Evidence Based Protocol for Structural Rehab of Spine


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Evidence Based Practice (EBP) is defined as clinical decision-making based on, sound external research evidence combined with individual clinical expertise and, the needs of the individual patient.

CBP® is unique, in that, unlike most chiropractic techniques,245 CBP® has laid a solid foundation of basic science research (spine modeling, x-ray line drawing reliability, x-ray positioning repeatability, posture reliability, biomechanical stress analysis), clinical research (case studies, clinical trials), and educational research (reviews, position papers).

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Evidence Based Protocol for Structural Rehab of Spine

  1. 1. 0008-3194/2005/270–296/$2.00/©JCCA 2005 Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP®) publications Paul A. Oakley, DC, MSc* Donald D. Harrison, PhD, DC, MSE ** Deed E. Harrison, DC† Jason W. Haas, DC†† b a c k g r o u n d : Although practice protocols exist for a n t é c é d e n t s : Quoi qu’il y ait des protocoles SMT and functional rehabilitation, no practice protocols d’exercice établis pour la manipulation vertébrale et la exist for structural rehabilitation. Traditional réadaptation fonctionnelle, il n’existe aucun protocole chiropractic practice guidelines have been limited to pour la réadaptation structurale. Les directives acute and chronic pain treatment, with limited inclusion d’exercices chiropratiques traditionnels se limitent à des of functional and exclusion of structural rehabilitation traitements pour la douleur aigue et chronique avec une procedures. inclusion limitée des procédures de réadaptation o b j e c t i v e : (1) To derive an evidence-based practice fonctionnelle et une exclusion des procédures de protocol for structural rehabilitation from publications réadaptation stucturale. on Clinical Biomechanics of Posture (CBP®) methods, o b j e c t i f : (1) Faire dévier des publications sur les and (2) to compare the evidence for Diversified, SMT, procédures biomécaniques cliniques de la posture (BCP) and CBP®. un protocole d’exercice, avec preuve à l’appui, pour la m e t h o d s : Clinical control trials utilizing CBP® réadaptation structurale, et (2) Comparer la preuve pour methods and spinal manipulative therapy (SMT) were la techniques diversifiée, la manipulation vertébrale obtained from searches in Mantis, CINAHL, and Index et la procédure biomécanique de la posture (BCP). Medicus. Using data from SMT review articles, evidence p r o c é d u r e s : Des essais de contrôle clinique avec for Diversified Technique (as taught in chiropractic l’utilisation des procédures biomécaniques cliniques et la colleges), SMT, and CBP® were rated and compared. manipulation vertébrale ont été obtenus, suite à des r e s u l t s : From the evidence from Clinical Control recherches dans Mantis, CINAHL et Index Medicus. En Trials on SMT and CBP®, there is very little evidence utilisant, les données des rapports de synthèse sur la support for Diversified (our rating = 18), as taught in manipulation vertébrale pour la technique diversifiée chiropractic colleges, for the treatment of pain subjects, (tel qu’enseigné dans les collèges de chiropractie), la while CBP® (our rating = 46) and SMT for neck pain manipulation vertébrale et les procédures BCP ont été (rating = 58) and low back pain (our rating = 202) have évaluées et comparées. evidence-based support. r é s u l t a t s : Fondés sur la preuve des essais de c o n c l u s i o n s : While CBP® Technique has contrôle clinique sur la manipulation vertébrale et les approximately as much evidence-based support as SMT procédures BCP, il existe peu de preuve pour soutenir la for neck pain, CBP® has more evidence to support its technique diversifiée (notre taux = 18), tel qu’enseigné methods than the Diversified technique taught in dans les collèges de chiropractie, pour le traitement de la chiropractic colleges, but not as much as SMT for low douleur des sujets, contrairement aux procédures BCP ** Corresponding author: Paul A. Oakley, DC, MSc, 11C-1100 Gorham Street, Newmarket, Ontario L3Y 8Y8, Phone 905-868-9090 Email p.oakley@juno.com ** PO BOX 1590, Evanston, Wyoming, USA, 82931. †† 123 Second Street, Elko, NV, USA 89801. †† 1180 Main Street, Suite 7, Windsor, CO, USA 80550. © JCCA 2005. 270 J Can Chiropr Assoc 2005; 49(4)
  2. 2. PA Oakley, DD Harrison, DE Harrison, JW Haas back pain. The evolution of chiropractic specialization (notre taux = 46) et la manipulation vertébrale pour la has occurred, and doctors providing structural-based cervicalgie (taux = 58) et le lumbago (notre taux = 202) chiropractic care require protocol guidelines for patient qui sont soutenues par la preuve. quality assurance and standardization. A structural c o n c l u s i o n : Tandis que la procédure BCP possède rehabilitation protocol was developed based on evidence approximativement, autant de preuve à l’appui que la from CBP® publications. manipulation vertébrale pour la cervicalgie, la méthode (JCCA 2005, 49(4):270–296) BCP possède davantage de preuves à l’appui, pour soutenir ses procédures que la méthode diversifiée, enseignée dans les collèges de chiropractie, mais pas autant que la manipulation vertébrale pour le lumbago. L’évolution de la spécialisation de la chiropractie est devenue une réalité et les médecins qui fournissent des soins de chiropractie, à base structurale, nécessitent des directives de protocole pour offrir aux patients une assurance de la qualité des soins et une normalisation. Un protocole de réadaptation structurale a été élaboré, fondé sur la preuve des publications, reliées aux procédures BCP. (JACC 2005; 49(4):270–296) k e y wo r d s : chiropractic, spinal manipulation, m o t s c l é s : chiropractie, manipulation vertébrale, rehabilitation. réadaptation. Introduction ability studies, validity studies, and randomized clinical Recently, the buzzwords “evidence-based,” “evidence- control trials (RCTs). Critics of a certain healthcare based medicine” (EBM), and “evidence-based practice” method often condemn that method if RCTs have not (EBP) have appeared in clinical practice protocols. EBP been published. This might seem unreasonable as there is defined as clinical decision-making based on (1), may be more agreement amongst researchers for other sound external research evidence combined with individ- types of evidence. There are other types of clinical (non- ual clinical expertise and (2), the needs of the individual randomized clinical trial, cohort, case report, etc.) and patient.1,2 EBP protocols have recently been written for basic scientific studies that can provide “evidence” that a several conditions.2–9 certain type or method of care might be reasonable, suffi- The goal of EBP is to improve patient outcomes, qual- cient, or standard. In fact, the RCT may not be the best ity of care, and provide some standardization of treat- source of evidence for the clinical practice of chiroprac- ment. Systematic reviews of available published evidence tic.1,13,14 are required. The value of these literature reviews, how- The exact question being debated is “what does and ever, depends on the quality of the review (selection bias what does not provide evidence in EBM.15–17 In 2001, by those doing the review) and the quality of the publica- Bolton1 discussed the reliance on RCTs in EBP proto- tions.10 To have “evidence” on aspects of all treatment cols. Although the first few published RCTs on spinal methods is nearly impossible in any healthcare discipline, manipulative therapy (SMT) were important for the including medicine11 and chiropractic.12 chiropractic profession, RCTs are so narrow in methodol- The highest form of “evidence” would seem to be reli- ogy as to not often be useful in clinical chiropractic prac- J Can Chiropr Assoc 2005; 49(4) 271
