Legitimizing Instrument Adjusting

Christopher J. Colloca, D.C.

CEO and Founder of Neuromechanical Innovations

A ISO 13485 Certified Medical Device manufacturer of the Impulse® family of adjusting instruments, based in Chandler, Arizona.



As the popularity and utilization of Instrument Adjusting grows worldwide, mainstream acceptance continues to be hampered by outdated technology and technique approaches that are associated with traditional Instrument Adjusting techniques.  The exciting challenges of integrating chiropractic care into mainstream healthcare are subsequently plagued by the esoteric chiropractic techniques that are not accepted or recognized among general healthcare professionals.  Take for example, the Activator Method, which advocates that changes in leg length while a patient places their hand on their lower back constitutes a positive clinical finding for an L5 or L4 vertebral subluxation.  Try explaining this test to a physician or even a chiropractic colleague! 

Recently claims submitted to Aetna by Activator practitioners have been denied simply based upon the technique used.   There is also the problem of using the Activator Method isolation tests to identify a subluxation under Medicare.   So, while the Activator group should be congratulated for celebrating their 45th Anniversary in business, their decades old approach doesn’t pass the sniff test in today’s healthcare arena.

Recognizing the inherent dangers in being associated with other Instrument Adjusting approaches, our team set out to carve our mission of legitimizing Instrument Adjusting not only within chiropractic, but also to the general health care community and to the public. To this extent, our team crafted a strategic plan to assess instrument adjusting utilization and perception and to provide the improvements and enhancements necessary to advance the technique and the profession. 

Instrument delivered chiropractic care can be broken down into two parts – The instrument technology itself and the clinical application that the technique is based upon (Figure 1). 

 Figure 1. Instrument Adjusting includes the technology of the product represented by the instrument brand and the functionality or performance of the device as well as the clinical application that is taught in the clinical training that includes the indications to administer the treatment and the clinical decision making accompanying the actual technique application. 

First level strategic inputs to assess in legitimizing Instrument Adjusting include Technology development and evaluation of the Clinical Applications.  As shown in Figure 2, these inputs are driven by research and development resulting in scientific journal publications that validate the technology that is developed.  Medical Device Certifications ensure quality and further solidify the medicolegal ramifications of using instrument adjusting technology in your practice.  Through literature review, evidence-based Technique Development comprised the incorporation of clinical tests with the best evidence as inclusion criteria, and Clinical Training and practical testing to ensure clinical proficiency.  Last, efforts to increase the awareness of the Instrument Adjusting movement within chiropractic were created through a Marketing and Business Expansion effort to increase the utilization of chiropractic care by the public. 


Figure 2. Categorization of the strategic input drivers identified to legitimize Instrument Adjusting.   


  • Technology Inputs

Instead of starting with an instrument and then doing retrospective research the way instrument adjusting research has traditionally been approached, we set out to prospectively develop a new family of adjusting instruments to improve the performance and efficiency of chiropractic adjustments.  The Impulse® and Impulse iQ® Adjusting Instruments were born of this research.

We quantified the forces and speeds that were necessary to maximize vertebral motions and neuromuscular responses (1,2) and investigated how instrument delivered thrusts differed among normal and pathological states such as disc degeneration and muscle hyperactivity (2-4).  We then compared our new technology to existing adjusting instruments in the market and demonstrated the superiority of the biomechanical characteristics of the new Impulse® Adjusting Instruments (5,6).  Validation of a new non-invasive method of dynamic spinal stiffness assessment was conducted and published it in the Journal Spine (7).

  • Medical Device Certifications

To meet the growing demand for our products, I began a new medical device manufacturing company to manufacture the devices to the required specifications.   We created several new jobs and instituted a Quality Management System to drive our business that fostered our ISO 13485 Medical Device Certification.  Independent audits conducted in our facility ensure the safety and efficiency of our systems and procedures and our products UL Listing® attests to the high standards we hold.  Our international growth pushed us to receive our Class II Medical Device Certifications throughout the World.  Manufacturing a chiropractic device to the highest quality medical standards allows our equipment to be used in hospitals as well as private chiropractic clinics further serving the purpose to legitimize instrument adjusting.

  • The Instrument Adjusting Problem - Esoteric Techniques

Unfortunately however, Instrument Adjusting has been traditionally associated with esoteric chiropractic analyses that border on summoning the supernatural.  Followers of the Activator Method stare at the feet looking for leg lengths to change while asking the patient to put their arms on their back or over their head to confirm a vertebral subluxation at a specified level.  Without any validation whatsoever, these arm movement are assigned to a particular vertebral segment and flexing the legs supposedly tells the clinician what side to adjust the patient on.  Borrowed and adapted from Directional Non-Force Technique (DNFT), Activator technique is closer to Network and Applied Kinesiology with its leg checks, pressure tests and challenges that are seen by many as nothing short of strange and indefensible.

Without any credible explanation or rationale at all behind this analysis, the Activator Method is taught in our chiropractic colleges and in college sponsored post-graduate education courses.  There aren’t too many chiropractic techniques that could be more far-fetched; yet, Activator Methods boasts that approximately 150,000 chiropractors have been trained in the technique.  It’s hard to understand how this is even possible when there are approximately 50,000 chiropractors practicing in the USA and 90,000 abroad (8).  Another descendant of DNFT, Koren Specific Technique, advocates that you can “adjust disks … see dramatic retracting … and specifically analyze and adjust yourself.”  Rather than passing judgment, let’s have you decide for yourself what type of Instrument and technique method that you would like to subscribe.  At the very least, I think you can understand why I felt the need to legitimize instrument adjusting.

  • Clinical Application Inputs

            In developing Impulse Adjusting Technique (the clinical application training accompanying our products), we knew that we needed to incorporate logical, clear and readily acceptable objective assessments that were validated, accepted, and easy to perform.   We embraced the Centers for Medicare (CMS) Services mandated P.A.R.T. analysis to keep chiropractors in compliance with regulations and increase their reimbursements at the same time.  Incorporating accepted orthopedic tests combined with static palpation, and range of motion assessment of the spine and extremities, Impulse Adjusting Technique® considers the patients response in terms of their pain response (P), asymmetries (A), restrictions in range of motion (R) and the texture and tone changes in the muscles (T) as clinical indicators.  With this approach, the most valid clinical indicators are incorporated and a straightforward patient encounter on each visit can subjectively and objectively track patients’ progress consistent with the chiropractic standard of care.

Clinical training in the Impulse Adjusting System® is offered in most U.S. Cities and many international destinations.  Didactic and practical sessions are offered in the proper product usage and clinical applications training.  A written and practical certification examination is offered to measure student’s proficiency.  We have further developed a business and marketing expansion module to assist chiropractors in promoting and marketing their unique niche in chiropractic practice.  More information can be found online at

Legitimizing instrument adjusting and advancing the chiropractic profession begin with raising the standards of the products offered to DC’s replacing nonsensical chiropractic analyses with those techniques that have stood up to the scrutiny of research. 







