CASE REPORTS

            Case One: A 28 year old male with no prior history of cervical spine trauma presented for treatment of right-sided neck, upper back and mid-back dull pain that became sharp with movement such as twisting. He rated the pain as a four level on a 0-10 pain scale and stated that it had been constant for approximately two weeks.

            Radiography examination demonstrated a 41 millimeter anterior translation of C2 in relation to C7. Posterior vertebral body lines intersected to reveal a five degree upper cervical lordotic, eight degree lower cervical kyphotic s-curve. The Atlas Angle to horizontal measured at 13 degrees.(See X-ray #1A) All radiography measurements were in accordance with proven  

Chiropractic Biophysics¨ procedures.5                

            This patient then received 19 treatments of CBP®¨ Mirror-Image¨, diversified-style spinal adjustments. Eighteen of the treatments also included supine two-directional cervical extension traction that started at two pounds for five minutes and progressed to nine pounds for eight minutes. On twelve of the treatments, an eight minute walking exercise was preformed while the patient wore a Cervical Remodeling Collarª. This device draws and holds the head into posterior translation while applying a mid-cervical anterior force. (See picture #1) The ambulatory exercise was performed on a treadmill at two to three miles per hour. 

            A full re-examination was completed and a new lateral cervical radiograph was taken. The patient’s pain had been eliminated and all his range of motions had improved. In spite of this the new lateral x-ray showed a 43 millimeter anterior translation of C2 to C7, a 12 degree upper cervical lordotic, 10 degree lower cervical kyphotic s-curve and the Atlas Angle was now at 16 degrees.(See X-ray #1B) In comparison with the first lateral cervical x-ray, the patient’s structural problem had become slightly worse!

            The extension traction therapy was stopped and the patient continued on for 19 more treatments of CBP®¨ Mirror-Image¨, diversified-style spinal adjustments. Eighteen of these treatments also included the ambulatory eight minute walking exercise with the Cervical Remodeling Collarª. On 14 of the treatments, the patient stayed on the treadmill and completed an additional seven minutes, at two to three miles per hour, with a nylon lined neoprene head band that held from two to six pounds of lead weight against the front of the patient’s forehead. I designed this Posture Corrective Exercise Beltª because the existing head weighting devices on the market are designed for seated use and would not stay up on the forehead during active ambulatory exercise.(See picture #2)

            Applying additional weight to the head to improve posture is an age-old technique that dates back to putting a book on top of young girls heads while they walk around balancing it. The additional weight triggers the body’s natural righting reflexes to draw and hold the head into a direction of posterior translation. This induces specific posture corrective neuro-muscular re-education and re-balancing. I hope to write an article for a future issue of this journal on the subject of ambulatory posture corrective body weighting and its effect on multi-axis translations. For now let me share with you the results of its use. 

            After this additional treatment, a new lateral x-ray showed 25 millimeters anterior translation of C2 to C7, a 6.5 degree cervical lordosis and the Atlas Angle was now at 24 degrees. (See X-ray #1C) In comparison to the last radiograph, the forward head posture had been reduced by 18 millimeters and thus the cervical spine un-coupled and returned to a single harmonic lordotic curve while the Atlas Angle increased to its normal value of 24 degrees to horizontal.6  

            Case Two: A 63 year old female with chronic neck and upper back stiffness presented for a postural examination and evaluation.

            Radiography examination demonstrated a 18 millimeter anterior translation of C2 in relation to C7. Posterior vertebral body lines intersected to reveal an 8 degree upper cervical lordotic, 10.5 degree lower cervical kyphotic s-curve. The Atlas Angle to horizontal measured at 19 degrees. Moderate lower cervical degenerative joint disease was noted. (See X-ray #2A)

            It is not a coincidence that the starting point of the spinal degeneration is also the point of kyphotic reversal. Five different studies have shown a relationship between altered posture and abnormal bone production.7 The greatest amounts of bone were formed at the apex of a curve on the concave side due to the increased compression. This increased compression is also subjected upon the lower cervical intervertebral discs. Their degeneration in this radiograph indicate the long standing, chronic nature of this abnormal structural condition.

            This patient received 18 treatments of CBP®¨ Mirror-Image¨, diversified- style spinal adjustments. On four of the treatments, she also received a five to eight minute session on a Posture Pump¨. This is a gentle extension traction type modality that can be used to make sure the patient can tolerate stronger extension traction therapy. With no reaction to the Posture Pump¨, the patient’s next ten treatments included supine two-directional cervical extension traction that started at two pounds for five minutes and progressed to three pounds for seven minutes.  

