Certification Exam Study Guide

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

1 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 C1 Transverse Process Contact... 9

2 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 Wrist and Hand... 12

3 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 CONTENT 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.). 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. Good luck in your studies.

4 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 Low Medium High Switch Position Down Middle Up Typical Use On Occiput, TMJ, Upper Cervical Spine, Pediatric or Geriatric Patients, Excessively Tender Areas Lower Cervical, Thoracic, Lumbar Spine, and Extremity Joints Lumbar Spine, Sacrum, Sacroiliac Joint, Hip Joints Force (Newtons) Force (Pounds) 100 22 200 45 400 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

5 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

6 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. Threedimensional 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

7 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).

8 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 Adjustments

9 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

10 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 Achilles Tendonitis Posterior Calcaneus Gastrocnemius Hyperactivity Eccentric Loading For Tendonopathy Inversion Ankle Sprain Anterior-Lateral Talus Posterior Distal Fibula

11 Eversion Ankle Sprain Differential Diagnosis: Medial (Posterior) Tarsal Tunnel Syndrome Inferior-Medial Talus Inferior-Medial Navicular Inferior-Medial Tibia Instep (Dorsal Ankle) Pain Anterior Talus Superior Medial Cuneiform 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 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 Step Down Test

12 Hip Differential Diagnosis: Hip Posterior Hip Pain Posterior Trochanter Lateral Hip Pain Lateral Trochanter Anterior Hip Pain Anterior Trochanter Upper Extremity Introduction Shoulder Scapulothoracic Joint Medial Scapula Superior Scapula Differential Diagnosis Rotator Cuff Combination Adjustments 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 Wrist and Hand Carpal Tunnel Syndrome Medial Scaphoid Medial Pisiform

13 Wrist Pain Lateral Distal Ulna Lateral Distal Radius Thumb Pain 1st Metacarpocarpal Joint