Chiropractic Today and Tomorrow

Randall Hammett, DC

Private Practice of Chiropractic



To be or not to be, is the final question for chiropractic. I believe that chiropractic will survive in the future, but I am not sure in what form. With small groups of confused and disillusioned chiropractors trying to ape to medical doctors by trying to prescribe drugs or becoming  spa owners by  performing cosmetic alterations or poking holes in the body with needles to stimulate or inhibit yin or yang. The whole profession seems to be confused about what it is and isn’t, and is the public.

In these economic times, as with the past poor economic times, chiropractors jump to fringe of healthcare or in other words they try anything to make a buck. Don’t get me wrong, there is still a strong undertow of traditional chiropractic out there, but every year it seems to weaken.  Chiropractors sucking at the trough of ever lessening insurance coverage look to supplement their incomes outside chiropractic. In the main, this is not a bad idea from a business standpoint of view but the main problem is with the public’s perception.

The perception in the public is that chiropractors are back doctors or are they? Our fate was sealed years ago when we did not demand our own set of Chiropractic CPT Codes and now we have pigeonholed ourselves into the “back business” instead of the health business. Chiropractors who are desperate for more business profess “Wellness” clinics at the same time the medical profession is doing the same. If history has taught us anything about chiropractic, it is that when a chiropractor stands upon the platform of correcting nerve interference his or hers practice thrives with or without insurance. BJ Palmer warned us years ago of what is now become the norm in chiropractic. Meaning, chiropractors educated without the knowledge of when, where and where not to adjust for nerve interference is the norm. But boy, can they pass board exams. Chiropractic colleges of today are not even calling themselves chiropractic colleges, not because chiropractic doesn’t work, but because they need more money to survive. So, I have to ask you what chiropractic is to you, because that’s what it has become to your patients. Is it correcting vertebral subluxation or is it physical, nutritional or laser therapy, weight control or spa services such as pedicures and manicures?

You see we’ve already screwed up chiropractic pretty good by confusing the public on when they need a chiropractor and when they don’t. We have further gone the wrong direction, in my opinion, by not emphasizing and all agreeing that our profession is about what its founder said it was.  Don’t get me wrong, people need therapies, advice on nutrition and exercises that they are not getting from the medical profession and we should give it to them and charge a fair fee, but the emphasis of a chiropractic office must be about correcting nerve interference.  As we move further away from this, I predict that there will be a schism in the profession and that you will have to decide what type of chiropractic you are going to practice and accept the consequences of your decision. If you are looking for your practice to grow and to be re-energized you only need to look at your precision in finding and correcting nerve interference, treating your patients with respect and earning their trust as their family doctor, not as their “wellness” doctor.    


I know this for the truth, that the public is hungry for the old family doctor. The role their medical physician can no longer fill, but you can. Focus on becoming your patient’s family doctor, not just a sign on your clinic that says “family practice”, but truly a doctor who families will come to see and trust as they once did 50 years ago. If you want a better practice give your patients what they want… A real Doctor!  Till next time…



The Risk Mitigation Business 

Vince Covino

Legacy Consulting

Boise, ID

Mr. Vince Covino is an investment representative with Prospera Financial Services, Inc. a SEC registered Investment Advisor. Investment Advisory Services Provided by Prospera Financial Services, Inc. An SEC Registered Investment Advisor


I once sat down to dinner with a Risk Mitigation Expert that worked with several Fortune 500 retailers. He offered scintillating hors d’oeuvre conversation because the tales of what people would try to steal and the motivation behind it offered an interesting look at human behavior. These people were artists at deception—they’d been liars their whole lives, and only the truly skilled could strip away their personae. In a strange way, after being caught, these criminals were also in the Risk Mitigation business. Surprisingly, the majority of his work in dealing with loss for these companies was loss from employees. Getting the right employees was absolutely critical. 


The Employee ‘Interview’

Jokingly, I had him put me through this type of interview, and without hesitation he fired off the first question, “When was the first time you stole from the till—it wasn’t today, was it six months ago?” 

My eyes narrowed as the uncontrolled nervousness bubbled up within; a simple “no” response didn’t clear up the possibility of me stealing from the company today, and anything else implicated me at some time. 

I stammered a confused response, “I’ve never stolen anythi-….”

He interrupted through a subdued grin, not letting me assert my innocence. “Come on, it wasn’t a year ago, was it?” Complete with sympathetic disbelief. This questioning escalated for the next five or ten minutes in a pattern of sympathy, disbelief, assertion and offers to capitulate. His insistence brought me to the point of a re-analysis of all self-doubt.

From the very beginning of the interview or should I say, interrogation, I was on my heels, struggling just to articulate my honesty. The pace at which he methodically took me through questions didn’t give me much time for contrivance. He mentioned they typically have the employee on tape stealing from the till, or shuffling merchandise out the back door, so by starting without the informational asymmetry that goes on in a normal employee hiring interview, he had the advantage. 


The Prepared Employee Seeks Assistance

Great questions were the key to his discoveries, but he had another superiority; I was an unskilled liar. Dealing with people that have been consistently dishonest is a bit trickier than tripping up a guy who second guesses taking a spurious tax loophole for fear of an audit. I simply wasn’t well-equipped enough to convince him of my innocence—and I was innocent! Unfortunately, anyone hiring talent today struggles with a vastly refined group that not only knows the questions you are going to ask, but how to navigate around the majority of interview pitfalls. The Internet gives instant access to company research, a list of commonly asked questions, responses, and potential interviewer information all that give the candidate an edge. Candidates today are better prepared than ever before; however, business owners aren’t prepared enough to deal with them.

If you haven’t been trained in Law Enforcement Interrogation techniques outside your weekly patronage of Law & Order, then might we humbly suggest that you hire a firm that specializes in hiring, and that can show you demonstrable results through their system? Let’s take a look at how our system puts Business Owners in a position to make the right decision.

First, we take a look at your practice, and after some observation of the facts, we settle on what position you really need. DC’s get it in their head that they need someone for massage or to do sales; when their biggest need could really be to have a solid AR function. Business Owners, all of them, have blind spots; we help you see past them by taking measurements of you personally and then of your team. Second, we help you write the copy that will attract the candidates you want and deter the ones you don’t.

Third, despite all this, some candidates will still have delusions of grandeur, so our extensive behavioral and background research will cull out the undesirables before any contact is made (This is really where the special sauce comes in).

Fourth, we collect all this data in a format that’s easily accessible for our first interview with the candidate.

Fifth, we take an objective and removed approach to the interview that allows us to ask the uncomfortable questions that you would never ask. By the way, this stage of the process is also a tremendous liability for the interviewer. “Do-it-your-selfer’s” that ask the wrong question can violate the “protected class” status of a candidate and face Equal Opportunity Employment violations or potential lawsuits. 

