SYSTEMATIC REVIEW. Restoration of Pediatric Cervical Lordosis: A Review of the Efficacy of Chiropractic Techniques and their Methods

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1 SYSTEMATIC REVIEW Restoration of Pediatric Cervical Lordosis: A Review of the Efficacy of Chiropractic Techniques and their Methods Paul Oakley, DC, MSc 1 & Deed Harrison, DC 2 Abstract Background: The cervical lordosis is a normal postural development that occurs as early as weeks in utero. We reviewed the existing literature for any and all peer reviewed evidence of any chiropractic technique system that has documented an improvement of cervical lordosis in pediatric patients (age <18 years). Methods: A systematic review of peer reviewed clinical studies was performed in Index Medicus and the Index to Chiropractic Literature databases using relevant keywords related to correcting cervical lordosis. All retrieved references were reviewed for their references, and relevant articles were retrieved. Self published technique manuals were not included. Only articles featuring pediatric patients (age <18 years) were included in this review. Results: Listed in descending order of quantity, Chiropractic Biophysics (CBP, 5), Gonstead (2), Toggle (2), Atlas Orthogonal (AO, 1), and Pettibon (1) were the technique papers located. There was only one level I evidence paper by AO. Discussion: Of the 11 cases included for review, only 7 reported an x ray measurement documenting the increase in cervical curve resulting from treatment, the other 4 papers merely commented on a post treatment improvement in lordosis. Only 5 studies used a reliable measurement method; that being the Harrison posterior tangent method. These 5 studies were all CBP cases. Conclusion: Although the amount of evidence is small, for pediatric patients, there appears to be reliability in extension-traction procedures for increasing lordosis, as well as promise in upper cervical treatments to have effect on lordosis due to AARF. Keywords: Cervical lordosis, subluxation, chiropractic techniques, restoration, correction Introduction The cervical lordosis is a normal postural development that occurs as early as weeks in utero. 1,2 It s lordotic nature is an element required for functional integrity including the allowance of normal flexibility, as well as to protect the neural structures housed within Private Practice of Chiropractic, Newmarket, ON, Canada 2. Private Practice of Chiropractic & President - Chiropractic Biophysics Nonprofit, Inc., Eagle, ID The loss of normal cervical curve has been found to relate to pain and disability. 3-5 There have been many cases of therapeutic restoration of the cervical lordosis in the successful treatment of head and neck related disorders in the chiropractic literature, albeit the majority being adult cases. 6 Regardless of practice type, the chiropractor may be presented with a pediatric case involving cervical and/or cephalgic Restoration of Pediatric Cervical Lordosis J. Pediatric, Maternal & Family Health - September 21,

2 symptoms that correlate with poor postural alignment of the cervical spine and related structures. The purpose of this paper is to review the existing literature for any and all peer-reviewed evidence of any chiropractic technique system that has documented an improvement of cervical lordosis in pediatric patients (age <18 years). Methods A systematic review of peer-reviewed clinical studies was performed in Index Medicus and the Index to Chiropractic Literature databases. Keywords used included: cervical lordosis, neck curve, forward head posture, cervical kyphosis, and cervical spine, as well these words were tagged with: improvement, correction, reduction, restoration, or increasing. All studies were reviewed for their references, and relevant articles were retrieved. Selfpublished technique manuals were not included. Only articles featuring pediatric patients (age <18 years) were included in this review. Results We were able to locate 11 studies documenting improvement in cervical lordosis in pediatric patients (Table 1). Listed in descending order of quantity, Chiropractic Biophysics (CBP, 5), 7-11 Gonstead (2), 12,13 Toggle (2), 14,15 Atlas Orthogonal (AO, 1), 16 and Pettibon (1) 17 were the technique papers located. There was only one level I evidence paper by AO, 16 a randomized trial comparing AO upper cervical care to full spine treatment. All others were level IV evidence case reports. 