Enhance yourskillswiththedefnitiveguide tothe ActivatorMethod! FromBasicScanProtocolstoadvancedassessmentprocedures,this comprehensive resource presents the ActivatorMethodin an easy-to-understand,how-toapproach.This updated second edition coversallaspects ofthiscontrolled low-forceanalyticalandadjusting system, including thehistoryofthetechnique,in-depthexaminations ofbodystructures, andmuch more. ThisNEWeditionincludes: A convenientappendixwith ActivatorQuick Notes for Basic and Advanced Protocols thatprovidesat-a-glancereviewsofimportant pointstorememberwhenperformingbasic andadvanced protocols. A newchapteronLegLength Analysisproceduresthatoferscomprehensivecoverage ofthiscriticalstepinusing the ActivatorMethod. Thirteennewcontributorswhobringfresh insighttothe ActivatorMethod. Brand-new,full-colorphotosthatdetailassessmentprocedures,specifcanatomical contact points,andLines ofDrive. Plus,thesegreatfeatures: UNIQUE! As theonly ActivatorMethodtextbookinthefeld,itis theundisputed authorityonthe Activator Method. Expertauthor,Dr.ArlanFuhr,isco-founderofthe ActivatorMethod,bringinghis unparalleled expertise tothesubject. Clinical Observations boxessharetheauthor's knowledgefromyearsofexperience and provide tipsonanalysis of certain conditions and suggestions foratypicalcases. Summarytablesineachclinicalchapterallowyoutoquicklyaccesspertinent information. Step-by-stepinstructionthroughouttheActivatorMethod Analysissectionhelpsyou understandtheprinciples ofthetechnique. Arlan W Fuhr DC, co-founder of the Activator Method, is the co-inventor of the Activator Adjusting Instrument 780323048521> The Activator Method The Activator Method SecondEdition ArlanW.Fuhr,DC Presidem,NationalInstiwteofChiropracticResearch; SeniorMember,lmerationalSocietyfortheSwdyoftheLumbarSpine; Co-FounderandCEO,ActivatorMethods,Inc. Phoenix,Arizona AssociateEditor RebeccaS.Fischer,DC,FIACA Secretary,ClinicalAdvisoryBoard SeniorClinicalInstructor,ActivatorMethods,Imerational; PrivatePractice,Doctor'sChiropracticCemer,Inc. ColoradoSprings,Colorado With 530illustrations Table in photographs courtesyof Lloyd Table Com/any MOSBY ELSEVlER MOSBY ELEER 11830WestlineIndustrialDrive St.Louis,Missouri63146 THEACTIVATORMETHOD,EDITION2ISBN:97803 23048521 Copyright2009,1997byMosby,Inc.,anaffiliateofElsevierInc. Allrightsreserved.Nopartofthispublicationmaybereproducedortransmittedinanyformorbyanymeans,electronic ormechanical,includingphotocopying,recording,oranyinformationstorageandretrievalsystem,withoutpermissionin writingfrom thepublisher.Permissions maybesoughtdirectlyfromElsevier'sRightsDepartment:phone:(+ I)215 2393804 (US)or(+44)1865843830(UK);fax:(+44)1865853333;email:healthpermissions@elsevier.com.Youmayalso completeyourrequestonlineviatheElsevierwebsiteathnp://www.elsevier.com/permissions. Notice NeitherthePublishernortheAuthorsassllmeanyresponsibilityforanylossorinjuryand/or damagetopersonsor propertyarisingOlltoforrelated toanyuseofthematerialcontainedinthisbook.Itistheresponsibilityofthetreating practitioner, relying on independent expertise and knowledgeof thepatient, todetermine the best treatmentand method ofapplicationforthepatient. LibraryofCongressControlNumber:2007933194 VicePresidentandPublisher:LindaDuncan SeniorEditor:KellieWhite SeniorDevelopmentalEditor:JenniferWatrous EditorialAssistant:AprilFalast PublishingServicesManager:PatriciaTannian SeniorProjectManager:KristineFeeherty CoverDesigner:PaulaCatalano TextDesigner:PaulaCatalano PrintedinChina Lastdigitistheprintnllmber:98654 ThePublisher Workingtogethertogrow librariesin developingcountries ww.elsevier.comIww .bookaid.orgIw.sabre.org Tomywife,Judi,withoutwhosehelpthe ActivatOrMethodwouldnothave survivedintheworldofchiropractic asitistoday.Herunconditionallovecarriedmethrough themostdifficulttimesIhavefaced,both personallyandprofessionally. ArlanW.Fuhr,O JamesDeVocht,DC,PhD Assistant/AssociateProfessor Palmer CenterforChiropracticatPalmer Collegeof Chiropractic Davenport,Iowa RebeccaS.Fischer,DC,FIAC Secretary ClinicalAdvisoryBoard SeniorClinicalInstructor ActivatorMethods,International; PrivatePractice DoctorsChiropracticCenter,Inc. Colorado Springs,Colorado Gregor N.Kawchuk,BSC,DC,MSc,PhD AssistantProfessor FacultyofRehabilitationMedicine UniversityofAlberta,Edmonton Alberta,Canada t JosephC.Keating,Jr.,PhD,LinD(hon),FICC(h) ProfessorandNCMICHistorianofthe Profession ClevelandChiropracticCollege; Member,BoardofDirectors Association fortheHistoryofChiropractic KansasCity,Missouri TianyeLi UndergraduateStudent UniversityofAlberta,Edmonton Alberta,Canada RandallC.McLeodDC,FCCRS(c),DACRB PrivatePractice ImmanuelHealingCentre StonyPlain,Alberta,Canada JoelG.PickarDCPhD Professor PalmerCenterforChiropracticResearch Davenport,Iowa tOeceased. N.C.NarasimhaPrasad AssociateProfessor DepartmentofMathematical&Statistical Sciences UniversityofAlberta,Edmonton Alberta,Canada WalySchaefer,DC PrivatePractice SchaeferChiropractic Coralville,Iowa Xue-JunSong,MD,PhD DepartmentofNeurobiology ParkerCollegeResearchInstitute Dallas,Texas; JiangsuProvinceKeyLaboratoryof Anesthesiology XuzhouMedicalCollege Xuzhou,J iangsu,China TashaStanton GraduateStudent UniversityofAlberta,Edmonton Alberta,Canada CharloteJ.Wat,BS,DC,FICPA SeniorClinicalInstructor ActivatorMethods,International; Professor ParkerCollegeofChiropractic Dallas,Texas; PrivatePractice GrandPrairie,Texas QiaohaoZhu Statistician IntegratedCentreforCare AdvancementthroughResearch(iCare) CapitalHealth Edmonton,Alberta,Canada VII THIS PAGE INTENTIONALLY LEFT BLANKRebeccaS.Fischer,DC,FIAC Secretary Clinical AdvisoryBoard SeniorClinicalInstructor ActivatorMethods,International; PrivatePractice DoctorsChiropracticCenter,Inc. ColoradoSprings,Colorado PeterArizzi,DC,FIAMA SeniorClinicalInstructor ActivatorMethods,International; ArizziChiropracticHealth&WellnessCenter Middleton,Massachusetts WayneA.Comeau,DC,DACBOH,FACC SeniorClinicalInstructor ActivatorMethods,International; ComeauHealthCareAssociates Danvers,Massachusetts ThomasR.DeVita,DC,FACC ViceChairperson ClinicalAdvisoryBoard SeniorClinicalInstructor ActivatorMethods,Interational; Director DeVitaChiropracticOfficePC Acton,Massachusetts RichardDussault,DC ClinicalInstructor ActivatorMethods,Interational; PrivatePractice CentreChiropratiqueDussault Longueuil,Quebec,Canada JosephB.Steinhouser,DC Clinical AdvisoryBoard SeniorClinicalInstructor ActivatorMethods,International; PrivatePractice LakeElsinore,California; Instructor ActivatorMethods,Inc. Phoenix,Arizona LoisE.WardDC Clinical AdvisoryBoard Senior Clinical Instructor ActivatorMethods,Interational; PrivatePractice Farmington,Missouri Charlote J.Watt,BS,DC,FICPA SeniorClinicalInstructor ActivatorMethods,International; Professor ParkerCollegeofChiropractic Dallas,Texas; PrivatePractice GrandPrairie,Texas Ronald(Chip)R.WeiselII,DC Senior ClinicalInstructor ActivatorMethods,International; PrivatePractice Hartville,Ohio ix THIS PAGE INTENTIONALLY LEFT BLANKAspecialthankstothefollowingindividualswhocontributedtothe developmentoftheActivatorMethod. Frank Antonino,DC,Naperville,Illinois PeterArizzi,DC,Middleton,Massachusetts BirgerBaastrup,DC,Juneau,Alaska AnthonyJ.Barone,DC,Lakewood,NewJersey ScottD.Bautch,DC,Wausau,Wisconsin RichardBoatright,DC,Pinetop,Arizona StephenBradford,DC,WestSussex, UnitedKingdom RichardR.Bray,DC,Windsor,Ontario, Canada PaulC.Brooks,DC,Norway,Maine StevenR.Conway,DC,Janesville,Wisconsin William J.Coykendall,DC,PuntaGorda, Florida DonaldH.Dearth,DC,Tempe,Arizona JohnDeLuca,DC,Belmar,New Jersey DavidA.Dengler,DC,Albuquerque, NewMexico Kurt J.Deutscher,DC,Athabasca,Alberta, Canada LisaM.Devlin,DC,MountainView,California RandyR.Dierenfield,DC,Ankeny,Iowa D.MichaelDinkin,DC,WestHills,Califoria RichardP.Dussault,DC,Longueuil,Quebec, Canada AronW.Enns,DC,Abbotsford,British Columbia,Canada JohnH.C.Ewart,DC,Pembroke,Ontario, Canada RebeccaS.Fischer,DC,FIACA,Colorado Springs,Colorado DeanA.Flora,DC,Saginaw,Michigan RexW.Fowler,DC,Jackson,Tennessee AlbertGadomski,DC,Oldsmar,Florida Edward J.Galvin,DC,Oswego,NewYork GaryR.Gaulin,DC,PalmDesert,California Jonathan Golub,DC,Seaford,NewYork LawrenceL.Gray,DC,Scarborough,Maine R.DeanHarman,DC,SanMateo,California DwightA.Hayden,DC,Findhorn,Moray, Scotland,UnitedKingdom GeraldF.Hendrickson,DC,Oshkosh, Wisconsin MichaelP.Hergenroether,DC,SantaBarbara, California TeresaC.Hill,DC,Sterling,Colorado DavidR.Hughes,DC,Paulding,Ohio CaseyJ.Iverson,DC,GrandIsland,Nebraska lrvJacobs,DC,VanNuys,California HarlenH.Johnson,DC,BigFork,Montana PaulM.Kell,DC,SanDiego,California EdKinumIII,DC,Scotia,NewYork Ed Kinum,Sr.,DC,Scotia,NewYork Edward J.Klein,DC,Tujunga,California BradleyP.Kristiansen,DC,CedarRapids,Iowa Rick Ksenda,DC,Orange,California WardC.Lamb,DC,San Jose,California WarrenH.Landesberg,DC,BriarcliffManor, NewYork DonaldC.Leary,DC,Salem,Oregon HowardF.Lewis,DC,Fallston,Maryland RichardE.Lind,DC,Orange,California JackLube,DC,Tallahassee,Florida T.J.McKay,DC,Calgary,Alberta,Canada RodericMcLean,DC,Waratah,NewSouth Wales,Australia SidneyL.Mouk,DC,BatonRouge,Louisiana GaryNadler,DC,Cottonwood,Arizona StephenA.Nedd,DC,FortMyers,Florida Linda J.Patterson,DC,Mesa,Arizona DonaldD.Pattison,DC,Albuquerque, NewMexico StevenJ.Pavia,DC,Monroe,NewYork JamesJ.Peck,DC,Andover,Massachusetts JaneE.Perry,DC,Allen,Texas EricPetermann,DC,Phoenix,Arizona HowardA.Pettersson,DC,Davenport,Iowa BradleyS.Polkinghorn,DC,SantaMonica, California VernonS.Redd,DC,Albuquerque,New Mexico DavidR.Reich,DC,RichmondHill,New York xi xiiDEVELOPMENTALACKNOWLEDGMENTS RichardA.Richett,DC,NorthHampton, NewHampshire RobertD.Ross,DC,Ephrata,Washington VeronM.Rowe,DC,LittleRock,Arkansas RichardRoy,DC,Lasalle,Quebec,Canada F.RoccoRuggiero,DC,Napa,California Dan J.Rutz,DC,LasVegas,Nevada ThomasH.Sawyer,DC,LaCanada,California SidW.Schultz,DC,St.Cloud,Minnesota WayneP.Seddon,DC,GlenRoy,Victoria, Australia GordonL.Shepro,DC,Juneau,Alaska DonaldA.Sickmeyer,DC,Chester,Illinois RonSingleton,DC,Wenatchee,Washington MalikSlosberg,DC,Pleasanton,California BartSmith,DC,Honolulu,Hawaii NormanR.Smith,DC,Rockland,Maine JosephB.Steinhouser,DC,LakeElsinore, California JudithL.Steinhouser,DC,LagunaHills, California LeoB.Stouder,DC,Hollywood,Florida RobinT.Swaim,DC,Oregon,Ohio Myron W. Thatcher,DC,AnnArbor,Michigan JohnP.Thompson,D,AppleValley, Minnesota