PREPARED FOR. Marsha Eichhorn DATE OF INJURY : N/A DATE OF ANALYSIS : 12/14/2016 DATE OF IMAGES : 12/8/2016. REFERRING DOCTOR : Dr.

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1 Accent on Health Chiropractic 405 Firemans Ave PREPARED FOR Marsha Eichhorn DATE OF INJURY : N/A DATE OF ANALYSIS : 12/14/2016 DATE OF IMAGES : 12/8/2016 REFERRING DOCTOR : Dr. David Bohn This report contains important information concerning structural changes that can be affecting your overall level of health and well-being. Spinal stability is a basic requirement for the protection of your nervous structures and the prevention of early mechanical deterioration of your spinal component Instability is generally considered to be a global increase in the movements associated with the occurrence of back, neck, and/or nerve root pain. Damage to any spinal structure produces some degree of spinal instability. This computer aided digital analysis is an overview of your current level of spinal stability.

2 Posture Head Tilt (inches) : 0 Low Shoulder (inches) : 0 Low Hip (inches) : 0 Head Translation (inches) : 0.39 Thoraic Translation (inches) : 0 Pelvic Translation (inches) : 0.39 Head Angle : 0 Shoulder Angle : 0 Pelvic Angle : 0 Body Weight(lbs) : 130 AP Head Translation(inches) : 0.37 Your head actually weighs : 10.7 Due to the shift in posture your head feels like it weighs(lbs) : Shoulder Shift(inches) : Hip Shift(inches) : 2.03 Hip Angle(deg) : 1.82

3 Cervical Motion Analysis Cervical Extension Cervical Flexion Performed : 65 Degrees / Normal 60 0% Loss of Motion Cervical Left Rotation Performed : 55 Degrees / Normal 50 0% Loss of Motion Cervical Right Rotation Performed : 39 Degrees / Normal % Loss of Motion Cervical Latflex Left Performed : 67 Degrees / Normal % Loss of Motion Cervical Latflex Right Performed : 43 Degrees / Normal % Loss of Motion Performed : 38 Degrees / Normal % Loss of Motion

4 Lumbar Motion Analysis Lumbar Flexion Lumbar Extension Performed : 49 Degrees / Normal % Loss of Motion Lumbar Left APFlexion Performed : 19 Degrees / Normal 25 24% Loss of Motion Lumbar Right APFlexion Performed : 25 Degrees / Normal 25 0% Loss of Motion Performed : 25 Degrees / Normal 25 0% Loss of Motion

5 Cervical Flexion / Extension This RED line denotes the location of the posterior longitudinal ligament (PLL) and surpasses normal acceptable segmental motion indicating the location of posterior longitudinal ligament laxity. This GREEN line denotes the location of the posterior longitudinal ligament (PLL) with normal alignment to the surrounding vertebrae indicating no significant ligamentous laxity. A blue line denotes a segmental motion that is clinically significant. Alteration of motion segment integrity is defined as abnormal translation or angular motion between two adjacent vertebrae. This motion is measured using lateral flexion and extension x-rays. Translational motion segment integrity is assessed on flexion and extension imaging by comparing and measuring the position of the posterior edge of adjacent vertebral bodies in each position. Alteration of angular motion segment integrity is assessed by comparing the angles formed by the superior endplates of adjacent vertebral bodies (adjacent motion segments). These spinal translation and angulation are measured using a process referred to as Digital Radiographic Mensuration Analysis (DRMA). SpineTech Pro software captures articular motion to quantify spinal motion pathology and identify the presence and location of ligamentous laxity (ICD and ICD-10 M24.28). The World Health Organization has rated this method of analysis as "ESTABLISHED".

6 Cervical Flexion / Extension - Translational Motion Results Posterior Longitudinal Ligament Injury Anterior Longitudinal Ligament Injury Vertebral Level Flexion Extension Patient Result Clinically Rateable Limit Comments C2-C mm mm > 3.5 mm C l i n i c a l l y C3-C mm mm > 3.5 mm C l i n i c a l l y C4-C mm mm > 3.5 mm Normal C5-C mm mm > 3.5 mm C l i n i c a l l y C6-C mm mm > 3.5 mm C l i n i c a l l y

7 Cervical Flexion / Extension - Angular Motion Results FLEXION Posterior Longitudinal Ligament Injury EXTENSION Anterior Longitudinal Ligament Injury Vertebral Level Flexion Clinically Rateable Limit Comments C2-C > 11 Normal C3-C > 11 Normal C4-C > 11 Normal C5-C > 11 Normal C6-C > 11 Normal