7-15,17 Of the eleven studies located here, 4/11 did not provide any post-measurement; improvement in lordosis had to be verified by either pre-post x-ray photos or comments in the manuscript. Of the 7/11 that did provide post-measurements, two (Cassista 17 Dobson 14 ) provided measurement from use of the AcuArc ruler, 18 that to our knowledge has no established reliability. The other 5/7 cases (Bastecki; 7 Fedorchuk; 8 Fedorchuk; 9 Oakley; 10 Fedorchuk 11 ) provided postmeasurements, all CBP cases, utlized the reliable Harrison posterior tangent method. 19 Discussion There were eleven total papers located documenting an improvement in cervical lordosis in pediatric patients Five different techniques were employed; namely, CBP, 7-11 Gonstead, 12,13 Toggle, 14,15 AO, 16 and Pettibon 17 (Table 1). In all, the total treatments ranged from 1 to 72, and the duration of treatments ranged from one visit to three years. Clinical trials evaluating the efficacy of manual adjusting techniques alone on the restoration of cervical lordosis have routinely shown not to be effective that is, the cervical spine alignment does not significantly change. Oakley and Harrison (2015) 6 however, have recently noted that in adults, there are a number of reports, of varying techniques, documenting improvement in cervical lordosis. Most of these reports, however, document procedures taken beyond just a manual/mechanical adjustment that might be expected to 113 J. Pediatric, Maternal & Family Health - September 21, 2015 increase cervical lordosis, such as extension traction, cervical pillows, and/or extension/retraction corrective neck exercises. In the 11 studies located for this review, we found a similar trend. For the 7 cases that had a post-measurement, all the CBP cases (5/7) 7-11 used neck extension traction methods as well as extension/retraction neck exercises. In Cassista s Pettibon case, 17 although using the AcuArc ruler, a small increase in lordosis is visually seen on comparison of the prepost x-rays although the forward head posture remained. A Thompson drop on the lower cervicals was done as well as the Pettibon -z adjusting instrument for the occiput. Although Cassista comments: the anterior head translation had almost completely normalized, upon visual inspection, this is not the case. 17 Dobson s Toggle case however, only provided upper cervical Toggle adjustments, but for a primary complaint of poor posture. 14 For the 4 cases not having post-mensuration, Cassista s 17 comments on the reduction of forward head posture - that did not occur - exemplifies the inability to accurately quantify by visual inspection an accurate reflection of the cervical lordosis and forward head position. It has been proven that without measurement it can be inaccurate to visually objectify a curve of the spine. 24,25 In fact, Oakley et al. 26 recently provided evidence that even trained medical radiologists have a complete inability to qualitatively, accurately describe alignment features of the lateral cervical x-ray as compared to them being measured. Thus, to consider the 4/11 cases that merely state an increased lordosis etc. as an accurate reflection of actual re-alignment of the cervical spine would be tenuous. Perhaps the only reliable visual description could come from a dramatic change as in pre-treatment kyphosis to a post-treatment lordosis as in the case by Kessinger. 15 This Toggle case provided classic Toggle upper cervical adjustments but also required the patient to lay supine on a cervical support for 60 minutes at a time, a procedure proven to increase lordosis. The largest issue with restoring a pediatric cervical lordosis is with the presumed magnitude of normalcy. Although the cervical spine in adults has been well studied and modeled (Harrison 1996, Harrison 2004, McAviney 2005), 3-5 the pediatric spine has not been. Bagnall et al. 2 demonstrated the cervical lordosis is present in 83% of fetuses and illustrates a fetus having a clearly established lordosis at 9.5 weeks in utero. Data from Kasai et al. 27 indicates the lordosis is most prominent in ages 2-4, where it decreases steadily from ages 4-9, then steadily increases up to age 18 approaching normal adult lordosis. The adult cervical lordosis has been determined to be normal in the range of 31 through to 42, the upper end being the CBP ideal or essentially the gold standard. 3,4 Re-analyzing the data from Kasai et al., 27 Harrison et al. 28 presented a table of normal Cobb and ARA values for pediatrics aged 2-18 years. Oakley 29 adapted this table to compare normative values for pediatrics in order to numerically illustrate the potential issue of over-correction in pediatrics when application of the adult normal cervical lordosis is inadvertently applied to the pediatric patient in practice (Table 2). Restoration of Pediatric Cervical Lordosis

