Certification Exam
Study Guide
Neuromechanical Innovations 101 South Roosevelt Avenue
Chandler, AZ 85226 U.S.A. Tel. 480-785-8448 Fax. 480-785-3916 www.impulseseminars.com
Table of Contents
General Certification Information... 3
The Impulse Adjusting Instrument®... 4
Forces... 4
Preload... 4
Single vs. Multiple Thrusts... 4
Single vs. Dual Syluses... 5
Impulse® Research and Development... 5
Bench Test Experiments Comparing Instrument Adjusting Devices... 5
In Vivo Experiments Comparing Instrument Adjusting Devices... 6
Effects of Multiple-Impulse Thrusts... 6
Instrument Adjusting and Medicare... 7
The Neuromechanical System™... 8
CMS Requirements and PART Documentation... 8
P - Pain... 8
A - Asymmetry... 8
R - Restriction or ROM... 8
T - Tone, Texture, Temperature... 8
Five Step Lumbopelvic Analysis and Adjusting Procedures... 8
Bilateral Nachlas Test... 8
Unilateral Nachlas Test... 8
Hip Rotation Tests... 8
Lower Extremity Muscle Compression Tests and Adjustments... 8
Suprapelvic Evaluation (Quadratus Lumborum) and Adjustments... 8
Pelvis... 9
Sacroiliac Joint Adjustment... 9
Hip Joint Adjustments (External and Internal Rotation)... 9
Lumbar Spine... 9
Introduction... 9
Differential Diagnosis: Referred vs. Radicular Symptoms... 9
Analysis and Adjustment... 9
Mamillary Process Contact... 9
Spinous Process Contact... 9
Multifidus Atrophy Assessment... 9
Dual Stylus Contact... 9
Cervical Spine... 9
Introduction... 9
Cervical Zygapopyseal Joint Referred Pain Patterns... 9
Muscular Involvement... 9
Cervical Spine Kinematics... 9
Analysis and Adjustment... 9
Occiput - Single Stylus... 9
Occiput - Dual Stylus... 9
C2 Spinous Contact... 9
Cervical Rotation Test... 9
C2 Transverse Process Contact... 9
C2 Dual Stylus Contact... 9
Cervical Lateral Flexion Test... 9
Lower Cervical (C3-C7) Transverse Process Contact... 9
Lower Cervical (C3-C7) Dual Stylus Contact... 9
Muscle Adjustments... 9
Scalene Adjustment... 9
Upper Trapezius Adjustment... 9
Levator Scapula Adjustment... 9
Splenius Test and Adjustment... 9
Temporomandibular Joint (TMJ)... 10
Active TMJ Range of Motion Exam... 10
Passive TMJ Range of Motion Exam... 10
TMJ Adjustment... 10 Posterior-Superior TMJ Adjustment... 10 Anterior TMJ Adjustment... 10 Posterior TMJ Adjustment... 10 Superior TMJ Adjustment... 10 Lateral TMJ Adjustment... 10 Thoracic Spine... 10
Thoracic Compression Test... 10
Thoracic Spine Adjustment... 10
Thoracic Transverse Process Adjustment... 10
Thoracic Posterior Rib Adjustment... 10
Thoracic Dual Stylus Adjustment... 10
Anterior Rib Adjustment... 10
Lower Extremity... 10 Introduction... 10 Foot... 10 Knee... 11 Hip... 12 Upper Extremity... 12 Introduction... 12 Shoulder... 12 Elbow... 12
General Certification Information
ABOUT This study guide has been prepared to assist you in successfully completing the Instrument Adjusting Certification examination provided at The Neuromechanical System seminars.
ELIGIBILITY To be eligible to sit for the Instrument Adjusting Certification examination, you must be a doctor of chiropractic or a student currently enrolled in a CCE accredited chiropractic college. You must also have attended one prior Impulse Adjusting System® seminar to have received prior training on The Neuromechanical System™ and instrument adjusting protocols.