GrantThomson,DC,BanoraPoint,New South Wales,Australia CharlotteJ.Watts,DC,FICPA,GrandPrairie, Texas Karl W.Weber,DC,Cooma,New South Wales, Australia RonaldR.WeiselII,DC,Hartville,Ohio ChrisL.Wertin,DC,Lawrence,Kansas JohnM.Wertin,DC,Manhattan,Kansas RandallS.Widmaier,DC,Phoenix,Arizona MichaelW.Youngquist,DC,Willmar, Minnesota AnnZajac,DC,TinleyPark,Illinois AtfirstIwassurprisedtoreceiveaninvitation fromArlanFuhr,D,toconsiderwritingthe forewordtothenewesteditionofhistext,The ActivatorMethod.However,knowingArlan,it eventually made sense.Recognizing that Iwould notwriteaboutsomethingIhadnotseen, Dr.Fuhrsentmeall17chapterssothatmy commentary could be basedon anactualreview ofthetext.Hewasn'tseekingmereperfunctory comments-he wanted a real review.Still,given mystrongadvocacyformanualmanipulation, IfounditparticularlystrangethatDr.Fuhr wouldaskmetoreviewhistext.However,he isarisktakerandwasconvincedthattheevidencewouldsupportafairreview.Histhought wastoasksomeonewhohasacontrarianview andperhapshewouldgetaforewordthatjust mightbeobjective. Dr.Fuhrhas aninsatiable thirst for thetruth, andinhissearchhewasbraveenoughtogo wheretheresearchtookhimregardlessof whetherornotitmightprovecountertohis beliefs. Anyone who has been around the profession forany lengthof timeknowsof theinextricabletiebetweenArlanandtheActivator-a linkthatnowspans40years.Despitethetie, Dr.Fuhrhasprovidedfundingforresearchand maintainedahighlevelofintegrityinthe researchhehasconductedonandwiththe Activatorinstrument. Despitemybiasconcerningmanipulationby hand,Ihave beenextremely impressedwithtwo individuals whose names are affiliatedwith techniques or equipment in this profession, and I have so statedpubliclymanytimes.These twoindividualsareArlanFuhr,DC;andJamesCox,DC. Both of these gentlemen have been strongly committed to the advancement of the profession, and bothusemechanicallyassisteddevicestohelp their patients. Perhaps the most impressive thing about these twoindividualsisthefactthat they havespenttheirlivesconductingresearchto investigatewhattheyclaim.They"puttheir moneywheretheirmouthsare,"andtheprofessionhasbeen thebeneficiaryoftheireforts.As Ilookdownthe listof chapter authors,Icannot help but be impressed.From the"universalskeptic,"JosephKeating,PhD;toJoelPickar,DC, PhD;GregKawchuk,DC,PhD;Xue-J unSong, MD, PhD; Rebecca Fischer, DC; Wally Schaeffer, D; and James DeVocht, DC,PhD, the choice of chapter authors predicts the quality that follows. TheprevioustextonActivatorMethodswas publishedadecadeago,anditwasnoteworthy thenforitsempiricalorientation.Thisneweditiondoesnot disappoint,and it isimpressive for itsinclusionofadecadeofnewresearchthat addressestheneurologicalmechanismofthe adjustment.The readercan feel confident about theauthors'commitmenttotheevidence. Asanolderpractitioner,nowinmyfortyfifthyear,Iamdelightedthatagainthecommentaryinthisnewtextdoesnotskirtamajor issueofconcerntomeandtoahostofother practitioners.Inhischapter,"Chiropractic Science:TowardUnderstanding Spinal Manipulation,"Dr.Pickarclearlyposesthequestion thatIhaveaskedmanytimes:"Istheclinical encounterbetweenthepatientandthedoctor affected by the methodof delivery of the manipulativeintervention?"Inotherwords,isthe adjustmentalonethemostimportantitemin thepatientencounter?Theanswertothis questionrequiresfurtherinvestigation. ReaderswillfindaninterestingandinformativehistoryofthedevelopmentofActivator MethodsbyDr.JoeKeating.Wetendtoforget theturmoil,trials,andtribulationsthateach newidea,invention,orinnovationcanelicit, andtheevolutionoftheActivatorMethodis noexception.Inlightofthisrichhistory, Ithink I'll never look atan ActivatorAdjusting Instrumentquitethesamewayagain. Alltheauthorsplaceagreatdealoffocuson theveryessenceofthatcomplexbeing,which Dr. Joseph Jansereferredtoas"manthebiped." xiii XIVFOREORD Fromthechapteronthetemporomandibular jointby WallySchaefer,DC,onhow thiscomplexjointcananddoeshaveanimpactonthe globalstructuretotheclearandinformative aspectsofspinal stabilization,thistext hasmany wonderful"clinicalpearls"forthepractitioner touseinhisorherpractice.Throughoutthe text, the authors weave a recognition and appreciationofthecomplexityoftheneurological chainofeventsrequiringconsciousandunconsciouscoordinationthroughtheneurological system.Thetexthasatremendousfocuson theverycomplex biomechanical conditions that doctorsofchiropracticencountereachdayin theirpractices.Theemphasisonmobilityand the complex mechanismsof neuralcoordination wasindeedenlightening.Stabilityandmobility ofthelocomotorsystemareclearlyofprimary concern,andthetextilluminateshowdysfunctionandabnormalneuro-biomechanicscancreatethemyriaddysfunctionaldisordersandtheir ramificationsthatareseenbydoctorsofchiropracticeveryday. Thechaptersdealingwiththetests,evaluations,andadjustmentsfortheanalysisofthe humanspineandextremitiesareverywellwrittenandeasilyunderstood.Whethertheclinicianisanexperiencedpractitioneroranew graduate,theillustrationsandcommentary concerningtheevaluationandtreatmentare equallyrelevant. IhavehadtheprivilegetoattendtwoActivatorinstructorconferences.AlthoughIhave beentomanyseminarsinmylifetime,Iwasn't surewhattoexpectatfirst.However,Iwas indeedsurprisedandpleasedtosee that theprogramsstartedontime,thatthequalityofthe speakers wasasgoodasany researchsymposium, andthattheprofessionalismoftheattendees spokevolumesabouttheintenttolearnrather than the desire forcontinuingeducationcredits. TheprofessionalisminevidenceatActivator seminarsisreflectedalsoinDr.Fuhr'snewtext. AfterreadingthisbookIamcertainyouwill comeawaywithabetterunderstandingofthe entireActivatorMethodAnalysis,butmore important,youwillhavereadatextthatis backedmorebysoundresearchdatathanthe charismaofthedeveloper.It istimeinourprofessionthatwebegintoaskthetoughquestions whenweencounterunsubstantiatedclaimsby individualsorgroupsoffering"theanswer." This bookofferssomeofthoseanswers,at leastabout Activator. TheActivatorMethodisaworthwhileread andprovidessomeprovocativethoughts concerningthethingswedoandseeeveryday inouroffice.Dr.Fuhrhasalotofcourage becauseifIwerehe,IdonotknowifIwould haveaskedsomeonelikeme,whoispartialto anonmechanicalmethod,towrite the foreword. Butthenagain,thatiswhatmakesActivator Arlan-andArlanActivator. LouisSporteIli,DC Palmerton,Pennsylvania Tenyearshavepassedsincethefirsteditionof theActivatorMethodsChiropracticTechnique waspublished.Weneverexpectedittobethe all-timebest-sellingtechniquebookeverin chiropractic,butithasbeen.Ithinkitwas sosuccessfulbecauseitwasfullofpractical informationforthestudentandtheveteran practitioner. IstillbelievethequoteImadeinthefirst paragraphofthefirstbook:"Ifitisn'twritten down,itdidn'thappen"isastruetodayasit was10yearsago.Thisreallycamethroughto meonlythisyear,whenIheardmyminister explainthediferencebetweentheworld'sreligionsandcults.Heexplainedthattheworld's greatestandlastingreligionsprevailedbecause oftheir writtenword.Likewise,the most studied chiropractictechniqueswillhaveabetter chanceofremainingsobyvirtueoftheirtexts. Itisforthefutureofthetechniqueandfuture generationsofdoctorsthatwehavetakenso much time to write down all ofourobservations. The onething that reallyimpressed meabout thisrevisionisthefactthatwehavecomesuch a longwaydocumentingourfindingsin10 years withsuchlimitedresources.Inthefirstbook therewerechapters,especiallyinthetechnique sections,thathadveryfewreferences.Inthis revision we have succeeded in showing scientific progressinmanyareas. Thecontributingauthorsinthiseditionare publishedscientistsofthehighestcaliber,well knownfortheirexpertisethroughoutthescientificcommunity.MostofthemhaveaDoctor ofChiropracticdegree,oradegreeinmedicine aswell as aPhD in advanced study in their field. Webelievethislevelofcompetencywillgive readersthebestvalue fortheirtimeandmoney. We have reorganized the book based onmore than40yearsofteachingexperienceandwhat we'vegleanedfrompastreaders.Thenewbook makesiteasierforstudentstofollowandapply theActivatorMethodclinically. InthefirsteditionImadethestatement,"I findscientificinvestigation a bit like taking your clothesoffinpublic."Istillfeelthatway.For every question youanswer,fourmorenew questionsappear.Oneofthedefinitionsofbeinga professionisobtainedwhentheprofessionand thepeoplelaboringinitcontributesomething newtothebodyofknowledge.Inthistextbook Itrulybelievewehaveaccomplishedthatgoal. ArlanW.Fuhr x THIS PAGE INTENTIONALLY LEFT BLANKThisprojectrequiredagroupeffortfrommany differentpeople.Firstofall,Iwanttothankall ofthecontributingchapterauthorswhogave oftheirtimeandexpertisetomakethisbooka reality.All oftheauthorsinvolvedare very busy peoplewhoalreadyhadtheirschedulesfull whenIprevaileduponthemtocontributeto thisproject.However,Istronglybelievethat wehaverecruitedthebestpeopleintheir respectivefieldstomakethisafirst-rate textbook. NextIwanttothanktheAssociateEditor andChairpersonoftheEditorialCommittee, RebeccaFischer.Thenumberofhourssheput incouldneverbecalculatedbecauseitwent beyondatimeclock.Westartedbyusing GoToMeeting.com,whichsavedtheday because she lives in Colorado andI live in Phoenix.Wespentnumeroushoursstaringatour computersandlisteningtoeachotheronour speakerphones.Rebeccapossessesnotonlya keenmindbutalsotheabilitytobeextremely detailed.Shepersevereduntilthefinaledits weredoneandallthereferencesandpictures werecheckedandrechecked,andshenever oncecomplainedaboutthetediousnatureof thework.Thisbookwouldnothavebecome whatitiswithouthertalentanddedication. Next I would like tothank theeditorialcommittee,which consists offield practitionerswho havethegreatestamountofclinicalexperience ofanygroupintheactualapplicationofthe ActivatorMethod.TheynotonlyusetheActivatorMethodintheirdailypracticesbutare instructorsaswei\.Becauseofthisexpertise, theirinputwasinvaluable.Forthemthiswas notajobbutalaboroflove,andnotypeof compensationwouldhavebeenadequate. Iwouldalsoliketothankthemanyfield doctorswhocontributedtheirfindingsoverthe yearsandhavespentthetimewritingdown theirclinicalobservations. Abookisalwayseasierwhenyouhavegood editors.IwasthrilledwhenElsevierassigned KellieWhitetothisproject.Iworkedwithher onthe first edition,and she is a real professional with agreatdealoftalent. Jennifer Watroushas beenwiththisprojectfromthebeginning,and onecouldnotfindaharderworkingormore funperson.KristineFeeherty wasourfinalproof