Archive for category Radiology



Outcome measurements are used to validate chiropractic adjustments, and they have not always been compared to each other under the same treatment conditions and trials.


Twenty-one participants were non-randomly assigned to a treatment or a control group. The Oswestry index questionnaire was completed, and lateral bending lumbar radiographs were collected. Treatment group participants received nine treatments in two weeks, the control group was untreated, and both groups were re-evaluated after two weeks.


The average number of segments manipulated per day went from 8.3 ± 1.0 (day 1) to 3.0 ± 2.6 (day 9), with a standardized effect size of 2.69. The Oswestry disability index for the treatment group was 29.8% ± 11.8% disability pre-treatment and 14.20% ± 11.5% disability post-treatment, with a standardized effect size of 1.34. In the radiograph analysis, the number of dysfunctional segments changed from 6.8 ± 2.3 pre-treatment to 1.8 ± 5.2 post-treatment, with a standardized effect size of 1.24.


A significant correlation was found between pre- and post-treatment measurements of the Oswestry index and dynamic radiographs.

Spine Research. 2016 Vol. 2 No. 1: 12 (iMedPub Journals)

Author information: Roy RA, Bouchera JP, Comtois AS. University of Quebec in Montreal, Department of Kinanthropology, Montreal, Quebec, Canada. Identifier: NCT00739570

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D. Wayne Rhodes

Private Practice of Chiropractic, Tuscaloosa, AL 35401

Phillip A. Bishop

Department of Kinesiology, University of Alabama

To the Editor:

The Cooperstein and Lew1 article, “The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature,” referenced our work.2 We feel that their statements should distinguish between anatomical leg length inequality (LLI) and functional LLI.

In the discussion section, they indicated that there was “… poor agreement found by Rhodes et al. between visual methods of leg checking and upright radiographs.” We reported the relationship between prone LLI measurements and standing radiograph as “The … correlation coefficient (r) between the two variables was … 0.719.”2 Most statisticians characterize this as a moderate positive correlation and not “poor agreement.”

Anatomical LLI exists. The LLI incidence is not known perhaps because of confused definitions. Mannello3stated, “It appears that the least controversial issue associated with LLI is its anatomical existence.” As we previously stated,2 “Structural, anatomical or actual LLI are synonymous terms and are diagnosed when either the femur or tibia is longer in one leg than in the other, as shown on X-ray.” Mannello3 defined it similarly.

Anatomical LLI denotes different bones lengths of right and left lower extremities. The criterion standard for anatomical LLI is the scanogram, radiograph of both femurs and tibias; so comparisons can be made. Of the scanogram, Mannello3 said, “This procedure is considered a valid indicator of lower extremity length.”

The Cooperstein and Lew review on anatomical LLI did not include any studies involving actual bony differences in leg length. However, Mannello3 pointed out, “Others define anatomical short leg as that which is shorter in length from the floor to the weight bearing surface of the femoral head.” This seems to be the definition adopted by Cooperstein and Lew, but no definition of anatomical LLI was included in their review.

Of the 9 studies in their review, 7 involved simulated LLI, with no anatomical bone length differences seen on radiograph. Of the other 2 included, one used tape measures of legs, which have been shown to be unreliable; as Cooperstein and Lew1 pointed out in their article, “Tape measure methods for measuring LLI have been found to be of equivocal accuracy and may be less accurate than radiological criterion standard method for assessing anatomical LLI.…” The other study included used radiographs of the femur heads, without full views of both lower extremities (Friberg4 method). A developer of that radiograph technique stated, “The method described here is not meant to substitute the methods for measuring accurately the length of the different parts of the lower extremity.”4 One cannot distinguish anatomical (structural) LLI from functional LLI with the Friberg method of comparison.

Methods that incorporate both anatomical and functional LLI without distinction (eg, Friberg method) necessarily overestimate the incidence of anatomical LLI5 compared with a stricter definition.


