April 2005, Vol. 15, Iss. 2

Table of Contents

Altered Cervical Lordosis and DJD • Chiropractor Invents Car Seat Headpiece • DACBRs Cause Professional Embarrassment at RAC • Eight Major Aberrant Forms of the Lumbo-Pelvic Spine • European Spine Journal to Publish 6th CBP® Clinical Control Trial • Evidence Based or Not • Glutamate/Aspartame - Pain and Your Brain • Greg Buchanan Donates $30,000 to CBP® Nonprofit • Inappropriate Characterization of CBP® Technique • Missed Appointments and Patient Education • Money, Taxes, Life and Practice • Palmer College Takes Alumni Group to Court • PosturePrint™ Research with ICA • Presenting Defendable Care Options to Patients • Published Papers Near 81 • Resign or be Terminated • Thermography: Renewed Interest • Using Silence to Communicate • Whiplash Injuries: Pathophysiology, Diagnosis, Medical Management and Prognosis

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Counter Point - Round 2

Selective Reviews, Misrepresentation of Studies, and Side Stepping Biomechanics Lead to an Inapprpriate Characterization of CBP® Technique - Part II

by Deed E. Harrison, DC

Deed E. Harrison, D.C., completed his undergraduate pre-chiropractic courses at the University of Utah and graduated from Life-West Chiropractic College in 1996. He has authored 70 peer reviewed manuscripts in a wide variety of index medicus journals. He is a peer reviewer for several scientific journals including: Spine, Clinical Biomechanics, Clinical Anatomy, and the Archives of Physical Medicine and Rehabilitation. He is a member of the orthopedic society: The International Society for the Study of the Lumbar Spine (ISSLS). Dr. Harrison is the lead instructor for CBP® Seminars, and is Vice-President of CBP® Nonprofit, Inc. Along with his wife, he maintains a 300 P.V.W. clinical practice in Elko, NV.

               I would like to thank Dr. McDaniel for his second counter point article in the AJCC. Again, due to the number and nature of criticisms, this article is longer than usually permitted. I have itemized Dr. McDaniel’s criticisms into 20 points and provide a rebuttal to each below.

              A) Some studies I cited in my 1st counterpoint are out dated, one is from a conference, and some are in press.

              Apparently, because an article is dated, Dr. McDaniel believes its validity is suspect. Considering the breadth of scientific fields that have been built upon discoveries 100, 200, or even a thousand years ago, Dr. McDaniel’s view is ludicrous. For example, Euclidean Geometry, used everywhere in our daily lives (including x-ray line drawing procedures), was developed and validated in about 300BC.1 Furthermore, along with this article from 1938, I cited more recent ones including ones as recent as 2004 (see my previous AJCC article2). In fact, I established the validity by the breadth of data on these topics.

              Dr. McDaniel’s inability to access manuscripts presented at and published in scientific conference proceedings is not my problem and in no way detracts from the validity of these investigations. It is well known that these venues are peer-reviewed scientific forums and that the majority of these presentations go on to review and publication in the scientific literature. Similarly, articles that are in press can be accessed when in print and as an author of these, I am privy to this information and can assure the reader and Dr. McDaniel the accuracy of my interpretation.

              B) Dr. McDaniel believes he did not mischaracterize the CBP® “ideal spine model”

              Apparently, Dr. McDaniel did not appreciate my response in the last issue of the AJCC.2 I never stated that CBP® does not have an ideal sagittal plane model. I emphatically stated that we have two types of models (Ideal and Average) that we teach and utilize. Dr. McDaniel is again ignoring the fact that we have an Ideal and Average geometric model and segmental angles for sagittal curvatures. This was my point and I reiterate this. The reader and Dr. McDaniel are referred to my previous response.2

              C) Dr. McDaniel believes that the Shaikewitz’s3 study was reasonably well done article even without an IRB

              I offered a thorough critique in the last issue of the AJCC.2 Shaikewitz’s3 methods were very poor. First, without IRB approval, it should have never made it into a peer-reviewed scientific journal. In today’s world (not 1938), high quality scientific journals will not accept a prospective study on human subjects without IRB approval, in fact, it is a violation of federal regulations.

