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Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects?

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  • Ideal Spine Health Center and CBP NonProfit, Inc. --A Spine Research Foundation in Eagle, ID

Abstract and Figures

Objective: To test the hypothesis that improvement of cervical lordosis in cervical spondylotic radiculopathy (CSR) will improve cervical spine flexion and extension end range of motion kinematics in a population suffering from CSR. Methods: Thirty chronic lower CSR patients with cervical lordosis < 25? were included. IRB approval and informed consent were obtained. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received stretching exercises and infrared; the SG received 3-point bending cervical extension traction. Treatments were applied 3 ? per week for 10 weeks, care was terminated and subjects were evaluated at 3 intervals: baseline, 30 visits, and 3-month follow-up. Radiographic neutral lateral cervical absolute rotation angle (ARA C2-C7) and cervical segmental (C2-C7 segments) rotational and translational flexion-extension kinematics analysis were measured for all patients at the three intervals. The outcome were analyzed using repeated measures one-way ANOVA. Tukey's post-hoc multiple comparisons was implemented when necessary. Pearson correlation between ARA and segmental translational and rotational displacements was determined. Results: Both groups demonstrated statistically significant increases in segmental motion at the 10-week follow up; but only the SG group showed a statistically significant increase in cervical lordosis (p < 0.0001). At 3-month follow up, only the SG improvements in segmental rotation and translation were maintained. Conclusion: Improved lordosis in the study group was associated with significant improvement in the translational and rotational motions of the lower cervical spine. This finding provides objective evidence that cervical flexion/extension is partially dependent on the posture and sagittal curve orientation. These findings are in agreement with several other reports in the literature; whereas ours is the first post treatment analysis identifying this relationship.
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Journal of Back and Musculoskeletal Rehabilitation -1 (2017) 1–5 1
DOI 10.3233/BMR-150464
IOS Press
Brief Report
Does rehabilitation of cervical lordosis
influence sagittal cervical spine flexion
extension kinematics in cervical spondylotic
radiculopathy subjects?
Ibrahim Moustafa Moustafaa,b,, Aliaa Attiah Mohamed Diabband Deed E. Harrisonc
aDepartment of Physiotherapy, College of Health Sciences, University of Sharjah, UAE
bBasic Science Department, Faculty of Physical Therapy, Cairo University, Egypt
cCBP NonProfit (a Spine Research Foundation) and Private Practice, Eagle, ID, USA
Abstract.
OBJECTIVE: To test the hypothesis that improvement of cervical lordosis in cervical spondylotic radiculopathy (CSR) will
improve cervical spine flexion and extension end range of motion kinematics in a population suffering from CSR.
METHODS: Thirty chronic lower CSR patients with cervical lordosis <25were included. IRB approval and informed consent
were obtained. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received
stretching exercises and infrared; the SG received 3-point bending cervical extension traction. Treatments were applied 3 ×per
week for 10 weeks, care was terminated and subjects were evaluated at 3 intervals: baseline, 30 visits, and 3-month follow-up.
Radiographic neutral lateral cervical absolute rotation angle (ARA C2–C7) and cervical segmental (C2–C7 segments) rotational
and translational flexion-extension kinematics analysis were measured for all patients at the three intervals. The outcome were
analyzed using repeated measures one-way ANOVA. Tukey’s post-hoc multiple comparisons was implemented when necessary.
Pearson correlation between ARA and segmental translational and rotational displacements was determined.
RESULTS: Both groups demonstrated statistically significant increases in segmental motion at the 10-week follow up; but only
the SG group showed a statistically significant increase in cervical lordosis (p<0.0001). At 3-month follow up, only the SG
improvements in segmental rotation and translation were maintained.
CONCLUSION: Improved lordosis in the study group was associated with significant improvement in the translational and
rotational motions of the lower cervical spine. This finding provides objective evidence that cervical flexion/extension is partially
dependent on the posture and sagittal curve orientation. These findings are in agreement with several other reports in the literature;
whereas ours is the first post treatment analysis identifying this relationship.
Keywords: Cervical spine, lordosis, flexion and extension, traction, spondylotic radiculopathy
Corresponding author: Ibrahim Moustafa Moustafa, 7 Mohamed
Hassan, El Gamal Street, Abbas El Akaad, Nacer, Egypt. E-mail:
ibrahiem.mostafa@pt.cu.edu.eg.
