DMX

Philips Veradius Unity, som er installeret på Specialklinikken Rebild

Hvad er DMX?

DMX står for Digital Motion X-Ray, som er på Specialklinikken Rebild en dynamisk fluoroskopisk røntgenundersøgelse af nakken hvirvelsøjlen.

Philips Veradius Unity, som er installeret på Specialklinikken Rebild

Der findes i Danmark omkring 200.000 mennesker, som lever med eftervirkningerne af forskellige nakketraumer, og de har det rigtigt dårligt med at være blevet sat helt eller delvis udenfor samfundet. Det er en enorm opløftende følelse, at kunne hjælpe så mange mennesker, blot med en diagnose, men selvfølgelig også fordi jeg nu, havde et godt ”roadmap” til at behandle efter.

Jeg havde arbejdet intenst med at analysere hver hvirvels bevægemønster, og diskuterede mine opdagelser med kolleger og radiologer, så vi sammen kunne udvikle en opdateret viden om DMX. En viden som sammenfører MRI, CT og fluoroskopiske undersøgelser til et klart entydigt billede af hidtil negligerede tilstande specielt i cervical columna. Her tænkes specifikt på alle de små ligamentstrukturer i kranie-cervical overgangen, som betyder så meget for udfaldet af en et nakketraume.

Samtidig er det muligt, gennem DMX at kunne tilbyde en vægtig arbejdsdiagnose, baseret på faktuelle neuro – vaskulære – skeletale sammenhænge, som enhver behandler ville kunne forstå og kunne bruge i behandlingen. Der mangler nemlig oftest konkrete sammenhænge i helsesystemerne – som var tankerne omkring Translational Medical Science and Practice.

DMX døde lidt hen i 80’erne da MRI, efter al frygt for denne nye modalitet blev elimineret, og MRI blev den nye ”golden standard”, hvilken kom til at optage alles sind herefter. MRI blev snart en ”settled diagnostic science, og proceduren blev enormt populær. Mange er dog nu af den opfattelse, at der bør ske noget nyt indenfor radiologien, og der er gang i nye udviklinger fra især de store virksomheder som Siemens og Philips, som peger imod en sammenføring af forskellige trends indenfor området. Det bliver rigtigt spændende, at være med til at bidrage til denne udvikling med vores viden og erfaring med fluoroskopiske undersøgelser af cervical columna.

Vi ønsker at samarbejde med forskningsinstitutioner, så der kan skabes nye rammer for fremtidens diagnosearbejde. Automatiseret robotanalyse af billeder i bevægelse er en vanskelig men sikkert en nødvendig fremtidig facilitet, der vil kunne standardisere forståelsen af bevægelse for behandlere.

Vi har muligheden for at kunne være med i videreudviklingen af den cervicale undersøgelsesprotokol, og samtidig at være med til at udvikle både software og hardware til dette formål. Lejligheden byder sig nu, hvor firmaer som Philips og Siemens har robotteknologi sammen med fluoroskopi og de har CT i 3D og 4D under udvikling. Med den ekspertise indenfor dynamisk strukturdiagnose, som vi står foran, er det en ære at få lov til at deltage i og at bidrage til udviklingen. Vores viden indenfor dynamisk analyse af nakkehvirvelsøjlen er forhåbentlig vigtig, for at kunne drive videnskaben til nye udfordringer og resultater.

Der er så meget at skrive om DMX og videofluoroskopi, men jeg har sammen med min amerikanske forskningspartner Mike Winberry D.C. skrevet en, detaljeret artikel om DMX / videofluoroskopi, som jeg gerne vil dele med alle, der har interesse for denne teknologi. Vi forberedte artiklen, som baggrund til de danske sundhedsmyndigheder, for at støtte op om mit arbejde, med at få DMX godkendt i Danmark. Den er på engelsk, men jeg er håber, at de fleste kan læse den. Jeg vil lægge flere ting om DMX ind på dansk i den kommende tid. Det var blot vigtigt at få så megen information lagt ind på min hjemmeside straks, så vi kan få den åbnet igen.

