X线指导整脊的可靠性分析综述9608381

w
1/34(W)
Record: 1 Title: Reliability of spinal displacement analysis on plain X-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique. Authors: Source: Publication Type: Language: Major Subjects: Harrison DE ; Harrison DD ; Troyanovich SJ Journal of Manipulative & Physiological Therapeutics (J MANIPULATIVE PHYSIOL THER), 1998 May; 21(4): 252-66 (166 ref) journal article - pictorial, review, tables/charts English Spinal Curvatures -- Radiography Reliability and Validity Chiropractic Minor Subjects: Abstract: Funding Source ; Posture ; Patient Positioning ; Education, Chiropractic -- Trends ; Radiography -- Education BACKGROUND: Current medical, biomechanical, and chiropractic literature indicates that X-ray line drawing analysis for spinal displacement is reliable, with high Interclass Correlation Coefficients (ICCs) found in most studies. Normal sagittal spinal curvatures are being accepted as important clinical outcomes of care; however, just the opposite is taught in many chiropractic college radiology courses. OBJECTIVE: To review the current literature on X-ray line drawing reliability and abnormal static lateral positions. DATA SOURCES: Searches were performed on Medline, Chiro-LARS, MANTIS, and CINAHL on X-ray reliability, normal spinal position, and sagittal spinal curvatures as clinical outcomes. RESULTS: X-ray line drawing analysis for spinal displacement was found to have high reliability with a majority of ICCs in the .8-.9 range. The reliability for determining X-ray pathology was found to be only fair to good by both medical doctors and chiropractors and by both chiropractic and medical radiologists, with a majority of ICCs in the range .40-.75. Muscle spasms, facet hyperplasia, short pedicles and patient positioning errors have not been shown to alter sagittal plane alignment. The sagittal spinal curves are desirable clinical outcomes of care in surgery, physical therapy, rehabilitation and chiropractic. These results contradict common claims found in the indexed literature. CONCLUSION: X-ray line drawing is reliable. Normal values for the sagittal spinal curvatures exist in the literature. The normal sagittal spinal curvatures are important clinical outcomes of care. Patient positioning and postural radiographs are highly reproducible. When these standardized procedures are used, the pre-to-post alignment changes are a result of treatment procedures applied. Chiropractic radiology education and publications should reflect the recent literature, provide more support for X-ray line drawing
http://web.ebscohost.com/ehost/delivery?sid=c6d66196-2c6c-4a97-8d95-c45ecdd31d3f... 2012/2/20
2/34(W)
analyses and applications of line drawing analyses for measuring spinal displacement on plain radiographs. Journal Subset: ISSN: MEDLINE Info: Publisher Info: Grant Information: Entry Date: Revision Date: Accession Number: Database: Alternative/Complementary Therapies; Peer Reviewed; USA 0161-4754 PMID: 9608381 NLM UID: 7807107 URL: www.cinahl.com/cgi-bin/refsvc?jid=954&accno=1998041544 Supported by CBP Nonprofit, Inc 19980701 20050428 1998041544 CINAHL with Full Text
Reliability of Spinal Displacement Analysis on Plain X-Rays: A Review of Commonly Accepted Facts and Fallacies with Implications for Chiropractic Education and Technique
Reliability of Spinal Displacement Analysis on Plain X-Rays: A Review of Commonly Accepted Facts and Fallacies with Implications for Chiropractic Education and Technique ABSTRACT Background: Current medical, biomechanical, and chiropractic literature indicates that Xray line drawing analysis for spinal displacement is reliable, with high Interclass Correlation Coefficients (ICCs) found in most studies. Normal sagittal spinal curvatures are being accepted as important clinical outcomes of care; however, just the opposite is taught in many chiropractic college radiology courses. Objective: To review the current literature on X-ray line drawing reliability and abnormal static lateral positions Data Sources: Searches were performed on Medline. Chiro-LARS, MANTIS, and CINAHL on X-ray reliability, normal spinal position, and sagittal spinal curvatures as clinical outcomes. Results: X-ray line drawing analysis for spinal displacement was found to have high reliability with a majority of ICCs in the .8-.9 range. The reliability for determining X-ray pathology was found to be only fair to good by both medical doctors and chiropractors and by both chiropractic and medical radiologists, with a majority of ICCs in the range .40-.75. Muscle spasms, facet hyperplasia, short pedicles and patient positioning errors have not been shown to alter sagittal plane alignment. The sagittal spinal curves are desirable clinical outcomes of care in surgery, physical therapy, rehabilitation and chiropractic. These results contradict common claims round in the indexed literature. Conclusion: X-ray line drawing is reliable. Normal values for the sagittal spinal curvatures exist in the literature. The normal sagittal spinal curvatures are important clinical
3/34(W)
outcomes of care. Patient positioning and postural radiographs are highly reproducible. When these standardized procedures are used, the pre-to-post alignment changes are a result of treatment procedures applied. Chiropractic radiology education and publications should reflect the recent literature, provide more support for X-ray line drawing analyses and applications of line drawing analyses for measuring spinal displacement on plain radiographs. (J Manipulative Physiol Ther 1998; 21:252-66). Key Indexing Terms: Clinical Outcomes; Posture; Reliability; Spine; X-ray INTRODUCTION In 1997, Ct et al. suggested that the normal sagittal spinal curvatures should be desirable clinical outcomes of patient management ( 1). They found good agreement of subjective classification of curve pattern, with an Interclass Correlation Coefficient (ICC) of .71, into three categories: lordotic, straight and kyphotic. Also, using the rating method of Landis and Koch ( 2) adapted by Fleiss ( 3), they reported excellent (high) ICCs for Cobb angle analysis of cervical lordosis (.96-.97), but only fair to good ICCs (.45-.71) for evaluation of pathologies such as different types of spinal degeneration. In 1996, Harrison et al. provided a review of stress-strain analyses in vertebrae, discs, ligaments and central nervous system (CNS) in kyphosis, which supported the normal sagittal spinal curves as desirable clinical outcomes ( 4). In the lumbar spine, medical doctors ( 5-8) have determined that a normal sagittal lumbar curve is necessary for successful clinical outcomes after surgery. Breig ( 9-12), Johnston and Birch ( 13), Goto and Kita ( 14), Katsuura et al. ( 15), the Cervical Spine Research Society ( 16) and Frymoyer et al. ( 17) have all shown that a cervical lordosis is necessary for successful clinical outcomes. In reference to cervical lordosis. Katsuura et al. state, "we speculate that failure to maintain cervical lordosis may lead to change of static and dynamic stress on paraspinal muscles" ( 15), and The Cervical Spine Research Society states, "The importance of retaining the lordotic curve is indicated by the dorsal migration of the cord away from the floor of the canal. Spondylotic protrusions have little effect unless coexisting stenosis reduces the available space"( 16). When the preponderance of recent medical and biomechanical literature suggests normal sagittal spinal curves as clinical outcomes of care, one might ask why some in the chiropractic profession seem to be largely opposed to this idea ( 18-23). This is especially odd given that the major premise of chiropractic, historically speaking, has been that altered spinal position and dynamics (subluxations) are major contributors to health problems. Perhaps the large standard error of measurement (SEM) in Cobb angle analysis [SEM 3-5; SEM 8-9; and SEM = 10] ( 1, 24-26), has been a stumbling block to the wide use of lordotic measurements in clinical studies. In contrast to the high SEMs for Cobb angle methods, the posterior tangent method ( 27-28) of measuring spinal curvature has a very low SEM of < 1.75. One wonders why the posterior tangent method has not been more widely used. Perhaps in chiropractic, criticism should land on the shoulders of chiropractic college faculty, chiropractic radiologists (DACBRs) and other
4/34(W)
faculty teaching radiology courses for not teaching the posterior tangent line drawing methods and for not suggesting a normal sagittal spinal configuration as a desirable clinical outcome. In regard to this, Owens states methods for the detection of skeletal pathology are taught in radiology courses in all schools. On the other hand. subluxation measurement, if taught at all, is presented by entirely different departments of the colleges, usually in a technique or chiropractic methods department ( 29). Instead, some chiropractic and medical radiologists and clinicians have adopted a variety of arguments that seem to negate the use of spinal radiographs for diagnosing and treating spinal subluxations and for verifying their correction. Even though Yochum and Rowe devote approximately 50 pages to line drawing analysis, the lines discussed are generally orthopedically visualized lines and are not for measurement of spinal subluxation ( 30). In fact, at the beginning of this section of their text, they stated that there are "inherent, uncontrolled error[s]" in: (a) image unsharpness, (b) projectional geometric distortion, (c) patient positioning, (d) anatomic variation, (e) locating standard reference points and (t) observer error. This must be a consistent, inherent part of radiology training in general, because several chiropractic radiologists, medical radiologists and clinicians ( 22, 23, 31-47) have made one or more of the following claims: Normal spinal position does not exist. Variations in X-ray positioning simulate subluxation or correction. Posture and biomechanical analysis are not repeatable phenomena. Slight head nodding/flexion creates kyphosis in the cervical spine. Acute muscle spasms cause cervical and lumbar kyphosis or hypolordosis. Normal anatomic variants cause the spine to appear to be subluxated. X-rays should not be taken for biomechanical or postural screening and post-treatment Xrays are not warranted. Radiographic line drawing for measuring spinal displacements are not reliable. The purpose of this review is to demonstrate that spinal displacement analysis on plain radiographs is very reliable (item 8, line drawing analysis) and actually more reliable than pathological diagnosis on spinal X-rays. A secondary purpose is to evaluate items 1-7 in the above list for validity. A third purpose is to suggest that teachings and publications of chiropractic radiologists and college faculty should be more consistent with recent literature results. DISCUSSION Item 8: X-Ray Line Drawing Reliability In the medical literature, the Cobb angle analysis ( 1, 24-26, 48-50) has been the method of choice for measurement of overall lordosis and kyphosis of the sagittal spinal curves on the lateral radiographs (Figure 1) and for levo- and dextroscoliosis on anteroposterior (AP) radiographic views. Good to high interclass coefficients were found for inter- and intraexaminer reliability, but standard errors of measurement (SEM) were high (8 < SEM
