0008-3194/2012/49–57/$2.

00/©JCCA 2012

Clinical effectiveness of the activator adjusting

instrument in the management of musculoskeletal
disorders: a systematic review of the literature
Tiffany Huggins, BA(Hons), BEd, DC
Ana Luburic Boras, BA, DC
Brian J. Gleberzon, DC, MHSc*
Mara Popescu, BA, DC
Lianna A. Bahry, BKin, DC

Objective: The purpose of this study was to conduct a But : La présente étude a pour objet d’effectuer un
systematic review of the literature investigating clinical recensement systématique des écrits portant sur les
outcomes involving the use of the Activator Adjusting résultats cliniques suivant l’utilisation de l’instrument
Instrument (AAI) or Activator Methods Chiropractic d’ajustement activateur (Activator Adjusting Instrument
Technique (AMCT). ou AAI) ou de la technique chiropratique des méthodes
Methods: A literature synthesis was performed on the de l’activateur (Activator Methods Chiropractic
available research and electronic databases, along with Technique ou AMCT).
hand-searching of journals and reference tracking for Méthodologie : Une synthèse des écrits a été effectuée
any studies that investigated the AAI in terms of clinical à partir des bases de données de recherches et celles sur
effectiveness. Studies that met the inclusion criteria support informatique disponibles, ainsi qu’en cherchant
were evaluated using an instrument that assessed their manuellement dans des revues et en effectuant un suivi
methodological quality. des références trouvées dans les études portant sur
Results: Eight articles met the inclusion criteria. l’efficacité clinique de l’AAI. Les études qui répondent
Overall, the AAI provided comparable clinically au critère d’inclusion ont été évaluées au moyen d’un
meaningful benefits to patients when compared to high- instrument calculant leur qualité méthodologique.
velocity, low-amplitude (HVLA) manual manipulation or Résultats : Huit articles ont répondu au critère
trigger point therapy for patients with acute and chronic d’inclusion. En général, les bienfaits cliniquement
spinal pain, temporomandibular joint (TMJ) dysfunction significatifs de l’AAI sont comparables à ceux de la
and trigger points of the trapezius muscles. manipulation à haute vitesse et faible amplitude ou de
Conclusion: This systematic review of 8 clinical trials la thérapie par zone gâchette pour les patients souffrant
involving the use of the AAI found reported benefits de douleur aiguë ou chronique à la colonne vertébrale,
to patients with a spinal pain and trigger points, de dysfonction de l’articulation temporomandibulaire
although the clinical trials reviewed suffered from many (ATM) et de zone gâchettes du trapèze.
methodological limitations, including small sample size, Conclusion : Selon la présente revue systématique de
huit essais cliniques portant sur l’utilisation de l’AAI,
on rapporte des bienfaits pour les patients souffrant de
douleur à la colonne vertébrale et de zones gâchettes,
quoique les essais cliniques étudiés étaient soumis à de
nombreuses limites sur le plan méthodologique, comme
un échantillon de petite taille, des périodes de suivi

* Professor, Chair of Department of Chiropractic Therapeutics, CMCC, 6100 Leslie St. Toronto, Ontario, M2H 3J1.
E-mail: bgleberzon@cmcc.ca
© JCCA 2012

J Can Chiropr Assoc 2012; 56(1) 49

Clinical effectiveness of the activator adjusting instrument in the management of musculoskeletal disorders

relatively brief follow-up period and lack of control or relativement brèves, et d’un manque de groupes témoins
sham treatment groups. ou placebo.
(JCCA 2012; 56(1):49–57) (JCCA 2012; 56(1):49–57)

m o t s c l é s : Technique chiropratique des méthodes

de l’activateur (Activator Methods chiropractic
k e y w o r d s : Activator Methods chiropractic technique), instrument/dispositif d’ajustement à
technique, mechanically assisted adjusting instrument/ assistance mécanique, manipulation aidée par un
device, instrument assisted manipulation instrument