1. Introduction 1
Cervical spondylotic radiculopathy (CSR) is one of 2
the most common causes of cervical radiculopathy [1]. 3
The degenerative state of the intervertebral disc, and its 4
adjacent structures, often occurs in combination with 5
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2I.M. Moustafa et al. / Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics
an alteration of the sagittal alignment of the cervical6
spine; both at the segmental and global levels [2].7
It has been found that altered alignment of the8
sagittal cervical spine affects spinal coupling kinemat-9
ics [36]; which could potentially increase any inflam-10
matory processes and increase symptoms of CSR. In11
2002 Frobin et al. [7] introduced a new protocol for12
measuring motion of cervical segments from lateral ra-13
diographs taken in flexion and extension; they reported14
good examiner reliability and small standard error of15
measurement.16
The appropriate conservative and surgical interven-17
tions for a given patient with CSR remains contro-18
versial; especially regarding health quality of life out-19
comes and costs. Recently, Alvin and colleagues [8]20
investigated the cost-effectiveness of surgical inter-21
ventions for CSR. It was identified that the limited22
studies demonstrate preliminary cost-effectiveness of23
surgical intervention, no studies were located that24
compared cost-effectiveness of surgical versus non-25
operative treatment for CSR patients. Thus, continued26
research into both conservative and surgical interven-27
tions for CSR patients is mandated.28
To our knowledge, there are no studies that have29
been conducted to clarify exactly what impact the30
sagittal cervical curve correction has on segmental mo-31
tion of the lower cervical spine in cases with CSR. The32
current study investigates the relationship between loss33
of the cervical lordosis and flexion extension move-34
ments of the cervical spine and what effect, if any,35
improvement of the cervical lordosis has on the kine-36
matic outcome of patients suffering from CSR. We37
hypothesized that improvement of cervical lordosis in38
CSR will improve cervical spine flexion/extension end39
range of motion kinematics in a population suffering40
from CSR.41
2. Methods42
Thirty chronic lower CSR patients with cervical lor-43
dosis <20were included in this investigation. Partic-44
ipants had unilateral radiculopathy due to spondylotic45
changes of the lower cervical spine (C5–C6 and/or C6–46
C7) and side to side amplitude differences of 50% or47
more in dermatomal somato-sensory evoked potential48
(DSSEPs) measurements and a duration of symptoms49
more than 3 months. IRB approval and informed con-50
sent were obtained through our University department.51
Exclusion criteria included spinal canal stenosis,52
rheumatoid arthritis, vestibulobasilar insufficiency, os-53
teoporosis, and an inability to extend the cervical spine 54
without increased pain and or radiculopathy. 55
Patients were assigned randomly into two equal 56
groups, study (SG) and control (CG). 57
Both groups received stretching exercises and in- 58
frared radiation; additionally the study group received 59
3 point bending cervical traction as performed in the 60
non-randomized trial by Harrison et al. [9] Treatments 61
were applied 3 ×per week for 10 weeks (30 ses- 62
sions). Participants were re-evaluated at 10 weeks and 63
again 3-months. Patient demographics and outcome re- 64
sults of the cervical lordosis (C2–C7), patient pain, and 65
dermatomal somato-sensory evoked potentials are re- 66
ported in a separate investigation [10]. In the current 67
study we report on only the kinematic investigation. 68
Radiographic neutral lateral cervical absolute ro- 69
tation angle (ARA C2–C7) and cervical segmental 70
(C2–C7 segments) rotational and translational flexion- 71
extension kinematics analysis were measured for all 72
patients at the three intervals. We used the method of 73
Frobin et al. [7] to assess cervical kinematics. 74
2.1. Kinematic data acquisition of cervical spine 75
Sets of two lateral radiographic views taken in ex- 76
tension and flexion view. The definition of rotational 77
and translational motion is outlined first for Segments 78
C2/C3–C6/C7. The centre point is the geometric cen- 79
tre of corners 1–4. The vertebral mid-plane is defined 80
as a line running through the midpoints between cor- 81
ners 1, 3 and corners 2, 4, respectively. The angle be- 82
tween two vertebrae is given by the angle between their 83
mid-planes. The angle is counted positive if the wedge 84
opens anteriorly. Rotational motion of a segment is de- 85
fined as the difference of the angle in extension minus 86
the angle in flexion. Rotational motion is quoted in de- 87
grees 88
Perpendiculars are constructed from the centre 89
points of adjacent vertebrae onto the bisectrix between 90
the mid-planes. Postero-anterior displacement is de- 91
fined as the distance between those points where the 92
perpendiculars intersect the bisectrix. Thus, displace- 93
ment (and consequently translational motion) is mea- 94
sured along a direction coinciding in good approxima- 95
tion with the mid-plane of the disc. Displacement is 96
counted positive if the projection of the cranial centre 97
point is located anteriorly from the projection of the 98
caudal centre point. 99
To correct for radiographic magnification and varia- 100
tion in stature, displacement measured in millimeters is 101
divided by the mean depth of the caudal vertebra. The 102
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I.M. Moustafa et al. / Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics 3
Tab le 1
Repeated measures one-way ANOVA for translational displacement in both groups using the method of measurement of Frobin et al. [7]
Pre treatment Post 10 weeks 3-month follow up FP Post test pre Post test post
value treatment vs. post 10 treatment
10 weeks treatment vs. follow up
MD MD
C2–C3 (S.G) 0.00529 ±0.0011 0.00676 ±0.0013 0.00710 ±0.0013 11.27 0.0003* 0.00146* 0.00033
C2–C3 (C.G) 0.005287 ±0.001214 0.00671 ±0.00134 0.005705 ±0.0014 5.393 0.0104* 0.00142* 0.001
C3–C4 (S.G) 0.005493 ±0.0016 0.007663 ±0.0019 0.007783 ±0.0019 9.674 0.0006* 0.00216* 0.00012
C3–C4 (C.G) 0.005465 ±0.0017 0.007675 ±0.0019 0.006801 ±0.0015 10.20 0.0005* 0.0022* 0.00087
C4–C5 (S.G) 0.004575 ±0.0012 0.005791 ±0.0013 0.005703 ±0.0013 6.182 0.006* 0.0012* 8.8
C4–C5 (C.G) 0.004591 ±0.0013 0.005815 ±0.0012 0.004612 ±0.0011 5.755 0.008* 0.0012* 0.0012*
C5–C6 (S.G) 0.002246 ±0.00086 0.003068 ±0.0012 0.003163 ±0.0012 5.187 0.012* 0.00082* 9.5
C5–C6 (C.G) 0.002465 ±0.00084 0.00308 ±0.0012 0.02455 ±0.0246 0.9986 0.027* 0.00061* 0.00037
C6–C7 (S.G) 0.001131 ±0.0001978 0.001435 ±0.0003303 0.001381 ±0.0003106 4.852 0.0127* 0.0003* 5.4
C6–C7 (C.G) 0.00123 ±0.0003725 0.001497 ±0.0002992 0.001328 ±0.0002981 3.664 0.0386* 0.00025* 0.00016
SG: study group CG: control group; *: significantly different; MD: mean difference.
