Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 210

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

“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:

Mark, 
 
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*

 
As an example, in a rear end collision, we might see C4 or C5 or both slipping posteriorly on extension. (I would have to check the current AMA guides, but it has been considered a 25% whole person impairment at 3.5mm instability, I believe) An instability like this might have compensations / compensatory VSC's. Alteration of treatment might be more frequent less aggressive treatments and techniques - toggle, activator, techniques that don't go to the point of extension that causes poster slippage at the damaged levels as seen on the lateral extension DMX view. Every case is different, but yes, it will probably alter the way you treat the patient including which segments you adjust.

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

 
If it’s unstable, off you go to the neurosurgeon, do not pass go – do not collect $200.  If there are no instabilities, treat according to your normal treatment protocol.

Dean Brown DC

 
In simple terms Chiro adj are forces by hand, instrument , table assist etc, to either unlock something that is stuck or improve structural alignment.  If an area is hyper mobile determined by stress x-rays or DMX  I would avoid a force at that level and work below or above  the hyper mobile-loss of motion segment integrity area.  The ligamentous test by x-rays affect tx plan in five key areas... 1- refer for neurosurgical consult ...2- where and where not to adjust...3-Rehabilitation both in terms of frequency and intensity...4- lifestyle recommendations e.g.: no contact sports , martial arts , rugby ...limited house work , limited computer work if ligament damage...5-Prognosis will def change if ligaments are damaged.

Greg Kramer DC, DAAMLP

 
Ligament laxity would be a contraindication to any thrust, and treatment would indeed be to stabilize the surrounding tissue.  So this would definitely change my Tx plan.  Prolotherapy may be indicated in this case as the aim to is strengthen weakened connective tissue.  I've never used it or referred, but I've heard about it. Just to throw it out there for someone.

Jordan L. Kovacs, D.C., CCSP, DAAMLP
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