Introduction reported that the widest base of evidential support existed

With the notable exception of the manual Diversified tech- for side posture HVLA manipulations and a panel of ex-
nique, which involves high velocity and low amplitude perts ascribed a value of 9.3/10 with respect to clinical ef-
(HVLA) thrusting spinal manipulative therapy (SMT) fectiveness for acute low back pain and 8.1/10 for chronic
(also commonly referred to as spinal adjustments), the low back; by contrast, instrumented-adjusting was only
therapeutic intervention most commonly used for patient allocated a score of 3.7/10 for acute low back pain and
care by chiropractors is instrumented-adjusting using the 1.6/10 for chronic low back pain.9 This led Cooperstein
Activator Adjusting Instrument (AAI). According to the et al. to assert: “These considerations suggest that those
2005 National Board of Chiropractic Examiner’s (NBCE) researchers attempting to validate the appropriateness of
Job Analysis1 51.2% of American chiropractors report their favored methods had best focus more on the type of
using the AAI for patient care, although this data does research they do- more on outcomes and less on periph-
not differentiate between those practitioners who use the eral matters such as modeling and the reliability of diag-
AAI only (often as a substitute for HVLA manipulation) nostic procedures.”8p410
from those practitioners who use the Activator Methods A review of the literature conducted in 2001 found that
Chiropractic Technique (AMCT), a technique system that the number of retrievable articles from the peer-reviewed
involves a group of specialized diagnostic procedures literature on AMCT (n = 21) was second only to the num-
during prone leg length checking.2 [The 2005 NBCE Job ber of retrievable articles on Upper Cervical techniques
Analysis is the most recent source of information on the (n = 28).10 [It should be noted that the developers of
rates of use of different technique systems by chiropractor Chiropractic BioPhysics/Clinical Biomechanics of Pos-
since the NBCE’s Practice Analysis of Chiropractic 2010 ture have also been very prolific with respect to publish-
did not capture this data]. The 1993 NBCE Job Analysis3 ing in the peer-reviewed literature, but many of those
reported roughly 40% of Canadian chiropractors use an studies principally focused on mathematical modeling of
AAI, although more recent estimates range from 31.4%4 the spine.11,12].
to 22%.5 A survey of British chiropractors reported 82% Since that time, investigations of AAI and AMCT have
of respondents indicated they use an AAI, although only continued at an impressive rate. That being said, many
2% of them stated they used it as their primary treatment of these published articles have investigated the mechan-
method6 and the NBCE 19947 reported that 72.7% and ical properties of the AAI, the reliability and validity of
54.3% of Australian and New Zealand chiropractors, re- prone leg length checking and the reliability and validity
spectively, used an AAI. of diagnostic tests unique to AMCT (isolation, stress and
In 2001, Cooperstein et al.8 and Gatterman et al.9 pressure tests). Despite Cooperstein et al’s admonishment
published companion articles that sought to character- a decade earlier, relatively few studies have investigated
ize the literature with respect to chiropractic technique the clinical effectiveness of the AAI. For example, the
procedures for various low back conditions and rate the 2001 review of the literature cited above10 found only 6
effectiveness of specific chiropractic procedures for low case studies, 2 case series and 2 clinical trials involving
back conditions, respectively. These systematic reviews AAI or AMCT. A textbook chapter devoted to describ-