editor,andshewasataskmasterwhosettimelinesandmadeussticktothem.Toallofthe Elsevierstaff:Youweregreattoworkwith. FinallyIwouldliketothankmywife,Judi, whoheardmoreaboutthisbookthansheever wantedtobutgoodnaturedlykeptencouraging mewhenIhadahundredotherthingsonmy plate.ForthatIthankherwholeheartedly. Arlanw.Fuhr xii THIS PAGE INTENTIONALLY LEFT BLANKSEalONI SEalONII SEalONIII INTRODualONTOTHEAalVATORMETHOD 1.HistoryofaTechniqueSystem-JosephC.Keating,Jr. ,PhD,LittD(hon), FICC(h);andArlanW.Fuhr,DC3 2.ChiropracticScience:TowardUnderstandingSpinalManipulation -JoelG.Pickar,DC,PhD26 3.VariabilityofForceMagnitudeandForceDurationinManualandInstrumentBasedManipulation Techniques-GregoryN.Kawchuk,BSC,DC,MSc,PhD; N.G.NarasimhaPrasad;RandallC.McLeod,DC,FCCRS(c),DACRB; TashaStanton;TianyeLi;andQiaohaoZhu34 4.PainMechanismsandControl-Xue-JunSong,MD,PhD43 CLINICALOBSERVATIONSANDADVANCEDASSESSMENTPROCEDURES65 5.LegLengthReactivity-RebeccaS.Fischer,DC,FIACA67 6.TheActivator Method Analytical Technique112 AalVATORMETHODANALYSIS139 7.TheActivatorMethodBasicScanProtocol141 8.AdditionalTestsfortheSacrum,Pelvis,andRelatedStructures192 9.AdditionalTestsfortheHipandRelatedStructures226 10.Additional LumbarTestsand Adjustments242 1 1.Additional TestsandAdjustmentsfortheThoracicVertebrae,Ribs,and AnteriorThorax266 12.AdditionalTestsandAdjustmentsfortheCervicalSpine303 13.TheTemporomandibular JointandRelatedTestsandAdjustments-James DeVocht,DC,PhD;andWallySchaefer,DC333 14.AdditionalTestsandAdjustmentsfortheKneeandRelatedStructures356 15.AdditionalTestsandAdjustmentsfortheFootandAnkle393 16.Additional TestsandAdjustmentsfortheShoulderandRelated Structures424 17.Additional TestsandAdjustments fortheElbow,Wrist,andHand478 APPENDIX:Activator QuickNotes-CharlotteJ.Watts,BS,DC,FICPA5 17 GLOSSARY533 xix CONTRAINDICATlONS SeeGuidelinesforchiropractic qulityassuranceand practice parameters:Proceedings of the MercyCenter ConsensusConference,Gaithersburg,MD,1993, Aspen. ItisrecommendedthattheActivatorAdjustingInstrumentbeusedinadjustingprocedures onlybythosewhohavereceivedproperinstructionfromachiropracticcollegethatteachesthe ActivatorMethodorwhohaveattendedanActivatorMethodsTechniqueSeminar. The Activator Method THIS PAGE INTENTIONALLY LEFT BLANKINTRODUCTIONTOTHE ACTIVATORMETHOD Chapter1 Chapter2 Chapter3 Chapter4 HistoryofaTechniqueSystem ChiropracticScience:TowardUnderstanding SpinalManipulation VariabilityofForceMagnitudeandForce DurationinManualandInstrument-Based ManipulationTechniques PainMechanisms andControl THIS PAGE INTENTIONALLY LEFT BLANKJosephC.Keating,Jr.,andArlanW.Fuhr ThesagaoftheActivatorMethodismultifaceted.This account encompasses some of the several instruments used to treat the musculoskeletal system in various cultures and the careers ofthefoundersoftheActivatorMethod.The story includethetheoreticalpathwaysthatled to the development of many features of the ActivatorMethodandthegenerationsofActivator AdjustingInstrumentsthathaveemerged.The talemust alsotakeintoaccountthedisseminationoftheActivatorMethodwithinthechiropracticcultureandthemanypeoplewhohave contributed to this effort; only a few of these folks canbementionedhere.Surely,asingle chapter can do no more than focus on the highlights and leave the details to future raconteurs. The Activator Method is referred to as a "technique." This term(sometimes written"technic") hasmultiplemeaningsandusesamongdoctors ofchiropractic(DCs).Techniquecanreferto relativelycircumscribedassessmentprocedures (asinpassivemotionpalpationofjoints)orto elaboratetheoriesandmethodsforevaluating patients(as inappliedkinesiologyortheMeric system).Manyifnotmostchiropractictechniques involve both assessment and treatment components, and the Activator Method is among this lattergroup.Accordingly,toaddress the history oftheActivatorMethod,wemustdistinguish between its analysis andinterventionaspects. TheActivatorMethodofjointanalysisand diagnosisrepresentsauniquecontributionto the healthcare field,but many of its component proceduresanditstheoreticalrationalescanbe foundinpriorliteratureandmethodswithin theprofession.Similarly,theActivatorisnot thefirstinstrumentalmeansofproducingthe segment-specificthrustingthatDCshavetraditionallyprized sohighly,butits easeofapplication and presumed safety havemadeitthemost popularofmechanicallyassistedmanualmethodsamonghealers.Itsevolutionisinextricably entwinedwiththecareersofitsinventors, Drs.WarrenLeeandArlanFuhr.Andbecause a product,no matter how good,must find a marketinordertobesuccessfulinthebusiness sense,thestoryoftheActivatorMethodis also ataleofthemarketinganddisseminationof theinstrumentandanalysisstrategiesused withinthechiropracticprofession,aswellas thereactions ithas yielded. BEFORETHEACTIVATOR Although adjusting instruments find their widest applicationamongDCs,theuseofobjectsand devices in the service ofmanualtherapiesis not uniquetochiropractic.Hinojosa,lforinstance, documentstheapplicationofsacredobjects, huesoorba,amongtheMayabonesettersof Guatemala.Apaperinthe March1935 issue of theNationalChiropracticAssociation's Journal reportedthepurchaseofatoolsupposedlyused byMontana'sCrowIndianhealerstorelieve "stomachtroubleandboweltrouble"bymeans ofthrusts and massage ofthespine.2 These simple,hand-heldpercussivedevicesareafar cryfromtheActivatorAdjustingInstrument (AAI),buttheymeritrecognitionaspre-chiropractic examples of manipulative tools. Theearliestknownchiropracticversionof instrument adjusting is credited toDuluth,Minnesota,residentThomasH.Storey,DC,aformer"vitapathicphysician"(magnetichealer) turedchiropractorunderthetutelageofD.D. Palmer.3 Dr.Storey,a1901graduateofthe PalmerSchool, introduced"some strange adjustingparaphernalia:awoodenmalletandstick.,,4 BeforerelocatingtoSoutherCaliforniain 1902,Storeyintroducedthenewmethodtoa numberofMinnesotaDCs,who"thusgotto usingthemalletandchiseltosetthespineof thewholevertebralcolumn. . .,,4(Figure1-1). Althoughthefatherofchiropracticdidnot initiallyapproveofthisinnovation,onthe groundsthatitviolatedhismeaningofchiropractic-onebyhand-hiscuriositywasobviouslystimulated.Heauthoredawhimsical 3 4SEGIONIINTRODUGIONTOTHEAGIVATORMETHOD Figure1-1Earlywoodenchiselsandmal l etsusedbychiropractors for adjusting.(Courtesy Polmer Colege of Chiropracti c Archives.) allegoryof"ASpineSetPersonified"sand includedaphotographofStorey'ssimpletools inhisclassic1910tome.6 Accordingtoan accountpassedalongbyT.F.Ratledge,DC, founderoftheschoolthatistodayCleveland ChiropracticCollegeofLosAngeles,OldDad Chiromadeuseofa"rubberhammer(pleximeter)withwhichheexperimentedadjusting vertebrae.Thiswas usedforthesolepurposeof freeingthenervesfromobstructivepressure" {Ratledge)7 (Figures 1-2to1-4). Dr. Storey employed his instrumental method ofadjustingonhispatient,CharlesA.Cale, whowouldlater(1911)establishtheLos Angeles College ofChiropractic{LACC)8(Figures 1-5and1-6). Manyyears later,Cale's wife, Figure1 -2ThomasH.Storey,DO,DC,1905. Figure1 -3CharlesA.Cale,DC,NO,ci rca1928. Linnie,achiropractorandosteopathicphysician,recalledtheprimitivemethod: [n1 895shemarriedCharlesA.Care. [n1900 theymovedtoCaliforniafortheirhealth. In1 904theyheardofaDr.Storeywhowas practicingchiropracticinLosAngelesandwho wasagraduateofDr.D. o.Palmer.Theyboth took treatments ofDr.Storey and regained their health.Mr.Calehadstomachtrouble.Quite sometimelaterhisstomach troublereturned.He got down onhisstomachon the floor and asked Dr.Linnie Cale to get one of the chi ldren's blocks and a hammer.He had her place the block in the region of the 5th and 6th vertebrae and hit it with thehammer.Doing this a few times relieved him ofhis stomachtrouble.Thatwasherfirstchiropractic adjustment,55years ago.9 Figure1 -4Li nni e A.Cale,DC,DO,circa1924. Figure1 -5ThissimpleconcussorwasofferedbyDr.J. S.Riley(ci rca1921)for tappi ng spi nal joints. Figure1 -6Dr.J.S.Rileyemploysapneumaticconcussorto treatapatient. Instrumentadjustingalsofoundfavoratthe Palmer-GregoryCollegeofChiropracticin OklahomaCity.Theschool,foundedcirca 1907byD.o.PalmerandCarverChiropractic CollegealumnusAlvaGregory,MD,DC,gave impetus toavarietyof"mixer"methods,among themconcussiondevices.1OSpinalconcussors werealsopropagatedbytheinstitution'svice president, JoeShelbyRiley,DO,DC, whomarketedandtaughttheuseofvariousthrusting machines.Riley'sinstructionininstrument adjustingextendedbeyondOklahoma,forhe establishedschoolsinMassachusettsllandthe DistrictofColumbia 12 inlateryears,and authoredbooksthatdescribedhis methods. Dr.Gregory'sinfluencealsoextendedto AlbertW.Richardson,DC, 13 purchaserof theLACCin1913andfounderofvarious branches of the California Chiropractic College. B.].Palmer,DC,reportedthatRichardsonand his faculty at theSan Francisco branch ran afoul ofthelawwhena patient whohadbeentreated witha"plesameter"and"mallet"filedcharges Chapter1HistoryofaTechniqueSystem5 forassault. 14The"developerofchiropractic" waspleasedtoreporttohisreadersthatthe PalmergraduatesofSanFranciscohadpublicly declaredthat"Nomalletorotherinstrument ofanykindorcharacteriseverusedasapart ofCHIROPRACTICtechnique.Onlythe handsareusedingivingaCHIROPRACTIC adjustmentandthey are not employedtostrike, massage,stretch,twistorotherwiseinjurethe patient.,,14Therationaleforthisdictumwas notofered. AlbertAbrams,MD,fonneradministrator oftheCooperMedicalCollege(today,the MedicalSchoolofStanfordUniversity),isperhapsbestrememberedforhiscreationofradionics.However,hecametoD.D.Palmer's attention6 becauseofhisinterestin"spondy-Ih ,,15 16 f . I ' .Ioterapy, ' aform\ mantpu atlOnmvo v-ingstimulationofnervesforthetreatmentof disease(Figure1-7,A): Thishammerfor evoking thevertebral refexes (page7),is called aftertheFrench neurologist, plexorofDejerine.Althoughemployedchiefly for diagnostic purposes,it may substituteaconcussion-apparatusinspondylotherapy.Indeed, manyphysicianshaveusedtheplexorexclusivelytoattaintheirtherapeuticresults.The rubberaffixedtotheplexori s designedtogive resiliencytotheblow,animportantdesideratumintheelicitationofthereflexes. Thispleximeterofmetal,coveredatone end with rubber,is employed concurrently with theplexor. . .IAbramspromotedavarietyofinstruments, includingpneumaticandelectricaldevices,and distinguishedbetweentheusefulnessofvibratoryvs.concussivestimulation(Figures1-7,B, 1-8,and1-9): Pneumatic hammerwithconcussors.Thisoperateswithapressureof40poundsandyieldsa blowequivalentto12pounds. This hammer is very eficient but becauseit isnoisyandcompressedairisnotalways available,theelectro-concussoroftheauthoris preferable .. .. Theauthor'selectro-concussor.Thisapparatuswasconstructedforthepurposeofsecuringpercussion-efectsandthelatteronly. Practicallyalltheinstrumentsdesignedforsismotherapy aremerevibratorsand areabsolutely uselessforexecutingthemethodsofspondylotherapy.Thiselectro-concussorisportable, anditsflexibleshaftisreadilyattachedtoan "AC"or"DC"motor.Ataslightexpense, 6SEaloNIINTRoDualoNTOTHEAalVATORMETHOO Figure1-7A,Dr.AlbertAbramswithoneofhismanycontraptions.B,Dr.AlbertAbrams'useof"plexorandpleximeter." (8,FromAbramsA.Spondylotherapy:spinalconcussionandtheappli cationof othermethodstothespineinthetreatment of disease.SonFrancisco:Philopoli sPress; 1910' 'N ...:1 . Figure1-8Dr.AlbertAbrams'pneumatichammer withconcussors.