Outlining the Importance of Radiographic Imaging in Determining Outcomes of Chiropractic Care Cameron Banks, BS Student Clinician, Life University Curtis Fedorchuk, DC Better Health: By Design 425 Peachtree Parkway Ste 315 Cumming, Ga. 30041 Cameron Banks 2207 River Green Dr. Atlanta, Ga. 30327 (706) 889-3304 [email protected]1
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Outlining the Importance of Radiographic Imaging in Determining the Outcome of Chiropractic Care
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Outlining the Importance of Radiographic Imaging in Determining Outcomes of Chiropractic Care
After the data quantifying the state of the spine, the patient management plan is
created to restore proper structural alignment and posture.11,12 Structural rehabilitation is
the process that is used to restore ideal spinal alignment. The feature of CBP that is
unique is Mirror Image adjusting. The protocol for rehabilitation is to apply Mirror Image
exercises, adjustments, and traction. Mal-alignments are illustrated with Cartesian
coordinates,12 and the adjustments required are ‘mirror image’ of those coordinates. The
possibilities for displacement within the Cartesian system related to the spine are
translation and rotation. The three axes upon which translation and rotation occur are x,
y, and z. There are positive and negative coordinates on each axis, and relative to the
anatomic position, positive values project towards the left in the x-plane, superiorly in the
y-plane, and anteriorly in the z-plane. Conversely, the –x-plane projects toward the right,
the –y-plane projects inferiorly, and the –z-plane projects posteriorly. For instance, if the
cervical spine is translated anterior on the z-plane, described as +z translation (equivalent
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to anterior head carriage), the Mirror Image adjustment is to place the head and cervical
spine in –z translation to perform the adjustment. Mirror image exercises and traction
would also be used to properly address the rehabilitation of all tissues involved in spinal
alignment and proper function.12, 13
Results
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After reviewing the data for all three subjects, it is clear that improvement according to
digitized postural assessment via methods such as PostureScreen does not necessarily
indicate that structural correction occurred. The literature15-17 agrees that there is low
accuracy of posture assessment when comparing visual versus radiographic evaluation.
In Subject #1, the radiographic findings suggest that the cervical curvature
worsened. The initial cervical lordosis was assigned the value of -7.7°, and the post-
evaluation revealed that the curve slightly decreased to -3.4°. The anterior head
translation improved from 21.7mm to 15.2mm, a decrease of 6.5cm. The PostureScreen
program reported a positive outcome from care: A resolution of head tilt and lateral
translation, and a reduction of anterior head translation from 57.2mm to 51.0mm.
In Subject #2, comparing the radiographic pre- and post-films reveal that there
was no significant change in curvature, but there was a decrease from -3.8° to -2.8°.
Anterior head translation also slightly worsened from 23.0mm to 23.9. This isn’t a
statistically significant amount, but it demonstrated no improvement, unlike the
PostureScreen digitized posture assessment. The lumbar spine radiographs reveal that
there was little to no significant improvement in alignment. The findings from the
digitized postural assessment of Subject #2 reveal that the anterior head translation
decreased from 74mm to 51mm. It was also noted that the shift in the ribcage was
resolved, there was a significant decrease of shoulder translation in the X-plane, and the
anterior translation of the hips was reduced.
Lastly, comparing the findings for Subject #3 reveals more inconsistency between
digitized postural analysis and radiographic analysis. Radiographic analysis revealed that
there was 26mm of anterior head translation, compared to almost double that amount
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reported by PostureScreen, at 48.5mm.
Discussion
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Reliability of diagnostic information is crucial to proper patient care.2 As far as
Methods of analyzing radiographs that have been suggested as reliable
measurement tools are the Cobb method and the Harrison posterior tangent method. This
study utilized the Harrison method, and the literature suggests that the posterior tangent
measuring system was as reliable as the Cobb method, but the Harrison method had a
lower standard of error measurement.18
All spinal movements deform the spinal canal. Literature suggests that ‘static and
dynamic deformations of the spinal column are directly translated to the central nervous
system (CNS).19 Under normal conditions, extension in the cervical and lumbar spine
results in decreased strain in structures involved in the central nervous system, and
flexion increases the load on the structures in the cervical and lumbar regions.