50 J Can Chiropr Assoc 2012; 56(1)

 T Huggins, AL Boras, BJ Gleberzon, M Popescu, LA Bahry

ing AMCT published in 200413 found only one additional case series; studies using some type of outcome measure
clinical trial published between 2001 and 2004. More- for determining the effect of chiropractic care [i.e. Vis-
over a DVD14 listing all published studies on the AAI or ual Analogue Scale (VAS), Numerical Pain Rating Scale
AMCT [distributed by Activator Methods Inc to attendees (NPRS), Neck Disability Index (NDI), Oswestry Dis-
of the 2011 Association of Chiropractic Colleges and Re- ability Index (ODI), McGill Pain Questionnaire, range
search Agenda Conference (ACC-RAC)] had only one in- of motion, algometer/goniometer devices]; published in
complete additional clinical trial, indicating a continued peer-reviewed journal and; only studies involving human
under-representation of studies of this nature. Even so, subjects.
notwithstanding the relative paucity of clinical investiga- Subject age, sex, demographic, and pain type and
tions, advocates of the AAI and AMCT continue to extol duration were not consistent among studies and were
its clinical value and usefulness.13,14 therefore not utilized as inclusion criteria in this review.
The purpose of this study was to conduct a systematic Manuscripts from conference proceedings or abstracts of
review of the literature investigating clinical outcomes in- studies were not included in this review since the criteria
volving the use of the AAI or AMCT. A brief narrative for inclusion in a conference proceeding is often much
review of each article that met the inclusion criteria is also less stringent than the criteria used for inclusion in peer-
provided. reviewed indexed journals. Using these inclusion criteria,
eight articles qualified for review.
Methods
This study was approved by the Ethics Review Board of Instrument Used to Review Eligible Articles
the Canadian Memorial Chiropractic College. The articles selected for review were evaluated using an
The following electronic databases were searched instrument developed by Sackett (see Table 1).15
from their earliest date of publication to April 2010: ICL, Four authors (TH, ALB, MP, LB) independently re-
MANTIS, and AMED. CINHAHL and MEDLINE were viewed the studies meeting the inclusion criteria. The
searched through EBSCO publishing. The following data from all included articles were recorded onto a data
key terms were used: “Activator Adjusting,” “Activator extraction sheet by the authors as part of the review. The
Technique,” “Neck pain,” Low back pain,” “Mechan- authors checked and edited all entries for accuracy and
ical manipulation,” “Mechanically assisted device” and consistency. Recorded data included study authors and
“Instrument assisted manipulation.”) The initial search quality score, details of the study design, sample, inter-
strategy was then further refined by using the following ventions, outcome measures, and main results/conclu-
MeSH terms: chiropractic*, therapy*, joint dysfunc- sions of the study. These four authors met on April 5th,
tion* and cervical vertebrae*. References were also used 2010 to compare their graded scores. Any discrepancies
from citations found in papers that were included after of scores between the authors were settled via discussion
reviewing the inclusion and exclusion criteria for each. until consensus was reached.
Citations from specific articles (reference tracking) were
then researched independently through selected databases Results
followed by hand searching throughout the periodicals. The initial search strategy yielded 283 hits when using
the search terms “Instrument and Manipulation.” Many
Inclusion/exclusion criteria articles found that discussed instrumentation other than
Several inclusion/exclusion criteria were used to select an AAI or discussed unrelated topics such as historical
studies eligible for this review. Inclusion criteria were as development of the Activator, diagnostic testing used by
follows: studies must involve more than one subject; treat- AMCT practitioners or other non-clinical issues. Once
ments must have been administered by a qualified chiro- refined to “Mechanically Assisted Manipulation” 51
practor; papers were written in English; were published articles were found. Of these 51 articles, only eight met
between January 1980 and March 2010; prospective or our inclusion criteria.16–23 After methodological quality
retrospective studies including RCTs, controlled clin- assessment of each article using the grading instrument,
ical/quasi-experimental trials, cohort, case control and papers were allocated scores out of a possible 50 points

J Can Chiropr Assoc 2012; 56(1) 51

Clinical effectiveness of the activator adjusting instrument in the management of musculoskeletal disorders