              Second, the cervical curve measurement method used by Shaikewitz3 had never been subjected to a reliability study before, during, or after the study. Without reliability of a utilized measurement method, there is no way that the data can be used to validate/reject a study hypothesis.4 I am astonished Dr. McDaniel won’t acknowledge this fact.

              Third, the 17cm normal radius of curvature measurement method used by Shaikewitz3 is not a valid measurement method. Here’s why: the radius of curvature is linearly dependent upon the height of a curved column. For example, the slope (exact angle of cervical lordotic curvature) can be the same for two different height cervical curves but the radius of curvature will be different (Refer to Figure 1 in Jan AJCC2). This is “simple geometric fact” and is not open to debate unless Dr. McDaniel wants to rewrite Euclidean Geometry texts. Furthermore, use of radius of curvature is valid only if the cervical curvature has a circular geometry and the cervical column is the same height between subjects; these were not validated by Shaikewitz.3 When a measurement method has no validity for its intended purpose, then investigations using them are invalid and moot.5

              Finally, teenagers (13-19 years) do not have significant DJD in the cervical spine and these subjects should have been excluded from Shaikewitz’s data analysis.3 Personally, I seriously question Dr. McDaniel’s ability to critique the scientific literature. Critique of scientific studies should be left to individuals with expertise in the respective study field and with extensive training in the area of manuscript reviewing!

              D) Dr. McDaniel did not make an ad hominem statement about CBP®’s IRB protocol. Dr. Perle does not remember doing this either at RAC 2004.6

              For Dr. McDaniel, I have the following response: What was your purpose then, when you were questioning the informed consent procedure utilized and clearly stated in our manuscript7 in your first point article in the AJCC?8

              To Dr. Perle: I am sorry, he’s having memory loss. I personally recall this exactly and to confirm this, I contacted three individuals who were present (one who was on the platform with me and two who were in audience attendance). Dr. Christopher Colloca (Phoenix, AZ), Dr. Paul Oakley (Canada), and Dr. Jason Haas (Windsor, CO) were all present during this “Ad Hominem” comment made by Dr. Perle and they would be more than happy to assist his memory recovery.

              E) Less costly and time consuming treatment approaches should be used for neck pain than CBP structural rehab

              To begin, it is interesting that Dr. McDaniel brings up “time” and “cost” in a debate related to validity of corrective care using CBP® technique. According to Stein,9 this is one of the five fallacies in scientific debates known as “the fallacy of irrelevant conclusion.” This fallacy is evident when an individual intends to establish a particular conclusion by shifting his argument to another topic’s conclusion. Analogously, I can conclude that McDonald’s hamburgers and large fries are healthier because they are less costly and less timely compared to traveling to the organic health store, purchasing, and then cooking my own meal. ‘Irrelevant conclusion,’ Dr. McDaniel.

              Second, traditional spinal manipulation treatment is short sighted and inadequate to relieve chronic pain and disability. For example, Dr. McDaniel and all others relying on “standard care” fail to acknowledge that this treatment only relieves an average of 48% (4.8 pre-treatment to 2.5 post-treatment on a numerical rating scale, NRS) of the chronic pain intensity.10-15 See Table 1. I note the definition of a 2 = Constant Minimal to Intermittent Slight Pain and a 3 = Constant Slight Pain with some handicap.

              Therefore, subjects following a program of SMT would not be described as MMI. The recent studies by Haas et al15 and Leboeuf-Yde et al16 are good examples of this. Thus, practice protocols based on pain in SMT studies are incomplete. Also, such practice protocols must include more visits than 12, because treated subjects, in published RCTs, were left in chronic pain (NRS = 2.5) after up to 12 treatments of SMT. In contrast, the same pain data comparison found for the CBP® clinical trials indicate an ending value of NRS/VAS = 1 = Minimal Pain or annoyance.17-21 Table 2.

              Third, there are other outcomes than basic (NRS) pain relief that are just as relevant if not more relevant, for determination of patient improvement. For example, recent publications have found that health related quality of life and functional disability measures (Short Form-36, Oswestry, Neck Disability questionnaires, etc...) are more sensitive and important to patient function than simple pain intensity outcomes.22 Furthermore, recent publications have found strong correlations between altered sagittal spinal alignment (specifically loss of the distal lumbar lordosis), health quality of life, and physical function as measured with the Short Form-36 questionnaire.23,24

              Therefore, CBP® recommends that clinicians utilize health status and disability questionnaires at all initial and follow-up examinations. In this manner, strong evidence can be used to support the need for and outcome effects of CBP® treatment methods past the 8-12 visit “bench mark” of traditional SMT based studies.