Sixth, we question in a way that prompts for a variety of answers in an unfamiliar format to most candidates.

Finally, we package up our research and offer recommendations without the bias of nepotism, or the charm of the candidate. If we can’t agree, then you have the freedom to proceed at your own peril.


Some Questions To Ask

As a reward for slogging through this article, here are a few of my favorite questions to ask unsuspecting candidates. These normally put people in a “crisis” state wherein they won’t be comfortable in their responses. Armed with the behavioral and background intelligence we have collected, we feel like these questions put you in a good scenario to get reality.

  • In my experience, people who haven’t been kicked in the teeth in their lives don’t really have the passion required to be great at Sales; tell me about your failures.” I like this because people respond in kind to your questions. You’ve set it up here that you are really looking for Passion, but in reality this is the question you ask the candidate that has all the answers. You should get some honesty here, and if they don’t have some kind of failure story after this question then they’re schizophrenic; end the interview.
  • You’ve marked all of your attributes here as 10’s on a scale of 1 to 10; I appreciate the statement you’re trying to make, and we’ll come back to intellectual honesty in a minute. Pretend you had to rank these in succession; what would be the bottom three?” Implied dishonesty makes them feel as if they have to prove themselves; you allow them to save face by the “making-a-statement” comment, and you should get some real weaknesses here.
  • (Phone Interview) “We’ve never met, but it sounds to me like you look a certain way (derived from their experience); I think in part your past success has stemmed from this—do people feel intimidated by you, and how do you make them feel comfortable?” Nobody that is good-looking wants to characterize their success based solely on their looks. The great thing about this question is, you haven’t seen them yet, so they are wondering how you know this while simultaneously trying to assert their greatness. Fantastic to determine if someone is a team player and how motivated they are.



Because employees can be our greatest asset and potentially our greatest liability, hiring exceptional talent is easily in the top-five most important things you will ever do as a business owner. The right choice will propel your growth and drive innovation, but the wrong choice could cost you millions and bring an end to your business.  



Eric Huntington, DC

Co-Owner Developer of the Chiropractic Business Academy


It’s a practice in which the staff members take an active role in creating the future of the practice.

Staff members do this by working effectively and efficiently, without the need for much oversight. They are guided by the general direction of the owner through company policy and training. They don’t need orders to know what to do. Orders ARE issued, however, as a method of coordination but not as a necessary part of getting the staff member into action.

More important than just doing their jobs, the group members of a staff driven office create on their posts. They don’t just handle the work created by the blood sweat and tears of the owner, but they create more opportunity for the organization through their own efforts.

In short, the work, the responsibility, and the energy needed to maintain or grow a practice are truly shared amongst all in a staff driven office.



First, it’s more fun to play in a group that you like than by yourself. Whether you are truly the only person in your office, or it just feels that way, I’m sure you can imagine that it would be more fun and more productive to have staff in your office sharing in the work, responsibility and rewards of practice.

Secondly, you can get more done with a group than you can by yourself. Each person has a limit as to what they can accomplish alone. This is what stalls the growth in most practices—the personal limitation of the owner doctor. This limitation does not occur in the Chiropractic Business Academy model because it’s staff driven. The only limitation is your ability to hire, train, apprentice and keep great staff, and to organize. The limitation is not your own energy, or time.

Lastly, you build an asset that will continue to pay you money after you retire, move on to another game, or that you can sell for a significant price. Even the largest of chiropractic offices can’t usually be sold for more than a few hundred thousand dollars because the owner selling the practice is the person who wears all the major hats within the practice—and he or she is leaving! What’s that worth?



It starts with an owner who is hatted as an executive. He must know how to envision an ideal scene for an activity, organize it’s into parts, organize those parts into workable actions, and assign those actions to manageable posts that can be occupied by a staff member.

That executive must also know how to assign proper statistics to each of the activities and set up a reporting system so that vital information is logged and routed to him on a regular basis. This allows him to monitor areas without micromanaging them, or having to do them himself. It also allows him to predict future needs of the office, and reverse a downturn in statistics before that downturn crashes the income.

If that executive also logs significant changes in the organization against graphed stats, such as key hires or new marketing activities, he then has a tool on which he can look back to evaluate the effectiveness of changes on stats.

  • Key #1 of how to build a staff driven office is that the owner is trained in executive skills.

The executive must be hatted on how to find potential staff members. It rarely happens that you will find a great staff member in an interview. It’s more likely that you will find a potentially great staff member in an interview.

By and large, great staff members are created, not found. This is more a comment on our current education system and the commonly excepted work ethic of this society, than on any one individual staff member. 

Most people are willing and need a lot of help. Some are very capable and can be great with some training and guidance. Few arrive ready to take on the world—because most in that condition run their own organization or have found their way into higher paying industries.

  • Key #2 is that the key staff members are trained in some or all of the executive skills, just as the owner. It is also critical that all staff are trained thoroughly on how to perform their job duties and on the general administrative workings of the office.

Staff pay should somewhat mirror the incentives of the owner. A business operating in a capitalistic system promises certain rewards to an owner, in exchange for value provided by that business to society. If the owner of a company provides value to others, in excess of the resources he expends providing that value, he earns a profit. This is a good incentive.

If staff members earn greater compensation, as the business provides greater benefit to the community in excess of its expenses, then the staff member will most likely work harder, smarter and more efficiently, to continue expanding the company—just like an owner. Not all staff will respond this way, but the ones you want, will.

  • Key #3 is to pay a low base and an incredible production bonus for staff.

In chiropractic practice, we have a worthy purpose and an effective method of achieving that purpose. A staff driven office has a leader who sets the direction of advance.  It can be the owner, or someone designated by that owner. 

  • Key #4 is to be the leader of your group. Everyone wants to go somewhere, and you either need to lead or get out of the way, by assigning a leader and letting them lead.

This is by no means a complete list of everything you need to build a staff driven office—but if you get these points in, you’ll be well on your way.

The Chiropractic Business Academy (CBA) trains chiropractors to build profitable staff driven offices. CBA does this by training the owner and staff, and providing ALL the administrative, marketing and sales tools needed to build profitable practices.

Our program is thorough, detailed and easy to implement. Best of all, its success to your bottom line is guaranteed in your service contract with CBA. Call my office to learn more.


            Call CBA for your FREE Practice Expansion Estimate. There is no cost (It’s FREE) and we will share with you exactly what we can do to help close the gap between you and your dreams!

CALL CBA NOW! 888-989-0855


Spinal Biomechanics: Lumbar Spine Ergonomics Part 1: The 5 Key Contemporary Concepts

Paul Oakley, MD, DC


     Ergonomics is not adequately taught to the chiropractic student.1 It is not until in practice that the chiropractor experiences frustration for particular cases of patients who just don’t get better! Oftentimes, it is these patients who are compromising their chiropractic care by unknowingly and inadvertently partaking in movements and physical tasks that are overstressing the spine and posture resulting in a continuation of nociceptive tendencies. This is why ergonomics is so important in daily practice.