8 Alteration Of Motion Segment Integrity (AOMSI) Analysis patient's NAME: Marsha Eichhorn DATE OF BIRTH: 03/16/1961 DATE OF INJURY: N/A DATE OF ANALYSIS: 12/14/2016 Digital Radiographic Mensuration Analysis (DRMA) DRMA analysis is a digital radiologic analysis necessary to determine AOMSI and alignment and ligamentous stability after trauma. DRMA technology provides an accurate diagnosis. In addition, DRMA follows the strict criteria of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition in calculating impairment from lateral Cervical Flexion / Extension flexion and extension radiographs. (Cocchiarella Land Andersson GBJ. AMA Press 2001). This is not a radiology report, it is a distinct and separate biomechanical analysis and the findings should be clinically correlated by the treating physician. Lateral Flexion/Extension Views of the Cervical Flexion / Extension Spine Were Obtained and Reviewed for AOMSI: Cervical Flexion / Extension Angular Motion is below ratable threshold. The translation motion segment integrity is not ratable, but is clinically significant at C2-C3 at 3.36 mm, C3-C4 at 2.67 mm, C5-C6 at 2.16 mm and C6-C7 at 1.6 mm. IMPRESSIONS : Translation variation of Motion Segment Integrity is clinically significant, but not ratable, at C2-C3 at 3.36 mm, C3-C4 at 2.67 mm, C5-C6 at 2.16 mm and C6-C7 at 1.6 mm and this may add to this patient's total impairment. Dr. David Bohn

9 Analysis Notes: Measuring Translation : In any of the spinal segments, lateral flexion and extension x-rays are analyzed. in the presence of true loss of motion segment integrity, the upper vertebrae will move forward on the lower vertebrae in flexion and move backwards on the lower vertebra in extension. Thus, the line along the back cortex of the upper vertebra will be anterior to the line along the posterior cortex of the lower vertebra on the flexion x-ray and posterior to it on the extension x-ray. The measurable angle is the sum of the two measurements. If the total of the of the two measurement exceeds 4.5 mm in the lumbar spine or 3.5 mm in the cervical spine, the definition of loss of motion segment integrity is met. In the event that the line along the posterior cortex of the upper vertebra remains anterior to the line along the posterior cortex of the lower vertebra on the extension view, then consider only the distance between the lines on the flexion view, as it would not be appropriate to subtract the distance on the extension view from that on the flexion view. Measuring Angular Motion: Lateral flexion and extension x-rays are used. Lines are drawn along the superior cortex of the two vertebrae adjacent to the level in question on both the flexion and the extension xrays and the angles where these lines intersect measured on both views. The angle on the extension view is then subtracted from the angle on the flexion view. Normally, the angle on the flexion view will be positive and the angle on the extension view will be negative. The net result will be that the negative extension angle will be subtracted from the positive flexion angle resulting in a net addition of the two angles. ( +8 (-18) = +26). If the angle is greater than 15 degrees at L1-2, L2-3 or L3-4 or greater than 20 degrees at L4-5 or grater than 25 degrees at L5-S1, the definition of loss of motion segment integrity is met. In the cervical spine, the method is different. A lateral flexion view only is taken. Lines are drawn along the inferior cortex of the two vertebrae above and below the level in question. Three angles are measured, the angles at the levels above and below the level question and the angle at the level in question. If the flexion angle at the level in question is more than 11 degrees greater than either of the angles at the levels above or below, the definition of loss of motion segment integrity is met. The figure in the 5th Edition is correct, but the text under the figure suggests that both flexion and extension films are necessary when actually only a flexion view is necessary. These are the only definitions of loss of motion segment integrity.

10 Lumbar Flexion / Extension RED lines denotes vertebral motion greater than the ratable threshold indicating alteration of motion segment integrity. GREEN lines denotes segmental motion below the ratable threshold A blue line denotes a segmental motion that is clinically significant. Alteration of motion segment integrity is defined as abnormal translation or angular motion between two adjacent vertebrae. This motion is measured using lateral flexion and extension x -rays. Translational motion segment integrity is assessed on flexion and extension imaging by comparing and measuring the position of the posterior edge of adjacent vertebral bodies in each position. Alteration of angular motion segment integrity is assessed by comparing the angles formed by the superior endplates of adjacent vertebral bodies (adjacent motion segments). These spinal translation and angulation are measured using a process referred to as Digital Radiographic Mensuration Analysis (DRMA). SpineTech Pro software captures articular motion to quantify spinal motion pathology and identify the presence and location of ligamentous laxity (ICD and ICD-10 M24.28). The World Health Organization has rated this method of analysis as "ESTABLISHED".

