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The Outcome Assessment of Physical Therapy and Chiropractic Spinal Adjustments on Low Back Pain, Opioid Use, and Health Care Utilization - Lowering Opioids by 55% vs. Raising Opioids by 90%

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The Outcome Assessment of Physical Therapy and Chiropractic
Spinal Adjustments on Low Back Pain, Opioid Use, and Health Care Utilization

Studin Mark1 , Capoferri Don2 , Birinyi Paul3 , Roche Patricia4 , Gerrow Geoffery5


Reference: Mark Studin DC, Don Capoferri DC, Paul Birinyi MD, Patricia Roche DO, Geoffrey Gerow DC. Lumbar Disc Herniation and Biomechanical Dysfunction - A Case Study. Discussion of - The Outcome Assessment of Physical Therapy And Chiropractic Spinal Adjustments On Low Back Pain, Opioid Use, and Health Care Utilization,” Medpix: National Institute of Health/National Library of Medicine, Published March 3, 2024. 

Link: https://medpix.nlm.nih.gov/case?id=302fa559-7313-44de-8eb4-786045c03c0f   (Case History Reported First) 


1. Mark Studin DC, FPSC, FASBE(C), DAAPM is an Adjunct Clinical Assistant Professor at the State University of Buffalo, Jacobs School of Medicine and Biomedical Sciences, Department of Family Medicine, and an Adjunct Associate Professor at the University of Bridgeport, School of Chiropractic and an Adjunct Professor at Cleveland University Kansas City, Chiropractic and Health Sciences 

2. Don Capoferri, DC, FSBT, FPSC, BCN, is an Adjunct Professor at Cleveland University Kansas City, Chiropractic and Health Sciences

3. Paul Birinyi, MD, FAANS, is a neurosurgeon with a Peripheral Nerve Mini-Fellowship and a Master's in Molecular Science. He has been on the surgical staff at teaching universities in 7 states.

4. Patricia Roche, DO, Radiology and Neuroradiology, is an Associate Professor of Radiology and an Attending Physician at the State University of New York at Stony Brook School of Medicine

5. Geoffrey Gerow DC, DABCO, is an Adjunct Clinical Assistant Professor at the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Department of Family Medicine, Founding Director of Chiropractic at D'Youville College.


ABSTRACT


Opioid use is an indicator of the efficacy of care for low back pain. All physical therapy modalities realize no lowering of opiate use, while the addition of active and passive care increases use by 90%. Longer physical therapy care increases the use of opiates, spinal injections, MD specialty care, and hospitalizations. Chiropractic care reduces the use of opioids by 55%, with patient satisfaction of 96%, while decreasing disability by 313% compared to physical therapy. The mechanism is neuroplastic changes with central segmental motor control in chiropractic, high velocity-low amplitude thrust, where manipulation does not affect these changes. Despite the outcomes in the evidence, most of our healthcare systems and the providers they influence still list physical therapy as the cornerstone to treating low back pain, costing hundreds of billions annually. Low back pain is escalating, and it is considered a worldwide epidemic, where an evidence- based, cost-effective solution is readily available but grossly underutilized. This is not a referendum against physical therapy or medicine, as collaboration with every healthcare discipline is required, and each provider brings a unique skill set to the healthcare marketplace. However, with low back pain, the evidence in the literature strongly suggests that to help eradicate the low back pain epidemic and reduce the use and costs of opioids, chiropractic should be the first provider.

 

INTRODUCTION


The necessity for opiates is an indicator of the efficacy of treatment and should be the precursor for treatment
protocols. Perhaps the necessity for opiates is the pathway to a solution to the worldwide epidemic of low
back pain. This is not a calculus of opiate use but the reason for opiate use. Historically, opiates have been the
most common drug prescribed for back pain (Ivanova et al. 2011) and accounted for 50% of opiate use, given
the prevalence of back pain.