mean depth is the mean of the distance of corners 1,103
2 and 3, 4, respectively. Postero-anterior translational104
motion is given by the difference of the displacement in105
extension minus the displacement in flexion. As quo-106
tients of lengths, displacement and translational mo-107
tion are dimensionless quantities.108
3. Data analysis109
The outcome measure of ARA and kinematics anal-110
ysis of cervical spine in terms of segmental rotational111
and translational displacement were measured using112
repeated measures one-way ANOVA to compare mea-113
surements made before treatment, after the 10 weeks114
of treatment, and at follow up period of 3 months).115
Tukey’s post-hoc multiple comparisons was imple-116
mented when necessary.117
Person correlation studies between ARA and kine-118
matics data of cervical spine in terms of translational119
and rotational displacements for C2–C7 level. For all120
correlations the results are categorized into two sets, a121
baseline correlation for pre treatment data and a sec-122
ond for post manipulating data. Statistical level of sig-123
nificance was set at p<0.05.124
4. Results125
The study group receiving traction had an increase126
in cervical lordosis post treatment (p<0.0001)127
whereas the control group did not.128
4.1. Translational displacement129
For study group, the repeated measures one-way130
ANOVA showed that variation among column means131
is significantly greater than expected by chance for 132
all measured levels and the post test reveal insignif- 133
icant changes at follow up measurement compared 134
with the 10 weeks post treatment for all measured lev- 135
els. For control group, the repeated measures one-way 136
ANOVA reveled that variation among column means 137
is significantly greater than expected by chance for all 138
measured levels but the post test revealed significant 139
changes at follow up measurement compared with the 140
10 weeks post treatment for all measured levels except 141
for c4–c5 (Table 1). 142
4.2. Rotational displacement 143
For study group, the repeated measures one-way 144
ANOVA showed that variation among column means 145
is significantly greater than expected by chance for 146
all measured levels and the post test reveal insignifi- 147
cant changes at follow up measurement in comparison 148
with the 10 weeks post treatment for all measured lev- 149
els. For control group, the repeated measures one-way 150
ANOVA showed that variation among column means 151
is significantly greater than expected by chance for all 152
measured levels while The post test revealed a signifi- 153
cant decrease in the mean values at follow up measure- 154
ment compared with 10 weeks post treatment values 155
for all measured levels (Table 2). 156
Pearson correlation coefficients between initial and 157
follow up cervical lordosis and segmental rotational 158
movements are shown in Table 3. Pearson correlation 159
coefficients between initial and follow up cervical lor- 160
dosis and segmental translation movements are shown 161
in Table 4. 162
5. Discussion 163
We hypothesized that the study group receiving cer- 164
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4I.M. Moustafa et al. / Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics
Tab le 2
Repeated measures one-way ANOVA for rotational displacement in both groups using the method of measurement of Frobin et al. [7]
Pre Post 10 3-month Fvalue PPost test pre Post test post 10
treatment weeks follow up treatment vs. post weeks treatment vs.
10 weeks treatment 3-month follow up
MD MD
C2–C3 (S.G) 8.41 ±1.95 10.1 ±2.3 9.84 ±2.14 4.48 0.0206* 1.7* 0.3
C2–C3 (C.G) 8.2 ±1.8 9.0 ±27.05±1.5 14 <0.0001* 0.96 2.1*
C3–C4 (S.G) 12 ±1.6 15 ±1.41 14 ±1.3 13 0.0001* 2.36* 0.9
C3–C4 (C.G) 12 ±0.99 12 ±0.96 11 ±0.96 11 0.0004* 0.73* 1.1*
C4–C5 (S.G) 15.4 ±2.0 17.3 ±1.7 16.4 ±1.7 8.55 0.0013* 1.95* 0.9
C4–C5 (C.G) 13.99 ±1.7 14.81 ±1.9 12.7 ±1.4 24.42 <0.0001* 0.82* 2.13*
C5–C6 (S.G) 12.1 ±2.19 14.44 ±2.6 13.6 ±2.5 11.72 0.0002* 2.36* 0.89
C5–C6 (C.G) 11.67 ±1.79 12.31 ±2.11 11.15 ±2.21 5.310 0.0111* 0.64 1.15*
C6–C7 (S.G) 8.440 ±1.89 10.06 ±1.98 9.847 ±1.56 3.703 0.0374* 1.6* 0.21
C6–C7 (C.G) 10.4 ±2.1 10.97 ±2.3 9.8 ±2.13 16.15 <0.0001* 0.57* 1.22*
SG: study group CG: control group; *: significantly different; P: probability value; MD: mean difference.
Tab le 3
Person Correlation between rotations and ARA. P: probability
value; r: Pearson correlation coefficient. Significant values are indi-
cated (*)
Sample Pearson Pvalue
size r
C2–C3 (pre treatment data) 30 0.58 0.0008*
rotational
Post manipulating data 15 0.52 0.0455*
rotational study control 15 0.2 0.457
C3–C4 (pre treatment data) 30 0.56 0.0010*
rotational
Post manipulating data 15 0.79 <0.0004*
rotational study control 15 0.14 0.6
C4–C5 (pre treatment data) 30 0.48 0.007*
rotational
Post manipulating data 15 0.59 0.0184*
rotational study control 15 0.4 0.09
C5–C6 (pre treatment data) 30 0.47 0.0078*
rotational
Post manipulating data 15 0.52 0.0436*
rotational study control 15 0.3 0.19
C6–C7 (pre treatment data) 30 0.61 0.0003*
rotational
Post manipulating data 15 0.5 0.05*
rotational study control 15 0.49 0.06
P: probability value; Pearson r: correlation coefficient.
vical extension traction combined with infrared and165
neck stretches to improve the cervical lordotic curve166
would show improved cervical flexion and exten-167
sion end range of motion kinematic patterns as com-168
pared to the control group receiving infrared and neck169
stretches only. We found significant improvement in170
translational and rotational displacements for both the171
study group and control groups at 10-weeks after 30172
treatment sessions. The improved kinematic move-173
ment was maintained at 3-month follow up only in174
the study group receiving traction. In contrast, at 3-175
month follow-up (with no further treatment), the con-176
Tab le 4
Pearson Correlation between translational displacement and ARA.