11 Lumbar Flexion / Extension - Translational Motion Results Posterior Longitudinal Ligament Injury Anterior Longitudinal Ligament Injury Vertebral Level Flexion Extension Patient Result Clinically Rateable Limit Comments L1-L mm mm > 4.5 mm Loss of Motion Segment Integrity L2-L mm mm > 4.5 mm C l i n i c a l l y L3-L mm mm > 4.5 mm Loss of Motion Segment Integrity L4-L mm mm > 4.5 mm C l i n i c a l l y L5-S mm mm > 4.5 mm C l i n i c a l l y

12 Lumbar Flexion / Extension - Angular Motion Results FLEXION Posterior Longitudinal Ligament Injury EXTENSION Anterior Longitudinal Ligament Injury Vertebral Level Flexion Extension Patient Result Clinically Rateable Limit Comments L1-L > 15 Normal L2-L > 15 C l i n i c a l l y L3-L > 15 C l i n i c a l l y L4-L > 20 C l i n i c a l l y L5-S > 25 Normal

13 Alteration Of Motion Segment Integrity (AOMSI) Analysis patient's NAME: Marsha Eichhorn DATE OF BIRTH: 03/16/1961 DATE OF INJURY: N/A DATE OF ANALYSIS: 12/14/2016 Digital Radiographic Mensuration Analysis (DRMA) DRMA analysis is a digital radiologic analysis necessary to determine AOMSI and alignment and ligamentous stability after trauma. DRMA technology provides an accurate diagnosis. In addition, DRMA follows the strict criteria of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition in calculating impairment from lateral Lumbar Flexion / Extension flexion and extension radiographs. (Cocchiarella Land Andersson GBJ. AMA Press 2001). This is not a radiology report, it is a distinct and separate biomechanical analysis and the findings should be clinically correlated by the treating physician. Lateral Flexion/Extension Views of the Lumbar Flexion / Extension Spine Were Obtained and Reviewed for AOMSI: The angular motion segment integrity is not ratable, but is clinically significant L2-L3 at 2.06, L3-L4 at and L4-L5 at The translation motion segment integrity is ratable for permanent impairment at L1-L2 at 4.76 mm and L3-L4 at 8.26 mm but is clinically significant at L2-L3 at 3.07 mm, L4-L5 at 2.72 mm and L5-S1 at 1.14 mm. IMPRESSIONS : Ligamentous instability is indicated in the Lumbar Flexion / Extension spine. The patient has tested positive for one of the highest rated spinal injury types as recognized by strict criteria of the AMA Guides for diagnosing this injury referred to as "Alteration of Motion segment integrity"(aomsi). These findings must be clinically correlated with the doctor s clinical findings. This patient's Lumbar Flexion / Extension analysis indicates Lumbar Flexion / Extension Translation Motion Segment Integrity abnormality(aomsi) and is a ratable loss. According to the AMA Guides, Fifth Edition this loss of motion segment integrity is ratable at 25%. An abnormal measurement of more than 4.5 mm of Translation Variation at one level results in instability and equates to a whole person impairment of 25%. Ligamentous instability(aomsi) is present at L1-L2 at 4.76 mm and L3-L4 at 8.26 mm. Translation variation of Motion Segment Integrity is clinically significant, but not ratable, at L2-L3 at 3.07 mm, L4-L5 at 2.72 mm and L5-S1 at 1.14 mm and this may add to this patient's total impairment. Angular variation of Motion Segment Integrity is clinically significant, but not ratable, at L2-L3 at 2.06, L3-L4 at and L4-L5 at and this may add to this patient's total impairment. Dr. David Bohn

