We wish Usain Bolt continued success and health as he competes in the 200 meter race this week.

Bolt receiving AMI treatment

A 55 year old man presented in my office with right sided neck pain along with pain into the upper right arm into his triceps, and pain along the right medial scapula border. He was having a difficult time sleeping particularly lying on his right side and difficulty sitting for more than five minutes without increasing of the symptoms. The problem started 6 weeks prior and just came on over time and had been getting worse each week. He works as an accountant which requires sitting frequently, computer work and lots of reading and phone work. He visited his PCP who gave him pain killers along with anti-inflammatories. He was told to rest and check back in 2 weeks with his PCP if he did not improve. Films of the cervical spine revealed extensive DJD at C4-5, C5-6, C6-7.He stopped the medication as it made him unable to focus on his work or drive.  He was also told if not improved in the 2-3 week time frame an MRI of his cervical spine may be ordered. He decided to pursue care in my office on a recommendation from one of his work colleagues.

After a consultation and full examination we decided to embark on a trial of care. We decided to do a trial of 3x a week for 3 weeks with re-evaluation. If at re-examination there was not improvement of his VAS scores , Neck Disability Index,positive orthopedic test and severity of symptoms we would consider an MRI as well. We started our adjusting protocol by using the AM  basic scan and using the cervical facet tests when we go the cervical spine. We told the patient after the first visit to avoid sitting for long periods at work and we talked about postural considerations to deal with his forward head posture. On his second visit he reported back in saying he was able to sleep through the night for the first time in about 5 weeks. The pain levels were cut by 60% and sitting and driving was remarkably improved. On the second visit we again followed the basic scan protocol along with the cervical facet tests and the right rhomboid test. He continued to improve with each visit and by the end of 2 weeks his VAS scores was zero, his neck disability index was a minimal 5% down from 40%, and his daily ADL’s were almost back to normal. We continued to work with adjusting as well as teaching specific cervical exercises and specific postural work to help him avoid exacerbation of the original issues.

Christophe Dean, DC

It’s easy for us to jump to diagnostic conclusions when we see certain symptoms and signs collected in a patient in front of us. When I first saw John, a gentleman of 45 years, he was bent in flexion and lateral antalgia and complaining of pain radiating from his right lower lumbar quadrant into his right buttock and posterior thigh. My instant diagnosis was L4/L5 disc herniation with impingement of the L4 nerve root. The x-rays, taken in weight bearing, demonstrated one of the most alarming reversals of lumbar curvature I have ever seen in 36 years of looking at x-rays. He was in such a flexed antalgia that I couldn’t get him to perform a Kemp‘s test and with the amount of pain he was in, it wouldn’t have been a humane thing to demand. He was able to heel/toe walk WNL and lower extremity deep tendon reflexes were brisk and symmetrical. I had difficulty laying him supine but when I eventually did, found no nerve root tension signs on straight leg raising. So here I had a case that seemed obvious yet none of the orthopedic tests are supporting my initial impression.

In these cases, I rely on the AMCT basic scan since my experiences have taught me that even when the orthopedic/neurological tests don’t line up, if I adjust according to AMCT protocol I will usually get a good outcome. The most significant finding was an L4 on the side opposite PD with laterality to the side of PD but no significant superiority/inferiority (contrary to my expectations). I adjusted him accordingly, gave him instructions to ice/heat at 10min/10min x 4 and to return to the office on the following day.

I really expected to see a significant improvement and was surprised to find none.  He continued to emphasize the burning nature of the right lower lumbar quadrant pain. I checked him again and found the same persisting L4 listing. This time I checked for a quadratus lumborum on the same side and found it but the L4 reappeared as soon as I put him back on his feet. I put him back down on the table and this time, checked for psoas (The deep part of the psoas originates from the transverse processes of L4. The superficial part originates from the lateral surfaces of T12, L1 – L4, and from neighboring invertebral discs. The lumbar plexus lies between the two layers.) I got a strong leg length imbalance and was pretty certain that I had found the problem. I had him perform a Thomas test. Thomas test is normally a test for hip joint fixation but also is positive in the case of a hypertonic psoas muscle. The test is performed with the patient supine with his knees at the end of the table and his lower legs hanging down. The uninvolved knee is flexed to the chest enough to rock the pelvis into flexion/nutation. If the opposite knee lifts up and is unable to make contact with the table, the test is indicative of either a fixated hip joint or a hypertonic psoas. In the later case, with some force the leg can be pushed down. The Thomas test was spectacularly positive with a marked difference between left and right. Confident that I had located an important element of the condition, I adjusted the psoas muscle and brought the patient up. Immediately, he was able to stand much straighter and noted his pain which had been 9/10 had dropped to 6/10. He also remarked that the burning had subsided and his leg pain had centralized to the mid-buttock. The next day, his pain had reduced to 4/10 and he had had a good night’s sleep. I scheduled him to return in 2 days.