Table 1 Instrument Categories Used to Grade Articles for this Review

Grading Criteria:
Assignment of patients (/9)
No mention of randomization-score 0; case study fully described-score 2; retrospective study fully described-score
4; prospective study fully described-score 5; non-randomized clinical trial-score 6; randomized clinical trial-score 7;
non-randomized controlled trial with inadequate randomization-score 8; randomized controlled trial with adequate
randomization described-score 9.
Baseline values of groups (/8)
No mention of baseline values-score 0; baseline values mentioned but not statistically significant-score 4; baseline
values mentioned and not statistically significant-score 8.
Relevance of outcomes and clinical significance (/7)
No mention of outcomes and clinical significance-score 0; subjective outcome measures-score 3; objective outcome
measures-score 5; both subjective and objective outcome measures-score 7.
Prognostic stratification (comorbidity and risk factors) (/6)
No clear mention of study inclusion or exclusion criteria-score 0; inadequate mention of inclusion or exclusion criter-
ia-score 3; complete mention and description of inclusion and exclusion criteria-score 6.
Blinding strategies (/5)
No blinding strategies mentioned-score 0; single blinded study without method described and appropriate-score 2;
single blinded study with method described and appropriate-score 3; double blinded study without method described
and appropriate-score 4; double blinded study with method described and appropriate-score 5.
Contamination/co-intervention (/4)
No mention of ways to control for contamination or co-intervention-score 0; some patients received some sort of con-
tamination or co-intervention-score 2; assumed that no contamination or co-intervention took place due to immediate
follow-up-score 3; contamination and co-intervention closely monitored and accounted for-score 4.
Compliance of subjects to study procedures (/4)
No mention or detail given to compliance of study subjects-score 0; compliance and co-intervention of patients mon-
itored but not closely monitored-score 1; some patients were compliant and did not receive co-interventions and was
closely monitored and detailed-score 2; compliance of subjects was assumed due to immediate follow-up-score 3; all
patients were compliant and closely monitored and detailed-score 4.
Drop-out rates of subjects (/3)
No mention of drop-out rates-score 0; drop-out rates mentioned-score 1; no drop-out rates assumed due to immediate
follow-up-score 2; number and reason for drop-outs described- score 3.
Follow-up levels (/2)
No mention of subject follow-up-score 0; immediate follow-up mentioned/performed-score 1; adequate follow-up
mentioned/performed-score 2.
Publication date of research (/2)
Published prior to 1990-score 0; published after 1990 and before 2000-score 1; published after 2000-score 2.
Total Score: /50