P: probability value; r: Pearson correlation coefficient. Significant
values are indicated (*)
Sample Pearson Pvalue
size r
C2–C3 (pre treatment data) 30 0.78 <0.0001*
translational
Post manipulating data 15 0.53 0.0409*
translational study control 15 0.03 0.898
C3–C4 (pre treatment data) 30 0.56 <0.0001*
translational
Post manipulating data 15 0.8 0.0002*
translational study control 15 0.23 0.408
C4–C5 (pre treatment data) 30 0.64 0.0001*
translational
Post manipulating data 15 0.61 0.0149*
translational study control 15 0.18 0.511
C5–C6 (pre treatment data) 30 0.05 0.7
translational
Post manipulating data 15 0.61 0.0151*
translational study control 15 0.29 0.287
C6–C7 (pre treatment data) 30 0.18 0.33
translational
Post manipulating data 15 0.4 0.07
translational study control 15 0.003 0.991
P: probability value; r: correlation coefficient.
trol group not receiving cervical curve traction re- 177
vealed a significant decline in the translational and ro- 178
tational displacements towards pre-study or baseline 179
values. 180
Thus it would appear that our hypothesis is sup- 181
ported in as much as our results provides objective 182
evidence that biomechanical dysfunction, in terms of 183
sagittal curve cervical curve malalignment, and not 184
just pathoanatomy, influences the functional patterns 185
of lower cervical movement. 186
Our primary results are consistent with the study 187
by Darnel [11] who reported that “proper mechani- 188
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I.M. Moustafa et al. / Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics 5
cal alignment is essential for cervical joint function”.189
These findings are in general agreement with the state-190
ments of White and Panjabi [12] who indicated that191
coupled movements in the cervical spine depend on192
many factors, such as the orientation of the facet joints,193
geometry of the individual vertebra, and spinal pos-194
ture. Furthermore, Miyazaki et al. [3] conducted a ret-195
rospective analysis using kinetic magnetic resonance196
images to investigate the relationship of changes in the197
sagittal alignment of the cervical spine on the kinemat-198
ics of the functional motion unit and disc degenera-199
tion. They [3] reported that when the alignment shifted200
from normal to less cervical lordotic curvature, the seg-201
mental translational motion and angular displacements202
tended to decrease at all levels.203
Certain limitations of the present study are appar-204
ent. Our method of measurements was based on hand205
marked locations for landmark (“corners”) instead of206
computer aided measurement. However, we minimized207
the subjective observer influence on localization of cor-208
ners by conducting the allocation process by only one209
well trained radiologist.210
6. Conclusion211
The 3-point bending cervical traction with stretch-212
ing exercises and infrared radiation produced signifi-213
cant increases in the cervical lordosis for patients with214
cervical spondylotic radiculopathy and consequently215
improved translational and rotational displacements of216
the lower cervical spine. Follow up measurements at217
3-months revealed stable improvement in all measured218
variables for the cervical extension traction treatment219
group.220
The observed effects of sagittal curve correction and221
its association with kinematics improvements in cervi-222
cal flexion and extension that we report herein should223
be of value to clinicians and health professionals in-224
volved in the treatment of cervical disorders. Appro-225
priate physical rehabilitation for CSR should include226
cervical sagittal curve correction in properly selected227
patients.228
Conflict of interest 229
The authors have no conflict of interest to report. 230
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uncorrected proof version
... breaks, fractures, dislocations, etc.), it is just as often used for biomechanical assessment and treatment, particularly by spine surgeons, (16)(17)(18), specialty trained chiropractors, (19)(20)(21)(22) and other manual therapists. (23)(24)(25)(26) Radiology reports are a standard and required companion to imaging studies. The radiology report as taught throughout healthcare disciplines (i.e. ...
... (13)(14)(15) Altered segmental motion patterns are also a direct result of abnormal cervical sagittal alignments, indicating that static alterations of the sagittal cervical posture and curvature directly cause altered flexion-extension kinematics at the segmental and global levels. (1,24) Although many factors will come into play, it is conceivable that altered cervical alignment which simultaneously alters segmental coupling patterns will, over time, lead to degenerative changes, and not that insidious degenerative changes lead to a loss of lordosis. Both Hohl (53) found that patients with cervical kyphosis after injury have a significantly higher incidence of degenerative changes. ...
... (23)(24)(47)(48)(49)(50)(51)(52) Gore, (47) for example, found no statistically significant differences in lordosis measures between repeat lateral cervical x-rays taken an average of 10 years apart. Cooke et al.(50)(51)(52) found no differences in several repeat studies evaluating neutral head posture repeatability radiographs in several patients taken minutes, 3-6 months, 5 years, and 15 years apart. ...
