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

cbanks@student.life.edu

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Table of Contents:

I. Abstract………………………………………………………….……..3

II. Introduction…………………………………………………………….4

III. Case Reports

a. Subject #1…………………………………………………………..5

b. Subject #2………………………………………………..…………7

c. Subject #3…………………………………………………..………9

IV. Methods…………………………………………………..…………..10

V. Results..………………………………………………..............……..12

VI. Discussion………………………………….……...………..…..……14

VII. Conclusion…………………………………………….……..……….17

VIII. Acknowledgements…………………………………………………..18

IX. References.…………………………………………....………...…….19

X. Figures

a. Subject 1 (Fig. 1-6) …………………………………………….22

b. Subject 2 (Fig. 7-11)…….……………………………………...28

c. Subject 3 (Fig. 12-14)…………………………………………..33

VII. Informed Consent…………………………………………..……..37-38

VIII. Cover Page……………………………………………………………39

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Abstract

Objective: The goal of this study is to outline the importance of radiographs as an

outcome measure of structural correction, as visual postural assessment may not be

reliable as an outcome of structural correction.

Clinical Features: Three subjects were analyzed via pre- and post-radiographs. Structural

correction achieved was determined according to the degree of change measured on the

radiographs. The subjects also underwent digitized pre- and post-postural assessments

using the PostureScreen Mobile program.

Results: The subjects in the study under care had improved posture as measured by

digitized postural analysis. However, the radiologic analysis pre- and post-findings

illustrated that there was little to no structural correction.

Conclusion: Objective postural analysis validity and reliability has been questioned, and

as such, should not be the only method of outcome assessment. Radiographic imaging as

an outcome measure in structural and functional rehabilitation of the spine has been

proven accurate and highly reproducible. As illustrated in this case series, radiographic

analysis should be the primary method of determining the degree of structural correction

of the spine.

Key Words: CBP, Chiropractic Biophysics, PostureScreen, PostureRay, X-Ray,

Radiograph.

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Introduction

Presently in the world of Chiropractic, there has been much discussion on the

necessity of radiographs being taken for uncomplicated cases.1 The conversation seems a

little misguided in the times in which the profession is going down the path of acting as

primary care physicians (PCP). In order to meet standards of care that are included in

Evidence-Based Practice (EBP) guidelines,2 it is crucial that radiographs be taken. Not

only does this serve as a method of primary care, it also allows the provider to properly

analyze the patient, create a management plan, and educate the patient.

Part of the resistance in taking radiographs in chiropractic practice is that there

has been apprehension to expose patients to low-dose radiation. It has been reported that

there is risk involved in being exposed to low-dose radiation. However, this stance has

been created on extrapolated data, and has been solidified even without data. In fact,

there is even a small amount of evidence that Hormesis, the exposure to low-dose isn’t

harmful, but is beneficial to patient health.1

The goal of this study is to outline the importance of radiographic evaluation as

the keystone in measuring outcomes of postural and structural correction. Other methods

of determining the outcomes of care are visual assessment,3-6 using an on-skin device,7, 8

and comparison against plumb lines.9, 10

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Case Reports: Subject #1

There were three subjects in this study. All three subjects underwent radiographic

evaluation. The following radiographs were taken: lateral cervical, anterior-posterior

lower cervical (APLC), lateral lumbar, and an anterior-posterior lumbopelvic.

The first subject in this study presented for radiographic evaluation on June 17, 2013.

The radiographic findings for Subject #1 were:

• Hypolordosis of the cervical spine, with and Absolute Rotational Angle

(ARA) of -7,7° on the x-plane.

• Right listing of the cervical spine, with 9.9° of rotation on the z-plane.

• Posterior translation of the lumbar spine of -45.3mm on the z-plane.

• Very slight right curvature of the lumbar spine, with an apex at L3-L4.

• The lumbodorsal (LD) angle from L1-L5 was -5.7° on the z-plane.

Figure 1 illustrates the pre- and post-radiographs for the lateral cervical view. Figure 2

illustrates the pre- and post-radiographs for the APLC view. The lateral lumbar views are

shown in Figure 3, and the anterior-posterior lumbopelvic views are shown in Figure 4.

The PostureScreen digitized postural pre-assessment of Subject #1 was performed

on June 20, 2013. The findings were:

• The head was shifted 27.4mm right on the x-plane, was tilted 7.4° right,

and was translated 57.1mm anterior on the z-plane.

• Shoulders were shifted 3.6mm right and were tilted 2.2° right, and were

translated 37.1mm posterior on the z-plane.

• The ribcage was shifted 22.1mm left.