  3. 3. Structural rehab protocol tice.1,14 Although the RCT is unarguably the best re- will use some of Bolton’s1 ideas of evidence for EBP search design, “randomization and controlled conditions guidelines when discussing recent published research play no part in everyday clinical practice”1 and thus, evi- concerning CBP® structural rehabilitation procedures. To dence for effectiveness in that arena cannot be collected insure communication with the reader, a table of defini- by RCTs. The strengths and limitations of the RCT have tions is presented31–35 (Table 1). been discussed elsewhere.18 Given the limitations of the RCT in evaluating chiro- Methods practic treatment,14 it has been stated that it does not In order to compare the evidence for Diversified, SMT, make sense to exclusively pursue the RCT in the future.13 and CBP®, literature searches were conducted in Mantis, Other research designs such as qualitative and outcomes CINAHL, and Index Medicus for Clinical Control Trials research are now being recognized as very meaningful on SMT, Diversified, and CBP® methods. ways of providing the evidence in EBP.1 Additionally, it We identified 73 RCTs on SMT, including only two is known today that well-done case studies most often clinical control trials on Diversified technique (as defined demonstrate findings consistent with that of the RCT.19,20 in Table 1), and 6 non-randomized clinical control trials Since 1975, the chiropractic profession has enjoyed on CBP® technique methods. In 2004, Bronfort et al.36 improved political support in a number of countries due had identified 69 of the RCTs on SMT and performed a to some published analyses favorable to chiropractic meta-analysis. This manuscript will adapt the Bronfort et care.21–25 Unfortunately, because early evidence (RCTs) al.36 analysis of the 69 RCTs identified before February for manipulation had been on the effectiveness for treat- 2003, and apply this analysis to two additional RCTs lo- ing acute and chronic pain complaints (i.e. LBP), the en- cated since February 2003.37–38 Additionally, there have suing guidelines have primarily been based on acute/ been two other review articles discussing SMT.39–40 chronic pain care. Consequently, in North America, In these RCT papers’ methods, we were looking for chiropractic’s inclusion in government health insurance (1) any pain scales, (2) any disability scores, (3) the and private insurance programs has coincided with re- number of subjects, (4) whether SMT was actually used strictions in frequency and duration of the care permitted. or only PT Mobilization, (5) if Diversified technique was In response, some chiropractic organizations have written used (as defined in Table 1), and (6) if DCs, MDs, or PTs their own guidelines in an attempt to obtain fairness in performed the treatment, and (7) the number of treat- these systems.26–28 ments (visits). Chiropractic treatment protocols could ideally be cate- Bronfort et al.36 deleted RCTs with 10 subjects or less, gorized into either: (a) Acute pain care, (b) Chronic pain while in this manuscript, we deleted any RCTs if (1) care, (c) Functional rehabilitation care, or (d) Structural there were 11 subjects or less (there were 3 such RCTs) rehabilitation care. Recently, the profession has shown and (2) if instead of SMT, authors utilized Physical Ther- renewed interest in structural rehabilitative care. In a sur- apist’s mobilization (MOB) techniques. Table 2 provides vey of 108 participating North American practices, Hawk our adapted analysis from Bronfort et al.,36 who catego- et al.29 (their Table 10, page 167) reported Clinical Bio- rized RCTs into acute pain, chronic pain, and mixed pain mechanics of Posture (CBP®) technique to be the 7th in each of the neck and low back regions, and our number most utilized technique in chiropractic practices. Prob- of RCTs excluded and included for analysis. In 2004, two lematically, there is only one manuscript detailing pro- additional RCTs were published.70–71 While Hurwitz et posed guidelines for structural rehabilitation of the spine; al.’s 2004 study71 is a re-look at previous 2002 data,59 the this was based on a few preliminary studies.30 2004 Haas et al. study70 had less than 10 subjects in the Our objectives are two-fold: (1) Compare the evidence treatment groups. We compared pain scale data in the 29 for Diversified, General Spinal Manipulative Therapy remaining RCTs41–69 and the two RCTs published since (SMT), and CBP® for reduction in neck and low back February 200337–38 to the CBP® published clinical con- pain intensity; (2) Derive an evidence-based practice pro- trol trials.72–77 tocol for structural rehabilitation from publications on Table 3 provides the authors’ rating scale for Clinical Clinical Biomechanics of Posture (CBP®) methods. We Control Trials used in this manuscript. This rating scale is 272 J Can Chiropr Assoc 2005; 49(4)
  4. 4. PA Oakley, DD Harrison, DE Harrison, JW Haas Table 1 Definitions of terms used in this manuscript Term Operational Definition Functional Rehabilitation Rehabilitation with a purpose of treating/preventing deconditioning syndrome and abnormal illness behaviors via: relaxing/stretching overactive/tight muscles, mobilizing/adjusting stiff joints, facilitating/strengthening weak muscles, re-educating movement patterns (Liebenson, 1996).31 Structural Rehabilitation Rehabilitation with a purpose to normalize both posture and spine alignment primarily via mirror image exercises, mirror image adjusting, mirror image/ extension traction. Weak Muscle Muscles that result in loss of movement if that muscle cannot contract sufficiently to move a body part through its partial or complete range of motion (Kendall et al. 1993).32 Shortened Muscle Muscles with a degree of shortness that results in slight to moderate loss of range of motion (Kendall et al. 1993).32 SMT Spinal Manipulative Therapy defined as application of high-velocity, low- (Spinal Manipulative Therapy) amplitude manual thrusts to the spinal joints slightly beyond the passive range of joint motion (Haldeman & Phillips, 1991).33 Diversified Technique Specific Spinal Manipulation Technique with the following steps: 1) spinal listing (body left, PRS, etc) derived from Motion Palpation or X-ray analysis; 2) specific patient position; 3) specific doctor position; 4) specific contact point; 5) specific line of drive opposite the spinal listing. Acute pain Pain less than 6 weeks duration. Subacute pain* Pain of 6 weeks to 3 months duration. Chronic Pain* Pain of greater than 3 months or of multiple occurrences (Carr, 2004).34 MMI Term often used interchangeably with Maximum Chiropractic Improvement (Maximum Medical Improvement) (MCI) or Maximum Therapeutic Benefit (MTB) indicating that further recovery and restoration of function can no longer be anticipated to a reasonable degree of medical/therapeutic certainty (Bryans, 2000).35 * Bronfort et al.36 defined chronic pain as greater than 6 weeks and did not use the subacute category. J Can Chiropr Assoc 2005; 49(4) 273