*Students who sit for the examination and successfully pass may not use the designated “Instrument Adjusting Certified™” status until they provide proof of graduation from Chiropractic College.
EXAM The Instrument Adjusting Certification examination consists of a written and a practical assessment to determine your knowledge of the subject matter. The written examination consists of multiple choice and true false questions. You must score 80% on the written examination to be eligible for the practical examination. The practical examination will pair you with a patient as the examiner determines your practical knowledge of using the Impulse Adjusting Technique™ analysis and instrument adjusting protocols (analysis procedures, segmental contact points, lines of drive, force settings, etc.).
CONTENT Examination content will consist of chiropractic analysis and instrument adjustment techniques. Contained within this course study guide in the pages that follow you will find testable material for the examination. This information is based upon knowledge about the Impulse Adjusting Instrument® and the Impulse Adjusting Technique®.
Please reference your Impulse Adjusting System™ seminar notes for details about segmental contact points, lines of drive, and combination adjustments for the most common conditions that are covered. This is all testable material.
The Impulse Adjusting Instruments®
Forces
Impulse® & Impulse iQ® have three distinct force settings (low, medium, and high) that are achieved by means of the three-position switch located just above the handle grip. Selection of the appropriate force setting is essential for safety and achieving the best results with patients. Prior to applying the instrument to the patient, first thrust into your own hand to get a feel for the thrust that the chosen force setting produces. Below are some general guidelines.
Setting Switch
Position Typical Use On
Force (Newtons)
Force (Pounds)
Low Down or Geriatric Patients, Excessively Tender Areas Occiput, TMJ, Upper Cervical Spine, Pediatric 100 22 Medium Middle Lower Cervical, Thoracic, Lumbar Spine, and
Extremity Joints 200 45 High Up Lumbar Spine, Sacrum, Sacroiliac Joint, Hip
Joints 400 90
Preload
Prior to adjusting, pressing too hard into a patient can reduce the amount of bone movement that will occur, while conversely, not pressing hard enough will cause the force to be absorbed by the soft-tissues rather than the target vertebra. Research has shown that about 20 Newtons of preload is utilized by chiropractors performing manual adjustments (Herzog et al., Spine 2001;26(19):210510) . Impulse is equipped with a 20 Newton spring in the nosepiece of the instrument that is ideal for just the right amount of tissue compression (tissue pull) prior to thrusting. You’ll notice when you preload the instrument, the red LED adjacent to the force-adjustment switch will turn green signaling that appropriate preload has been achieved. Note that the instrument will not fire unless the stylus is preloaded.
Single vs. Multiple Thrusts
Impulse® is equipped with an electronic trigger that interfaces with an internal optical sensor that enables you to perform single or multiple pulse thrusts for accomplishing the chiropractic adjustment. After preloading the stylus, the red LED will turn green indicating that proper preload has been achieved. Pulling the trigger once and immediately releasing it causes the instrument to thrust once. Pulling the trigger and holding it causes the instrument to enter the multiple pulse mode and the instrument will thrust 12 times in a row over 2 seconds (6Hz). You can release the trigger at any you feel is clinically indicated allowing you to perform number of thrusts you desire ranging from 1-12.
Generally speaking, one thrust is recommended for articular adjusting with new patients, whereas the multiple pulse mode is commonly used for excessively fixated segments or for neuromuscular applications. Our research has shown that multiple pulses can increase the vertebral motions by 25%. Thus, in areas you desire to create greater mobility, engaging the multiple pulse mode will enable you to create more vertebral motion than is capable with a single thrust. Please note that applying more than 12 thrusts on a segmental contact point is contraindicated. In many instances you
will observe clinically that only 3 or 6 thrusts are necessary to achieve your desired adjusting objectives. Over adjusting is more work for the doctor, can cause excessive soreness for the patient, as well as can shorten the lifespan of the instrument. The Impulse iQ® was developed by incorporating an accelerometer inside the nosepiece of the Impulse Adjusting Instrument. This accelerometer senses spinal motion signals during the adjustment and in real-time relays them back to a microprocessor controller computer chip inside the Impulse iQ® device.