Article
Full-text available
Objective: To compare medical radiologists' subjective qualitative commentary on cervical spine alignment to the images' actual quantitative and objective mensuration. Methods: One-hundred-and-eight consecutive lateral cervical x-ray radiology reports were reviewed for commentary about cervical alignment. The radiographs were digitized and quantified into theoretical categories and compared to the commentary. Results: Of the 100 images included for evaluation, 55 images had comments pertaining to 'normal,' 20 had 'no comment,' and 25 reports mentioned some sort of 'abnormal' alignment. Excessively hypolordotic/kyphotic necks were typically labeled as normal. Forward head posture and intersegmental kyphosis were frequently found in this patient sample but were never mentioned in a report even when in the severe range. Conclusion: Medical radiologists in this study made generalized, non-specific comments regarding cervical lordosis, if mentioned at all. This suggests that they may not perceive the importance of cervical spine alignment as being involved in a patient's complaint even when evidence suggests that cervical spine sagittal alignment is implicated in neck and headache symptomatology, physiological function, neurophysiological outcomes, and degenerative changes. This situation may fuel existing barriers between differing healthcare professionals as to how much emphasis should be placed on spinal alignment in the etiology of a patient's cranio-cervical complaints. (J Contemporary Chiropr 2021;4:17-25)
... (32,33) Advances in CBP technique involving cervical extension traction methods have demonstrated consistency in the non-surgical structural reestablishment of cervical lordosis in symptomatic patients in several clinical trials. (25)(26)(27)(34)(35)(36)(37) CBP is a full-spine and posture rehabilitation approach to correct poor posture and deviation of normal spinal alignment through incorporating mirror image® exercises, spinal adjustments, and traction procedures. (10)(11)(12) These trials (25)(26)(27)(34)(35)(36)(37) have demonstrated that in 30-60 treatments over 2.5-3.5 months, an improvement of up to 18° in cervical lordosis may be achieved. ...
... (25)(26)(27)(34)(35)(36)(37) CBP is a full-spine and posture rehabilitation approach to correct poor posture and deviation of normal spinal alignment through incorporating mirror image® exercises, spinal adjustments, and traction procedures. (10)(11)(12) These trials (25)(26)(27)(34)(35)(36)(37) have demonstrated that in 30-60 treatments over 2.5-3.5 months, an improvement of up to 18° in cervical lordosis may be achieved. All these trials were multimodal rehabilitation programs aimed at improving the cervical lordosis utilizing cervical extension traction methods as well as other manual procedures. ...
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Chiropractic Biophysics® (CBP®) technique is a full-spine and posture correcting method that incorporates mathematical principles into a unique approach to treat spinal disorders. It considers that the identification of postural rotations and translations of human postures are first evaluated and compared to the radiographic assessment of the spine alignment. Mirror image® postural positions and movements are utilized including spinal extension positions to improve the spine and posture towards a normal/ideal alignment. Specifically, corrective exercises, corrective traction and chiropractic adjustments are performed encompassing a multimodal rehabilitation program with the goal of improving the posture and spine alignment. CBP Rehabilitation programs are typically performed in-office with supportive at-home measures. Repeat assessment including radiographs are used to quantify and monitor structural improvements. CBP technique is an evidence-based approach to treat spine deformities and is supported by all forms of clinical evidence including systematic literature reviews, randomized controlled trials, non-randomized controlled trials, case reports/series as well as is supported by biomechanical posturespine coupling validity, radiographic and posture analysis reliability/repeatability and use of a validated biomechanical spinal model as the outcome goal of care. CBP technique is a proven method to improve pain, disability and quality of life in those with structural deformities.
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Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.
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There is a faction within the chiropractic profession passionately advocating against the routine use of X-rays in the diagnosis, treatment and management of patients with spinal disorders (aka subluxation). These activists reiterate common false statements such as "there is no evidence" for biomechanical spine assessment by X-ray, "there are no guidelines" supporting routine imaging, and also promulgate the reiterating narrative that "X-rays are dangerous." These arguments come in the form of recycled allopathic "red flag only" medical guidelines for spine care, opinion pieces and consensus statements. Herein, we review these common arguments and present compelling data refuting such claims. It quickly becomes evident that these statements are false. They are based on cherry-picked medical references and, most importantly, expansive evidence against this narrative continues to be ignored. Factually, there is considerable evidential support for routine use of radiological imaging in chiropractic and manual therapies for 3 main purposes: 1. To assess spinopelvic biomechanical parameters; 2. To screen for relative and absolute con-traindications; 3. To reassess a patient's progress from some forms of spine altering treatments. Finally, and most importantly, we summarize why the long-held notion of carcinogenicity from X-rays is not a valid argument.
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Increasingly, there is more attention being directed to the role that full spine sagittal alignment plays in causing or exacerbating a variety of musculoskeletal disorders. Similarly, spinal displacements, termed subluxation, are thought to cause dysfunctions in the entire neuromusculoskeletal system that may lead to altered neurophysiological function, abnormal sensorimotor control, and altered autonomic nervous system function. Abnormalities in neutral upright spine alignment (sagittal translation or flexion deformities) are known to increase mechanical loads (stresses and strains) on the central nervous system. These increased mechanical loads may subtly or overtly impair neurophysiological function as measured with evoked potentials in terms of latency and amplitudes of potentials. Proprioceptive afferentation from spine ligaments, muscles and discs are considered a major component of sensorimotor control. The voluminous mechanoreceptors in spinal muscles, ligaments, and discs plays an intimate role, providing the necessary neurophysiological input in a feed forward and feedback system for sensorimotor control via connections to the vestibular, visual and central nervous systems. Of particular interest, a network of neurophysiological connections between spine mechanoreceptors and the sympathetic nervous system has been documented. This chapter explores the hypothesis and evidence that restoring normal posture and spine alignment has important influences on neurophysiology, sensorimotor control and autonomic nervous system functionality. There is limited but high-quality research identifying that sagittal spine alignment restoration plays an important role in improving neurophysiology, sensorimotor control, and autonomic nervous system function. Accordingly, in the current chapter, we review this work in hopes of stimulating further investigations into structural rehabilitation of the spine and posture.
