient method to determine the broadband dynamic mechanical response of a structure is to use transient testing techniques such as impact testing. During impact testing, a hand-held instrument (typically a hammer) with a load cell mounted to it is used to deliver a force impulse to the structure, and the motion response is measured using an accelerometer either mounted to the structure or mounted directly to the instrument (driving-point). It is this technique that we have refined and patented for our unique approach of simultaneously monitoring spinal motions during chiropractic adjustments. In the next issue of the Journal, we will review the benefits of adjusting at the resonant frequency of the spine.

References

1. Colloca, C.J., Keller, T.S., Moore, R.J., Harrison, D.E., & Gunzburg, R. 2009. Validation of a noninvasive dynamic spinal stiffness assessment methodology in an animal model of intervertebral disc degeneration. Spine 2009, 34, (18) 1900-05.
2. Kazarian, L.E. 1972. Dynamic response characteristics of the human vertebral column. Acta Orthop Scand., Suppl 146, 1-186
3. Keller, T.S., Colloca, C.J., & Beliveau, J.G. 2002. Force-deformation response of the lumbar spine: a sagittal plane model of posteroanterior manipulation and mobilization. Clin Biomech, 17, (3) 185-196
4. Nachemson, A. 1985. Lumbar spine instability. A critical update and symposium summary. Spine, 10, (3) 290-291

Legitimizing Instrument Adjusting

Christopher J. Colloca, D.C.

CEO and Founder of Neuromechanical Innovations

A ISO 13485 Certified Medical Device manufacturer of the Impulse® family of adjusting instruments, based in Chandler, Arizona.

INTRODUCTION

As the popularity and utilization of Instrument Adjusting grows worldwide, mainstream acceptance continues to be hampered by outdated technology and technique approaches that are associated with traditional Instrument Adjusting techniques.  The exciting challenges of integrating chiropractic care into mainstream healthcare are subsequently plagued by the esoteric chiropractic techniques that are not accepted or recognized among general healthcare professionals.  Take for example, the Activator Method, which advocates that changes in leg length while a patient places their hand on their lower back constitutes a positive clinical finding for an L5 or L4 vertebral subluxation.  Try explaining this test to a physician or even a chiropractic colleague! 

Recently claims submitted to Aetna by Activator practitioners have been denied simply based upon the technique used.   There is also the problem of using the Activator Method isolation tests to identify a subluxation under Medicare.   So, while the Activator group should be congratulated for celebrating their 45^th Anniversary in business, their decades old approach doesn’t pass the sniff test in today’s healthcare arena.

Recognizing the inherent dangers in being associated with other Instrument Adjusting approaches, our team set out to carve our mission of legitimizing Instrument Adjusting not only within chiropractic, but also to the general health care community and to the public. To this extent, our team crafted a strategic plan to assess instrument adjusting utilization and perception and to provide the improvements and enhancements necessary to advance the technique and the profession. 

Instrument delivered chiropractic care can be broken down into two parts – The instrument technology itself and the clinical application that the technique is based upon (Figure 1). 

 Figure 1. Instrument Adjusting includes the technology of the product represented by the instrument brand and the functionality or performance of the device as well as the clinical application that is taught in the clinical training that includes the indications to administer the treatment and the clinical decision making accompanying the actual technique application. 

First level strategic inputs to assess in legitimizing Instrument Adjusting include Technology development and evaluation of the Clinical Applications.  As shown in Figure 2, these inputs are driven by research and development resulting in scientific journal publications that validate the technology that is developed.  Medical Device Certifications ensure quality and further solidify the medicolegal ramifications of using instrument adjusting technology in your practice.  Through literature review, evidence-based Technique Development comprised the incorporation of clinical tests with the best evidence as inclusion criteria, and Clinical Training and practical testing to ensure clinical proficiency.  Last, efforts to increase the awareness of the Instrument Adjusting movement within chiropractic were created through a Marketing and Business Expansion effort to increase the utilization of chiropractic care by the public. 

Figure 2. Categorization of the strategic input drivers identified to legitimize Instrument Adjusting.   

• Technology Inputs

Instead of starting with an instrument and then doing retrospective research the way instrument adjusting research has traditionally been approached, we set out to prospectively develop a new family of adjusting instruments to improve the performance and efficiency of chiropractic adjustments.  The Impulse® and Impulse iQ® Adjusting Instruments were born of this research.