3 When we evaluate the ending lordosis angles achieved in the sample of 4 cases (only 46% of studies used reliable measurement of lordosis improvement), we can see that overcorrection has occurred in 4/5 cases that presented the posterior tangent measurement. If we include Cassista s case, using the AcuArc ruler in the Pettibon case it was reported as fully restoring lordosis to +17 which is equal to a 60 lordosis by the ARA method and it would mean 5/6 cases of over-correction. To note, a 60 lordosis was the presumed normal cervical lordosis adopted by Pettibon in the 1970s, as was also believed and taught by Don Harrison in the 1980s, until his own research had proved otherwise. 3 A 60 lordosis in a pediatric patient would be a gross over-correction. The only case presenting an ending lordosis improved to a more ideal pediatric lordosis is the case by Oakley et al. (2011). 10 The actual lordosis decreased with treatment, as the neck curve was initially a double harmonic (buckled with a high kyphosis; low lordosis) and corrected to a single harmonic (overall lordosis). Oakley, in a letter to the editor regarding one of these cases (Fedorchuk et al. 2009) 8 has previously questioned What are the implications involved with over-correcting the cervical lordosis in a pediatric patient? 29 While currently this is unknown, certainly, in the correction of pediatric cervical lordosis, the treating doctor must consider age-specific normality which is not as large as an adult lordosis. Although there are several clinical trials documenting routine correction to the cervical spine in adults (receiving extension cervical traction with or without manipulation and corrective exercise), 21,30-33 there is only one in the pediatric literature. The trial by Khorshid et al. (2006) 16 comparing AO upper cervical adjustments to full spine adjusting in Autistic patients demonstrated, by radiographs (no quantification), that AO adjustments increased the lordosis after a single adjustment. Because this is a clinical trial as opposed to merely a case report it obviously holds more supportive evidence. There were however, only 7 children in the AO treated group, but these were randomly assigned. The fact that the postradiograph was taken immediately after the adjustment may have important implications as immediate after-effects in cervical spine structure may not be representative of the longterm after-effects, or true stability and alignment of the neck. Also, it may be that a pediatric spine may be more amenable to structural change vs. an adult spine to the direct forces of manipulation. To our knowledge, no pre-post manipulation trials evaluating structural changes have been done on pediatrics other than this trial; all the trials showing no structural changes resulting from manipulative procedures were done on adults Another plausible explanation of immediate lateral curve changes after single treatments may result as secondary due to the correction of anterior-posterior viewed atlanto-axial rotatory fixation (AARF) subluxations. These are frequent in pediatrics due to birth and other traumas, and may cause gross visual asymmetrical head and neck positions concomitant with neurological dysfunction. 34 It has been noted in these type of pediatric subluxated patients that symptoms may resolve greatly, even after a single treatment. 35 The sagittal plane alignment and forward head posture in these cases may be altered because of direct three-dimensional compensation for the AARF. Limitations to this review come from the obvious lack of total studies included (n=11). Future recommendations for chiropractors are to include use of reliable radiographic measurements, such as the Cobb or posterior tangent methods, and to provide better detailed documentation of all procedures performed on pediatric patients. Conclusion Although the amount of evidence is small, for pediatric patients, there appears to be reliability in extension-traction procedures for increasing lordosis, as well as promise in upper cervical treatments to have effect on lordosis in those with AARF. References 1. Gray s Anatomy (eds.) Bagnall KM, Harris PF, Jones PR. A radiographic study of the human fetal spine. I. The development of the secondary cervical curvature. J Anat 1977 Jul;123(Pt 3): Harrison DD, Janik TJ, Troyanovich SJ, et al. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996; 21: Harrison DD, Harrison DE, Janik TJ, et al. Modeling of the sagittal cervical spine as a method to discriminate hypo-lordosis: results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects. Spine 2004; 29(22): McAviney J, Schultz D, Bock R, et al. Determining the relationship between cervical lordosis and neck complaints. J Manipulative Physiol Ther 2005; 28(3): Oakley PA, Harrison DE. Efficacy of chiropractic techniques to improve cervical lordosis: a systematic review of all evidence and clinical commentary. Proceedings of WFCs 13 th biennial congress/ecu annual convention. Athens, Greece May 13-16, 2015;p Bastecki AV, Harrison DE, Hass JW. Cervical kyphosis is a possible link to attention-deficit/hyperactivity disorder. J Manipulative Physiol Ther 2004;27:e Fedorchuk C, Wheeler G. Resolution of headaches in a 13-year old following restoration of cervical curvature utilizing chiropractic Biophysics: a case report. J Pediatr Matern & Fam Health - Chiropr 2009(4):Online access only 7p. 9. Fedorchuk C, Opitz K. Improvement in quality of life and improved cervical curve in an 11-year old child with asthma following chiropractic intervention: A case study. J Pediatr Matern & Fam Health - Chiropr 2014(2):Online access only p Oakley PA, Chaney SJ, Chaney TA, Maddox A. Resolution of chronic headaches following reduction of vertebral subluxation in an 8 year old utilizing chiropractic biophysics technique. J Pediatr Matern & Fam Health - Chiropr 2011(3):Online access only p Restoration of Pediatric Cervical Lordosis J. Pediatric, Maternal & Family Health - September 21,

4 11. Fedorchuk C, Cohen A. Resolution of Chronic Otitis Media, Neck Pain, Headaches & Sinus Infection in a Child Following an Increase in Cervical Curvature & Reduction of Vertebral Subluxation. J. Pediatric, Maternal & Family Health - June 17, Alcantara J, Plaugher G, Araghi J. Chiropractic care of a pediatric patient with myasthenia gravis. J Manipulative Physiol Ther 2003;26: Araghi HJ. Post-traumatic evaluation and treatment of the pediatric patient with head injury: a case report. ICA Rev: Jan/Feb 1995(51:1): Dobson GJ. Structural changes in the cervical spine following spinal adjustments in a patient with Os Odontoideum: A case report. JVSR Aug 1996;1(1): Kessinger RC, Boneva DV. Case study: Acceleration/deceleration injury with angular kyphosis. J Manipulative Physiol Ther 2000;23: Khorshid KA, Sweat RW, Zemba DA, Zemba BN. Clinical efficacy of upper cervical versus full spine chiropractic care on children with Autism: A randomized clinical trial. JVSR Mar 9 th, 2006, 7p. 17. Cassista, G. Improvement in a child with attention deficit hyperactivity disorder, kyphotic cervical curve and vertebral subluxation undergoing chiropractic care. JVSR Apr 20 th, 2009, 5p. 18. Pierce WV. Results. Xcellent Xray Company, Dravosburg (The AcuArc rular is a functional rular measuring from +17cm (60 lordosis) to -17cm (60 kyphosis). 19. Harrison DE, Harrison DD, Cailliet R et al. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine 2002;25: Plaugher G, Cremata EE, Phillips RB. A retrospective case analysis of pretreatment and comparative static radiological parameters following chiropractic adjustments. JMPT 1990;13: Harrison DD, Jackson BL, Troyanovich SJ 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. JMPT 1994;17: Pedersen PL. A prospective pilot study of the shape of cervical hypolordosis. Eur J Chiropr 1990;38: Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine 1996;21: Tuck AM, Peterson CK. Accuracy and reliability of chiropractors and Anglo-European college of chiropractic students at visually estimating the lumbar lordosis from radiographs. Chiro Tech 1998;10: Frymoyer JW, Phillips RB, Newberg AH, MacPherson BV. A comparative analysis of the interpretations of lumbar spinal radiographs by chiropractors and medical doctors. Spine 1986;11: Oakley P, Sanchez L, Kim G, Harrison D. A comparison of subjective qualitative assessment of cervical spine alignment vs. objective quantification mensuration: How do medical radiologists fare? Proceedings of WFCs 13 th biennial congress/ecu annual convention. Athens, Greece May 13-16, 2015;p Kasai T, Ikata T, Katoh S, et al. Growth of the cervical