Diagnostics


The Lateral Films–Objective and Reliable Evidence
Diagnostics
Written by Mark R. Payne D.C.   
Friday, 24 September 2010 12:01

The Lateral Films–Objective and Reliable Evidence

by Dr. Mark R. Payne D.C.

 

For years, we’ve been bombarded about the need for objective evidence to support our care programs. Third party payors and peer review types are the first to nail doctors who fail to document clinical findings with hard, objective evidence. In a time when our very right to take X-rays is under assault, many doctors aren’t aware of how much scientific documentation is available to support the validity of certain X-ray measuring techniques. This is particularly true if a biomechanical analysis of the lateral radiographs is included as part of the workup. Since this issue’s focus is on X-ray and other diagnostics, let’s talk about the reliability of the information we get from the lateral films.

Many chiropractors will perform a radiographic exam on a typical new patient. Once the decision to X-ray has been made, two perpendicular views (Ex. A-P and lateral) are generally considered the accepted minimum. For the purposes of our discussion here, let’s assume that you have elected to get A-P and lateral films on your patient. What kind of information can we get from a simple lateral film and how reliable is that information?



As it turns out, we can learn a lot from the lateral films. In addition to the diagnostic value of the films, the amount of biomechanical information we gain is significant. I would make the case that no other films offer the chiropractor as much relevant information as the lateral spinal views. By taking just a few moments to make some simple measurements, we can actually get a great deal of reliable, objective information about our patient.

Jackson’s Angle: First popularized in the late fifties by Ruth Jackson, MD, in her landmark book, The Cervical Syndrome, this simple measurement gives us a wealth of useful information about the patient’s biomechanical status. Measurement of Jackson’s angle generally requires the construction of only two simple lines and a measurement of the resultant angle of intersection between the two. Fig. 1 shows how lines are constructed along the posterior body of C2 and C7 and drawn down and upward respectively until they intersect. Once this is done, it is a simple matter to use a protractor to accurately measure the acute side of the angle. The method can be used equally well in the thoracics and lumbars as well.


 

Jackson’s Angle tells us exactly how much lordosis is present in our patient. While there is some disagreement in the scientific literature as to how much lordosis is needed for long term spinal health, there is basically no disagreement at all regarding the validity and reliability of measuring the angle on the films. A number of studies have looked at this measurement and determined that the angle can be reliably measured with a very small margin of error.

Occasionally, the lines from C2 and C7 won’t intersect in the neck. This typically happens when the patient’s sagittal posture has assumed some sort of "S-shaped" configuration. If that happens, it becomes a simple matter of just drawing a third line off one of the middle vertebrae so as to best represent the middle of the "S." (See Red line in Fig. 2) Now, instead of two lines intersecting to form a single angle, we have three lines intersecting to form two angles. In this case, we drew the additional line off C4.


 

By convention, degrees of lordosis are recorded in negative numbers and degrees of kyphosis are recorded in positive numbers. With this in mind, values for the lordotic neck in Fig. 1 would be recorded as -31 degrees. The kyphotic upper portion of the neck in Fig. 2 would be recorded as +10 degrees OVER the -16 degrees of the lordotic lower spine (or +10/-16). Pretty easy, eh?

Anterior Head Carriage: Finally, we can easily get one more important piece of information…an accurate analysis of the weight bearing status of the spine. We do this by simply extending a line straight upward from the posterior-superior corner of T1. That line should intersect the C1 vertebrae at the junction of the posterior arch and the lateral mass. If the head is held forward of the line, a common finding, we would record it in millimeters as a positive number. If the head is carried posterior of the reference line from T1, we would record the position as a negative number. Fig. 3 shows a patient with pronounced forward head carriage.

With one simple film and a couple of quick measurements, we now have an accurate picture of the patient’s overall spinal status and an objective benchmark against which we can gauge the efficacy of any treatment efforts directed at restoring normal posture. Best of all, this method of measurement is well established in the scientific literature and should stand up very well, if you are ever questioned about your findings.

Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To learn more about implementing postural rehab into your practice, call 1-334-448-1210 or link to www.MatlinMfg.com to request our FREE REPORT, "The Best Corrections of Your Career."

 
The Real Necessity for Diagnostics and Imaging
Diagnostics
Written by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP   
Friday, 24 September 2010 11:58

The Real Necessity for Diagnostics and Imaging

by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP

 

You get a letter from the insurance company stating that your utilization of MRI’s is not within their acceptable standards and they give you a warning that you will be excluded from their panel if your referral pattern continues. At first, you are angry, then confused and, finally, you call every friend you have in chiropractic to solicit their opinion. The consensus is that you will now treat the patient for as long as possible, until all else fails, and then consider ordering the MRI, so as to meet the standards of the insurance company. As a result, you have also influenced everyone within your sphere of influence to behave in the same manner.