  5. 5. Structural rehab protocol Table 2 RCT studies using SMT as the treatment Health RCTs Number Number excluded Number Number used as conditioned identified by excluded by if MOB & not excluded for evidence in this studied in RCT Bronfort3 6 Bronfort36 SMT utilized # 11 patients manuscript Acute LBP 15 9 1 0 540–44 Chronic LBP 15 4 4 1 645–50 Mix LBP 16 2 0 2 1251–62 Acute NP 5 3 1 0 163 Chronic NP 7 2 2 0 364–66 Mix NP 11 6 2 0 367–69 MOB = Physical Therapy Mobilization without SMT cavitation. Acute = Pain for a duration of less than 6 weeks. Chronic = Pain greater than 6 weeks duration, as defined by Bronfort et al.36 LBP = Low Back Pain. NP = Neck Pain. RCT = Randomized Clinical Control Trial. SMT = Spinal Manipulative Therapy. Table 3 Rating scale for clinical control trials used in this manuscript Rating* for Index where published Controlled Trial Mantis CINAHL Index Medicus RCT with greater than 29 patients 6 8 10 RCT with less than 30 patients 4 6 8 Non-RCT with greater than 29 patients 4 6 8 Non-RCT with less than 30 patients 3 5 7 *If the RCT methods do not provide pain scales, which negates analysis of pain improvement, then 2 additional points are subtracted from the ratings above. based on four parameters including: indexing data base six identified clinical trials on CBP® technique were ex- of manuscript publication, type of clinical trial (RCT vs. trapolated to estimate durations of care necessary to cor- non-RCT), the number of subjects, and use of pain rect varying postural displacements. The extrapolations scales, at minimum, either a numerical rating scale are reasonable as the CBP® controlled trial data is not lin- (NRS) or visual analogue scale (VAS). Outcome tools ear (i.e. multiple pairs of data points, xi,yi, that make a construction is rather a difficult procedure and, although line when plotted), but are average improvements for 36 simple and intuitively obvious, our new rating tool (Table treatments in a sample of more than 30 subjects, over a 3) has not been tested. long time period (36 treatments over 3 months), and is In order to derive an evidence-based practice protocol exactly the kind of average data that can be extrapolated for structural rehabilitation from publications on Clinical to another time period. Biomechanics of Posture (CBP®) methods, data from the 274 J Can Chiropr Assoc 2005; 49(4)
  6. 6. PA Oakley, DD Harrison, DE Harrison, JW Haas Table 4 Rating and analysis of 25 RCTs for low back pain using general SMT and Diversified Low Back Pain RCT # Treated # Pain score Treatment Diversified General Rating patients visits VAS/NRS DC, MD, used? SMT pre/post DO, PT? used? *Glover et al, 197441 43 1 NR PT no yes 8 *Godfrey et al, 198442 22, 22 1 NR MD/DC no yes 6 Hadler et al, 198743 26 1 NR MD no yes 6 *MacDonald et al, 199044 49 5 NR DO no yes 8 Mathews et al, 198745 165 <10 NR PT no yes 8 *Bronfort et al, 199646 71, 51 10 5.4 / 3.7 DC yes no 10 Burton et al, 200047 20 6–18 NR DO no yes 6 *Coxhead et al, 198148 8G of 16 5–10 NR PT no yes 6 Herzog et al, 199149 16 10 3.2 / 1.8** DC no yes 8 Pope et al, 199450 69 9 Improved 2.4 DC no yes 10 Triano et al, 199551 47 12 3.8 / 1.3 DC no yes 10 *Anderson et al, 199952 83 12 4.9 / 3.2 DO no yes 10 Cherkin et al, 199853 133 6.9 5.5 / 2.0 DC no yes 10 Doran et al, 197554 116 6 NR MD no yes 8 Evans et al, 197855 15, 17 9 NR MD no yes 6 Giles et al, 199956 23 6 5.0 / 2.5 DC NR NR 8 Hoehler et al, 198157 56 2–8 NR MD no yes 8 Hsieh et al, 200258 49 9 NR DC yes no 8 *Hurwitz et al, 200259 171 NR 4.7 / 2.5** DC NR yes 10 Meade et al, 199060 384 9 NR DC NR ? 8 Postacchini et al, 198861 87 16–22 NR DC no yes 8 Skargren et al, 199762 138 7 NR DC NR NR 8 *Wreje et al, 199263 18 1 4.0 / 4.0 MD no yes 8 Williams et al, 200337 72 3 NR DO no yes 8 Licciardone et al, 200338 91 7 NR DO no yes 8 Totals (Pain & Rating) Mean 202 4.6 / 2.6 * Methods include additional treatments besides just SMT. ** Interpreted from graphs. NR = Not Reported. J Can Chiropr Assoc 2005; 49(4) 275
  7. 7. Structural rehab protocol Results of SMT in Tables 4–6, there is considerable evidence for Overall, there is a considerable amount of evidence sup- the treatment of general spinal manipulation to be uti- porting the use of SMT for low back (our rating = 202) lized for neck pain (our rating = 58) and back pain (our and neck pain (our rating = 58), as well as support for rating = 202). However, there is very little evidence for CBP® technique for pain (our rating = 46). Surprisingly, Diversified Technique, as defined in Table 1 (rating = there is little data existing on Diversified technique (as 18). Thus, there is more evidence for CBP methods (our defined in Table 1) for either low back (our rating = 18) rating = 46) than for the Diversified technique (rating = or neck pain (our rating = 0). Tables 4–6 summarize this 18), which is the technique method mandated by the data. Council on Chiropractic Education (CCE-USA and CCE- Using reported VAS (divided by 10) or NRS scores in Canada) to be taught in all Chiropractic College curricula Tables 4–6, an average pain reduction can be computed in the USA and Canada. for the clinical control trials for low back pain using SMT According to our review of studies on SMT and reduc- techniques, neck pain SMT techniques, and CBP® meth- tion in chronic pain intensity, it is readily apparent that ods. This comparison shows that the average reported nu- the average neck pain subject is left with a NRS/VAS = merical rating of initial (I) and follow-up (F) pain for 2.5 and the average for low back pain subject is left with Neck SMT studies is I/F = 4.8 / 2.5, the average for Low a NRS/VAS = 2.6 (review Table 5). We note, the defini- Back SMT studies is 4.6 / 2.6, while the average for tion of a 2 = Constant Minimal to Intermittent Slight Pain CBP® studies is 4.0 /1.0. Thus, while the average pain re- and a 3 = Constant Slight Pain with some handicap. In duction (NRS) in SMT studies is approximately 48%, the contrast, the same pain data comparison found for the average for CBP® studies is 75%. CBP® clinical trials indicate an ending value of NRS/ Using only the papers that reported numerical pain VAS = 1 = Minimal Pain or annoyance (Table 6). There- data in Tables 4–6, ending clinical pain can be assessed. fore, it is obvious that while short-term usage of SMT re- Simple pain outcome data (i.e. NRS, VAS) comparing duces chronic pain intensity, it does not relieve it and in pre-to-post treatment results indicate that, although par- fact these subjects would not be described as MMI. The tial reductions in pain levels are achieved for SMT trials, recent studies by Haas et al.71 and Leboeuf-Yde et al.78 post-treatment pain levels are reported to be at significant are good examples of this. Thus, practice protocols based clinical levels, e.g., an average of ending NRS = 2.6 in on pain in SMT studies are incomplete. Also, such prac- Table 4 and ending NRS = 2.5 in Table 5. The same pain tice protocols must include more visits than 12 because data comparison found for the CBP® clinical trials indi- treated subjects, in published RCTs, were left in chronic cate minimal-to-negligible pain levels in the post-treat- pain (NRS = 2.6) after up to 12 treatments of SMT. ment groups (average ending NRS = 1.0 in Table 6). In a pilot RCT with a small number of subjects (n = 8 A similar analysis to numerical pain using disability in each group), Haas et al.71 found that an increased scores (not shown) from the RCTs in Tables 4 and 5 indi- number of treatments, up to 12, was associated with cates that treatment subjects, on average, have significant greater improvement of headache pain. However, even in disability at follow-up in these SMT studies (using those the 12 treatment group, the headache pain was still less papers which report disability with NDI, SF-36, Roland- than 50% improved.71 Likewise, in a recent large multi- Morris, and/or Oswestry). For example, the reader is re- center trial, after 4 treatments of SMT for lower back ferred to the recent study by Leboeuf-Yde.78 pain, Leboeuf-Yde et al. found that subjects were left Extrapolated CBP® clinical trial average data (Table 7) with a NRS of 2.6 (12 month follow up data). Leboeuf- could be easily interpreted to estimate hypothetical treat- Yde et al.78 also reported that these subjects still had sig- ment durations based on the magnitude of postural devia- nificant levels of disability on the Oswestry scale (35- tions (millimeters/degrees) as starting points in patient Moderate Disability down to 22.2-Moderate Disability). care (see Table 8). Recent publications have found that health related quality of life and functional disability measures (Short Discussion Form-36, Oswestry, Neck Disability questionnaires, etc. From the analysis presented on RCTs with the treatment ...) are more sensitive and important than simple pain in- 276 J Can Chiropr Assoc 2005; 49(4)