     It is important to emphasize that ergonomics is not always easy or simply black and white in its application - “there is no magic answer.”2 That is, general biomechanical principles must be realized then applied appropriately to specific tasks accommodating any special needs of the patient. With this in mind it is good practice to get feedback from the patient when suggesting appropriate ergonomic recommendations so as not to overlook any critical factor, as most advice will be offered without performing a direct task analysis. In addition, this practice involves the patient in the solution process motivating their participation. Blind doctor recommendations for patient ergonomic issues is not optimal, therefore, educating the patient on general concepts so the solution can be cooperatively contrived between the doctor and patient is advised. Tough cases, however, may require ergonomic assessment by those with expertise.  

     The CBP® Doctor knows that the efficacy of common back treatments are poor.3 Even newer approaches involving evidence-based spine stabilization protocols (See McGill, 2002) admit to failure for so-called ‘failed’ backs. The reason for common LBP treatment failures are probably two fold. First, as eminently stated by McGill “those paying for injury could reasonably argue …that, to reduce costs, care for the injured back should be removed from medical hands and given to ergonomists.”4 No treatment will be effective if the contributing ergonomic factors are not eliminated or reduced. Second, only CBP traction procedures have been proven to restore the normal structure of the lumbar posture.5 In fact, only with a normal lumbar posture static posture will one have normal dynamic functioning, the simple concept of ‘Structure determines Function,’ a concept which has been established throughout the spine.6-8

  • Five Key Concepts to Lumbar Spine Ergonomics:
  1.  Maintain the Neutral Lumbar Lordosis
  2.  Appropriate Timing of Spinal Loads
  3. Optimal Spinal Loading: Not too much, not too little
  4. Reduce the Reaction Moment
  5. Maintain Spine Stability


         Part 1 of this series of articles will review the first two contemporary ergonomic concepts to aid the CBP doctor in helping their patients’ needs to eliminate ergonomic related obstacles for optimum structural rehabilitation of the lumbar spine.

  1. Maintain the Neutral Lumbar Curve

            Many have stressed the importance of maintaining the normal lordotic curve during the performance of tasks such as lifting and sitting. This is important due to the fact that “maintaining a more neutrally lordotic spine will maximize shear support, ensure a high tolerance of the joint to withstand compressive forces, eliminate the risk of ligamentous damage since the ligaments remain unstrained, (and) eliminate the risk of disc herniation since this is associated with a fully flexed spine.”4     

  1. Sitting:

            While seated a lumbar support should be used! Fortunately most seating now incorporates this aspect into its design. Since the low back is elliptical in configuration, it is of no surprise that lumbar support provided over the L4-5 area is preferred over higher locations.9 Caution should be taken to not position a support too low thereby translating the pelvis forward in the seat or too high which flattens the lumbar spine.10 The combination of tilting the seat backrest up to 120° in combination with a 5cm lumbar support has an optimal effect of reducing lumbar disc pressures.11 Arm rests also reduce up to 25% of low back loads12 by reducing disc pressures and myoelectric activity.13 A good computer chair should have at least four ‘degrees of freedom’ or adjustable features.14;15 See Figure 1.

 Figure 1: A good chair should have several adjustable features.



  1. Lifting:

            When lifting the common adage of ‘lift with your legs, not your back’ is a myth! This has been propagated since the 1930s16;17 and has not reduced the incidence in low back injuries.18 In fact, many have questioned the validity of such a thing as a single universal lifting technique.17;19;20 This is because above all else the goal to lifting should be to: 1) Reduce the reaction moment (ie. by carrying objects close to the body) which reduces the extensor forces and the resultant compressive low back loading; 2) Avoid a fully flexed posture (ie. maintain the neutral lordosis by bending at the hips) which minimizes low back shear loading.21 One method to maintain the lordosis while picking up light objects is to perform the golfer’s lift.  This involves bending the neutral torso over a single hip to reach down while balancing the body with the other leg out behind. It should now be apparent that by satisfying these two criteria that many postures may be successfully used to accomplish a safe lift.     

  1. Appropriate Timing of Spinal Loads

            When considering the order of activity performance, one must appreciate that the spine has a loading memory.21;22  That is, prior activity modulates subsequent spine function.  The spine may be at significant risk of a destabilizing injury after either cyclic or sustained loading.23 This is due to the viscoelastic tissues of the spine. For example, after cyclic loading (ie. repeated lifting), laxity in the soft tissues causes a reduced protective muscular reflexive activity due to mechanoreceptor desensitization.23 Thus, a lifting activity should not be performed immediately following prolonged sitting or stooping and repetitive tasks. Instead the patient should recover spine stability (achieve redistribution of the nuclear material and recover ligament stiffness)24;25 by simply standing (which is a good rest from sitting),26 or consciously extend the spine (easily achieved by reaching for the ceiling).4 Walking for five minutes could also be recommended prior to lifting24 especially if preceded by prolonged vibration.27     

            The spine has a diurnal variation that affects its biomechanics and ultimately its injury mechanics. In fact, intervertebral disc-bending stresses are 300% and ligament stresses are 80% greater after rising from bed in the morning than later in the afternoon.28 This is why it may be a dangerous practice to perform early morning full range flexions of the spine as would be required of lifting and stooped postures. Snook et al. (1998)29 have demonstrated that simply avoiding full flexion early in the morning is a successful strategy for recovering LBP patients. After 30 minutes of upright posture, 54% of the daily disc height loss is achieved which reduces the potential risk of early morning back flexions, after 3 hours one loses about 80% of the total daily height loss!30

            It is a wise recommendation to avoid full flexion postures soon after rising including those that may be a part of a daily exercise routine especially for those undergoing rehabilitation. This is one concept that is critically important. I have seen on many occasions where a patient starts to respond to care, then one day confesses frustration that they are not getting any better or regressing. Upon questioning them I invariable discover that they are so motivated to get well they never skip their intensive early morning stretches – of course, excessively flexing their backs first thing in the morning and therefore damaging their disks! Tell your patients to stretch later in the day, at least after lunchtime. Taking garbage out to the curb the night before garbage day is another good example of using this principle. 


See the next issue of the AJCC for the continuation of the 5 key contemporary ergonomic concepts.


References---See AJCC Online for detailed list of references accompanying this article


10.  Andersson GBJ, Murphy RW, Ortengren R, Nachemson AL. The influence of backrest inclination and lumbar support on lumbar lordosis. Spine 1979; 4(1):52-58.

11.  Chaffin DB, Andersson GBJ. Occupational biomechanics. 2 ed. John Wiley & Sons, New York, 1991

12.  Cailliet R. Neck and arm pain. 3 ed. F.A. Davis Company, Philadelphia, 1991

13.  Andersson GBJ, Ortengren R. Lumbar disc pressure and myoelectric back muscle activity during sitting. III. Studies on a wheel chair. Scand J Rehab Med 1974; 6:122-127.