5/34(W)
< 10). However, other methods have been employed for measurement of sagittal spinal curves, such as endplate lines ( 51-56) for RRA (Figure 2) and posterior tangents ( 27-28) for absolute rotation angles (ARA) and RRA (Figure 3). Of the studies that used Farfan's endplane lines ( 56), only Wood et al. provided any information on inter- or intraoberver errors analysis (SEM = 1.1) ( 54). Shaffer et al. determined the reliability of seven different line drawing methods for determining Z-axis translations (retrolisthesis and spondylolisthesis) ( 57). They found that all seven methods had very high ICCs for agreement between and among examiners. Dvorak et al. have shown that templating of the flexion, neutral and extension lateral cervical views has high reliability and low SEMs ( 58). In 1995, Skalli et al. evaluated the Y-axis rotations methods on AP radiographs ( 59), and they determined that the pedicle method of Drerup ( 60) has high reliability. In the chiropractic literature, Jackson et al. ( 61) and Rochester ( 62) have shown that the AP haslum upper cervical line drawing analysis had high reliability and very low standard errors of measurement (SEM < 1). Plaugher et al. ( 63, 64) and Burk ( 65) reported high reliability and low SEMs for AP pelvis line drawing analysis and AP full spine Gonstead analysis. In the lateral view, Plaugher et al. have shown high reliability for Cobb angle analysis on the sagittal spinal curves ( 24). The SEMs reported were smaller than in similar medical studies (3 < SEM < 5). For the Harrison Chiropractic Biophysics (CBP) technique lateral radiographic line drawing analysis, Jackson et al. ( 28) and Troyanovich et al. ( 27, 66) have reported a majority of high reliability and low SEMs for the posterior tangent method for RRAs and ARAs in the cervical and lumbar areas (Figure 3). High reliability and low SEM were also found for Ferguson's sacral base angle, for the new CBP arcuate angle of pelvic tilt and for the atlas plane angle to horizontal (SEMs < 2). They also determined high reliability and low SEMs for atlas translation relative to T1, T12 translation relative to S1 and a high reliability and low SEM for Cobb angles (SEMs < 3).
6/34(W)
7/34(W)
X-Ray Pathology Diagnosis Reliability Assendelft et al. ( 67) and Frymoyer et al. ( 68) have studied a comparison of medical doctors' and chiropractors' spinal radiograph interpretations for various pathological conditions and found only a fair-to-good inter- and intraexaminer reliability for both types of physicians. Most pathological conditions were in the range .4< ICCs < .75. In an additional study on X-ray pathology diagnosis agreement. Taylor et al. compared the
8/34(W)
interpretative skills of medical and chiropractic students, clinicians, radiology residents and radiologists ( 69). Twenty-one abnormal lumbosacral radiographs, depicting abnormal, pathological conditions ranging from fractures to abdominal aortic aneurysms, were used to test the diagnostic interexaminer reliability accuracy of the whole and individual groups. The correlation coefficients showed a range from .23-.70. Only the diagnosis of Paget's disease reached the .7 mark, five of the 21 were in the .6-.69 range and the vast majority were in the range from .44-.59. Thus, these can be considered to be in the fair range with only 25% in good range. ICCs were not presented separately for the individual groups. However, based on percentage correct, the chiropractic and skeletal radiologists performed the best, but the ICCs were still only in the fair-to-good range.
9/34(W)
Normal Spinal Alignment There are several types of spinal models in the biomechanics literature including: (a) anthropomorphic, (b) discrete parameter, (c) continuous elastic and (d) finite element ( 70). Spinal modeling began in the 1950s to investigate injuries to Air Force pilots during seat ejections. In 1969, Clauser et al. published a thorough investigation of the locations of centers of mass for various body parts for the Air Force (71); in 1978, Belytschiko and
10/34(W)
Privitzer published a complete three-dimensional spinal model with in vivo and in vitro validation (72). They found that the spinal alignment must be a true vertical in the AP view, have lordotic cervical and lumbar curvatures in the lateral view and be without any anterior head translation or posterior thoracic translation (72). Another early spinal model was reported by Schultz and Galante in 1970 (73). In a recent biomechanics text, Schultz and Miller state that for the AP spinal alignment, "the spine is approximately straight when viewed frontally because each vertebra and disc is approximately symmetric about the sagittal plane" (74). Unfortunately, in the lateral view for the cervical spine, Schultz and Miller (74) misquote the Gore et al. (75) average lordosis (they used the average kyphosis value of 9 instead of the lordosis value), which was 23 for Ruth Jackson's stress lines on C2 compared with C7 (an ARA analysis). Using the same posterior tangent line analysis at C2 and C7, Harrison et al. (76-78) and Janik and Harrison (79) from 1995-1997 presented validation of a circular sagittal cervical model with an average ARA of 34 and an ideal ARA of 42. They also presented average relative rotation values for each pair of cervical vertebrae from a large population of 400 subjects (Table 1) (76). For the thoracic kyphosis, Stagnara et al. ( 52) and Bernhardt and Bridwell (80) have presented average RRAs and an ARA thoracic kyphosis value from T1-T12 and T4T12 (Table 2). The Harrison ideal normal thoracic model is presently being refined from a full-spine lateral radiographic study of normal volunteers. In a recent study, Troyanovich et al. (81) compared results for the lumbar lordosis from seven separate standing lateral lumbar studies. They found that a fundamental, unique lumbar lordosis existed across a large range of age groups in 552 subjects. They determined average RRAs, ARAs, Cobb angles, Ferguson angles, arcuate angles and thoracic T12 to SI Z-axis translations (Table 3) (8l). While refining the Harrison Spinal Model (76-79,81-83). Harrison et al. (82) and Janik et al. (83) successfully modeled the sagittal lumbar lordosis with an 85 portion of an ellipse from the inferior of T12 to the superior sacral base. Thus, the Harrison spinal model provides qualitative normals (geometric shapes are cervical circular arc, thoracic circular arc and lumbar elliptical arc) and quantitative normal sets of values for the cervical lordosis and lumbar lordosis.
11/34(W)
From the multitude of X-ray reliability studies, which show a good-to-high degree of interand intraexaminer reliability, it is obvious that line drawing analysis on plain radiographs is one of the most investigated topics in the literature. The vast majority of results indicate that X-ray line drawing of all types has good-to-high ICCs and Pearson coefficients; therefore, these methods are acceptable for clinical research and clinical practice. In a review of cervical spine line-drawing methodology. Owens states "The major question should no longer be if X-ray analysis can be used as a tool in the scientific investigation of chiropractic subluxation" ( 29). This literature evidence is contrary to the beliefs of some medical researchers and chiropractic radiologists. For instance, Phillips states "Given the lack of scientific evidence to support the validity and reliability of X-rays in the biomechanical evaluation of the patient, medicolegal concerns should question the value of unjustified exposure to ionizing radiation" ( 33). As another example, in a recent publication, Schultz and Bassano concluded "Radiography has not demonstrated adequate reliability or validity for the detection and characterization of subluxations" ( 32).
12/34(W)
However, it should be noted that only an extremely few medical and chiropractic physicians publish, whereas the vast majority of practicing chiropractors probably use some form of line drawing analysis, as inferred from a 1993 random sample survey (84). However, a more recent survey by Harger et al. indicated that only 51% of 197 practicing DC respondents thought that evaluation for posture and biomechanics was an important reason for taking X-rays of patients ( 35). This may potentially indicate that items 7 and 8, which are advocated by radiologists, are perhaps having a large impact on the chiropractic profession. This is because the techniques used most often in 1993 require X -ray analysis; however, only 51% of the 1997 respondents were taking X-rays for posture and biomechanical reasons. Also in 1993, the Mercy Center Proceedings stated that "Spinal radiography is used widely as a reassessment tool"; these proceedings give a Rating of necessary, Evidence of Class III, and Consensus Level of I for periodic reassessment in Chapter 9 (page 136), in which spinal radiography was included as a reassessment procedure (85). Besides the fact that many studies that describe the geometry of the spine have used measuring methods without doing reliability studies (l), some studies use poor methodology when analyzing line drawing methods (86). Barker and Jackson (87) asserted that Sigler and Howe ( 31) used poor methodology and inappropriate statistics, which led the latter to report inaccurate low reliability results for AP nasium line drawing. Sigler and Howe's ideas have been continually presented in chiropractic radiology courses and literature by Haftman ( 22-23), Schultz and Bassano ( 32), Phillips ( 33) and Mootz et al. ( 45), and line drawing on radiographs is discouraged or minimized by chiropractic radiologists.
