Radiography and Clinical Decision-Making in Chiropractic

Mark A. Lopes, Roger R. Coleman, and Edward J. Cremata Dose-Response (2021)
The concern over x-ray exposure risks can overshadow the potential benefit of radiography, especially in cases where manual therapy is employed. Spinal malalignment cannot be accurately visualized without imaging. Manual therapy and the load tolerances of injured spinal tissues raise different criteria for the use of x-rays for spinal disorders than in medical practice. Current regulatory bodies rely on radiography risk assessments based on Linear-No-Threshold (LNT) risk models. There is a need to consider radiography guidelines for chiropractic which are different from those for medical practice. Radiography practice guidelines are summaries dominated by frequentist interpretations in the analysis of data from studies. In contrast, clinicians often employ a pseudo-Bayesian form of reasoning during the clinical decision-making process. The overrepresentation of frequentist perspectives in evidence-based practice guidelines alter decision-making away from practical assessment of a patient’s needs, toward an overly cautious standard applied to patients without regard to their risk/benefit likelihoods relating to radiography. Guidelines for radiography in chiropractic to fully assess the condition of the spine and spinal alignment prior to manual therapy, especially with high velocity, low amplitude spinal manipulation (HVLA-SM), should necessarily differ from those used in medical practice.

Evidence-Based Imaging Guidelines for Chiropractic Biomechanical Spine Care, Reconsideration of X-Ray Exposure Risks, and Practical Applications of Research Evidence

Mark A Lopes Journal of Alternative Complementary & Integrative Medicine
Evidence-based imaging guidelines in chiropractic are used in policy-making to direct practitioners in their usage of imaging, especially with radiology. The practical application of these policies is often at odds with conventional approaches to biomechanically based chiropractic spine care. Many factors are involved in the different perspectives on the use of imaging between factions in the chiropractic profession, such as the importance of evidence of the biomechanics of spinal conditions on imaging, the risks versus benefits of x-ray examinations, the goals of care, interpretations of data from research, and the practical applications of the research findings. First, the perceived risks of very low dose radiation exposures from x-rays in health care must be reconsidered with regard to their effects in humans. Second, a more practical application of data analyses from research is needed than the prevailing current approach. And third, the biomechanical conditions of previously injured spines in patients who present for chiropractic spine care should, when possible, be examined by imaging prior to applying forces from spinal manipulation or adjustments to ensure optimal safety and effectiveness.

Pelvic Rotation Calculator App

We have developed the Pelvic Rotation Calculator App which is a program to calculate true measurements and rotation amounts using measurements taken from the radiograph and the x-ray positioning environment. It was developed as a non profit contribution by the Gonstead Clinical Studies Society Research Department. It is based on the article published in the Journal of Chiropractic Medicine which proposed a mathematical method to quantify Y-Axis pelvic rotation on the anteroposterior radiograph.

Click on the README document link and follow the directions to access the free Pelvic Rotation Calculator App

A Proposed Mathematical Method to Quantify y-Axis Pelvic Rotation on the Anteroposterior Radiograph

Roger R. Coleman, DC, Mark A. Lopes, DC, and Derek A. Lopes, AA Journal of Chiropractic Medicine 2017 Sep; 16(3): 204–210.
OBJECTIVE: Researchers have identified potential errors in the Gonstead method’s analysis of pelvic alignment resulting from y-axis rotation of the pelvis on the anteroposterior (A-P) radiograph. The purpose of this article is to propose a method that can be used to determine the magnitude of y-axis rotation of the pelvis present on the A-P radiograph.
METHODS: In this proposed method, measurements are obtained from the patient and from the lateral and A-P radiographs. With a mathematical method, these measurements are used with the focal film distance to calculate the degree of pelvic rotation present on an individual A-P radiograph.
RESULTS: This method may help with the accuracy of measurement of pelvic y-axis rotation on the A-P radiograph.
CONCLUSION: The method proposed can be used to calculate the magnitude of pelvic y-axis rotation on an A-P radiograph.

Exploratory Evaluation of the Effect of Axial Rotation, Focal Film Distance and Measurement Methods on the Magnitude of Projected Lumbar Retrolisthesis on Plain Film Radiographs

Roger R. Coleman DC, Edward J. Cremata Jr. MA , Mark A. Lopes DC, Rick A. Suttles BS, Vaughn R. Fairbanks DC Journal of Chiropractic Medicine (2014) 13, 247-259
OBJECTIVE: The purpose of this exploratory study was to evaluate the amount of error in retrolisthesis measurement due to measurement methods or projection factors inherent in spinal radiography. In addition, this study compared how accurately these methods determine positions of the lumbar vertebrae being studied and the expected projected size of the retrolisthesis.
METHODS: Vertebral models were situated in a retrolisthesis position. Radiographs of the models were obtained in positive and negative y-axis rotations at 40- and 84-in focal film distances. The projected retrolisthesis was measured using the Gohl, Iguchi, and Lopes methods.
RESULTS: At the 40-in focal film distance, the Iguchi method and Lopes methods were significantly more accurate than the Gohl method. At the 84-in focal film distance, the Lopes method was significantly more accurate than the Gohl method. Almost all measurements overestimated both the actual amount of retrolisthesis as well as the amount of trigonometrically calculated retrolisthesis that should have been present on the radiographs. Findings suggest that measurements were less accurate with vertebrae rotated more than 10°.
CONCLUSION: This study demonstrated that lumbar vertebral rotation, focal film distance, and measurement methods are potential sources of error in retrolisthesis measurement