Low Back pain affects 33.9% or 2.66 billion adults worldwide, costing more than $365 billion annually (Lo et al.
2021). Low back pain remains the leading cause of years lived with disability in the world since 1990, with the
number of incidents increasing since 2019. The ages peak at 45-54 years for both sexes and finalize at 80-84.
The highest incidence globally is in North America. When managing chronic low back pain (CLBP), much of the
literature supports lifestyle modification, diet, education, physical therapy, pharmacological treatments,
psychotherapy, and surgery. (Chen et al., 2022) There are many clinical guidelines globally that are,
unfortunately, too similar. Despite those guidelines for managing low back pain, the gap between the
evidence and practice is pervasive. (Foster et al., 2018)


It is past time that we get it right and use the outcomes evidenced in the literature as our only guideline
because the global society continually gets it wrong despite the scientific findings. John Hopkins Medicine
recommends activity modification, drugs, physical therapy, osteopathic manipulation, occupational therapy,
weight loss, smoking cessation, prevention programs, surgery, and assistive devices. The Mayo Clinic
recommends heat and pain relievers (OTC), followed by NSAIDs (non-steroidal anti-inflammatory drugs,
muscle relaxers, topical pain creams, narcotics, antidepressants, physical therapy, movement modification to
minimize pain, cortisone injections, radiofrequency ablations, implanted nerve stimulators, and surgery.


EVIDENCED TREATMENT OUTCOMES


When considering well-respected institutions' care path for managing low back pain, as listed above, it
epitomized the gap Foster et al. (2018) reported between the evidence and clinical practice. Opiate use with
low back pain has been well-tracked over the last decade, and utilizing clinical outcomes for the lowering of
opiate use is perhaps the best arbiter for creating guidelines when treating low back pain sufferers.
There have been no physical therapy treatments that lower the use of opioids in acute or chronic pain
(Farrokhi et al., 2023). This includes direct care: manual therapy, active care: physical activity, and passive
care: exercise therapy, heat, needle therapy (acupuncture or dry needling), therapeutic exercise,
neuromuscular re-education, ultrasound, mechanical traction, and electric stimulation. If any combination of
active or passive care is performed, opiate use increases by 50%. If one passive intervention is used, spinal
injections increase by 32%, and M.D. specialty care increases by 27%. If any combination of passive and active
care is performed, spinal injections increase by 53%, and M.D. specialty care increases by 50%. If 2 or more
passive interventions were used, there was a 50% to 80% greater likelihood of the escalation of care events.


Despite the above outcomes, active interventions with physical therapy were done in 89.9% of low back pain
patients, hot/cold packs 42.5%, manual therapy 35.4%, electric stimulation 17.9%, needle therapies 10.6%,
and mechanical traction 9.5%. Patients with prolonged physical therapy considered 10% over the mean of 63.6
days had an (over the above statistics) 7% increase in hospitalizations, 5% higher opioid use, 11% spinal
injections, and 10% higher M.D. specialty care (Farrokhi et al., 2023).


The use of opioid prescriptions for patients receiving chiropractic care vs. other therapies was 55% less. The
cost of opioid prescriptions was 74% lower than other therapies (Whedon et al. 2018). The adjusted risk of
filling an opioid prescription within 365 days of the initial visit was 56% lower among recipients
of chiropractic care as compared to non-recipients in an older population. No matter the demographic or
cohort, chiropractic lowers the risk of opioid use (Whedon 2021). The opioid epidemic costs the United States
$1.5 trillion annually (JEC, 2022), and it was reported that more than 50% of opioid users report back pain
(Deyo et al., 2015). Based on the above Unites States Congress, Joint Economic Committee, if all back pain
patients were treated initially with a chiropractor, it could reduce annual opioid prescription costs by a
minimum of $550,000,000,000 ($555 billion).


MECHANISM OF TREATMENT THAT REDUCES OPIOID USE


Lowering opioid use requires changes in spinal biomechanics, leading to changes in central segmental motor
control (changes in the central nervous system) due to direct intervention, as described by Farrokhi et al.
(2023). Manipulation was found to have the same benefit as mobilization (Minnucci et al., 2020) and will be
reported as the same. Manipulative therapy, as taught in the physiotherapy profession in the form of joint
mobilization, was the development of manual therapy with gradual force (Anggiot et al., 2020). It is divided
into arthrokinematic and osteokinematic to determine the direction of mobilization (Kaltenborn et al. 1993).
The aforementioned forms of mobilization each involve the movement of the joint with increasing force
through the planes of the joint. Manipulation and mobilization do not affect central segmental motor control
(Haavik et al. 2021), which is consistent with not lowering opioid use.