13/34(W)
From the values reported for reliability of diagnosis of spinal pathologies on plain radiographs (only fair-to-good ICCs), it is evident that line drawing analysis for spinal displacement on plain radiographs is much more reliable (good-to-high ICCs). Therefore, more time in chiropractic radiological courses should be spent on the more reliable and valid methods out of the multitude of X-ray line drawing methods available in the literature. It is not surprising that X-ray line drawing has high reliability. After all, it is simply Euclidean geometry in most cases. A plethora of accurate uses of Euclidean geometry by mathematicians and engineers are found everywhere in our daily lives. Why would a few simple lines and angles on plain radiographs be any different? Also, it is not surprising that the posterior tangent methods on the sagittal spinal curvatures are more reliable and valid than a Cobb angle analysis. According to Voutsinas and MacEwen, "Cobb's method, although the accepted method, is unable to represent an actual arc and reflects changes in the end vertebral bodies, rather than changes within the curve itself" (88). Harrison et al. also demonstrated that the Cobb angle is not an accurate representation of sagittal plane curves (82,83). Whereas a Cobb angle analysis requires a four-line procedure, the posterior tangent analysis is a two-line procedure; thus, the possibility for human error is halved. Mathematicians and mechanical engineers have used a continuity and slope analysis of structures, based upon a tangent line method, for more than 350 yr (Newton and Kepler in the 1600s, Euler in the 1700s, etc.). Mechanical engineers, while being taught to analyze the loads, deflections, stresses, strains, bending moments, shears, optimal designs, and failures of structures, learn to draw tangent lines on structures; the lines are actually just the concept of a derivative at a point in calculus (89). Applications of the Reliability of X-Ray Une Drawing Analysis The important applications of reliable X-ray spinal displacement analyses are found in the clinical setting. These include diagnosis of structural problems, choice of techniques, applications of patient care methods, case management and establishment of goals of care, which includes anatomic structural alignment outcomes (90). Adding introduction items 1-7 to reliability criticisms, we suggest that chiropractic radiologists and some clinicians in the indexed literature have been inappropriately critical of numerous technique procedures and goals. Item 1: Fictitious normal. For the first example, Hariman ( 22-23) stated that chiropractic radiologists should decide what normal spinal alignment might be based on their experience of looking at contours on radiographs. After comparing chiropractic radiologists education with mechanical engineering, Harrison et al. (91,92) concluded that this Harman claim was unfounded. Structures must be evaluated for their ability to withstand loads with a stress-strain analysis, buckling analysis, strength of materials, etc., whereas radiological education is completely lacking in these areas of mechanics. As reported below, average normal values and ideal normal values exist in the literature for spinal alignment on radiographs and these two types of normal values are based upon
14/34(W)
engineering principles. One such model of normal, the Harrison spinal model, has been refined and validated in the lumbar and cervical areas (76-79,81-83). Item 2: X-ray positioning. Yochum and Rowe ( 30), Schultz and Bassano ( 32), Mootz et al. ( 45) and Phillips (93) claim that pre-and post-treatment X-rays can not be used to show spinal alignment changes because of the inability to consistently place patients in repeatable positions. Contrary to this belief, Plaugher et al. have shown that pelvic positioning is repeatable ( 64). Jackson et al. ( 61) and Rochester and Owens (94) demonstrated that nasium positioning was repeatable. Harrison et al. had a control group that had lateral cervical X-rays taken 90 days apart with no change in structural measurements, illustrating that the CBP technique positioning for a lateral cervical view is repeatable (95). Sandham demonstrated that lateral head and neck radiographs are repeatable "...with a method error of only a few degrees..." (96). Stagnara et al. state that "the clinical and X-ray measurements of kyphoses and fordoses are remarkably constant to within a few degrees, provided the position is clearly stipulated" ( 52). Singer et al. compared 22 pairs of in vivo and in vitro lateral radiographs of the same subject ( 50). The average elapsed time between radiographs was 7 months; the longest was 77 months (6.5 yrs). They stated that "no significant differences existed between the in vivo and in vitro films" ( 50). Milne and Williamson compared 261 patient sets of lateral thoracic radiographs taken 5 yr apart and found no significant changes in thoracic curve measurements (97). Item 3: Posture not repeatable. We have all heard the old cliche that posture changes on a day-to-day basis and is not a consistent, repeatable phenomenon. The incorrect assumption that posture is not consistent and repeatable is very similar to the fallacy that X-ray positioning is not consistent and repeatable, as just discussed in item 2, above. If patients' postures were found to be unreliable and ever-changing, considerable problems would exist for the structurally oriented physician. However, in contrast, just the opposite has been shown over and over again by researchers studying posture. In a 2-yr follow-up study, Bullock-Saxton has shown that lateral resting posture is highly repeatable (98). She states that "in the normal, symptom-free, young adult subject, the perception of posture, and therefore postural alignment, remains constant for at least two years" (98). In 27 consecutive patients, Lundstrom et al. demonstrated that repeat photographs of "natural head posture" is highly reproducible, with a correlation coefficient of r = .9 (99). Refshauge et al. found cervical and cervico-thoracic posture to be reproducible on the same day and 1 wk later (100). Grimmer found cervical resting posture in 93 subjects to be repeatable 1 month later (101). Other studies also corroborate the finding that posture is highly repeatable and measurements are reliable (95-97). Item 4: Slight head nodding. Another example of a perpetuated fallacy by radiologists and clinicians is that "slight head nodding" can reverse the cervical curve. Thus, this is used to invalidate any "apparent cervical curve corrections" on before/after radiographs when any slight nodding is present (i.e., change in the hard palate angle to horizontal). We found approximately 12 references to this effect in the literature ( 19, 30, 37, 39-44,102,103). However, only three studies ( 39, 40, 42) and one case study ( 41) actually addressed this
15/34(W)
issue. The rest of the eight authors either claimed this with no support [e.g., Clark et al. ( 43) and Kettner and Guebert ( 38)] or reference the four studies ( 39-42) that addressed the issue of head nodding. In 1996, Keats offered two cases where he claimed "slight alteration in head position" dramatically changed the cervical lordosis ( 41). In the first example, it is not apparent which position was used to "alter" the lordosis and the lordosis is already significantly hypolordotic in the neutral position. In the second example offered by Keats, the neutral lordosis is straight or slightly kyphotic from C3-C7 and then the "slight position" change is 15-16 of additional head flexion ( 41). Thus, this is a large amount of head-neck flexion and should not be considered as a slight position change. Keats ( 41) is a poor reference to cite when claiming that head nodding reverses the curve. In 1975, Weir claimed to have taken radiographs in the neutral position and with 1 in. of chin depression (flexion) in 360 adults ( 42). Weir states "20 percent of the patients had either a straight spine or kyphotic curve in the neutral lateral position. With the chin depressed one inch, this figure increased to 70 percent" ( 42). However, close scrutiny reveals that Weir offers no radiographs demonstrating this effect, does not mention how the chin depression was measured, does not mention if any radiographic measurements of lordosis were used to demonstrate a change in lordosis and certainly does not provide any statistical data verifying his claims ( 42). If Weir used a Cobb angle from C1 to C7, then changes from occiput-C1-C2 could occur without any change in curvature from C2 to C7. Figure 4 illustrates that head nodding will change the flexion of the skull and atlas (and thus a Cobb angle from C1 to C7), but not the curvature from C2 to C7. Therefore, without a segmental rotation analysis, Weirs claims should be suspect. Thus, this reference cannot be used with any certainty to claim that head nodding reverses the cervical lordosis. In 1963, Fineman et al. took repeat radiographs of 129 patients "with the chin slightly lowered" ( 39). According to their results, flexion altered the cervical lordosis in only 41% of the subjects and, in the other 59% (or 76 subjects) (the majority), flexion did not effect the cervical configuration. The authors used a unique method of line drawing, which they claimed gave "a rough measure of the forward inclination of the whole cervical column," but no reliability or statistical analysis was performed. From reading their study's Methods section, it is apparent that they actually lowered the chin a distance of 1.5-2.0 vertebral bodies on the second radiograph. We calculated chin to condyle distances on some radiographs (4 in. average) and an atlanto-occipital joint to inferior T1 distance of 6 in. (Figure 5). Using trigonometry, we calculate the amount of head flexion as = arcsin (1.5/4) = 22 for the chin lowered two vertebral bodies. Actual measurements of three of their comparative radiographs demonstrates that approximately 12, 19 and 20 of flexion was used and therefore, our calculation in Figure 5 is relatively accurate. This amount of flexion does not qualify for "slight head nodding." From page 88 in the AMA Guides to the Evaluation of Permanent Impairment (104), the normal amount of average total head flexion is 60. Thus, this 1962 study used 33% of the total head flexion and
16/34(W)