(From Abrams A.Spandylotherapy: spinal concussion and the application of other methods to the spine in the treatmentof disease.SonFrancisco: Philopoli sPress; 1910' anextramotormaybepurchasedandasboth motorsareinterchangeable,theapparatusmay beusedoneithercurrent.Itisprovidedwith twoconcussorswhichdeliverblowstoboth sidesof aspinousprocess. !The use of manipulative devices was also popular amongotherdruglesshealers.TheZoeJohnson Company of St. Joseph, Michigan,marketed concussion and vibration devices andbooks on their applicationformanyyears.17, 18 BenedictLust, MD,NO,DC,thefatherofnaturopathyin America,washappytoincludeadvertisements for"BenkoHandConcussionSets,"whichhe marketedduringthe1920sthrough1940sinhis widelydistributedperiodical,Naturopath&Heraldof Health(Figure 1-10): SPINALCONCUSSION CorrectinPrincipleandDesign Spondylotherapy,orthescienceofconcussionofthespinalnervecentres,was originated and developed byDr.Abrams,whohas written ascientifictreatiseofconsiderablelengthon thesubject.Oflate,Dr.AlvaGregoryandDr. ].S. Rileyhavewrittenmuchofvalueand interest concerningthisnew method . . . every practitionerofexperiencewillconfirmthe statementthatspinalconcussionisoneofthe most powerful adjunctsto drugless therapy . . . Interest inmechanicalforms of manipulation evencapturedtheimaginationofafewallopathicphysicians(Figures1-11to1-13): CLINICALMEDICINEANDSURGERY Volume43,Number1 NotesfromInternationalMedicalAssembly ReportedbyGeorgeB.Lake,MD,WaLlke gan,Ill. . . .Amoreelaborateapparatusisthe Articultor(showninFig.3),whichisintendedto do,inanaccuratelyregulatedandscientific Figure1 -9Dr.AlbertAbrams'electricconcussorhammer. (FromAbramsA.Spondylotherapy:spinalconcussionand the applicati onof other methods to the spine in the treatment of disease.SanFrancisco: Philopoli sPress; 1910.) Figure1 - 1 0PalmerstudentAndreaBenko,granddaughter of Andrew Benko, an original founder of theBenkoHandConcussionI nstrument,withActivatorcofounder,Dr.ArlanFuhr, whoishol di ngoneoftheoriginalinstruments.(Courtesy ArIonFuhr.) Chapter1HistoryofaTechni queSystem7 Figure1-1 1Spinal Adjusting Machine of ArdenZi mmerman,DC,ci rca1965. Figure1 -1 2 FuturamicCervicalSpecificInstrument.(From AdvertisementforFuturamicCervicalSpecihcInstrumentDig ChiroprEcon.1968;10[4]:36. 8SECIONIINTRODUCTIONTOTHE ACTIVATORMETHOD Figure1-1 3 Imageofanadjustingmachinefromanadfor thePetti bonMethod.(FromAdvertisementforthePettibon MethodDigChiroprEcon.7968,11[3].52.) manner,everythingthatachiropractorcando withhis hands,anda good deal more.It is used inthetreatmentoffractures,sprains,dislocations,stiffj oints(includingthoseofthespine) and all other conditions where gentle, exact and rhythmicpullingandstretchingofanypartof thebodyis indicated. EditorialNote-TheMedicalProfessiononce contended that the vertibrae [sic] could not be moved norintererewiththetransmissionof nerveenergy. Now they are recognizing this basic principle. 20 Osterbauerandcoauthors21suggestedthat development of"Hole-in-One"(HIO),anupper cervicaladjustingstrategythatinvolvesa"togglerecoil"thrust,byB.].Palmer,DC,gave impetus(unintentionally,nodoubt)tothe developmentof manipulative devices.Thedifficultiesexperiencedbychiropractorsasthey attemptedtoskillfullyperformthistechnique encouragedthedevelopmentofmechanical d h.hh 22 23 eVlcestatmigtservetesamepurpose. ' Some of this equipment resembled a punch-press thatdelivereda thrust verysimilarto"the force displacementpatternofthetogglemechanism.,,23 Grosticreviewedthemechanicalcharacteristicsofseveralofthesemachines, includinga"cam-stylus"adjustinginstrument thatcanbemotorizedorcomputeroperated, resultinginvaryingcamrotationspeeds.23 ExemplaryofthesearetheLifeCollegeAdjustingInstrumentandthePettibonAdjusting Instrument. Osterbauerandco-workers21alsodescribe theThrustAir Model2001,ahand-held,"gunstyled"compressedairunitpoweredbyaseparateaircompressor.Otherhand-heldmechanicaladjustinginstrumentsusetwobasicsystems: solenoid-activatedandspring-activateddevices. "Whileboththesolenoidandspring-activated unitshavesimilarkineticenergy-inducedforce displacementcurvescharacteristicofsuch percussiondevices,thesolenoidtypeunitsare limitedbythestrengthofthecoilandwhether ornotthestylusisattachedtotheironcore . f . ddI f' ,,21EorISreetomoveLnepenenty0It.xam-piesofsolenoid-activateddevicesarethe Humber-KingKH-4ElectronicPulseandthe KineticPrecisionSpinalAdjuster(Figures1-14 to1-16). Figure1-1 4TheThruster,apneumaticdevice,fromanad. (FromAdvertisementfortheThrusterAdjusti ngInstrument. DigChiroprEcon.7985;28[ 7]:9.) Figure1 -1 5 G-Sinstrument fromStandardDistributorsdelivers"nearly4,000oscillationspermi nute."(FromAdvertisement:Controllingkineticenergy.JFloChiroprAssoc.7970; Winter:25.) Figure1 -1 6 Student Charles Cushing andDr.ViNicksondisplay apneumatic adjusting device.(FromLogan student honoredbyAlumniAssocati onandRedCross.Tower(Logan Colege]7993;Summer: 7 0. Hltll ...''. 7heeledronicperCUSSorthatsetsanewstandard ofperformanceforpercussion,vibration, andmassagingdevice. Onlypercussionodionconforming tothedefinitionoftheterm Positivecontroloffrequency Positivecontrolofintensity lightweightandbalance Mechanicalsimplicity Modernappearance Fordemonstration,askyourdeoler-rwrite ROBERTC.McSHIRlEY,1520W.Glendal.Blvd.,Gledal.I,Calilaria Figure1 -1 7 Adverisement for Percuss-O-Motor; fromChirogramforApril1951.(Courtesy SoutherCalioriaUniverity of HealthSci ences.) Itisagainstthisbackgroundofinnovation andinventionthattheAAImadeitsdebutin thelate1960s(Figure1-17). FOUNDERSOFACTIVATOR BornDecemberS, 1914, in ruralVillard, Minnesota,WarrenClemensLeeenrolledatthe Northwestern College ofChiropractic(NWCC) inMinneapolisandgraduatedonMarch1, 1942.24 Foundedin 1941, theNWCCaccepted anumberoftransferstudentsfromthenearbl MinnesotaChiropracticCollege(MCC)2; WarrenLeemayhavebeenoneofthese.Hugh B.Logan,DC,founderoftheLoganBasicCollegeofChiropractic(LBCC)inSt.Louis,had visitedtheMCCin1941andcontemplateda Chapter1HistoryofaTechni queSystem9 contracttopermitinstructioninhisproprietary method,BasicTechnique(BT),withinthe MCCcurriculum.26 Dr.Leehadalsoreceived "advancedplacementfromLoganBasic Collee ofChiropractic(attended01/42toOS/42)"4 (FigureI-IS). AftercompletinghisstudiesinBT,Lee practicedasanassociateofaSt.Paul,Minnesota,chiropractorbeforeestablishinghimselfin his ownpracticein the southwestern Minnesota farm town ofRedwoodFalls in 1946.He supplementedhistraininginBTwiththeworkof l.N.Toftness,DC,andradionics.Amonghis newpatientsin1953wasa13-year-oldfarm boynamedArlanWilliamFuhr(Figures1-19 to1-21). BornSeptember2,1939,inSheridanTownship, Minnesota,ArlanFuhrwas alsotheproductofaruralbackground.Theyoungster sufferedfromchronicsorethroats,andatage 13wastakenbyhismother,apatientofLee, toseethefamilychiropractor.Fuhrhasaclear recollectionofseeinghisx-raysshowinga "leaningtowerspine"duringhisfirstvisitto Dr.Lee'sclinic.HereceivedadozenToftness adjustmentsfromanassociateatLee'sfacility, Dr.Wilson,andhisthroatdifficultyresolved withoutrecurrence.Thishappyoutcomeset theyoungmanonanearlycareerpath:He resolvedtobecomeachiropractor.Hewas stronglysupported inthis choicebyhis mother, despitediscouragementsreceivedfromsome familymembersandgradeschoolteachers. ArlanenrolledattheUniversityofMinnesotatotakethepre-chiropractic,basicscience courseworkrequiredoflicensedpractitioners inMinnesota.HematriculatedatLBCCthe followingyearandbelievedhehadfounda newhome.Aspecialbonddevelopedwiththe College'spresident,VintonF.Logan,DC,and thefutureDr.Fuhrfondlyrecallshismentor's callfordevelopmentofa"push-buttonBasic" toacceleratedeliveryofBT.Arlanwouldmeet thatchallengewiththedevelopmentofthe ActivatorMethod.HegraduatedfromLBCC in1961(Figure1-22). FollowingastintintheU.S.Navy,during whichtimeheservedonawooden-bottomed minesweeperoftheCubancoastduringthe missile crisis of 1962,Arlanreturnedto Minnesotatopractice.HeacceptedDr.Lee'sofferof anassociateshipinRedwoodFalls.Theduo foundacommonbondinLogan'steachings aboutthestructural unityof theskeletalsystem andtheefectsofgravityonthespinalcolumn. BTfocusedattentionontherelationshipof thesacrumtothepelvisandcompensatory 1 0SEGIONIINTRODUQlON TO THEAGIVATORMETHOD CONTRAeT Lo,anBasicTchnique 7701FlorissantRoad,St.Louis,Missouri THISAGREEMNTmadeandentered1ntobyandbetween. ___ ___ . _________ atthet1rstpart.andHUGHB.LOGAN,D.C.,partyatthesecondpart. WITNESSETH party WHEREAS,HughB.Logan,D.C.,partyatthesecondpart,teaches,expla1ns,1nstruct,anddel1verslecturesontheph110sophyandtechn1QUeofthatnewadJust1ngmethodknownas'LOGANBASIC TECHNY QUE'; WHEREAS,_ ___________ ,D.C.'