A chiropractic spinal adjustment (CSA) is a high velocity-low amplitude thrust and significantly differs from
manipulation or mobilization, as reported above, has reduced opioid use by 55%. The CSA is divided into three
phases: the pre-load, thrust, and resolution phase, which mostly occurs in under 1 second, the amount of
force to the joint is approximately 100N, 350N, and 400N (cervical, sacroiliac, lumbar). This defines the high
velocity and low amplitude (Pickar et al., 2012). This process increases the gapping of the zygapophyseal joint,
which has been suggested to have developed adhesions after hypermobility. The gapping may be the breaking
up of putative fibrous adhesions that create hypomobile or fixed zygapophyseal joints Z joint). A CSA creates
gapping and is thought to help re-establish a physiological range of motion (Cramer et al. 2002).


Unfortunately, that range of motion, if the joint capsule has a strain injury, cannot normalize and the tissue
cannot heal. It "wound repairs" with different tissue (collagen and elastin are replaced only with collagen) that
renders permanent joint failure predicated on the amount of ligamentous injury (Hauser et al. 2013).


With repetitive micro or a single macro trauma to the spine, the inferior articular process goes into flexion. On
attempted extension, the inferior articular process returns to the neutral position. Instead of reentering the
joint cavity, the meniscoid (joint spacer) impacts against the articular cartilage and buckles, entrapping the
meniscoid and forming a space-occupying lesion. There are a large number of nociceptors (type III and type IV)
in the Z joints, which have been associated with joint pain as the distension of the joint capsule provides
sufficient stimulus to depolarize the receptors. A high velocity-low amplitude CSA involving gapping of the Z
joint reduces the impaction and opens the joint, encouraging the meniscoid to return to its normal anatomical
position in the joint cavity (Figure #1). This decreases the distention of the joint capsule, thus reducing pain
(Evans 2002).


When the joint separates, misplacing the meniscoid, the joint capsule, composed of ligaments, acts as a
mechanoreceptor, sensitive to outside forces, and the muscle reacts. The action provided a clear pathway for
central segmental motor control. The ligaments have Ruffini corpuscles (stretch receptors), Pacinian
Corpuscles (crimp receptors), and Golgi Tendon Organs (proprioceptors in the tendons), which are the primary
sensory organs related to the effects of meniscoid displacement. The mechanoreceptors and proprioceptors
innervate the lateral horn. (Tsuchitani, Neuroscience 2024).


The neurological impulses, with the meniscoid entrapment and joint capsule triggering the mechanoreceptors,
nociceptors, and proprioceptors, feed into the deep paraspinal muscles in the lateral horn. The deep
paraspinal muscles, in turn, through Piezo 2 ion channels and Golgi Tendon Organs, innervate the lateral horn
(Bornstein et al., 2021)


The sensory information from deep paraspinal muscles around a central segment motor control (CSMC)
problem is thought to create widespread maladaptive neuroplastic changes within the central nervous system
(CNS). It is likely to reduce the ability of the CNS to accurately perceive what is going on at that level of the
vertebral Column (which, over time, is likely to lead to poor vertebral motor control, maintaining a central
segmental motor control problem (Haavik et al., 2021; Brown et al., 2011; Change et al., 2019). This can lead
to maladaptive changes in neural function, as well as maladaptive changes in body structure and function,
worsening its ability to adapt and respond to internal and environmental cues, thus leading to the
development of less-than-ideal motor control, a variety of symptoms, diseases, and disorders. The altered
sensorimotor and multimodal integration of the afferent input changes the accuracy of the inner body and
external world schemas (Haavik et al., 2021; Holt et al., 2016; Alcantra et al., 2013).


Altered central segmental motor control through deep paraspinal muscle maladaptation can lead to dizziness,
visual disturbances, unsteadiness, physical injury, pain, inflammation, and acute or chronic physiological stress
(Haavik et al., 2021; Hellstrom et al., 2005; Meier et al. 2018). According to Haavik et al. (2021), "The brain
creates a map of sound localization; the sound localization map is influenced by somatosensory, visual,
vestibular, and auditory information, as well as from proprioceptive and mechanoreceptive information and
from efference copies from the brain itself, all of which can impact neuromuscular function.

Several brain structures are involved in the creation of these maps, including brainstem centers, the insular

cortex, and other interoceptive centers, primary and secondary sensory cortices for exteroceptive inputs,

frontal cortical areas, including the prefrontal cortex, as well as the cerebellum, the vestibular cortex, the

autonomic ganglia, and many limbic areas" These areas validate that a CSA directly affects brain regions and
the functions they control.


