Reduction of thoraco-lumbar kyphosis results in the alleviation of low back pain in an adolescent basketball player: a Chiropractic Biophysics^® (CBP^®) case report

Abstract

[Purpose] To present the case of a significant reduction in thoraco-lumbar deformity and alleviation of chronic low back pain in an otherwise healthy and active adolescent male basketball player. [Participant and Methods] A 17 year old was assessed with chronic low back pain persisting for 4 years. Radiographic assessment revealed a prominent thoraco-lumbar kyphosis. Chiropractic Biophysics^® structural rehabilitation including mirror image^® exercise and traction methods as well as spinal manipulative therapy was performed 2–3 times per week. [Results] There was a 12° improvement in the thoraco-lumbar deformity corresponding with the alleviation of chronic low back pains and near complete reduction in disability after 36 treatments over a 4-month period. [Conclusion] This case adds to the growing literature showing the efficacy of the non-surgical spinal rehabilitative methods of Chiropractic Biophysics in improving spine alignment and relieving spinal pain syndromes. This case also demonstrates the importance of the routine screening for spine alignment via radiography in leading to proper biomechanical diagnosis and treatment.

INTRODUCTION

Thoraco-lumbar kyphosis is the exaggerated kyphotic deformity of the thoraco-lumbar junction. It is usually associated with low back pain, and in older ages can be associated with significant osteoarthritic changes. Treatment of thoraco-lumbar kyphosis has traditionally been aimed at the reduction of symptoms via non-surgical approaches, and surgical reduction in severe cases¹⁾.

Recent advancements in non-surgical spine altering methods includes Chiropractic Biophysics^® (CBP^®) technique methods^2,3,4,5). This technique was developed in the 1980s and has since established itself as a leading method for altering/improving spine and posture alignment in the manual therapies. Several reviews have summarized the evidence of clinical trials and case studies spanning over 25 years showing the efficacy of CBP methods of, for example, increasing cervical lordosis^6,7,8), increasing lumbar lordosis^{9, 10)} reducing thoracic kyphosis¹¹⁾, as well as reducing lateral head¹²⁾ and lateral thoracic¹³⁾ translations. Other spinal deformities, however, have also been shown to be improved including the reduction of thoraco-lumbar kyphosis¹⁴⁾.

In the non-surgical treatment of thoraco-lumbar kyphosis, there has only been one case demonstrating its reduction by CBP methods¹⁴⁾. Gubbels et al.¹⁴⁾ showed a 22° reduction in a thoraco-lumbar deformity (T10–L3) in a 16 year old female after 24 treatments over an 8-week period. The structural realignment corresponded with the reduction of back pains associated with standing for prolonged periods and the alleviation of pain during sleep. The purpose of this case is to illustrate the significant reduction in thoraco-lumbar deformity and the alleviation of chronic low back pain (LBP) in an otherwise, healthy and active adolescent male basketball player.

PARTICIPANT AND METHODS

On October 26, 2022, a 17-year-old avid basketball playing male (70 kg weight; 180 cm height) presented with LBP persisting for approximately 4 years. He described the pain started after bouncing on a trampoline. The pain was reported to average 6/10 on an 11-point pain intensity scale (0=no pain; 10=bed-ridden with pain) and he scored a 22% on the Oswestry low back pain disability questionnaire (ODI)¹⁵⁾. Specifically, for section 1 on the ODI, the pain intensity was indicated as “the pain comes and goes and is severe”. The pain was aggravated with standing for too long and bending forward. There were no other complaints.

An assessment of the thoraco-lumbar range of motion (ROM) demonstrated slight loss of flexibility on flexion and bilateral bending, with pain elicited as well as random cavitations (popping sounds) on bilateral spinal rotation with normal ROM. Other orthopedic testing such as the straight leg raiser were unremarkable. Palpation of the paraspinal muscles indicated hypertonicity in the lower back region bilaterally.