We quantified the forces and speeds that were necessary to maximize vertebral motions and neuromuscular responses (1,2) and investigated how instrument delivered thrusts differed among normal and pathological states such as disc degeneration and muscle hyperactivity (2-4).  We then compared our new technology to existing adjusting instruments in the market and demonstrated the superiority of the biomechanical characteristics of the new Impulse® Adjusting Instruments (5,6).  Validation of a new non-invasive method of dynamic spinal stiffness assessment was conducted and published it in the Journal Spine (7).

• Medical Device Certifications. 

To meet the growing demand for our products, I began a new medical device manufacturing company to manufacture the devices to the required specifications.   We created several new jobs and instituted a Quality Management System to drive our business that fostered our ISO 13485 Medical Device Certification.  Independent audits conducted in our facility ensure the safety and efficiency of our systems and procedures and our products UL Listing® attests to the high standards we hold.  Our international growth pushed us to receive our Class II Medical Device Certifications throughout the World.  Manufacturing a chiropractic device to the highest quality medical standards allows our equipment to be used in hospitals as well as private chiropractic clinics further serving the purpose to legitimize instrument adjusting.

• The Instrument Adjusting Problem - Esoteric Techniques

Unfortunately however, Instrument Adjusting has been traditionally associated with esoteric chiropractic analyses that border on summoning the supernatural.  Followers of the Activator Method stare at the feet looking for leg lengths to change while asking the patient to put their arms on their back or over their head to confirm a vertebral subluxation at a specified level.  Without any validation whatsoever, these arm movement are assigned to a particular vertebral segment and flexing the legs supposedly tells the clinician what side to adjust the patient on.  Borrowed and adapted from Directional Non-Force Technique (DNFT), Activator technique is closer to Network and Applied Kinesiology with its leg checks, pressure tests and challenges that are seen by many as nothing short of strange and indefensible.

Without any credible explanation or rationale at all behind this analysis, the Activator Method is taught in our chiropractic colleges and in college sponsored post-graduate education courses.  There aren’t too many chiropractic techniques that could be more far-fetched; yet, Activator Methods boasts that approximately 150,000 chiropractors have been trained in the technique.  It’s hard to understand how this is even possible when there are approximately 50,000 chiropractors practicing in the USA and 90,000 abroad (8).  Another descendant of DNFT, Koren Specific Technique, advocates that you can “adjust disks … see dramatic retracting … and specifically analyze and adjust yourself.”  Rather than passing judgment, let’s have you decide for yourself what type of Instrument and technique method that you would like to subscribe.  At the very least, I think you can understand why I felt the need to legitimize instrument adjusting.

• Clinical Application Inputs

            In developing Impulse Adjusting Technique (the clinical application training accompanying our products), we knew that we needed to incorporate logical, clear and readily acceptable objective assessments that were validated, accepted, and easy to perform.   We embraced the Centers for Medicare (CMS) Services mandated P.A.R.T. analysis to keep chiropractors in compliance with regulations and increase their reimbursements at the same time.  Incorporating accepted orthopedic tests combined with static palpation, and range of motion assessment of the spine and extremities, Impulse Adjusting Technique® considers the patients response in terms of their pain response (P), asymmetries (A), restrictions in range of motion (R) and the texture and tone changes in the muscles (T) as clinical indicators.  With this approach, the most valid clinical indicators are incorporated and a straightforward patient encounter on each visit can subjectively and objectively track patients’ progress consistent with the chiropractic standard of care.

Clinical training in the Impulse Adjusting System® is offered in most U.S. Cities and many international destinations.  Didactic and practical sessions are offered in the proper product usage and clinical applications training.  A written and practical certification examination is offered to measure student’s proficiency.  We have further developed a business and marketing expansion module to assist chiropractors in promoting and marketing their unique niche in chiropractic practice.  More information can be found online at www.impulseseminars.com.

Legitimizing instrument adjusting and advancing the chiropractic profession begin with raising the standards of the products offered to DC’s replacing nonsensical chiropractic analyses with those techniques that have stood up to the scrutiny of research. 

References