14.  Scalet EA. VDT health and safety: Issues and solutions. Ergosyst Associates, Lawrence, Kansas, 1987

15.  Carter JB, Banister EW. Musculoskeletal problems in VDT work: A review. Ergonomics 1994; 37(10):1623-1648.

16.  U.S.Preventive Services Task Force. Screening for risk of low back injury. Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions. Williams & Wilkins, Baltimore, 1989, pp. 245-249.

17.  Parnianpour M, Bejjani FJ, Pavlidis L. Worker training: the fallacy of a single, correct lifting technique. Ergonomics 1987; 30(2):331-334.

18.  Brown JR. Lifting as an Industrial Hazard.  1972.  Labour Safety Council of Ontario, Ontario Department of Labour.

19.  Graveling RA, Simpson GC, Sims MT. Lift with your legs, not with your back: a realistic directive? Brown ID, Goldsmith R, Coombes K, et al., editors.  910-912. 1985. London, Taylor & Francis. Ninth Congress of the International Ergonomics Association.

20.  Chaffin DB, Park KS. A longitudinal study of low back pain as associated with occupational weight lifting factors. Am Ind Hygiene Assoc 1973; 34:513-525.

21.  McGill S. The biomechanics of low back injury: Implications on current practice in industry and the clinic. Journal of Biomechanics 1997; 30(5):465-475.

22.  McGill SM. Biomechanics of low back injury.  22-23. 1995.  XV International Society of Biomechanics. July 2-6, Finland.

23.  Solomonow M, Zhou BH, Baratta RV, Lu Y, Harris M. Biomechanics of increased exposure to lumbar injury caused by cyclic loading: Part I. Loss of reflexive muscular stabilization. Spine 1999; 24(23):2426-2434.

24.  McGill SM, Brown S. Creep response of the lumbar spine to prolonged full flexion. Clinical Biomechanics 1992; 7:43-46.

25.  Magnusson ML, Aleksiev AR, Spratt KF, Lakes RS, Pope MH. Hyperextension and spine height changes. Spine 1996; 21(22):2670-2675.

26.  Callaghan JP, McGill SM. Low back joint loading and kinematics during standing and unsupported sitting. Ergonomics 2001; 44(3):280-294.

27.  Pope MH, Magnusson M, Wilder DG. Low back pain and whole body vibration. In: Kumar S, ed. Biomechanics in ergonomics. Taylor & Francis, Philadelphia, PA, 1999, pp. 233-241.

28.  Adams MA, Dolan P, Hutton WC. Diurnal variations in the stresses on the lumbar spine. Spine 1987; 12(2):130-137.

29.  Snook SH, Webster BS, McGorry RW, Fogleman MT, McCann KB. The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. Spine 1998; 23:2601-2607.

30.  Reilly T, Tyrrell A, Troup JDG. Circadian variation in human stature. Chronobiology International 1984; 1(2):121-126.



The Link Aborted Fetuses Have to Autism

Thomas D. Pound, M.Ed.

Jennifer Brandon, DC


In Vermont, Seth Mnookin recently discussed his recent work, “The Panic Virus:  A True Story of Medicine,”7 a book that concludes that the fear of vaccines is based primarily on myths.  With several of their officers, past and present, in attendance, Vermont’s Department of Health sponsored the talk. Mnookin’s logic follows the standard party line of the pharmaceutical industry; scientists, such as Andrew Wakefield, who lack any level of ethos, create the fear with false claims and biased research.  Influential advocates and celebrities, including Jenny McCarthy, then exacerbate the fear.  Mnookin’s bottom line?  Vaccines are beneficial.

On this particular evening, Mnookin did allow for a question and answer session.  Anecdotally, it appeared that out of the approximately 50 in attendance, only two were anti-vaccine.  Dr. Erin Sepic, a well-versed chiropractor from Richmond, questioned Mnookin’s claims that thimerosal was no longer a continuing factor as a risk effect of vaccines.  As it relates to autism, Mnookin’s answer during the talk was consistent with his position in his book where he writes about the “relative harmlessness”7 of the compound. 

Mnookin was then asked about recent studies indicating that the use of cells from aborted fetuses in the development of vaccines maybe accelerating the rate of autism.  He answered that he had not heard of that theory.  What is shocking is Mnookin’s lack of knowledge about an issue that is potentially bigger than the thimerosal controversy, because it has already reached the EPA and The Vatican.  It is alarming, because this is an issue where warnings were issued decades ago, and it is believed here that this will be the explanation for the rise in the numbers of autistic children.


It is important to provide background.  Leonard Hayflick and his Wistar Institute developed a line of cells from an unborn fetus labeled WI-38.3  Additional fetal lines were also developed later4 for the purposes of developing vaccines for 31 separate viruses including those more familiar to the public such as measles, polio, varicella, rabies, herpes simples, and influenza.3  Currently vaccines for rubella, hepatitis A, and varicella were developed using the WI-38 fetal line.8  The MMR-II (introduced in 1989), the Varivax vaccine (introduced in 1995), and the VAQTA vaccine (introduced in 2002) all use the WI-38 fetal line for their respective virus propagation.11



It should not be surprising that those who are against abortion have already spoken out against these vaccines; even The Vatican issued a ruling on the matter.9 Previously, warnings about the use of fetal cells were theorized by no less an authority than Kevin McCarthy, the developer of the measles vaccine, when he stated one of two things he worried about “…in regard to WI-38 cell substrate,” and highlighting, “…the possibility of there being human genetic material passed over into the vaccine.2

It appears that Dr. McCarthy’s warnings should have been heeded.  Studies are now indicating that the years 19885 and 19951 are change point years, showing exact periods where the rate of autism accelerated.  If the theory holds, then 2002 should show itself as a change point year, since that was the first year for the introduction of the hepatitis A vaccines.  Ironically, Andrew Wakefield and his team predicted, “If there is a causal link between measles, mumps, and rubella vaccine and this syndrome (autism), a rising incidence might be anticipated after the introduction of this vaccine in the UK in 1988.”12



It is unfortunate that this latest work in support of vaccines has left this important issue out of the discussion.  The possibility of vaccines having a genetic causal link to the rise in autism spectrum disorders is more than “tenuous”.6 As long as this theory is not part of any discussion about the harms from vaccines; it puts more children at risk with each injection.  The Vatican has spoken out against the use of fetal cells, the EPA has now looked into the issue, and the scientific community is now studying the link.  If Mr. Mnookin is going to hire himself out to speak in support of these poisons, then he needs to look into this issue deeper.



10.  Stephenson, R. W. (1948). Chiropractic Textbook. Davenport, Iowa: The Palmer School of Chiropractic.

11.  United States Food and Drug Administration. (2010, October updated 20). Vaccines Licensed for Immunization and Distribution in the US with Supporting Documents. Retrieved from

12.  Wakefield, A. J., Murch, S. H., Anthony, A., Linnell, J., Casson, D. M., Malik, M., et al. (1998). Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The Lancet, 637-641.