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Low back and neck pain disorders are among the leading causes for work loss, suffering, and health care expenditures throughout the industrialized world. It has been extensively demonstrated that sagittal plane alignment of the cervical and lumbar spines impacts human health and well-being. Today there are reliable and predictable means through the application of extension spinal traction as part of comprehensive rehabilitation programs to restore the natural curvatures of the spine. High-quality evidence points to Chiropractic BioPhysics® (CBP®) methods offering superior long-term outcomes for treating patients with various craniocer-vical and lumbosacral disorders. CBP technique is a full spine and posture rehabilitation approach that incorporates mirror image® exercises, spinal and postural adjustments, and unique traction applications in the restoration of normal/ideal spinal alignment. Recent randomized controlled trials using CBP's unique extension traction methods in conjunction with various conventional physiotherapeutic methods have demonstrated those who restore normal lordosis (cervical or lumbar) get symptomatic relief that lasts up to 2 years after treatment. Comparative groups receiving various 'cookie-cutter' conventional treatments experience only temporary symptomatic relief that regresses as early as 3 months after treatment. The economic impact/benefit of CBPs newer sagittal spine rehabilitation treatments demand continued attention from clinicians and researchers alike.
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Purpose: This study was conducted to test the hypothesis that improvement of cervical lordosis in CSR, using 3-point bending traction, will improve the clinical features in a sample population of patients suffering from Cervical Spondylotic Radiculopathy( CSR )with defined cervical hypo-lordosis. Relevance: This study assists in the understanding of the association between sagittal curve alignment and lasting improved function providing physiotherapists with a guidelines for proper rehabilitation of CSR. Participants: Thirty patients with lower CSR and with a cervical hypo-lordosis were included in the study. The patients were assigned randomly into two groups of equal number, study and control groups. Methods: Both groups received stretching exercises and infrared radiation; additionally the study group received 3 point bending cervical traction. Treatments were applied 3 x per week for 10 weeks after which a 12 week follow up was performed. The peak to peak amplitude of dermatomal somatosensory evoked potentials (DSSEPS), absolute rotation angle (ARA C2-C7), cervical flexion-extension kinematics analysis, and visual analogue scale (VAS) were measured for all patients at three intervals (initial, after 10 weeks of treatment, and at follow up of 3 months). Analysis: The outcome measure of ARA, pain, peak to peak DSSEPS, and kinematics analysis of cervical spine were measured using repeated measures one-way ANOVA to compare measurements made at three intervals. Results: In the study group, an increase in cervical lordosis (ARA C2-C7) was found (p< 0.0001, F=49.81) and maintained at follow up. No statistically significant improvement in lordosis was found for the control group. A Significant reduction in VAS for study group after 10 weeks of treatment and at 12 weeks follow up was found. In contrast, there was a less significant decrease in post treatment VAS and the follow up measures revealed a significant increase in the VAS score towards initial baseline values. An inverse linear correlation between increased lordosis and VAS was found (r=-.49; p=0.0059) for both groups initially and maintained in the study group post treatment (r=-.6; p=0.0138). At 10-week follow up, we found statistically significant improvements in DSSEPS for both groups (one way ANNOV, p< 0.0001). However, at 12 week post treatment follow up, only the study group showed statistically significant improvement compared to initial (p < 0.006) whereas the control group values returned to baseline measurement (p<0.153). We identified a linear correlation between initial DSSEPs and ARA for both groups (r=.65; p<0.0001), where as this relationship was only maintained in the study group at final follow-up (r=.55; p=0.033). Conclusions: Improved lordosis in the study group was associated with significant improvements in nerve root function, VAS rating, and translational and rotational motions of the lower cervical spine. Only in the study group were the results maintained at long-term follow up. Implications: Appropriate physical rehabilitation for CSR should include cervical sagittal curve correction, as it is may to lead greater and longer lasting improved function. Key-words: 1. cervical sagittal curve 2. 3-point beding traction 3. DSSEPS
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To determine the state of knowledge relative to three-dimensional spinal coupled motion and to check the validity of currently accepted two-dimensional coupling as taught in chiropractic. A hand search of available reference texts and a computer search of literature from Index Medicus were collected with an emphasis on three-dimensional studies of human spinal movements. Most postural movements result in complicated three-dimensional spinal coupling in six degrees of freedom. Previous spinal coupling results based upon two-dimensional radiographic studies are inadequate and inaccurate. It is important that chiropractic colleges and techniques use the three-dimensional spinal kinematics to update their curricula and advance chiropractic treatment procedures. Full three-dimensional investigations of spinal coupling patterns have shown that the vertebrae rotate and translate in all three axes and that previous theories of spinal coupling based upon two-dimensional studies are inaccurate and invalid. Postural rotations and translations, which are the main motions studied in spinal coupling research, and altered configurations of the normal sagittal plane curves are the cause of both normal and abnormal spinal coupling patterns in three dimensions. Chiropractic letter listings (such as PRS, ASRP, etc.) are outdated, incomplete, invalid representations of coupled segmental movements. Mechanical loading of the neuromusculoskeletal tissues plays a vital role in position, dynamics, proper growth, repair and symptoms. Future studies of spinal kinematics should study the postural translations of the skull and thorax for their associated coupling in three dimensions. Combined postural rotations and translations along with altered sagittal curvatures need to be studied for their associated coupling characteristics as well.