              Fourth, as stated in my 1st article but ignored by Dr. McDaniel, other important patient outcomes that are statistically correlated to abnormal postural displacements and altered sagittal curvatures are:

              • Spinal Range Of Motion (ROM)25-27

              • Vertebral coupled motion28

              • Gait abnormalities29,30

              • Tissue stress/strain relationships31-35

              • Increased potential for injury36,37

              • Muscle moment arms38-39

              • Muscular endurance40

              • Maximum isometric contraction40

              • Low back pain and Sick leave41

              For others see my initial response.2

              F) There is nothing to say that more expensive CBP® lordosis correction is better or worse than self limitation or other types of care for neck pain

              I would like to point out, that in a recent publication, we addressed the cost of one or two rehabilitative programs of CBP® care for the treatment of “the flat back syndrome” (straightened or kyphotic lumbar spine), with 36-100 treatments.42 This spinal rehabilitative program ranged from $1000-$5000 and is within the accepted range of spinal/postural rehabilitative care programs published in the scientific literature.43,44

              More importantly, you are wrong, Dr. McDaniel, when you state there is no information to say that lordosis rehabilitation is superior to other types of care. For example, we have recently published several case studies where “standard care” failed to resolve a patient’s chronic condition; whereas CBP® lordosis/postural rehabilitation showed dramatic improvements in pain, ROM, disability scales, and health status (depending upon the study).44-50 Does more work need to be performed on this type...yes we do need more advanced studies in this area.

              However, it is known today that well-done case studies (such as CBP®’s) most often demonstrate findings consistent with that of the RCT.51,52 Therefore, the published CBP® case studies provides good evidence contradicting your statement. Can you provide a reference supporting your opinion?

              G) The studies I cited2 had post surgical complications causing alterations in their curvatures and increased DJD and these are not supportive of cervical lordosis validity

              To begin, in these surgical studies, there is no direct support that degenerative joint disease (DJD) came first and altered the sagittal curvature second. This is merely Dr. McDaniel’s opinion. In contrast, several of these studies definitively prove otherwise.

              These studies provide direct evidence that altered sagittal plane curvature after surgery is strongly correlated to generalized poor outcomes and axial symptoms (non-radicular),53-57 and directly causes early/premature (DJD).58-66 The breadth of the conditions these studies deal with is significant (generalized DJD, spondylosis, disc herniation, rheumatoid conditions, myelopathy, radiculopathy, pain conditions not relieved by conservative care, etc...). Some of these are less common (rheumatoid) in Chiropractic practice but some are very common (disc herniation and spondylosis). It does not matter what specific condition they deal with as they all indicate that cervical kyphosis, s-curves, etc... are abnormal.53-64

              H) Surgical studies don’t support that CBP® techniques could have substituted for surgery nor that CBP® technique could have stabilized the post surgical collapse of the cervical spine

              Again, Dr. McDaniel is guilty of the “fallacy of Irrelevant Conclusion.” In my first counterpoint article, I never stated this issue. What was clearly stated was that these studies provide strong evidence that abnormal spinal curvatures are linked to a variety of conditions including poor outcomes after surgery, axial pain after surgery, the need for a revision surgery, and premature degenerative joint disease.2,53-65

              I) Hohl’s67 study did not find that DJD was due to the altered curve

              I absolutely disagree with Dr. McDaniel. In 146 subjects with no DJD and involved in a motor vehicle accident (MVA) with at least a 5-year follow up, Hohl67 found that 39% developed disc degeneration. In the results section, he states, “Compared with the other patients there was a significantly higher incidence of degenerative changes in the twenty who had sharp reversal of the normal cervical curve (p0.05).” (page 1679, paragraph 1, line 1).67

              Of interest, Hohl67 refers to figures 2-A and 2-B for an example of the DJD and his definition of ‘sharp reversal.’ In this figure, it is clear that a ‘sharp reversal’ was in fact only a very subtle segmental reversal with a straightened cervical curve. I provide a similar figure to Hohl’s67 for understanding (Figure 1) and refer Dr. McDaniel and the reader to Hohl’s67 study for proof. Why would you intentionally misrepresent this information, Dr. McDaniel?