52 J Can Chiropr Assoc 2012; 56(1)

 T Huggins, AL Boras, BJ Gleberzon, M Popescu, LA Bahry

(Table 2). Articles are listed in descending order of their adjusting demonstrates a better safety profile compared
score using the Sackett criteria; in the event two or more to manual manipulation with respect to serious adverse
articles had the same score, they were arranged alphabet- events (i.e stroke) in patients with identified or unidenti-
ically (Table 3). fied vascular risk factors, since manual manipulation has
not been conclusively linked to the incidence of stroke at
Discussion all.34
When assessed in terms of clinical effectiveness, AAI and From the perspective of the practitioner, instrumented
manual manipulation were both found to result in equally adjusting can be used in cases of doctor injuries (disabil-
statistically significant patient outcomes, although the dif- ities of the hand, wrist, elbow or shoulder, for example)
ferences between the use of these two treatment interven- and it can used to compensate for anthropomorphic dif-
tions was not statistically significant. Studies investigating ferences between a small doctor and a large patient.2,30
the use of AAI only reported that it conveyed clinically Lastly, AAI conveys benefits to the research community
meaningful benefits to patients. since it can be used as a “sham” procedure by setting it
to “0” since even set to “0” the AAI will still produce an
Instrumented-Adjusting in Chiropractic audible sound.2
Instrumented adjusting has grown in popularity since the Currently, instrumented-adjusting is permitted for use
time Solon Langworthy first developed a table mount- by chiropractors in all Canadian, American, British and
ed percussive device in the early 19th century.24 Along Australian jurisdictions,5 although that has not always been
with the AAI other chiropractic technique systems have the case. As recently as 2004, Saskatchewan prohibited its
developed adjusting instruments. There are a number of members from instrumented adjusting. The reasonable-
instrumented Upper Cervical techniques that involve cer- ness of this standard of practice was raised in an article by
vical adjusting devices that are handheld, floor-mounted one the authors of this review (BG) in an article published
or table-mounted.25 Other notable examples include the in 2002;30 this spawned a heated exchange of letters to
Integrator associated with Torque Release Technique26 the editor.35–37 Contemporaneously, the Chiropractic As-
and a floor mounted device used by CBP practitioners.27 sociation of Saskatchewan (CAS) struck a Committee to
An internet search for “instrumented-adjusting devices evaluate the literature on the efficacy, safety, usage and
in chiropractor” found a device called an “Impulse Ad- educational requirements for chiropractic practice rela-
justing Instrument” developed by NeuroMechanical In- tive to AAI [or mechanical adjusting devices (MAD) as it
novations,28 and a device called the “Pro-Adjustor”29 has was termed in that report38,39]. Overall, the majority of the
recently been demonstrated at chiropractic trade shows Committee members (4–2) concluded that, while all of
over the past few years (for example, the 2011 World the studies it reviewed were flawed to varying degrees and
Federation of Chiropractic conference in Rio de Janeiro, the literature was generally weak, the evidence supported
Brazil and the 2010 Canadian Chiropractic Conference in the statement that AAI procedures were as effective as
Toronto, Ontario, Canada). manual HVLA procedures in producing clinical benefits
Instrumented adjusting is thought to convey multiple and biological change.38 The Committee reached consen-
benefits to both patients and practitioners.2,30–33 From the sus (5–1) that AAI procedures are widely used for spine
perspective of the patient, benefits conveyed by instru- related and extremity conditions, is safe and has no more
mented-adjusting include: the management of patients risk than do manual HVLA procedures (majority opinion
with osteoporotic bone fragility;2,31–33 for children; for 4–2).39 Lastly, the Committee reached consensus (5–1)
patients who are fearful of manipulative procedures that that there was no evidence with respect to educational re-
result in joint cavitation (i.e “cracking”); for extremity quirement to form any conclusions.39
adjusting; to (theoretically) achieve greater joint specifi-
city2,30 and; it can be used for patients who wish not be General Weaknesses of Studies Reviewed
physically touched (perhaps they have been physically or Irrespective of the wide utilization rates among chiro-
sexually abused, for example).30 To date, no experimental practors, and despite the plethora of practical benefits to
or clinical evidence exists that the use of instrumented- patients and practitioners championed by its proponents,

J Can Chiropr Assoc 2012; 56(1) 53

Clinical effectiveness of the activator adjusting instrument in the management of musculoskeletal disorders

Table 2

ARTICLE
Gemmell Yurkiw/ DeVocht Osterbauer Wood et Gemmell Schneider Shearar
et al. 2009 Mior. 1996 et al. 2003 et al. 1993 al. 2001 et al. 1995 et al. 2010 et al. 2001
CRITERIA

Assignment of Patients
7 7 5 6 7 7 7 7
(/9)

Baseline Values of
Groups 4 4 4 4 4 0 8 4
(/8)

Relevance of
Outcomes & Clinical
7 7 7 7 7 3 3 7
Significance
(/7)

Prognostic
Stratification
(Comorbidity and 6 3 6 3 6 6 6 6
Risk factors)
(/6)

Blinding Strategies
3 3 0 0 0 3 0 0
(/5)

Contamination/
Co-Intervention 3 3 3 2 4 3 2 0
(/4)

Compliance of Subjects
to Study Procedures 4 4 3 4 0 3 0 0
(/4)

Drop-out Rates of
Subjects 3 2 2 3 0 2 0 0
(/3)

Follow-Up Levels
2 1 0 2 2 0 0 2
(/2)

Date of Publication
2 1 2 1 2 1 2 2
(/2)

Total
41 35 32 32 32 28 28 28
(/50)

54 J Can Chiropr Assoc 2012; 56(1)

 T Huggins, AL Boras, BJ Gleberzon, M Popescu, LA Bahry

Table 3
Patients/ Main Outcome Follow-Up
Reference Objective Trial Design /50 Conditions Interventions Measures Period Main Results/Conclusions

