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GCSS Research Article Accepted!
Coleman RR, Lopes MA, Suttles RA. Computer Modeling of Selected Projectional Factors of the 84-in Focal Film Distance Anteroposterior Full Spine Radiograph Compared WIth 40-in Focal Film Distance Sectional Views. Journal of Chiropractic Medicine March 2011; 10(1):18-24.
(From the March 2011issue of The “G”Note)
Dr. Coleman describes the article that he co-wrote which was accepted and published in the March 2011 issue of the Journal of Chiropractic Medicine:
So there you have it. The article has been published in the Journal of Chiropractic Medicine. The time was lengthy; the effort immense. So why would we expend so much time and effort on this article? Because this article lays a cornerstone for further research and shines the light of science onto a most maligned and misunderstood tool of spinal care, the A-P full spine radiograph. This article was absolutely necessary in the endeavor to intelligently discuss and bring forward this important element of the Gonstead Technique.
The A-P full spine radiograph has long been a tool utilized by the Gonstead practitioner to aid in the evaluation of the patient’s spine in a clinical setting. This view has been discussed by such noteworthy authors as Winterstein, Hildebrandt and Rowe, but it has been criticized by Harrison, who stated that the view “was highly susceptible to projection distortion.” But in an era where the use of x-ray is under attack and where clinicians of all types must provide proof regarding the procedures they utilize, we can no longer rely on the statements, such as, “It’s a part of our technique,” or “We’ve always done it that way.” We must show the advantages and the disadvantages of any procedure so that it may appropriately be applied in patient care.
A recurring complaint, offered up by some critics regarding the A-P full spine, is that due to the angles of incidence (angles of divergence) of the rays, objects (vertebrae) being projected on the film will be struck by the rays more obliquely and could project in a more distorted fashion. In addition, the greater angle of the rays would also contribute to projectional overlap of structures on the radiograph (more on that later). This thought has been ingrained into the general pool of clinicians to such an extent that they have just shortened the argument to saying: “full spine films create too much distortion”. In reality, this is a serious concern, and if it were true, it might very well provide a genuine reason to rethink the use of the A-P full spine. Unfortunately, for those uttering such harsh statements: “You are no longer supported in the peer reviewed literature.” With the publication of this article, we have once and for all put to rest the myth perpetuated by such statements. We can now see exactly the true angles of divergence, and they come down to this: the A-P full spine’s angles of divergence (the angles at which the rays from the tube intersect with the uppermost and lowermost edges of the x-ray film) are equal to that of the 14x17 inch sectional film taken at 40 inches and 70% of the A-P full spine is within the angles of divergence of a 10x12 inch film taken at 40 inches. This means that all but a 5.4 inch section at the top and bottom margins of the 14x36 inch film is within the angles of divergence of the 10x12 inch film, and if you (as you should) collimate in to the areas of interest, there is no or at least little of the 14x36 inch film that is not within the angles of the 10x12. But that is not all. In the discussion section, from the work of Winterstein, it is pointed out that the visualization of the disc spaces is equal to the “sectional views in the cervical, upper and midthoracic and lower lumbar areas, being less good than sectionals in the lower thoracics, but slightly better than a sectional view in the upper lumbar area.” So the next time someone says that full spines “are not diagnostic”, whatever that means, you can point to the scientific literature and say that the 84-inch A-P full spine that you take has the qualities that are delineated in this article.
However, there is an area in which the 84-inch focal film distance view clearly is superior to the sectional view and that area involves translation. If the object being viewed is not being struck by the central ray, but is laterally off-centered (as when a patient with a disc problem is bent to the side), then it is well established that lateral translation of a vertebra (translation on the x-axis) results in axial (y-axis) projected rotation of the vertebra on the film. In other words, lateral movement results in the projection of the vertebra as being rotated. A rotation that, in fact, may not exist. But when the radiograph is taken at an 84-inch focal film distance as opposed to a 40-inch film distance, this article clearly shows that it takes a greater amount of translation to produce the same amount of erroneously perceived axial rotation. The 84-inch focal film distance view is more resistant to this type of error.
The article goes on to state, “We are hopeful that our findings will cause both clinicians and policy makers to consider the use of the A-P full spine taken at an 84-inch focal film distance as an alternative to other views when a radiograph of the entire spine is indicated.”
