April 2002

The Value of Posture Photographs

by Grant Reid, D.C.

Dr. Reid practiced CBP® in Lynnwood, Washington for five years before moving to Japan several years ago. He graduated class salutatorian from Life Chiropractic College - West in 1983, is a Certified Chiropractic Extremity Practitioner, and prior to leaving Washington State, was a State Appointed Washington Labor & Industries Consultant. He holds licenses to practice chiropractic in both California and Washington. Dr. Reid is also currently a CBP® Instructor, and of course, our first in Japan.

            In America, how often do chiropractors take postural photographs of our patients? I would suggest borderline never. The Holy Grail for accessing subluxations will probably always remain the x-ray. From an x-ray, one can see overall alignment, lateral curvature of the spine, disease, fracture, etc. Another reason to take x-rays is insurance companies. They pay for x-rays, but they don’t pay for postural photos (at least not often). As a final reason; impact. When a patient sees his/her spine on x-ray, it has meaning to them.

            In addition to x-rays, or when x-rays are not available, we fall back on range of motion, static, and motion palpation, and leg-length checks as a method of determining subluxation. Other methods of determining subluxation (DTG, Nervoscope, sEMG, etc.) are also available.

            But for a moment, let’s look at and compare medicine, and its methods of evaluation as opposed to chiropractic. If one goes to the medical doctor’s office with diabetes, high blood pressure, or another common ailment, in many cases a blood lab test is performed. Regardless of where the patient goes, and regardless of which physician reads the results, the findings are the same. Compare this to chiropractic. Doctor “A” uses Activator Methods and analyzes subluxation by leg-length. Doctor “B” uses Diversified technique and determines subluxation from range of motion and orthopedic examination. Doctor “C” is a “Motion Palpation” Doctor, and hence uses motion palpation to determine the subluxations. In Doctor “D’s” case, he/she takes an x-ray, and then marks the x-ray with PRS, ASRP, and other Gonstead-Firth listings (or diversified listings).

            So now, Doctors A, B, C, and D, in having used completely different methods of analysis, have come up with completely different subluxations. From this, they also apply different (or similar) methods of treatment. With disrelated definitions of subluxation, and different methods of analysis, of course, the four doctors will come up with different subluxation diagnosis.

            It is a known fact from several studies that many patients derive symptomatic as well as physiological changes from the placebo effect alone.1,2,3 Turner found that up to 70% of all patients derive results from the placebo effect alone.4 Wyke demonstrated that spinal manipulative therapy will reduced pain, and increase spinal motion temporarily.5 He found that simply popping the joints, without regard to direction, or misalignment will produce pain relief. For this reason, whether or not the patient gets well from the various methods of treatment is not really at issue at this point. What is at issue is the methods of analysis.

            For starters, we fall back on the age old question; what is subluxation? For doctors A, B, C, and D, they are defining the subluxation based on the examination methods. That is to say, the motion palpation doctor centers the meaning of subluxation around loss of motion of the vertebra. The activator doctor centers the subluxation around facilitation of the nervous system with regards to the subluxated segment, and so on.

            Crap! What is subluxation again? I forgot. I thought DD and BJ Palmer agreed on one thing anyway; subluxation has to do with loss of normal alignment of the vertebra to one degree or another. In any case, the illness is not supposed to be defined by the method of examination. The method of examination is supposed to be defined by the illness.

            The purpose of this article is to make claim for the usage of postural photos as a method of determining subluxation, so without drifting too far from this purpose, this article will first define subluxation as any alignment of the spine that is other than the normal as defined by common sense (meaning the spine as viewed from the front or back should obviously be straight, and perpendicular to the earth), and the findings from research.6,7,8,9 I, for one, believe this is the best definition of subluxation since it does have to do with displacement of the vertebra from normal alignment. Second, if Doctors A, B, C, and D all use this definition of subluxation, they will all come up with the same findings. Improvement of the subluxations is regardless of the placebo affect, since improvement requires anatomical changes. There are no studies in the literature relating placebo to anatomical changes (at least none I have found).