  8. 8. PA Oakley, DD Harrison, DE Harrison, JW Haas Table 5 Rating and analysis of seven SMT RCTs for neck pain Neck Pain RCT # Treated # Pain: Treatment by Diversified General Rating patients visits VAS/NRS DC, MD, Used? SMT Pre/post DO, PT? used? *Howe et al, 198364 26 1–3 NR MD no yes 6 *Bronfort et al, 200165 64 24 5.7 / 3.7 DC no yes 8 Jordan et al, 199866 33 12 4.3 / 2.0 DC NR NR 10 *Sloop et al, 198267 21 1 Improved 1.8 MD no yes 6 Giles et al, 199956 23 6 4.5 / 1.5 DC no yes 8 Hurwitz et al, 200268 171 1 4.8 / 2.6 DC no yes 10 Skargren et al, 199769 41 7 4.6 / 2.5 DC no yes 10 Totals (Pain & Rating) Mean 58 4.8/2.5 *Methods include additional treatments besides just SMT. NR = Not Reported. Table 6 Rating & analysis of six CBP® clinical control trials72–77 CBP® # # Chronic Treatment by Diversified General Rating Clinical Control Trials Treated visits Pain: NRS DC, MD, Technique SMT used? patients Pre/post DO, PT? Used? Harrison et al, 199472 35 60 NR DC no yes 6 Harrison et al, 200273 30 35 4.3 / 1.6 DC no yes, 0–3 wk 8 Harrison et al, 200274 30 38 4.1 / 1.1 DC no yes, 0–3 wk 8 Harrison et al, 200375 48 38 4.4 / 0.6 DC no yes, 0–3 wk 8 Harrison et al, 200476 51 37 4.0 / 0.7 DC no no 8 Harrison et al, 200477 63 36 3.0 / 0.8 DC no yes, sporadic 8 Totals (Pain & Rating) Mean 46 4.0 / 1.0 NRS = Numerical Rating Scale for pain (0 = no pain, 1, 2, ..., 8, 9, 10 = severe disabling pain). Diversified = a specific conglomeration of SMT maneuvers that requires specific listing, patient position, doctor position, and thrust opposite the listing (see definition Appendix 1). NR = Not Reported. 0–3 wk = SMT given only in first 3 weeks of care out of 12 weeks of care. sporadic = only a few subjects received an SMT, in only 0–3 weeks of care. J Can Chiropr Assoc 2005; 49(4) 277
  9. 9. Structural rehab protocol tensity outcomes.79 It is of interest that recent publica- ever, many monotherapies, have been found to have ei- tions have found strong correlations between altered ther limited effectiveness or complete lack of success in sagittal spinal alignment (specifically loss of the distal treating chronic low back pain. Bogduk136 has discussed lumbar lordosis), health quality of life, and physical func- that these monotherapies include analgesics, NSAIDs, tion as measured with the Short Form-36 questionnaire.80 muscle relaxants, antidepressants, physiotherapy, sur- Therefore, we recommend that clinicians utilize health gery, and manipulative therapy. In contrast, Gross et al.137 status and disability questionnaires at all initial and fol- have reported that the multi-modal care of exercise com- low-up examinations. In this manner, strong evidence can bined with cervical manipulation provides better results be used to support the need and outcome effects of CBP® than either procedure used alone. The criticism of mono- treatment methods (or any other chiropractic care) past therapies is taken into consideration by CBP® technique the 8–12 visit “bench mark” of traditional SMT based as it uses a multi-modality care regimen of SMT as well studies. as mirror image® exercises, mirror image® adjusting and Thus, CBP® multi-modal methods can be utilized to mirror image®/extension spinal traction procedures, achieve health and disability improvements. But im- other stretching procedures, and ergonomic counseling. provements in structural alignment are the primary inter- vention goal. Before deriving a protocol for structural Limitations rehabilitation from CBP® publications, a brief review is Limitations of using data from RCTs on SMT and CBP® given for an appreciation of the clinical relevance of Clinical Control Trials in this review study are the same structural rehabilitation of the spine and posture. as those expressed by Bronfort et al.36 The interested reader is referred to page 350 of their study. Clinical relevance for structural rehabilitation It is known that spinal function is directly related to spinal Goals in structural rehabilitation structure, as has been proven for the cervical and lumbar If we categorize chiropractic treatment into: (a) acute spinal regions.80–84 With mal-alignment in neutral posture, pain care, (b) chronic pain care, (c) functional rehabilita- static and especially dynamic function from this mal- tion care, and (d) structural rehabilitation care, the goals alignment dictates altered stress/strain relationships of as- of care in structural rehabilitation may encompass the sociated spinal structures, including the bones,85–87 in- first two (acute and chronic pain care). Considering the tervertebral discs,88–91 facet joints,92 musculotendinous relationship between spinal function and structure,80–84 it tissues,93 ligamentous tissues,94 and neural elements.95–100 is probable that functional rehab and structural rehab are Postural alterations are known to be associated with a attempts to treat the same patient dysfunction; albeit with plethora of human afflictions from general pain syn- different approaches. dromes,101–109 to problems with specific joints such as the For example, a patient presenting with acute or chronic hip110–111 and the knee,112 to problems with specific spi- neck pain with 50 mm of anterior head translation, ini- nal regions such as the flat-back syndrome,113 and cervi- tially would be treated with a trial of traditional SMT in- cal kyphosis,109 to local organ ailments such as uterine cluding any ancillary procedures (heat, ice, massage, prolapse,114–115 gastric herniation,116 and respiratory stretching, etc. ...) for about 2–4 weeks to attempt to im- function,117–119 to thinking,118,120 and even to morbidity prove pain levels and spinal motion. Following this, func- and mortality.121–125 Improved posture alignment has tional rehabilitation would seek to improve strength in been one of the most sought-after goals in the treatment weakened muscles and flexibility in shortened or tight- of human ailments for ages; this continues today in all ened muscles; muscle dysfunction is considered to be the medical arenas, such as dentistry, physiotherapy, physia- cause of the displacement.32 In the case of anterior head try, surgery, and chiropractic.126–134 translation it has been found that the neck flexors have Since traditional SMT has not been found to be associ- decreased endurance and maximal isometric contraction ated with routine improvement in spinal alignment, its strength.138 therapeutic effects are thought to be in reducing pain and In contrast, structural rehabilitation procedures would facilitating increased spinal motion.135 Of interest, how- seek to improve the postural abnormality by exercising 278 J Can Chiropr Assoc 2005; 49(4)
  10. 10. PA Oakley, DD Harrison, DE Harrison, JW Haas Figure 1. Algorithm for Structural Rehabilitation J Can Chiropr Assoc 2005; 49(4) 279