should not be used to claim that "slight nodding" can cause large changes in lordosis ( 39). In 1962, Juhl et al., claimed that position changes of the skull because of muscle contraction can cause loss or reversal of the cervical lordosis ( 40). However, from reading their Methods section, it is noted that the patients were instructed to posteriorly translate their heads with slight chin flexion, which is similar to the McKenzie complete head retraction position (105) but is not a typical cervical muscle contraction. Penning has shown that posterior translation of the skull causes flexion of the upper three or four cervical vertebrae and slight extension of the lower vertebrae (106). This is consistent with the findings of Juhl et al. ( 40) of an S-curve or local kyphosis in some of their patients. The literature indicates that patient and nonpatient populations have anterior translation of their skulls relative to their thorax with varying magnitudes (95,100,101). Therefore, the study of Juhl et al. is not relevant to patient positioning; it should not be used to claim that slight head nodding, positioning errors or muscle spasms drastically reduce the cervical lordosis ( 40). Obviously, what has been claimed as "slight head nodding" in these studies needs to be updated and corrected in the chiropractic literature. Careful reading of the methods sections of these studies reveals that many authors ( 19, 30, 37, 43, 44,102,103) have completely taken their "slight head nodding" criticism out of context. None of these studies have actually measured the claimed change in curvature with appropriate, reliable linedrawing procedures. Also, none of these studies have measured relative rotation angles and none have done any statistical analysis to confirm their claims, whereas other studies use large degrees of head flexion and head retraction, which would be extremely unlikely to be present in a patient's posture. Other studies have suggested that, in fact, head nodding does not change the cervical lordosis. For example, Bland states, "Nodding occurs at the atlanto-occipital joints, with the atlan-toaxial joints participating to some degree" (107). Dvorak et al. state that "the atlanto-occipital joint (OCC-C1) acts as the pivot for the flexion/extension motion of the cranium" (108). The occiput-to-C2 articulations average about 23 of flexion/extension (107). Therefore, head nodding occurs in the upper cervical spine and, according to Torg, 30 of head/neck flexion is required to straighten the neutral lordotic cervical curve (109). Additionally, in 1994, Wallace et al. used two methods of before-and-after positioning in each of 31 subjects studied for the effects of chiropractic adjustments on cervical curve restoration (110). One method involved the subjects assuming a natural lateral head position, the second method involved placing a tongue depressor in the mouth to be used "as a reference for maintaining subjects'" head level at constant position. After 12 wk of care, a statistically significant change of 6.35 using the tongue depressor method and 5.9 of change in the natural position were found using posterior tangent lines from C2C7. This led Wallace et al. to conclude that "the posture of the subject during the X-ray process does not alter the outcome" (110).
17/34(W)
Thus, slight head nodding occurs in the upper cervical spine and does not affect curve measurements from C2 to C7. Further investigation into this area is warranted before any solid conclusions are made. Studies should include reliable methods of measuring the head flexion change, RRAs of all cervical vertebrae, and statistical analysis to demonstrate where the majority of flexion occurs.
Item 5: Acute muscle spasms. Another commonly accepted notion is that lack of lordosis on pretreatment X-rays is caused by cervical muscle spasms ( 37, 39, 40, 43, 44. 46, 103). Gehweiler et al. ( 44) cite Clark et al. ( 43) for this. Clark et al. claim this to be true but offer no evidence ( 43), which is also the case for Kettner and Guebert ( 37) and Deltoff and Kogon ( 46). Pedersen (103) and Yochum and Rowe ( 30) cite Juhl et al. ( 40). However, the study of Juhl et al. used active posterior translation of the skull to change the cervical curve in subjects ( 40); it should not be used to claim that muscle spasm reverses the curve without concomitant posterior head translation. With regard to this
18/34(W)
item, we could locate no study that specifically verified muscle spasm as the cause of cervical curve reversal; all were speculations. We suggest that this is an illogical belief because the volume of muscle in the posterior erector spinae compared with the anterior muscles (longus colli) would dictate a hypefiordosis from cervical spasms. In fact, the work of Helliwell et al. (111) in the cervical spine and McGill et al. (112) in the lumbar spine contradict this hypothesis. McGill (113) and McGill et al. (112) have shown that spasms of neither the psoas nor the lumbar erector spinae can cause hypolordosis. The posterior muscles cause extension, compression, and shear forces, whereas the psoas muscle causes lateral flexion of the lumbar spine and flexion of the hip (112,113). Helliwell et al. state "The stronger extensor muscles, however, would be expected to induce an increase in lordosis in both the lumbar and the cervical spine or a rotational displacement such as is seen in acute torticollis" (111). The various types of reversed curve configurations have been classified as single, double, triple and quadruple harmonics by Harrison et al.. This classification corresponds to the number of apices in the curve (a single harmonic would be a total reversal of the normal lordosis, a double harmonic is an S curve, and a triple harmonic has lordotic-kyphoticlordotic or kyphotic-lordotic-kyphotic regions). These different types of curve reversals are types of sagittal plane buckling and have been caused by pure compressive or compressive combined with flexion loads (112-116). The various configurations can be created by changing the magnitude, direction and rate of load application and by altering the type and angle of the surface with which the spine or skull comes into contact. Figure 6 illustrates abnormal curvatures associated with buckling of the cervical spine. During this type of loading. Nightingale et al. state "injuries occur two to three times more quickly than the muscles of the cervical spine react" (114). Thus, muscular effort does not create the various reversed configurations of the cervical and lumbar spines. In recent studies, Svensson et al. (117) and Grauer et al. (118) have produced "S-shaped curvatures" during whiplash injuries while monitoring sagittal plane intervertebral rotations with highspeed cinematography. After any buckling, muscular effort and activity must increase in response to and as a result of the change in position of the sagittal plane configuration to stabilize the structure. Item 6: Normal anatomic variants. Another criticism concerning attempts to restore normal cervical lordosis is the hypothetical idea that "hyperplasia of the facets" and anomalies of the pedicles limits lordosis or creates a "normal kyphosis" ( 36, 38, 47,119-121). Nordhoff discusses hyperplasia of the facets in some detail and claims they create a structural kyphosis (119); he cites Peterson and Wei ( 38) for this. Plaugher et al. also cite Peterson and Wei for this idea (120). The Peterson and Wei reference is only a case report; they offer two radiographs of "facet hyperplasia" in association with straightening and reversal of the cervical curve. However, no additional radiographs of flexion/extension were offered to indicate that these individuals had altered sagittal plane motion.
19/34(W)
The use of flexion/extension films is paramount because the neutral lateral position is simply the resting position somewhere between the end points of motion. To claim that "hyperplasia of the facets" causes a change in the neutral position (lordosis), it would first have to be demonstrated that the segmental flexion and extension motions were altered at these levels. Also, fixations at these same levels would need to be ruled out because fixations can cause a change in segmental motion parameters without concomitant facet hyperplasia. We searched the literature for such studies but none could be located. In support of their speculation. Peterson and Wei cited MacCrae ( 36). We found MacCrae to be the earliest reference to "facet hyperplasia" causing kyphosis of the cervical spine, but he presented no statistical evidence. Additionally, MacCrae ( 36) claimed short pedicles, increased facet angles and decreased facet size will all create a structural hypolordosis. Stillwagon and Stillwagon claim pedicle size, articular pillar size, and facet angles alter the cervical curve but do not provide any references (121). Additionally, Stillwagon and Stillwagon present information gleaned from lateral X-rays that they claim indicates that changes in facet angles to horizontal are the cause of altered lordosis (121). However, no statistical data or reliability data are presented and motion analysis is not performed. Plaugher et al. (120) cite Stillwagon and Stillwagon (121). However, MacCrae ( 36) seems to be the originator of these ideas; he stated these conjectures and provided a few drawings of these anomalies without any supporting references or proof. After searching Medline, chiropractic literature and radiology texts, we were unable to locate any anatomical or radiographic studies that cross-referenced any such hyperplasia of the facets. Thus, we can only conclude that this is an unsupported hypothesis not to be construed as fact. Item 7: Screening X-rays should not be taken. There is a belief ( 32-35) that routine evaluation of posture or mechanics of the spine with radiographs "borders on abdication of the right to take X-rays" ( 33). Furthermore, Phillips claims the guidelines put forth by Deyo and Diehl (122) in 1986 should be considered the "standards for consideration of the use of X-rays for diagnostic purposes" ( 33). However, we feel that this proposed list of guidelines is inadequate; only under strict circumstances are radiographs recommended for evaluation of the alignment of the spine and post-treatment X-rays are never recommended. Spinal X-ray analysis is the only reliable method for viewing the static alignment of the spine. There is sufficient evidence to suggest that the sagittal and AP configurations of the spine are related to pain, degeneration, function, and development of the neuromusculoskeletal system ( 5-17,89,102,123-132).