Vidofluoroscopy by Mike Winberry D.C. and Erling Pedersen-Bach D.C.:

Indeed, there is a long history in the medical literature regarding the use of videofluoroscopy for the purpose of diagnosing spinal lesions.  Through the decades, videofluoroscopy has been known by many names such as: cineradiography, cineroentgenography, cinefluorography, dynamic radiography, dynamic spinal visualization, and digital motion x-ray (DMX).  The modern use of the term “cineradiography” refers to CPT code 76120, which is a non-diagnostic use of videofluoroscopy, in instances in which fluoroscopy is used to locate internal structures, such as facet joints, for the proper placement of injection therapies. The last term, “Dynamic Radiography,” needs some explanation, because it can be used to describe, at one end of the spectrum, plain film stress x-rays, and at the other end, digital motion x-ray.  The term “dynamic” is used to refer to any imaging which is not done in the neutral position.  For instance, plain film stress x-rays are done in full flexion and full extension, and not in the neutral position, which would be the neutral lateral cervical projection.   So, there are now “dynamic” or “functional” MRI’s, for instance, in which the cervical spine is placed in a position other than neutral for the collection of the data.  When the title of an article mentions anything dynamic or functional, the text has to be checked to see as to just which type of study is being referred.  Most recently, the technology has been known as DMX, which is a registered trademark of DMX Works Imaging, Inc., of Tampa, FL, which manufactures a DMX machine called the Visualizer 2000, but the common usage of the term has made it take on a generic meaning, like Kleenex or soda pop.

DMX technology is not a new technology- it is an improvement on the older, established fluoroscopic technology which has been around since 1896.  Remember, the first x-ray machine was built shortly after the discovery of x-ray in 1895, and by one year later, in 1896, no less than Thomas Edison built the first fluoroscope.  By the mid 1920’s, the first attempts were being made to record the fluoroscopic findings.  The history of videofluoroscopy from its beginnings to the 1990’s is chronicled in an excellent article by Gene Bell, D.C. [1]

  1. William Fielding, MD, was the earliest authority on cervical spine motion studies which utilized videofluoroscopy. He wrote the forward for the first edition of White and Panjabi’s Clinical Biomechanics of the Spine in 1981. He described the use of image intensifiers in producing the fluoroscopic image and in reducing the radiation exposure, and stated, “This paper is an attempt to describe some of the motions visualized in the cineroentgenogram which must seen to be fully appreciated.”[2]  He regularly presented papers and taught courses at the annual meetings of the American Orthopaedic Surgeons in the 1960’s and 1970’s.[3]

Malcolm Jones, MD, was an emergency room radiologist who worked at the University of California Department of Radiology and was the first doctor to utilize videofluoroscopy to study the cervical spine following a motor vehicle collision.  In the 1960’s, he documented that videofluoroscopy, which he called cineradiography, was of benefit in demonstrating either excessive or decreased motion and stated that “it has proved value in localizing the areas of abnormalities which correlate well with symptoms.”[4]  He was the first one to find that videofluoroscopy was effective in detecting failed arthrodesis when static films failed to do so.[5]

Joseph Howe, DC, DACBR, used cineradiography for identification and description of spinal motion abnormalities.  Dr. Howe was the one who said that motor units showing degeneration tended to be hypomobile, while levels above them tended to compensate with hypermobility. [6,7,8] He came up with a measurement scale for the motion abnormalities, but his scale used descriptive terms, so his “results” were subjective and not quantifiable.  He was published extensively in chiropractic peer-reviewed journals. [1]

Numerous other researchers used videofluoroscopy for the purpose of identifying spinal lesions during the 1970’s and 1980’s.  Neither plain film radiography nor videofluoroscopy permitted the detection of all the lesions which were found on the other, but videofluoroscopy was by far the more sensitive technology when compared to plain films. [9] Spinal videofluoroscopy was found to be a useful tool in determining the “precise vertebral level prior to spinal surgery.” [10,11] This is possible because the definition of spinal stability is the ability of the spine under physiologic load to limit patterns of displacement which would otherwise result in deformity and injury to the delicate neurological structures the spine is designed to protect.  “Physiologic load” refers to the normal mechanical stresses and strains the spine should be able to handle without a problem.  “Patterns of displacement” refers to exactly what part of the spine could possibly be displaced- the vertebral bones.  By a process of elimination, the tissue which must fail for bones to be displaced has to be the ligaments.  When the ligaments fail, “patterns of displacement” can no longer be managed, even under normal physiologic loads, and the brain stem, spinal cord, and spinal nerves can be damaged by intermittent osseous insult. [12] It is a consensus opinion in the literature that standard static flexion-extension radiography can only provide information about bony malalignment at the end of the range of motion, thereby missing important information in the rest of the range of motion. [9,10, 13-19].  For the past six or seven decades, one of the basic tenets of radiology has been that soft tissue injury can be inferred from bony malalignment, and the spinal distortions began to be examined quantitatively with computer mensuration in the 1970’s. [20] Though crude by today’s standards, numerous attempts to quantify spinal motion appeared in the medical literature into the 1970’s and 1980’s [21-23], and then abruptly stopped.  Today, numerous computer mensuration systems exist today which significantly improve diagnosis and the grading of ligament injury. [24]