In the next 4 days his pain had resolved to a mild soreness and it completely resolved by day 7. As has been pointed out by Nikolai Bogduk, it can be difficult to distinguish pain generating structures by orthopedic testing alone. In AMCT we have a system that allows us to determine where and when to adjust even if we are misled about the exact nature of the diagnosis. A facilitated and hypertonic psoas, because of its intimate relationship with the lumbar plexus, can easily mimic the symptoms of a lumbar disc complete with radiating lower extremity pain. Check this and the quadratus lumborum whenever there is a failure of the problem to resolve with the Essential Scan but also when there is antalgia and/or a persistent L4 and/or L3 opposite the PD side.

When I started utilizing Activator in the school clinic, “critics” of the technique said it was a “cookbook” approach. This comment was supposed to be somehow derogatory, but I never understood what was wrong with a step-by-step procedure. I would always remind the critics that science requires a step-by-step process. Why wouldn’t you want to know what you are doing? Decades have passed, and I’m still using the procedure that today has been enhanced by yet another step-by-step approach – research that proves its effectiveness. So much for the critics!

Dr. Joseph Steinhouser, DC, is a member of the Activator Methods Clinical Advisory Board and has been an instructor for years.

The patient’s main complaint in his visit to me was low back pain. He did have restriction of the lumbar motion, some of which I attributed to the extensive taping applied to his back. Despite his condition, it quickly became apparent that adjusting this patient was easy, thanks to the Activator Method. With the patient in a comfortable neutral prone position and using an Activator IV with the small contact point, I was able to place the Activator between the tubing and on the appropriate lumbar contacts. Resolution of his pain and return of his motion occurred within six treatments.  

Dr. Joseph Steinhouser, DC, is a member of the Activator Methods Clinical Advisory Board and has been an instructor for years.

It is a good idea to ask yourself and evaluate your results with your patients.  Am I adjusting and checking enough or too much?  There are time factors to consider.  We all need to value not only our patient’s time schedule, but value our own services for their true worth.  Most chiropractors are very giving, patient-serving doctors.  That doesn’t mean you have to spend 15 minutes per patient and perform at least 50 Activator tests on them.   A 2-minute, 5-adjustment treatment can be just as effective as a 15-minute, 50-adjustment treatment.  Which way is right?

The Protocol outlined in The Activator Method, Second Edition provides some answers.
1.    Always start with the Basic Scan.  Once you approach the area of chief complaint, both biomechanically and neurologically, then you can start adding extra tests.
2.  Make sure you utilize all your Positions in areas of chronic subluxation and the active complaint areas.  Every time you go from Position #1, to #2, then #3 and so on, you are accumulating neurology.
3.  Look for the BIG change in leg length reactivity.  This should give you more confidence in giving your patient the best adjustment.  Remind yourself how the joints are coupled.  Don’t let yourself get caught up in minutiae.  Follow our chiropractic philosophy of the “whole.”
4.  Add your extra tests relative to the chronic subluxations and patient complaint.  In the back of the textbook is a great reference to help you remember all the additional tests per area.  Utilize this by copying and putting it in each or your adjusting rooms.  If you are stagnating with a patient’s progress, make some notes of tests to perform prior to the visit.
5.  For extra tests not in the textbook, look through your manuals from the Advanced seminars and make yourself a list.  Add a new test each day or week to focus on until you have confidence to be able to see how patterns emerge per conditions.  “Favorite” tests will start to appear as you are in practice longer and utilize the new tests.  Instead of performing all 45 knee tests, start with your favorites, or “majors” as I like to call them.  On subsequent visits, start adding others.  Over time you will find tests that seem best per condition.
6.  At the end of your treatment, take a few seconds to ask your patients if there is anything else they would like for you to check or focus on.  This is a great way to instill confidence in your patients, demonstrating how you care about them and their treatment.  It is also a great step to take to assess if you are under testing or under adjusting.

Dr. Rebecca Fischer, DC, is an Activator Methods Clinical Advisory Board member and longtime clinical instructor.

Following the rules is an imperative that is ingrained in me, and has served me well in my personal and professional paths. Unfortunately, I have observed some recent behavior in the chiropractic world that leaves me unsettled and hoping that I am not witnessing a trend.

I am reminded of a time when I attended a prominent chiropractic seminar at which doctors take courses that qualify for license renewal. I saw a handful of registrants check in to a given session, leave the room, and then return near the end of the session to “prove” their attendance. I was so frustrated by this behavior that I left the seminar feeling rather defeated.  As a proponent of continuing education, not only for licensure but also for mastery of a given technique or strategy, I felt the doctors that failed to attend the full course were not only cheating the system, but also cheating themselves out of a tremendous professional growth opportunity.

