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·  AmericanAcademy ofPainManagementPracticalGuideto Clinicians,FifthEditionstates,"...digital motionradiographyiscurrentlyavaluablediagnosticmethod inevaluatingpainfulhyper- mobilityand instabilityof capsularandaxial ligaments in thecervical spine."

·  TheAmericanMedical Association,GuidestotheEvaluationofPermanentImpairmentFifthEdition states,"Alteration ofmotion segment integrityis definedfromflexionandextensionradiographsasat least3.5mm of translation ofonevertebraonanother,orangularmotion ofmorethan 11 degreesgreaterthaneachadjacent level..."as a criteriato determinethe"Impairment oftheWholePerson".

·  TheOccupationalMedicinePracticeGuidelines,SecondEdition2004(AmericanCollege of Occupationaland Environmental Medicine)states, "Ifprobableligamentous injurywith persistent pain,consider fluoroscopicallydirectedflexion study."

·  DonaldResinck:ProfessorofRadiology,UniversityofCalifornia,SanDiego. Diagnosis ofBone/Joint Disorders:1988,chapter3."Videofluoroscopy isusefulintheevaluationofjointmovement.Usedduring R.O.M.,(rangeofmotion)itidentifiesthelevel ofInstability secondary to ligamentousdamage."

·  TheCervicalSpine: theCervicalSpineResearchSociety: 1989, page260."Videofluoroscopy is adynamictechniquethatallowsprecisepositioningduring R.O.M.studies. Anteriorgappingofadisc space suddentranslationofavertebral bodyonanothermayindicateintersegmental instability."

·  Buonocare, Edward, MDet.at.kCineradiogramsofCervicalSpinein Diagnosis ofSoft-tissueInjuries,Journal American Medical Association.Theauthorconcludes thatcineradiographyaddsanotherdiagnosticmethodof evaluating suspectedsoft-tissueinjuries ofthecervical spinebydemonstrating itsmotionduringexercise. Furthermore,thecineradiographicstudywillhaveits greatest valueifitcandetectabnormalmotionin patientswhoshownormal spines instandardroentgenogramsandbeforedegenerativechangeshave occurred.

·  JohnBland: Disorders oftheCervicalSpine: 1987, page144. "Videofluoroscopy isthemostvaluabletechniqueinanalyzingcervical spinemotion."

·  Jones,Malcomb,D.,MD,CervicalSpineCineradiographyAfterTrafficAccidents,Archives of Surgery.Cineradiographicstudiesdemonstrated one (1)or moreabnormalitiesin43of50patients involvedinrear-endvehicle collisions."

·  JohnBland:Professorof Medicine,Universityof Vermont.Disordersof theCervicalSpine: 1987,page134."The Stabilityof thecervicalspinedependson bonystructuresonlyto aminordegree; instability depends to a major degree on theligamentousstructures."

·  Suchinjuryisnotalwaysdetectedonstaticplainfilmx-rays (standardroentgenograms).The next bestmedicallyreasonablediagnostictoolfordeterminingligamentousinjury(abiomechanical source ofpain)isthefluoroscopicexam.

·  RuthJackson:instructorof OrthopedicSurgery;BaylorUniversity,theCervicalSyndrome: 1977"Videofluoroscopy showsareasoflimitedorunstablemotionresultingfromligamentousand capsularinjuries."

·  RobertBaily:Professorof OrthopedicSurgery,Universityof Michigan,AnnArbor.TheCervical Spine1974,chapter3.DynamicAnatomyandCineradiographyof theCervicalSpine."Video fluoroscopy showsabnormalsecondaryto softtissue(ligamentous)damage.Stabilityis dependenton ligaments."

·  Jones,Malcomb,D.,MD,CineradiographicStudiesof Abnormalitiesof theHighCervicalSpine, ArchivesofSurgery. Theauthorbeginsbynotingcineradiographyisbecoming widelyavailable andreports of itsusein orthopedic problems,particularthoseof thecervicalspine.Cineradiography, itwas concludedthattheuseofcineradiographyhas elucidatedabnormalities seenon plain roentgenogramsofthecervicalspine.