The reason for the brief disappearance of videofluoroscopic literature in the late 1980’s was not because new information became available which disavowed all that had gone before- what happened was that MRI, which had been invented about ten years earlier, came into its commercial own.  Suddenly, the medical world had to deal with this startling new technology, which incidentally, had more than its share of detractors who claimed that “no good information will ever be gleaned from this technology.”[25]  But someone had to figure it out, with the radiologists leading the way, and figure it out they did, resulting in its status as the “gold standard” today in the investigation and diagnosis of countless human maladies.  As a result, videofluoroscopy sort of fell by the wayside as investigators chased the “shiny new object.”  But videofluoroscopy was never completely forgotten, though it had been easy to do so, because medical radiologists are not trained in spinal biomechanics, both then and now.  But without the influence of videofluoroscopy, numerous tenets of musculoskeletal practice which we chiropractors and medical doctors alike take for granted today, which do not require referencing, would not otherwise be known.  The knowledge that hypomobility is associated with muscle spasm, that intervertebral foramina expand and constrict with flexion and extension, and that motor units showing degeneration move less than their normal counterparts, all came out of the research done by the videofluoroscopy community.  To date, no studies have appeared which indicate that videofluoroscopy should be dropped altogether as a diagnostic tool.  If you are aware of any peer-reviewed medical literature which suggests that we should do so, we would be appreciative if you make us aware.

In fact, the opposite has occurred.  Validation of the use of videofluoroscopy for the diagnosis of spinal lesions appears in four areas of acceptance:  government acceptance, medical acceptance, medicolegal acceptance, and chiropractic acceptance.

In the United States, all medical machines require approval from the Food and Drug Agency (FDA) before general public usage.  It takes years and money to get the stamp of approval from the United States government.  DMX Works, Inc., received their FDA approval in 1994 as a Category B medical machine.  According to the FDA paperwork, the definition of a Category B device is that it is both “non-investigational” and “non-experimental.” [26]

The two largest trauma centers in the world- Walter Reed National Military Medical Center (4494 North Palmer Road, Bethesda, MD 20889, 1-800-526-7101) and San Antonio Military Medical Center (3351 Roger Brooke Drive, Fort Sam Houston, TX 78234, 1-210-9164141)- each possess two Visualizer 2000’s which they use for the screening and treatment of amputee military veterans in the prosthetics departments. [27]

All medical, osteopathic, chiropractic, and dental professionals must practice under the recognized practice guidelines established by their own professions.   Failure to do so can result in sanctions or discipline from medical and chiropractic boards, or malpractice charges from parties alleging injury due to incompetence.  The most common reason for malpractice claims in the United States is failure to diagnose correctly.

From the U.S. Department of Health and Human Services- which is a Cabinet-level office- and its Agency for Healthcare Research and Quality- comes the National Guidelines Clearinghouse.  The National Guidelines Clearinghouse contains descriptions of the standard of care for any and all health care interventions.  The National Guidelines Clearinghouse presents guidelines for Whiplash Associated Disorders (WAD).  The WAD Guidelines list videofluoroscopy as one of six accepted modes of diagnostic imaging, and that list includes x-ray, MRI, kinetic MRI, CT, and SPECT scan.  Whenever nouns occur in a series, separated by commas, it means that they all have equal grammatical weight.  Videofluoroscopy is included as part of the examination protocol for WAD “with continued moderate/severe complaints between six weeks and three months,” and the statement is made that videofluoroscopy screening may be useful for evaluating cervical instability injuries.”  In the Chiropractic Subluxation guidelines section, the following is included: “Videofluoroscopy may be employed to provide motion views of the spine when abnormal motion patterns are clinically suspected.  Videofluoroscopy may be valuable in detecting and characterizing spinal kinesiopathology associated with subluxation.” [28] Videofluoroscopy is an accepted diagnostic modality in U.S. government documents for evaluating those with Whiplash Associated Disorder.

