Structural rehabilitation of the cervical lordosis and forward head posture: a selective review of Chiropractic BioPhysics® case reports

Paul A Oakley; Sean Z Kallan; Deed E Harrison

doi:10.1589/jpts.34.759

. 2022 Nov 1;34(11):759–771. doi: 10.1589/jpts.34.759

Structural rehabilitation of the cervical lordosis and forward head posture: a selective review of Chiropractic BioPhysics^® case reports

Paul A Oakley ^1,^*, Sean Z Kallan ¹, Deed E Harrison ²

PMCID: PMC9622351 PMID: 36337218

Abstract

[Purpose] To characterize the case report evidence of Chiropractic BioPhysics^® (CBP^®) technique methods applied to increase cervical lordosis and improve forward head posture. [Methods] The CBP Non-profit website as well as PubMed and Index to Chiropractic literature were searched for case reports/series documenting the increase of cervical lordosis and improvement of forward head posture in the treatment of various craniocervical spinal disorders by CBP technique methods. [Results] Sixty patients were reported in 41 unique manuscripts detailing the improvement in cervical spine alignment by CBP technique methods. On average, there was a 14° improvement in cervical lordosis and a 12 mm reduction in forward head position after 40 treatments over 16 weeks with a 5-point reduction in pain rating scores. Thirty-eight percent of cases included follow-up showing only slight loss of lordosis, but maintenance of pain and disability improvements after an average of 1.5 treatments per month for 1.8 years. [Conclusion] An abundance of reports document improvement in craniocervical and other ailments by CBP methods that increase cervical lordosis. Routine radiographic imaging of the spine is recommended as it is safe and the only current practical method of screening for critical biomechanical biomarkers of sagittal spine alignment.

Keywords: Cervical lordosis, Forward head posture, Cervical spine

INTRODUCTION

There has been increasing interest from the spine research community of the importance of the cervical spine over the last decade¹^,²^,³^,⁴^,⁵⁾. Many reviews have presented common biomechanical parameters that are important in the comprehensive assessment of the cervical spine, and these can easily be quantified from radiographic imaging⁶⁾. Of many craniocervical parameters, the cervical lordosis and sagittal head posture are among the most important as the lordotic shape and a neutral sagittal vertical alignment of C2 relative to C7 of the cervical spine are both important for optimizing joint loading⁷⁾, maintaining cervical range of motion⁸⁾, achieving a horizontal gaze⁹⁾ and preserving the pons-cord tract in a normal slackened position¹⁰⁾.

The cervical lordosis is a critical feature of early intrauterine development¹¹⁾, is the normal configuration in adulthood¹²⁾ and can be used to discriminate between symptomatic and asymptomatic persons¹³⁾. A loss of normal lordosis in the cervical spine is an important clinical predictor of poor outcomes after fusion surgery¹⁴⁾, is associated with degenerative processes¹⁵⁾, neck pain¹³^,¹⁶⁾, headache¹⁷⁾, myelopathies and radiculopathies¹⁸⁾ and dizziness¹⁹⁾.

A recent systematic review located 9 controlled trials featuring Chiropractic BioPhysics^® (CBP^®) methods used in the rehabilitation of the cervical lordosis (i.e. some form of cervical extension traction)²⁰⁾. It was determined that there were “several high-quality controlled clinical trials substantiating that increasing cervical lordosis by extension traction as part of a spinal rehabilitation program reduces pain and disability and improves functional measures, and that these improvements are maintained long-term”²⁰⁾. Since this review (2020), three more trials have emerged further supporting the clinical importance of increasing the cervical curve and reducing forward head posture in patients who present with neck related disorders concomitant with a loss of normal lordosis and forward head alignment²¹^,²²^,²³⁾.

CBP technique is a full-spine, spine and posture correcting method that utilizes mirror image^® adjusting, exercises and traction procedures²⁴^,²⁵^,²⁶⁾, where mirror image refers to the reversing of the spine and posture into the opposite of the presenting malalignment during the performance of rehabilitative procedures. CBP also employs unique extension traction methods which have proven effective for restoring normal lordosis and reducing forward head posture²⁰^,²¹^,²²^,²³⁾.

CBP Nonprofit (www.cbpnonprofit.com) lists all publications involving CBP methods and is updated annually; currently, there are 277 listed peer-reviewed publications²⁷⁾. Over the years there have been many case reports documenting the clinical effectiveness of improving sagittal cervical spine alignment leading to simultaneous positive clinical outcomes in the treatment of various pathological conditions²⁷⁾. As mentioned, several controlled trials have demonstrated the efficacy of CBP cervical extension traction to increase lordosis, these have been primarily on mid-aged, neck pain/radiculopathy individuals. Therefore, despite these trials there is a gap in the literature on the efficacy of CBP methods to patients varying in age and pathological condition. In fact, since the manual therapies literature is generally lacking in scientific evidential support²⁸⁾, the case report is an important source of evidence to ‘fill the gap’ for rehabilitative therapies and specific populations which lack higher levels of scientific support (e.g. randomized clinical trial, systematic literature reviews, and meta-analyses)²⁹^,³⁰⁾.

The purpose of this review is to characterize the clinical evidence as specifically presented in case reports/series featuring the clinical application of CBP technique methods to increase cervical lordosis and reduce forward head posture. We further aim to highlight the varied pathological conditions treated as well as the various outcome variables documented in order to explore future types of clinical case reports that are needed to fill gaps in this type of literature.