. partyorthetlrstpart:1sdeS1rousort h epr1vllegeotattend1ngsaldlectures,explanat10ns,and1nstruct10nsg1venbySaldpartyotthe secondpart; NOW,THEREFORE,1ncons1derat10natthemutualprom1seshere1nconta1nedandothervaluablecons1derat10n,1 t1sherebyunderstoodandagreedbetweenthesaldpartIes,that: partyofthef1rstpartagreestopaytopartyofthesecondpartdollars forthepr1vllegeotattendlngsaIdabovementIonedlectures,Instructions,andexplanations,givenbypartyatthesecondpart. partyatthesecondpartagreestodelIversaIdlectures,makesaidexplanat10ns,andg1vesald 1nstructionsin"LOGANBASICTECHNIQUE"atat1meandplacetobedes1gnatedbySaldpartyat thesecondpart,andInwhatevermannerpartyatthesecondpartmaydeemtobetitandproper. ItIsfurtherunderstoodandagreedbetweenthepartlesthatpartyotthesecondparLreserves therIghtatanytimetodenypartyattheBrstparI}theprivllegeotattend1ngsaidlectures, explanat10ns,and1nstruct1ons,w1thoutanyexplanationswhatsoever. partyatthef1rstpartagreestoass1st1nresearch,tocooperate1nallclasswork,andto aSSist1ntherecoveryandma1ntenanceofCh1ropract1cConstltut10nalr1ghts. Intheeventthatpartyatthet1rstpart1mparttoanypersonorpersonsnotQualltiedbyparty otthesecondpart,byanymeans,anyport10natthemethodkownas'LOGANBASICTECHNIQUE", saidpartyatthetlrstpartagreesto,andwill,paytosaidpartyatthesecondpart,thesum otone'thousanddollars($1,000.00):1t1sexpresslyunderstoodthatthesa1donethousanddollars($1,000.00)1sl1Quldateddamagesandnottobecons1deredasapenalty. It1sfurtherunderstOOdandagreedthatpartyatthe!1rstpartwlllpayareasonableattorney's teeandcourtcostsIntheeventthatpartyotthesecondpartresortstolegalmethodstorthe collectionatanysumorsumsheldtobedueunderth1sagreement. Wehereunto 1nthectty Figure1 - 1 8ContracttostudyLogan'sBasicTechnique,signedbyWarrenC.LeeandHughB.LoganonJanuary26,1942. (Courtesy ActivatorMethodsInterati onal) distortions.Intheserespects,BTfollowedthe theoreticalleadofWillardCarver,LLB,DC, whose"structuralapproach"tospinalanalysis andadjustingstoodincontrasttothesegmentalismoftraditionalPalmertheory.27,28 LeeandFuhrpracticedtheirown integration ofBTandToftness methods,andtheysearched forpracticalmethodsbywhichtobetterdeterminepatients'preadjustiveandpostadjustive spinal status. By 1965Fuhrhadgrown interested Figure1-1 9 Dr.WarrenC.Lee,circa1977.(Courtesy AdivotorMethodsInterati onal) RESEARCHIIE'IS Figure1-20Dr. I . N.Toitness, from thecover ofaLoganCollegeperiodical.1951. intheleglengthmeasurementsanddouble thumblocktoggleadjustingprocedurestaught byRichardVanRumpt,DC,inhisDirectional NonforceTechnique(DNFT)seminars.However,hewasnot comfortable withsomeof Van Rumpt'smoreesotericprocedures,particularly "droppingthebomb, "inwhichtheclinician observedrelativeleglengthswhilesilentlyaskingInnateIntelligencetocommunicatethe locationsandlistingsofsubluxations.Thiswas beyondthepaleofreasonforFuhr,whoceased attendingtheDNFTseminarsin1967. Inthelate1960s,whilestaffingaMinnesota ChiropracticAssociationbloodpressuretesting booth at thestate fair inMinneapolis,Fuhr took Chapter1HistoryofaTechni queSystem1 1Figure1-21ArlanFuhr,age16,memberofhishighschool band.(Courtesy ArionFuhr. Figure1 -22Dr. Arl anFuhri ntheNavy,1961.(Courtesy ArionFuhr. anadditionalstepalongthepathtowardwhat hasbecometheActivatorMethodassessment method.Anelderlywomancameuptothe boothandaskedtohaveherbloodpressure checkedandbegantalkingtoFuhr aboutchiropractic.SheintroducedherselfasMabelDerefield.WellknownwithinthePalmerbranchof theprofession,theDerefieldnamemeantnothingtotheyoungLogangraduate,whowasonly halflistening.However,whenDr.Derefield begantooutlineonanapkinasystemofpelvic analysiswhileusingarelativeleglength 1 2 SECIONIINTRODUCTIONTOTHEACTIVATORMETHOD measurement,Fuhrwasintrigued.Helater realizedthatthewomanwasachiropractorand hadgivenhimalessonintheDerefieldLeg Checkprocedures,whichshehaddeveloped withherhusband.LeeandFuhrincorporated these procedures into their patient examinations (Figure1-23). LeeandFuhrwerealsoinfluencedbythe TruscottSystemofAngularAnalysisandControlledAdjusting.29 DevelopedbyLeonLewis Truscott,DC,PhC,ofSan Jose,California,this methodofspinalanalysisinvolvedleglength measurementattheadductortuberces.AccordingtoTruscott,"Subluxationsofthecervical vertebraemanifestthemselvesbyproducinga functionalshorteningofoneleg,thuscreating bodilyimbalance.,,29 AsLeeandFuhr'sleglengthmethodofsubluxationanalysisevolved,newfeatureswere introduced.Thespecialtytables(manufactured byTriW-G)thattheyhaddevisedinvolveda manuallyoperatedfootpiece,whichrequired pullingitupwiththelefthandintothelocked position.Atsometimein1976,Fuhrbeganto noticeafairlyconstant,dullachingpaininhis leftribcageatthelevelofthetwelfththoracic vertebra.Fuhraskedayoungassociatedoctor foranadjustmentandexplainedtohimthat whenheraisedhisleftarmoverhishead,the painincreased.Theassociatenoticedthatthis maneuver seemedto dramatically shortenFuhr's functionalshortleg.Thuswasborn thefirst IsolationTest,specifictothetwelfththoracic vertebra. Thisphenomenonprompteddevelopmentof otherprovocativemaneuversupanddownthe spineandintheextremitiestotest forsubluxationsofspinalvertebraeandotherarticulations. Subsequently,chiropractorswhoattendedActivatorseminarsbegansendingintheirclinical observations,whichweretestedbyLeeand Figure1 -23TheDrs.DerefieldwithPal mer College president DavidPalmer,DC,1971. Fuhrandeventuallybya review panel made up ofActivatorMethodinstructors.Thereviewers usedthesetestsontheirownpatientsand notedtheresults.Thosethatseemed"valid" wereincorporatedintothemainbodyofthe technique. ACTIVATORADJUSTINGINSTRUMENT TheasessmentcomponentsoftheActivator Method,derivedfromtheconceptsofVan Rumpt,theDerefields,andTruscott,evolved beforetheinventionoftheAAl.Thiinstrument,whichwouldbecomestandardequipment formostmembersoftheprofession,hadits originsinthephysicalstressthatLeeandFuhr experiencedwithrepeateduseofthethumb toggleadjustment.Althoughthesemaneuvers producedafairdegreeofarticularspecificity, theyalsogeneratedextremefatigue,muscle strain,andfrequentelbowinjurycausedby theelbowsstrikingeachotherduringrapid movementwhenthrustingintopatients'spines. Theysoughtanalternativemeansofproducing amanipulationwithequivalentorsuperior controlofthespeed,force,anddirectionof thrust,butwithoutthewearandtearonthe doctor. In1966SteveInglis,alocaldentist,suggestedthatadentalimpactormightprovidea solution.Thissmallinstrumentwasdesignedto forceamalgamintocavitiesintheteeth.Lee andFuhrusedthedevicetorenderthruststo thejointsofafewpatientsbutbelievedthat theimpactordidnotgeneratesufficientforce tomakeadiferenceintheirpatients'conditions.Severalotherdevicesweretriedbutwere consignedtothegrowingcrapheap,including acenterpunch(whichrequiredtoomuchpreloadbeforefiring),aninstrumentmadebya patient,andanotherinstrumentdevelopedby FrederickG.Proehl,BS,DC,a formerbasicscienceinstructorat LoganCollege.Noneofthese seemedtoservethepurpose(Figure1-24). Anotherdentist-patientintheLee-Fuhr Clinic,Dr.StavaofMarshall,Minnesota, ofered a somewhatmore promising contraption. Heprovidedasurgicalimpactmalletthatwas used to split impactedwisdom teeth.The scalpel tipwasreplacedwithabrakeshoerivet,anda smallrubberdoorstopwasfastenedtotheend. Thisdevicetestedsuccessfullyonpatients,and thefirstfunctionalancestorofthemodern AAIwasborn.LeeandFuhrfurthermodified this instrument andarrangedfor itsmanufacture bytheUnionBroachCompanyinNewJersey until1976(Figures1-25to1-27). Figure1-24Dr.FreddyProehl,fromthe1950issueof theLoganCollegeyearbook,/cy:Iorc. Figure1-25Dentalamalgamsnapperswereprecursors oftheActivatorAdjustingInstrumentbutwerepainfulfor patients.(o0tIc:y ^cIivcIotHcIhoJ:/rIcmc| orcI) ThisearlyActivatorInstrumenttendedto breakunderheavyusage.Totherescuecame FreddyHunziker,thenastudentatCleveland ChiropracticCollegeinLosAngeles.Hunziker worked nightsinthe Western Airlinesmachine shop,wherehemadeuseofthefacilitiesto design andbuild amore reliable internal mechanismfortheinstrument.Hisversioninvolved ahammer-anvileffectthatproducedadependable and controlled force to osseous spinal structures.30 Hunzikersoldthepatentrightsforthis designtoActivatorMethods,Inc.,in1976and introducedFuhrtoaSwiss-Americanfirmthat wasabletomanufacturetheAAItoahigh standard of quality(Figure1-28). Chapter1Hi storyofaTechni queSystem1 3Figure1 -26Earlydevices thatprecededthe Activatorinstrument.(o0iIc:y ^cIivcIot HcIhoJ:/rIcmc| orcl) ..

- -1'- J.i.1= . -. -#..-.. Figure1 -27EarlygenerationsoftheActivatorAdjusting I nstrument,derivedfromasurgicalimpactmal l et.circa1967. (o0tIc:y ^cIivcIotHcIhoJ:/rIcmcIiorc|) Anvil Sprng #2Spring #1 RubberAdjustmentHammer tip knob Figure1 -28Schematic ofmechanismoftheActivator instrument.('tom00cIIHl.lhcIotccoI Ihc^cIivcIotcJj0:| r ir:It0mcrI.0ihitoptlcor./84,2Z]Jj l/.) Production of this newly designed instrument beganin1976,butanotherdependabilityproblemsoonsurfaced.Thesmallspringsinsidethe AAIlastedonly3monthsunderheavyusage. CreditforresolvingthisdifficultygoestoClark Bumgarner,DC,ofCoffeyville,Kansas,who 1 4 SEGIONIINTRODUGIONTOTHEAGIVATORMETHOD informedFuhrin1978thatthespringina29-centParkerballpointpenworkedwelland lastedmuchlonger.3o ThespringsofallAAIs instockwerereplacedbytheParkerballpoint springsuntilstrongerspringscouldbeinserted duringthemanufacturingprocess. ActivatorMethods,Inc.,wasgranteda patentforitsAAIonSeptember26,1978. Thepatentacknowledgedthatthepurposeof thedevicewas"toprovideamanuallymanipulatableinstrumentcapableofprovidinga dynamicthrustwhichincludesacontrolled forceofadjustmentappliedatapreciseand specificlineofdriveatahighspeed"(U.S. Patent4,116,235).TheAAIwassubsequently registeredwiththeU.S.Foodand Drug AdministrationpursuanttotheMedicalPractices DevicesAct.ThisearlygenerationofAAI remainedthestandardforthenext16years (Figure1-29). By1994,studiesconductedbyTonyKeller, PhD,attheUniversityofVermonthad promptedfurtherrefinementintheAAl.Dr. Keller'sinvestigations31-34 suggestedthatan instrumentre-equippedwith aparticulartypeof impedanceheadwouldsignificantlyimprove thefrequencycontentoftheforcedeliveredto the spine.33-35 Activator Methods,Inc.,reported thefollowingintheNovember/December1994 issue of itsperiodical,the Updte(Figure1-30): ActivatorMethodscommissionedtheVermont OrthopaedicandBiomechanicConsultantsto testtheoriginalActivatorinstrumentforthe purposeofperfectingthedesign. Oneofthe resultingimprovementswas apermanentcervicalattachmentwhichsolvedthecommon problem ofthe cervicaltiplooseningand losing lineofdrivewhenadjustingdifficultcontact points onthe body.In addition,during the processofevaluation... wefoundthatthewhite tipbetweentheinstrumentandthecervical attachmenthad adampeningeffectwhichloweredtheenergydeliveredtothespine. Inthe caseofthehumanspine,theresonant Figure1 -29Fi rstmass-producedActivatorAdjustingI nstrument(MI-l).(o0ttc:y ^CtvctotHcthod:|ntcmcttoncl) Figure1 -30Next-generationActivatorAdjustingInstrument (ActivatorII),ci rca1994.