Medical acceptance of videofluoroscopy appears in numerous forms, the first being the plethora of articles written by medical authors concerning the topic, some mentioned already.  One extremely notable recent article by Joel Franck, MD, a Tampa FL neurosurgeon, states, “The essential radiological feature of the CCS (Craniocervical syndrome) is lateral C1-C2 ligamentous instability. Easily detected utilizing DMX, all patients underwent this low-radiation, portable, 15minute, video-fluoroscopic exam of cervical motion in all axes, including open-mouth, odontoid, coronal lateral flexion-extension views.”  Dr. Franck’s article is a retrospective study of 39 of his patients prior to 2011, in which C1-C2 laterolisthesis was corrected with two pedicle screws and bony fusion, with remarkable positive results reported in a six-week follow-up. [29] To date, Dr. Franck has performed the procedure on 160 patients with the same excellent results. [30]

Just as it is in all professions, all radiologists are not created equal; some are more cognizant of the seriousness of ligamentous subfailure than others.  While radiologists are trained to interpret mainly static studies and are not familiar with radiographic interpretation of motion studies, a number of notable radiologists are the exception to the rule, and are strong proponents of videofluoroscopy:  David Harshfield, MD (Little Rock, Arkansas), Sean Mahan, MD (and his staff of eight radiologists, Miami, Florida), Joseph Ugorji, DO (Phoenix, Arizona), and Francis Smith (UK).

As the number of musculoskeletal practitioners in the United States who realize the importance of ligamentous subfailure in chronic pain has grown, so has the resistance from the auto insurers who ultimately must pay for the injuries to their insured clients, or to people injured by their clients.  Personal injury attorneys have had to increase their knowledge of soft tissue injuries as the insurance industry has dug in their heels and turned to junk science such as MIST (minor injury soft tissue) to keep from paying deserved compensation.  Trialguides.com is an online service from attorneys David Ball and Don Keenan which provides evidence-based strategies via books, CD’s, and DVD’s for presenting ligament injury cases to judges, juries, and arbitrators.  Aaron DeShaw, DC, JD, one of their contributors, practiced as a personal injury chiropractor in the UK for six years before going to law school, so for the past 20 years he has been in very successful private law practice in Portland, Oregon.  He wrote the book on Colossus [31], which is a software program designed by the insurance industry for determining the cash value of injuries caused by motor vehicle collisions.  He is the one who has been responsible for increasing awareness of the role of ligament injury in chronic pain cases, along with Jeff Cronk, DC, JD, owner and CEO of Spinal Kinetics, a company which employs board certified medical radiologists to perform CRMA (Computerized Radiographic Mensuration Analysis) on both plain films and digital motion x-rays to determine spinal instability.  The determinations the radiologists make are based on the guidelines described in the American Medical Association’s Guides to the Evaluation of Permanent Impairment, which currently is in its 6th edition.  The AMA Guides is a universally accepted medicolegal textbook used in the evaluation of permanent bodily impairment.  For years, the chiropractic profession has been maligned for its pursuit of the elusive chiropractic subluxation.  Now, in a book published by the American Medical Association, there is an equivalent to the vertebral subluxation- Alteration of Motion Segment Integrity (AOMSI).  In Chapter 17, “The Spine and the Pelvis,” the procedures for quantifying spinal instability in translation and angulation are described [32] and they are consistent with the work of Augustus White, MD, and Manohar Panjabi, MD. [33]

In the American jurisprudence system, testimony can be subjugated to the Daubert challenge, which is basically a challenge to the scientific validity of a claim or a statement.  In 1975, the U.S. Congress codified the rules for expert witness testimony in Rule 702 of the Federal Rules of Evidence, which essentially means that “if scientific, technical, or other specialized knowledge will assist the judge or jury to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify about these issues in the form of expert opinion testimony.”  Rule 702 was modified in December 2002, by Congress, incorporating U.S. Supreme Court decisions over the previous decade in this area of law beginning with the case of Daubert vs. Merrell Dow Pharmaceuticals.  A modified Rule 702 now sets forth appropriate review standards that make the judge responsible for ensuring that scientific evidence proffered in the form of expert testimony is reliable and reproducible. [34] Most importantly, DMX has passed the Daubert challenge in Federal Appeals Court.