METHODS

A review of the CBP NonProfit website citation listings²⁷⁾ was performed for clinical papers reporting on the treatment of cervical hypolordosis and forward head posture via CBP technique methods²⁴^,²⁵^,²⁶⁾. This review was focused on only case reports and case series; therefore, no clinical trials were considered other than to use as a comparison to identified results. A thorough review of clinical trials on these methods has been published recently²⁰⁾; thus, the current project was a systematized literature review of clinical case reports and not a systematic review per se.

Since the CBP NonProfit website lists all the peer-reviewed CBP publications and gets updated every fall, there was a search performed in PubMed and in the Index to Chiropractic Literature (ICL) for any cases published within the last year (i.e. Oct. 2021−July, 2022). Search terms included the keywords cervical spine, cervical lordosis, forward head posture, combined with chiropractic biophysics, CBP, extension traction and rehabilitation. Any recent located cases were also screened for references related to the topic. Further, authors having multiple previous case reports were searched individually on PubMed, ICL and ResearchGate for any recent case reports involving the cervical spine.

The CBP nonprofit site lists 129 case reports/series. These were systematically searched to locate any report documenting treatment directed at improving the lordotic and sagittal alignment of the cervical spine regardless of the title and abstract. Only cases that specifically described some form of cervical ‘extension traction’ were included. Details extracted from located studies included both the age and sex of patient, primary symptomatic complaint, number of treatments, time duration of treatment, treatment specifics including traction set-up, traction duration, exercise protocol and adjusting protocol. Details of pain, disability and health-related quality of life scores as well as the biomechanical X-ray parameters of cervical lordosis, anterior head translation (AHT) and atlas plane line (APL) were also noted. The first two authors extracted details from the located articles independently and any discrepancies existing after consolidation of data were solved by consensus.

RESULTS

Sixty individual patients were reported to be treated by CBP methods to restore the cervical lordosis and/or reduce AHT as reported in 41 peer-reviewed manuscripts³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷^,³⁸^,³⁹^,⁴⁰^,⁴¹^,⁴²^,⁴³^,⁴⁴^,⁴⁵^,⁴⁶^,⁴⁷^,⁴⁸^,⁴⁹^,⁵⁰^,⁵¹^,⁵²^,⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷^,⁵⁸^,⁵⁹^,⁶⁰^,⁶¹^,⁶²^,⁶³^,⁶⁴^,⁶⁵^,⁶⁶^,⁶⁷^,⁶⁸^,⁶⁹^,⁷⁰^,⁷¹⁾ (Table 1). The majority of cases were located from the CBP NP website, however, 5 more cases were located from searchers on Pubmed (n=1³¹⁾) ICL (n=1³²⁾) and ResearchGate (n=3³³^,³⁴^,³⁵⁾). Not including the series by Shahar⁷¹⁾ (reported group average only), on average, there was a 14.1° improvement in cervical lordosis after an average of 40 treatments over an average of 16 weeks. The range of ages treated were between 18–75 (average 43), the average reduction in AHT was 11.9 mm, the average increase in APL was 9.2°. The average reduction in pain rating was 4.9-points on an 11-point scale (0–10) representing an 80% average reduction in pain intensity. Of the fourteen cases that included pre-post disability scores, there was an average 38% reduction in disability over the respective patient courses of treatment; disability was usually quantified by the neck disability index (NDI).

Table 1. Details of case reports showing improved cervical lordosis in the treatment of patients with various pathological disorders.

