RESEARCH RELIABILITY RESULTS ACTIVATOR METHODS CLINICAL TOPICS CLASS Dr. Fuhr will be teaching at each class via short videos on clinical topics including: How to predict when a patient will be getting well How to handle the patient that starts with a left PD and shifts to a right PD How to handle a very acute low back The Activator Method Chiropractic Technique, and the research that supports it, is designed for use only with genuine Activator Adjusting Instruments. facebook.com/activator twitter.com/activatormethod Activator.com
Copyright 2017 All rights reserved. No part of this manual may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from Activator Methods International, Ltd. Activator Methods International, Ltd. 3822 East University Drive, Suite 5 Phoenix, Arizona 85034 800-598-0224 602-224-0220 ver. 01-2017 Copyright 2017 Activator Methods
CLINICAL TOPICS in Activator Methods 2017-2018 Schedule Agenda CORE ESSENTIALS 8:00 am The Activator Method Analytical Technique Leg Testing Workshop 9:00 am The Activator Adjusting Instrument Protocol Landmarks Workshop Clinical Topics with video training by Dr. Fuhr in each module 10:00 am Additional Tests and Adjustments for the Sacrum, and Pelvis 11:00 am Additional Tests and Adjustments for the Hip and Lumbar Spine 12:00 pm LUNCH BREAK 1:00 pm Additional Tests and Adjustments for the Thoracic Spine 2:00 pm Additional Tests and Adjustments for the Cervical Spine 3:00 pm Tests and Adjustments for the Cranial Bones Proficiency Testing Grand Rounds Workshop 4:00 pm Proficiency Testing and Clinical Grand Rounds Workshop
Instrument Adjusting for Extremities 2017-2018 Schedule Agenda Core Essentials 8:00 am The Activator Method Analytical Technique Leg Testing Workshop 9:00 am The Activator Adjusting Instrument Protocol Landmarks Workshop The Lower Extremity 10:00 am The Hip, Knee, and Related Structures 11:00 am The Foot, Ankle, and Related Structures 12:00 pm LUNCH BREAK The Upper Extremity 1:00 pm The Shoulder, and Related Structures 2:00 pm The Elbow, Wrist, Hand, and Related Structures Review of Advanced Tests and Adjustments 3:00 pm Review of Advanced Tests and Adjustments Proficiency Testing Grand Rounds Workshop 4:00 pm Proficiency Testing and Clinical Grand Rounds Workshop
Fundamentals of Activator Methods 2017-2018 Schedule Agenda Conducting the Initial Leg Check 8:00am 9:00am Module 1: Conducting the Initial Leg Check Module 2: Interpreting the Results of the Initial Leg Check The Basic Scan Protocol 10:00am 11:00am 12:00pm 1:00pm 2:00pm 3:00pm Module 3: Pressure/Stress Testing; Knees and Feet; Pelvis Module 4: Isolation Testing; Short/Long Rule; Symphysis Pubis LUNCH BREAK Module 5: Lumbar Vertebrae; Thoracic Vertebrae and Ribs Module 6: Scapulae / Shoulder Involvement Module 7: Cervical Vertebrae and Occiput Proficiency Testing Technique Workshop 4:00pm Proficiency Testing and Technique Workshop
Activator Methods Leg Testing Workshop Measures of LLI using the AM protocol enable the practitioner to: Isolate neuroarticular dysfunction of the axial skeleton and extremities Determine the direction of misalignment Confirm the direction of adjustment Confirm post-adjustment assessment p 113 keypoint The AM Leg Length Analysis (LLA) is used to help determine: WHERE to adjust WHEN to adjust WHEN NOT to adjust What do research and clinical experience show? Proficiency-rated doctors who use Activator methodology have good to very good intra-examiner reliability when evaluating Pelvic Deficiency (PD), or Leg Length Inequality (LLI). See Table 6-1 (p 134) of The Activator Method, Second Edition What is a functional short leg? While not anatomically shorter, the functional short leg appears shorter during analysis and treatment Traditionally designated as the Pelvic Deficient, or PD leg Also referred to as the reactive leg Proper footwear should: Have a back or a strap that maintains contact with the heel and helps prevent gripping of the toes by the patient Allow access to the bones of the feet Fit the foot tightly, not be badly worn, and slip on and off easily when needed Copyright 2017 Activator Methods 1
