Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 210
“Ligament Laxity Care & DMX Results”
Last week, I sent you a question seeking answers on how you would treat a patient where ligamentous instability was conclusively diagnosed via DMX (digital motion x-ray, formerly called video fluoroscopy) and the following are the answers. I included the doctor's names, as they deserve the credit for taking the time to share their level of clinical excellence.
As for DMX, although there is no peer reviewed research currently, it is incredible technology. However, without the research, it can't go far in either the medical or legal communities. As a result, Dr. Bill Owens and I have partnered with an MRI teaching facility who will do the DMX utilizing MRI technology to verify the validity of the results and have added to our team an orthopaedic surgeon who is also credentialed in engineering and believes in both the DMX technology and chiropractic. Together, the team will be submitting for publication research on the accuracy and clinical implications of DMX technology. A process that will take more than a year and a couple of bucket loads of $$$, but is needed. I don't need your money on this research project, but I will on future ones.
Last week, I posted an e-mail from a doctor who asked a question about DMX technology and if I would recommend the testing. I posed 1 question about how the DMX findings would change his treatment plan because if there were no changes in the treatment plan, there would be no indication to order the test. I got his answer and wasn't happy. Therefore, I posed the same question to everyone. Here is what I received from one doctor:
You have an uncanny ability to make me feel like an idiot!
I don't know if I can answer the question raised in this consult. I have been meaning to ask this very question of you, "how does ordering a test/results of that test affect your care plan?", since I don't seem to come up with the appropriate answers in most cases (even to myself!!).
In the case of the DMX ligamentous laxity testing, it seems the test would be ordered to determine if laxity exists, at what level or levels, and to what extent there is damage. Referring back to a neurosurgeon with these results in hand seems a reasonable response to me as new information would now be present. Additionally, it seems that extended treatment with a focus on stability of surrounding tissue as well as home exercise to assist in same and possibly cervical pillow, etc. for continued support would be appropriate if the neurosurgeon thought surgery was still not required.
I then wrote to everyone the following:
This was just sent to me on yesterday's consultation...I need your help in crafting a response to this doctor's question. I believe I have a very good response, but would like input from you on how to best answer this question. This is also an area that I will be expanding on to help you with every diagnostic modality at our disposal...Mark
How would you answer the question of how does DMX change the treatment plan for the patient? The correct answers:
If the DMX reveals ligamentous instability I would presume that the neurosurgeon would perform the proper surgery. If the DMX does not show ligamentous instability then we will continue conservative physical medicine and alternate the treatment plan as clinically indicated.
Unless you mean that she has already seen the neurosurgeon, which she has. Then I would set up an appointment with the neurosurgeon to show him the DMX video and ask his opinion. I would expect that he would be thrilled to see it
Micah D. Carter DC, CCST
In DMX testing, the goal is to identify any laxity and where it is present. If it exists, then a neurosurg consult is appropriate, especially as it relates to C0-3 complexes.
If the neurosurgeon states that it is not surgical, then two primary things should be done:
(1) increase the postural stability of the involved area(s) via rehab, etc.
(2) counsel the patient on the significance of the laxity and avoidance of provocative positions, activities, etc. and leave the areas of laxity alone in regard to manipulation (with the exception of possible gentle mobilization and distractive techniques).
Sheldon Hoxie DC, FACFN, FABES, FABVR, DAAMLP*
Every ligament instability is unique. A significant atlas instability with the dens potentially compressing the cord on flexion has higher risk factors (like with a damaged transverse ligament). If such a patient comes to a sudden stop... you get the point. Refer for ortho / neuro / surgical consult when necessary.
Ligament stretching damage is plastic deformation and is permanent. I have never seen it resolve. Sometimes the ligaments are torn / ruptured. Referrals are wise. I have seen some serious instabilities, but haven't yet seen a surgical recommendation to correct one on the spine. I have, however, seen surgical recommendations for instabilities in the extremities. Prolotherapy might be indicated in the extremities - I don't know, but a referral to the appropriate physician to make such a determination is logical.
Michael Haley, DC
Dean Brown DC
Greg Kramer DC, DAAMLP
Jordan L. Kovacs, D.C., CCSP, DAAMLP