These areas are critical for coordinated everyday movements of all kinds, as well as a host of other functions,
such as homeostatic regulation of the body, how you feel emotionally, how your body functions and feels, and
they even influence your motivations and behaviors.


A CSA affects the dorsal horn through the mechanoreceptors, nociceptors, and proprioceptors by reducing the
biomechanical pathology of meniscoid displacement, creating a neurological cascade by removing the
aberrant impulses into the later horn (Coronado et al. 2012). This reverses the negative neurological cascade
by removing the biomechanical lesion at the facet level. Immediately after the CSA, functional MRI reveals
changes between brain regions, modulates the pain experience, and allows for central segmental motor
control (Gay et al., 2014).


With the CSA and correction of the underlying biomechanical pathology, there is no longer a need for
homeostasis in the form of antalgia, removing the necessity for plumbing the body in all planes. Therefore,
disparate regions of the body no longer need to be spastic, and through central segmental motor control, pain
thresholds were reduced or disappeared after the CSA (Coronado et al., 2012) (Figure #4).

When considering the best approach to treating spinal biomechanical lesions that lead to opioid use,
outcomes must be the determinant factor. The key to realizing neuroplastic changes is CSMC, and only a CSA,
high-velocity, low-amplitude thrust accomplishes those changes. As a result, a CSA realized a 38.4% increase
in muscular activation vs. manipulation/mobilization, whereas 6 months post-CSA, 19% of the increase has
been retained. Maximum voluntary contractions with CSA vs manipulation/mobilization increased by 55%-
60% and by 64.2% with chronic stroke survivors. A CSA increased motor evoked potentials in the
upper limb by 54.5% and in the lower limb by 44.6% and a 16.76% change in neurophysiological
changes at the 30N SEP (brain impulses). Manipulation/mobilization had no changes. These are the
outcomes validating why a CSA reduced opioid use by 55%.


HOW TO IDENTIFY THE BIOMECHANICAL LESION TO EFFECT OPIOID CHANGES


Identifying the biomechanical pathology of the spine is the key to delivering an effective high-velocity, low-
amplitude thrust, or CSA (Haavik et al., 2021). A significant part of the global and national low back pain
epidemic, the $750 billion dollar price tag, and escalating incidence, including the misnomer “non-specific
back pain,” which has become dogma, is at the epicenter. Nonspecific low back pain is defined as low back
pain, not from fracture, tumor, infection, osteoporosis, structural deformity, inflammatory disorders, disc
pathology, or cauda equina syndrome that accounts for a minimum of 95% of low back pain sufferers (Oliveira
et al., 2018). Medicine has identified how they handle 5% of low back pain cases, or 130 million cases
worldwide. What about the other 2.53 billion people? There needs to be a pathway towards the solution,
which starts with identifying the lesion, as it is very specific, although not in the training of medical doctors

(Humphreys et al., 2007). The increased incidence of low back pain, with continually failed treatments,

validates the necessity for changes in the curriculum of those who manage these cases.
The following case history highlights an evidenced-based care path in identifying the primary lesion of the
spine and a solution for managing low back pain.


CASE SYNOPSIS


A 28-year-old female presented post-MVA and complained of constant sharp, aching, shooting pain with
tightness and significant discomfort in the lower back. Using the Visual Analog Scale (VAS), she rated the
intensity of discomfort as a level 8 on a scale of 0 to 10, with 10 being the most severe. The discomfort was
reported to increase with movement and prolonged sitting.


Constitutional: slightly overweight, clean/neat, well-dressed, and well-groomed
Vital Signs: Height: 5'4"; Weight: 161 lbs., Pulse: 83 bpm. BP: 105/78, mm/Hg left arm in the seated position.
Temperature: Taken with skin surface scanner. 97.8 degrees Fahrenheit.


Pulse Ox: 99%. Appearance: has difficulty changing positions. Palpation of the C5, C6, T2, L4, and L5 vertebrae
produced centralized spinal pain. Palpation of the facet joints produces pain at the C5 and L5 level (s)


DeKlyn's and Maigne's tests were negative. O'Donaghue's test was positive in active and passive ROM. An Arm
Squeeze Test was performed. The patient indicated pain that was 8 out of 10 (10 being the most severe) on
the right compared to equal pressure on the acromioclavicular area. Spurling's Test, Soto Hall, Valsalva’s,
Sternal Compression Straight Leg Raising, Double Straight Leg Raising, Braggards, Minor’s, Iliac Compression,
Fabere-Patrick, and Babinski tests were all negative.