spine with special reference to its lordosis and mobility. Spine 1996; 21(18): J. Pediatric, Maternal & Family Health - September 21, Harrison DE, Harrison DD, Haas JW. CBP structural rehabilitation of the cervical spine. Harrison CBP Seminars, Evanston, WY Oakley PA. Letter to the Editor: [Fedorchuk C., Wheeler G. Resolution of headaches in a 13 year-old following restoration of cervical curvature utilizing chiropractic biophysics: A case report. J Pediatr Matern & Fam Health - Chiropr: Fall 2009(2009:4): Online access 7 p.] J Pediatr Matern & Fam Health - Chiropr: Summer 2010(2010:3): Online access 2 p. 30. Harrison DE, Cailliet R, Harrison DD, et al. A New 3- Point Bending Conservative Method of Restoring Cervical Lordosis: Non-randomized clinical control trial. Arch Phys Med Rehab 2002; 83(4): Harrison DE, Harrison DD, Betz J, et al. Increasing the cervical lordosis with seated combined extensioncompression and transverse load cervical traction with cervical manipulation: Nonrandomized clinical control trial. J Manipulative Physiol Ther 2003;26: Moustafa I, Mohamed A, Harrison D. The efficacy of cervical lordosis rehabilitation for nerve root function, pain, and segmental motion in cervical spondylotic radiculopathy. Proceedings of WFCs 13 th biennial congress/ecu annual convention. Athens, Greece May 13-16, 2015;p Moustafa I, Mohamed A, Harrison D. Does improvement towards a normal cervical sagittal configuration aid in the management of lumbosacral radiculopathy: A randomized controlled trial. Proceedings of WFCs 13 th biennial congress/ecu annual convention. Athens, Greece May 13-16, 2015;p Roche CJ1, O Malley M, Dorgan JC, Carty HM. A pictorial review of atlanto-axial rotatory fixation: key points for the radiologist. Clin Radiol Dec;56(12): Biedermann H. Kinematic imbalances due to suboccipital strain in newborns. J Manual Med 1992;6: Hardacker JW, Shuford RF, Capicotto PN, Pryor PW. Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms. Spine. 1997; 22(13): Restoration of Pediatric Cervical Lordosis

5 Table 1. Pediatric studies documenting increase of lordosis by Technique, Author, Year, Age, and Primary Condition Technique Author, year Age Primary Condition CBP Bastecki, ADHD CBP Fedorchuk, Headaches CBP Fedorchuk, Otitis Media CBP Fedorchuk, Asthma CBP Oakley, Headaches Gonstead Alcantara, Myasthenia Gravis Gonstead Araghi, Head injury Toggle Dobson, Posture/Asthma Toggle Kessinger, Whiplash AO Khorshid, 2006 (4-16) Autism Pettibon Cassista, ADHD Table 2. Pediatric global lordosis angles () for ages 2-18 years (Kasai et al. 27 ) as compared to adult and ideal values 3,28 (in degrees). Adapted from Oakley. 29 Age C3-7 Cobb(SD) (Kasai 27 ) estimated Cobb (add 2.6 )* ARA equivalent (add 9 )** Adult ARA(SD) (Harrison 3 / Harrison 28 ) Adult Cobb** Adult ideal ARA 3 Adult ideal Cobb ** Difference between ARA ideal (42.2 ) and normal*** (3.3) (9.2)/-35.7(9.7) -25.1/ (2.8) (9.2)/-35.7(9.7) -25.1/ (3.2) (9.2)/-35.7(9.7) -25.1/ (4.0) (9.2)/-35.7(9.7) -25.1/ (3.8) (9.2)/-35.7(9.7) -25.1/ (5.0) (9.2)/-35.7(9.7) -25.1/ (5.3) (9.2)/-35.7(9.7) -25.1/ (5.5) (9.2)/-35.7(9.7) -25.1/ (6.7) (9.2)/-35.7(9.7) -25.1/ (5.9) (9.2)/-35.7(9.7) -25.1/ (5.5) (9.2)/-35.7(9.7) -25.1/ (4.6) (9.2)/-35.7(9.7) -25.1/ (5.2) (9.2)/-35.7(9.7) -25.1/ (6.1) (9.2)/-35.7(9.7) -25.1/ (5.1) (9.2)/-35.7(9.7) -25.1/ (7.7) (9.2)/-35.7(9.7) -25.1/ (5.6) (9.2)/-35.7(9.7) -25.1/ Note: Negative (-) represents extension; SD, Standard Deviation; ARA, Absolute Rotation Angle. *To convert Kasai et al. 27 C3-7 Cobb angles to Cobb angles add 2.6 (Hardacker et al. 36 ). **To convert Cobb to/from Absolute Rotation Angles (ARA) add/subtract 9, respectively (Harrison et al. 28 ). ***Example, in a 9-year old, 42.2 ideal ARA 21.1 pediatric normal lordosis = 21.1 difference. The CBP adult ideal is actually twice the magnitude of the actual appropriate angle for a 9-year old. Restoration of Pediatric Cervical Lordosis J. Pediatric, Maternal & Family Health - September 21,

CASE STUDY. Resolution of Chronic Headaches Following Reduction of Vertebral Subluxation in an 8-Year-Old Utilizing Chiropractic Biophysics Technique

CASE STUDY. Resolution of Chronic Headaches Following Reduction of Vertebral Subluxation in an 8-Year-Old Utilizing Chiropractic Biophysics Technique CASE STUDY Resolution of Chronic Following Reduction of Vertebral Subluxation in an 8-Year-Old Utilizing Chiropractic Biophysics Technique Paul A Oakley DC, MSC 1, Stephanie J Chaney DC 2, Tom A Chaney