Standing radiographs were taken without shoes on a level surface, and with the patient standing with his feet positioned at hip-widths apart (Fig. 1). A large thoraco-lumbar kyphotic deformity was diagnosed with a magnitude of 41.9° ranging from T8–L2 as measured by the Harrison posterior tangent method^16,17,18). According to modelling studies done by Harrison et al.^19,20,21), the normal kyphosis from T8–T12 should be +19°, whereas, the patient had a +30.1° curve (158% increase); the normal lordosis from T12–L2 should be −6°, whereas, the patient had a +11.4° kyphosis (290% increase). All images were digitized using the PostureRay^© radiographic EMR (Trinity, FL, USA) using the posterior tangents to quantify spine alignment which has established reliability^16,17,18).

Fig. 1.

Lateral full-spine. Left: Pre-treatment; Right: post-treatment.

Treatment was directed at reducing the spinal deformity/subluxation by utilizing CBP methods^2,3,4,5). CBP technique has been described elsewhere, but is a full spine and posture correcting program that uses mirror image^® exercises, spine and posture traction methods as well as manual therapy adjusting methods.

The patient performed five thoraco-lumbar extension mirror image^® exercises (Fig. 2). The first was the birddog, on all fours, the patient raised the arm and opposite leg holding it for 5-seconds before alternating limbs. The second exercise was the superman, laying on the stomach the head and shoulders and arms are raised at the same time as the legs. The third exercise was ‘W’s’, where in a standing position the patient would start in the anatomical position, then raise the arms into a ‘W’ position, and then proceed into to a fully extended position overhead, all the while keeping the arms in the coronal plane and attempting to extend the back. The fourth exercise was horizontal arm extensions using a resistance band, each extension was held for 5-seconds before repeating. The last exercise involved the patient standing against the wall with a block between the thoraco-lumbar hunch and the wall, the head and pelvis would be pulled back to the wall simultaneously and held for 5-seconds and performed for 50 repetitions. The first four exercises were performed on the PowerPlate^® (Northbrook, IL, USA) for durations of 60-seconds in order to increase their intensity²²⁾.

Fig. 2.

Mirror image exercises. A: Horizontal arm extensions with resistance; B: Retracting head and pelvis towards the wall; C: Birddog, raising opposite arm and leg; D: Superman, raising arms and legs; E–G: W’s, arms are raised into a ‘W’ then overhead, then reversed back to start position. All exercises are held for 5-seconds before repeating or changing sides (C).

Spinal traction was similar to that performed in the Gubbels et al. case (Fig. 3)¹⁴⁾. The patient was standing with a strap placed to hold the patient against a vertical backboard as it was positioned across the anterior portion and at the top of the leg. A corrective anterior pulling strap was placed at the peak of the thoraco-lumbar kyphosis with a slight upward forward angle. A third strap was placed across the front of the shoulders to simply prevent the forward tilt of the upper body. The pulling corrective band would be tightened 1–2 times throughout the performance of the traction for a duration of 10-minutes per session. Spinal manipulative therapy (SMT) was also performed consisting of high-velocity, low-amplitude spinal manipulations to the cervical, thoracic and lumbar areas. The patient was treated 2–3 times per week for a duration of 4-months. The patient and parent gave verbal and written consent to the publication of this case including any X-rays and pictures.

Fig. 3.

Spine traction. Mirror image traction where the corrective pulling strap is hyper-extending the thoraco-lumbar deformity.

RESULTS

A post-treatment assessment was performed on February 27, 2023, after 36 sessions over a 4-month period. The patient reported not experiencing any ‘random muscle pains’ and reported feeling taller. Indeed, the patient who was originally 180 cm tall, now measured almost 183 cm. The pain was reported to average 0/10 (vs. 6/10) and no pain was elicited while bending forward or standing for long periods. The ODI now scored 4% (vs. 22%). ROM assessment showed a slight loss of flexibility on bilateral bending, all other movements were within normal limits and no movements elicited pain. Post-treatment X-rays (Fig. 1) showed a dramatic reduction in the thoraco-lumbar kyphosis, where the measurement between T8–L2 now measured 30.2° (vs. 41.9°), a near 12° reduction in deformity over a 4-month period.