When our state Board of Chiropractic Examiners took a hard line on inadequate record keeping, many of the doctors reacted strongly, complaining that the regulatory body was overstepping its bounds and being too aggressive.  Somewhere along the way, those doctors forgot why the Board exists in the first place:  To protect both patients and doctors.  After all, shouldn’t we seek to offer the best patient care possible, which includes keeping accurate and substantial documentation on each patient? Why would we want to put our patients at risk, and for that matter, our practices, by not keeping proper records?  And if those considerations don’t resonate, then think about the third-party payers who cannot justify reimbursement because of sub-standard record keeping.

It is detrimental to our profession when a few of us elect to sidestep guidelines or rules, when so many others are working diligently to maintain the integrity of chiropractic.  Not only does it detract from our credibility, but there is clearly an explicit price to be paid when rules are broken.

I am still a firm believer that the majority of chiropractors are following the rules, and ultimately realizing great benefits as a result. I can think of two colleagues in particular who underwent Medicare audits in recent months.  Because their documentation was intact, they did not incur any fines or additional fees from Medicare, and could take pride in the fact that their practices are managed efficiently and in conjunction with regulatory standards. By following the rules, these two doctors did not suffer financially as a result of the audit, and have even stronger confidence that a system that supports rule-following is one that pays dividends in the end.

I also know that following the rules can lead to positive patient outcomes.  The doctor who adheres to the guidelines associated with a given chiropractic technique is more likely to see results in his or her patients than the doctor who is unwilling to commit to the rules. Utilizing proper technique will help the patient heal faster, and also protects the doctor from extensive third-party investigation.  For example, a patient who is treated three times per week for a year without seeing results is probably not being treated using the correct protocols.  This leaves the patient suffering but also calls into question whether all of these visits can be reimbursed by insurance. And in more than one case that I can think of, reimbursements were declined because the insurance company couldn’t support so many visits if they weren’t yielding results. 

By following the rules, we maintain our professional credibility, help support our bottom lines, and protect the integrity of chiropractic on the whole. So, the next time you feel compelled to skip a step in documentation, leave a course early, or deviate from technique protocol, remember that the value of following the rules far outweighs the consequences of trying to skirt them.  And know that, in the process, you are upholding the chiropractic image for which we all strive.

Examination revealed limited range of motion of the cervical spine along with muscle spasm and tightness of the SCM, trapezius and levator scapulae muscles bilaterally. Besides the 10mm mouth opening measurement on anterior /posterior stressed motion, there was significant pain bilaterally along with popping of the TMJ. The same issues occurred with lateral to medial motion of the joint under stress. Neck pain disability index revealed a score of 30 which was also significantly high.

Adjusting protocol started with the Activator Basic protocol, working up the spine with adjustments in the pelvis , thoracic and cervical spine. After the Basic protocol was completed, advanced tests of the TMJ protocol were utilized with adjustments to specific jaw areas as found. This protocol was followed over a three week period of time with a re-evaluation to determine outcomes at three weeks. She was also taught postural consideration for her neck in particular, along with specific cervical spine exercises. She was told to cut her food into small pieces and to chew slowly and completely with each mouthful. She was to avoid hard crusty foods, and if she ate an apple, she should cut it into slices as opposed to taking a big bite.

On re-exam her mouth opening measurement went from 10mm to 35mm. On stressing the TMJ with AP and lateral to medial motion, pain was minimal with less popping and clicking. Cervical range of motion improved in all ranges with less pain and discomfort; headaches were no longer an issue.  The patient also explained that eating was now significantly easier and close to normal. Frequency of care was decreased and the adjusting and exercise protocol continued. At the end of six weeks of care her mouth opening was at 40mm and pain was very minimal in the jaw. Residual popping and clicking remained but at a very mild level. She was then moved to monthly care and told to continue with her postural and exercise protocols as well as chewing slowly while eating. Utilizing Activator Methods Basic and Advanced protocols enabled us to have a good outcome with this case.

Dr. Tom DeVita, DC, is a longtime seminar instructor and Clinical Advisory Board member with Activator Methods International.

That brings me to the importance of focusing on function and not chasing symptoms.  When I teach doctors and students the Activator Method, I always try to reinforce the importance of following the “system” of analysis when they are treating patients.  When you stick to the protocol, it eliminates jumping all over the place as the patient rattles off symptoms while lying on the table.  If there are other areas to evaluate for the patient, then we have the tests that allow us to do so.

Systematized analysis and adjusting ensure that we are consistent with every patient on every visit. We are thorough in our analysis, and most importantly, we know when to leave the patient alone so the body can respond to the changes we have introduced; or in some cases, when the patient may require additional evaluation or treatment.

In the process of applying the Activator Method, we are influencing the nervous system globally and often we see the body respond to this by resolving other symptoms that the patient, and even the doctor, did not anticipate.  This is obviously the best practice building tool you could ever employ and it does not cost you a dime.  It also presents a unique teaching opportunity to educate the patient on how the nervous system controls and coordinates all functions of the body, and how chiropractic adjustments help to restore normal function and the body’s ability to adapt to its environment.

Dr. Galvin is a longtime Activator instructor and member of the Activator Methods Clinical Advisory Board.