  11. 11. Structural rehab protocol the head in the exact opposite displacement (i.e., posteri- their results to twenty other manuscripts in the literature. or head translation). Posterior head translation causes Their149 results were similar to previous investigators, contraction of the upper neck flexors and stretches the namely that x-ray positioning is highly repeatable even upper neck extensors.139 Therefore, it is apparent the two when taken by different examiners. approaches (functional vs. structural) are attempting to treat the same disorder by different means. 2) Ideal and Average Spinal Model Figure 1 provides an algorithm that outlines the proto- To determine abnormality of radiographic spinal align- cols, procedures, and time frames for a structural rehabil- ment, the radiographic measurements are compared to a itation program of chiropractic care. This structural published normal spinal model that provides ideal and rehabilitation algorithm will be first supported and then average alignment values (Figure 2). This normal spinal detailed in the duration of the manuscript. The unique- model is based, in part, on average values from normal ness of structural rehabilitation is the goal of normalizing subjects and has been published in orthopedic and chiro- both posture and spine alignment to evidence based val- practic journals.150–156 Normal values have been pub- ues. This goal requires (1) a precise definition of normal lished for each sagittal vertebral segmental angle (RRA = posture; (2) reliability and validity of postural measure- relative rotation angle, e.g., T8–T9) and for sagittal re- ment; (3) a precise definition (model) of the normal gional global angles (ARA = absolute rotation angle, e.g., spine; and (4) reliability and validity of spinal measure- C2–C7, T3–T10, and L1–L5). This model is “evidence- ments. based.” In fact, the CBP® sagittal lumbar model153 and the sagittal cervical model156 were found to have discrim- Overview of CBP® Procedures inative validity in as much as they can distinguish be- tween normal subjects, acute pain subjects, and chronic 1) Radiographic Procedures pain subjects.153,156 Radiographic line drawing analysis has been shown to be Further validity for an optimum upright spinal position one of the most reliable tools in clinical practice.134 The comes from an analysis of loads and stresses based on Harrison posterior tangent method for measurement of minimum energy expenditure.89,121,157–159 Also, statistical sagittal spinal curves and the modified Riser-Ferguson analyses have derived an average normal spine.160,161 A bi- method for measurement of frontal plane spinal displace- omechanical analysis of spinal loads dictates a vertical ments have both been studied for reliability. These two spine in the antero-posterior view (see AP view in Figure methods have been found to have good to excellent inter 3A), while more work must be done to derive a normal and intra-examiner reliability with small mean absolute postural position in the sagittal view. Both ideal and aver- values of observer differences for both angles and dis- age sagittal human postural alignments have been dis- tances.140–143 cussed.134,160–163 Figures 3B and 3C illustrate the ideal and The validity of radiographic analysis is supported by average sagittal postures, respectively. The average sagit- knowledge of posture and coupling, termed main motion tal posture in Figure 3C has a forward head posture and (posture) and coupled motion (spinal segmental move- poor sagittal balance of C1, T1, T12, and S1; recent pub- ments) in the literature.144–148 The radiographic spinal lications negate this position as normal due to increased alignment (spinal coupling) can be compared to the ini- muscle and disc loads, and tissue stresses.89,109,121,128,158, tial posture of the patient (main motion) to determine if 163,164 the coupling patterns are the same as published move- With normal posture precisely described (Figures 3A ments in the literature. This is valid, however, only if the and B), abnormal posture can be determined. Using bio- clinician utilizes the same radiographic positioning meth- mechanical concepts, abnormal posture has been de- ods as that used in the published studies;149 in fact, the scribed as rotations and translations of the head, rib cage, CBP® standardized x-ray positioning procedures have and pelvis from normal position in a 3-dimensional coor- been studied for their repeatability. Harrison et al.149 pre- dinate system (Figures 4 and 5).165,166 The last item nec- sented data on pre-post lateral and AP spinal x-rays as- essary to complete the goals of structural rehabilitation certained in six different control groups and compared protocols is the measurement of standing human posture. 280 J Can Chiropr Assoc 2005; 49(4)
  12. 12. PA Oakley, DD Harrison, DE Harrison, JW Haas Figure 3. In A, normal AP postural alignment is depicted. In B and C, ideal sagittal and average sagittal alignment are illustrated, respectively. Since the average human sagittal alignment (C) has forward head posture and poor C1, T1, T12, and S1 sagittal balance, it is not considered normal. Adapted with permission from Harrison DE et al. Spinal Biomechanics for Clinicians. Vol. I. Evanston, WY: Harrison CBP® Seminars, Inc., 2003. There are several computerized systems offered by vari- ous companies (e.g., Biotonix, PosturePro, ChiroVision) that use digital images of a patient to analyze their pos- ture. Only one, however, can determine abnormal posture as numerical data of rotations (in degrees) and transla- tions (in millimeters) for each displacement of the head, thorax, and pelvis (Biotonix’s new module: Posture- Figure 2. The CBP® Full-spine Normal Model is the path of PrintTM).167–168 the posterior longitudinal ligament through the posterior body As with measures of pain intensity, range of motion, margins. It is composed of separate ellipses in the different and quality of life, periodic assessment of structural align- spinal regions (cervicals, thoracics, & lumbars). It has near ment is important to evaluate progress and determine perfect sagittal balance of vertical alignment of C1-T1-T12-S1. when maximum medical improvement has been reached This model provides normal sagittal plane curves and normal values for all segmental angles and global angles. The sagittal (Figure 1). Posture analysis via digital photography is curves have points of inflection (mathematic term for change in non-invasive. While use of multiple follow-up radio- direction from concavity to convexity) at inferior of T1 and graphs are deemed necessary for use in surgical treatment inferior of T12. Reprinted with permission from Harrison DE by orthopedic surgeons,169 some chiropractors have con- et al. Spinal Biomechanics for Clinicians. Vol. I. Evanston, demned the use of post-radiographs to collect alignment WY: Harrison CBP® Seminars, Inc., 2003. data.170–175 Importantly, these condemnations170–175 can J Can Chiropr Assoc 2005; 49(4) 281
  13. 13. Structural rehab protocol Table 7 Average data from six CBP® non-randomized clinical control trials72–77 CBP® Study Traction Number Number Initial Post Average Minutes of Visits Months ARA ARA Improvement Sagittal Cervical: Compression- 10 60 3.0 –14.5° –27.7° 13.2° Extension72 2-way73 20 35 3.0 –12.4° –26.6° 14.2° Combined 2-way & 20 38 3.4 –4.2° –22.1° 17.9° Comp-Extension74 Sagittal Lumbar: APM&R 200275 20 38 3.0 –22.4° –33.7° 11.3° AP Cervical: Lateral Translation76 20 37 3.0 13.7 mm 6.8 mm 6.9 mm AP Lumbar: Lateral Translation77 20 36 3.0 15 mm 7.3 mm 7.7 mm Note: The only CBP® non-randomized clinical control trial to not have pain data is Ref #72. be considered expert opinion evidence only, without sup- The structural rehabilitation algorithm for x-ray imag- porting data. In contrast, there is data to show that the use ing frequency is minimal, compared to that of orthopedic of medical x-rays constitutes a very minor health risk.176– surgeons, who often take initial pre-operative, immediate 185 In fact, Cohen (University of Pittsburg) has written ex- post-operative, one month, 6–12 months, and long-term tensively on the over-exaggeration of exposure from med- follow-up radiographs (total of 5 sets of x-rays) for sur- ical x-rays.171,181–184 The following section will review the gery cases.169 In fact, according to Fischgrund (2005, pp relative health risks of spinal radiography. 