(o0tIc:y^CtvctotHcthod: /ntcmc| oncl) frequencyoccursatdynamicfrequencies between40-50Hertz.Atthesefrequencies, theposterior-anteriormotioninresponseto theadjustmentisat amaximum.The presence ofthewhitetipcausedthefrequencycontent oftheinputenergytobereducedbyapproximatelyone-half. To addressthisissue,we examined dynamic loadinput/accelerationresponseorimpedance headinterface(rigidvs.flexible)andimpulse deliverytechnique(continuousvs.temporary contact).Ourresearchrevealedthatarigid interface,combinedwithatemporarycontact impulsedeliveryprocedure,resultedinsignificantimprovementintheinputfrequencycontent.ThenewACTIVATORIIencompasses theseimprovements. Developmentofathird-generationAAI soughttoovercomehumanerrorintheuseof theadjustingdevice.InusingtheAAI-Iand theAAI-II,thecliniciancompressedtheinternalspringsoftheinstrumentwhentheyput toomuchpressure onthepatientbeforedelivery ofthethrust.As well,eachdoctor createda different,oftenexcessivepreloadpressure.This idiosyncraticcompressionoftheinternal springscausedtheinstrumenttoloseforceand toreducethespeedofthethrust.Discussionof thispreloadproblemwithaconsultingengineer promptedtheideaofconstructinganinstrumentwitha rack built aroundit that would prevent the clinician from compressing the internal springs,therebypreservingforceandspeed. After 'severalmonthsofconversationand collaborationwiththemanufacturer,the AAI-IIIemergedasa "clinician-proof"adjusting toolwitharackandautomaticpreload (Figure1-31,AandB). TheAAI-IVwouldfurthertherefinements previouslyintroduced.Thisfourth-generation Activatorincludedahigherspeedsettingand lightenedthepreloadfortheverysensitive patient.Thislatestmodelwasfield-testedto B Chapter1HistoryofaTechni queSystem15 Figure1-31A.Thi rd-generationActivatorAdjustingInstrument.B. Fourth-generationActivatorAdjustingI nstrument.(ouitc:y ^ctivctotHcthod:/ntcmc| oncI) determinewhatwouldworkbest.Aswell,this latestmodelovercameaproblemthathad plagued the AAIforyears.Most cliniciansheld theinstrumentbetweentheirtriggerfingerand theirmiddlefinger.However,someheldit betweentheirmiddlefingerandtheirringfinger.If the latter method was used,itcausedwear ontheinstrument.Thesolutionwastoallow thetriggeringhandletospin,inwhichcaseit madeabsolutelynodifferencehowtheActivatorwasheld(Figure1-32). Bylate1967,LeeandFuhrhaddevelopeda method of biomechanical analysis and an adjustinginstrument,butthistechniquepackagewas asyetunnamed.Inspirationforthe"Activator" brandcameinpartfromthenameofthecompany,Active-Aid,withwhomtheyhadcontractedtoproduceauniqueadjustingtable. LeeandFuhrhadresistedanytemptationto nametheirmethodafterthemselves,reasoning thatthelongevityofthetechniquethenmight benogreaterthantheirlifespans.AtLogan, theyhadlearnedtoadjustthevertebraepassivelybyusingtheapexBasiccontact.Leeand Fuhrnowbelievedthattheywereactively movingbonesbyusingthelow-force,high-Figure1-32Advertisementfor ActivatorMethodsappearing in the September-October1976 issue of 0ic:t oI hitoptcc| c lconomic:. speed,mechanicaladjustinginstrumentthat they had developed;they were in effect "activating"the vertebrae.The "push-button Basic"that VintonLoganhadchallengedstudentsto developwouldemergeasActivatorMethods. Earlypromotionsforthenewmethodsuggested that Activator practitioners would know "where, when,andwhennottoadjust." ACTIVATORMETHODSADJUSTING TABLEDEVELOPMENT SimilartotheAAI,developmentof thespecial tablesemployedintheActivatorMethodwas promptedbyneed.Patients required astep stool toclimbontoa29-inch-highwoodenbenchliketableforlegcheckanalysisandthenwere moved tothe lower Zenith Hi-Lo tables for doublethumbtoggleadjustments.Aswell,Leeand Fuhrwerefatiguedbybendingoveradjusting tables.Theyrealizedthatalessstressfulmethod wasneededforpatientsandforthemselves. In1969amotorizedadjustingtablewas designed that took the patient from the standing totheproneposition(andviceversa)andalso raisedthepronepatienthigherfromthefloor. Assessmentandtreatmentnowrequiredthe patient to mount just one table,and adjustments wereadministeredwiththeclinicianinamuch morecomfortableposture.Alocalmanufacturer ofphysicaltherapyequipment,Active-Aid, begantoproducethenewadjustingtable (Figure1-33). Difficultieswiththemotorsthatdrovethe Active-AidtablespromptedLeeandFuhrto lookforanothermanufacturer.Whilevisiting theActive-Aidfactorytodiscusstheproblem, theypickedupanadvertisingpamphletfor 1 6SEGIONIINTRODUaJON TO THEAGIVATORMETHOD Figure1-33Eighth-generationTriW-Gtableempl oyedfor ActivatorMethodsChi ropractic Technique.(o0tIc:y ^cIivcIot HcIhod:/nIcmcIioncI) TriW-G,Inc.,aValleyCity,NorthDakota, manufacturerofphysicaltherapyequipment. JohnWeber,presidentofTriW-G,wascontactedin1971,andavisittotheplantwas arranged.Therelationshipbetweentheequipmentmanufacturerandthetechniquecompany was cemented when Fuhr's treatment of Weber's wife,whose recent back surgery had not resolved herpain,enabledhertowalkforthefirsttime in 6 weeks. Tri W-G developed a new, chiropracticdivision.WhenActivatorMethodsbecame an international company, Lloyd Table Company tookoverastheActivatortabledeveloperand distributor because of its capability for worldwide distribution. ACTIVATORMETHODINSTRUCTION Weekendseminarshaveservedastheprimary modeofdeliveringinstructionintheActivator Method.Inthetraditionofpostgraduateeducationthathaspersistedthroughoutchiropractic history,Drs.LeeandFuhrcommencedtoteach theirnewmethodtoanyinterestedchiropractor.Thistrainingbeganratherinformally witha fellowMinnesotaDC,whorespondedto rumorsaboutthenewtechniqueandinquired oftheRedwoodFallspractitioners.By1970 thepairhaddecidedtooffertheActivator Methodonaregularbasistochiropractorsnear and far.The firstoftheseseminars,whichdrew 10curiousdoctors,wasorganizedbytwoof Fuhr'sformerLoganclassmates,IrvinChessin DC,andEricPerlmanDC,andwasheldin GardenGrove,California,at the clinical ofices Figure1-34BernardA.Coyle,PhD,circa1995.(o0!Ic:y 6cmctd^.oy'c.) ofCarlRemlin,DC.Instructionalcontent includedproceduresfordetectingsubluxations bymonitoringLegLengthInequalityandfor makinginstrument-assistedadjustmentsofthe pelvisandlowerlumbaranduppercervical vertebrae.Itwasahumblebeginning. Weekendseminarsinchiropractichaveelicitedcriticismovertheyears,largelyonthe groundsthattheyareunregulatedandoffer instructionofunequalqualityandsometimes dubiouscontent.Nonetheless,manyofthe "brandnamed"techniquesemployedbyDCs, someofwhicharetaughtintheaccreditedcolleges,have their roots in private seminars. Nowadays, many of these seminars ofer license renewal credit through co-sponsorship with a chiropractic school.Althoughchiropracticcollegefaculty havesometimesquestionedtheappropriateness oftechniqueentrepreneurs,sentimenttoward techniqueseminarsisnotuniversallynegative. Drs.BarneyCoyleandRobertTolar,former senior administratorsat two chiropractic institutions, have opined the following (Figure 1-34): Enthusiasmhasalsosparkedabevyofprivate entrepreneurialeducators,manyofwhom, despitemakingclaimsthathaveoftenbeen quiteoutrageous,havemadesomecontribution,evenwhenspumedbythecolleges.Too seldomhastherebeenanhonestattemptto synthesizewhatisoffered fromdiverse activity. Ithasbeentooeasytoignorethemandshut thedoors,therebyallowingsomewisdom togetherwithaliberalquantityofincoherent orforgettablematerialtofalloutside . . . .Afar betterapproachforacollegethatvaluesacademicintegrityistoallowpersonsprominent intheprofessiontomakeformalpresentation oncampusandtoindulgeinhonestacademic argument.36 Joseph Donahue, DC,suggests that private techniqueintructorshaveservedavaluablerolein professionaldevelopment: [believeclinicalentrepreneurshavehistoricallyfilledavoid.Consideringthepoorstate of our CD lieges over most of theprofession'shistory,chiropracticwouldnothavesurvived without techniquesystems...Without atechniquesystemtoguidehim/herthechiropractor wasverylikelytofailinpractice. Inmany ways,chiropractictechniquesystems arenecessaryheuristicdevices.37 Suchissuesweresurelynotaconcernwhen LeeandFuhrcommencedseminarofferingsin Minneapolisin1971.Theirintentwastodisseminatewhattheybelievedwasaworthycontributiontotheclinicalarmamentariumof chiropractors.Thefollowing year sawtheir largestattendance to date-56 doctors-atan ActivatorMethodoferinginColumbia,South Carolina.And awindowwas aboutto open that would bringthenewtechniqueto theattention of amuch wider segmentoftheprofession. In1973FuhrpresentedtheActivator MethodataseminarattheBakerHotelin Dallas, Texas. Although only eightdoctors were in attendance,one of themwas Karl Parker,DC, arecentgraduateoftheTexasChiropractic CollegeandsonofJamesW.Parker,DC,well knownforhispractice-buildingseminars.Very impressed with the Activator Method,the youngerDr.ParkervisitedtheLee-FuhrClinicin Redwood Fallsin1975toobservethe high-volumeoperation.Pleasedwiththeencounterand what hehadlearned,Dr.Parker suggestedthat LeeandFuhrmightwishtoattendoneofhis father'sParkerseminarsandconsiderjoining theteachingstafoftheParkerSchoolfor Professional Success(Figure1-35) .SometimeelapsedbeforeDr.Fuhrtookup theoffer.Inthemeanwhile,Dr.Leeoffered Activator Methodtraining inweekendseminars onthecampusofPalmerCollegeofChiropracticandathotelsinDavenport,Iowa,and St.Louis;thelatterpresentationswerewell attendedbyLoganCollegestudents.Thefirst internationalseminarintheActivatorMethod waspresentedbyDr.LeeatBournemouth, England(homeofthe Anglo-EuropeanCollege Chapter1HistoryofaTechni queSystem1 7Figure1 -35TexasChi ropracticCollegefreshman,Karl Parker,fromthe1966editionoftheCol l ege'syearbook. (o0!tc:y lcxc:h|!op!ccttcoIcc.) ofChiropractic)in1972;in1974Dr.Fuhr venturedtoSydney,Australia,where twoweekendtrainingsessionswereprovided. InSeptember1976,Fuhrattendedhisfirst "Parkerextravaganza"and,2monthslater,commencedinstructionintheActivatorMethodas partof theParkerprogram.Inthecomingyears, ActivatorMethodinstructionwouldbecomea regularfeatureoftheParkeroferings.Fuhrwas named a Parker Associate Lecturer (PAL)and,in thiscapacity,taughttheActivatorMethodand practicemanagementprocedures.Althoughthe ActivatorMethodwouldcontinuetbetaught inothervenues,itwastheParkerseminarsthat providedthe"kickstart"thatbroughtthenew method to the national attention of chiropractors andboostedattendanceatActivatorseminars.30 Currently,ActivatorMethodseminarsareheld in major cities across the UnitedStates,Canada, and Australia, and occasionally,in Europe, Japan, and Taiwan.In most instances, Activator Method trainingqualifiestheparticipatingchiropractor for license renewal credits (Figures 1-36 and 1-37).ActivatorMethods'weekendseminarshave evolvedoverthe years andnowcomprisethree sections( tracks).TrackIintroducesthebasics of prone leg length measurements, I solation Testing(from the pelvis to the occiput) ,andinstrument-adjustment procedures for the same.Track I I, which builds on the first module, reviews prone leg measurements and introducesI solation Tests andadjustingproceduresofamoreadvanced nature.ThethirdmodulereviewstheTrackII material,introducesmorespecificisolation adjusting procedures, case management methods, treatmentalgorithms,outcomeassessments,and credentialing for managed care requirements. 