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To evaluate a new 3-point bending type of cervical traction. Nonrandomized controlled trial of prospective, consecutive patients compared with control subjects. Follow-up patient data were obtained at 3 and 15(1/2) months, and 8 1/10 months for controls. Data were collected at a spine clinic in Nevada. Volunteer subjects consisted of 30 patients and 24 controls. Subjects had cervicogenic pain (neck pain, headaches, arm pain, and/or numbness). Subjects were included if their Ruth Jackson radiographic stress lines measured less than 25 degrees but were excluded if they had suspected disk herniation or canal stenosis. All subjects completed the first follow-up examinations, and 25 of 30 patients completed the long-term follow-up examination. Spinal manipulation for pain and a new form of 3-point bending cervical traction to improve lordosis. Cervical manipulation was provided for the first 3 to 4 weeks of treatment. Traction treatment consisted of 3 to 5 sessions per week for 9 +/- 1 weeks. Besides pain visual analog scale (VAS) ratings, pre- and posttreatment lateral cervical radiographs were analyzed. Control subjects reported no change in the pain VAS ratings and had no statistically significant change in segmental or global radiographic alignment. For the traction group, VAS ratings were 4.3 pretreatment and 1.6 posttreatment. Traction group radiographic measurements showed statistically significant improvements (P <.008 in all instances of statistical significance), including anterior head weight bearing (improved 6.2mm), Cobb angle at C2-7 (improved 12.1 degrees ), and angle between posterior tangents at C2-7 (improved 14.2 degrees ). For the treatment group, at 15(1/2)-month follow-up, only minimal loss of C2-7 lordosis (3.5 degrees ) was observed. Sagittal cervical traction with transverse load at midneck (2-way cervical traction) combined with cervical manipulation can improve cervical lordosis in 8 to 10 weeks as indicated by increases in segmental and global cervical alignment. Magnitude of lordosis at C2-7 remained stable at long-term follow-up.
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To compare the effects of manual therapy and stretching exercise on neck pain and disability. An examiner-blinded randomized cross-over trial. Patients: A total of 125 women with non-specific neck pain. Patients were randomized into 2 groups. Group 1 received manual therapy twice weekly and Group 2 performed stretching exercises 5 times a week. After 4 weeks the treatments were changed. The follow-up times were after 4 and 12 weeks. Neck pain (visual analogue scale) and disability indices were measured. Mean value (standard deviation) for neck pain was 50 mm (22) and 49 mm (19) at baseline in Group 1 and Group 2, respectively, and decreased during the first 4 weeks by 26 mm (95% Confidence Interval 20-33) and 19 mm (12-27), respectively. There was no significant difference between groups. Neck and shoulder pain and disability index decreased significantly more in Group 1 after manual therapy (p=0.01) as well as neck stiffness (p=0.01). Both stretching exercise and manual therapy considerably decreased neck pain and disability in women with non-specific neck pain. The difference in effectiveness between the 2 treatments was minor. Low-cost stretching exercises can be recommended in the first instance as an appropriate therapy intervention to relieve pain, at least in the short-term.
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Study design: Systematic review. Objective: To perform an evidence-based synthesis of the literature assessing the cost-effectiveness of surgery for patients with symptomatic cervical degenerative disc disease (DDD). Summary of background data: Cervical DDD is a common cause of clinical syndromes such as neck pain, cervical radiculopathy, and myelopathy. The appropriate surgical intervention(s) for a given problem is controversial, especially with regard to quality-of-life outcomes, complications, and costs. Although there have been many studies comparing outcomes and complications, relatively few have compared costs and, more importantly, cost-effectiveness of the interventions. Methods: We conducted a systematic search in PubMed/MEDLINE, EMBASE, the Cochrane Collaboration Library, the Cost-Effectiveness Analysis registry database, and the National Health Service Economic Evaluation Database for full economic evaluations published through January 16, 2014. Identification of full economic evaluations that were explicitly designed to evaluate and synthesize the costs and consequences of surgical procedures or surgical intervention with nonsurgical management in patients with cervical DDD were considered for inclusion, based on 4 key questions. Results: Five studies were included, each specific to 1 or more of our focus questions. Two studies suggested that cervical disc replacement may be more cost-effective compared with anterior cervical discectomy and fusion. Two studies comparing anterior with posterior surgical procedures for cervical spondylotic myelopathy suggested that anterior surgery was more cost-effective than posterior surgery. One study suggested that posterior cervical foraminotomy had a greater net economic benefit than anterior cervical discectomy and fusion in a military population with unilateral cervical radiculopathy. No studies assessed the cost-effectiveness of surgical intervention compared with nonoperative treatment of cervical myelopathy or radiculopathy, although it is acknowledged that existing studies demonstrate the cost-effectiveness of surgical intervention for these 2 clinical entities. Conclusion: A paucity of high-quality economic literature exists regarding cost-effectiveness of surgical intervention for cervical DDD. Future research is necessary to validate the findings of the few studies that do exist to guide decisions for surgery by the physician and patient with respect to cost-effectiveness. Level of evidence: 2.
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Retrospective analysis using kinetic magnetic resonance images (MRIs). To investigate the relationship of changes in the sagittal alignment of the cervical spine on the kinematics of the functional motion unit and disc degeneration. Normal lordotic alignment is one of the most important factors contributing to effective motion and function of the cervical spine. Loss of normal lordotic alignment may induce pathologic changes in the kinematics and accelerate degeneration of the functional motion unit. However, the relationship of altered alignment on kinematics and degeneration has not been evaluated. Kinetic MRIs in flexion, neutral, and extension were performed. Study participants were classified into 5 groups based on the C1-C7 Cobb angle of sagittal alignment--Group A: Kyphosis (n = 19), Group B: Straight (n = 29), Group C: Hypolordosis (n = 38), Group D: Normal (n = 63), and Group E: Hyperlordosis (n = 52).Intervertebral disc degeneration was graded (Grades 1-5), and the kinematics of the functional spinal unit were obtained. When the alignment shifted from normal to less lordotic, the translational motion and angular variation tended to decrease at all levels. The contribution of the C1-C2, C2-C3, and C3-C4 levels to total angular mobility tended to be higher in Group C than Group D. However, the contribution of the C4-C5, C5-C6, and C6-C7 levels tended to be lower in Group C than in Group D. The grade of disc degeneration associated with loss of lordosis tended to be higher than that associated with normal alignment at the C2-C3 and C3-C4 levels. The present study demonstrated that the changes in sagittal alignment of the cervical spine affect the kinematics. Consequently, it may cause changes in the segment subjected to maximum load for overall motion and accelerate its degeneration.