14 Analysis Notes: Measuring Translation : In any of the spinal segments, lateral flexion and extension x-rays are analyzed. In the presence of true loss of motion segment integrity, the upper vertebrae will move forward on the lower vertebrae in flexion and move backwards on the lower vertebra in extension. Thus, the line along the back cortex of the upper vertebra will be anterior to the line along the posterior cortex of the lower vertebra on the flexion x-ray and posterior to it on the extension x-ray. The measurable angle is the sum of the two measurements. If the total of the of the two measurement exceeds 4.5 mm in the lumbar spine or 3.5 mm in the cervical spine, the definition of loss of motion segment integrity is met. In the event that the line along the posterior cortex of the upper vertebra remains anterior to the line along the posterior cortex of the lower vertebra on the extension view, then consider only the distance between the lines on the flexion view, as it would not be appropriate to subtract the distance on the extension view from that on the flexion view. Measuring Angular Motion: Lateral flexion and extension x-rays are used. Lines are drawn along the superior cortex of the two vertebrae adjacent to the level in question on both the flexion and the extension xrays and the angles where these lines intersect measured on both views. The angle on the extension view is then subtracted from the angle on the flexion view. Normally, the angle on the flexion view will be positive and the angle on the extension view will be negative. The net result will be that the negative extension angle will be subtracted from the positive flexion angle resulting in a net addition of the two angles. ( +8 (-18) = +26). If the angle is greater than 15 degrees at L1-2, L2-3 or L3-4 or greater than 20 degrees at L4-5 or grater than 25 degrees at L5-S1, the definition of loss of motion segment integrity is met. In the cervical spine, the method is different. A lateral flexion view only is taken. Lines are drawn along the inferior cortex of the two vertebrae above and below the level in question. Three angles are measured, the angles at the levels above and below the level question and the angle at the level in question. If the flexion angle at the level in question is more than 11 degrees greater than either of the angles at the levels above or below, the definition of loss of motion segment integrity is met. The figure in the 5th Edition is correct, but the text under the figure suggests that both flexion and extension films are necessary when actually only a flexion view is necessary. These are the only definitions of loss of motion segment integrity.

15 Lateral Cervical Gravity Line STANDARD RESULT Result : Lateral Cervical Gravity Line : 11 mm Anterior The Cervical Gravity Line is created by first locating the center of the tip of the Odontoid Process, then dropping a line downward, perpendicular to the bottom of the film. This line should just touch the anterior body of C7. When the line falls forward of the anterior body of C7 abnormal anterior head translation or forward head posture is present.

16 Normal Lateral Cervical Curvature The image above shows your vertebral position in red and average or ideal in green. The red lines and the green line should be one on top of the other. Any deviation is generally considered to be abnormal.

17 Lateral Cervical Baseline STANDARD RESULT Result : Lateral Cervical Baseline : Abnormal Lateral base lines extend posteriorly from the inferior epiphyseal plates of each lumbar vertebra. These lines normally meet posteriorly at a common point. If a base line intersects with its superior vertebra s base line, fixed flexion of the inferior vertebrae is present. If a vertebrae s base line intersects with its inferior vertebra, then fixed extension of the superior vertebrae is present. Fixed flexion or extension of a segmental unit can cause biomechanical dysfunction, which can lead to premature spinal degeneration.

18 Forward Head Posture (FHP) STANDARD RESULT Result : Forward Head Posture FHP : mm One of the first indicators of poor posture is a slouching or forward head posture. This posture causes strain on the posterior neck muscles and increases loading on the spinal discs. For every inch (25.4 mm) of forward translation the weight-bearing load on the cervical spine increases by approximately 10 pounds. Car accidents, sports injuries, working with computers and loss of bone density can contribute to this abnormality. FHP creates muscle strain and uneven wearing of the discs and joints of the cervical spine. The abnormal spinal weight bearing associated with this type of posture can lead to premature spinal degeneration of the spinal joints and discs.

19 Lateral Cervical Spondylolisthesis STANDARD RESULT Result : C2-C3 : 9.73 % C3-C4 : 2.64 % C4-C5 : 3.80 % C5-C6 : 4.26 % C6-C7 : 4.55 % Spondylolisthesis describes the anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. The Meyerding grading system categorizes severity based upon measurements on lateral X-ray of the distance from the posterior edge of the superior vertebral body to the posterior edge of the adjacent inferior vertebral body. This is reported based on the total superior vertebral body length. Grade 1 is 0 25%, Grade 2 is 25 50%, Grade 3 is 50 75%, Grade 4 is %, and over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra.

20 Cervical Spinal Stenosis Result : C2-C3 : mm C3-C4 : mm C4-C5 : mm C5-C6 : mm C6-C7 : mm C7-C8 : mm In adults, the width of the spinal canal on x-ray is normally 13 mm. Patients with spinal stenosis due to degenerative disease are at increased risk of spinal cord injury with minor trauma. As the diameter of the spinal canal decreases, pressure can increase on the spinal cord or the nerve roots. Pressure on these nerves in the spinal cord can cause numbness, tingling, or pain in the arms, hands, and legs. This condition is sometimes called cervical myelopathy.

21 AP Cervical Baselines STANDARD RESULT Result : AP Cervical Baselines : Abnormal Anterior-posterior baselines evaluate the spine for the presence of lateral flexion subluxations. Baselines are drawn across the inferior endplate of each cervical vertebra and should be parallel to a true horizontal line. Abnormal baselines can indicate the presence of dysfunction that may cause nerve irritation or accelerate degenerative spinal changes.