DISCUSSION

This case documents the dramatic reduction in thoraco-lumbar kyphosis in an active adolescent male. Initially the patient presented with a 158% increase in the lower thoracic spine (T8–T12) and a 290% flexion deformity in upper lumbar region (T12–L2). There was an approximate 12° reduction in the thoraco-lumbar deformity corresponding with the alleviation of chronic LBP after 4-months of treatment where the lower thoracic flexion decreased 4.7° (T8–T12) and the upper lumbar spine reduced 6.6° (T12–L2) towards the normal alignment^19,20,21). This case is similar to that described by Gubbels et al.¹⁴⁾ who also showed a dramatic reduction of a thoraco-lumbar kyphosis in an adolescent. Together, these two cases represent a growing literature base demonstrating the efficacy of CBP technique methods to show reductions in spine deformities accomplished by non-surgical spinal rehabilitation^{6,7,8,9,10,11,12,13)}.

Non-surgical reductions of spinal deformities have been shown in multiple studies to reduce pain in multiple pathological groups following CBP structural rehabilitation programs^{6, 9)}. The improvement in spine alignment is thought to improve spinal pains by lessening the biomechanical strains by optimizing the spinal loading²³⁾. Thus, the optimized spinal loading resulting after spinal rehabilitation likely reduces both the likelihood of the patient continuing to suffer from LBP²⁴⁾ as well as to reduce the development of thoraco-lumbar kyphosis deformity into adulthood; that is, adult spinal deformity (ASD)²⁵⁾. ASD is a significant factor negatively affecting the quality of life^{26, 27)}, and therefore, the diagnosis of spinal deformity and so-called, ‘pre-ASD’ should be considered a critical finding and treatment should be aimed at its reduction at the earliest timepoint. Logically, a smaller deformity would be easier to rehabilitate versus a larger deformity, thus, it seems intuitive that small deformities that are thought to have an untoward etiology (i.e. likely progressive) should be aggressively treated prior to their evolution into larger deformities²⁸⁾.

Some may argue that radiography is not appropriate or could be potentially harmful due to radiation exposure given to an adolescent. This argument is now understood to be baseless and without merit considering many factors, including the oxidative burden of breathing air (largest exposure to free radical damage^{29, 30)}) and the fallacy associated with the linear-no-threshold model (linear assumption that all radiation is harmful^{31, 32)}). Importantly, the potential for the underlying spinal deformity to have gone undiagnosed and untreated by biomechanical treatment without radiography would likely, at least long-term, have been more detrimental than the presumed risks often attributed to X-rays. A missed condition by not utilizing radiography as a screening tool likely leads to the evolution of chronic pains and increased disability in the transition of LBP in adolescent into adulthood, which is a common occurrence²⁴⁾. Further, as mentioned, the likely progression of spinal deformity into definitive ASD, an extremely high contributor to the global burden of disease is also a significant risk without radiography and correct biomechanical diagnosis and treatment. Thus, without use of upright spinal radiographs as a screening tool, and which are regarded as the gold standard in the diagnosis of ASD, this patient would likely have remained undiagnosed in terms of having a biomechanical disorder and in turn, would likely have endured an unfavourable etiology of the progression of their condition.

Limitations of this study include that the patient has not been followed into adulthood to assess the stability of the correction. Also, this is a multi-modal treatment approach and therefore, it is not known which modalities contributed to the structural improvements; however, several carefully designed randomized clinical trials have demonstrated that spinal traction performed in “mirror image” positions do alter the spine towards a normal alignment as compared to other common treatment modalities. Finally, this is a single case, so the generalizability is limited. Nonetheless, this case adds to the evidence accumulating to show the CBP approach to reducing spinal deformities can be effective in certain cases. More research is needed to verify the efficacy in reducing thoraco-lumbar deformities in larger samples and other age groups.

Conflict of interest

Dr. Paul Oakley (PAO) is a paid consultant for CBP NonProfit, Inc.; Dr. Jason Haas is an instructor for CBP Seminars; Dr. Deed Harrison (DEH) is the CEO of Chiropractic BioPhysics^® (CBP^®), and provides post-graduate education and rehabilitation devices to health care providers/physicians. DEH is the president of CBP NonProfit, Inc.—a spine research foundation.