When I graduated from chiro-practic college in 1978, I elected to come back to my home state of New York to practice. At the time, the law didn’t allow for chiropractors to X-ray below L2. Chiropractors couldn’t order X-rays below L2. We were reduced to hoping there were no pathologies or contraindications. Since that time, I’ve come across a couple abdominal aortic aneurysms, several bowel issues and several bone cancers. Fortunately, I had the good sense to X-ray the patient prior to treatment.
As a new graduate, I was thrust into the cold realities of practicing on the front lines in comparison to the womb-like comforts of being a student. It was a moral, ethical, clinical and legal tennis match in the mind of every practicing chiropractor in New York.
The only precedent I was able to use to assist in my decision was the memory of chiropractors in jail for defending what they believed in. I had just graduated from National College, where I had instructors such as Terry Yochum, Joseph Howe and Reed Phillips. I believed I was more trained in radiology than any other practitioner in my county. The decision to go ahead and X-ray below L2 was an easy one for me.
Today’s X-Ray Crisis
I sit here today, almost twenty-nine years later, and see our profession faced with another X-ray challenge: how to use X-ray in a chiropractic practice. To begin with, regardless of any of our individual beliefs, our differences on this point is a critical contributor to the weakness of our profession. The public is confused about us. In medicine, an X-ray is taken and interpreted, and for the most part, all interpretations are distinctly similar. In chiropractic, we’re everything but similar.
First of all, our profession has suc-cumbed to the ranks of treating people with symptoms. Despite knowing that getting adjusted on a regular basis is a good thing, we’ve not figured out how to convey this message to the masses. So, when a patient with low back pain comes into our office, all of us use different protocols. Some take X-rays; some don’t. Some order X-rays from an X-ray facility, and rely fully on their medical reports. Of those who take their own X-rays, many will only rule out pathology, and then begin a palliative approach using chiropractic adjustments as the primary modality. And, then, there are some who use some biomechanical measurements; however, due to the restraints of insurance coverage and the pre-conceived perception by the public as to what chiropractic does, the treatment only addresses the elimination of symptoms. Rarely, will a doctor utilize quality biomechanical information as seen on X-rays, interpret and communicate it effectively to the patient, and use the biomechanical defects as the objectives for care, recommending more than just the elimination of symptoms. This approach, although rare, not only improves symptoms, but changes the future of that patient and elevates the perception and quality of chiropractic.
Structural Management™ X-Ray Protocol
Based on the premise that human beings are architectural structures influenced by gravity and many other daily stresses, combined with the fact that all of us are continually aging and many of us have suffered with multiple neuro-musculo-skeletal injuries, it makes sense to use the status of a patient’s structure before recommendations can be made. Secondly, every other valued asset a person owns is critically managed, such as their car, their house, their finances, etc. The thought that the human structure is only considered during a time of crisis is illogical. Using symptomatic elimination as our treatment goal ignores the very laws of nature with regard to preservation and health. If members of society knew they could preserve and slow down the degenerative changes of their structures, as well as maintain a higher level of function over the course of their lifetime, most would anxiously ask “Where do I need to go and what will it cost?”
Therein lies the need for Structural Management™.
A person’s structural status is based on age, prior injuries, genetics, conditioning, job, shoes worn, mattress used, diet, height, weight and many more contributing factors. Regardless of the symptomatic picture that exists, a standard X-ray series is performed on each patient. The three reasons for X-raying each patient is to 1) rule out pathology, 2) determine biomechanical defects, and 3) to show the patient for improved communication and understanding. If additional X-rays are required, it is up to the practitioner to make that decision.
The Structural Fingerprint™ Exam (X-Ray Component)
A four-view series is taken on every patient to determine the status and biomechanical imbalances from which all people suffer. These views consist of an A-P open mouth view, a lateral cervical view, an A-P L-S view and a lateral L-S view. All are performed in the standing position with shoes off. If the patient is in a distorted postural position due to spasms or any other condition, then only the area of involvement is X-rayed, with further X-rays taken at a later, more appropriate date.
A-P Open Mouth
Biomechanical measurements and interpretation:
1) Alignment of odontoid process with sp of C2
2) Equal atlanto-axial joint spaces
3) Equal atlanto-odontoid spaces
4) Balance of occiput with the spine
The abnormal views show imbalances in the atlanto-odontoid spaces, the relationship between the occiput and the spine and the rotation of the axis relative to the atlas. Any of these findings predictably produce an elevated irritation of the spinal column at the highest level. This finding is impossible to quantify, but as chiropractors, we’ll all agree that the “normal” X-ray is preferred over the “abnormal” X-ray, and the health of the individual with the “normal” X-ray is predictably better (all other factors being equal). The goal in this case should be an improved occipital-atlanto-axial relationship.
Lateral Cervical
Biomechanical measurements and interpretation;
1) A lordotic curve for shock absorp-tion
2) The center of gravity (cervical gravity line) bisecting each bone so each bone can share in the distribution of the weight of the cranium (approx. 10% of body weight).
3) Healthy disc integrity
The abnormal views show a disruption (reversal) in the curvature of the neck, with the weight-bearing line falling anterior to the spine. This biomechanical imbalance predictably increases the stresses of the C5/6 and C6/7 joint space over time, encouraging increased demands and premature degenerative changes at those levels. There is also anterior bone growth with this type of biomechanical finding, which is a reflection of Wolff’s Law in action.
A-P L-S
Biomechanical measurements and interpretation;
1) Level iliac crests
2) Alignment between spine and symphysis pubes
3) Equal obturator foramen shape
4) Alignment of the spine
The abnormal views show an imbalance in crest heights, an unequal size of the obturator foramen, a misalignment between the spine and the symphysis pubes as well as a mass in the lower bowels potentially being a pathology.
Lateral L-S
Normal Abnormal Abnormal
Biomechanical measurements and interpretation:
1) Sacral Base Angle between 36°-42°
2) Ferguson’s Gravity Line—the center of L3 bisecting the anterior 1/3 of the sacral base (center of gravity from the side)
3) Healthy disc integrity
The abnormal views show a decrease in the sacral base angle, a posterior Ferguson’s Gravity Line and a degeneration of L4, predictably an indication of an injury with inadequate rehabilitation rather than premature wear and tear which typically causes degeneration of L5 first.
Conclusion
If the chiropractic profession would standardize this biomechanical approach, beginning with the use of X-rays in a discreet and professional manner, we would benefit in a variety of ways;
1) The public would know what to expect when they come to us as we work to standardize not only our protocols, but our identity.
2) The chiropractic profession would address a serious need in our society today, that of Structural Management™. We, as a profession, would no longer be competing with all other providers out there who only work to alleviate symptoms.
3) As a profession, we would further reduce the incidence of malpractice claims, as a more thorough evaluation will have been done on all patients before any inappropriate care might be given.
4) The profession would begin the previously unsuccessful attempt to unify, at which time chiropractic would begin to receive the long overdue recognition we deserve.
Most importantly, many people can have biomechanical lumbar distortion patterns without symptoms. Many can have cervical distortion patterns without symptoms. If we don’t examine and identify these biomechanical faults sooner rather than later, then correction becomes an impossibility. The medical model of care, authored by the medical industry, wins, and the biggest losers are all members of society. Since we have but one life to live, shouldn’t we take part in the effort to make all people’s lives more active and less painful, more joyous and less costly? The answer is to pay now or pay later and if, presented properly, most people would gladly pay now, as the value of preserving the human structure is worth more than most of us realize.
For more information on The Structural Management™ Program, contact Dr. Maggs at 1-518-393-6566 or email him at [email protected].