Accurate interpretation of subjective findings is paramount in properly managing
patient care.2 Without proper understanding of outcomes, the resulting care or perceived
chiropractic improvement may be incorrectly conveyed to the patient. In the case of
interpreting outcomes of structural rehabilitation, the accuracy and reliability of
radiographs is unequaled. Regarding visual postural analysis, an article written by Dunk,
Chung, Compton, and Callaghan stated, “The poor repeatability of postures documented
using the studied method brings into question the validity of this postural analysis
approach for either diagnostic use or tracking changes in response to treatment.”3 In
another study, an instrument called the Flexicurve was used to measure the cervical
lordosis superficially, and was then compared to radiographs. The results of the study
deemed that the instrument provided poor validity, and could not differentiate between
lordosis, straightened, S-curves, and kyphotic alignments of the cervical curve. The
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device could predict a cervical lordosis, but the reported curve was found to be
exaggerated compared to radiographic measurements.7 In a study by Hinman, the
objective was to determine thoracic stiffness by comparing thoracic curves in normal and
maximally erect postures using the Flexicurve.8 The study provided reliable results,
according to the authors. The difference in this study compared to the 2005 Harrison et
al. study is that the Flexicurve cannot accurately measure the degree of a curvature, but
rather only that a certain curve exists. This is not a reliable method of determining
outcome of structural rehabilitation.
A reliable radiographic interpretation requires a method that can easily be
reproduced and accurate. The literature suggests that the Cobb method and the Harrison
posterior tangent method are two great ways to determine the degree of curvature in the
spine, but the posterior tangent method illustrated a lower standard of error
measurement.18
According to a study by Janik et al., the PosturePrint method of analyzing
digitized posture showed that the system was sensitive to changes in posture on inanimate
subjects, and was still reliable as a method of posture analysis.5 This means that digitized
postural assessment is sensitive to change and can accurately describe what changes have
been made over time, but is unable to properly assess characteristics or degree of change
of sagittal curvature in the spine. A study by Johnson concluded, “Anatomic alignment of
the upper cervical vertebrae cannot be inferred from variation in surface measurement of
head and neck posture. This is the case even in those people identified with more extreme
head and neck postural tendencies.”15
Lastly, Refshauge and Goodsell found,
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“A strong relationship between surface and vertebral data was not established. Two factors were identified as contributing to the observed differences: length of spinous processes and depth of soft tissue overlying the spinous processes at each spinal level… The assumption that the surface curve is the same as the vertebral curve is not supported by these results, suggesting caution is needed in inferring vertebral alignment from observed surface contours.”16
This further validates the fact that although digitized postural assessment is repeatable
and sensitive to change, there is no value in it when determining intersegmental structure
or function.
Conclusion
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After reviewing the data presented by the radiographic and PostureScreen
assessments, there was very little statistical agreement in all three subjects. A brief
review of previous studies of digitized postural exams3,5 and other postural
measurements,7,8,15,16 showed that while they are sensitive to change, they cannot
accurately depict structural or curvature change achieved over the course of care. It
should be concluded that radiographic evaluation is of utmost importance in the proper
analysis of the structure of the human spine.
Acknowledgements
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Dr. Curtis Fedorchuk at Better Health: By Design in Cumming, Georgia made this study
possible. Gratitude must also be expressed for the participants in this study.
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References
1. Oakley P, Harrison DD, Harrison DE, Haas J. On “Phantom Risks” Associated
with Diagnostic Ionizing Radiation: Evidence in Support of Revising
Radiography Standards and Regulations in Chiropractic. J Can Chiropr Assoc
2004; 49(4): 264-269.
2. Bolton, JE. The evidence in evidence-based practice: what counts and what