Author	Year	Journal	Primary complaint	Age	M/F	No. Txts	Txt duration	Pre-post ARA	ARA increase	Pre-post APL	APL increase	Pre-post AHT	AHT reduction	Pre-post pain	Pain reduction	Pre-post disability	disability reduction	Other outcomes	F/u time
Fortner	2022	JPTS	Cervicogenic headache	26	f	25	2 m	−7.5°/−36°	28.5°	−25.5°/−32.9°	7.4°	6.6 mm/ 9.6 mm	−3 mm	n/r	n/r	66%/16%	50%	C2-6 kyhosis to lordosis	2.5 y
Fortner	2022	JPTS	Cervicogenic headache	26	f	25	2 m	−7.5°/−36°	28.5°	−25.5°/−32.9°	7.4°	6.6 mm/ 9.6 mm	−3 mm	n/r	n/r	HDI	50%	Improved HDI, NDI & SF-36	2.5 y
Jaeger	2022	JCC	Total disc replacement	38	f	69	4.5 m	−1.9°/−30.4°	28.5°	n/r	n/r	15.4 mm/ 4.6 mm	10.8 mm	7/1	7	24%/0%	24%	Improved lordosis pre- and post-surgery, NDI	2.5 y
Jaeger	2022	JCC	Total disc replacement	38	f	69	4.5 m	−1.9°/−30.4°	28.5°	n/r	n/r	15.4 mm/ 4.6 mm	10.8 mm	7/1	7	NDI	24%	Improved lordosis pre- and post-surgery, NDI	2.5 y
Chu	2022	Radiol CR	Cervical radiculopathy	24	m	32	4 m	?/−2°	23°+	n/r	n/r	n/r	n/r	5/2	3+	n/r	n/r	C4-5 23° kyphosis reduced to ~0°	0.25 y
Chu	2021	JCC	TOS	30	m	24	3 m	−3°/−35°	32°	n/r	n/r	n/r	n/r	6/0	6	n/r	n/r	Resolved TOS	1 y
Chu*	2021	J Med Cases	Cervicogenic dizziness	40	m	36	3 m	+5°/−10°	15°	n/r	n/r	n/r	n/r	7/0	7	68/20	48	Restored normal clivo-axial angle, resolved dizziness	1 y
Chu*	2021	J Med Cases	Cervicogenic dizziness	40	m	36	3 m	+5°/−10°	15°	n/r	n/r	n/r	n/r	7/0	7	DHI	48	Restored normal clivo-axial angle, resolved dizziness	1 y
Berry	2020	JCC	Trigeminal neuralgia	64	m	108	9 m	−1°/−14°	13°	−10°/−18°	8°	45 mm/ 26 mm	19 mm	7/2	5	18%/ n/r	?	Dramatic reduction of symptoms, off meds	1 y
Berry	2020	JCC	Trigeminal neuralgia	64	m	108	9 m	−1°/−14°	13°	−10°/−18°	8°	45 mm/ 26 mm	19 mm	7/2	5	NDI	?	Dramatic reduction of symptoms, off meds	1 y
Gerstin	2020	JPTS	Dizziness	57	f	115	12 m	−13.7°/−33.2°	19.5°	−29.8°/n/r	n/r	26.6 mm/ 24 mm	2.6 mm	9w/1	8	56/12	44	Improved dizziness, NDI, QOL	1.5 y
Gerstin	2020	JPTS	Dizziness	57	f	115	12 m	−13.7°/−33.2°	19.5°	−29.8°/n/r	n/r	26.6 mm/ 24 mm	2.6 mm	9w/1	8	DHI	44	Improved dizziness, NDI, QOL	1.5 y
Fortner	2020	JCC	WAD	29	f	36	3.75 m	−11.2°/−24°	12.8°	−28.9°/−35.7°	6.8°	2.4 mm/ 7.4 mm	−5 mm	5/0.5	4.5	98%/4%	94%	Improved symptoms/NDI/HDI/SF-36/grip strength	1.1 y
Fortner	2020	JCC	WAD	29	f	36	3.75 m	−11.2°/−24°	12.8°	−28.9°/−35.7°	6.8°	2.4 mm/ 7.4 mm	−5 mm	5/0.5	4.5	HDI	94%	Improved symptoms/NDI/HDI/SF-36/grip strength	1.1 y
Chu (n=3)	2020	J Fam Med Prim Care	Cervical pain	49	f	n/r	2 m	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	Case 2: Resolved radicular pain	0.75 y
Chu (n=3)	2020	J Fam Med Prim Care	Cervical pain	43	f	n/r	3 m	n/r	n/r	n/r	n/r	n/r	n/r	4/ n/r	?	n/r	n/r	Case 3: Improved symptoms	2 y
Fedorchuk (n=7)	2020	J Radiol Case Rep	Cervical stenosis & spondylolisthesis	63	f	30	3 m	−50.6°/−46°	−4.6°	n/r	n/r	17.4 mm/ 5.2 mm	12.2 mm	n/r	n/r	34.5%/4.3%	30.2%	Reduced NDI/3 spondys	no
				67	f	30	3 m	−3.5°/−19.3°	15.8°	n/r	n/r	8.7 mm/ 7.8 mm	0.9 mm	n/r	n/r	34.5%/4.3%	30.2%	Reduced NDI/2 spondys	no
				53	f	30	3 m	−6.1°/−16.8°	10.7°	n/r	n/r	2.6 mm/ 10.7 mm	−8.1 mm	n/r	n/r	34.5%/4.3%	30.2%	Reduced NDI/3 spondys	no
				46	f	30	3 m	−12.4°/−19.1°	6.7°	n/r	n/r	1.5 mm/ 7.4 mm	−5.9 mm	n/r	n/r	34.5%/4.3%	30.2%	Reduced NDI/1 spondy	no
				51	f	30	3 m	+2.4°/−4.4°	6.8°	n/r	n/r	27.3 mm/ 21.9 mm	5.4 mm	n/r	n/r	34.5%/4.3%	30.2%	Reduced NDI/4 spondys	no
				58	f	30	3 m	−11.7°/−11.8°	0.1°	n/r	n/r	23.4 mm/ 23.8 mm	−0.4 mm	n/r	n/r	34.5%/4.3%	30.2%	Reduced NDI/2 spondys	no
				36	f	30	3 m	−12.7°/−17.1°	4.4°	n/r	n/r	24.3 mm/ 19.1 mm	5.2 mm	n/r	n/r	34.5%/4.3%	30.2%	Reduced NDI/1 spondy	no
				36	f	30	3 m	−12.7°/−17.1°	4.4°	n/r	n/r	24.3 mm/ 19.1 mm	5.2 mm	n/r	n/r	NDI	30.2%	Reduced NDI/1 spondy	no
Spriggs	2019	AVSR	Chronic migraine	35	m	24	2 m	−9°/−21.5°	12.5°	−5.7°/−15.6°	9.9°	33.8 mm/ 15.8 mm	18 mm	8/0	8	39%/10%	29%	Resolved migraines, Reduced disability	0.4 y
Spriggs	2019	AVSR	Chronic migraine	35	m	24	2 m	−9°/−21.5°	12.5°	−5.7°/−15.6°	9.9°	33.8 mm/ 15.8 mm	18 mm	8/0	8	PDQ	29%	Resolved migraines, Reduced disability	0.4 y
Fortner	2019	JCC	Exertional dyspnea	18	m	24	2.25 m	−20.3°/−28.2°	7.9°	−17.6°/−25.9°	8.3°	n/r	n/r	2–3/1	2–3	n/r	n/r	Improved dyspnea/asthma/ODI/SF-36	0.6 y
Breton	2019	JCC	Carpal tunnel syndrome	29	m	33	3.25 m	−3.7°/−18.3°	14.6°	−13.1°/−24.7°	11.6°	16 mm/ 5.1 mm	10.9 mm	5/0	5	n/r	n/r	Resolution of CTS, improved SF-36	no
Anderson	2019	JPTS	Parkinson’s	59	m	38	5 m	−29.6°/−37.2°	7.6°	−7.6°/−19.8°	12.2°	67.5 mm/ 36.5 mm	31 mm	6/2	4	n/r	n/r	Improved ODI, gait, balance, hand tremors, back & knee pain, SF-36	1.75 y
Chu	2019	Arch Clin Med Case Rep	Cervicogenic headache	37	f	60	6 m	−7°/−22°	15°	n/r	n/r	n/r	n/r	7/0	7	60%/ n/r	?	Resolved headaches/neck pain off meds	1 y
Chu	2019	Arch Clin Med Case Rep	Cervicogenic headache	37	f	60	6 m	−7°/−22°	15°	n/r	n/r	n/r	n/r	7/0	7	HDI	?	Resolved headaches/neck pain off meds	1 y
Dennis	2018	JPTS	Neck pain/headaches	24	m	24	2.5 m	+3°/−18.6°	21.6°	n/r	n/r	44.9 mm/ −5.6 mm	50.5 mm	8/0	8	66%/0%	66%	Resolution of pain, headaches	no
Dennis	2018	JPTS	Neck pain/headaches	24	m	24	2.5 m	+3°/−18.6°	21.6°	n/r	n/r	44.9 mm/ −5.6 mm	50.5 mm	8/0	8	NDI	66%	Resolution of pain, headaches	no