            A full re-examination was completed and a new lateral cervical radiograph was taken. The new lateral x-ray showed the same 18 millimeter anterior translation of C2 to C7, a 11 degree upper cervical lordotic, 12 degree lower cervical kyphotic s-curve and the Atlas Angle was now at 20 degrees. (See X-ray #2B) As in case one of this paper, in comparison with the first lateral cervical x-ray, the structural problem had become slightly worse.

            The extension traction therapy was stopped and the patient continued on for 28 more treatments of CBP®¨ Mirror-Image¨, diversified-style spinal adjustments. Twenty-four of these treatments also included the ambulatory eight minute walking exercise with the Cervical Remodeling Collarª. On 19 of the treatments, the patient stayed on the treadmill and completed an additional six minutes at two miles per hour with the Posture Corrective Exercise Beltª that held from two to four pounds of lead weight against her forehead.

            A new lateral radiograph revealed 10 millimeters anterior translation of C2 to C7, a 15 degree cervical lordosis and the Atlas Angle was now at 27 degrees. (See X-ray #2C) The change

to a negative translation oriented treatment resulted in a reduction of the forward head posture by eight millimeters and an associated un-coupling of the cervical spine into a normal lordosis.

CONCLUSIONS

            Ambulatory Postural Remodelingª is what I have termed the combination therapy of ambulatory negative translation traction and ambulatory negative translation neuro-muscular re-

education/re-balancing. This type of weight-bearing, closed-chain rehabilitative traction/exercise program is, without question, an effective way to correct a lordotic/ kyphotic cervical s-curve or any forward head posture related condition. These include thoracic outlet syndrome, chronic migraine or tension-type headache and TMJ problems.8,9 This 15 minute service is usually billed out as neuro-muscular re-education or therapeutic exercise. The increased return for this level of service, both financially and in satisfied patient referrals, more than justifies the small expense of the necessary equipment. A good treadmill is available for as little as $400 and can fold up into a two foot by three foot space.

            My case studies and the basic concepts of three-dimensional spinal coupling mechanics also explain why traditional extension traction can make a lordotic/ kyphotic s-curve worse and may not be very good at reducing forward head translation.10 We are mistakenly applying a force that reinforces the upper cervical extension subluxation instead of opposing it. It is my opinion that this is equally true with any altered cervical curvature with a notable forward head posture of 20

millimeters or more.

            Two-directional extension traction therapy, from my clinical observations, is still the optimum choice for the correction of any notably reduced or reversed lateral cervical curvature,

except lordotic/kyphotic s-curves, that have no more than 15-20 millimeters of forward head translation. If your patient presents with more than 20 millimeters of forward translation of C2 to C7, your first priority should be to reduce the main abnormal motion of forward skull translation and thereby reduce the abnormal cervical coupling influences before determining if extension traction therapy is indicated.

            The ambulatory, head weighting posture corrective exercise can be employed no matter which type of traction is being used, but I no longer provide or recommend applying extension traction and negative translation traction within the same treatment. I choose one or the other depending on the configuration of the patient’s lateral cervical spine as I have just outlined. It is my observation, as occurred in case one of this paper, that extension traction retards the effects of the negative translation traction.

REFERENCES

1.         White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: J. B. Lippincott; 1990 p. 53.

2.         Penning L. Acceleration injury of the cervical spine by hypertranslation of the head. Part I, Effect of normal translation of the head on cervical spine motion: a radiological study. Eur Spine J 1992; 1:7-12.

3.         Penning L. Kinematics of cervical spine injury. A functional radiological hypothesis. Eur Spine J 1995; 4:126-132.

4.         Harrison DE, Harrison DD, Troyanovich, SJ. Three-dimensional spinal coupling mechanics: Part I. A review of the literature. J Manipulative Physiol Ther 1998; 12(2):101-113.

5.         Jackson BL, Harrison DD, Robertson GA, Barker WF. Chiropractic Biophysics¨ lateral cervical film analysis reliability. J Manipulative Physiol Ther 1993; 16(6):384-91.

6.         Harrison D et al. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996; 21;667-675.

7.            Troyanovich S et al. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998; 21(1):37-49.

8.         Marcus DA, Scharff L, Mercer S, Turk DC. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache 1999; 39;21-27.

9.         Hanten WP, Lucio RM, Russell JL, Brunt D. Assessment on total head excursion and resting head posture. Arch Phys Med Rehabil 1991; 72:877-80.

10.        Harrison D et al. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. J Manipulative Physiol Ther 1994; 17(7):454-60.