CBP Chiropractors: We Must Practice What We Teach


Cindy Boyd, BS, DC

Private Practice of Chiropractic Alameda, CA

Faculty Life Chiropractic College West



Deed E. Harrison, DC

President CBP Seminars, Inc.

Vice President CBP Non-Profit, Inc.

Chair PCCRP Guidelines




In previous issues of the AJCC, we have presented a number of articles on the indications and contra-indications of the cervical denneroll orthotic device as a method for restoration of an abnormal cervical lordosis. Also, several patient case studies have been presented describing the successful ability of the cervical denneroll orthotic device in restoring the cervical lordosis and improving patient health disorders as a consequence. In the current case, we report on the improvement in the cervical spine with a large disc herniation and complex injury-buckling of the cervical segments including retro-listhesis, hyper-extension, and flexion at different cervical spine joints. This report represents the actual conditions of one of the authors (CB) and these are her results.

Key Case Features

A 34 year old female presented with chronic neck pain, decreased range of motion, headaches with extension of the head and neck and a recent onset of heart palpitations of unknown etiology. The symptoms were reportedly getting worse over the past few months, and causing the patient to refrain from practicing in her chiropractic clinic providing one on one patient care. After administering 1-2 adjustments on any given day, the symptoms were exacerbated causing disability and significant discomfort.

The patient had a past history of two head and neck injuries. The first direct impact injury was sustained during a bicycle accident that occurred in the spring of 2008. The patient was riding a bicycle at a high speed and traversed over old railroad tracks at an awkward angle causing an immediate crash. Her head hit the pavement with significant force, and unfortunately she was not wearing a helmet. Fractures were ruled out and no lacerations were present. A mild concussion was sustained. Bruising and swelling was present in the right zygomatic region at the site of direct impact. 

Two years later, a double direct impact injury occurred during a snowboarding accident where the patient fell on an ice patch directly landing on the sacrum and a second impact occurred during the same fall when she fell backwards and hit her skull on the ice patch with significant force. This time the patient was wearing a helmet.  

  • ·      Health Status, Pain, and Disability Questionnaires

The short form (Sf)-36 health status questionnaire, numerical rating scale for pain intensity and the neck disability questionnaires were administered. The patient had considerable pain, disability, and depressed health. See Figure 1 for the initial NDI and SF-36 abnormalities.

Figure 1. Patient initial neck disability and SF-36 scores indicating considerable pain, disability, and abnormal health status.

  • Radiographic Evaluation

Lateral Cervical Radiograph:

On 8/24/11 a digital lateral cervical was obtained. See Figure 2. The radiographic analysis was done using the Posture RayÒ computerized radiographic mensuration system. The patient’s radiographic displacement values are shown in Figure 2B and are compared against normal. Several cervical spine subluxation-displacements are present including: an abnormal kyphosis from C4-C7, a C3-C4 segmental retro-listhesis, and a considerable hyper-extension of C2-C3 were identified. The radiographic and clinical findings indicated a possibility of herniation one or more cervical discs and instability in multiple levels of the cervical spine.  Thus, an MRI was obtained, and the findings confirmed a central/sub-ligamentous disc herniation at C2/C3 and C5/C6 with concomitant instability.

Figure 2. Initial lateral cervical radiograph and abnormal findings of alignment compared to ideal values. The PostureRay™ system was used.












Lateral Thoracic Radiograph:

            On 8/24/11 a lateral thoracic radiograph was also obtained. Figure 3 depicts the patient's lateral thoracic radiograph. Relative to the CBP ideal thoracic elliptical model, the patient's upper and mid-thoracic segments are in a relative subluxated extension position. This is consistent with an extension abnormal postural position of the thorax relative to the pelvis or lumbar spine.

Figure 3. Lateral thoracic radiograph. The green elliptical line is the Harrison ideal thoracic model representing the proper path of the posterior vertebral bodies of the thoracic spine. Note that the patient has extension-backwards bending of the upper-mid thoracic spine relative to the lower thoracic spine.

Denneroll Stress Radiography:

These values and findings indicate the patient’s candidacy for the Denneroll Cervical Orthotic. Based on MRI findings and significant abnormal segmental cervical translation measurements, Denneroll stress X-rays were taken using the large cervical Denneroll. Figure 4 depicts the lateral stress x-ray. Based on the initial radiographs, it was determined additional upper thoracic flexion and translation was needed in this setup to make a considerable correction in the injured and postural distorted regions. Thus, a 10 millimeter foam block was used under the denneroll device to increase the height of the orthotic in order to induce additional upper thoracic flexion and translation during the stress study.  The peak of the denneroll was placed in the lower cervical spine. Particular attention was given to the hyperextended upper cervical segments, and another block measuring 10 millimeters in height was placed under base of the skull during the stress analysis. Further, to limit the amount of skull extension and upper cervical extension, the patient was asked to actively flex-tuck her chin (although painful) at the time the radiograph was taken. Figure 2 shows the upper cervical spine extension on the initial patient x-ray. 

The stress analysis study showed considerable correction in the cervical abnormal values including the segmental translations and relative rotation angles that were present on the neutral lateral cervical study.

Figure 4. Denneroll stress lateral thoracic radiograph to ensure proper location of the denneroll peak and if the denneroll is effectively improving the cervical alignment.

  • Denneroll Cervical Orthotic Intervention

Based on the outcomes of the stress radiographic analysis, the patient agreed to participate in a study to determine the outcome of cervical curve correction using the Denneroll home traction device.  No other forms of treatment were administered. Spinal manipulation, CBPÒ drop table adjustments, Mirror ImageÒ exercises and in office traction types, were all avoided during this particular patient treatment phase with the Denneroll. 

The large cervical Denneroll was used at a frequency of 1-2 times daily, 4-6 days a week for a 30 day period. Each home session involved the patient lying supine on the large cervical Denneroll with a 10 millimeter block under the device. Refer to Figure 4 for the denneroll setup. In addition, a 10 millimeter block was placed under the skull to limit the amount of upper cervical extension.  The patient was also instructed to actively flex the chin while on the device. The amount of upper cervical hyperextension and thoracic extension measured on the lateral cervical and thoracic radiographs warranted the degree of specificity in this setup. Between the dates of 8/24/11-9/22/11 approximately 36 home Denneroll sessions were performed at a duration of 10-18 minutes each.

A follow up lateral cervical x-ray was taken on 9/22/11 to determine if the intervention had made any significant changes.

  • Case Outcome

      Subjectively, at the end of the 1-month treatment phase, the patient was asymptomatic including the disappearance of the heart palpitations, headaches and pain.  There were significant improvements in the SF-36 and neck disability outcomes. The follow up lateral cervical radiograph exam showed significant improvements in all cervical regions that were abnormal initial. Figure 5 and Table 1 describe these results.