Weiner	2018	JPTS	Spinal stenosis	66	f	78	6.5 m	−16.3°/−26.8°	10.5°	−12.3°/−23.2°	10.9°	29.8 mm/ 34.9 mm	−5.1 mm	n/r	n/r	62%/18%	44%	Reduced radiculopathy/pain	no
Weiner	2018	JPTS	Spinal stenosis	66	f	78	6.5 m	−16.3°/−26.8°	10.5°	−12.3°/−23.2°	10.9°	29.8 mm/ 34.9 mm	−5.1 mm	n/r	n/r	ODI	44%	Reduced radiculopathy/pain	no
Fortner	2018	JPTS	Spine pain/headaches	32	m	36	3.25 m	−12.4°/−22.4°	10°	+0.3°/−18.5°	18.8°	38.2 mm/ 23.1 mm	15.1 mm	5–8/1	4–7	38%/4%	34%	Resolution of pains	no
Fortner	2018	JPTS	Spine pain/headaches	32	m	36	3.25 m	−12.4°/−22.4°	10°	+0.3°/−18.5°	18.8°	38.2 mm/ 23.1 mm	15.1 mm	5–8/1	4–7	NDI	34%	Resolution of pains	no
Fortner	2018	JPTS	WAD/dizziness	46	m	46	4 m	−17.4°/−23.2°	5.8°	−2.8°/−12°	9.2°	22.1 mm/ 31.2 mm	−9.1 mm	5/0	5	n/r	n/r	Resolution of dizziness/pain/ringing in ears	1 y
Fortner	2018	JPTS	WAD	31	f	30	5 m	−18.8°/−32.1°	13.3°	n/r	n/r	n/r	n/r	3/0	3	n/r	n/r	Resolution of headaches/pain	no
Fortner	2018	JPTS	Advanced osteoarthritis	38	m	30	4.5 m	−4.8°/−31.7°	26.9°	−18.8°/−32.5°	13.7°	7.3 mm/ 3.8 mm	3.5 mm	4/2.4	1.6	30%/16%	14%	Reduced disability/pain, improved QOL/blurred vision	no
Fortner	2018	JPTS	Advanced osteoarthritis	38	m	30	4.5 m	−4.8°/−31.7°	26.9°	−18.8°/−32.5°	13.7°	7.3 mm/ 3.8 mm	3.5 mm	4/2.4	1.6	NDI	14%	Reduced disability/pain, improved QOL/blurred vision	no
Harrison	2018	JPTS	Post-surgical fusion	52	m	21	2.25 m	−25°/−31°	6°	+3°/−6°	9°	59 mm/ 39.5 mm	19.5 mm	6/1	5	18%/12%	6%	Reduced radiculopathy/pain/disability	2.5 y
Harrison	2018	JPTS	Post-surgical fusion	52	m	21	2.25 m	−25°/−31°	6°	+3°/−6°	9°	59 mm/ 39.5 mm	19.5 mm	6/1	5	NDI	6%	Reduced radiculopathy/pain/disability	2.5 y
Betz	2018	JPTS	Exertional dyspnea	19	m	37	3 m	−1°/−30°	29°	−7°/−28°	21°	13 mm/ 0 mm	13 mm	n/r	n/r	n/r	n/r	Reduced dyspnea/neck/back pain	2.75 y
Wickstrom	2017	JPTS	Cervical radiculopathy	31	m	40	4.25 m	+16°/−30.6°	46.6°	n/r	n/r	49 mm/ −5.6 mm	54.6 mm	6/1	5	46%/0%	46%	Resolution of radiculopathy/pain/disability	1 y
Wickstrom	2017	JPTS	Cervical radiculopathy	31	m	40	4.25 m	+16°/−30.6°	46.6°	n/r	n/r	49 mm/ −5.6 mm	54.6 mm	6/1	5	NBQ	46%	Resolution of radiculopathy/pain/disability	1 y
Fedorchuk	2017	AVSR	Post-surgical fusion	43	f	36	3 m	−11.1°/−23.8°	12.7°	−11.7°/−24.6°	12.9°	19.8 mm/ 10.9 mm	8.9 mm	n/r	n/r	n/r	n/r	Reduced pain/headaches/improved ADL	no
Fedorchuk	2017	AVSR	Fibromyalgia	40	f	44	5 m	+0.4°/−11.8°	12.2°	−18°/−22.8°	4.8°	32.7 mm/ 15.4 mm	17.3 mm	n/r	n/r	n/r	n/r	Reduced pains, improved SF-36	no
Fedorchuk	2017	J Mol Genet Med	Dysautonomia	35	f	36	5 m	−18.8°/−27°	8.2°	−20.2°/−25°	4.8°	24 mm/ 17.7 mm	6.3 mm	5/1	4	n/r	n/r	Telomere lengthening,improved QOL	no
Oakley	2017	CJA	Tourette’s	19	m	81	3 m	+12°/−16°	28°	0°/−17°	17°	46 mm/ 24 mm	22 mm	n/r	n/r	40%/20%	20%	Reduced tics, off meds	13 y
Oakley	2017	CJA	Tourette’s	19	m	81	3 m	+12°/−16°	28°	0°/−17°	17°	46 mm/ 24 mm	22 mm	n/r	n/r	YGTSS	20%	Reduced tics, off meds	13 y
Oakley	2017	CJA	Unsteady gait	75	f	25	2.5 m	−22°/−33°	11°	−18°/−30°	12°	35 mm/ 21 mm	14 mm	3–6/0	3–6	42%/0%	42%	Able gait, resolution of pain/disability	0.2 y
Oakley	2017	CJA	Unsteady gait	75	f	25	2.5 m	−22°/−33°	11°	−18°/−30°	12°	35 mm/ 21 mm	14 mm	3–6/0	3–6	NDI	42%	Able gait, resolution of pain/disability	0.2 y
Fedorchuk	2016	AVSR	Anterolisthesis	52	f	30	3 m	−22.8°/−26°	3.2°	−32.8°/−31.2°	−1.6°	19.6 mm/ 9.0 mm	10.6 mm	n/r	n/r	n/r	n/r	Reduction of anterolisthesis/pain/swelling	no
Bak	2015	AVSR	Hypothyroidism	44	f	n/r	6 m	−8.1°/−15°	6.9°	n/r	n/r	17.2 mm/ 13.7 mm	3.5 mm	n/r	n/r	n/r	n/r	Reduced thyroid meds	no
Cardwell	2014	AVSR	Headaches/sinuses	34	m	33	9 m	−31°/−38°	7°	n/r	n/r	28 mm/ 0 mm	28 mm	n/r	n/r	n/r	n/r	Decreased headaches/ sinus symptoms	no
Fedorchuk	2014	AVSR	GERD	27	f	19	2 m	−6.2°/−28°	21.8°	−26.1°/−44.5°	18.4°	17.5 mm/ 4 mm	13.5 mm	5/4	1	n/r	n/r	Decreased GERD symptoms	no
Jaeger	2014	AVSR	Urinary incontinence	63	f	22	2 m	−6.9°/−11°	4.1°	−30.9°/−27.2°	−3.7°	13.3 mm/ 17.7 mm	−4.4 mm	?/0	?	n/r	n/r	Resolution of incontinence/pain	no
Shapiro	2012	AVSR	Parkinson’s	67	m	38	3 m	−24°/−39°	15°	n/r	n/r	n/r	n/r	3/2	1	n/r	n/r	Reduced pain, Improved ADL	no
Fedorchuk	2011	AVSR	Dyslipidemia	49	f	?	3 m	28.7°/−31.4°	2.7°	−19.3°/−14.3°	−5°	52.7 mm/ 35.8 mm	16.9 mm	n/r	n/r	n/r	n/r	Improved cholesterol levels/SF-36	1.5 y
Oakley	2007	JVSR	Post-surgical laminectomy	35	m	36	3 m	−19°/−32°	13°	−16°/−23°	7°	47 mm/ 36 mm	11 mm	8/0	8	n/r	n/r	Reduced ODI, pain/sciatica	0.75 y
Haas	2005	JMPT	Syringomyelia	41	m	26	0.75 m	−10°/−30°	20°	0°/−14°	14°	38 mm/ 15 mm	23 mm	8.5/4.5	4	n/r	n/r	Reduced pain	1 y
Ferrantelli	2005	JMPT	WAD	40	m	64	9.5 m	+3°/−17°	20°	−13°/−16°	3°	74 mm/ 32 mm	42 mm	5/0	5	46%/0%	46%	Reduced disc protrusions/pain/disability	no
Ferrantelli	2005	JMPT	WAD	40	m	64	9.5 m	+3°/−17°	20°	−13°/−16°	3°	74 mm/ 32 mm	42 mm	5/0	5	NDI	46%	Reduced disc protrusions/pain/disability	no
Colloca	2003	JMPT	Ehlers-Danlos syndrome	49	f	43	6 m	+9°/−2°	11°	n/r	n/r	12 mm/ 8 mm	4 mm	5/3	2	23%/11%	12%	Reduced pain/disability	no
Colloca	2003	JMPT	Ehlers-Danlos syndrome	49	f	43	6 m	+9°/−2°	11°	n/r	n/r	12 mm/ 8 mm	4 mm	5/3	2	NDI	12%	Improved symptoms	no