Hoffman's sign was positive during the examination bilaterally. Mental Status: Evaluations were performed,
and the patient was observed to be alert and oriented X 3 (person place time) and cooperative. Sensory Pain:
Evaluations performed bilaterally. Dermatomal hyper-esthesia is at right C4, right C5, and right C6. Elvey's test
is positive on the right. Neuro- Deep Tendon Reflexes (normal 2+): Biceps: Left 2+, Right 3+, Triceps: Left 2+,
Right 2+, Brachioradialis: Left 2+, Right 2+, Patellar: Left 3+, Right 3+, Achilles: Left 2+, Right 2+.


Upper extremity resistive isometric motor testing (normal 5/5): Shoulder Elevation: Left: 5/5 Right: 5/5,
Deltoid: Left: 5/5 Right: 4/5, Biceps: Left: 5 /5 Right: 3/5, Triceps: Left: 5/5 Right: 5/5, Wrist Flexors: Left: 5/5
Right: 5/5, Wrist Extensors: Left: 5/5 Right: 5/5, Finger Abductors: Left: 3/5 Right: 3/5, Palmar Interossei: Left:
5/5 Right: 5/5. Neuro-Lower extremity resistive isometric motor testing (normal 5/5): Iliopsoas: Left: 5/5 Right:
5/5, Quadriceps: Left: 5/5 Right: 3/5, Anterior Tibialis: Left: 5/5 Right: 3/5 Biceps Femoris Left: 5/5 Right: 5/5,
Ext Digitorum Longus & Brevis: Left: 5/5 Right: 5/5, Gluteus Medius: Left: 5/5 Right: 5/5
Cranial Nerves I to XII were examined, revealing normal function to the following: I through XII.


Musculoskeletal - Gait and Station: normal gait and normal balance. Tonicity: moderate spasm right deltoid,
erector spinae, latissimus dorsi, levator scapulae, multifidus, paraspinal, rhomboid, scalene, medial, scalene
posterior, and upper trapezius.


Physical Findings - Neck Tissue: Supple, non-tender, without cervical lymphadenopathy noted. The thyroid
gland was not palpable, without nodules. Otherwise, unremarkable findings.


The patient complained of discomfort in her back, head, neck, and left shoulder with numbness down her arm,
post-car accident, with supplemental complaints of numbness or tingling, depression, headaches, tightness,
soreness, shock, dizziness, stress, irritability, tiredness, anxiety, and low energy. She states that during the 3
weeks intervening time since the accident, her overall condition and complaints have deteriorated, inclusive of
loss of daily functioning, increased pain, loss of ranges of motion in her cervical spine with radiation of pain,
and loss of motor strength in her upper extremities.


Lumbar Rages of Motion were performed using a 2-piece inclinometer: Flexion 77/80, Extension 8/25, Left
Lateral Flexion 39/25 (hypermobile), Right Lateral Flexion 42/25 (hypermobile).


Due to the motor weakness and ranges of motion hypermobility, X-rays were performed and revealed
moderate biomechanical pathology at L2, L4, and L5. There was significant biomechanical pathology at L3. As a
result of the biomechanical pathology and motor loss, a lumbar MRI was performed.


The mid-sagittal T2 sequence demonstrates a mild disc bulge at L4-L5 and a posterior central disc herniation at
L5-S1. A posterior annular fissure was seen. The mid-sagittal T1 sequence demonstrates a mild disc bulge at
L4-L5 and a posterior central disc herniation at L5-S1. The T2 axial view reveals a posterior disc herniation at
L4-L5 and high signal in the annulus (Figures #2-#4). Because there was no root compression and ample
cerebral spinal fluid space, the patient underwent chiropractic treatment consisting of chiropractic spinal
adjustments in the cervical, thoracic, and lumbar regions. In collaboration with a neurosurgeon, this was
deemed non-operable in the conventional sense, as surgery would have a poor prognosis for resolving her
pain due to no significant neurological compression or compromise.