·  Woesner, Merlin,E.,MD,andMitts,TheEvaluationof CervicalSpinemotion belowC2: A comparison of CineroentgenographicandConventionalRoentgenographicMethods. AComparison studyof 40randomlyselectedpatientswhohadroentgenographicinvestigationof thecervical spinebyboth cineradiographyandconventionallateralroentgenograms inflexion, neutralposition,andextensionwasmade forthe analysisofmotion. In14of the40patients, abnormalmotionwasdetectedinthespinethatwasnotseen ontheplainroentgenograms.

·  Itisfurtherappropriatetodeterminethelevelof thisindividual'slong-termprognosisrelated to injury.Ligamentousinstabilityisrecognizedas“wholeperson"impairmentbytheAmericanMedical Association (AMA). Anytranslationof onevertebralbodyonanotherin theCervical Spineisabnormal, andas littleas 3.5mmisconsideredgroundsfor25%wholeperson impairment.

·  It should benoted that the ACCRandCommitteeonScientificAffairshas determinedthat theutilization ofFluoroscopyis useful imagingmodality forthedemonstration ofspinal intersegmental jointdysfunction.

·  SpinalImpairmentCategories: AMA Guides(DiagnosisImagingoftheAmericanChiropractic Association/PositionStatement of6/13/91)."With thepublication oftheseguidelines...theAmericanCouncil of ChiropracticRadiologyno longerconsidersSpinal Videofluoroscopyas investigational within thechiropractic profession."

·  Fluoroscopyis supportedbytheACOEM(AmericanCollegeofOccupationaland Environmental Medicine) Guidelines.

·  Occupational MedicinePracticeGuidelines:Evaluationand Management ofCommon HealthProblemsand FunctionalRecoveryinWorkers,second Edition."Ifprobableligamentous injurywithpersistentpain,consider fluoroscopicallydirectedflexionstudy."

·  TheCentersforMedicareand MedicaidServicesfurthersupport theappropriateness offluoroscopyasan examination techniqueutilized to determinebiomechanicalabnormalities(subluxation). Medicarecoverage database; LCDforChiropracticService(manual spinalmanipulations) (L15759).

·  The National Guideline Clearinghouse (NGC) NGC-6978: (2008) Vertebral subluxation in chiropractic practice. “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 with vertebral subluxation.” Rating: Established Evidence: E, L

Magnetic Resonance Imaging (MRI): “Its use is generally restricted to instances where the desired information cannot be obtained by less costly procedures.” Rating: Established Evidence: E, L

Radiographic Digitizing Analysis: “Computerized x-ray analysis may be used by chiropractors to objectively analyze the biomechanical and misalignment improprieties related to vertebral subluxation. Clinical necessity is justified for assessing the degree of insult and the effect upon the patient’s health and future well-being by way of impairment rating. “ Rating: Established Evidence: E, L

·  The National Guideline Clearinghouse (NGC) NGC-7408 (2009) Management of whiplash associated disorders.

Videofluoroscopy is part of the Examination. The following signs may be helpful in the selection of patients for musculoskeletal problems: Hypermobility. Hypomobility. Aberrant motion. Instability. Aberrant coupling. Paradoxical motion. Evaluation of spinal arthrodesis.

“Standard MRI may be used for signs and symptoms of radicular disorders.”

·  The National Guideline Clearinghouse (NGC) NGC-7250 (2009) Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) for biomechanical assessment of spinal subluxation in chiropractic clinical practice. Motion X-ray/Videofluoroscopy for Kinematic Instability Evaluation: Production and analysis of VF, Cine, and DMX images are well accepted part of clinical chiropractic practice.” www.pccrp.org Section X pg. 149-160.