Average	(n=47)			42.6383	26 f	39.74419	4 m	−9.1°/−23.9°	14.1°	−14.7°/−23.3°	9.2°	27.9 mm/ 16.0 mm	11.9 mm	5.6/1.1	4.9	44.8%/7.9%	37.6%		1.8 y
SD				(14)	21 m	(21.4)	(2.2 m)	(13.6°/10.2°)	(9.7°)	(10.4°/8.5°)	(6.6°)	(18.0 mm/ 12.3 mm)	(14.9 mm)	(1.6/1.3)	(2.1)	(21.5%/7.6%)	(23.4%)		(2.6 y)
SD				(n=47)		(n=43)	(n=47)	(n=44/n=45)	(n=45)	(n=26/n=25)	(n=25)	(n=38/n=38)	(n=38)	(n=28/n=28)	(n=27)	(n=16/n=14)	(n=14)		(n=23)

Case series
Shahar (n=13)	2019	Spine	Craniocervical symptoms	18–36	xf	84	3 m	−8.5°/−14.5°	6°	13°/18°	5°	25 mm/19 mm	6 mm	n/r	n/r	n/r	n/r	Reduced pain, improved QOL	no
Shahar (n=13)	2019	Spine	Craniocervical symptoms	18–36	xm	84	3 m	−8.5°/−14.5°	6°	13°/18°	5°	25 mm/19 mm	6 mm	n/r	n/r	n/r	n/r	Reduced pain, improved QOL	no

