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Month 2005, Vol. 15, No. 1
Table of Contents
ACA's New CCGPP Guidelines • An Opinion of Shortcomings of CBP® • ASHN: Chiropractic Enemy • CBP® fosters international Research Collaboration • CBP® Research Corner • Contraction/Expansion Mentally • COX Inhibitors and the FDA • Counter Point • Do You Practice CBP®? • Don's Opinion • European Spine Accepts CBP® Clinical Control Trial • Regarding the Use of Body Weighting • SAC Reaffirms Life University's Accreditation • Spine Accepts CBP® Research • The Diminishing Return Triangle • Traction Details • Validity of PosturePrint™
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An Opinion of Shortcomings of CBP® Technique, Research and Practice Protocols
by John McDaniel, DC, DACBSP
Dr. John McDaniel received his DC degree in 1986 from Palmer College of Chiropractic-West. He studied CBP® at that time receiving instruction in the early stages of this technique from Don Harrison, DC in Sunnyvale, CA. After graduation, he followed CBP® protocols for a couple of years but discontinued using them. Since then, Dr. McDaniel has pursued teaching undergrad and continuing ed at Palmer-West, published some literature reviews and case studies, obtained his Diplomat from the American Chiropractic Board of Sports Physicians, served on committees for the CCA and the ACBSP, is the current president of the ACBSP, and maintained a private practice in Mountain View, CA. He has continued to follow the progress of chiropractic research in general and CBP® in particular.
First, let me congratulate the CBP® group on a coherent and expansive research program. Chiropractic in general and techniques in particular are often found wanting for more research to support their claims. Adding to the research pool is important. However, equally important is paying attention to the research we already have. More important is what we are demanding of our patients.
I understand that CBP® has been following a research protocol similar to this1:
1. Find the ideal curves in a spine
2. Show that the characteristics of an ideal spine can be reliably measured.
3. Show that a human spine can be made to be ideal.
4. Show that creating an ideal spine helps humans.
From a review of the literature published by CBP®, it would appear that at least two and possibly three steps have been completed. I do notice that you have begun to note pain scales and pre-post treatment outcomes in some of your more recent works.4,12 Plus, a recent single case study addressed ADHD2 which addresses part 4. I assume more will be forthcoming. I have read many of your papers and it would seem that you rigorously follow research protocols including informed consent for research subjects. I note that in a recent paper utilizing both treatment and control groups it was noted that, “Subjects gave informed consent.”4 Can I assume that this was informed consent to be a subject of biomedical research?
A large part of the protocol of CBP® seems to be restructuring a cervical curve to a mathematical normal.3 One contention which I consistently hear and read is that such a mathematically normal spine will have a reduced rate and quantity of degeneration and reduced pain. A recent article authored by yourself noted, “...the configuration of the sagittal cervical curve has been shown to be an important clinical outcome of health care, especially in cervical postsurgical outcomes.”4 This is a two part statement. One, the configuration has been shown to be an important clinical outcome of health care, and, two, especially in postsurgical outcomes. These are two very different statements rolled into one sentence. They deserve separate citations. But, the only citations for this claim were three studies performed using post-surgical fusion patients suffering from either severe degenerative joint disease or rheumatoid arthritis.5-7 These are hardly the typical patient subjected to curve restructuring. These citations also do not support the first half of that statement. Can you provide citations in support of the first half of that statement?