1017 and 1023), “Routine cervical spine radiographs taken for the evaluation of degenerative disc disease and Health Risks of Radiography in Structural Rehabilitation cervical radiculopathy include lateral, anteroposterior, and In structural rehabilitation care, it is necessary that the oblique views.”169 “Typical follow-up of these patients in- Doctor obtain initial and follow-up posture and radio- cludes an office visit at 1 week, with routine anteroposte- graphic measurements. The frequency suggested for radi- rior and lateral radiographs. By 6 weeks, lateral flexion ography is an initial examination, with follow-up and extension views usually show that the fusion construct measurements at 36 visit intervals, which could be 4 vis- is stable ...”.169 Fischgrund further stated that follow-ups its per week for 9 weeks or 3 visits per week for 12 are ascertained at 1 year, 2 years, or 5 or more years de- weeks.186–187 Data from CBP’s® 6 clinical control pending upon the specific study. Therefore, according to trials72–77 indicate that the average chronic pain patient Fischgrund, surgery patients receive initial, 1-week post needs 6 months of intensive care to achieve a near normal op, 6-week post op, and 1, 2, or 5 year follow ups.169 spinal and postural alignment. This would mean, on aver- As orthopedists use radiographs to evaluate and moni- age, one initial set of x-rays and single plane follow-up x- tor structural spinal changes, so too do doctors utilizing rays depending on the part of the spine being treated. CBP® structural rehabilitation protocols. 282 J Can Chiropr Assoc 2005; 49(4)
  14. 14. PA Oakley, DD Harrison, DE Harrison, JW Haas Table 8 Hypothetical programs extrapolated from data from 6 CBP® clinical control trials72–77 CBP® Study Example Normal Expected Number of Number Initial ARAs or ARA150,153 or Average 3 Months of Visits Tx Tx150 Improvement in Programs Suggested 3 months needed Cervical: JMPT 199472 –27.7° –43° 13.2° 1 60 Comp-Ext –14.5° –43° 13.2° 2 120 –1° –43° 13.2° 3 180 APM&R 200273 –26.6° –43° 14.2° 1 35 2-way –12.4° –43° 14.2° 2 70 +2° –43° 14.2° 3 105 JMPT 200274 –22.1° –43° 17.9° 1 38 Combined 2-way –4.2° –43° 17.9° 2 76 & Comp-Ext +14° –43° 17.9° 3 114 JRRD 200376 7 mm 0 6.9 mm 1 37 Lateral Translation 14 mm 0 6.9 mm 2 74 21 mm 0 6.9 mm 3 111 Lumbar: APM&R 200275 –33° –40° 11.3° 1 38 Extension –22.4° –40° 11.3° 2 76 –11.1° –40° 11.3° 3 114 Eur Spine J 200377 7 mm 0 7.7 mm 1 36 Lateral Translation 15 mm 0 7.7 mm 2 72 22 mm 0 7.7 mm 3 108 ARA = absolute rotation angle. Tx = translation on the x-axis. From Maurer:178 “Authorities agree that while no radi- ment, the trend in science has been away from the “per- ation dose level is risk-free, the level used in diagnostic missible or acceptable” dose concept to the current “risk” radiology provides low-dose risk and is considered as ac- concept. In either approach, the end result is similar: “for ceptable to the average individual.” The 1949 National the information gained with diagnostic radiology, the ra- Council on Radiation Protection and Measurements diation risk is minimal.” (NCRP) defines permissible dose as: “the dose of ioniz- To educate the reader to the minimal risks of medical ing radiation that, in light of present knowledge, is not x-rays, some equivalent risks are provided from the liter- expected to cause appreciable bodily injury to a person at ature. Medical x-rays are of very minimal health risk any time during his lifetime.” Since this NCRP state- compared to the risks associated with environmental fac- J Can Chiropr Assoc 2005; 49(4) 283
  15. 15. Structural rehab protocol Table 9 Relative Risks of Different Environmental Exposures176,178,179,184 (These values relate to equivalence of reduced life expectancy) Environmental Item Exposure Equivalent Exposure Equivalent Pilot Flying: New York City-Athens 4200 microSv/yr 420 mrem/yr Pilot Flying: Chicago-San Francisco 2800 microSv/yr 280 mrem/yr Chest x-ray 100 microSv 10 mrem Extremity x-ray 10 microSv 1 mrem Dental x-ray 100 microSv 10 mrem Head/neck x-ray 200 microSv 20 mrem Cervical Spine x-ray 220 microSv 22 mrem Lumbar spinal x-rays 1300 microSv 130 mrem Smoking a Cigarette 70 microSv 7 mrem Fat Person Eating Pie-a-la-mode 350 microSv 35 mrem tors such as air travel (in Table 9, exposure equivalent re- or soft-drinks, a pilot can cancel out his equivalent radia- lates to life expectancy). From Butler,179 for example, tion risks! The government website states that a flight one can calculate the routine exposure of airplane passen- from LA to NY and back is approximately worth one gers and crew; based on 0.60 mSv (0.6 x 0.1 rem) per 100 chest x-ray due to being in the upper atmosphere. Thus, block hours (the mean for a flight between New York pilots who fly two round trips from LA to NY per week, City and Athens, Greece), a pilot flying 700 block hours get the dose equivalent of two chest x-rays per week or per year would receive an annual occupational exposure about 100 per year! After 10 years, for example, an air- of 4.2 mSv (0.42 rem). In contrast, a pilot flying 700 line pilot could accumulate an equivalent of 1,000 chest block hours on a Chicago-to-San Francisco route (0.41 x-rays! mSv/100 block hours) would receive an annual dose of Cohen and Lee176 and Cohen184 provided a look at ra- approximately 2.8 mSv (0.28 rem). diation risk levels, along with other examples of risks as- This Chicago-San Francisco dose is 0.28 rem/yr = 280 sociated with various activities and how they translate mrem/yr = 5.4 mrem/wk. For comparison, according to into equivalence in loss of life expectancy. It provides the Cohen and Lee,176 “smoking a cigarette has the risk likely results of both general patterns of behavior and equivalent of 7 mrem of radiation, and an overweight per- one-time occurrences. According to their study, the son eating a pie a-la-mode runs a risk equal to that of 35 drinking of one diet soft drink per day reduces life ex- mrem.” Equating absorbed dose and dose equivalent, pectancy by two days; ingesting 100 calories per day by 1 rem = 0.01 J/kg = 1 rad, Table 9 provides the minimal drinking regular soft drinks increases body weight by 7 dose equivalent for medical x-rays. However, it is noted pounds and reduces life expectancy by 210 days. If you that current high-frequency machines and use of filtration are 30 percent overweight you lose 1,300 days; 20 per- systems (i.e. Nolan filters) allow human exposures to be cent overweight 900 days; unmarried males lose 3,500 reduced very significantly (50%) as compared to earlier days; smokers lose 2,250 days.176 These studies and equipment.188 many others point out that risks are associated with near- It now becomes obvious why Federal Governments ly all activities of daily living. and airplane companies do not tell pilots to stop flying af- While DACBRs’ (chiropractic radiologists) opinions, ter one year. By simply reducing rich desserts, cigarettes, with minimal supporting data, condemned the use of ini- 284 J Can Chiropr Assoc 2005; 49(4)