• The hips were shifted 21.1mm to the left on the x-plane, were not tilted,

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and were shifted 55.1mm anterior on the z-plane.

The post-findings of the PostureScreen digitized postural assessment for Subject #1 were:

• The head was not translated significantly to the left or right, was not tilted,

and was translated 51.1mm anterior on the z-plane.

• The shoulders were translated 7.1mm to the left on the x-plane, and were

not tilted, and were translated 29mm posterior on the z-plane.

• The ribcage is not tilted significantly to the left or right.

• The hips were translated 19.1 left on the x-plane, were not tilted, and were

translated 46mm anterior on the z-plane.

The initial findings according to PostureScreen digitized postural analysis are illustrated

in Figure 5. The post findings are found in Figure 6. It is important to note that the data

reported in the figures have been converted to millimeters for ease of comparison to the

radiographs taken in this study.

Case Report: Subject #2

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The second subject presented for radiographic evaluation on July 1, 2013. The patient

underwent the full radiographic exam as described in this study. Figures 7, 8, and 9 are

images of the subject’s lateral cervical radiograph, lateral lumbar radiograph, and

anterior-posterior lumbar films respectively. The findings were as follows:

• Hypolordosis of the cervical spine, with an ARA from C2-C7 of -3.8° on

the X plane. There was also anterior head translation of 23mm on the z-

plane.

• Posterior translation of the lumbar spine, with an ARA of -41.2° on the x-

plane. A slight left simple scoliosis was present T12-L5, with the apex at

L2. The lumbodorsal angle from T11-S1 was 5.8° of rotation on the z-

plane.

The PostureScreen digitized postural pre-assessment for the Subject #2 was as follows:

• The head was translated 3.0mm to the right on the x-plane, and was

translated 73.9 anterior on the z-plane.

• The shoulders were translated 8.3mm to the right on the x-plane, and were

translated 38.1 posterior on the z-plane

• The ribcage was translated 34.0mm to the left on the x-plane.

• The hips were translated 6.9mm to the left on the x-plane, and were

translated 45.7 anterior on the z-plane.

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The PostureScreen digitized postural data for the post-assessment was as follows:

• The head was translated 8.6mm to the right on the x-plane and was not

tilted. It was also translated 58mm anterior on the z-plane.

• The shoulders were translated 3.3mm to the left on the x-plane and were

not tilted. They were also translated 3.0mm posterior on the z-plane.

• The hips were translated 7.8mm to the right on the x-plane, were not tilted,

and were translated 42mm anterior on the z-plane.

The initial findings according to PostureScreen digitized postural analysis are illustrated

in Figure 10. The post findings are found in Figure 11.

Case Report: Subject #3

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Subject #3 presented for radiographic evaluation on April 5, 2013. The patient underwent

only the cervical radiographic exam (lateral cervical, APLC). Figures 12 and 13 illustrate

Subject #3’s lateral cervical and APLC radiographs, respectively. The findings were as

follows:

• Hypolordosis of the cervical spine, with an ARA of -24.0°. There was

26.1mm of anterior head translation on the z-axis.

• Right cervical rotation of 3.2° on the z-axis.

The PostureScreen digitized postural data for the post-assessment was as follows:

• The head was translated 11.8mm to the left on the z-axis, is rotated 7.0° to

the left on the Z-axis, and is translated 50.5mm anterior on the z-axis.

• The shoulders were not shifted significantly, and they were rotated 3.7° to

the left on the z-axis.

The findings according to PostureScreen digitized postural analysis are illustrated in

Figure 14.

Methods

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The patients in this case underwent a radiographic evaluation in accordance to

Chiropractic Biophysics (CBP) protocol. There is a standardized radiograph set-up

process in CBP.11, 12 After the radiographs are taken, the structural alignment is analyzed

using the Harrison posterior tangent method for sagittal spinal curves, and the Riser-

Ferguson method for frontal plane displacement. These have been studied for reliability

and have good inter- and intra-examiner reliability.7

The next step is to analyze the radiographs for abnormality against a normal

spinal model.13 Two basic values are collected to gauge the state of the spine, the

Absolute rotation angles (ARA), measured C2-C7, T3-T10, and L1-L5, and the relative

rotation angles, measured inter-segmentally (example: C3-C4).14

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

doesn’t count? J Manipulative Physiol Ther 2001; 24: 362-366.

3. Dunk N, Chung YY, Compton D, Callaghan J. The reliability of quantifying

upright standing posture as a baseline diagnostic clinical tool. J Manipulative

Physiol Ther 2004; 27(2): 91-96.

4. Normand M, Descarreaux, Harrison DD, Harrison DE, Perron D, Ferrantelli J,

Janik T. Three dimensional evaluation of posture in standing with the

PosturePrint: an intra- and inter-examiner reliability study. Chiropr Osteopat

2007; 15(15).