A retrospective consecutive case analysis of pretreatment and comparative static radiological parameters following chiropractic adjustments

Plaugher G, Cremata EE, Phillips RB. J Manipulative Physiol Ther. 1990 Nov-Dec;13(9):498-506.
An investigation was undertaken to determine the effect of chiropractic adjustments on static radiological parameters. Standard plain film radiography was used. A retrospective consecutive case analysis approach was used for obtaining the data from the pretreatment and comparative posttreatment radiographs. Measurements for cervical lordosis, sacral base angle, lumbar lordosis, scapular angle, Cobb's angle and retrolisthesis of adjusted lumbar segments were determined by marking films in a blinded fashion. Intra- and interexaminer reliability for the measurement of cervical lordosis and retrolisthesis were determined to be excellent with a low standard error (Pearson's r range 0.89-0.97, p < .001 for cervical lordosis and Pearson's r 0.74-0.90, p < .001 for retrolisthesis). The data from pre- and comparative post-measurements of retrolisthesis showed a significant reduction of approximately 34%. No reduction was seen in a control group with retrolisthesis. No pre/post comparative changes were observed with cervical lordosis angle, sacral base angle, lumbar lordosis angle, scapular angle or Cobb's angle.
A. Letter to the editor; In reply. J. Manipulative Physiol Ther 1991; 14:335-336.
B. Letter to the editor; In reply. J Manipulative Physiol Ther 1991; 14:539.
C. Letter to the editor; In reply. J Manipulative Physiol Ther 1992; 15:331-332.

Computer modeling of selected projectional factors of the 84-in focal film distance anteroposterior full spine radiograph compared with 40-in focal film distance sectional views

Coleman RR1, Lopes MA, Suttles RA. J Chiropr Med. 2011 Mar;10(1):18-24.
OBJECTIVE: The purpose of this study was to compare the 84-in focal film distance anteroposterior (A-P) full spine view to selected sectional views taken at a 40-in focal film distance for angles of divergence and changes produced by lateral translation and variation in source object distance.
METHODS: Computer models were used to determine angles of divergence and study the effects of lateral translation and changes in source object distance.
RESULTS: Lateral translation produced less projected axial (y-axis) vertebral rotation on the 84-in A-P full spine view than the film at 40 in. Angles of divergence are equal on the 14 × 17-in film at 40 in compared with the 84-in A-P full spine, and 70% of the 84-in full spine view is within the angles of divergence of the 40-in 10 × 12. The 84-in A-P full spine produced lowering and lengthening of the projected ilium when source object distance was reduced.
CONCLUSION: In this study, the 84-in A-P full spine produced less projected vertebral rotation on lateral translation. Its angles of divergence were greater than the 40-in 10 × 12 and equal to the 40-in 14 × 17-in film. Except for a 5.4-in section at both the upper and lower margins, the 84-in full spine view was within the angles of divergence of a 40-in 10 × 12. The full spine film produced projected ilium lengthening and lowering.

 The inter- and intraexaminer reliability of the Gonstead pelvic marking system

Plaugher G, Hendricks AH.J Manipulative Physiol Ther. 1991 Nov-Dec;14(9):503-8.
An investigation was undertaken to determine the inter- and intraexaminer reliability of the Gonstead pelvic radiographic marking system. This methodology analyzes the relative dimensions and spatial positions of the two innominate bones and sacrum and measures leg length inequality through an evaluation of femur head height. Two examiners marked 71 full spine radiographs twice to provide data from 284 analyses. Reliability was ascertained with the Pearson r, Spearman, intraclass correlation coefficient (ANOVA) and Kappa statistics. All results were statistically significant (less than 0.001) and indicated high levels of concordance. In every case, intraexaminer agreement was superior to interexaminer concordance.

The reliability of Patient Positioning for Evaluating Static Radiologic Parameters of the Human Pelvis

Plaugher G, Hendricks AH, Doble RW Jr, Bachman TR, Araghi HJ, Hoffart VM. J Manipulative Physiol Ther. 1993 Oct;16(8):517-22.
OBJECTIVE: To determine the reproducibility of patient positioning on radiographically evaluated static configurations of the human pelvis.
DESIGN: Repeat anteroposterior radiography of the human pelvis was performed in vivo. Comparative examinations were performed after 1 hr in one subject pool. A second sample underwent repeat examination after a mean of 18 days.
SETTING: Outpatient private practice chiropractic clinic.
SUBJECTS: Thirty-seven relatively asymptomatic subjects participated in the experiment.
MAIN OUTCOME MEASURES: Millimetric evaluations were made for leg length inequality, right/left sacral discrepancies and right/left innominate differences. The null hypothesis was that the difference of the measurements from the two radiographs would be equal to zero. A paired t-test was used to analyze if there were any significant differences. The mean measured difference in millimeters and correlation coefficients were also determined for each variable.
RESULTS: Individual variations for several roentgenometric parameters, including leg length inequality and pelvic torsion, did not reach statistical significance (p > .05) although minor millimetric discrepancies were recorded. Correlation coefficients, in most cases, were relatively high.
CONCLUSION: A subject can be reliably positioned for repeat anteroposterior pelvic radiography for both 1 hr and 18-day intervals. The methodology described has applicability to full spine radiography when roentgenometric parameters of the pelvis are scrutinized.

Gonstead Technique

Plaugher G. Letter to the editor; re: Chiropractic 1991; 7:62.

The Role of Plain Film Radiography in Chiropractic Clinical Practice

Plaugher G. Chiropractic Journal of Australia 1992; 22(4):153-161.