The importance of weight bearing x-rays for chiropractic spinal analysis cannot be understated. In-fact, I would argue that for any spinal analysis, the importance of weight bearing imaging cannot be underestimated.
As a Chiropractor, I hear some of the craziest things that come from the mouths of patients’ and the public at large about both Chiropractic and the spine. This misinformation is mainly fed to them by other healthcare professionals, the media and their friends and family. These are phrases such as:
- “Chiropractors shouldn’t be x-raying people”.
- “Everyone has a ‘slight’ curve in their spine”.
- “It’s normal to have one leg shorter than the other”.
- “Your posture has nothing to do with your health”.
- “Degenerative joint disease is normal in someone of your age”.
These are all common myths that I will be addressing in the coming few months both on this forum and in my blog and other media outlets. I want to address them because these are all important topics that influence our decision making processes when discussing our health. They are also common in my practice and so the more opportunities I create to address them the better I believe. Today I will simply be discussing why we take upright, weight bearing x-rays at Spriggs Chiropractic and the importance of Chiropractors taking spinal x-rays.
Understanding the reason for taking weight bearing x-rays simply requires an understanding of spinal biomechanics. Bess et al (2016) explained in their article that “through radiographic evaluation is critical to identify causes of pain and disability for all Adult Spinal Deformity (ASD) patients”. They go on to discuss that “Supine images and/or images that only include the thoracic of lumbar spine often underestimate the amount of sagittal and coronal deformity, and preclude accurate and concomitant assessment of the cervical spine and spinopelvic parameters”. What the authors are saying is that by taking x-rays of patients lying down, the spinal alignment is altered resulting in inaccurate structural and alignment measuring. You see the spine isn’t a passive structure like Stonehenge, that maintains its structure purely with the force of gravity. The human frame is a tensegrity structure (more accurately a biotensegrity structure), meaning that is maintains is structural integrity with the use of prestressed tensile loads acting on each joint (Swanson 2013). This means it will maintain its integrity even in the absence of gravity, it also means that if the segmental alignment of spine is altered (or any other joints of the body), then other areas of the spine and body will be altered. This is why it is so important that x-rays of the spine are taking with the patient standing, to accurately assess the spinal column.
Normal X-ray of the neck
The next thing I would like to discuss is the comments made about Chiropractors x-raying their patients to begin with. This is a common issue that some members of the public are told. As part of our undergraduate training, Chiropractic students are taught to take x-rays by the university program, taught by radiographers, not other Chiropractors might I add. We adhere to the same laws as radiographers and radiologists in other areas of healthcare. So, in thr UK and other parts of the world, chiropractors are entitled by law to take appropriate x-rays of our patients, much the same as dentists do. This is also in adherence with IRMER Radiation Guidelines (2006 and 2011).
As for why we should take them, there are the obvious diagnostic reasons, such as fractures, serious pathology, scoliosis, spinal degenerative changes (patients over the age of 50) etc. This issue is eloquently discussed in the book “CBP® Structural Rehabilitation of the Lumbar Spine” by Deed Harrison et al (2002). On the topic of appropriate x-ray taking, studies have shown that between “66%-91%” of patient can have significant abnormalities that affect the treatment intervention of the Chiropractor (Bull 2003, Pryor et al 2006, Beck et al 2004). In addition, 33% can have relative contraindications to certain Chiropractic adjustment procedures and an incredible 14% of patients can have absolute contraindications to certain types of Chiropractic adjustment procedures (Bull 2003).
In a more recent paper, Jenkins et al (2010) found that 28.5% of cervical spine x-rays and 18.3% of lumbar spine x-rays obtained of patient presenting to a chiropractor for treatment had “clinically significant congenital or developmental anomalies”. These anomalies may alter the types of treatment options for chiropractors to administer such as spinal manipulation due to possible increased risks of injury to the patient. Jenkins et al state that these findings “warrant a closer inspection of the current x-ray guidelines” for chiropractors due to these unforeseen potential risks to the patient.
So one could argue that simply taking an x-ray of the patients spine is a necessity to determine what chiropractic procedure should be applied. By utilising appropriate diagnostic imaging, the clinician has the patients health at the forefront of their mind before commencing any chiropractic intervention or making an appropriate referral. As a primary care clinician, it is my job to aid in forming the correct diagnosis, which may involve the use of x-rays before making decisions on treatments or referrals to other healthcare experts.
References:
- Bess S, Protopsaltis TS, Lafage V, Lafage R, Ames CP, Errico T, Smith JS and The International Spine Study Group 2016. Clinical and Radiographic Evaluation of Adult Spinal Deformity. Clinical Spine Surgery 29(1);6-16.
- Swanson RL II, 2013. Biotensegrity: A unifying theory of biological and architecture with applications to osteopathic practice, education and research – A review and analysis. Journal of American Osteopath Association 113(1);34-52.
- Deed E. Harrison, Donaldson D. Harrison, Jason W. Haas 2002. CBP Structural Rehabilitation of the Lumbar Spine. Harrison Chiropractic Biophysics Seminars Inc, Eagle, Idaho, USA.
- Bull PW 2003. Relative and absolute contraindications to spinal manipulative therapy found on spinal x-rays. Proceedings of the World Federation of Chiropractic 7th Biennial Congress, Orlando, FL, May 2003 p376.
- Pryor M, McCoy M 2006. Radiographic findings that may alter treatment identified on radiographs of patients receiving chiropractic care in a teaching clinic. Journal of Chiropractic Education 20(1);93-94
- Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL 2004. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. Journal of Manipulative and Physiologic Therapeutics 27(9); 554-559.
- Jenkins H, Zheng X and Bull P 2010. Prevalence of Congenital Anomalies Contraindicating Spinal Manipulative Therapy within a Chiropractic Patient Population. Chiropractic Journal of Australia 40: 69-76