X-ray digitizing revealed permanent damage to the capsular ligaments and ligamentum flava at L2 and L5.
Treatment in the lumbar spine was with vectors right to left at L2 and left to right at L5 based on
biomechanical studies. Care was rendered with instrument adjusting 3 times per week for 8 weeks. (Figures #5
- #12). The cervical spine had biomechanical failure at C2-C3 and C5-C6. A CSA was also performed at these
levels with an instrument. Treatment also included an infrared laser at 6 jewels for 44 seconds on every visit
before the adjustment. Spinal decompression was also performed before the CSA, as both modalities
decreased swelling and increased circulation. During chiropractic care, the pain gradually diminished, and the
patient’s activities of daily living returned.


On discharge at 12 weeks, after the cessation of care at 8 weeks, using the Visual Analog Scale (VAS), she rated
the intensity of discomfort at a level of 0 on a scale of 0 to 10, with 10 being the most severe. The pain was
reported to decrease with chiropractic care, and the patient returned to full activities of daily living.

CONCLUSION


Despite evidence for managing low back pain, the gap between the evidence and practice is pervasive as
previously discussed (Foster et al., 2018). This is evidenced by too many highly regarded medical institutions
continuing to recommend less successful pathways to help curb opioid use. States such as New York are taking
opioid reduction to the next level and recently signed into law S.4640. A mandate for providers to consider
opiate alternatives, including allopathic non-opioid and non-allopathic pathways to treat
neuromusculoskeletal conditions before prescribing opioids. Regarding the largest users of opioids, back pain
patients, which account for approximately 50% of opioid use, the care path should follow the evidence in the
literature. The arbiter for low back pain, as all treatment should follow evidence-based outcomes.
Even though there are many stakeholders in this $750 billion industry, the evidence shows that physical
therapy realizes upwards of an 80% increase in opioids in 90% of patients, with a 0% reeducation in the last
10%. In contrast, chiropractic has a 55% reduction in opioid use for the same population of low back pain
patients with a 74% decrease in opioid drug costs. Consistent with those statistics, chiropractic has reduced
secondary disability by 313% compared to physical therapy for back-related conditions and by 239% for
primary disability for the same (Blanchette et al., 2017), where medicine is diagnosing 95% of patients with
low back pain as nonspecific and predominantly referring to perpetual failed pathways. At the same time,
chiropractic helps 96% of its patients, including low back pain (Ntedan et al., 2020). This is not a referendum
against physical therapy or medicine, as collaboration with every healthcare discipline is required, and each
provider brings a unique skill set to the healthcare marketplace. However, with low back pain, the evidence in
the literature strongly suggests that to help eradicate the low back pain epidemic and reduce the use and
costs of opioids, chiropractic should be the first provider.


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Figure #1

Picture2

Mechanism of meniscoid entrapment

Figure #2

Picture3

The mid-sagittal T2 sequence demonstrates a symmetrical disc bulge at L4-L5 and a posterior central disc herniation at L5-S1.

Figure #3

Picture4

The T2 axial view reveals a posterior disc herniation at L4-L5 and high signal in the annulus and reversal of the cervical lordosis, contributing to the indentation of the ventral thecal sac, with a focus of high signal at the annulus.

 

Figure #4

Picture5

A T1 mid-sagittal sequence demonstrates a symmetrical disc bulge at L4-L5 and a posterior central disc herniation at L5-S1

 

Figure #5

Picture6

A lateral lumbar X-ray, once pathology was ruled out, was digitized to diagnose and determine a treatment plan for biomechanical pathology

 

Figure #6

 Picture7

A neutral lateral X-ray, once pathology was ruled out, was digitized to diagnose and determine a treatment plan for biomechanical pathology

Figure #7

Picture8

A lateral lumbar flexion X-ray, once pathology was ruled out, was digitized to diagnose and determine a treatment plan for biomechanical pathology

Figure #8

Picture9

A lateral Lumbar extension X-ray, once pathology was ruled out, was digitized to diagnose and determine a treatment plan for biomechanical pathology

Figure #9

Picture10

An A-P lumbar X-ray

Figure #10

Picture11

An A-P lumbar extension X-ray, once pathology was ruled out, was digitized to diagnose and determine a treatment plan for biomechanical pathology

Figure #11

Picture12

X-ray digitization of the lumbar rotational biomechanical pathology

Figure #12

Picture13

X-ray digitization of lumbar translation showing biomechanical failure

 

 

 

 

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