In the case of Graftenreed vs. Seabaugh, in which the aforementioned radiologist David Harshfield was prominently involved, the defense argued that DMX technology did not meet the Daubert test standard because it had not been proven to aid in diagnosing or treating any injury and that DMX’s give no more information than standard x-rays.  The judge in the case ruled that because Daubert factors are applicable only to “novel” evidence, theory, or methodology, a Daubert analysis was not appropriate in this case.  The judge opined that as shown by the expert testimony and the documents filed by the plaintiff, DMX technology is not “novel;” it is simply a technological advancement of established, reliable procedures, as are MRI’s and CT scans.

The defense also argued that the scientific community had not generally accepted the use of DMX studies for diagnosing or treating an injury or ailment.  In answer, the plaintiffs filed supporting documents showing that DMX technology was approved by the FDA for patients with spinal and peripheral joint disorders and that the Arkansas Department of Human Services had given its approval in 2003.  They also showed that DMX technology had been endorsed by a number of other professional agencies, including the National Guideline Clearing House, the Arkansas Board of Chiropractic Examiners, the American Chiropractic Association Council of Diagnostic Imaging Physicians, the Arkansas Chiropractic Society, the American Academy of Pain Management, and the American College of Occupational and Environmental Medicine [35].

In addition to the Chiropractic acceptance noted above, in 1989, the Board of Directors of the International Chiropractic Association (ICA) signed off on “Guidelines for the Use of Videofluoroscopy in Chiropractic,” which was developed by the American Chiropractic College of Radiology [36]. In 1991, the American Chiropractic College of Radiology and the Council on Diagnostic Imaging released a position statement through the American Chiropractic Association regarding a protocol for the use of spinal videofluoroscopy.  This position was also adopted by the Chiropractic College of Radiologists in Canada.  The protocol was remarkably similar to the protocol published in the National Guidelines Clearinghouse, preceded it by two decades, and was far more specific in its requirements.  In fact, all of the existing guidelines for the use of spinal videofluoroscopy have been based on the original 1989 document.  Since then, guidelines have been published by the Mercy Center Consensus Conference [37], the Canadian Chiropractic Association [38], The Council on Chiropractic Practice [39], and The College of Chiropractic Radiologists of Canada [40].

The International Chiropractors Association established a special committee for the purpose of defining the role of x-ray in the scope of chiropractic practice.  The documents produced by the Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) can be viewed (without membership in the organization) at the ICA website.  In regard to the use of videofluoroscopy, they state, “In summary, the production of videofluoroscopic, cineradiographic, and digital motion X-ray images are a well-accepted part of clinical chiropractic practice.  These imaging techniques are irreplaceable in the chiropractic office with regards to clinical relevance.  There is substantial data on the reliability, predictive validity, and clinical utility of these imaging techniques.”  Concerning radiographic mensuration analysis, they go on to say, “The reliability of videofluoroscopic measurement by computer assisted method has been reviewed by several investigators.  In the case of video frame capture, measurement is performed on individual video frames and as such would be subject to the same reliability and validity computer analysis of plain film roentgenograms.  The reliability of fluoroscopic motion examinations analyzed by computer analysis has been reported.” [41]

In recent years, the insurance industry in the United States has become more discerning when it comes to reimbursement for diagnostic and interventional care.  More and more, lack of medical necessity is cited as a reason for non-payment of services rendered.  Videofluoroscopy previously has been used by pain management practitioners interventionally, but it is now being used diagnostically to establish the medical necessity for expensive injectional protocols and has been endorsed for use by the American Academy of Pain Management and by the American College of Occupational and Environmental Medicine.