  16. 16. PA Oakley, DD Harrison, DE Harrison, JW Haas Figure 4. Abnormal Postural Rotations. Rotations of the head relative to the thorax; thorax relative to the pelvis; and pelvis relative to the feet are depicted from the top to bottom rows, respectively. Regional rotations about the x, y, and z-axes are depicted from the left to right columns, respectively. Reprinted with permission from Harrison DE et al. Spinal Biomechanics for Clinicians. Vol. I. Evanston, WY: Harrison CBP® Seminars, Figure 5. Abnormal Postural Translations. Translations of the Inc., 2003. head relative to the thorax; thorax relative to the pelvis; and pelvis relative to the feet are depicted from the top to bottom rows, respectively. Regional translations along the x, y, and z-axes are depicted from the left to right columns, respectively. tial and post-radiographs to collect alignment measure- Reprinted with permission from Harrison DE et al. Spinal ments,170–175 data actually exists that indicates medical x- Biomechanics for Clinicians. Vol. I. Evanston, WY: Harrison ray exposure may have a health benefit.191 However, min- CBP® Seminars, Inc., 2003. imal risk is inherent in everything we do as part of the hu- man experience. While we must constantly work towards the reduction of health risks in all endeavors, we may be ment values; whereas surface contour methods (e.g., led to accept a minimal level as normal. While there is no flexible ruler) are invalid and unreliable.192–196 data indicating diagnostic radiology has a present risk, any radiation dose must be compared to the benefits of Radiation Hormesis useful information gained. The necessity for appropriate Radiation hormesis is the stimulatory or beneficial effect treatment selection is indeed an acceptable trade-off of low doses of ionizing radiation. While an actual bene- when put into perspective. The need for x-ray imaging is fit from radiation exposure may seem outrageous, there is especially clear when one considers that radiographic im- much scientific evidence for this phenomenon. This topic aging is the only valid method for attaining spinal align- is in direct conflict with the “Linear No-Threshold Hy- J Can Chiropr Assoc 2005; 49(4) 285
  17. 17. Structural rehab protocol pothesis” (LNT), which has been assumed to be true for The reason for postural mirror image® exercises, ad- more than 50 years. This LNT model comes from esti- justments, and traction procedures is to address all the mating the risks at lower doses of radiation, in the ab- tissues involved in spine and posture alignment. Al- sence of data, by extrapolating in a linear model from though strength and conditioning exercise has not proven large doses of radiation from atomic bombs dropped on to correct posture,219 mirror image® exercises have Japan in the 1940s. shown initial promise in the reduction of posture and spi- This LNT model has been used to set limits of radia- nal displacements.220–224 These exercises are performed tion exposure by all official and governmental associa- to stretch shortened muscles and to strengthen those mus- tions.185 Recently in 2003, Kauffman180 reiterated that cles that have weakened in areas where postural muscles authors critical of exposure from diagnostic radiation al- have adapted to asymmetric or ill-positioned postures. ways use the LNT model. This use of the LNT model in- Postural adjustments as performed with drop table, cludes the recent 2005 report by the USA National hand-held instrument, or even mirror image® manipula- Research Council.197 This report stated, “there will be tion procedures, are performed for resetting the nervous some risk, even at low doses (100 mSv or less), although system regulation of postural muscle balance.225,226 Pos- the risk is small” and “there is no direct evidence of in- tural mirror image® extension traction provides sus- creased risk of non-cancer diseases at low doses.”197 This tained loading periods of 10–20 minutes and is necessary 2005 report ignored and contradicted an earlier 2003 re- to cause visco-elastic deformation to the resting length of view by Kant et al.198 the spinal muscles, ligaments, and discs.227 For a comparison of exposures, USA citizens are ex- From 1994–2004, CBP® has completed seven case posed to an average annual natural background radiation studies,228–234 and has completed six non-randomized level of 3 mSv, while exposure from a chest x-ray is ap- clinical control trials.72–77 While case studies are ranked proximately 0.1 mSv and exposure from a whole body as the lowest level of clinical studies evidence on the tra- computerized tomography (CT) scan is approximately 10 ditional scientific evidence hierarchy, non-randomized mSv.197 Also it is noted that 10mSv = 1,000mrem, which control trials are the 2nd highest type of evidence; ranked equates to about 46 cervical series or 8 lumbar series (see second only to the RCT.1,14 Recalling that RCTs are inad- Table 9). equate for evaluating multi modal chiropractic care regi- The LNT model has been questioned for its application mens,1 these seven CBP® case studies228–234 and six to low levels of exposure by many researchers.183,189,199– CBP® control trials72–77 provide a growing clinical evi- 202 Actually, below a certain level of exposure, there are dence base to support the need for CBP® structural care beneficial health effects, (termed radiation hormesis), programs of sufficient durations to provide as near nor- which do not follow from extrapolation of the high-dose mal as possible posture and spine structural rehabilita- portion of the curve.182,189–191,203–217 tion/re-alignment. From CBP’s® six clinical control trials, 72–77 Table 7 presents the average total number of Structural Rehabilitation Protocols visits, frequency, duration of care, and the amount of spi- While other methods may provide evidence for structural nal alignment improvement found for the cervical and rehabilitation, we discuss only recent research outcomes lumbar lordoses and cervical/lumbar frontal plane align- in CBP® Technique. CBP® is unique in chiropractic, in ments, respectively. that it utilizes a “mirror image®” concept applied to hu- Table 8 presents actual and extrapolated data estimat- man posture; this basic tenet has a sound foundation in ing durations of care necessary for correcting hypotheti- Linear Algebra, an area of study common to both en- cal sagittal plane displacements; we note that a negative gineering and mathematics.218 CBP® multi-modal care sign means lordotic curvature and a positive sign indi- consists of three primary procedures: mirror image® ex- cates kyphotic curvature for measurements in the cervical ercises, mirror image® adjustments, and mirror image®/ and lumbar regions.140–142 Table 8 also gives average and extension traction. These mirror image® posture posi- extrapolated data estimating the duration of care neces- tions are the rotation and translation pairs in or about sary to reduce/correct a head and trunk list (side shift each coordinate axis (Figures 4 and 5). posture) in the AP cervico-thoracic and lumbar radio- 286 J Can Chiropr Assoc 2005; 49(4)
  18. 18. PA Oakley, DD Harrison, DE Harrison, JW Haas graphs as measured appropriately (i.e. measured as a hor- es, misquoted references, and performed a selective liter- izontal displacement of: 1) Mid-C2 dens compared to ature review.134 In fact, this Harrison-Haas debate was a vertical line up from estimated center of mass (CM) of series of three publications.134,170,236 Additionally, the uni- Thoracic #4 in an AP cervico-thoracic analysis;144 2) Es- formed often state that the extension position in CBP® cer- timated CM of T12 compared to a vertical line up from vical traction methods are dangerous. the S2 tubercle in an AP lumbar analysis.143,235 Numerous articles from the literature lead to the con- From Table 8 one can estimate structural care dura- clusion that this is definitely not the case. In fact, in a tions based on extrapolations from the CBP® clinical 1999 thorough review of the literature on varying posi- trials. It should be mentioned that these are merely aver- tions of the head associated with vertebral and basilar ages; and are in fact extrapolations from the current clini- artery blood flow and dissection, Haldeman et al.237 con- cal trial data. Therefore, individual patients may change cluded that “examination of the data fails to show a con- in shorter or longer times; thus, follow-up radiological sistent position or movement of the neck that could be exams provide the clinician with valuable insight into in- considered particularly dangerous.” dividual patient response to treatment. The following In addition, Thiel et al.238 found no occlusion of verte- provide examples of estimating average durations of care bral artery blood flow during various head and neck posi- hypothetically necessary to