There are three studies which may provide a refutation of the first half of that statement. These studies do examine a more normal population with an eye toward evaluation of the effect of curve on degeneration. In 1986, Donald Gore, MD published an examination of 200 asymptomatic people. He concluded, “..kyphotic deformities were relatively equally distributed to all age groups and did not relate to degenerative changes,” and, “...kyphotic deformities are probably normal variations.”8
In 1987, Donald Gore, MD published the ten year follow up to this report noting, “The presence or severity of pain was not related to the presence of degenerative changes, the sagittal diameter of the spinal canal, the degree of cervical lordosis.......”9
In 1996, Micheal Shaikewitz, DC examined 188 volunteers for a relationship between cervical sagittal curvature and degeneration. He concluded, “Cervical spinal curvature is not related to phase of cervical spine degeneration. Consequently, cervical spinal curvature may reflect a biomechanical adaptive phenomenon linked to age, gender and other variables, but not necessarily a predisposing factor of cervical spine degeneration.”10
Even some of your own works note a lack of pain with variations in cervical curve. Cooperstein writes, “In their definitive 1996 Spine article, Harrison et al found that their geometric spinal model pretty much predicted the average cervical spine among 400 subjects. Moreover, there was virtually no difference between the lordotic angles found among all 400 subjects, and a subset of 252 subjects without cervicocranial symptoms: each group had lordotic cervical angles of about 34 degrees, with a standard deviation of about 9 degrees.”12
Even an analysis of an injured population failed to confirm that a kyphosis is associated with a poor clinical outcome. In 1983 Norris’ evaluation of 61 whiplash patients concluded, “Factors which adversely affect prognosis include the presence of objective neurological signs, stiffness of the neck, muscle spasm and pre-existing degenerative spondylosis.”11
The ability of a mathematically ideal cervical curve to resist degeneration and pain is, at the very least, controversial. At worst, it is a hypothesis which lacks support and may even be refuted by current evidence. Further, although some studies have shown pre-post improvements in pain, none have really demonstrated that this change is superior to that achieved with simple adjusting or standard exercises. These ideas can be discussed at length in the literature and may eventually be resolved with research. My concern is of a more practical and immediate nature. What do you tell your patients?
Given the idea that showing benefit for humans is part 4 of CBP®’s research protocol and has not been achieved, that CBP® prides itself on proper experimental protocols, that no studies have shown benefit above simple adjusting, that similar pain control can be achieved in far fewer visits at far less cost and given the controversial nature of the claims for long term degeneration resistance, what do you tell your patients?
Let’s assume that a 45 year old female of average weight were to present with neck pain. Let’s further assume the x-rays showed a straightened neck. What would be your complete report of findings? What would you tell her? Please provide us with an example of your report.
I look forward to your reply.
1) Personal communication Stephen Perle, DC recollections of ACC/RAC 2002.
2) Bastecki A, Harrison D, Haas J; Cervical Kyphosis is a Possible Link to Attention-Deficit/Hyperactivity Disorder. JMPT Oct. 2004; 27(8) 525 & online.
3) Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996;21:667-675.
4) Harrison D, Harrison D, Betz J, Tadeusz J, 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.
5) Katsuura A, Hukuda S, Imanaka T, et al. Anterior cervical plate used in degenerative disease can maintain cervical lordosis. J Spinal Disord 1996; 9:470-6.
6) Kawakami M, Tamaki T, Yoshida M, et al. Axial symptoms and cervical
alignments after cervical anterior spinal fusion for patients with cervical myelopathy. J Spinal Disord 1999; 12: 50-6.
7) Matsunaga S, Sakou T, Sunahara N, et al. Biomechanical analysis of buckling alignment of the cervical spine: predictive value for subaxial subluxation after occipitocervical fusion. Spine 1997; 22: 765-71.
8) Gore D, Sepic S, Gardner G. Roentgenographic Findings of the Cervical Spine in Asymptomatic People. Spine 1986, 11(6); 521-524.
9) Gore D, Sepic S, Gardner G, Murray M. Neck Pain: A Long-term Follow-up of 205 Patients. Spine 1987, 12(1) 1-5
10) Shaikewitz M, A Demographic and Physical Characterization of Cervical Spine Curvature and Degeneration. JVSR [Vol. 1, No. 2, p. 1-8]
11) Norris SH, Watt I, The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg Br. 1983 Nov;65(5):608-11
12) Personal communication Robert Cooperstein, DC and excerpts from, “Technique Systems in Chiropractic”
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