Every year in the United States, approximately 11 million motor vehicle collisions (MVC) occur, resulting in approximately 1 million cases of whiplash.  “90% of all road-traffic collisions occur at speeds less than 14 mph and “it is in these that whiplash occurs.” [42] By the most conservative estimates, 33% of those cases result in chronic symptoms [43].  Numerous other sources put the number of chronic pain sufferers much higher, at 55-88% [44-48].  Similarly, approximately 15,000 Danes suffer from a whiplash injury each year. [49] Up to 50% of these victims develop ongoing symptoms and long-term disability, and 10% of those initially injured will suffer from symptoms to an extent that their working capabilities are reduced, i.e. with an ongoing handicap or disability [50].  The cost to the health care system is enormous.

The first step in getting someone well is getting the diagnosis correct; otherwise you may end up barking up the wrong tree.  Motor vehicle collisions produce significant ligament injury which goes either undiagnosed, partially diagnosed, or misdiagnosed.  However, MRI has always been considered to be the “gold standard” when it comes to diagnosing ligament injuries.  But while it is effective in diagnosing the large ligaments in the extremity joints, it is relatively ineffective in diagnosing spinal ligament subfailures.  The technology is able to do it; what is lacking is the skill of the imagers in both the application of the technology and the ability to interpret the findings.  The question actually should be if MRI should really be the gold standard when it comes to spinal ligaments, after all.  The fact is that the resolving power of X-ray and MRI is insufficient to visualize the full spectrum of trauma.

A number of articles point out the fallibility of MRI examinations.  In one, ten victims of catastrophic head trauma were examined for evidence of concurrent neck trauma by plain film x-ray, MRI, and special forensic analysis.  While 28 serious lesions were identified overall, only 11 of the lesions were identified by MRI.  The examination of specially prepared 3-micrometer tissue slides under microscope identified the other 17 injuries, which were later confirmed by the radiologists who missed them in the first place.  One of those radiologists was Donald Resnick, MD, who happens to be the author of the five-volume textbook Diagnosis of Bone and Joint Disorders and is the world’s leading authority on bone and joint radiology today.  The authors concluded that significant findings at autopsy were not present on plain films, and in some cases, MRI, and that “direct depiction of the ruptured apophyseal (facet) joint capsule was almost impossible,” even though facet capsule ligament tears are known to be the leading cause of chronic neck pain following the whiplash event. [51] In another similar study, the authors did a review of several studies which utilized cryomicrotomy during autopsy of car crash victims, with a control group, in order to investigate damage to the cervical spine following a fatal head injury.  Plain film and MRI missed most of the traumatic findings, which were found only in the traumatized patients, with no similar lesions found in the non-traumatized patients in the control group. [52]

A medical doctor sent the same 63-year-old woman with a history of low back pain and right L5 radicular symptoms for 10 lumbar MRI examinations at separate sites.  The patient was examined by a wide variety of machines, everything from the 0.3T Open MRI to a 3.0T MRI machine.  The basic premise of this study was that radiologist reports from multiple imaging centers performing a lumbar MRI on the same patient over a short period of time would have marked variability in interpretive findings, and a broad range of interpretative errors.  Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment.  No one interpretive finding was reported in all 10 studies, and only one finding was reported in 9 out of 10 study examinations.  The statistical analysis indicated that there was poor overall agreement on the interpretive findings.  The Kappa score for inter-tester reliability was applied to the data, and no score was above 0.2 (1.0 represents perfect correlation, >0.80 necessary for statistical significance).  The authors concluded: “Where a patient obtains his or her MRI examination and which radiologist interprets the examination may have a direct impact on the radiological diagnosis, subsequent choice of treatment, and clinical outcome.” [53]

Does this mean that we should just throw out MRI in favor of DMX?  Absolutely not!  As Nikolai Bogduk stated, “…. this fact reinforces the principle that medical imaging in vivo may fail to identify lesions that are definitely present at postmortem.  Consequently, in the context of whiplash injury, normal radiographs, or even normal magnetic resonance imaging, do not mean that the patient has no lesion.” [54] It just means that you’ve used the wrong tool.   For the most part, MRI is a tool which is designed to provide information about the intervertebral disc.  The intervertebral discs make up about 10% of the tissues of the neck, which means that an MRI provides information about only 10% of the neck.  A DMX is intended to provide information about the status of the ligaments of the neck.  Though it is x-ray, which blows right through the ligaments and renders them invisible on the study, the unusual gapping between the bones caused by motion of the spine is proof that the ligaments have been compromised.  One diagnostic test does not replace the other- the fact is that the two technologies are complementary and the use of both provides a more complete clinical picture of the patient so that the treating clinician can design the best possible course of treatment for the ultimate good of the patient.  “Modern studies of the biomechanics of whiplash have used high-speed photography and high-speed cineradiography to determine the kinematics of the cervical spine as a whole and of individual segments, both in cadavers and in human volunteers.  The results have been illuminating.” [55]