My personal journey was similar to many of yours; approximately fifteen years ago, I was denied the ability to refer MRI’s to the imaging center, as they were told by the insurance companies that the scans would be denied. The parameters set forth in arbitration, the lowest level of Court in New York State, ruled that an MRI is compensable only if it is deemed an emergency and then must be performed in an emergency room in a hospital, if done prior to six weeks of conservative care.

Armed with this information, I placed two calls: one to the New York State Department of Education, Secretary to the Board of Chiropractic, and the other to the New York State Department of Education, Secretary to the Board of Medicine, as those were the two highest ranking officials in the State of New York that govern over both chiropractic and medical doctors’ licenses. I wanted to get both opinions to make sure the "world was not flat" all of a sudden.

The answers given to me by both were the same: If you suspect that your patient has spinal cord or root pathology, you treat without a conclusive diagnosis and they get hurt, or proper care is delayed, be prepared to lose your license, no matter what the insurance company says. They do not govern the standard of your care. The New York State Department of Education does. Armed with that knowledge, I found an imaging center to work with who would take MRI’s of my patients as long as my documentation was thorough. We prevailed in overturning that ridiculous ruling within a very short amount of time as a result of the documentation and reasonable minds in the courts.

Your standard of care is the same as mine and every other chiropractor’s in the nation. We are governed by our state board’s standard, not the insurance industry and, after a careful review of numerous states, it has been determined that most states have similar standards. The goal of your state board is not to help your practice or to protect you, the chiropractor. The goal is to protect the people of your great state and that is a covenant taken very seriously by all state boards.

The next question is, "What are your standards of utilization of advanced imaging of the spine, specifically, MRI?"

During your clinical evaluation, you would be on very safe ground to order an MRI if there are documented findings of myelopathic and/or radiculopathic findings. The opposition would argue that you should treat the patient conservatively for approximately six weeks to see if those symptoms resolve. That is a very dangerous gamble on your part. What if there is a space occupying lesion and your well intentioned adjustments create further damage? What if there is a tumor and your six weeks’ delay contributed to the metastasis of that tumor? What if, what if…?

Doctors…DO NOT TOUCH YOUR PATIENTS IF YOU DO NOT HAVE A CONCLUSIVE DIAGNOSIS. This is a non-negotiable issue.

Here is the language you use with your patient:

"Mrs. Jones, your evaluation revealed some neurological involvement that I believe a series of adjustments will help. I will give it five to six weeks to respond and, if it doesn’t, I will then consider an MRI to see what’s preventing you from getting well as quickly as I think you should."

Quite eloquent…. However, here is what you are really saying: "Mrs. Jones, I have examined you and have taken X-rays and can’t determine what is wrong with you. I am going to commence with a series of high velocity thrusts into your spine and hope that I have guessed correctly and you do not have a space occupying lesion in your spinal cord or spinal nerve roots. If you do, and I have guessed wrong, you could end up needing surgery that could have been avoided and, in the worst case scenario, you could end up a paraplegic or be diagnosed with cancer that has spread unnecessarily. Let’s get started."

What’s the difference between the first and second explanation? The answer is simple. The second explanation is the truth and the first is eloquent nonsense.

Would a neurologist, neurosurgeon, orthopedic surgeon or oncologist treat their patients without a conclusive diagnosis? The answer is a resounding, "No." We are no different. Simply because the chiropractor does not perform surgery, that does not mean we are exonerated from practicing within the standards of our license. I challenge every chiropractor in the United States to ask their Chiropractic Board if it is acceptable to render care without a conclusive diagnosis.

Do not practice to the standards of the insurance company. Your covenant is between you and your patient.

 

Dr. Mark Studin is the President of CMCS Management which offers the Lawyers Marketing Program, Family/MD Marketing Program and Compliance Auditing services and can be contacted at www.TeachChiros.com.

 
Heart Rate Variability; Insight into the Nervous System
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Diagnostics
Written by Christopher Kent, D.C.   
Friday, 25 December 2009 00:00

The heart, the brain, and the autonomic nervous system.

Heart rate variability (HRV) is an exciting technology for evaluating autonomic nervous system balance and activity.  HRV enables doctors of chiropractic to objectively evaluate how effectively the nervous system is regulating the activity of a vital organ.