1 8 SECTIONIINTRODUCTIONTOTHEACTIVATORMETHOD ACTIATORMETHODS "MoreThanaTechnique" Up ToDate Research Public i License Education / Renewal Activator Continuing Methods Chiropractic Education Seminar Technique Chiropractic / ! Profciency ProductsRating "OneStopShopping"Better Results "IncreasedPatient Retention" Figure1-36Services offeredbyActivatorMethods,Inc.,1998.(o0ttc:y ^cttvctotHcthod:/ntcmc| onc|) Figure1-37Instructorsgather withNobell aureateLinusPauling,PhD,duri ng aParker seminar. 5tcndtn Ic1 to r ht.BillBrown of theParkerSchoolofProfessionalSuccess;MajorBertrandDejarnette,DO,DC;JohnF.Thie,DC;MonteGreenawalt,DC;David Walther,DC;J. ClayThompson,DC;LamarRosquist,DC;GeorgeJ. Goodheart,DC;Gl ennStillwagon,DC;andKarlParker,DC. 5cctcdonchctt:,lc1 tottht.ArlanW.Fuhr,DC,andDr.Paul ing.5cctcdon1oo/lc1 tor h|DavidDenton,DC,andRuss Erhardt,DC,DACBR.(o0tIc:y ^:ttvctotHcthod:/ntcmcttoncI} The"proficiencyrating"forActivator Methodseminarattendeeswasintroducedin theearly1980s,justasDr.Leechosetoretire. Fuhr describedthe processina 1985newsletter: TheProficiencyRatingswillcontinuetobe givenatallActivatorsponsoredseminars. Aboutonequarterofthedoctorsattending havebeentakingthepracticalandoraltest . .. . Thedoctors who pass areplacedonourPreferredReferralDirectoryandthosenamesare thefirsttobegivenoutinresponseto requests forreferrals.Allthatisneededto keepcurrent istoattendoneseminarayeartobeinformed ofnewdevelopments.38 This certification process was augmented by a subsequentcategory,"advancedproficiency rating,"inthelate1980s.ActivatorMethods, Inc.,establishedareferralnetworkforpatients andreferredpatientstoproficiency-ratedActivatorpractitionersinAmerica,Europe,and Australia during1988-1994.39 Today,because of thewidespreaduseoftheInternet,www.activator.comreceivesmorethan1millionhitsper month.There arenow more than2000 Activatorproficiencyrateddoctorsthroughoutthe world whoreceivethe benefitfromthisreferral list.ItwasDr.Fuhr'sdreamtousetheI nternet asaresourceforpatientstofindqualified chiropractorswhouseastandardizedprocedure (Figure1-38). To facilitate the dissemination of the ActivatorMethod,thecompanyassembledateamof Activatorinstructorstoprovidedidacticand experientialtraininginseminarsaroundthe world.Anannualre-credentialingrequirement forinstructorswasinstitutedin1986,soasto enhanceconsistencyintrainingcontentand methodswherevertheActivatorMethodis taught.Thisrecertificationforinstructors includesatleastoneannualmeetingwherein standardmethodsarereviewed,newprocedures areintroduced,andpublishedresearchfindings relatedtotheActivatorMethodarereviewed. Several of these instructors also constitutea clinicaladvisoryboard,whichofersitsperspectives to the company (Figure 1-39). In1999Dr.FuhrwasmarriedtoJudithJ .Hamilton,Presidentof HamiltonConsulting, oneofthetoptengovernmentalrelationsfirms inPhoenix,Arizona.JudibroughtherorganizationalabilitytoActivatorMethodsInternational.Itwasfromthisexpertisethataclinical advisoryboardwasestablished,andthecompanywasorganizedintoregionsthroughoutthe world.JudialsoformedaBusinessAdvisory Board,whichhelpsoverseethebusinessaspects of the company.This turned Activator Methods Chapter1HistoryofaTechniqueSystem1 9Internationalintoafullyfunctionalworldwide corporation(Figure1-40). The success of Activator Method instruction in terms of number of seminars and quality of instruction isattestedtoby the reception it has enjoyed withinthechiropractic profession.Anestimated 45, 000 doctors worldwide make use of some or all oftheActivatorMethodprocedures,4o although regionalvariationseemslikely.Pedersen 41 estimatedthatEuropeanchiropractorsemploythe Activator Methodin14%of their cases.Surveys bytheNationalBoardofChiropracticExaminers,42,43 ontheotherhand,suggestthatapproximatelyhalfofallchiropractorsmakesomeuse of Activator Method procedures in approximately 20% of their cases,making itone of the most popularofchiropractictechniques.Thesesurveys have notdifferentiated betweenuseof Activator analysis vs.use of the AAl.However,since1967 an estimated 75, 000 AAIs have been sold.40 InstructionintheActivatorMethodwas acceleratedbyitsintroductiontothecourse oferingsatvariousschools,beginningin1980, when Logan College of Chiropractic offered the Activator Method as an elective. The Parker CollegeofChiropracticwasthefirstinstitutionto requireinstructionin the ActivatorMethodof all doctoral students.Today,required or elective course work in the Activator Method is provided atmany chiropractic schools (Table1-1)andin postgraduate settings. On many college campuses, both those that include the ActivatorMethod in theircurriculaandthosethatdonot,Activator clubsarethriving.Theseclubsaregenerally headedbyenthusiasticstudentsandareguided byafacultyadvisorwhoisproficientinthe Activator Method (Figure 1-41) . Figure1-38Activatorinstructors,1986.(o0c:y ^cItvcIotHcIhod:|nIcmc| oncl) 20SECIONIINTRODUCTIONTOTHEACTIVATORMETHOD Figure 1 -39Drs.Lois WardandArlanFuhr(ccnIct)meet withAustral i an Activatorinstructors,2002. (o0tIc:y ^cIivcIot HcIhod: |nIcmcIionc|) Figure1 -40Judi Fuhr.(o0tIc:y^cIivcIotHcIhod: |nIcmc| oncl) ACTIVATORMETHODS,RESEARCH, ANDCREDIBILITY Since antiquity, spinal and articular manipulation has been practiced based on anecdote and private clinicalexperience.Theearliestknownsystematic clinicaltrials of such methods did not aPfear until the latter half of the twentieth century.4-5 1 Thefirstrandomized,controlledclinicaltrialof adjustingreportedbi chiropractorsmadeits appearancein1986. 5Theearliestknowncontrolledstudyofinstrumentadjustingemployed asactive(asopposedtoplacebo)intervention was contributed by Yates and co-workers.53 ThefoundersoftheActivatorMethodtook their clinical training during the preexperimental era in chiropractic.However,by the early1980s Fuhrhadbecomeconcernedthatanecdotes andinformalclinicalobservationsprovidedan insufficientbasisforclaimsofefficacyand effectivenessfortheActivatorMethodorany otherformofmanipulation.Aswell,theintroductionofAAIhadgeneratedconsiderable controversywithintheprofession;somechiropractors voiced opinions that the device was hazardoustopatients,andothersconsideredan instrumental thrust a poor substitute for adjusting by hand. Although quite unprepared by his formal training,Fuhrchoseto entertheresearcharena (Figures1-42 and1-43). Itwassomethingofanordealforthisresearchnovice,whoacceptedachallengefrom thepresidentofTRIW-G,L.JohnWeber,to seekafederalgranttounderwriteActivator research.Fuhrsolicitedtheaidofimmunologist DennisSmith,PhD, and Logan Collegeresearch administratorBarryP.Davis,PhD.Dr.Smith wasself-taughtinbioengineeringbutnonethelessledasuccessfulgrant-writingteam,which submitteditsapplicationtotheSmallBusiness InnovativeResearchGrantsProgramofthe NationalInstitutes ofHealth(NIH).Theirproposalsoughtfundingtoinvestigatethe safetyof theAAIwiththeuseofadogastheresearch subject.Theproject,conductedatLogan Collegeandat theSchool of ComparativeMedicineatSt.LouisUniversity,garnered$50,000 fromthefederalgovernment.Thiswasa minisculeamountbynationalstandardsbut probablyrepresentedthefirstfederaldollars receivedbyanychiropractor-investigator.The studyrevealed"relativebonemovement"as aresultofthrustswiththeAAI,therebydisconfirming critics'suggestionthattheActivator Methoddidnot"moveabone."Thisinitial Chapter1HistoryofaTechniqueSystem21Table1 - 1 InstructionintheActivatorMethodatVariousChiropracticColleges Requiredi nElectivei nPostdoctoral DoctoralDoctoral(Relicensure)Activator CollegeProgramProgramOferingClub* CanadianMemorialChiropracticCollegeX ClevelandChiropracticCollegeofKansasCityXXX ClevelandChiropracticCollegeofLosAngelesXX LifeUniversity,GeorgiaXXX LifeChiropracticCollegeWest,CaliforniaXX LoganCollegeofChiropractic,MissouriXXX NewYorkChiropracticCollegeXX PalmerCollegeofChiropractic,IowaXX PalmerCollegeofChiropracticWestXX ParkerCollegeofChiropractic,TexasX ShermanCollegeofStraightChiropracticX NorthwesternUniversityofHealthSciencesX TexasCollegeofChiropracticX Universitedu-QuebecaTrois-Rivieres,CanadaX AngloEuropeanCollegeofChiropractic,EnglandX MacquarieUniversity,Sidney,AustraliaX Universidad Estatal del Valle de Ecatepec,Mexico CityX CompiledfromFuhrA W, Menke ]M.Status of ActivatorMethods chiropractictechnique,theoryandpractice. ]Manipulative PhysiolTher.2005; 28(2):135.* Activatorclubsactiveas of Spring2002term. researchwaspublishedintheprofession'spreeminent scholarly periodical, the}oumal of Manipulative&PhysiologicalTherapeutics.54,55 Whether relativebonemovementisanecessarycondition for therapeutic benefit remains undetermined. Unsuccessfulinhissecondgrantapplication totheNIH,andnowrealizingthemagnitude Figure1-41MichellePetermann(Ic(, alongtimeseminar staff member, is seen here with Drs. Gary andLois Ward,Activatorinstructors,in1 985.(o0i|c:y^c||vo|o!Hc|hod: /n|cmo|ono/) ofthefinancialresourcesneededinthechiropracticresearchcommunity,in1987FuhrsolicitedtheaidofhisActivatorinstructorsto establishanonprofitresearchfoundation,the Figure1-42Dr.BarryDavis,fromthe1 975editionof theLoganCollegeyearbook,/cytonc. 22SEGIONIINTRODUGIONTOTHEAGiVATORMETHOD Figure1 -43Dr.DennisSmithisseenat farleftduring1986 diagnosticstudieswithultrasoundequipment.(o0rIc:y ^cIivctorHcthod:/ntcmctionc/) NationalInstituteofChiropracticResearch (NICR).ThepurposesoftheNICRevolved somewhatover the yearsbutwereclearlystated in1992: . . .raise fundsforfundamentalscientific,clinicalandhistoricalresearchandscholarshipin chiropractic.The NICRconducts research,and through a modest extramural grant-making program,has funded anumberof research projects by other investigators.To date, funds have been awardedtoinvestigatorsatLifeChiropractic College-West,LoganCollegeofChiropractic, NorthwesterCollegeofChiropractic,the (Pacific) Consortium for Chiropractic Research, Palmer College of Chiropractic,Palmer College ofChiropractic/West,theUniversityofthe Pacific,andArizonaStateUniversity,among others. Awards have also been made to the AssociationfortheHistoryofChiropracticand PalmerCollege of Chiropractic/W est in support of projects in chiropractic history. The NICR is a memberoftheAssociationfortheHistoryof Chiropracticandthe(Pacific)Consortiumfor ChiropracticResearch.