5. Janik T, Harrison DE, Cailliet R, Harrison DD, Normand M, Perron D. Validity

of a Computer Postural analysis to Estimate 3-Dimensional Rotations and

Translations of the Head From Three 2-Dimensional Images. J Manipulative

Physiol Ther 2007; 30(2):124-129.

6. Harrison DE, Janik T, Cailliet R, Harrison DD, Normand M, Perron D, Oakley P.

Upright Static Pelvic Posture as Rotations and Translations in 3-Dimensional

From Three 2-Dimensional Digital Images: Validation of a Computerized

Analysis. J Manipulative Physiol Ther 2008; 31(2): 137-145.

7. Harrison DE, Haas J, Cailliet R, Harrison DD, Holland B, Tadeusz J. Concurrent

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Validity of Flexicurve Instrument Measurements: Saggital Skin Contour of the

Cervical Spine Compared with Lateral Cervical Radiographic Measurements. J

Manipulative Physiol Ther 2005; 28(8): 597-603.

8. Hinman M. Comparison of Thoracic Kyphosis and Postural Stiffness in Younger

and Older Women. The Spine Journal 2004; 4(2004): 213-217.

9. Vernon H. An assessment of the intra- and inter-reliablity of the posturometer. J

Manipulative Physiol Ther 1983; 6:57-60.

10. Bullock-Saxton J. Postural alignment in standing: a repeatable study. Austr

Physiother 1993; 39: 25-29.

11. Harrison DD, Harrison DE, Colloca CJ, Betz J, Janik TJ, Holland B. Repeatability

over time of posture, radiograph positioning, and radiograph line drawing: an

analysis of six control groups. J Manipulative Physiol Ther. 2003 Mar-

Apr;26(3):211.

12. Harrison DD, Harrison SO. CBP Technique. Harrison Chiropractic Biophysics

Seminars, Inc.; 2002.

13. Harrison DE, Harrison DD, Troyanovich SJ, Harmon S. A normal spinal position:

It’s time to accept the evidence. J Manipulative Physiol Ther 2000; 23(9):623-

644.

14. Oakley P, Harrison D, Harrison De, Haas J. Evidence-based protocol for

structural rehabilitation of the spine and posture: review of clinical biomechanics

of posture (CBP) publications. J Can Chiropr Assoc 2005; 49(4): 270-296.

15. Johnson GM. The correlation between surface measurement of head and neck

posture and the anatomic position of the upper cervical vertebrae. Spine 1998;

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23:921-927.

16. Refshauge KM, Goodsell M, Lee M. The relationship between surface contour

and vertebral body measures of upper spine curvature. Spine 1994; 19:2180–

2185.

17. Mosner EA, Bryan JM, Stull MA, Shippee R. A comparison of actual and

apparent lumbar lordosis in black and white adult females. Spine 1989; 14:310–

331.

18. Harrison DE, Harrison DD, Cailliet R, Troyanovich S, Janik T, Holland B. Cobb

Method or Harrison Posterior Tangent Method, Which to Choose for Lateral

Cervical Radiographic Analysis. Spine 2000: 25(16); 2072-2078.

19. Harrison DE, Cailliet R, Harrison DD, Troyanovich S, Harrison SO. A Review of

Biomechanics of the Central Nervous System—Part II: Spinal Cord Strains From

Postural Loads. J Manipulative Physiol Ther 1999; 22(5): 322-332.

SUBJECT #1:

Figure 1

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Figure 2

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Figure 3

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Figure 4

24

Figure 5

25

Pre-assessment as presented in PostureScreen on June 20, 2013:

Figure 6

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The post-findings as reported by PostureScreen on August 23, 2013:

SUBJECT #2:

Figure 7

27

Figure 8

28

Figure 9

29

Figure 10

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Initial findings according to PostureScreen on August 2, 2013:

Figure 11

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Post-findings according to PostureScreen on August 23, 2013:

SUBJECT #3:

Figure 12

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Figure 13

33

Figure 14

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The findings as reported by PostureScreen on July 29, 2013:

Informed Consent

35

36

37

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December 10, 2013

To Whom It May Concern:

This is an original paper, that is not currently published or being considered for

publication. The patient data collected for this study was collected at Better Health: By

Design in Cumming, Ga, by Dr. Curtis Fedorchuk and his staff. The patients’ consent/

information release authorizations are included within this packet.

Signed,

Cameron Banks, BS

Cameron Banks 706-889-3304

2207 River Green Dr. cbanks@student.life.edu

Atlanta, Ga 30327

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