            Following this definition of subluxation, the only thing that remains is establishing a reliable and reproducible method of examination, hence postural photos, and this article. X-rays do such, but lack the ability to observe the spine in three dimensions. As will be shown in this article, viewing the posture by means of photograph and analyzing them via computer can prove to be exceptionally valuable. For example, if the thoracic spine is rotated to the right say 3 degrees, there is no way to measure, or observe this via x-ray. However, via postural photos this can be done. I should make note here, postural software available on the market today can not do this. Read further for a more detailed explanation of this.

How to take postural photos

            This is best done with a digital camera with remote control. It also requires a computer, printer, and simple software such as Photoshop, Microsoft paint, etc. This is not going to be a detailed explanation, as most readers probably won’t really start taking postural photos after having read this article, but I feel some explanation is necessary.

            The patient needs to be dressed in clothing that allows full visual analysis of the body. I have found spats, as seen in the below photos to be the best clothing for photos.

            The camera needs to be fixed in the same position for each photo. Changing the position of the camera each time an update photo is made allows for errors in evaluation.

            Photos are taken before treatment.

            It is a must that four full body views be taken. I haven’t found any postural software companies that do this yet. Once they see the value in this, maybe that will change. The four views are A-P, P-A, lateral left, and lateral right. All views go from the feet to the top of the head.

            I use Photoshop to assemble the four views on one sheet. The four views must be evenly aligned along the bottom (See Figure 1). Needless to say, the views must be perpendicular. This requires the camera being perpendicular.

Measuring the Photos

            1. FCL (Frontal Center Line) — (black) Run a line from the center of the feet and perpendicular to the floor up to the top of the head on both the A-P and P-A views (See Figure 2).

            2. SCL (Side Center Line) — (black) Run a line from the lateral malleolus and perpendicular to the floor up to the top of the head on the two lateral views (See Figure 2).

            3. SAL (Shoulder Angle Line) — (red) Run a line across the level of the shoulders on the A-P and P-A views (See Figure 3).

            4. HAL (Head Angle Line) — (red) Run a line from the bottom of the left ear to the bottom of the right ear on the A-P, and P-A (If this can be done as well) views (See Figure 3).

            5. AL (Arm Level) — (red) Mark a line across the bottom of the length of the hands on the A-P, and P-A views (See Figure 3).

            6. ASP (Actual Side Posture) — (red) Run a line from the lateral malleolus to the center of the hip, from the center of the hip to the center of the shoulder, and from the center of the shoulder to the center of the ear on the two lateral views (See Figure 3).

            The doctor can also add other lines for assessment, but these are the basic lines. The FCL and SCL lines are essential lines and always required for accurate assessment.

Analyzing the photos

            With the methods utilized above, one can make various and reliable determinations. First let’s look at the A-P view. Thoracic and cervical lateral flexion can be seen from the level of the shoulders in relationship to the level of the head. This is not complicated. If the shoulders are unlevel (SAL), and the head is perpendicular to the shoulders (HAL), the patient has lateral thoracic flexion present (+/-RTZ) (See Figure 4). If the shoulders are level (SAL), but the head is not (HAL), the patient has lateral cervical flexion (+/-RHZ) (See Figure 5). If the shoulders are unlevel (SAL), and so is the head (HAL), but not in the same manner as the shoulders the patient has thoracic as well as cervical lateral flexion (+/-RTZ, +/-RHZ) (See Figure 6).

            Looking at the level of the hands (AL) will confirm thoracic lateral flexion. When the arms are uneven in length there is lateral thoracic flexion present (+/-RTZ). Read closely, this is where the magic behind postural photos comes in. What if the arms are uneven, but the shoulders are level? Uneven arms (AL) indicates lateral flexion, but so does uneven shoulders (SAL), doesn’t it? No. Because of distortion, thoracic rotation can appear as unlevelling of the shoulders. Reliability in lateral thoracic flexion exists with the arm lengths, but not with the shoulders. Too many doctors when viewing thoracic x-rays or the patient’s posture from the rear are possibly making this mistake. In any case, rotation of the thoracic spine (or cervical and pelvis for that matter) can be acutely seen from the lateral views. This can not be done from x-ray, or postural software from the products I have seen.