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ADL: activities of daily living; AHT: anterior head translation; APL: atlas plane line; ARA: C2-7 absolute rotation angle; DHI: dizziness handicap inventory; GERD: gastroesophageal reflux disease; HDI: headache disability index; NBQ: neck Bournemouth questionnaire; NDI: neck disability index; ODI: Oswestry disability index; PDQ: pain disability questionnaire; QOL: quality of life; SF-36: short form-36 questionnaire; TOS: thoracic outlet syndrome; WAD: whiplash associated disorder; YGTSS: Yale global tic severity scale; *C2-7 Cobb angle.

Twenty-three cases (38% of total cases) reported follow-up outcome measures after an average maintenance treatment schedule of 1.5 treatments per month over an average of 1.8 years (range 0.25–13 years) (Table 2). There was an average loss of initial lordosis correction of 3.1°, and a maintenance within error of APL (−1.6°) and AHT (−1.6 mm). Of the cases reporting follow-up NPRS (n=10), there was on average no change (−0.1/10), or a long-term maintenance of the initial pain relief. Of the cases reporting follow-up disability scores (n=8), there was on average, stability of disability improvement as achieved following the initial post-treatment results. Only 3 out of the 41 (7%) manuscripts presented information on more than one case (case series) ³⁹^,⁴⁰^,⁷¹⁾.

Table 2. Details of the cases that reported a follow-up after the initial corrective care to restore cervical lordosis.