              J) Dr. McDaniel based, on Hohl67 and Norris and Watt,68 believes muscle spasms cause abnormal cervical curvatures

              The literature support for this item is based on Class III evidence or author “opinion.” In contrast, Helliwell et al69 compared three groups of subjects (normal, acute neck pain, and chronic neck pain) and found no relationship between muscle spasm and loss of cervical lordosis. They69 suggested that muscle spasm would cause an increased lordosis due to the larger volume and larger moment arms of the posterior extensor muscles of the cervical spine. Further, in a study of 100 asymptomatic controls compared to 100 patients with subacute (12 weeks) whiplash associated disorders (WAD), Giuliano et al70 found dramatic differences in the point prevalence of hypolordosis between the controls (4%) and the WAD patients (98%); 24.5 times more prevalent in the WAD patients. In the subacute 12-week time frame, the “muscle spasms” would be resolved but the hypolordosis still existed.70 The evidence69-71 contradicts the “muscle spasm theory” causing hypo-lordosis.

              Snap through, a type of buckling seen in sagittal plane radiographs, explains the various configurations seen post-injury following load applied to a curved column, such as the human spine.72-74 A lordosis would be described as neutral, an S-curve as the 1st order buckled mode, a flexion-extension-flexion as the 2nd order buckled mode, and so on.72-74 First order buckled modes have been produced under static and quasi-static compressive loads; while second order and high modes only occur during impact and/or dynamic loading experiments. Higher order buckled modes are associated with large potential energies and are a result of complex interactions between the mass, loading rate, and inertial effects of the spine.72-74

              Of primary importance, snap through buckling occurs 2-3 times faster than the cervical musculature can react.72-74 Thus, muscle spasms are the result, not the cause, of buckling (cervical kyphotic configurations).

              K) Neither Hohl67 or Norris and Watt68 noted any causal connection between altered lordosis and any factor

              This is outrageous! Regarding the Hohl67 study, see my statements under Item (I) and see Item (L) immediately below.

              Norris and Watt68 presented an initial and 2-year follow-up of 61 patients after a motor vehicle injury. They68 categorized subjects into WAD groups I-III. Statistically significant increases in abnormal cervical curvatures in the WAD groups II and III (more serious injury) compared to WAD I were found. They state, “Abnormal curves in the cervical spine, presumably reflecting spasm of the neck muscles, are more common in patients with a poor outcome.” (Page 611, 2nd column, 3rd paragraph).68 The muscle spasm issue has been discussed above in Item (J) and I would ask, “Do muscles spasm for 2-years?”

              Why are you falsifying statements regarding published studies in the literature? Your opinions regarding these studies’67,68 statistical results are contradicted by their data. This absolutely does not fly with me. You are intentionally misrepresenting scientific studies.

              L) According to Hohl,67 “A sharp reversal of the curve after injury, however, is a harbinger of degenerative changes in 60 percent of patients” whereas hypo-lordosis and straightened curves are considered normal

              While this statement made by Hohl67 is correctly summarized by Dr. McDaniel, it contradicts his own assertion in Item (K) above. Again, I refer the reader to Figure 1 for Hohl’s67 definition of ‘sharp reversal.’

In contrast, two recent MRI studies by Guiliano et al70,75 have found that hypolordosis of the cervical spine is statistically correlated to subacute (12 weeks at least) WAD compared to a matched control group. Table 3. I would like to note that Hohl67 did not provide numerical analysis of the subjects’ cervical lordosis making correlative comparisons impossible with a specific degree of lordosis. However, Guiliano et al70,75 did provide detailed measurement via MRI methodology. Furthermore, data from Marshall and Tuchin76 provides direct evidence that patients involved in an MVA have a 10° reduction in cervical lordosis compared to a control group

Therefore, taken as a whole, the literature on patient’s involved in an MVA and those with WAD indicates that hypolordosis,70,75 straightened cervical curves,68,77 and kyphotic67,68,77-79 curves are risk factors for and are in fact statistically correlated to several conditions including premature DJD, subacute WAD, neck pain, neurogenic thoracic outlet syndrome, WAD categories 2 and 3, and generalized poor long-term outcomes at 2-5 years.67,68,70,75,77-79

              In the last issue of AJCC,2 concerning neck pain and hypolordosis in non WAD injured subjects, I discussed two of our studies with extremely similar statistical findings in neck pain versus non-neck pain subjects.80,81 Specifically, chronic neck pain was statistically associated with lordosis of less than 20°,80,81 acute neck pain with lordosis less than 30°,80 cervical kyphosis and military necks were statistically associated with neck pain,81 and our cervical model was found to have discriminative validity with good sensitivity/specificity.80 I noticed you ignored this information. What’s your response to this work and will you accept it or discount it?