20/34(W)
Additionally, there are several studies that have demonstrated, using before-and-after radiographs, that treatment can positively correct or reduce the magnitude of the spinal displacement in the lateral (95,110,133-135) and AP projections (123-125). For example, concerning corrections on before-and-after lateral cervical radiographs, Harrison et al. reported an average correction in lordosis of 13.5 in Ruth Jackson's stress lines and 75% of kyphotic configurations returned to lordosis after 3 months of treatment with a frequency of 5 sessions per week (95). Itoi and Sinaki state that "increasing the back extensor strength in healthy estrogen-deficient women helps decrease thoracic kyphosis" (133). In the anterior-toposterior view, Weiss demonstrated improved posture and statistically significant decreases in the primary and secondary curvatures in scoliosis patients after a 4-6 wk in patient exercise program (123). Friberg (124) and Irvin (125) demonstrated correction of AP lumbo-pelvic postural curvatures secondary to anatomical leg length inequality. Friberg concluded that "without standing orthoradiography of the lumbar spine, the hip and knee joints, leg length inequality of less than 20 mm as well as the compensatory postural pelvic tilt scoliosis remain undiagnosed" (124). It should be noted that all these medical, physical therapy and chiropractic studies used a pre-and post-treatment X-ray analysis. In spite of the personal beliefs of Schultz and Bassano ( 32), Phillips ( 33), Taylor ( 34) and Harger et al. ( 35) about the use of before-and-after X -rays, it is obvious that dentists, podiatrists, orthopedic surgeons, physiatrists, chiropractors, and physical therapists have been documenting structural improvements in a variety of anatomical parts via pre- and post-treatment X-ray measurements in the literature for decades ( 5-17,95-97,102,105,110,115,123-125,128,133-135,136-165). Lastly, the studies from Wallace et al. (110) and Irvin (125) demonstrated statistically significant reductions in pain, pain intensity and decreased threshold of pain levels as a result of postural and structural correction. We are suggesting that further research involving randomized controlled clinical trials should be performed addressing the link between the structure of the spine, treatment methods and various outcome measurements. However, we note that there already exists an incontrovertible causal link between spinal positions and spinal growth, aberrant repair, degeneration and the increased probability for the experience of pain when abnormal spinal positions are maintained ( 5-17,90,102,123-132). As in the recent literature cited above, pre- and post-treatment spinal radiographs are important tools in the chiropractic evaluation and documentation of patients' improvement with a wide variety of conditions, including pain. Chiropractic radiologists and clinicians need to keep abreast of recent clinical and biomechanical studies as this information fully supports an anatomic (improved spinal alignment) outcome as an important clinical goal of care (90). CONCLUSION Chiropractic education in radiology courses should reflect the current biomedical and biomechanical literature which supports line drawing on plain radiographs. Extra education in evaluating radiographic contours should not be considered an education in
21/34(W)
mechanical engineering applied to biology. In fact, it has been shown that, contrary to many opinions, the following items are valid: Both a normal average and an ideal normal spinal model exist. Standing X-ray positioning is repeatable. Neutral resting standing posture is very reliable. Slight head nodding does not affect C2-C7 curve measurements. Acute muscle spasms of the paraspinal muscles would cause hyperlordosis, not hypolordosis. Facet hyperplasia, short pedicles, etc. have not been proven to cause a reduced lordosis. Anatomical alignment is a desirable clinical outcome and post-treatment X-rays are needed to evaluate progress. Geometric radiographic line drawing is very reliable; in fact, it is more reliable than diagnosis for spinal pathologies. Especially disconcerting is the secondary and tertiary referencing of early opinion papers without clinical evidence. For examples, considering items 4, 5, and 6 above, it has been shown that a fallacy has been perpetuated concerning cervical curve changes associated with "slight head nodding," muscle spasms, and anatomic variants. In fact, these fallacies can be traced back to studies in 1962 ( 40), 1963 ( 39), 1983 ( 36), and 1987 ( 38). The 1963 study ( 39) did not include "head nodding" in the methods; in fact, it was a posterior head translation study with a head retraction position similar to the posterior McKenzie position. The Methods section in the 1962 study indicate head flexion of approximately 20; this position cannot be considered slight head nodding ( 40). Although the Peterson and Wei reference is a case report ( 38), the MacCrae reference is opinion without clinical facts or statistics ( 36). Likewise, the study from Stillwagon and Stillwagon is not supported by any statistical analysis with reliable methods and is pure speculation (121). Radiologists should stop criticizing lateral cervical curve corrections on before-and-after radiographs with these studies ( 36, 38-40) which obviously do not apply. Resting standing posture is very repeatable and X-ray positioning using resting standing posture has been shown to be reliable. Also, several normal spinal models have been presented and validated in the literature; the Harrison spinal model is one such normal model (76-79,81-83). Because this model is well documented in the Index Medicus literature, chiropractic education should utilize the published normals associated with this model as goals and clinical outcomes of care. Medical doctors, physical therapists, physiatrists, podiatrists, and dentists are using post-treatment X-ray analysis to determine success of both conservative care and surgical outcomes. Also, chiropractors who are attempting spinal rehabilitation should use post-treatment X-rays to determine anatomical alignment for postural and spinal outcome-based care. In the chiropractic literature, radiologists have been propagating what we feel to be inaccurate information concerning anatomical outcomes, normal spinal position, reliable X -ray line drawing, reliable patient positioning, and before-and-after radiographic evidence of changes in spinal position, Because radiologists are held in high esteem in the chiropractic profession, their opinions carry considerable weight and authority. We hope
22/34(W)
that intellectual honesty and the information presented herein will aid in changing outdated, inaccurate and invalid beliefs from being continually disseminated in chiropractic radiology courses, reference texts and clinical literature. ACKNOWLEDGEMENT We thank Sanghak O. Harrison, D.C., for her artwork, and Lyndon Greco for assistance in the collection of reference material. REFERENCES (1.) Ct P, Cassidy JD, Yong-Hing K, Sibley J, Loewy J. Apophysial joint degeneration, disc degeneration, and sagittal curve of the cervical spine. Spine 1997; 22:859-64. (2.) Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33:159-74. (3.) Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: Wiley & Sons; 1981. p. 212-36. (4.) Harrison DD, Troyanovich S J, Harrison DE, Janik TJ, Murphy DJ. A normal sagittal spinal configuration: a desirable clinical outcome. J Manipulative Physiol Ther 1996; 19:398-405. (5.) Guanciale AF, Dinsay JM, Watkins RG. Lumbar Lordosis in Spinal Fusion: a comparison of intraoperative results of patient positioning on two different operative table frame types. Spine 1996; 21:964-9. (6.) Hasday CA, Passoff TL, Perry J. Gait abnormalities arising from iatrogenic loss of lumbar lordosis secondary to Harrington instrumentation in lumbar fractures. Spine 1983; 8:501-11. (7.) Peterson MD, Nelson LM, McManus AC, Jackson RP. The effect of operative position on lumbar lordosis. Spine 1995; 20:1419-24. (8.) Tan SB, Kozak JA, Dickson JH, Nalty TJ. Effect of operative position on sagittal alignment of the lumbar spine. Spine 1994; 19:314-8. (9.) Breig A. Adverse mechanical tensions in the central nervous system: analysis of cause and effect, relief by functional neurosurgery. New York: Wiley & Sons; 1978. (10.) Breig A, Troup JDG. Focal intramedullary tension in patients with cord lesions and its surgical relief by spinal cord relaxation. Lancet 1984; 1:739-40. (11.) Breig A. Overstretching of and circumscribed pathological tension in the spinal cord - a basic cause of symptoms in cord disorders. J Biomech 1970; 3:7-9. (12.) Breig A, Renard M, Stefanko S, Renard C. Healing of the severed spinal cord by biomechanical relaxation and surgical immobilization. Anat Clin 1982; 4:167-81.
23/34(W)
(13.) Johnston C, Birch JG, Daniels JL. Cervical kyphosis in patients who have Larsen syndrome. J Bone Joint Surg Am 1996; 78:538 -45. (14.) Gott S, Kita T. Long-term follow-up evaluation of surgery for ossification of the posterior longitudinal ligament. Spine 1995; 20:2247-56. (15.) Katsuura A, Kukuda S, Imanaka T, Miyamoto K, Kanemoto M. Anterior cervical plate used in degenerative disease can maintain cervical lordosis. J Spinal Disord 1996; 9:4706. (16.) Cervical Spine Research Society Editorial Committee. The cervical spine. Philadelphia: JB Lippincott; 1983. p. 406. (17.) Frymoyer JW. The adult spine, Principles and practice. 2nd ed. Philadelphia: Lippincott-Raven; 1997. p. 1110-7, 1401-12. (18.) Owens EF. A normal sagittal spinal configuration: a desirable clinical outcome (letter). J Manipulative Physiol Ther 1997; 20:133-4. (19.) Morgan L. A normal sagittal spinal configuration: a desirable clinical outcome (letter). J Manipulative Physiol Ther 1997; 20:130-1. (20.) Jutkowitz J. A normal sagittal spinal configuration: a desirable clinical outcome (letter). J Manipulative Physiol Ther 1997; 20:288-90. (21.) Taylor JAM. The role of radiography in evaluating subluxation. In: Gatterman MI, editor. Foundations of chiropractic subluxation. St. Louis: Mosby; 1995. p. 68-85. (22.) Hariman DG. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study (letter). J Manipulative Physiol Ther 1995; 18:42. (23.) Hariman DG. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study (letter). J Manipulative Physiol Ther 1995; 18:323-4. (24.) Plaugher G, Cremata EE, Phillips RB. A retrospective consecutive case analysis of pre-treatment and comparative static radiographic parameters following chiropractic adjustments. J Manipulative Physiol Ther 1990; 13:498-506. (25.) Gelb DE, Lenke LG, Bridwell KH, Blanke KB, McEnery KW. An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine 1995; 20:1351-8. (26.) Polly DW, Kilkelly FX, McHale KA, Asplund LM, Mulligan M, Chang AS. Measurement of lumbar lordosis: evaluation of intraobserver, interobserver, and technique variability. Spine 1996; 21:1530-6.
