Focus on Quantitative Fluoroscopy – Interview with Prof. Alan Breen

Alan Breen is Professor of Musculoskeletal Research both in the Faculty of Science and Technology at Bournemouth University and at the AECC University College, where he is the Director of the Centre for Biomechanics Research.

Alan is also Clinical Director for Special Imaging at the AECC University College.

Alan’s PhD project, which was completed in 1991, involved the development of Quantitative Fluoroscopy, a technology that measures inter-vertebral motion in living subjects and which is now used to research spinal pain internationally.

Alan tells us more about Quantitative Fluoroscopy and its development and implementation at AECC University College. He reflects on its early beginnings and where he envisages the technology going:

Quantitative Fluoroscopy

“In 1986, I came to AECC University College [then the Anglo-European College of Chiropractic] to work as the Director of Research. It was my job to establish our research offering.

“At this time, there were two Chiropractors in Europe who had cineradiography machines: these were really the precursor to Fluoroscopy. They consisted of an X-ray machine, a cine camera and a screen. You could watch the bones move and this was then recorded onto cine film. The quality was poor and you couldn’t film the lower back as that part of the body was too thick: it was limited to the neck really.

“But surgeons and rheumatologists were interested in the potential of this. When I watched these films, I thought: you really need to be able to measure this. Research is about measurement. This is what Quantitative Fluoroscopy does: it’s a method for measuring the movement of body joints, especially spinal ones that are deep inside the body.

“I had just started my PhD with Southampton University, focusing on measurement of the movement of body joints using fluoroscopy and image processing. We used a motion table, an X-ray machine and an image processor that takes the images from the fluoroscopy motion screen and joins them up with lines to measure how far apart they are in each frame.

“The basis of my PhD was putting these three technologies together and whether this was at all feasible: could you even begin to do this? I concluded that this was feasible, but it was clunky technology. I applied for grants to continue working on the technology to optimise it: to make it better and faster.”

Honing the technology

“I didn’t have my own equipment, so I depended on my relationships with local Radiologists. I worked with Radiologists at Poole Hospital and in the Spinal Treatment Unit at Salisbury Hospital who let me use their fluoroscopes. Salisbury Hospital was interested in whether this technology could determine whether a spinal injury made the bones of the spine unstable – and whether it was possible to detect this.

“Orthopaedic departments were also interested to know what happened when spinal fusions came loose. They were keen to find a way to determine whether this had happened without having to open up the patient. They too could see the potential of this technology.

“I published papers on our findings and was awarded further grants, one of which was a technology grant from the NHS. The grant was for New and Emerging Applications of Technology. My proposal was to develop an Objective Spinal Motion Imaging Assessment, that was a new application of fluoroscopy and image processing. The idea was to create a prototype and demonstrate that it was accurate and acceptable to patients, practitioners and researchers.

“We developed a patient examination, but each examination took three weeks to analyse due to the volume of images created by movement. Working with this volume of images was a real challenge. We then developed a way of doing it automatically, using a computer image processing tracking algorithms.

“We received a further grant to investigate whether spinal movement was connected to non-specific low back pain in a PhD fellowship taken up by Fiona Mellor. The question was: is there a difference in the way that people’s bones move when they have chronic low back pain compared to people who are pain-free? We found that there was a difference in what proportion of the movement of the lower spine each one accepts when they have chronic back pain and how that changes during movement. It was a complex conclusion.

“We gained recognition for this work and it led to further grants. Alex Breen, who is a Physicist and able to write computer code joined the team. Because of him, our research really took off in terms of research volume.”

Sharing movement information   

“In the last six years, Quantitative Fluoroscopy has gained real attention. The technology has the potential to explain what movement has got to do with things that could cause pain, such as excessive muscle loading or ligament torques.

“However, to do this, you need to do something called Finite Element Modelling. Quantitative Fluoroscopy gives us a picture of how the spine really moves andyou can put this into the model and have a much more realistic idea of what is happening in somebody’s spine.

“A lot of stakeholders are interested in this information: Physiotherapists, Osteopaths, Kinesiologists, Surgeons and Rheumatologists – not to mention Chiropractors and their students! They can use this information to diagnose the problem that is causing disability in a patient. They want to know whether pain has anything to do with the way their bones move.

“In order to ascertain this, you have to know how the bones move normally and compare your patient’s movement with this. We have spent the last ten years imaging people, mostly from our student and staff community, to develop a normative database for inter-vertebral motion.

“Our research has also helped to dispel some widely-believed, but incorrect theories. For example, there is a theory that if your discs begin to degenerate, then your joints get slack and become unstable and you experience low back pain. This has been assumed for about 30 years. One of the research projects that we have just published shows this isn’t the case. Projects like this blow away incorrect assumptions about how the spine works.

“We also did a project with the European Space Agency to find out whether a SkinSuit developed by Kings College London could reduce disc height. In space, your discs swell up and when you return to Earth, they often burst causing pain. 23% of astronauts returning to Earth get low back pain and some get hernias. The SkinSuit was developed as a counter-measure to this and we found that it did reduce disc swelling.” 

The future of Quantitative Fluoroscopy  

“We’ve got the fastest, most accurate and most validated version  of Quantitative Fluoroscopy. There’s still a lot of potential for international research into this and we’re in a leading position in the world. We’re keen to collaborate to progress this research.

“We are currently looking at collaborating with some big University research centres in the US, Europe and the UK. In the past, we have collaborated with Exeter University, Cardiff University and Bournemouth University on research projects. That’s our current aim: to collaborate and to disseminate the technology.

“We believe the technology still needs to be refined further. We need to optimise the method, so it’s faster and more accurate. It comes down to the complexity of capturing movement deep inside the body. At the moment, it takes us four hours to analyse a patient because we’re producing 15 images per second; we want to further reduce the operator burden.

“We’re in a position where we know that abnormal motion is a biomarker for back pain but we don’t know why. That line of research is the next stage. We’re keen to incorporate artificial intelligence into the measurement, to better track vertebrae.

“We’ve reached a really exciting place now.”

You can find out more about collaborating with the Centre for Biomechanics here or by emailing alexbreen@aecc.ac.uk.

You can read more of Alan's research here.  

Alan Breen

Above: Professor Alan Breen