There is a two way communication system between the brain and the heart. Analysis of the beat to beat patterns of the heart may be used to evaluate balance between the sympathetic and parasympathetic divisions of the autonomic nervous system. When the two branches of the autonomic system are working together at maximum efficiency, you feel "in sync." This is because the sympathetic and parasympathetic divisions are not fighting one another. This state of being is called "entrainment."1

Variability in heart rate reflects the vagal and sympathetic function of the autonomic nervous system, and has been used as a monitoring tool in clinical conditions, characterized by altered autonomic nervous system function.2 Spectral analysis of beat to beat variability is a simple, non invasive technique to evaluate autonomic dysfunction.3

Wellness 

Normative data on heart rate variability have been collected.4,5,6 This technology appears to hold promise for assessing overall fitness. Gallagher et al.7 compared age matched groups with different lifestyles. These were smokers, sedentary persons, and aerobically fit individuals. They found that smoking and a sedentary lifestyle reduces vagal tone, whereas enhanced fitness increases vagal tone. Dixon et al.8 reported that endurance training modifies heart rate control through neurocardiac mechanisms. In occupational health, the effects of various stresses of the work environment of heart patients and asymptomatic workers may be evaluated using heart rate variability analysis.9  Low heart rate variability is predictive of mortality from all causes.10

Chiropractic care

Zhang et al. reported the results of an exciting study involving 520 subjects in a single visit group, and 111 subjects in a four week group. The purpose of the study was to investigate the effect of chiropractic care in a multi-clinic setting on the balance of the sympathetic and parasympathetic nervous system using HRV (heart rate variability) analysis. The study demonstrated consistent changes in HRV. The authors reported, "The decreased heart rate and increased total power from the HRV analysis indicated a healthy autonomic nervous system balance after correction of vertebral subluxation."11,12

Autonomic dystonia, or acquired dysautonomia, is one of the three elements in the three dimensional model of vertebral subluxation.12 Skin temperature changes, reflecting alterations in vasomotor tone, are used clinically to assess autonomic changes associated with vertebral subluxations, as well as nutritional, exercise, and lifestyle interventions.  

Heart rate variability represents an exciting, non-invasive technology to assess subluxation related autonomic function.  HRV technology will empower the practicing chiropractor to assess and communicate the far reaching impact of subluxation correction and a healthy lifestyle.


Christopher Kent, D.C.

Christopher Kent is co-founder of the Chiropractic Leadership Alliance.  Dr. Kent is a chiropractor and an attorney.  He was honored as Chiropractor of the Year by the International Chiropractors Association, and received Life University’s first Lifetime Achievement Award.  He may be contacted at
  This e-mail address is being protected from spambots. You need JavaScript enabled to view it .


 

References
1.  Childre D: "One Minute Stress Management." Planetary Publishers. Boulder Creek, CA. 1998.
2.  DeDenedittis G, Cigada M, Bianchi A, et al: "Autonomic changes during hypnosis: a heart rate variability power spectrum analysis as a marker of sympatho vagal balance." Int J Clin Exp Hypn 1994;42(2):140.
3.  Kautzner J, Camm AJ: "Clinical relevance of heart rate variability." Clin Cardiol 1997;20(2):162.
4.  O'Brien IA, O'Hare P, Corrall RJ: "Heart rate variability in healthy subjects: effect of age and the derivation of normal ranges for tests of autonomic function." Br Heart J 1986; 55(4):348.
5.  Toyry J, Mantysaari M, Hartikainen J, Lansimies E: "Day to day variability of cardiac autonomic regulation parameters in normal subjects." Clin Physiol 1995; 15(1):39.
6.  Sato N, Miyake S, Akatsu J, Kumashiro M: "Power spectral analysis of heart rate variability in healthy young women during the normal menstrual cycle." Psychosom Med 1995; 57(4):331.
7.  Gallagher D, Terenzi T, de Meersman R: "Heart rate variability in smokers, sedentary, and aerobically fit individuals." Clin Auton Res 1992; 2(6):383.
8.  Dixon EM, Kamath MV, McCartney N, Fallen EL: "Neural regulation of heart rate variability in endurance athletes and sedentary controls." Cardiovasc Res 1992; 26(7):713.
9.  Kristal Boneh E, Raifel M, Froom P, Ribak J: "Heart rate variability in health and disease." Scand J Work Environ Health 1995; 21(2):85.
10. Dekker JM, Schouten EG, Klootwijk P, et al: Heart rate variability from short electrocardiographic recordings predicts mortality from all causes in middle-aged and elderly men.  American Journal of Epidemiology 1997; 145(10):899.
11. Zhang J, Dean D: "Effect of short term chiropractic care on pain and heart rate variability in a multisite clinical Study." International Research and Philosophy Symposium: Abstracts. Sherman College of Straight Chiropractic, Spartanburg, SC. October 9 10, 2004.
12. Zhang J, Dean D, Nosco D, et al: Effect of chiropractic care on heart rate variability and pain in a multisite clinical study.  J Manipulative Physiol Ther 2006; 29(4):267.
13. Redwood D, Cleveland III CS: Fundamentals of Chiropractic.  Mosby.  St. Louis.  2003.  ISBN 0-323-01812-2.