restore a patient’s spine to tioning tests on the patient, including head extension. ideal spinal alignment: Inaccurate personal opinions about the dangers of ex- tension come from “Beauty Parlor Stroke.” There has a) If a patient had a kyphotic cervical curve ARA (C2 to been anecdotal criticism of the hyper-extension head po- C7) measuring +12°, then 3 programs (treatment sition at Beauty Parlors. Much of this criticism seems to blocks of 38 sessions) of 2-way extension-compres- be based on several letters to editors and case reports in sion traction would hypothetically correct the mis- the Index Medicus literature concerning “beauty parlor alignment. That is, three increments of average stroke.”239–243 The positions referred to were prolonged improvement of –17.9°, results in an extrapolated av- (1-hour or more) hyper-extension combined with axial erage correction of 3x(–17.9) +12° = –41.7°, which rotation,239–243 although Endo et al.243 did not discuss any approximates the ideal cervical lordosis of –43°.150 rotation of the head. In 1992 and 1993, Weintraub239–241 b) If a patient had a hypolordotic cervical ARA (C2 to reported on seven cases of “Beauty Parlor Stroke” in C7) measuring –29°, then one program of 35 visits of which clients at beauty parlors had symptoms of nystag- CBP® 2-way traction would be expected to correct the mus, ataxia, slurred speech, facial weakness, nausea, misalignment: –29° + 1x(–14.2°) = –43.2° (ideal nor- vomiting, vertigo, and dysarthria after having their hair mal).150 shampooed. Six of these seven individuals were older c) If a patient had a hypolordotic lumbar curve ARA (L1 than 75 years and one was 54-years-old. The 54-year-old to L5) of –18°, then two programs of CBP® lumbar subject had been left in a position of cervical hyper-ex- extension traction of 38 visits would hypothetically tension over the edge of a shampoo bowl in excess of two correct the misalignment. That is, two increments of hours. In 1995, Stratigos242 reported on the condition of average improvement of –11.3°, results in an extrapo- his mother after a trip to a beauty parlor. lated correction of 2x(–11.3°) + –18° = –40.6°, which All four of these articles discussed in detail that the approximates the average/ideal normal lumbar lordo- mechanism of vertebrobasilar injury is associated with sis value of –40°153 (see Table 8). cervical axial rotation while in hyper-extension. In 2000, Endo et al.243 reported a single case of a woman aged 62 Criticisms of CBP Methods who suffered a “beauty parlor stroke.” There was no In the past, criticisms of CBP® methods and x-ray proto- mention of the duration of shampoo treatment or a de- cols have been based on the 1999 Commentary by Haas et tailed explanation of the position of the head. al.170 These criticisms often neglect to provide the Harri- Unlike beauty parlor employees, individuals employ- son rebuttal written in 2000,134 which reported that Haas et ing CBP® spinal traction methods are trained physicians, al.170 misrepresented references, misinterpreted referenc- who do screening examinations on patients for tolerance J Can Chiropr Assoc 2005; 49(4) 287
  19. 19. Structural rehab protocol to head extension. Using our cervical traction protocol, mirror image® exercise, adjusting, and traction proce- patients are screened and then monitored while traction dures. time periods are increased at only a few minutes per visit, starting at 3–5 minutes, over a period of many visits to a Acknowledgement maximum of 20 minutes. These traction methods are also The authors acknowledge the assistance of Dr. Dennis not used or modified for those of advanced age and do Mizel DC with this manuscript. not involve axial rotation in the extended position. While any induced stroke symptoms would be unacceptable, References these “beauty parlor strokes” should not be applied to 1 Bolton JE. The evidence in evidence-based practice: what CBP® cervical extension traction methods, when used by counts and what doesn’t count? J Manipulative Physiol trained physicians. Ther 2001; 24:362–366. 2 Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: How to practice and teach EBM. Conclusions New York: Churchill-Livingstone, 1997. Besides the RCT, other forms of scientific evidence, if 3 Lipman G. Evidence-based pain management and existing, may be more than adequate to create goal-ori- palliative care. J Pain Palliat Care Pharmacother 2002; ented clinical guidelines.1,13,14,244 CBP® studies provide 16:1–3. 4 Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. the typical type of chiropractic care, as several proce- Can patients taking opioids drive safely? A structured dures are provided to the patient on each visit. At present, evidence-based review. J Pain Palliat Care Pharmacother there is evidence for SMT for neck and low back pain. 2002; 16:9–28. From published research for the treatment of chronic 5 Caramanica L, Cousino JA, Peterson S. Four elements of a neck and back pain at this time, CBP® Technique has successful quality program. alignment, collaboration, more supporting evidence than Diversified Technique, as evidence-based practice, and excellence. Nurs Adm Q 2003; 27:336–343. taught in all Chiropractic Colleges. 6 Jordan KM, Arden NK, Doherty M, et al. EULAR This paper has presented guidelines as a clinical tool recommendations 2003: an evidenced based approach to for the practice of structural rehabilitation by CBP® tech- the management of knee osteoarthritis: Report of a task nique methods. CBP® is unique, in that, unlike most force of the standing committee for the International chiropractic techniques,245 CBP® has laid a solid founda- Clinical Studies Including Therapeutic Trials. Ann Rheum Dis 2003; 62:1145–1155. tion of basic science research (spine modeling, x-ray line 7 Wassem RA, Stillion-Allen KA. Evidence-based drawing reliability, x-ray positioning repeatability, pos- management of the fibromyalgia patient. In search of ture reliability, biomechanical stress analysis), clinical re- optimal functioning. Adv Nurs Prac 2003; 11:34–38, search (case studies, clinical trials), and educational 41–43. research (reviews, position papers). 8 Hasenfeld R, Shekelle PG. Is the methodological quality of Because traditional practice protocols in chiropractic guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research have considered only acute and chronic pain conditions, (AHCPR) guidelines with those published subsequently. limited inclusion of functional rehabilitation, and a total Qual Saf Health Care 2003; 12:428–434. neglect of structural rehabilitation, there is a need to have 9 Sackett DL. Evidence-based medicine [editorial]. Spine published protocols for structural rehabilitation of the 1998; 23:1085–1086. spine and posture. This manuscript has proposed structur- 10 Davidson KW, Goldstein M, Kaplan RM. Evidence-based behavioral medicine: What is it and how do we achieve it? al protocol guidelines based on clinical evidence from a Ann Behav Med 2003; 26:161–171. significant quantity and quality of CBP® technique publi- 11 Smith R. Where is the wisdom ...? The poverty of medical cations. Tables 6–8 are based on CBP® mirror image® evidence. Br Med J 1991; 303:798–799. methods. The use of multiple clinical methodologies in 12 Brouwers M, Charette M. Evaluation of clinical practice these CBP® studies is consistent with Bolton’s ideas13 of guidelines in chiropractic care: A comparison of North clinical applications in EBP. Because of the focused liter- American guideline reports. J Can Chiropr Asso 2001; 45:141–153. ature herein, this guideline serves as a tool only for the 13 Bolton JE. Whence the evidence from evidence-based doctor practicing structural rehabilitation utilizing CBP® practice? Br J Chiropr 2000; 4:2–3. 288 J Can Chiropr Assoc 2005; 49(4)
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