              M) Claiming after an accident restoration of the cervical lordosis can prevent DJD is no more supported by these studies than claiming that avoiding cervical collars will reduce DJD

              The available evidence from finite element models,59 analytical engineering stress/strain models,31-35,58,62 longitudinal surgical outcome studies on matched patients with and without abnormal curves and a variety of conditions,58,60-66 non-surgical longitudinal studies,67 and cross-sectional studies82-84 all indicate that straightened, S-curves, and kyphotic cervical curves predict and/or statistically correlate to the development and/or existence of DJD. In other words, a broad scope (not just one type of evidence) of research data points to the same result; that abnormal curves correlate to DJD.

              In surgical and non-surgical studies, the subjects with a good lordosis did not develop the same extent and type of DJD.58,60-66,67 This indicates that lordosis protects from increased stress concentrations leading to DJD. I would agree that future studies need to address specific issues (some of which you raise). However, DJD from abnormal curvatures is a manifestation of Stress Generated Potentials Wolff’s Law. It is a law, Dr. McDaniel, and it can’t simply be discarded in favor of your personal views. I provide the following review for clarity:

Recall buckling is a term describing abnormal sagittal curvatures. From Mechanical Engineering Texts85 and biomechanical studies on the spine,65 “Buckling is a term indicating concentrated mechanical stress to a certain portion of the material, resulting from abnormal alignment that brings with it a risk of degradation of materials...” and “ The alignment which causes the buckling is called buckling-type alignment.”65,85 It is important to note that buckling alignment can be a retrolisthesis, S-Curves, Kyphosis, etc...and exists when and where the slope of the curve (1st derivative) changes direction.58,65,85 Engineering studies on subjects both prior to and at long-term follow-up after surgery have conclusively demonstrated that degenerative changes (calcification of ligaments, disc degeneration, spondylosis), retrolisthesis, and disc herniations all occur at the location of the buckling alignment.58,61-65 These studies are positive proof that DJD occurs in abnormal curvatures due to abnormal slope (1st derivative), bending moment (2nd derivative), and shear (3rd derivative).

              Please offer me your critique of these mechanical engineering principles with direct in vivo validation. I expect more than your opinion, because you are not an engineer and not an expert in this field. I expect references showing me these analyses are wrong and that you can suspend Wolff’s law whenever you see fit.

              N) Both Gore and Shaikewitz’s3 work rather resoundingly concludes no causation between lack of lordosis and DJD

              Shaikewitz’s3 study is so poorly designed that no conclusions can be made regarding this study. See my response under Item (C) above.

              Gore’s86 study did not address the link between the cause of DJD and cervical lordosis. Here are some direct methods and result issues from Gore:86

              1)              Gore86 did not analyze segmental lordosis in his long-term follow up study. Without segmental analysis, no statistical determination of buckling alignment as it correlates to DJD can be performed. For proper understanding, in Figure 2, without segmental analysis, one might conclude that a 40° is normal and not related to DJD at C4-C5. However, the entire curve is comprised of the segmental angle at C4-C5 and this is a segmental instability with excessive hyper-extension not found by end point curve analysis.

              2)              Furthermore, Gore87 admitted, in response to our letter to the editor87 that segmental kyphosis was related to the DJD, however, his “opinion” was that DJD caused kyphosis. Again, the engineering studies on buckling with in vivo validation prove this to be incorrect.58,61-65

              3)              Gore found no change in cervical lordosis at long-term follow up but DJD worsened. If DJD causes loss of lordosis and segmental kyphosis as Dr. McDaniel and Gore87 assert, then the lordosis should have decreased at long-term follow-up.