 
Diagnostics as a Part of an Evidence Based Chiropractic Practice
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Diagnostics
Written by Dwight C. Whynot, D.C.   
Wednesday, 26 October 2005 22:13

Chiropractors attend four-year college programs that teach the art, science and philosophy of chiropractic—or do they? Currently, chiropractic colleges do a great deal to teach and to prepare chiropractors in the art, philosophy and delivery of the clinical science of chiropractic, but the colleges are not doing enough to train chiropractors in the science of case management.  If the clinical chiropractor can create a more evidence-based practice approach utilizing diagnostic tests, the chiropractic profession would be able to gain the respect and acceptance of legislators that control healthcare dollars.  Our national organizations could make a much stronger argument for the effectiveness of chiropractic care versus the next alternative, if the chiropractic profession would utilize diagnostic tests to provide the needed clinical evidence.

Chiropractors learn a great deal of philosophy and history in school that transforms them into very passionate and dedicated practitioners.  I know this, because people I talk to about chiropractic in social settings outside of the office often state that they “believe in chiropractic,” as if chiropractic were a religion or faith that requires a higher than average conviction in order for them to accept what chiropractic does.  In school, the chiropractor also learns a great deal on the art of chiropractic in the form of compulsory adjusting classes as well as other optional techniques offered during weekend seminars. The chiropractic profession is well equipped with a plethora of techniques to choose from, each with its own philosophy of the how and why of the adjustment.

The art and philosophy portion of chiropractic training does not need to be improved; it is the science portion of the training that needs modification, specifically the case management in clinical science.  Doctors of chiropractic are very poor case managers.  A majority of chiropractors recommend treatment plans that are baseless.  This is a very serious weakness.  Chiropractors wonder why insurance companies deem care to be “NOT MEDICALLY NECESSARY” when they have treated a patient over a 40-50 visit treatment schedule with no evidence from re-examinations and/or diagnostic tests that supports that level of care. A weakness of chiropractic case management lies in the fact that those chiropractors that actually do perform re-exams are performing exams that are useless.  They are useless in that the initial examination and re-examinations performed contain orthopedic tests that are only positive 1 percent of the time and range of motion examinations are visualized or, at best, utilize testing equipment and procedures with very low levels of reproducibility.  The same type of situation is evident for muscle testing and neurological testing on re-examinations.  The majority of the evidence that chiropractors are gathering to determine the validity and effectiveness of their care is subjective, not objective.

The medical profession utilizes diagnostics tests for 90 percent of the care given to their patients.  Actual treatment from the medical doctor makes up 10 percent of the care given to the patient.  In chiropractic, just the opposite is true, ten percent of the care given the patient is diagnostic and the treatment portion makes up 90 percent of the care.  A majority of chiropractors use X-rays as their only source of objective evidence to justify a patient’s care for 40-50 visits.  That is not good enough.  The insurance companies know that it is not good enough, and that is why they continue to deny care for chiropractic patients.  Documenting a patient’s condition with objective evidence is the only way to prove that the care you provide in your office is medically necessary.

When a patient comes into the office with subjective complaints, a chiropractor must document those subjective signs and symptoms in the notes and then determine the exact nature of those complaints with objective evidence.  As a chiropractor, you treat spinal conditions.  The spine is comprised of three distinct tissues that need evaluation: 1) the bones, 2) the nerves, and 3) the muscles/ligaments/discs.  In chiropractic college, chiropractors learn about myopathology, neuropathophysiology, and kinesiopathology.  Chiropractors also learn to evaluate these entities with a number of orthopedic exams, range of motion evaluations, neurological exams, as well as palpation and percussion.  This exam process is fine.  The problem with this type of examination process, though, is that it stops there.  The only evidence gathered from an examination process of this type, which is in chiropractic colleges across the country, is subjective in nature. The information that needs to be gathered on each of the tissue pathologies above needs to be objective in nature.  The chiropractic physician needs to take the subjective signs and symptoms and put them in an objective form so they can easily be retested to determine that the treatment strategy chosen has worked.  Gathering objective evidence and comparing that objective evidence throughout the treatment allows the profession to go from an “I believe that chiropractic works” profession to an “I know that chiropractic works” profession.  Patients know they are getting better in an evidence-based practice, rather than relying on faith that the doctor can sense, in some mysterious fashion, that they are doing better and the treatment is working.

