Friday, October 25, 2013

The Spine and the X-Ray: What you should know.

This post is credited completely to the work of Serge Gracovetsky, a well-known researcher in spinal function.  Although his findings and research have been public for more than 3 decades, it is only recently that his hypotheses from way back in the 80's are proving to have been quite insightful and, arguably, ahead of its time.  Further, it is always encouraging to find some parallels and "symbiosis" between ones own philosophy and that of a renowned and true expert in the field.

The title of this post is relatively self explanatory: There is an intrinsic "disability" that exists within the diagnostic framework that is systemic and often leads to confusion and, in some cases, mis-interpretation of information.  

This "disability" takes many standardized diagnostic "language", established uniform standards of measurements, and obvious rampant objective differences.  Gracovetsky points this out rather explicitely in alot of his work...although he doesn't refer to "diagnostic disability", he often demonstrates the simplicity of past and current assessment protocol.  This isn't, in my view, and effort to discredit...rather to highlight that a more focused effort is required along with more broader perspectives of evaluation and assessment.  I will refer to work he formulated regarding the spinal "engine".

QUESTION:  What is the function of the spine? 

This SHOULD be an explicit and straightforward question...however, you would find that even among the "experts" you would have some objective differences and responses.  You would encounter some within the "spine is a supportive structure" camp...and you would also find some heavily entrenched within the "spine is a functional unit that generates movement"...and as expected, some would attempt to skirt this line.

REALIZATION:  If we cannot agree on the function, how can we decide on how to treat or do surgery? 

This is quite thought-provoking in my view.  How can a standardized protocol of practice and intervention be implemented when the function of a given biological unit cannot be unanimously understood and percieved?  We therefore come to the most popular diagnostic tool that has been the standard since it
 was discovered in 1895...the X-Ray.

Wilhelm Rontgen took this radiograph of his wife's left hand on December 22, 1895, shortly after his discovery of X-rays.
 Since that time, it has obviously undergone some significant technological refinement and has evolved into a very useful tool in the evaluative process.  Although its merits and advantages are obvious and beneficial, it has been elevated to a status that isn't truly warranted and, in my view, is potentially misleading. 

It is used very frequently as a diagnostic tool...which is something I have written about in the past...and this strategy is fundamentally flawed.  The most significant failure of this strategy is that it is a 2-dimensional representation of a 3-dimensional system...therefore a great deal of information is missing.  The explicit example of how much information is left out is one that almost everyone can relate to:  What is the difference between looking at a picture of a mountain top and actually being there live? The difference is exponentially different and distinct!  Further, it is fundamentally almost impossible to gauge function and movement potential from a still image...therefore as Gracovetsky postulates:

Function cannot be deduced by radiology

One of the most impacting realizations I have experienced came from one of his presentations on "The Spinal Engine".  He posted an image of  a spine and asked a straightforward question:  Can this person lift 10 lbs? 

The answers were understandibly varied...some refering to some degenerative symptoms that were observable, some refered to issues of alignment, etc.   Here is the "punch-line": 

This is an x-ray of a cadaver

Gracovetsky:  If radiology cannot determine if a patient is even alive...why is it used in disability assessment??  Quite insightful...

He goes on to stipulate that one of the most common errors made within the evaluative paradigm (and which is one that I have shared and expressed for quite some time) is the assumed link between anatomy and function.  In other words, the anatomical and topographical representation is a reflection of functional competence...and this is a simplistic and formally inefficient strategy.  Therefore the "Gracovetsky effect" results in a paradoxically simple rule: 

Function must be measured independantly as part of a comprehensive investigation of injury or dysfunction

I'm hoping that this insight results in similar broadening of perspective...even if only slightly.  


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