Patient A

            With Patient A below look at the Actual Side Posture Line (ASPL) (in white). The patient’s pelvis is anteriorly displaced on both lateral projections by about 2 centimeters. Since both sides are anteriorly displaced to the Side Center Line (SCL) the same amount, there is no rotation at the pelvic spine. Look at the shoulders. The left shoulder is centered, but the right is anteriorly displaced by as much as 3 to 4 centimeters. This indicates rotation of the thoracic spine (+RTY). The head is forward of the Side Center Line (SCL) by about 2 centimeters on the left projection, and perhaps 3 centimeters on the right projection. The head is following the rotation of the thoracic spine, and hence is not really in and of itself rotated in relation to the thoracic spine, hence there is no cervical rotation subluxation present. Now go back and look at the A-P and P-A views. Do you see thoracic rotation? No. But is it present? Yes. Can you do this with x-rays? No. Can measurements be made over time that indicate whether the thoracic rotation is being corrected? Yes. Will Don Harrison be happy to know this? (Who knows!)

            And on a final question is this method of assessment really reliable? Well, we know from studies available in the literature that posture does not change without intervention.10,11,12,13 If it does, x-rays are of no value as well. But it doesn’t. What if the patient stood in a rotated position when the picture was taken? The Side Center Line (SCL) is drawn from the outer malleolus, and perpendicular to the floor, hence, if the patients entire body is rotated, all lines will still be in the center. Remember to determine thoracic rotation we are comparing the center of the shoulders to the center of the pelvis, not to the center of the lateral malleolus. Hence, we have reliability, even if the patient stood rotated. In answer to the question, yes this method of assessment is extremely reliable theoretically, and through clinical experience.

Patient B

            Now look at Patient B. The pelvis is forward about 5 centimeters on the left view, but only about 3 or 3 on the right view. The shoulder is forward on the left view about 6 centimeters, but on the right view only about 3 centimeters. The head is forward about 7 centimeters on the left view, and about 5 centimeters on the right. Since the pelvis, thoracic and head areas are all forward in relation to the right view, the patient has pelvic rotation to the right (-RPY). There is in actuality no thoracic or head rotation subluxation present. Note that this is not due to poor patient positioning. If this were simply due to the patient standing rotated to the right (-RY) on the left view the pelvis would not be forward in relation to the lateral malleolus. The lateral malleolus would also be forward, hence canceling out the forward displacement of the pelvis (If you didn’t get that, read it again, slowly, and visualize, or stand and try it out. It is an important concept). Again, do we see pelvic rotation on the A-P, or P-A views? No, but it is present.

            Needless to say, correction of global subluxation first requires accurate diagnosis of the subluxation pattern, and then a means of follow up to see that it is being corrected.

Patient C

            As a final example of the value of 4 full view posture photographs, look at Patient C. On the A-P, and P-A photos the Shoulder Angle Line (SAL) is near level, but the Arm Level (AL) is completely different from left to right. So is there, or is there not right lateral thoracic flexion (+RTZ). Look at the side views, and draw a line across (white line). The left and right views are completely different. This patient has pronounced right lateral flexion (+RTZ), but barely visible on the A-P, and P-A views. Why don’t we see it? There is rotation of the pelvis to the left (+RPY), and rotation of the thorax in the opposite direction (-RTY) as seen on the lateral views. They are creating distortion on the A-P, and P-A views and giving the appearance of more or less level shoulders.

Conclusions

            Perhaps not complete as conclusions, but one can make the following positive statements with regards to full 4 view postural photos:

            1. As stated at the beginning of this article. If one is to agree that subluxation has to do with loss of normal anatomical alignment of the spinal posture, then this method of analysis is reproducible, and reveals subluxation patterns as defined. That is to say, the results will not vary from examiner to examiner.

            2. Rotation from lateral flexion can be clearly distinguished. This can not be done by x-ray. This can sometimes be done by observing visually without photos.