(StatementofPurpose, Activities &Afiliations,October 28,1 992) The founding members of the NICR board of directors included Arlan W. Fuhr,DC, President, TonyTrimble,] D,Secretary,Donald].Petermann,Treasurer,DonaldG.Kimble,DC, Anthony Pavia,DC,and Lois Ward,DC.Since 1987anumberoftalentedindividualshave contributedtheirexpertisetothisinitiativeas membersofthisboard,mostnotablyBernard A.Coyle,PhD,KennethF.DeBoer,PhD, RobertA.Leach,DC,andMalikSlosberg,DC. Theboardwasassistedatvarioustimesby employeesRoyW.Hildebrandt,D(founding editorof the Jouralof Manipulative&PhysiologicalTherapeutics), andPaul].Osterbauer,DC, MPH,agraduateofNWCCwhoservedas researchadministratorforNICRinthelate 1980s and early1990s (Figures 1-44 to 1-46) . In its two decades of operation,the NICR has distributed slightly more than $690,000 in externalgrantsandhassupportedatotalof262 scholarlypresentations,booksandchapters, and papers inscholarlyand scientific periodicals (Box1-1).Thescopeofthefoundation'swork hasextendedwellbeyondthequestionsposed bytheActivatorMethod,andtheNICRhas beenthemostfrequentsourceoffundingfor historicalinvestigationsintheprofession. Figure1 -44ThomasDeVita,DC, Activator instructor andvice presidentoftheNationalI nstituteofChiropracticResearch, 2002.(o0rIc:y ^cIivctorHcthod:/ntcmc| onc/) Figure1 -45Dr.PaulOsterbauer,circa1987.(o0iIc:y ^ctivctor Hcthod:/ntcmc|oncI) Figure1 -46Dr.KenDeBoer,memberoftheNationalI nstituteofChi ropracticResearchboardofdi rectors,2002. (o0rIc:y ^ctivctorHcIhod:|rtcmc|orc|) Box1 - 1 PeriodicalsinWhichNICR-Supported PapersHaveBeenPublished American JouralofChiropracticMedicine Chiropractic ChiropracticHistory Chiropractic Journalof Australia ChiropracticSportsMedicine ChiropracticTechnique D. C. Tracts European JourlofChiropractic JourlofBiomechanics JourlofChiropracticHumanities Jourl of Manipulative & Physiological Therpeutics JourlofSpinalDisorders Jourlofthe AmericanGeriatricSociety JourloftheCanadianChiropracticAssociation Philosophial Constructs for the Chiropractic Profession (renamed Jour of Chiropractic Humanities) Psychophysiology SkepticalInquirer Spine TopicsinClinicalChiropractic NICR,NationalInstituteof ChiropracticResearch. TheActivatorMethodhasbecomeoneof themostextensivelystudiedtechniquesystems inchiropractic,andtheActivatorcompany has been an active participant in the profession's emergingresearchcommunity.Osterbaueretal. observedthatsince1987, AMIhasparticipatedintheresearchmeetings oftheCaliforniaChiropracticFoundation (ConferenceonResearchandEducation), the Chapter1HistoryofaTechniqueSystem23 ConsortiumforChiropracticResearch,the FoundationforChiropracticEducationand Research(InterationalConferenceonSpinal Manipulation),and the several Consensus Conferenceson Chiropractic Methodssponsored by theACACouncilonTechnic.Concurrently, AMI has conducted a variety of clinical investigations. Thesestudieshaveyieldednumerous papersinthereferredscientificliteratureand conferencepresentationsandhaveinspired otherstostudythevalueofAMCT[Activator Methodschiropractictechnique] .Interestin studying AMCT has resulted in interdisciplinary collaborationwiththeDepartmentsofBioEngineeringandExerciseScienceandSport ofArizonaStateUniversity,theHarrington Arthritis Research Center,and the Department of MechanicalEngineeringat the University of VermontandtheVermontSpaceGrant ConsortiuminconjunctionwiththeNational Aeronautics and Space Administration.35 Thecompanyhasmaderepeatedefforts toensureaccessibilitytopractitionersofthe knowledebaserelevanttotheActivator Method.1 ,39,40Thisliteraturegarnereda"promisingtoestablished"ratingforthisformof instrumentadjustingduringthe1992Mercy Centerclinicalguidelinesconsensusconfer-56 d" 1 . fenceanasImI arratmgromaconsensus panelcommissionedbytheCanadianChiropractic Association. 57 Techniqueresearchinchiropracticisstill h". . . f ,,58ThhverymucmItSm ancy.ecompanyas repeatedlyacknowledgedthat,similartomost forms ofmanualhealing,theActivatorMethod requires a greater number of well-controlled outcome studies.4o That said, the Activator Method isoneofthebetterstudiedmethodsofchiropracticcare. 58 Nonetheless,controversyover instrumentadjustinghaspersistedwithinthe profession.InSaskatchewan, mechanical adjustingdeviceswerebannedbythelicensing authorityforatime,promptingacriticalreview of the evidence, which was conducted by a committeeappointedbytheprovincialsociety.59,60 Themajorityopinionwasthatmechanical adjustingprocedures,inparticular,theActivator,"wereasefectiveas manual(HVLA[highvelocity,lowamplitude])proceduresinproducingclinicalbenefitandbiologicalchange.,,59 However,aminorityreportreassertedthat "therewasnotenoughevidencetosupportor refutetheefficacy"ofinstrumentadjusting. Andalthoughmostcommitteemembersargued thattheAAIhas"nomorerelativerisk"than manualadjusting,aminorityofthegroup 24SEGIONIINTRODUQlONTOTHEAGIVATORMETHOD believedthattheevidencewastoothintojustify aconclusion.6o Because of this debatedocumentedintheliteratureanditsfavorable outcome,ActivatorisapprovedforuseinSaskatchewantoday. CONCLUSION The Activator Method is part of the tradition of instrumentadjustinginchiropracticdatingto thefirstdecadeoftheprofession,andevenfartherbackintoantiquity.Creditfortheorigin of the AAIrests withtwo rural Minnesota practitioners;ActivatorMethodassessmentprocedureshavemultipleconceptualroots,allof whichareanchoredinvarioussubluxationtheories.ThegrowthoftheActivatorMethodhas beenbasedprimarilyonpatientandclinician satisfaction,buttheActivatorcompanyhas soughttoholditsmethodsuptothecritical scrutinyofscientificinquiry.Bioengineering researchhassuggestedanumberofmechanical improvements in the AAI over the years, and this work continues. A still meager clinical outcomes evidence base combined with clinician judgment hasprompted generallyfavorablereviewsofthe ActivatorMethod.Thisformofinstrument adjusting has become usual and customary within the profession and is widely taught in chiropractic colleges and in postgraduate relicensure seminars. Muchworkremainstobedone. REFERENCES 1 . HinojosaSZ.Thehands,the sacred,and the context of changein Maya bonesetting. In: Oths KS, HinojosaSZ,editors.Healingbyhand:manual medicineandbonesettinginglobalperspective. Walnut Creek (CA):AltaMira Press; 2004. 2.Dorn WHoIndian lore:crudeuseof chiropractic fundamentalscenturiesago.ChiroprJ(NCA).1935; 4(3 ) : 1 7-8. 3.SmithBAThomasHenryStorey,DO,DC, 1 943to1 923. ChiroprHist.1 999; 1 9( 2) :63-84. 4. Zarbuck MV, Hayes MB.Following D.O.Palmer tothewestcoast:thePasadenaconnection, 1 902.ChiroprHist.1 990; 1 0( 2) : 1 7-22. 5. 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JCanChiroprAssoc.2004;48(2) :1 52-79. ] aelG.Pickar Thischapterdiscussesthedevelopmentof chiropracticscience.Itbeginsbyposinga question.Indeed,theimpulseforthescientific processisthedesiretoknow;thusthequestion posed in the next sentence bears the efort of evokingandfocusingaframeworkforunderstanding themechanismsunderlyingtheefectsofchiropracticcare."Howcouldamechanicalintervention,appliedtothespineandwhichtypically lasts but a fraction of a second(chiropractic spinal manipulation or adjustment), produce long-lasting clinicalefects?"Withthisquestionasthebackdropfordevelopingtestableresearchhypotheses, ourexperimentalworkcanbringusclosertoan evidence-based,biological understanding of spinal manipulation.Thisisnotknowledgeforknowledge'ssakebutknowledgeforthelong-termgoal of learing how best to apply ourskillstoimprove thehealthofthepublic.Thischapteraddresses threeareasofchiropracticresearchthatmay contributedatathatwillhelpustoanswerthis question. Aschiropracticscienceseekstoanswerthis fundamentalquestion,weshouldbe mindfulthat spinalmanipulationisalwaysdeliveredwithin thewider context ofthepatient's clinical encounterwithhis/herdoctor.It is notyetclearwhether orhowtheseinteractionsandthephysicalprocedurespreparatorytochiropracticadjustment contributetotheefectivenessofthemechanical interventionitself.Asresearchfindingsfrom bothclinicalandbasicsciencelaboratoriesare integrated into our understanding, we must rememberthattheselaboratory-basedmechanisms arelayeredontopotentialefectsthatmaystem fromsubjectiveandnonverbalcommunications involvedintheclinicalencounteritself. PRINCIPLES PainteduponahallwaywallthatIoftenpasson mywaytomeetings,anepigramattributedto Dr.Clarence S. Gonstead reads,"Remember that chiropractic always works. When it does not seem 26 to,examine your application but do not question theprinciple."Uponfirstreadingthisepigram, Ishookmyheadwithconcernanddiscomfort. Itsconclusionthatchiropractic"always"works smackedofthinkingthatwasbothdogmatic andself-serving.Itseemedrathernonspecific. Inchiropractic,didDr. Gonsteadincludeadjustmentsprovidedtothespineandtotheextremities,ordidDr.Gonsteadrefertoanapplication thatincludedmorethanadjustments?Byprinciple,washereferringtoametaphysicalconstruct likethepresenceofanInnateIntelligence,or toamorebiologicalconstructthatstatesthat nerveinterferencehasthecapacitytoaffect homeostaticmechanisms?WhenIconsidered membersoftheprofession,includingdoctorsof chiropractic,teachingfaculty,andchiropractic students,havingfullyinternalizedthisidea, Ienvisioneditspotentialtocurtaildialogue, discouragecriticalandanalyticalthinking,and sustainclinicaldecisionsthatmightnotreflect thepatient'sbestinterest.Andyet,becauseof theepigram'slocationonthewalloftheinstitutionandtheprofessionalstatureofitsauthor, Ifeltcompelledtoconsiderhowwisdommight becontainedinthewords.Didmyoriginalconcernaboutthequotemisssomethingimportant? Iundertookathoughtexperimentbyasking myselfatwhatconclusionImighthavearrived hadIreadasimilarepigramdisplayedonthe wallsof a MedicalCollege:"Remember that medicinealwaysworks.Whenitdoesnotseemto, examineyourapplicationbutdonotquestion theprinciple."Similartomypreviousissue,this statementwouldraisethequestionofwhatis meantby"medicine"?Wouldthistermreferto theuseofdrugs,theuseofsurgery,anallopathic philosophy,orsomethin