Activator Adjusting Shoes Proper Adjusting Table Wide enough to support patient s arms Bolster under patient s ankles to relax knees Long face slot to accommodate short and tall but leave ankles in proper position Tilt table preserves and enhances weightbearing distortions and postural compensations Lloyd Activator Hylo The 4 Essential Steps of the Initial Leg Check 1. Patient Placement 2. Visual Inspection 3. Position #1 procedure Identify the PD leg 4. Position #2 procedure Identify the starting point for analysis Proper Patient Placement Instruct the patient: Lean into the table Face centered in the slot Arms at the sides Back of each hand contacting and resting on the table Do not move or adjust your weight Place a hand firmly over patient s lower back Lower the table Proper Patient Placement The patient s legs need to extend past the bottom of the table far enough to allow ankles and feet to move freely. Doctor positioning: stance The position in which you stand is also important. Stand at the foot of the table with a stance that permits a clear line of sight to the plantar surfaces of the patient s feet Place one foot forward in an in-line, or scissor stance Keep an upright posture Copyright 2017 Activator Methods 2
Leg Length Analysis: Position #1 Procedures The Six-Point Landing Remove inversion or eversion Gently dorsiflex the feet Flare feet 10 Apply gentle headward pressure p 117 Tips for Minimizing Error Use a light touch Do not wiggle or play with the feet or legs Keep your index finger off the Achilles tendon in Position #1 Remove inversion (supination) and plantar flexion p 120 Leg Length Analysis: Position #2 Position #2 Procedure 1. Stand in an in-line, scissor stance 2. Contact the dorsal aspect of the patient s feet at the MTP junction with the middle fingers 3. Plantar flex the feet until slack is taken up, before lifting the legs p 119 Position #2 Procedure 4. Slowly lift the legs by raising the feet and flexing the knees 5. At ~30 of knee flexion, slide the index fingers into the welt of the shoe, and position the thumbs on the soles near the ball of each foot p 119 Copyright 2017 Activator Methods 3
Position #2 Procedure 6. Continue to raise feet until knees are flexed to no more than 90 7. Site an imaginary mid-line on the patient (2 nd sacral tubercle to EOP) 8. At 90, abduct the feet to a 10 toe-out foot flare p 119 Tips for Minimizing Error Move the legs deliberately from Position #1 toward Position #2 Keep your elbows tucked into the sides while raising the legs toward Position #2 Lower the legs slowly from Position #2 back down to Position #1 p 121 Tips for Minimizing Error Let the feet form a V in Position #2, keeping the heels from touching, with the toes flared out Do not force dorsiflexion of the feet in Position #2 p 121 Interpreting the Results of the Initial Leg Check Raise the legs to Position #2, observe for the PD leg to lengthen or shorten relative to its length in Position #1 Determine the starting point for AM assessment protocol based on the relative change Three Possibilities Summary Possibility One Possibility Two PD leg lengthens going from Position #1 to Position #2 PD leg shortens going from Position #1 to Position #2 Begin with knees and feet Skip knees and feet, and pelvis; begin with fourth lumbar vertebra (L4) Activator Methods Landmarks Workshop Possibility Three Legs are even/balanced in Position #1 and Position #2 Skip knees and feet, and pelvis; begin with pubic symphysis Copyright 2017 Activator Methods 4