              O) Dr. McDaniel believes that DJD and altered cervical lordosis are coincident with each other and related to age

              I do agree that the incidence and prevalence of DJD increases as we age. However, it is very strange that all vertebral joints in the same subject are the same age but that “age related” changes select which joints to affect. I further find it interesting that these age changes occur exactly at or immediately above/below the buckled alignment.58,61-65,67

              Come now, Dr. McDaniel, isn’t C5 the same age as C3? Your opinion regarding Stress Generated Potentials Wolff’s Law has no bearing on the facts. It’s a law not subject to opinion.

              P) None of the papers I referenced would be considered definitive proof between abnormal curvature and DJD especially the “theoretical models”

              In part, see my response under Item (M).

              All models have general limitations that include the assumptions used in the model, in vivo validation data, and error in approximation to name a few. However, when a model can predict outcomes for its intended application, then this model is valid for such purpose.

              For example, recently we have utilized a quadrilateral element model for upright static equilibrium in the sagittal plane to predict subject specific intervertebral disc loads and stresses, muscle loads, and spinal deformity progression.31-33 This model has been validated against known in vivo disc loads/stresses88 and creep related diurnal changes.89 Furthermore, another model we have utilized for stresses in the cervical vertebra in abnormal versus normal cervical lordosis has been shown to predict values in a similar range as the quadrilateral element model.34,35

              Unless you can provide exact data with references as to why and which “theoretical models” I’ve referenced are inaccurate, then you have no support for your opinion. These models have been validated for their intended purpose (predicting DJD in this case) and shown to predict the outcome with a good degree of accuracy.58,61-65 Your opinion on engineering and biomechanical models does not invalidate them.

              Q) Dr. McDaniel contends promoting that an ideal cervical lordosis can alter the course of DJD is both unproven and controversial

              See my response under Items (M) and (P).

              I do agree with Dr. McDaniel that a specific decrease (hypolordosis) in the amount of cervical lordosis has not been proven to lead to spinal DJD. However, as discussed above, there is definite evidence showing that buckled configurations (S-Curves, Kyphosis, etc...) lead to varying types of DJD at or immediately adjacent to the buckled region and that this is not age related. Therefore, it follows that having a lordosis protects from abnormal stress concentrations leading to tissue degeneration.

              It is alright to admit what has not been established, but it is not alright to ignore and/or use Class III evidence (opinion) to discount what has been established!

              R) Dr. McDaniel again wants my report of findings for a patient with neck pain and a straightened cervical curve and justification of “CBP® consisting of up to 56 visits”

              I already answered this last time.2 However, I will repeat. First, where did you get the number 56 visits from? Our recommended program consists of an initial 36 visit treatment plan of 9-12 weeks (see protocol of care on www.idealspine.com).17-21

              I would inform her that a straightened cervical lordosis is statistically correlated to neck pain,80,81 propensity for early or progression of DJD,34,35,58-67 and increased probability of more severe injury should she be involved in a whiplash injury36 or sustain head trauma.37 I would offer her three treatment options:

              1)              No treatment,

              2)              Possible relief for her neck pain solely using SMT, myofascial, pnf stretching, ice/heat as needed. However, according to Table 1, this would not improve her beyond 48% on average and she would not be at MMI. This would consist of 12 visits over 3 weeks with an ending re-examine, pain, disability, and health scales.

              3)              12 visits of Relief care combined with CBP® structural rehab care designed to improve the cervical lordosis to within evidence based values (30°-40°).80,81 This would include a re-exam after 12 visits and then implementation of 24 visits of CBP® care over 6 weeks added to the previous 12 visits for a total of 36 visits.

              The recommendation in #3 above is clinical implementation of the best available evidence on spinal treatment using CBP® Technique.17-21,80,81 And there is good evidence that this is superior to standard care for several chronic conditions.44-50

              S) Dr. McDaniel believes that CBP® is practice management based on our hotline and my endorsement of Total Practice Management International (TPMI)

              The CBP® hotline is not a “practice management forum.” Our hotline is answered by Dr. Pete Lope (a long-time CBP® instructor and clinician) and is for the sole purpose of advice for the management of difficult patient cases using CBP® treatment methods. Many doctors, especially new ones to CBP®, find this to be a great asset with understanding technique applications.