Gemmell et al. 1 To examine Randomized 52 volunteer 1 Ischemic 1 PGIC 10 minutes – Both interventions showed
2009 the effects Clinical Trial subjects w/ tender, compression 2 NRS improvement in all outcome
of ischemic active trigger points 2 Activator 3 PPA (Algometer) measures, but no statistical
41
compression of trapezius muscle significance b/w groups
vs. Activator on
trigger points

Yurkiw & Mior 1 Comparison of Randomized 14 established 1 Diversified 1 C-ROM Immediate – No statistical significance
1996 Diversified SMT Comparative patients w/ SMT Goniomentric b/w interventions
& Activator on Clinical Trial subacute unilateral 2 Activator (inclinometer) – Both interventions showed
35
ROM & Pain neck pain device improvement in all outcome
2 VAS measures, but no statistical
significance b/w groups

DeVocht et al. 1 To evaluate the Prospective 8 patients w/ 1 Activator 1 VAS None – Signs & symptoms of
2003 effectiveness Case Series chronic articular 2 Maximum active patient TMD improved
of Activator 32 TMD mouth opening w/ course of Activator
treatment on in pain free range treatment
TMD (ROM)

Osterbauer et al. 1 To evaluate Descriptive 10 patients w/ 1 Activator 1 VAS 1 year – Activator proved beneficial
1993 diagnostic and Case Series chronic sacroiliac 2 ODI in treatment of chronic SIJS
biomechanical joint syndrome 3 Lumbosacral
assessment of provocation tests
32
SIJS 4 Gait analysis
2 To assess 5 Postural Sway
treatment value of
Activator on SIJS

Wood et al. 2001 1 Comparison of Randomized 30 patients w/ 1 Diversified 1 NDI 1 month – No statistical significance
Diversified SMT Clinical Trial subacute neck pain SMT 2 NPRS b/w interventions
& Activator on 2 Activator 3 McGill Pain – Both interventions showed
32
cervical spine Questionnaire beneficial effects in
dysfunction 3 ROM w/ reducing pain & disability
Goniometer while increasing ROM

Gemmell et al. To examine the Randomized 30 established 1 Activator 1 VAS Immediate – Both interventions showed
1995 immediate effects of Control Trial patients w/ acute 2 Meric improvement in all outcome
Activator vs. Meric 28 LBP measures, but no statistical
technique on acute significance b/w groups
LBP

Schneider et al. 1 Examine Non- 92 established 1 Activator 1 NPRS None – Study found neither
2010 treatment effect Randomized patients from 3 2 Diversified 2 ODI intervention superior to
on NPRS and Cohort chiropractic clinics Side Posture the other, while providing
ODI when w/ 3 month history profession with valuable
28
comparing of low back pain information on the influence
Activator and of treatment expectation
manual SMT
(Low back)

Shearar et al. 1 Comparison of Prospective 60 subjects w/ a 1 Diversified 1 NRS-101 None – No statistical significance
2001 Diversified SMT Randomized previous history SMT 2 Revised ODI b/w interventions
& Activator of Clinical Trial of SIJS 2 Activator 3 Orthopedic rating – Both interventions showed
28
SIJS scales improvement in all outcome
4 Algometer measures, but no statistical
significance b/w groups

this study found only 8 clinical trials that sought to de- of them included a control (no-treatment) group or a sham
termine the clinical effectiveness of the AAI, the form treatment group or included patients without any clinical
of instrumented-adjusting with the most publication in symptoms at all.
the peer-reviewed journals. None of the clinical trials re- In general, examiners in the studies reviewed in this
viewed here were randomized clinical trials; that is, none article were seasoned practitioners well acquainted with

J Can Chiropr Assoc 2012; 56(1) 55

Clinical effectiveness of the activator adjusting instrument in the management of musculoskeletal disorders