24/34(W)
(27.) Troyanovich S, Robertson GA, Harrison DD, Holland B. Intra-and interexaminer reliability of the chiropractic biophysics lateral lumbar radiographic mensuration procedure. J Manipulative Physiol Ther 1995; 18:519-24. (28.) Jackson BL, Harrison DD, Robertson GA, Barker WF. Chiropractic biophysics lateral cervical film analysis reliability. J Manipulative Physiol Ther 1993; 16:384-91. (29.) Owens EF. Line drawing analyses of static cervical X ray used in chiropractic. J Manipulative Physiol Ther 1992; 15:442-9. (30.) Yochum TR, Rowe LJ. Essentials of skeletal radiology. Vol. 1. Baltimore: Williams & Wilkins; 1987. p. 169. (31.) Sigler DC, Howe JW. Inter- and Intra-examiner reliability of the upper cervical x-ray marking system. J Manipulative Physiol Ther 1985; 8:75-80. (32.) Schultz GD, Bassano JM. Is radiography appropriate for detecting subluxations? Top Clin Chiropr 1997; 4:1-8. (33.) Phillips RB. Plain film radiography in chiropractic. J Manipulative Physiol Ther 1992; 15:47-50. (34.) Taylor JAM. Full-spine radiography: a review. J Manipulative Physiol Ther 1993; 16:460-74. (35.) Harger BL, Taylor JAM, Haas M, Nyiendo J. Chiropractic radiologists: a survey of chiropractors' attitudes and patterns of use. J Manipulative Physiol Ther 1997; 20:311-4. (36.) MacRae JE. Roentgenometrics in chiropractic. 6th ed. Toronto, Canada: Canadian Memorial Chiropractic College; 1983. (37.) Kettner NW, Guebert GM. The radiology of cervical spine injury. J Manipulative Physiol Ther 1991; 14:518-26. (38.) Peterson CK, Wei T. Vertical hyperplasia of the cervical articular pillars. J Chiropr 1987; 24(4):78-9. (39.) Fineman S, Borrelli FJ, Rubinstein BM, Epstein H, Jacobson HG. The cervical spine: transformation of the normal lordotic pattern into a linear pattern in the neutral posture. A roentgenographic demonstration. J Bone Joint Surg Am 1963; 45:1179-83. (40.) Juhl JH, Miller SM, Roberts GW. Roentgenographic variations in the normal cervical spine. Radiology 1962; 78:591-7. (41.) Keats TE. Atlas of normal Roentgen variants that may simulate disease. 6th ed. St. Louis: Mosby; 1996. (42.) Weir DC. Roentgenographic signs of cervical injury. Clin Ortrop 1979; 109:9-17.
25/34(W)
(43.) Clark WM, Gehweiler JA, Laib R. Twelve signs of cervical spine trauma. Skeletal Radiol 1979; 3:201-5. (44.) Gehweiler JA, Clark WM, Schaaf RE, Powers B, Miller MD. Cervical spine trauma: the common combined conditions. Radiology 1979; 130:77-86. (45.) Mootz RD, Hoffman LE, Hansen DT. Optimizing clinical use of radiography and minimizing radiation exposure in chiropractic practice. Top Clin Chiropr 1997; 4:34-44. (46.) Deltoff MN, Kogon PL. The portable skeletal x-ray library. St. Louis: Mosby; 1998. p. 247. (47.) Leach R. An evaluation of the effect of chiropractic manipulative therapy on hypolordosis of the cervical spine. J Manipulative Physiol Ther 1983; 6:17-23. (48.) Goldberg MS, Poittras B, Mayo NE, Labelle H, Bourassa R, Cloutier R. Observer variation in assessing spinal curvature and skeletal development in adolescent idiopathic scoliosis. Spine 1988; 12:1371-7. (49.) Kolessar DJ, Stollsteimer GT, Betz RR. The value of the measurement from T5-T12 as a screening tool in detecting abnormal kyphosis. J Spinal Disord 1996; 9:220-2. (50.) Singer KP, Edmondston SJ, Day RE, Breidahl WH. Computer-assisted curvature assessment and Cobb angle determination of the thoracic kyphosis. Spine 1994; 19:13814. (51.) Pope MH, Bevins T, Wilder DG, Frymoyer JW. The relationship between anthropometric, postural, muscular, and mobility characteristics of males ages 18-55. Spine 1985; 10:644-8. (52.) Stagnara P, De Mauroy JC, Dran G, et al. Reciprocal angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine 1982; 7:335-42. (53.) Wambolt A, Spencer DL. A segmental analysis of the distribution of the lumbar lordosis in the normal spine. Orthop Trans 1987; 11:92-3. (54.) Wood KB, Kos P, Schendel M, Persson K. Effect of patient position on the sagittalplane profile of the thoracolumbar spine. J Spinal Disord 1996; 9:165-9. (55.) Cholewicki J, Crisco JJ, Oxland TR, Yamamoto I, Panjabi MM. Effects of posture and structure on three-dimensional coupled rotations in the lumbar spine. Spine 1996; 21:2421-8. (56.) Farfan HF. Mechanical disorders of the lower back. Philadelphia: Lea & Febiger; 1973.
26/34(W)
(57.) Shaffer WO, Spratt KF, Weinstein JE, Lehmann TR, Goel V. The consistency and accuracy of roentgenograms for measuring sagittal translation in the lumbar vertebral motion segment: an experimental model. Spine 1990; 15:741-50. (58.) Dvorak J, Froehlich D, Penning L, Baumgartner H, Panjabi MM. Functional radiographic diagnosis of the cervical spine: flexion/extension. Spine 1988; 13:748-55. (59.) Skalli W, Lavaste F, Descrimes JL. Quantification of three-dimensional vertebral rotations in scoliosis: what are the true values? Spine 1995; 20:546-53. (60.) Dremp B. Principles of measurement of vertebral rotation from frontal projections of the pedicles. J Biomech 1984; 17:923-35. (61.) Jackson BL, Barker WF, Bentz J, Gambale AG. Inter- and intra-examiner reliability of the upper cervical x-ray marking system: a second look. J Manipulative Physiol Ther 1985; 10:157-63. (62.) Rochester RP. Inter and intra-examiner reliability of the upper cervical x-ray marking system: a third and expanded look. Chiropr Res J 1994; 3:23-7. (63.) Plaugher G, Hendricks AH. The inter- and intraexaminer reliability of the Gonstead pelvic marking system. J Manipulative Physiol Ther 1991; 14:503-8. (64.) Plaugher G, Hendricks AH, Doble RW, Bachman, TR, Araghi HJ, Hoffart VM. The reliability of patient positioning for evaluating static radiographic parameters of the human pelvis. Manipulative Physiol Ther 1993; 16:517-22. (65.) Burk JM, Thomas RR, Ratlift CR. Inter- and intra-examiner agreement of the Gonstead line marking method. Am J Chiropr Med 1990; 3:114-6. (66.) Troyanovich S J, Harrison DE, Janik TJ, Harrison DD. A further analysis of the reliability of posterior tangent lateral lumbar radiographic mensuration procedure: concurrent validity of computer-aided x-ray digitization. J Manipulative Physiol Ther 1998; in press. (67.) Assendelft WJJ, Bouter LM, Knipschild PG, Wilmink JT Reliability of lumbar spine radiograph reading by chiropractors. Spine 1997; 22:1235-41. (68.) Frymoyer JW, Phillips RB, Newberg AH, McPherson BV. A comparative analysis of the interpretations of lumbar spine radiographs by chiropractors and medical doctors. Spine 1986;11:1020-3. (69.) Taylor JAM, Clopton P, Bosch E, Miller KA, Marcelis S. Abnormal lumbosacral spine radiographs: a test comparing the interpretations of students, clinicians, radiology residents, and radiologist in medicine and chiropractic. Spine 1995; 20:1147-54. (70.) Yogonandan N, Myclebust JB, Ray G, Sances A Jr.