Author	Year	Primary complaint	Age	M/F	F/u time	No. Txts	Txt Freq	Post-ARA/ f/u ARA	ARA dif	Post-APL/ f/u APL	APL dif	Post-AHT/ f/u AHT	AHT dif	Post-pain/ f/u pain	Pain dif	Post-Disability/ f/u disability	Disability dif
Fortner	2022	Cervicogenic headache	26	f	2.5 y	43	1/m	−36°/−33.3°	2.7°	−32.9°/−33.3°	−0.4°	9.6 mm/ n/r	?	n/r / n/r	n/r	16%/2%	−14%
Fortner	2022	Cervicogenic headache	26	f	2.5 y	43	1/m	−36°/−33.3°	2.7°	−32.9°/−33.3°	−0.4°	9.6 mm/ n/r	?	n/r / n/r	n/r	HDI	−14%
Jaeger	2022	Total disc replacement	38	f	2.5 y	n/r	n/r	−30.4°/−17.6°	12.8°	n/r / n/r	?	4.6 mm/ n/r	?	1/1	0	0%/2%	2%
Jaeger	2022	Total disc replacement	38	f	2.5 y	n/r	n/r	−30.4°/−17.6°	12.8°	n/r / n/r	?	4.6 mm/ n/r	?	1/1	0	NDI	2%
Chu	2022	Cervical radiculopathy	24	m	0.25 y	6	2/m	−2°/ n/r	?	n/r / n/r	?	n/r / n/r	?	2/ n/r	?	n/r / n/r	?
Chu	2021	TOS	30	m	1 y	n/r	n/r	−35°/ n/r	?	n/r / n/r	?	n/r / n/r	?	0/ n/r	?	n/r / n/r	?
Chu*	2021	Cervicogenic dizziness	40	m	1 y	n/r	n/r	−10°/ n/r	?	n/r / n/r	?	n/r / n/r	?	0/0	0	20/0	−20
Chu*	2021	Cervicogenic dizziness	40	m	1 y	n/r	n/r	−10°/ n/r	?	n/r / n/r	?	n/r / n/r	?	0/0	0	DHI	−20
Berry	2020	Trigeminal neuralgia	64	m	1 y	24	2/m	−14°/−18°	−4°	−18°/−22°	−4°	26 mm/ 21 mm	−5 mm	2/2	0	n/r / n/r	?
Gerstin	2020	Dizziness	57	f	1.83 y	n/r	n/r	−33.2°/ n/r	?	n/r / n/r	?	24 mm/ n/r	?		?	12/10	−2
Gerstin	2020	Dizziness	57	f	1.83 y	n/r	n/r	−33.2°/ n/r	?	n/r / n/r	?	24 mm/ n/r	?		?	DHI	−2
Fortner	2020	WAD	29	f	1.1 y	8	2/m	−24°/−18°	6°	−35.7°/−34.3°	1.4°	7.4 mm/ 11.6 mm	4.2 mm	0.5/ n/r	?	4%/10%	6%
Fortner	2020	WAD	29	f	1.1 y	8	2/m	−24°/−18°	6°	−35.7°/−34.3°	1.4°	7.4 mm/ 11.6 mm	4.2 mm	0.5/ n/r	?	HDI	6%
Chu (n=3)	2020	Cervical pain	49	f	0.75 y	n/r	n/r	n/r / n/r	?	n/r / n/r	?	n/r / n/r	n/r	n/r / n/r	?	n/r / n/r	?
Chu (n=3)	2020	Cervical pain	43	f	2 y	n/r	n/r	n/r / n/r	?	n/r / n/r	?	n/r / n/r	n/r	n/r / n/r	?	n/r / n/r	?
Spriggs	2019	Chronic migraine	35	m	0.4 y	7	1/m	−21.5°/ n/r	?	−15.6°/ n/r	?	15.8 mm/ n/r	n/r	0/0	0	10%/2%	−8%
Spriggs	2019	Chronic migraine	35	m	0.4 y	7	1/m	−21.5°/ n/r	?	−15.6°/ n/r	?	15.8 mm/ n/r	n/r	0/0	0	PDQ	−8%
Fortner	2019	Exertional dyspnea	18	m	0.6 y	4	1/m	−28.2°/−27.6°	0.6°	−25.9°/ n/r	?	n/r / n/r	n/r	1/0	−1	n/r / n/r	?
Anderson	2019	Parkinson’s	59	m	1.75 y	n/r	n/r	−37.2°/ n/r	?	−19.8°/ n/r	?	36.5 mm/ n/r	n/r	2/ n/r	?	n/r / n/r	?
Chu	2019	Cervicogenic headache	37	f	1 y	n/r	n/r	−22°/ n/r	?	n/r / n/r	?	n/r / n/r	n/r	0/0	0	n/r / n/r	?
Fortner	2018	WAD/dizziness	46	m	1 y	10	1/m	−23.2°/−30.4°	−7.2°	−12°/−20.9°	−8.9°	31.2 mm/ 15.9 mm	−15.3 mm	0/0	0	n/r / n/r	?
Harrison	2018	Post-surgical fusion	52	m	2.5 y	38	1/m	−31°/−30°	1°	−6°/−4°	2°	39.5 mm/ 46 mm	6.5 mm	1/2	1	12%/8%	−4%
Harrison	2018	Post-surgical fusion	52	m	2.5 y	38	1/m	−31°/−30°	1°	−6°/−4°	2°	39.5 mm/ 46 mm	6.5 mm	1/2	1	NDI	−4%
Betz	2018	Exertional dyspnea	19	m	2.75 y	12	1/m	−30°/−22°	8°	−28°/−28°	0°	0 mm/ 4 mm	4 mm	n/r / n/r	?	n/r / n/r	?
Wickstrom	2017	Cervical radiculopathy	31	m	1 y	24	2/m	−30.6°/−19.5°	11.1°	n/r / n/r	?	−5.6 mm/ 0.5 mm	6.1 mm	1/ n/r	?	0%/10%	10%
Wickstrom	2017	Cervical radiculopathy	31	m	1 y	24	2/m	−30.6°/−19.5°	11.1°	n/r / n/r	?	−5.6 mm/ 0.5 mm	6.1 mm	1/ n/r	?	NBQ	10%
Oakley	2017	Tourette’s	19	m	13 y	n/r	n/r	−16°/ n/r	?	−17°/ n/r	?	24 mm/ n/r	?	n/r / n/r	?	20%/ n/r	?
Oakley	2017	Tourette’s	19	m	13 y	n/r	n/r	−16°/ n/r	?	−17°/ n/r	?	24 mm/ n/r	?	n/r / n/r	?	YGTSS	?
Oakley	2017	Unsteady gait	75	f	0.4 y	44	4/m	−33°/ n/r	?	−30°/ n/r	?	21 mm/ n/r	?	0/ n/r	?	n/r / n/r	n/r
Fedorchuk	2011	Dyslipidemia	49	f	1.5 y	24	2/m	−31.4°/ n/r	?	−14.3°/ n/r	?	35.8 mm/ n/r	?	n/r / n/r	?	n/r / n/r	n/r
Oakley	2007	Post-surgical laminectomy	35	m	0.75 y	0	0	−32°/−32°	0°	−23°/ n/r	?	36 mm/ n/r	?	0/0	0	n/r / n/r	n/r
Haas	2005	Syringomyelia	41	m	1 y	n/r	n/r	−30°/−30°	0°	−14°/−15°	−1°	15 mm/ 3 mm	−12 mm	4.5/4	−0.5	n/r / n/r	n/r