During a typical diagnostic DMX study at Specialklinikken Rebild, the Philips Veradius Unity Fluoroscope typically produces a measurable radiation output of 6.72 mGy, which is well within the safe radiation ranges described by the National Council on Radiation Protection and Measurements (NCRP), the International Council on Radiation Protection and Measurements (ICRP), and the Health Physics Society.  The latter released a position statement on Radiation Risk in Perspective in March, 1996:  “In accordance with current knowledge of radiation health risks, the Health Physics Society recommends against quantitative estimation of health risk below an individual dose of 5 rad= 5000 mrad (50 mGy) in one year, or a lifetime dose of 10 rad (100mGy) in addition to background radiation.  Risk estimation in this dose range should be strictly qualitative accentuating a range of hypothetical health outcomes with an emphasis on the likely possibility of zero adverse health effects.  The current philosophy of radiation protection is based on the assumption that any radiation dose, no matter how small, may result in human health effects, such as cancer and hereditary genetic damage.  There is substantial and convincing scientific evidence for health risks at high dose.  Below 10 rad (100mGy) (which includes occupational and environmental exposures) risks of health effects are either too small to be observed or are non-existent.”  In other words, <10 rad (10,000 mrad or 100 mGy) is considered to be a very low dose of radiation, with no discernible adverse effects. [56]

References:

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  2. Fielding, J. William. Cineroentgenography of the Normal Cervical Spine. Journal of Bone and Joint Surgery {Am} 1957; 39:1280-88
  3. Fielding, J. William. Normal and Selected Abnormal Motion of the Cervical Spine from the Second Cervical Vertebrae to the Seventh Cervical Vertebra Based on Cineroentgenography. Journal of Bone and Joint Surgery {Am} 1964; 46:1779-81
  4. Jones, MD. Cervical Spine Cineradiography after Traffic Accidents. Archives of Surgery 1962; 85:974-81
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  18. Stokes, IAF, and Frymoyer, JW. Segmental Motion and Instability. Spine 1987; 12:68891
  19. Suh CH et al. The Fundamentals of Computer Aided X-Ray Analysis of the Spine, J Biomechanics, 1974, Vol. 7, p. 161-169
  20. Taylor M, and Skippings R. Paradoxical Motion of Atlas in Flexion: A Fluoroscopic Study of Chiropractic Patients.  European Journal of Chiropractic 1987; 35:116-34
  21. Breen A et al. A Digital Videofluoroscopic Techniques for Spine Kinematics, Journal of Medical Engineering & Technology, Vol. 13, No. 1/2, January/April1989, p. 109-113
  22. Masters B, and Sugiyama I. A Cineradiographic Study of the Kinetic Relationship between the Cervical Vertebrae. Thesis.  Bournemouth, England:  Anglo-European College of Chiropractic, 1978-79
  23. Brownstein SP, Cronk J et al. Evaluation of Spinal Ligamentous Injuries using Computerized X-Ray Interpretation, Orthopedics and Rheumatology Open Access Journal, Vol. 1, Issue 1, Aug. 2015
  24. Personal conversation with Francis Smith, MD, September 2018
  25. U.S. Food and Drug Administration, Center for Devices and Radiological Devices, 510(k) Premarket Notification Database, “Visualizer 2000, VF Works, Inc.,” 12/27/1994
  26. John Postlethwaite, D.C., presentation at DMX Certification Seminar, Parker University, Dallas TX, November 3-4, 2018
  27. National Guidelines Clearinghouse, Whiplash Associated Disorders, p. 5
  28. Smith FW and Dworkin JS (ed). The Craniocervical Syndrome and MRI, Chapter 2, by Franck JI and Perrin P. “The Cranial Cervical Syndrome Defined: New Hope for Postwhiplash Migraine Headache Patients- Cervical Digital Motion X-Ray, FONAR Upright Weight-Bearing Multi-Position MRI and Minimally Invasive C1-C2 Transarticular Lag Screw Fixation Fusion.” Basel, Karger, 2015, pp. 9-21
  29. Personal conversation with Dr. Joel Franck, September 21, 2018
  30. DeShaw, Aaron, Colossus- for Medical Providers, Trial Guides Webinar
  31. Rondinelli RD. Guides to the Evaluation of Permanent Impairment, 6th Ed., (American Medical Association), p. 579
  32. White AA and Panjabi MM. Clinical Biomechanics of the Spine, 2nd Ed. (J.B. Lippincott Company) 1990, pages
  33. Ibid, AMA Guides, 6th Ed., Chapter 1
  34. Graftenreed vs. Seabaugh, CA06-1289, Court of Appeals of Arkansas, Division Four, 100 Ark. App. 364; 268 S.W.3d 905; 2007 Ark. App. LEXIS 828, November 28, 2007
  35. Board of Directors, International Chiropractors Association, “Action on Dynamic Spinal Visualization Resolution,” February 24, 1989
  36. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference, 1993
  37. Clinical Guidelines for Chiropractic Practice in Canada, Canadian Chiropractic Association, 1994
  38. The Council on Chiropractic Practice, Clinical Practices Guideline, 4th Ed., “Vertebral Subluxation Practice and Videofluoroscopy,” 2013
  39. The College of Chiropractic Radiologists of Canada, Technical Protocol for Spinal Videofluoroscopy, Policy Statement, Chiropractic College of Radiologists (Canada) Inc.
  40. International Chiropractors Association’s (ICA) Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP), Section X, page 154, 2006
  41. Bannister G, Amirfeyz R, Kelley S, and Gargan M. Whiplash Injury, Journal of Bone and Joint Surgery (Br), July 2009, vol. 91B, No. 7, p. 845-850
  42. Ibid, Smith FW and Dworkin JS (ed)
  43. Gargan MF, Bannister GC. Long Term Prognosis of Soft Tissue Injuries of the Neck, J Bone joint Surg [Br], 1990: 72-B: 901-3
  44. Squires B, Gargan MF, Bannister GC. Soft Tissue Injuries of the Cervical Spine, J Bone Joint Surg [Br], 1996:78-B: 955-7
  45. Hidingsson C, Toolanen G. Outcome After Soft-Tissue Injury of the Cervical Spine. Acta Orthop Scand 1990;61(4):  357-359
  46. Benketorp L., Nordholm L, Carlsson J. A Descriptive Analysis of Disorders in Patients 17 years Following Motor Vehicle Accidents. Eur Spine J, 2002, 11:227-234
  47. Parmer HV, Raymaker R. Neck Injuries from Rear Impact Road Traffic Accident- Prognosis in Persons Seeking Compensation, Injury, 1993; 24(2): 75-78
  48. Holm LW, Carroll LJ, Cassidy JD et al. The Burden and Determinants of Neck Pain in Whiplash-Associated Disorders after Traffic Collisions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33:S52-S59.
  49. Carroll LJ, Holm LW, Hogg-Johnson S et al. Course and Prognostic Factors for Neck Pain in Whiplash-Associated Disorders (WAD): Results of the Bone and Joint Decade 20002010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33:S83-S92
  50. Stabler, A., Eck J., Penning R., Milz, SP, Bartl R., Resnick D, Reiser M. Cervical Spine: Postmortem Assessment of Accident Injuries- Comparison of Radiographic, MR Imaging, Anatomic, and Pathologic Findings.  Radiology, 2001; 221 (2):340-6
  51. Uhrenholt, L, et al. Cervical Spine Lesions after Road Traffic Accidents, Spine 2002, Vol. 27, No. 17, pp. 1934-1941
  52. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in Diagnostic Error Rates of 10 MRI Centers Performing Lumbar Spine MRI Examinations on the Same Patient Within a 3Week Period, Spine J 2017 Apr;17(4):554-561
  53. Bogduk N. On Cervical Zygapophysial Joint Pain After Whiplash, Spine 2011, Vol. 36, No. 255, pp. S194-S199
  54. Bogduk, N and Yoganandan N. Biomechanics of the Cervical Spine Part 3: Minor I Injuries, Clinical Biomechanics 16 (2001), p. 267-275
  55. International Chiropractors Association’s (ICA) Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP), Section VII, page 2-6, 2009