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There is evidence to suggest that abnormal coupling patterns in the lumbar spine may be an indicator of low-back problems. To quantify the normal coupling patterns, fresh cadaveric human lumbar spine specimens (L1-S1) were used. A pure axial torque or lateral bending moment of 10 N-m (in five equal steps) was applied to the specimen, in five spinal postures, and three-dimensional motions were measured at the five vertebral levels. The results indicated that the coupling patterns changed significantly with the intervertebral level. For example, in neutral posture, the left axial torque produced coupled lateral bending, which varied from approximately 2 degrees right lateral bending at L1-2, to approximately 0 degrees at L3-4, and to approximately 2.5 degrees left lateral bending at L5-S1. Additionally, there was coupled flexion of approximately 1 degrees to 2 degrees at all levels. Application of left lateral bending moment resulted in approximately 1.7 degrees of coupled right axial rotation at all levels, except at L1-L2, where it was 0 degrees. Additionally, there was coupled flexion of 0.7 degrees to 2 degrees at all levels. For example, at the L2-3 level, the left axial torque produced coupled right lateral bending that ranged from approximately 0.5 degrees at full extension to approximately 2.5 degrees at full flexion. There was also accompanying coupled flexion of approximately 0.4 degrees to 1.7 degrees. Application of left lateral bending moment at the L2-3 level produced axial rotation of approximately 2.5 degrees, which did not vary with the posture, while the other coupled motion varied from approximately 1.7 degrees flexion at full extension posture to approximately 0.8 degrees extension at full flexion posture.
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The purpose of this article is to attempt to organize some of the many ramifications of the position referred to as forward head posture (FHP). It will present a proposed chronology of events and attempt to explain why patients with masticatory disorders may also demonstrate other symptoms in anatomical locations that are not directly connected with the masticatory mechanism. Abnormal posture affects muscle length/tension relationships and joint biomechanics, and this may cause pain. Many of the observations made in this article are derived from clinical settings, while other observations are ones that have been documented throughout medical and dental literature.
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A biomechanical lumbar spine model was constructed to simulate three-dimensional spinal kinematics under the application of pure moments. Parametric analysis of the model allowed for the estimation of how much of the coupled motions could be predicted by the lumbar lordosis and the intrinsic mechanical properties of the spine. To evaluate the relative effects of lordosis and intrinsic mechanical spine properties on the magnitude and direction of coupled rotations. Clinical evidence suggests that abnormal coupled motion in the lumbar spine may be an indicator of low back disorders. The biomechanical lumbar spine model consisted of five vertebrae separated by intervertebral joints that provided three rotational degrees of freedom. In vitro experimental data, obtained from nine fresh-frozen (L1-S1) cadaveric specimens, were used to establish the mechanical properties of the intervertebral joints. Two different submodels were considered in simulating the three-dimensional intervertebral rotations in response to the applied moments. In the first, it was assumed that the coupled motions were generated solely as a result of the vertebral orientation caused by lordosis. In the second, additional intrinsic motion coupling was assumed. Intervertebral coupling was partially predicted by lumbar lordosis; however, the inclusion of intrinsic mechanical coupling dramatically improved the simulation of the intervertebral rotations (root mean square error < 1 degree). Comparison of the results from the two models demonstrated that the lumbar lordosis and intrinsic mechanical properties of the spine had about an equal effect in predicting the coupling between axial rotation and lateral bending. In contrast, coupled flexion, associated with lateral bending, was almost fully accounted for by the presence of lumbar lordosis. The lumbar lordosis and intrinsic mechanical properties of the spine were equally important in predicting the magnitude and direction of the coupled rotations.
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(1) Precise documentation of sagittal plane segmental rotational and posteroanterior translational motion of segments C0/C1-C6/C7 of the human cervical spine from lateral radiographic views. (2) Compilation of a database describing normal motion. (3) Comparison of individual motion patterns with the normal database. Descriptive study based on computer-aided measurements from lateral radiographic views taken in flexion and extension. Previous studies concentrated on segmental rotational motion of the cervical spine. Normal data for translational motion were not available. Description of cervical spine motion patterns thus remained incomplete. Based on computer-aided measurements from lateral radiographic views taken in flexion and extension, a new protocol determines rotational and translational motion for all segments (C0/C1-C6/C7) imaged on the radiographic views. Measured results are corrected for radiographic magnification and variation in stature; they are virtually uninfluenced by radiographic distortion and patient alignment errors. A database describing normal motion was compiled from 137 sets of lateral views of healthy adults taken in active flexion and extension. A specimen study as well as inter- and intra-observer studies quantify measurement errors. The error study demonstrated the error (SD) of a rotational motion measurement to amount to slightly less than 2 degrees. The error (SD) of a translational motion measurement amounts to less than 5% of vertebral depth; for a vertebra of 15 mm depth this corresponds to 0.7 mm. A normal database for rotational and translational motion was compiled. There was a linear relation between rotational and translational motion. This finding agrees qualitatively with results from previous studies; quantitative comparisons are not possible due to divergent definitions for translational motion. The relation between rotation and translation can be employed in individual cases to predict translational motion, in dependence on the rotation actually performed. A comparison of the rotational motion with the normal database and the difference between predicted and actual translational motion allow segmental hypo-, normal or hypermobility to be quantified. The new protocol measures segmental motion with high precision and corrects for radiographic distortion, variation in stature and alignment errors of patients. Thus, archive studies using existing radiographs are feasible. Flexion-extension radiographs of the cervical spine are performed to explore potential damage to the bony or ligamentous structure resulting in abnormal, segmental motion patterns. Determining rotational motion gives only an incomplete picture. The new protocol allows for precise quantification of translational motion and classification of segments as hypo- or hypermobile by comparison with normal motion data.