Of course, you need to read the article carefully and look at the fact that there are alterations in projected ilium heights on the full spine view when the pelvis is rotated, but the illustrations and the text clearly point out the intricacies of projection that occur in the full spine view so that they can be looked at in an objective manner.
Will this put an end to “technique bias”? Of course not! But it may aid in stopping the use of unfair and inaccurate statements concerning the A-P full spine. In order to move forward, one must be certain that their technique is based on sound scientific principles. You must have the knowledge to do the right thing and to support your actions. The use of x-ray is under attack, and the most derided commonly used view is the full spine. Now you can show that the A-P full spine view is a tool just like any other view, and if a radiograph of the entire spine is needed, it should be considered without prejudice and with a full understanding of its projectional properties as a reasonable method of acquiring the needed information.
But this is not the end of the discussion. It applies to much of what is done by Gonstead providers. One would logically think that, as this technique has withstood the test of time, and has provided relief from the suffering of so many patients that it would receive some immunity from the “slings and arrows of outrageous fortune”. But we live in a different era. We must be constantly providing evidence for our decisions lest the right to make decisions be taken from us. With the publication of this article, we have taken a significant step toward analyzing and presenting the aspects of the Gonstead Technique that are near and dear to the hearts of every Gonstead practitioner. And this is just the beginning. We have a huge amount of work to do. Not only must we analyze the tried and true methods of the past but we must, when possible, improve upon them, be ready to defend them when necessary and utilize them in the most appropriate manner. If we find some procedure to be wanting then, it must be corrected or discarded. We cannot know the brilliance of the diamond we possess until we wipe away the dust of time and view it anew.
At present, we are in review with an article on retrolisthesis and are in the later stages of a commentary on x-ray. We have completed the data collection on a large number of subjects at Life West. We are presently working on an article about the GCSS for submission to a peer-reviewed history journal, and while all those balls are in the air, we are continuing with our efforts to obtain funding for a study regarding femur head heights. We also have numerous other ideas that we discuss, improve, and consider. But this article on the A-P full spine radiograph, this seemingly innocuous article, has an importance that may be likely understated by many. For it presents itself as mathematics, not as a study with a limited sample size, not as a study whose methodology is questionable, not as a study that incorporates opinion into its findings, but as a study that is the result of straight forward calculations which lead to non-embellished, straight-forward discussion and conclusion. You can, by the simple act of collimating to the area of interest, utilize its findings and use it to logically argue, when a radiograph of the entire spine is appropriate, that the A-P full spine deserves careful consideration as a choice based solely on its projectional characteristics. You can now present your case calmly and coolly because now you will have the facts at your disposal. In addition, it appears that the distance of 72 inches for the A-P full spine should be expanded to the 84 inch focal film distance whenever possible.
These are two easy fixes that can continue to keep the Gonstead Technique at the lead of scientific care and even improve on the care that is currently being provided. As we objectively and meticulously scrutinize our procedures, one must wonder why so many others do not subject what they do to the same types of evaluation.
Editor-Steven T. Tanaka, DC:
If x-rays, in particular, full spine x-rays are important to your practice, please contribute to GCSS Field of Dreams. We have other papers in the works. Drs. Coleman and Lopes have been leading the effort to conduct research that is relevant to Gonstead practices.
More and more, you are seeing major policy changes without input from Gonstead doctors (sometimes with few active clinicians). One needs active research, papers published, and presentations at conferences to be recognized. You may have a busy practice and think that research is unimportant. What will happen to your kids or the excited young patient who may decide to follow in your steps? Policies may be made that will go against those who would chose the Gonstead technique. There are those in the profession who would like to limit our practice to the point where we have limitations similar to physical therapists.
Clinical sciences depend upon advances to better serve the patient. Advances don’t have to be major changes. As you know from specific adjusting, sometimes it’s the little things that make the difference. You also might have been burned by calls for donations to chiropractic research that resulted in no papers or anything. For the past ten years, GCSS has worked at accumulating sufficient funds so that we could hire a respected chiropractic researcher and be able to pay for affordable studies. We are finally beginning to bear fruit.
Many, many thanks to you who have made donations.