27/34(W)
Mathematical and finite element analysis of spine injuries. Crit Rev Biomed Eng 1987; 15:29-93. (71.) Clauser CE, McConville JT, Young JW. Weight, Volume, and center of mass of segments of the human body. Wright-Patterson Air Force Base (OH): Ohio Aerospace Medical Research Library (AMRL-TR-69-70), Aerospace Medical Division, Air Force Systems Command; 1969. (72.) Belytschiko T, Privitzer E. Refinement and validation of a three-dimensional headspine model. Wright-Patterson Air Force Base (OH): Ohio Aerospace Medical Research Library (AMRL-TR-78-7), Aerospace Medical Division, Air Force Systems Command; 1978. (73.) Schultz AB, Galante JO. A mathematical model for the study of the mechanics of the human vertebral column. J Biomech 1970;-3:405-16. (74.) Schultz AB, Miller JAA. Biomechanics of the human spine. In:Mow VC, Hayes WC, editors. Basic orthopaedic biomechanics. New York: Raven Press; 1991. p. 337-74. (75.) Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine 1986;6:521-4. (76.) Harrison DD, Janik TJ, Troyanovich S J, Holland B. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996;21:667-75. (77.) Harrison DD, Janik TJ, Troyanovich S J, Harrison DE, Colloca CJ. Evaluation of the assumptions used to derive an ideal normal cervical spine model. J Manipulative Physiol Ther 1997; 10:202-13. (78.) Harrison DD, Janik TJ. Clinical validation of an ideal normal static cervical spine model. In: Witten M, editor. Computational medicine, public health, and biotechnology. Vol. 2. Austin (TX): World Scientific Publishing; 1995. p. 1047-56. (79.) Janik TJ, Harrison DD. Prediction of 2-D static normal position of the cervical spine from mathematical modeling. In: Witten M, editor. Computational medicine, public health, and biotechnology. Vol. 2. Austin (TX): World Scientific Publishing; 1995. p. 1035-46. (80.) Bernhardt M, Bridwell KH. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 1989; 14:717-21. (81.) Troyanovich S J, Calliet R, Janik TJ, Harrison DD, Harrison DE. Radiographic mensuration characteristics of the sagittal lumbar spine from a normal population with a method to synthesize prior studies of lordosis. J Spinal Disord 1997; 10:380-6.
28/34(W)
(82.) Harrison DD, Calliet R, Janik TJ, Troyanovich T J, Harrison DE. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord 1998; in press. (83.) Janik TJ, Harrison DD, Calliet R, Troyanovich TJ, Harrison DE. Elliptical modeling of the normal sagittal lumbar curvature. J Orthop Res 1998; in review. (84.) Christensen MG, Delle Morgan DR. Job analysis of chiropractic: a project report, survey analysis and summary of the practice of chiropractic within the United States. Greeley (co): National Board of Chiropractic Examiners; 1993. (85.) Haldeman S, Chapman-Smith D, Petersen DM Jr. Guidelines for chiropractic quality assurance and practice parameters. Proceedings of the Mercy Center Consensus Conference; 1993 Jan 25-30; Burlingame, CA. Gaithersburg (MD): Aspen Publishers; 1993. p. 134-6. (86.) Haas M. Statistical methodology for reliability studies. J Manipulative Physiol Ther 1991; 14:119-32. (87.) Barker WF, Jackson BL. Statistical errors inherent in a study of x-ray marking systems. Dimensions 1988; 3( 7):7-8. (88.) Voutsinas SA, MacEwen GD. Sagittal profiles of the spine. Clin Orthop 1986; 210:235-42. (89.) Beer FP, Johnston ER Jr. Mechanics of materials. New York: McGraw-Hill; 1992. p. 478-569. (90.) Troyanovich S J, Harrison DE, Harrison DD. Review of scientific literature relevant to structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998; 41:37-50. (91.) Harrison DD, Troyanovich SJ, Robertson GA, DeGeorge DJ. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study (letter). J Manipulative Physiol Ther 1995; 18:42-4. (92.) Harrison DD, Troyanovich S J, DeGeorge DJ. The efficacy of cervical extensioncompression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study (letter). J Manipulative Physiol Ther 1995; 18:324-5. (93.) Phillips RB. The use of x-rays in spinal manipulative thrapy. In: Haldeman S, editor. Modern developments in the principles and practice of chiropractic. New York: AppletonCentury-Crofts; 1980:189-209.
29/34(W)
(94.) Rochester RP, Owens EF. Patient placement error in rotation and its affect on the upper cervical measuring system. Chiropr Res J 1996; 3:40-54. (95.) Harrison DD, Jackson BL, Troyanovich S J, Robertson GA, DeGeorge D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. J Manipulative Physiol Ther 1995; 17: 454-64. (96.) Sandham A. Repeatability of head posture recordings from lateral cephalometric radiographs. Br J Orthod 1988; 15:15762. (97.) Milne JS, Williamson J. A longitudinal study of kyphosis in older people. Age Ageing 1983; 12:225-33. (98.) Bullock-Saxton J. Postural alignment in standing: a repeatable study. Aust Physiother 1993; 39:25-9. (99.) Lundstrom A, Forsberg CM, Westergren H, Lundstrom F. A comparison between estimated and registered natural head posture. Eur J Orthod 1991; 13:59-64. (100.) Refshauge K, Goodsell, Lee M. Consistency of cervical and cervicothoracic posture in standing. Aust J Physiother 1994; 40:235-40. (101.) Grimmer K. An investigation of poor cervical resting posture. Aust J Physiother 1997; 43:7-16. (102.) Hohl M. Soft-tissue injuries of the neck in automobile accidents. Factors influencing prognosis. J Bone Joint Surg Am 1974; 56A: 1675- 81. (103.) Pedersen PL. Review of cervical trauma in relation to cervical hypolordosis. Eur J Chiropr 1990; 38:141-7. (104.) American Medical Association. Guides to the evaluation of permanent impairment. 3rd ed. Chicago: American Medical Association; 1990. p. 88. (105.) McKenzie RA. The cervical and thoracic spine. Mechanical diagnosis and therapy. Waikanae, New Zealand: Spinal Publications, Ltd; 1990. (106.) Penning L. Kinematics of cervical spine injury. A functional radiological hypothesis. Eur Spine J 1995; 4:126-32. (107.) Bland JH. Disorders of the cervical spine. Diagnosis and medical management. 2nd ed. Philadelphia: WB Saunders; 1994. (108.) Dvorak J, Panjabi MM, Novotny JE, Antinnes JA. In vivo flexion/extension of the normal cervical spine. J Orthop Res 1991; 9:828-34.
30/34(W)
(109.) Torg JS, Sennett B, Vegso JJ. Spinal injury at the level of the third and fourth cervical vertebrae resulting from the axial loading mechanism: an analysis and classification. Clin Sports Med 1987; 6:159-83. (110.) Wallace HL, Jahner S, Buckle K, Desai N. The relationship of changes in cervical curvature to visual analog scale, neck disability index scores, and pressure algometry in patients with neck pain. J Chiropr Res 1994; 9:19-23. (111.) Helliwell PS, Evans PF, Wright V. The straight cervical spine: does it indicate muscle spasm? J Bone Joint Surg Am 1994; 76:103-6. (112.) McGill SM, Patt N, Norman RW. Measurement of trunk musculature of active males using CT scans radiography: implications for force and moment generating capacity about the L4-L5 joint. J Biomech 1988; 21:329-40. (113.) McGill SM. Loads on the lumbar spine and associated tissues. In: Goel VK, Weinstein JN, editors. Biomechanics of the spine: clinical and surgical perspective. Boca Raton (FL): CRC Press; 1990. p. 65-95. (114.) Nightingale RW, McElhaney JH, Richardson WJ, Best TM, Myers BS. Experimental impact injury to the cervical spine: relating motion of the head and the mechanism of injury. J Bone Joint Surg Am 1996; 78:412-21. (115.) Matsunage S, Sakou T, Sunahara N, Oonishi T, Maeda S, Nakanisi K. Biomechanical analysis of buckling alignment of the cervical spine. Predictive value of subaxial subluxation after occipitocervical fusion. Spine 1997; 22:765-71. (116.) White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: JB Lippincott; 1990:259-61. (117.) Svensson MY, Aldman B, Hansson HA, et al. Pressure effects in the spinal canal during whiplash extension motion: a possible cause of injury to the cervical spinal ganglia. Proceedings of the 1993 International IRCOBI Conference on the Biomechanics of Impacts. Eindhoven, The Netherlands; 1993. p. 189-200. (118.) Grauer JN, Panjabi MM, Cholewicki J, Nibu KN, Dvorak J. Whiplash produces an S -shaped curvature of the neck with hyperextension at lower levels. Spine 1997; 22:248994. (119.) Nordhoff LS. Motor vehicle collision injuries: mechanisms, diagnosis, and management. Gaithersburg (MD): Aspen Publishers; 1996. (120.) Plaugher G, Doble RW, Lopes MA. Lower cervical spine. In: Plaugher G, editor. Textbook of clinical chiropractic. A specific biomechanical approach. Baltimore: Williams and Wilkins; 1993. p. 279.