Following the initial thrust of the Impulse iQ®, subsequent thrusts are delivered at a speed determined to optimize spinal motion (Intelliadjust™ Technology) while simultaneously comparing each consecutive thrust to its predecessors. Once maximum mobility is achieved, the Impulse iQ® ceases firing (AutoSense™ technology) and produces an audible beep which lets both the doctor and the patient know that the adjustment is completed.
The newest version of the Impulse iQ® has an LED indicator which provides a visual assessment of the improved spinal motion as the frequency changes from 5Hz to 12 Hz throughout the adjustment.
Single vs. Dual Syluses
Single stylus applications include chiropractic adjustment of body rotation subluxations or subluxations with lateral flexion dysfunction components. In essence, Impulsive thrusts utilizing the Single stylus application provide axial rotation motions coupled with lateral flexion of the functional spinal unit, as the single stylus contact unilaterally on the side of the spine.
Cervical and Lumbar Dual Styluses can be interchanged with the single stylus thereby contacting on both sides of the spinous process simultaneously. Application of the Dual stylus is used for accomplishing greater control during multiple thrusts and for instances desiring greater posteroanterior directed forces. Dual styluses are often used in addressing hypolordosis or kyphotic spinal configurations or retrolisthesis subluxations.
Impulse® Research and Development
Bench Test Experiments Comparing Instrument Adjusting Devices * Colloca CJ, Keller TS, Black P, Normand MC, Harrison DE, Harrison DD. Biomechanical comparison of mechanical force manually assisted chiropractic adjusting instruments. Journal of Manipulative and Physiological Therapeutics 2005; 28(6):414-22. A 2005 study published in the Journal of Manipulative and Physiological Therapeutics compared the forces, speeds, and frequency area ratio of six commonly used chiropractic adjusting instruments including Impulse®. The study reported a broader range of forces and a superior frequency area ratio among electromechanical adjusting instruments over traditional spring-loaded activation devices specifically favoring the Impulse Adjusting Instrument®. Impulse® was also found to be twice as fast
as the spring-loaded activation devices examined on all settings. These findings provide a scientific rationale supporting the anecdotal reports of better results with patients by clinicians using Impulse®.
In Vivo Experiments Comparing Instrument Adjusting Devices
* Keller TS, Colloca CJ, Moore RJ, Gunzburg R, Harrison DE, Harrison DD. Three-dimensional intersegmental motion validation of mechanical force spinal manipulation. Journal of Manipulative and Physiological Therapeutics 2006; 29(6):425-36.
A study published in the July/August, 2006 issue of the Journal of Manipulative and Physiological Therapeutics reported nearly three-fold greater vertebral motions during chiropractic adjustments delivered with the Impulse Adjusting Instrument® when compared to other chiropractic adjusting instruments. The study, conducted in Adelaide, Australia at the Institute for Medical and Veterinary Science, was the first to validate just how vertebrae move during different instrument-delivered chiropractic adjustments.
Activator® IV Adjusting Instrument (Activator Methods International, Ltd., Phoenix, AZ), the Chiropractic Adjusting Tool (CAT®, J-Tech Medical Industries, Inc., Salt Lake City, UT), and the Impulse Adjusting Instrument® (Neuromechanical Innovations, LLC, Phoenix, AZ) were researched to see how the spine would move during each of their force settings. Substantially larger magnitude vertebral motion responses were observed for thrusts delivered with the Impulse Adjusting Instrument® at most force settings and always at the high force setting. Interestingly, on the low force setting, larger magnitude vertebral accelerations were observed with Impulse® compared to the spring-loaded devices despite the fact that these devices exhibit higher peak forces on the low setting. Because Impulse® is twice as fast, and its near perfect half sine waveform, its efficiency is greatly improved, thereby explaining how this is possible. The Impulse Adjusting Instrument® has been shown to produce chiropractic adjustments at a rate of about a hundred times faster than traditional manual type chiropractic adjustments.