1. Cooperstein R., Lew M. The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature. J Chiropr Med. 2009;8(3):107–118. [PMC free article] [PubMed]
2. Rhodes D.W., Mansfield E.R., Bishop P.A., Smith J.F. The validity of the prone leg check as an estimate of standing leg length inequality measured by X-ray. J Manipulative Physiol Ther. 1995;18(6):343–346.[PubMed]
3. Mannello D.M. Leg length inequality. J Manipulative Physiol Ther. 1992;15(9):576–590. [PubMed]
4. Friberg O., Koivisto E., Wegelius C. A radiographic method for measurement of leg length inequality.Diagn Imag Clin Med. 1985;54:78–81. [PubMed]
5. Knutson G.A. Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. Chiropr Osteopat. 2005;13(1):11. [PMC free article] [PubMed]

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Assessments of spinal stiffness have become more popular in recent years as a noninvasive objective biomechanical means to evaluate the human spine. Studies investigating posteroanterior (PA) forces in spinal stiffness assessment have shown relationships to spinal level, body type, and lumbar extensor muscle activity. Such measures may be important determinants to discriminate between patients with low back pain (LBP) and asymptomatic subjects.


To determine the relationships between dynamic PA spinal stiffness and radiographic measures of lower lumbar disk height and disk degeneration.


L4 and L5 posterior disk height (PDH), vertebral body height (PVH), anterior disk height (ADH), and vertebral body height (AVH) were obtained from digitized plain film anteroposterior (AP) and lateral radiographs of 18 symptomatic LBP patients presenting to a chiropractic office (8 female patients and 10 male patients, aged 15-69 years, mean 44.3, SD 15.4 years). Disk degeneration (DD) and facet arthrosis (FA) were qualitatively assessed from the films by an independent examiner. Anterior disk height ratios (ADHR = ADH/AVH) and posterior disk height ratios (PDHR = PDH/PVH) were calculated from the disk height measurements and were compared to L4 and L5 posteroanterior spinal stiffness obtained using a previously validated mechanical impedance stiffness assessment procedure.


One third of the subjects were found to have radiographic evidence of mild or moderate DD and approximately two thirds of the subjects showed signs of mild or moderate FA. The L4 and L5 anterior disk height and posterior disk height were approximately one half and one fifth of the respective vertebral body heights, and the PA stiffness was greater at L4 than at L5. Male subjects had a greater ADHR than female subjects, but female subjects had a greater L4 and L5 PA stiffness in comparison to male subjects; however, these differences were not statistically significant. Posteroanterior L5 vertebral stiffness was found to be significantly correlated to the L5 PDHR.


Computations of spinal input impedance are relatively simple to perform, can provide a noninvasive measure of the dynamic mechanical behavior of the spine, appear to have potential to discriminate pathologic changes to the spine, and warrant further study on a larger sample of normal subjects and patients.

J Manipulative Physiol Ther. 2003 May;26(4):233-41. [PMID:12750657]

Author information: Colloca CJ, Keller TS, Peterson TK, Seltzer DE. New York Chiropractic College, Seneca Falls, NY, USA.

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To assess the validity and reliability of prone and supine measurements of leg length inequality and to determine the potential use of measurements at the iliac crests and patient demographics as predictors to estimate standing leg length differential.


Repeated prone and supine measurements of leg length inequality were made by an experienced chiropractor and compared with iliac crest and femur head measurements made on X-rays of standing patients. Multiple regression analysis was performed.


Private chiropractic practice.


The first 50 new patients with low back pain that were X-rayed were included in the study.


Intraexaminer reliability was excellent for the prone measurements. The supine tests were less reliable. The prone measurements were highly correlated with the standing X-ray femur head measurement. The supine measurements were poorly correlated. Measurements of deficiency at the iliac crests on X-ray were most highly correlated with X-ray measurements of discrepancy. In multiple regression, the prone measurements and duration of problem were the only significant predictors of standing X-ray difference.


In this study, crest measurements were made on X-ray; the degree of accuracy with which millimeter differences can be measured clinically on patients is unknown. In a few cases, the supine measurements were more accurate than the prone; however, the supine test validity was poor when compared with the standing X-ray measurements, and reliability was less than expected. Supine measurements should not be used to estimate standing leg length discrepancy in new low back pain patients but perhaps can be used in other clinically meaningful ways. Intraexaminer reliability of the prone measurements was higher, but further investigations need to focus on interexaminer reliability. The prone measurement as a predictor holds promise, but new measurement tools must be developed.

J Manipulative Physiol Ther. 1995 Sep;18(7):448-52. [PMID:8568426]

Author information: Rhodes DW, Mansfield ER, Bishop PA, Smith JF. University of Alabama, Tuscaloosa, AL,USA.

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