31/34(W)
(121.) Stillwagon G, Stillwagon KL. In search of the ideal cervical curve. Am Chiropr 1984; (Jan/Feb):38-42. (122.) Deyo RA, Diehl AK. Lumbar spine films in primary care: current use and effects of selective ordering criteria. J Gen Intern Med 1986; 1:20-5. (123.) Weiss HR. Influence of an in-patient exercise program on scoliotic curve. Ital J Orthop Traumatol 1992; 18:395-406. (124.) Friberg O. The statics of postural pelvic tilt scoliosis: a radiographic study on 288 consecutive chronic LBP patients. Clin Biomech 1987; 2:211-9. (125.) Irvin RE. Is normal posture a correctable origin of common, chronic, and otherwise idiopathic discomfort of the musculoskeletal system? Second Interdisciplinary World Congress on Low Back Pain: The integrated function of the lumbar spine and SI joints; 1995 Nov 9-11; San Diego, CA. Berkeley (CA): University of California Office of Continuing Education; 1996. p. 425-60. (126.) Mente PL, Stokes IAF, Spence H, Aronsson DD. Progression of vertebral wedging in an asymmetrically loaded rat-tail model. Spine 1997; 22:1292-6. (127.) Stokes IAF, Spence H, Aronsson DD, Kilmer NI. Mechanical modulation of vertebral body growth: implications for scoliosis progression. Orthop Trans 1996-1997; 20:603-4. (128.) Stokes IAF. Analysis of symmetry of vertebral body loading consequent to lateral spinal curvature. Orthop Trans 19961997; 20:788. (129.) Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-51. (130.) Adams MA, McMillan DW, Green TP, Dolan P. Sustained loading generates stress concentrations in lumbar intervertebral discs. Spine 1996; 21:434-8. (131.) Duncan NA, Lotz JC. Intervertebral disc degeneration may be a remodeling response to altered mechanical loads. Orthop Trans 1996-1997; 20:829. (132.) Kurowski P, Kubo A. The relationship of degeneration of the intervertebral disc to mechanical loading conditions on lumbar vertebrae. Spine 1986; 11:726-31. (133.) Itoi E, Sinaki M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc 1994; 69:1054-9. (134.) Sinaki M, Itoi E, Rogers JW, Bergstralh EJ, Wahner HW. Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil 1996; 75:370-4.
32/34(W)
(135.) Troyanovich SJ, Harrison DD, Harrison DE. A review of the validity, reliability, and clinical effectiveness of chiropractic methods employed to restore or rehabilitate cervical lordosis. Chiropr Technique 1998; 10:1-7. (136.) Lowe TG. Biomechanical aspects of the surgical treatment of kyphotc deformities. Spine: State of the Art Reviews 1996; 10:433-53. (137.) Miyazaki K, Tada K, Matsuda Y, Okuno M, Yasuda T, Murakami H. Posterior extensive simultaneous multisegment decompression with posterolateral fusion for cervical myelopathy with cervical instability and kyphotic and/or s-shaped deformities. Spine 1989; 14:1160-9. (138.) Okumura H, Homma T. Juvenile compression myelopathy in the cervical spine. Spine 1994; 19:72-6. (139.) Lowery G. Three-dimensional screw divergence and sagittal balance: a personal philososphy relative to cervical biomechanics. Spine: State of the Art Reviews 1996; 10:343-56. (140.) Snyder BD, Zaltz I, Breitenbach MA, Kido TH, Myers ER, Emans JB. Does bracing affect bone density in adolescent scoliosis. Spine 1995; 20:1554-60. (141.) Haher TR, Merola A, Zipnick RI, Gorup JG, Mannor D, Orchowski J. Meta-analysis of surgical outcome in adolesceidiopathic scoliosis. A 35-year English literature review of 11,000 patients. Spine 1995; 20:1575-84. (142.) Soyer AD, McConnell JR. Progressive scoliosis in Dubowitz syndrome. Spine 1995; 20:2335-7. (143.) Guven O, Kumano K, Yalcin S, Karahan M, Tsuji S. A single stage posterior approach and rigid fixation for preventing kyprosis in the treatment of spinal tuberculosis. Spine 1994; 19:1039-43. (144.) Wetzel FF, Hoffman MA, Arcieri RR. Freeze-dried fibular allograff in anterior spinal surgery: cervical and lumbar applications. Yale J Biol Med 1993; 66:263-75. (145.) Jorgenson SS, Lowe TG, France J, Sabin J. A prospective analysis of autograft versus allograft in posterolateral lumbar fusion in the same patient. A minimum of 1-year follow-up in 144 patients. Spine 1994; 19:2048-53. (146.) Benli IT, Tuzuner M, Akalin S, Kis M, Aydin E, Tandogan R. Spinal imbalance and decompensation problems in patients treated with Cotrel-Dubousset instrumentation. Eur Spine J 1996; 5:380-6. (147.) Vaughan JJ, Winter RB, Lonstein JE. Comparison of the use of spine bending and traction radiographs in the selection of the fusion area in adolescent idiopathic scoliosis. Spine 1996; 21: 2469-73.
33/34(W)
(148.) Hosman AJ, Slot GH, Beijneveld WJ, van Limbeek J, Kooijman MA. Correction of idiopathic scoliosis using the H-frame system. Eur Spine J 1996; 5:172-7. (149.) Sussman MD, Little D, Alley RM, McCoig JA. Posterior instrumentation and fusion of the thoracolumbar spine for treatment of neuromuscular scoliosis. J Pediatr Orthop 1996; 16: 304-13. (150.) Sanders JO, Herring JA, Browne RH. Posterior arthrodesis and instrumentation in the immature (Risser-grade-O) spine in idiopathic scoliosis. J Bone Joint Surg 1995; 77:39-45. (151.) Stokes IA, Ronchetti PJ, Aronsson DD. Changes in shape of the adolescent idiopathic scoliosis curve after surgical correction. Spine 1994; 19:1032-7. (152.) Reigel DH, Tchernoukha K, Bazmi B, Kortyna R, Rotenstein D. Change in spine curvature following release of tethered spinal cord associated with spina bifida. Pediatr Neurosurg 1994; 20: 30-42. (153.) Barrett DS, MacLean JG, Bettany J, Ransford AO, Edgar MA. Castoplasty in adolescent idiopathic scoliosis. Objective results in 55 patients. J Bone Joint Surg Br 1993; 75:881-5. (154.) Hopf C, Schwarz M, Wackerhagen A, Voth D. The operative treatment of spinal deformities in MMC. Neurosurg Rev 1993; 16:45-52. (155.) Neuwirth MG, Drummond DS, Casden AS. Results of interspinous segmental instrumentation in the sagittal plane. J Spinal Disord 1993; 6( 1):1-4. (156.) Shiraishi T, Crock HV. Re-exploration of the lumbar spine following discectomy: a review of 23 cases. Eur Spine J 1995; 4( 2):84-7. (157.) Crawford RJ, Askin GN. Fixation of thoracolumbar fractures with the Dick fixator: the influence of transpedicular bone grafting. Eur Spine J 1994; 3( 1):45-51. (158.) Farber GL, Place HM, Mazur RA, Jones DE, Damiano TR. Accuracy of pedicle screw placement in lumbar fusions by plain radiographs and computed tomography. Spine 1995;20:1494-9. (159.) Kant AP, Daum WJ, Dean SM, Uchida T. Evaluation of lumbar spine fusion. Plain radiographs versus direct surgical exploration and observation. Spine 1995; 20:2313-7. (160.) Grass JP, Dockendorff IB, Soto VA, Araya PH, Henriquez CM. Progressive scoliosis with vertebral rotation after lumbar intervertebral disc herniation in a 10-year-old girl, Spine 1993; 18:336-8. (161.) Bradford DS. Failed back syndrome secondary to previous spondylolisthesis surgery. Chir Organi Mov 1994; 79( 1):109-10.
34/34(W)
(162.) Sihvonen T, Herno A, Paljarvi L, Airaksinen O, Partanen J, Tapaninaho A. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 1993; 18:575-81. (163.) Laus M, Tigani D, Pignatti G, et al. Posterolateral spinal fusion: a study of 123 cases with long-term follow-up. Chit Ogani Mov 1994; 79( 1):69-79. (164.) Lehmer SM, Keppler L, Biscup RS, Enker P, Miller SD, Steffee AD. Posterior transvertebral osteotomy for adult thoracolumbar kyphosis. Spine 1994; 19:2060-7. (165.) Markwalder TM, Battaglia M. Failed back surgery syndrome. Part II. Surgical techniques, implant choice, and operative results in 171 patients with instability of the lumbar spine. Acta Neurochir (Wien) 1993; 123( 3-4): 129-34. (166.) Harrison DD. Spinal Biomechanics: a chiropractic perspective. Harvest (AL): D. D. Harrison; 1986. p. 33-41. (NLM WE 725 H318c) Article copyright Mosby, Inc. ~~~~~~~~ By Deed E. Harrison; Donald D. Harrison and Stephen J. Troyanovich Copyright of Journal of Manipulative & Physiological Therapeutics is the property of Lancet and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Source: Journal of Manipulative & Physiological Therapeutics, 1998 May; 21(4) Item Number: 1998041544

X线指导整脊的可靠性分析综述9608381

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

X线指导整脊的可靠性分析综述9608381

Hochgeladen von

Copyright:

Verfügbare Formate

w

Das könnte Ihnen auch gefallen