Effects of Multiple-Impulse Thrusts
* Keller TS, Colloca CJ, Moore RJ, Gunzburg R, Harrison DE. Increased multiaxial lumbar motion responses during multiple-impulse mechanical force manually assisted spinal manipulation. Chiropratic & Osteopathy 2006; 14(1):6-14.
A 2006 study published in the journal Chiropractic and Osteopathy determined that multiple-impulse chiropractic adjustments can create up to 25% more vertebral movement than single chiropractic thrusts. This study represents the first biomechanical investigation of the effect of multiple-impulse thrusts on vertebral motions. Using the Impulse® device the first thrust was compared to a series of consecutive thrusts delivered six times per second (6 Hz) to the spinous processes of sheep. Using high-tech tri-axial accelerometers, the intersegmental motions of the vertebrae were able to be measured and compared between the initial thrust and
subsequent thrusts. The research revealed a general trend toward maximizing vertebral motions typically anywhere between the third and eighth thrust.
Instrument Adjusting and Medicare
Medicare’s coverage of chiropractic services can be found in the Centers for Medicare & Medicaid Services Carriers Manual, Part 3, Chapter II Coverage and Limitations (2251) found online at http://www.cms.hhs.gov.
“Coverage of Chiropractic Services”
“2251.1 Manual Manipulation. - Coverage of chiropractic service is
specifically limited to treatment by means of manual manipulation, i.e., by use of hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself. …”
Medicare does not “approve” any specific chiropractic adjusting device, rather, states that the thrust of chiropractic adjusting instruments must be controlled manually. The force of the Impulse Adjusting Instrument® is controlled manually by means of a three-position force selection switch. In fact, new research has demonstrated a greater range of forces for electromechanical devices over their spring-loaded counterparts (Colloca et al. J Manipulative PhysiolTher, July/August, 2005).
The Impulse Adjusting System™
Please refer to your Impulse Adjusting Technique® seminar notes in studying the information itemized below. For both the written and practical portions of the examination you will be responsible for understanding and performing the content listed below.
Abbreviations Key:
SCP: Segmental Contact Point LOD: Line of Drive
CMS Requirements and PART Documentation P – Pain
• location, quality, intensity, and tenderness (by palpation) • qualitative via palpation
• quantitative via algometry
A – Asymmetry
• asymmetry assessed by observation • leg length inequality
• posture
• antalgia or scoliosis • muscle asymmetries • gait abnormalities
R - Restriction or ROM
• restriction or ROM decrease • active ROM
• passive ROM • orthopaedic tests
T - Tone, Texture, Temperature
• changes in soft tissues
• spasm/hyperactivity of muscles • muscle inhibition
• inflammation • color change
Five Step Lumbopelvic Analysis and Adjusting Procedures 1. Bilateral Nachlas Test
2. Unilateral Nachlas Test 3. Hip Rotation Tests
4. Lower Extremity Muscle Compression Tests and Adjustments 5. Suprapelvic Evaluation (Quadratus Lumborum) and
Pelvis
Sacroiliac Joint Adjustment
SCP: medial aspect of the PSIS
LOD: superior and lateral into the SI joint space External Hip Rotation Dysfunction
SCP: anterior aspect of the greater trochanter LOD: posterior
Internal Hip Rotation Dysfunction
SCP: posterior aspect of the greater trochanter LOD: anterior