Holding the Activator IV Hold between 2 nd and 3 rd digits May need 3 rd and 4 th digits Handle rests on thenar eminence Always maintain a neutral wrist Incorrect Wrist Angles i.e. not neutral Hand may need to be turned to get the correct LOD. The Classic Grip Example: PI ilium adjustment The Modified Grip The Inverted Grip Copyright 2017 Activator Methods 5
Holding the Activator V Trigger finger 1 st finger vs. 2 nd finger (or thumb) Grip Pressure Light vs. Firm Holding vs. Squeezing Instrument Patient Contact Maintain a firm, steady contact with the instrument to the patient throughout the duration of the thrust NOTE: In order to maintain a firm, steady contact It is better to hold the instrument more perpendicular to the patient than being as particular to the exact LOD. p 142 Preload RAMP Magnitude A smaller compared with a larger preload magnitude produces a larger increase in paraspinal muscle spindle discharge. Preload RAMP Magnitude Practical Application: 18% of the peak applied thrust force (PATF) is the preload magnitude target. J Manipulative Physiol Ther 2014;37:68-78 J Manipulative Physiol Ther 2014;37:68-78 ACTIVATOR IV Preload Targets ACTIVATOR V Preload Targets Instrument Setting Thrust Force (N) Thrust Force (lbs) Preload Magnitude Instrument Setting Thrust Force (N) Thrust Force (lbs) Preload Magnitude Setting 1 50N 10 lbs 2 lbs Setting 2 70N 16 lbs 3 lbs Setting 3 90N 20 lbs 4 lbs Setting 4 110N 24 lbs 5 lbs Setting 1 50N 10 lbs 2 lbs Setting 2 100N 20 lbs 4 lbs Setting 3 150N 30 lbs 6 lbs Setting 4 200N 40 lbs 8 lbs NOTE: Output force ranges are approximate. NOTE: Output force ranges are approximate. Copyright 2017 Activator Methods 6
Preload HOLD Duration A longer compared with a shorter preload duration produces a significantly larger increase in paraspinal muscle spindle discharge during the manipulative thrust. Preload HOLD Duration Practical Application: 4 seconds (compared to 1 second) is the preload duration target. J Manipulative Physiol Ther 2014;37:68-78 J Manipulative Physiol Ther 2014;37:68-78 Ensure Effective Adjustment For some adjustments, you will need to use the thumb or fingers of the free hand to: Take a tissue pull over the contact point in the recommended LOD Stabilize the tip of the instrument on the contact point Add pain provocation upon palpation to Activator tests Like all other diagnostic methods, AM is meant to be used in conjunction with other clinical skills of differential diagnosis, e.g. pain provocation upon palpation is another reliable and valid method to verify where to adjust. Triano, Budgell et al., Chiropractic & Manual Therapies 2013, 21:36 Anterior-Superior (AS) Ilium 1. Posterior Base Sacrum ½ lateral to the 1 st sacral tubercle LOD: Anterior-Inferior 2. Crest of the Ilium 1 Superior to the Posterior Superior Iliac Spine (PSIS) LOD: Inferior-Medial 3. Ischial Tuberosity LOD: Anterior-Inferior 1 3 2 AS Ilium Correction 1 Contact the base of the sacrum on the side Opposite Pelvic Deficiency about one-half inch lateral to the first sacral tubercle. LOD: Anterior and inferior Copyright 2017 Activator Methods 7