Figure 5. One-month follow-up lateral cervical. Note that this x-ray was taken a minimum of one day with no treatment interventions. There are considerable improvements in all radiographic abnormalities.


(-) values = extension

(+) = flexion

Segmental Translation

(-) values = posterior

Translation C2-C7



-1.6 mm







-0.8 mm








            This case report represents the actual conditions of one of the current study authors (C.B.). The uniqueness of this case lies in the severity of the cervical spinal displacements and the concomitant improvements in structural and functional abnormalities using the cervical Denneroll as the exclusive treatment intervention. While the patient's follow-up radiograph is still not considered to be within normal limits and further care is warranted, the improvements over the course of one-month are promising. The patient (C.B.) has committed to continuing her Denneroll intervention program to continue rehabilitating her cervical spine. Afterall, as a CBP Chiropractor, we must practice for ourselves what we teach our patients to do.


CBP® NonProfit, Inc. Research Update

Paul A. Oakley, M.Sc., DC

CBP Research & Instructor

Private Practice New Market, Ontario, Canada



CBP Non-profit Supports Research Into the Effects of Adjustments on the Sympathetic Nervous System


CBP Non-profit, Inc. has joined the Australian Spinal Research Foundation and the William M. Harris Family Foundation to support a research study to investigate the effects of chiropractic adjustments on the sympathetic nervous system. The study’s Principal Investigator, Christopher J. Colloca, D.C. formulated the research design to study the effects of cervical spine adjustments in an animal model of cervical disc degeneration while measuring needle electromyographic (nEMG), spinal nerve root, and neural responses from the sympathetic chain. The study began in December 2010, and data collection was recently completed in December 2011. Results will be forthcoming in scientific conference presentations and journal publications.

Dr. Colloca and his team have a proven track record of publications into the biomechanical and neurophysiological effects of adjustments and dynamic spinal stiffness assessment using the validated intervertebral disc model in sheep at the Adelaide Centre for Spinal Research in Australia.  This study adds to the line of investigation underway at this laboratory in conjunction with pathologist, Robert J. Moore, Ph.D., and Belgian spine surgeon, Robert Gunzburg, M.D., Ph.D. Dr. Gunzburg serves as the Assistant Editor in Chief of the European Spine Journal, and has been collaborating on research projects with Dr. Colloca for fourteen years.

Research into the benefits of chiropractic adjustments have traditionally focused upon the area of the musculoskeletal system where findings have substantiated chiropractic care in the management of many conditions including low back pain, neck pain, and headache. This international research collaboration (Australia, Belgium, USA) brings together investigators from the professions of chiropractic, orthopaedic medicine, and anatomy and pathology to study how chiropractic adjustments can influence nerves in the body that control physiologic processes, including organ function, blood pressure and heart rate among others. 

Using a validated animal model approved by a governmental ethics committee, measurements of nerve activity will be conducted during chiropractic adjustments delivered with a hand-held mechanical adjusting tool. In this manner, the study can determine the effect of chiropractic thrusts on nerve function to better understand the mechanisms responsible for the improvements that many patients experience with chiropractic care. This research will not only build on the body of scientific knowledge in this area, but will be one of the few studies using a “lesion” model to investigate the neurophysiologic effects as opposed to studying normal populations. 

The $20,000 annual grant provided by CBP Non-profit matched a two-year $20,000 grant by ASRF and the $25,000 matching grant that William M. Harris Family Foundation has provided to the International Spine Research (INSPIRE) Foundation where Colloca is a Director.  Membership in CBP Non-profit, Inc. can be obtained online by visiting and browsing through to the Research section of the product store. Members receive voting privileges at CBP Non-profit meetings and a Research DVD containing all of the CBP supported research publications.



Joseph Ferrantelli, DC

Private Practice New Port Richey, FL

CTO & Instructor CBP® Seminars

CEO PostureCo.



In many Chiropractic Techniques as in Chiropractic BioPhysics, standard of care requires the clinician to “hand draw” on x-rays and to measure spinal subluxations using a protractor or templates such as the CBP® OXI and Elliptical Normal Templates. Even when doctors upgrade to digital x-ray solutions, they are left with very limited analysis tools built in to their PACs, which unfortunately take considerable time to utilize - leaving less time for patient care.

As you know, X-ray line drawing is not only a tedious task, but also is very time consuming – thus why many in our profession fail to identify crucial spinal subluxations. For most doctors, they must analyze films themselves, which places a burden on the doctor, taking time away from adjusting patients. This leaves most to resort to simply using only the briefest of lines (like only using the CBP® normal templates for patient education). How do I know? Quite simply, because not only do most of you tell me this at seminars, but I too did this early in my career!

Sometimes, the doctor will fall victim of “believing” that they are good enough to treat patients without a thorough segmental and global analysis. However, if you have treated patients long enough, you soon realize, that many of the patients who failed to “respond” to care may have been because you, as a clinician, failed to recognize the significant yet subtle segmental vertebral hyper-extension or hyper-flexion buckling (2nd and 3rd harmonics) of the sagittal curves on lateral views. If you didn’t identify the displacement, how likely would you be to correct it?


PostureRay® to the Rescue!

PostureRay® was developed by PostureCo, Inc. for Chiropractic Techniques that use x-ray analysis and is today’s premiere X-ray Mensuration EMR Solution. This system allows you to quickly analyze your plain or digital films using lines of mensuration quickly, easily, and painlessly! No longer will you have to stay after hours or come in on the weekends to analyze your films. With PostureRay®, you simply have your office staff obtain digital pictures of your films (using an ordinary digital camera), obtain DICOM x-ray files from your digital x-ray system, or even obtain from an outside radiological facility on CDs. Regardless of how you obtain the x-ray digital images, they can be quickly analyzed and documented by the PostureRay® EMR system (see Figure 1). 

Provide your patients the evidence

Often chiropractors are reluctant on giving care plans or explanations as to why it will take time to alleviate symptoms, correct the underlying problem, and maintain wellness. As you decide about giving patients care recommendations, remind yourself as well as them that when conditions are diagnosed, traditionally there have been validated courses of care for that condition. The same is true with spinal subluxations and now you can provide them evidence as to what the scientific research demonstrates in cases such as theirs. This allows them to make a more informed decision about engaging in your/their care. The fact of the matter is patients need to understand WHY they need corrective care. We need to provide them with legitimacy about their condition along with information on how we can help them. The PostureRay® Report of Findings document is your tool to pass this crucial information on to them. This report synthesizes the information in a simple to understand X-ray ROF personalized for the patients (see Figure 2) and is a take home piece that everyone can understand. This provides them with the information they need to initiate and continue their care based upon your initial recommendations.





Figure 2. In the above examples, excerpts from PostureRay® ROF are shown. In the PostureRay® ROF, the patient’s spine vs. normal are displayed, along with text descriptions which are completely customizable by the doctor.  Tools such as PostureRay® allow a chiropractic clinic to “stand out of the crowd” as unique in their city or town, all through better patient education.