The diagnostic tests that should be performed on a regular basis in a chiropractic office or referred to a diagnostic testing center should include the following: computerized range of motion, computerized muscle testing, MRI, CT, X-ray, and NCV (Nerve Conduction Velocity).  Other objective evidence needs to be gathered in the form of outcome assessment forms such as the Visual Analogue Scale, Rand-36 Item Survey, Low Back Pain Questionnaire, Neck Pain Disability Questionnaire, and the Roland Morris.  If the patient has a decreased range of motion (ROM), then the doctor ought to evaluate the kinesiopathology of the patient utilizing computerized inclinometry (cROM) tests to document the exact loss of ROM.  This initial ROM exam will be the standard to which future ROM examinations will be measured.  Any future ROM examination should show an increase, if the treatment was effective.  If the cROM tests do not show an increase, then treatment must change in a manner consistent with the evidence gathered.  A decrease in muscle strength needs to be evaluated utilizing computerized muscle testing (cMT).  The numbness, tingling, radiculopathy, hand pain, and arm pain need to be evaluated with electrodiagnostics and computerized muscle testing. Suspected disc problems should be viewed with MRI, disc degeneration with an X-ray, and osteoporosis should be evaluated with a dexa scan.  These tests should be redone on a regular basis, for example, every 12 visits for cROM and cMT, or every three months for a dexo scan, so that the doctor can determine the treatment effectiveness. 

The chiropractic profession is in a period of change, and we have to embrace that change.  Whether it was for good or bad, the chiropractic profession joined the insurance industry; but the Mercedes 80’s are over.  Doctors of all disciplines are being held more accountable for the level of care they are providing.  The chiropractic profession must learn the rules of the insurance industry so they can receive a fair reimbursement for all services provided in the office.  One of the bigger rules is documenting the level of care recommended; and the only way to objectively provide evidence is through the use of diagnostic tests.

Dr. Dwight C. Whynot is a 1999 graduate of Logan College of Chiropractic.  He can be reached by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Blood Chemistry Analysis as a Nutritional Diagnostic Tool
Diagnostics
Written by Dr. James P. Cima, D.C.   
Wednesday, 22 June 2005 17:06

bloodtestvialsIf you are like many other doctors or students interested in nutrition, you must be able to determine when you should adjust physically or when a chemical adjustment is needed to keep that physical adjustment in place.  Whether it is from

• a high sugar diet causing midthoracic pain,
• a thyroid imbalance causing neck pain,
• a pituitary condition causing headaches,
• or  a patient's being just plain overweight from the wrong diet, which is resulting in low back pain,

how you distinguish what to do is what makes you an expert.

Using a saw (physical adjustment) when a hammer (nutritional protocol) is the tool of choice will not benefit you or your patient. So how do you determine the cause, be it physical or biochemical? More importantly, once you determine that this is a nutritional problem rather than a physical problem, how do you now determine if your patient has a problem with diet, or with an organ or glandular malfunction.

For example, if a patient has a high cholesterol, how do you distinguish if it is a dietary problem or an endocrine imbalance with the liver, adrenals, gonads, thyroid, or from a mid thoracic (T4-T9), or a vagus or phrenic nerve irritation? Or, if a patient comes in complaining of fatigue, is it because of a much-needed upper cervical adjustment, or is the patient suffering from a liver, pancreatic, adrenal, or immune system weakness?

The only method that I know of to determine the difference is a blood test. A blood test is:

1. a sound practice procedure to diagnose chemical imbalances in the body,
2. embraced by other professions,
3. considered rational with scientific data to back up the findings,
4. objective rather then subjective,
5. and it can be duplicated and is reproducible!

I have been utilizing biochemical blood chemistry evaluations for over 25 years and have written a 600-page book on the subject. I’ve also developed a software program that saves time and helps pinpoint any chemical imbalances in the body along with a recommended diet and nutritional program.

So, if you are looking for a great nutritional diagnostic tool and want to be an expert in nutrition instead of dabbling in it, then I suggest that you learn more about blood chemistry analysis and nutritional protocol.

For more information on Dr. Cima and the many books he has written, you may visit his web site at www.cimasystem.com.  For software information, visit http://www.famtech.com/CBA/web/splash.htm.

 
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