              We (CBP®) advocate that a doctor consider utilizing practice management organizations. One such organization is Total Practice Management International or TPMI. Practice management groups differ in philosophy, procedures, etc... and it is up to the doctor to seek out (if desired) the organization that fits their personal needs. Many doctors, including myself, have found TPMI to be invaluable for many facets of streamlining and running a successful business. Perhaps you should consider using them too!

              T) Dr. McDaniel wants to know if I think chiropractic “needs report of findings police”?

              I personally believe that the treating doctor is capable of looking at a patient’s presenting condition, exam findings, and personal goals and is competent enough to make a rational, logical treatment recommendation based on the “best” evidence and the needs/goals of the patient.

Conclusions

              Dr. McDaniel’s arguments fall short again due to the fact that he based his critiques on an incomplete/selective literature review, an inappropriate representation of studies in the literature due to forming an opinion about them when their data proves otherwise, an insufficient understanding of spinal biomechanics, his reliance on pain as the only outcome of patient care, and his failure to look into all categories of CBP® publications. Lastly, I note that this time Dr. McDaniel tried to focus primarily on DJD to invalidate spinal corrective work while ignoring the volume of other information.2

              Round 2: Need readers to judge the outcome. Care for Round 3 Dr. McDaniel?

References

              1. Bendick J, Levin M, Simon L. Mathematics illustrated dictionary. New York: McGraw-Hill, 1965; page 80-81.

              2. Harrison DE. Counter-point article-A Selective Literature Review, Misrepresentation of Studies, & Side Stepping Spine Biomechanics Lead to an Inappropriate Characterization of CBP Technique. AJCC January 2005.

              3. Shaikewitz M, A Demographic and Physical Characterization of Cervical Spine Curvature and Degeneration. JVSR 1(2): 41-48.

              4. Hinkle DE, Wiersma W, Jurs SG. Applied Statistics for the Behavioural Sciences. Chicago: Rand McNally College, 1979.

              5. Dreyfuss P, Michaelsen M, Pauza K, mcLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996;21:2594-2602.

              6. Research Agenda Conference 2004 March, Las Vegas NV. Question and answers session following the presentation: Harrison DE, Cailliet R, Betz JW, Harrison DD, Haas JW, Janik TJ, Holland B. Harrison Mirror Image Methods for Correcting Trunk List: A Non-randomized Clinical Control Trial. Eur Spine J 2004; In Press.

              7. Harrison DE, Harrison DD, Betz J, Janik T, Holland B, Colloca C, Haas J. Increasing the Cervical Lordosis with Chiropractic Biophysics Seated Combined Extension-Compression and Transverse Load Cervical Traction with Cervical Manipulation: Nonrandomized Clinical Control Trial. JMPT 2003; 26(3):139-151.

              8. McDaniel, J, An Opinion of the Shortcomings of CBP Technique Research and Practice Protocols, AJCC, vol. 15(1), Jan. 2005, pg. 22.

              9. Stein F. Anatomy of Research in Allied Health. New York: John Wiley & Sons. 1976, pg 45.

              10. Bronfort G, Evans R, Nelson B, Aker P, Goldsmith C, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001; 26:788-99.

              11. Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physical therapy, or manipulation for patients with chronic neck pain. A prospective single-blinded randomized clinical trial. Spine 1998; 23:311-19.

              12. Giles LGF, Muller R. Chronic spinal pain syndromes : a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J Manipulative Physiol Ther 1999; 22:376-81.

              13. Hurwitz EL, Morgenstern H, Harper P, et al. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study. Spine 2002; 27:2193-204.

              14. Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis of Chiropractic and physiotherapy treatment for low back and neck pain. Six-months follow-up. Spine 1997; 22:2167-77.

              15. Haas M, Groupp E, Aicki M, Fairweather A, Ganger B, Attwood M. J Manipulative Physiol Ther 2004;27:547-553.

              16. Leboeuf-Yde C, Gronstvedt A, Borge JA, Lothe J, Magnesen E, Nilsson O, Rosok G, Stig LC, Larsen K. The Nordic back pain subpopulation program: A 1-year prospective multicenter study of outcomes of persistent low-back pain in chiropractic patients. J Manipulative Physiol Ther 2005; 28(2):90-96.

              17. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: A nonrandomized clinical controlled trial.  Arch Phys Med Rehab 2002;83:447-453.

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