AS Ilium Correction 2 Contact the crest of the ilium about one inch superior to the PSIS. LOD: Inferior and medial parallel to the plane line of the sacroiliac articulation AS Ilium Correction 3 Contact the superior aspect of the ischial tuberosity LOD: Anterior and inferior Posterior-Inferior (PI) Ilium PI Ilium Correction 3 1 2 1. Spine of the Ischium LOD: Post-Sup-Lat 2. Under Sacrotuberous Ligament LOD: Post-Sup-Lat 3. Iliac Fossa LOD: Anterior-Superior 1 Position the tip of instrument in the soft tissue of the glutueus maximus just medial to the ischial tuberosity LOD: Posterior, superior and lateral PI Ilium Correction PI Ilium Correction 2 Place the tip of the instrument under the sacrotuberous ligament in the sciatic notch LOD: Posterior, superior and lateral 3 Contact the iliac fossa just lateral to the sacroiliac joint in the soft tissue of the gluteus medius LOD: Anterior and superior Copyright 2017 Activator Methods 8
Activator Methods Clinical Topics Class 50 Years of Clinical Observations by Dr. Arlan Fuhr View Featured Videos: Activator.com/Topics Predicting Response to Adjustments Position #2 Indicator Handling the Hot Low Back Patient Atypical Leg Length Testing Copyright 2017 Activator Methods 9
Subluxation Switch Subluxations Shift Sides Demonstrating that Chiropractic Works to a New Patient Cranial Bone Adjusting using the Activator Methods protocol Activator Methods Additional Tests and Adjustments for the Cranial Bones Not in Textbook Cranial Considerations IT IS IMPORTANT TO NOTE: These are clinical observations. Historically, cranial adjusting has been included in most techniques. The Activator protocol consists of Stress Tests and Pressure Tests. Copyright 2017 Activator Methods 10
Instrument Protocol Activator V Lowest instrument setting and direct contact with instrument. Activator II / IV Lowest instrument setting and over the finger or thumb. Cranial Bone Tests Frontal Bone Parietal Bone Occipital Bone Temporal Bone PD Side Temporal Bone OPD Side Cranial Involvement Cranial Involvement The Frontal, Parietal, and Occipital bones all subluxate superiorly. Subluxation of cranial bones is typically toward the anterior fontanelle. Frontal Bone Frontal Bone Stress Test: Superiorly CP: Superior aspect of the Frontal bone LOD: Inferior and anterior Copyright 2017 Activator Methods 11
Parietal Bone Stress Test: Superiorly Parietal Bone CP: Superior aspect of the Parietal bone LOD: Inferior Occipital Bone Stress Test: Superiorly Occipital Bone CP: Superior aspect of the Occipital bone LOD: Inferior Temporal Bone - PD Side Stress Test: Anterior and superiorly in a circular motion Temporal Bone PD Side CP: Anterior aspect of the Temporal bone LOD: Posterior and inferior Temporal Bone Copyright 2017 Activator Methods 12
Temporal Bone - OPD Side Stress Test: Posterior and inferiorly in a circular motion Temporal Bone OPD Side CP: Posterior aspect of the Temporal bone LOD: Anterior and superior Temporal Bone Visit: www.activator.com Activator Methods Find a Doctor Learn and/or review the Basic Scan Protocol at your convenience. Earn 12 hours C.E. credit online! Thank you for attending! We look forward to seeing you at a future Activator Methods seminar. Copyright 2017 Activator Methods 13
Activator Adjusting Instruments Peak Output Force Ranges NOTE: The compliance of human tissue plays a significant role in the output forces transmitted by adjusting instruments. The values listed are the output forces generated when applying our adjusting instruments to human tissue analogs that span the range of human spinal flexibility. Output Force Activator II Activator IV Activator V Lowest Setting Soft Tissue Analog 20N (4.5 lbs) 35N (7.9 lbs) 40N (8.9 lbs) Lowest Setting Stiff Tissue Analog 70N (15.7 lbs) 70N (15.7 lbs) 60N (13.5 lbs) Highest Setting Soft Tissue Analog 70N (15.7 lbs) 75N (16.9 lbs) 130N (29.2 lbs) Highest Setting Stiff Tissue Analog 165N (37.1 lbs) 109N (24.5 lbs) 189N (42.5 lbs) In Vitro Biomechanical Evaluation of Single Impulse and Repetitive Mechanical Shockwave Devices Utilized for Spinal Manipulative Therapy. Liebschner et al. Annals of Biomedical Engineering, Vol. 42, No. 12, Dec 2014. pp. 2524 2536.