The Best Marketing - Stimulate Internal Patient Referrals

By using PostureRay®, your office will benefit from not only a clinical standpoint - but a practice management standpoint as well. Your patients will get a detailed ROF on their x-ray findings, to go along with their PostureScreen Mobile or PosturePrint® findings. Using these to custom patient reports, your patient will be able to go home and show their family and friends their structural problem(s) in a clear and concise manner.

So what can PostureRay do that the “other” systems cannot?

  1. Compares your patient’s spine to normal from digital x-ray images of AP and lateral cervical, thoracic, and lumbar films, AP nasiums, AP or PA Ferguson sacral base views (obtaining true anatomical leg length inequality), lateral fullspine and flexion/extension stress views.
  2. PostureRay® allows a patient’s x-rays to be available in a simple and easy to use patient database and Digital ViewBox screen with all pertinent results – all with telestrator functionality!
  3. PostureRay® compares their subluxations at each level to normal and the percentage loss or gain from normal calculated automatically measuring all segmental relative rotational angles and the global absolute rotational angles in degrees along with all translational distances in millimeters.
  4. PostureRay® superimposes The Harrison Ideal Elliptical curves (using any color) and highlights George’s line (patient’s spinal position) on their digital x-rays. In addition, you can export these images to 3rd party practice management software. Furthermore, this is the ONLY system which can legally and correctly apply and overlay the copyrighted Harrison Spinal Model on digital images.
  5. PostureRay® compares patients pre-post care films with percentage improvement at each level of their spine, or conversely their worsening if they had a traumatic event such as a motor vehicle crash.
  6. PostureRay® objectively measures spinal instability crucial for calculating impairment ratings.



So with that being said, the question soon becomes, “How long can your practice survive without PostureRay®?” If you would like to learn on how the PostureRay radiographic analysis EMR solution can benefit your practice, please call 866.577.7297, email or visit


Knee Pain and Foot Orthotics

Stuart Currie DC,

Director of Research, Sole Supports.  



            There is an intuitive link in the kinetic chain between the foot and the knee, resulting in the common clinical practice of prescribing custom-made foot orthotics for patients with various types of knee pain.

Subjective knee pain is one thing that may prompt a clinician to think about foot orthotics in their treatment plan. There is an assumed relationship between feet and knees and a comprehensive knee evaluation considers both proximal and distal structures. What is relevant to the clinician is a determination of the root cause of the knee pain and whether foot pathology may be involved. While there are no hard and fast rules or substitute for a thorough history and physical exam, there are a few clues that can help determine the origin. 


A Few Clinical Clues

The first case is asymmetric knee pain with asymmetric pronation. When the knee pain is on the same side as the pronated foot, there is reason to look at the ipsi-lateral foot as the cause. Figure 1 illustrates pronation of the right foot, subsequent internal rotation of the tibia and femur with the consequent alteration in knee orientation and function. Pronation can and should be evaluated both statically and dynamically. Tests such as the navicular drop test, and walking or treadmill gait analysis can help determine if knee pain is a result of altered foot posture. When evaluating the effects pronation has on the knee, be sure to observe the patella and its orientation relative to pronation that may or may not be happening concomitantly.

Bilateral knee pain with a bilateral valgus knee posture that is alleviated by active or assisted supination of the foot can also be an indicator that knee pain is related to foot posture. While often not a long term solution, taping the arch or a prefabricated insert is an inexpensive way to determine if changing foot function might have positive effects on knee pain.


Once an initial assessment has been made and a determination that a corrected foot posture is required to address the root cause of the knee pain, a custom orthotic can be a valuable tool. The effects of orthotics on the knee have been demonstrated with a kinematic and kinetic investigation revealing that molded orthotics reduced vertical loading rate and ankle inversion moment and increased maximum foot inversion and maximum knee external rotation moment (1).


Knee Pain and Foot Orthoses

Knee pain can be complex and the different causes of knee pain must be considered separately when considering an orthotic device. The response of knee pain to orthotic devices has been described as “individualistic” and “nonsystemic” (2) implying that care must be used in both patient and treatment selection.

With regards to knee osteoarthritis, there is some debate in the literature regarding the effectiveness of various devices. Traditionally, a laterally wedged insert has been used – theoretically offloading the medial compartment of the knee. A review of the literature on lateral wedges reveals positive, negative and equivocal results. With regards to a custom orthotic with full contact medial support, there is a theoretical basis for utilization. It has been shown that the plantar center of pressure (of the foot) in patients with medial knee OA has shown a high lateral loading component (3). In other words, people with symptomatic medial knee OA load the lateral aspect of their foot to a greater degree. Considering this information with investigations that have shown a medial shift of plantar pressure with a full contact, MASS position custom orthotic (4), there is a basis for controlling aberrant foot loading resulting in more optimal knee function in this patient population.

When comparing flat versus contoured foot orthoses, it has been shown that patients perceive more support through the heel and arch regions with a contoured support (2). In addition, subjects in the patellofemoral pain group reported a clinically significant reduction in knee pain as a result of wearing foot orthoses (2). Another study showed that custom made orthoses were an effective treatment to reduce the symptoms of patellofemoral pain (5)

The reasons for the improvements seen with a custom foot orthotic are more difficult to ascertain. Foot postural factors are thought to play a role. Kinetics and kinematics of the foot and lower limb (such as tibial internal rotation) may be involved. “Emerging evidence suggests that orthotics, specific shoe types and footwear interventions may provide an effective nonsurgical intervention in rheumatic diseases. Yet good data are sparse, and it is premature to recommend guidelines” (6). 

The concept that foot mobility plays a role in the etiology of knee pain and the success of any treatment outcome has long been assumed. A recent study showed that foot mobility is related to knee pain outcomes; with results indicating that orthotics provide greater improvements in anterior knee pain than a wait-and-see approach and that individuals with greater mid-foot mobility are more likely to experience success from treatment (7). This underlines the importance of the evaluation of foot flexibility and mobility in the physical exam for prediction of treatment outcomes.



In summary, while there is a need for further investigation into the mechanisms of knee pain as it relates to foot posture, there is evidence for the utilization of foot orthotics as one part of a comprehensive treatment plan. 



1) Mundermann, A., (2003) Clin. Biomech. (Bristol., Avon.) 18, 254-262.

2) McPoil, T. G., (2011) J. Am. Podiatr. Med. Assoc. 101, 7-16.

3) Lidtke, R. H., (2010) J.Am. Podiatr. Med. Assoc. 100, 178-184..

4) Hodgon, B., (2006) Journal of Sport and Rehabilitation 15, 33-44.

5) Munuera, P. V., (2011) Prosthet. Orthot. Int. 35, 342-349.

6) Riskowski, J., (2011) Curr. Opin. Rheumatol. 23, 148-155.

7) Mills, K.,(2010).Br.J.Sports Med. 44, 1035-1046.


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