AAI use or with AMCT as well as the other treatment summary of the practice of chiropractic within the United
modality option employed (i.e. spinal manipulation, trig- States. Greeley, Colorado, USA. National Board of
ger point therapy). All the studies used small study popu- Chiropractic Examiners; 2005.
2 Cooperstein R, Gleberzon BJ. Activator Methods
lations, ranging from 8 to 92 subjects. Moreover, not all Chiropractic Technique. In: Technique Systems in
studies were adequately controlled with respect to both Chiropractic. Cooperstein R, Gleberzon BJ (editors).
subject and examiner blinding, with 5 of the studies be- Churchill-Livingston. 2004; 65–75.
ing assigned a “0” out of 5. An additional limitation was 3 National Board of Chiropractic Examiners. Job Analysis
that all but one study failed to either strategize or adjust of Chiropractic: a project report, survey analysis and
summary of the practice of chiropractic within Canada.
for relevant baseline characteristics. Due to the lack of Greeley, Colorado, USA. National Board of Chiropractic
long-term follow-up care and the use of a single treatment Examiners; 1993.
intervention, contamination and co-intervention grading 4 Kopansky-Giles D, Papadopoulos C. Canadian
had to be assumed in 4 of the 8 studies which may have Chiropractic Resource Databank (CCRD). A profile
further influenced the overall quality of these studies. A of Canadian chiropractors. J Can Chiro Assoc. 1997;
further limitation was that 7 of the 8 studies utilized a 41(3):155–191.
5 Watkins T, Saranchuk R. Analysis of the relationship
previously established patient base as study subjects, thus between educational programming at the Canadian
introducing the possible confounding factors of treatment Memorial Chiropractic College and the professional
expectancy and type II errors. practice of its graduates. J Can Chiro Assoc. 2000;
44(4):230–244.
Conclusion 6 Read DT, Wilson FJH, Gemmell HA. Activator as a
therapeutic instrument: Survey of usage and opinions
This systematic review of 8 clinical trials involving the use amongst members of the British Chiropractic Association.
of the AAI found reported benefits to patients with spinal Clin Chiropr. 2006; 9(2):70–75
pain and trigger points, although these results were not sta- 7 National Board of Chiropractic Examiners. Job Analysis
tistically significantly different when compared to the use of Chiropractic: a project report, survey analysis and
of HVLA manual manipulation or trigger point therapy. summary of the practice of chiropractic within the United
Given the wide use and clinical utility of the AAI, it is States. Greeley, Colorado, USA. National Board of
Chiropractic Examiners; 1994.
unfortunate that most of the clinical trials investigating its 8 Cooperstein R, Perle SM, Gatterman MI et al. Chiropractic
effectiveness were only pilot studies involving between technique procedures for specific low back conditions:
8 and 92 patients and typically involving only one or Characterizing the literature. J Manipulative Physiol Ther.
two treating doctors with a limited post-study follow-up. 2001; 24(6):407–411.
That said, there does exist case studies, case series, clin- 9 Gatterman MI, Cooperstein R, Lantz C et al. Rating
specific chiropractic techniques procedures for common
ical trials and now this systematic review that suggests low back conditions. J Manipulative Physiol Ther. 2001;
patients do experience positive and clinically meaningful 24(7):449–456.
benefits when treated for spinal pain and trigger points 10 Gleberzon BJ. Chiropractic Name Techniques: A review of
using an AAI. Clinically meaningful improvements were the literature. JCCA. 2001; 45(2):86–99
documented in patients with acute and chronic low back 11 Oakley PA, Harrison DD, Harrison DE, Haas JW.
or SIJ pain, acute and subacute neck pain, TMJ disorders Evidence-based protocol for structural rehabilitation of
the spine and posture: review of clinical biomechanics of
and trigger points in the trapezius muscle. posture (CBP) publications. JCCA. 2005; 9(4):270–296.
Further studies ought to include a larger patient base 12 Cooperstein R, Perle SM, Gleberzon BJ, Peterson DH.
using a placebo or sham group and a no-treatment group, Flawed trials, flawed analysis: Why CBP should avoid
better randomization and blinding protocols and longer- rating itself (Editorial). JCCA. 2006; 50(2):97–102.
term post-intervention follow-up in order to more defin- 13 Activator Methods Research DVD. Undated. Available
upon request.
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11, 2011.
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