Lateral Hamstring Hyperactivity
SCP: area of focal muscle hyperactivity (or trigger point(s)) LOD:
Lumbar Spine Introduction
Differential Diagnosis: Referred vs. Radicular Symptoms Analysis and Adjustment
Mamillary Process Contact Spinous Process Contact
Multifidus Atrophy Assessment Dual Stylus Contact
Cervical Spine Introduction
Cervical Zygapopyseal Joint Referred Pain Patterns Muscular Involvement
Cervical Spine Kinematics Analysis and Adjustment Occiput - Single Stylus Occiput - Dual Stylus
C1 Transverse Process Contact C2 Spinous Contact
Cervical Rotation Test
C2 Transverse Process Contact C2 Dual Stylus Contact
Cervical Lateral Flexion Test
Lower Cervical (C3-C7) Transverse Process Contact Lower Cervical (C3-C7) Dual Stylus Contact
Muscle Adjustments
Scalene Adjustment
Upper Trapezius Adjustment Levator Scapula Adjustment Splenius Test and Adjustment
Temporomandibular Joint (TMJ)
Active TMJ Range of Motion Exam Passive TMJ Range of Motion Exam TMJ Adjustment Posterior-Superior TMJ Adjustment Anterior TMJ Adjustment Posterior TMJ Adjustment Superior TMJ Adjustment Lateral TMJ Adjustment Thoracic Spine
Thoracic Compression Test Thoracic Spine Adjustment
Thoracic Transverse Process Adjustment Thoracic Posterior Rib Adjustment
Thoracic Dual Stylus Adjustment Anterior Rib Adjustment
Lower Extremity Introduction Foot Plantar Fascitis Medial Calcaneus Inferior-Medial Talus Inferior-Medial Navicular Inferior Medial Cuneiform Inferior 1st Metatarsal Inferior Lateral Cuneiform Combination Adjustment
Differential Diagnosis: Posterior Tibial Tendon Dysfunction
Differential Diagnosis: Shin Splints Support: Taping Procedure
Support: Motion Control Shoes Rehabilitation
Achilles Tendonitis
Posterior Calcaneus
Gastrocnemius Hyperactivity
Eccentric Loading For Tendonopathy Inversion Ankle Sprain
Anterior-Lateral Talus Posterior Distal Fibula Rehabilitation
Eversion Ankle Sprain
Differential Diagnosis: Medial (Posterior) Tarsal Tunnel Syndrome
Inferior-Medial Talus Inferior-Medial Navicular Inferior-Medial Tibia Rehabilitation
Instep (Dorsal Ankle) Pain Anterior Talus
Superior Medial Cuneiform Rehabilitation
Metatarsalgia
Differential Diagnosis: Halux Valgus (Bunion) Differential Diagnosis: Gout
1st Metatarsophalangeal Joint
Differential Diagnosis: Morton's Neuroma Inferior 5th Metatarsal
Knee
Introduction
Posterior Knee Pain
Posterior Proximal Tibia Posterior Tibiofemoral Joint Posterolateral Knee Pain Posterior Proximal Fibula Rehabilitation
Anterior Knee Pain Superior Patella Lateral Patella Medial Patella
Anterior Proximal Tibia Anterior Proximal Fibula
Differential Diagnosis: Knee Osteoarthritis Differential Diagnosis: Hip Involvement in Knee Conditions
Rehabilitation
Hip
Differential Diagnosis: Hip Posterior Hip Pain
Posterior Trochanter Lateral Hip Pain
Lateral Trochanter Anterior Hip Pain
Anterior Trochanter Rehabilitation Upper Extremity Introduction Shoulder Scapulothoracic Joint Medial Scapula Superior Scapula Differential Diagnosis Rotator Cuff Combination Adjustments Rehabilitation
Acromioclavicular (AC) Joint Seperation Superior Acromion Process
Superior Distal Clavicle Sternoclavicular Joint
Medial Proximal Clavicle Anterior Shoulder Pain
Anterior Humerus Elbow
Lateral Epicondylitis
Posterior-Superior Proximal Radius Medial Epicondylitis
Medial Epicondyle of the Humerus Medial Proximal Ulna
Rehabilitation Wrist and Hand
Carpal Tunnel Syndrome Medial Scaphoid Medial Pisiform
Wrist Pain
Lateral Distal Ulna Lateral Distal Radius Rehabilitation
Thumb Pain