            3. Rotation of the pelvis, thorax, and head in relation to one another can be clearly distinguished. This can not be done by x-ray. This can sometimes be done by observing visually without photos.

            4. Improvement in rotation can be accurately measured. This can not be done by x-ray. This can not be done by visually observing without photos.

            5. Improvement in thoracic or pelvic anterior (or posterior) translation can be accurately assessed and measured for improvement. This can not be done by x-ray (Head translation can be measured by x-ray). This can not be done by x-ray. This can not be easily done by visually observing without photos.

            6. Improvement in lateral flexion of the head or thorax can be accurately measured. This can not be done by x-ray. This can not easily be done by visually observing without photos.

The following negative conclusions can also be made:

            1. Failure of the examiner to properly place the lines on the film will result in erroneous findings.

            2. One can not measure the amount of lateral curvature of the cervical, thoracic, and lumbar spines, and hence can not measure improvements or lack thereof of such.

            3. Patients aren’t so impressed with postural photos as compared to x-rays.

            4. Insurance companies as of yet do not reimburse (or not sufficiently) payment for taking postural photos.

            5. There is a lack of published research correlating posture photos to the patient’s actual spinal posture. Normand etal., Performed one study on reliability of the BioTonix Video Posture Evaluation System.14 This study found reliability, but only compares one side of the body. The 4 view full spine system as mentioned herein is not the same; hence the study can not be used to validate this article.

References

1.         Dimond EG, Kittle CF: Comparison of internal mammary ligation and sham operation for angina pectoris. AM J Cardiol 1960; 5:483-486

2.         Cobb LA, Thomas I, Dillard DH, et al: An evaluation of internal-mammary artery-ligation by a double blind technique. N Engl J Med 1959; 260:1115-8

3.         Roberts AH, Kewman DG, Mercier L, Hovell M: The poser of nonspecific effects in healing: implication of psychosocial and biological treatments. Clin Psychol Rev 1993; 13:375-391

4.         Turner JA, Deyo RA, et al: The importance of placebo effects in pain treatment and research. JAMA 1994; 271(20):1609-1614

5.         Wyke B: Articular neurology and manipulative therapy. Aspects of Manipulative Therapy 1980; Idezak RM, Carlto Lincoln institute of Health Science, England

6.         Harrison DD, Janik TJ, Troyanovich SJ, Holland B: Comparisons of Lordotic Cervical Spine Curvatures to a Theoretical Ideal Model of the Static Sagittal Cervical Spine. Spine 1996; 21(6):667-675

7.         Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca DJ: Evaluation of the Assumptions Used to Derive an Ideal Normal Cervical Spine Model. J Manipulative Physiol Ther 1997; 20(4):246-256

8.         Troyanovich SJ, Cailliet R, Janik TJ, Harrison DD, Harrison DEE: Radiographic Mensuration Characteristics of the Sagittal Lumbar Spine From A Normal Population with a Method to Synthesize Prior Studies of Lordosis. J Spinal Disord 1997; 10(59:380-386

9.         Janik TJ, Harrison DDD, Cailliet R, Troyanovich SJ, Harrison DE: Can the Sagittal Lumbar Curvature be Closely Approximated by an Ellipse? J Orthop Res 1998; 16(6):766-770

10.       Bullock-Saxton J: Postural alignment in standing: a repeatable study. Aust Physiother 1993; 39:25-29

11.       Lundstrom A, Forsberg CM, Westergren H, Lundstrom F: A comparison between estimated and registered natural head posture. Eur J Orthod 1991; 13:59-64

12.       Refshauge K, Goodsell, Lee M: Consistency of cervical and cervicothoracic posture in standing. Aust J Physiother 1994;40:235-240

13.       Grimmer K: An investigation of poor cervical resting posture. Aust J Physiother 1997;43:7-16

14.       Normand MC, Harrison DE, Cailliet R, Black P, Harrison DD, Holland B: Reliability, Concurrent Validity, and Measurement Error of the BioTonix Video Posture Evaluation System. J Manipulative Physiol Ther 2001; 24:in press.