Average	(n=23)		39.8	9 f	1.8 y	18.8	1.5/m	−26.0°/−24.8°	3.1°	−21.4°/−23.8°	−1.6°	20.4 mm/ 16.5 mm	−1.6 mm	0.7/0.6	−0.1	8.9%/5.7%	−3.8%
SD			(15.0)	14 m	(2.6 y)	(15.2)	(1.0/m)	(−9.2°/6.3°)	(6.4°)	(8.6°/10.7°)	(3.8°)	(14.0 mm/ 15.7 mm)	(9.1 mm)	(1.2/1.4)	(0.5)	(7.8%/4.1%)	(10.1%)
			(n=23)		(n=23)	(n=13)	(n=13)	(n=21/n=11)	(n=11)	(n=14/n=7)	(n=7)	(n=16/n=7)	(n=8)	(n=14/n=10)	(n=10)	(n=9/n=8)	(n=8)

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AHT: anterior head translation; APL: atlas plane line; ARA: C2-7 absolute rotation angle; DHI: dizziness handicap inventory; HDI: headache disability index; NBQ: neck Bournemouth questionnaire; NDI: neck disability index; PDQ: pain disability questionnaire; TOS: thoracic outlet syndrome; WAD: whiplash associated disorder; YGTSS: Yale global tic severity scale; *C2-7 Cobb angle. Columns calculating difference (‘dif’) indicate ‘-‘ for further improvement and ‘+’ for loss of correction.

The cases reported positive patient outcomes for a wide range of pathological conditions not limited to craniocervical complaints. All patients did not necessarily have improvement in their presenting conditions, but all had some sort of improved outcomes (e.g. pain, disability etc; For details see Table 1). Primary conditions treated included: carpal tunnel syndrome⁴³⁾, cervical disc replacement³²⁾, cervical radiculopathy³³^,⁵⁴⁾, cervical spondylolisthesis⁴⁰^,⁶⁰⁾, cervical spondylotic myelopathy⁵⁹⁾, cervical stenosis⁴⁰^,⁴⁷⁾, dizziness³⁵^,³⁷^,⁴⁹⁾, dysautonomia⁵⁷⁾, dyslipidemia⁶⁶⁾, Ehlers-Danlos syndrome⁷⁰⁾, exertional dyspnea⁴²^,⁵³⁾, fibromyalgia⁵⁶⁾, gait and balance instability⁴⁴^,⁵⁹⁾, gastroesophageal reflux disease (GERD)⁶³⁾, headache (including migraine)³¹^,⁴¹^,⁴⁵^,⁴⁶^,⁴⁸^,⁶²^,), hypothyroidism⁶¹⁾, neck pain (most cases), osteoarthritis⁵¹⁾, Parkinson’s⁴⁴^,⁶⁵⁾, post-surgical fusion⁵²^,⁵⁵⁾, sinus problems⁶²⁾, syringomyelia⁶⁸⁾, thoracic outlet syndrome³⁴⁾, Tourette’s⁵⁸⁾, trigeminal neuralgia³⁶⁾, gait dysfunction⁵⁹⁾, urinary incontinence⁶⁴⁾ and whiplash associated disorders³⁸^,⁴⁹^,⁵⁰^,⁶⁹⁾. Many reports also detailed improvements in cervical range of motion, disability (e.g. neck disability index), health-related quality of life (e.g. SF-36), elimination of medication use and improved sleep. There were also reports of improved asthma symptoms⁴²⁾, relief of ringing in the ears⁴⁹⁾, resolution of blurred vision⁵¹⁾ and in one case, telomere lengthening⁵⁷⁾.

DISCUSSION

This selected literature review has summarized the details from case reports and case series documenting the improvement of cervical lordosis and forward head posture (AHT) by CBP technique methods. We located data on 60 patients as reported in 41 citations³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷^,³⁸^,³⁹^,⁴⁰^,⁴¹^,⁴²^,⁴³^,⁴⁴^,⁴⁵^,⁴⁶^,⁴⁷^,⁴⁸^,⁴⁹^,⁵⁰^,⁵¹^,⁵²^,⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷^,⁵⁸^,⁵⁹^,⁶⁰^,⁶¹^,⁶²^,⁶³^,⁶⁴^,⁶⁵^,⁶⁶^,⁶⁷^,⁶⁸^,⁶⁹^,⁷⁰^,⁷¹⁾. On average, a lordosis improvement of 14.1° was accomplished after an average of 40 treatments over an average of 16 weeks. There was also an average 11.9 mm reduction in AHT, an average 9.2° increase in the APL and a 4.9-point reduction in pain as rated on an 11-point scale.

Importantly, there were documented improvements in a wide variety of chief complaints not exclusively attributed to neck pain and/or headaches. For example, relief was documented in reported cases of sinus problems⁶²⁾, neurologic tics⁵⁸⁾, blurred vision⁵¹⁾, ringing in the ears⁴⁹⁾, dizziness³⁵^,³⁷^,⁴⁹⁾, gait and balance instability⁴⁴^,⁵⁹⁾ and incontinence⁶⁴⁾, among others. There were also structural spinal changes reported beyond lordosis and AHT changes such as reduction of cervical spondylolisthesis⁴⁰^,⁶⁰⁾, improved clivo-axial angle³⁵⁾, as well as reduction of forward head translation and increased lordosis in patients having presence of partial cervical spine fusion⁵²^,⁵⁵⁾. One case featured the documentation of telomere lengthening after cervical lordosis and AHT improvement after 36 treatments over 5-months⁵⁷⁾.

The summarized data indicate there is a 0.35° improvement in cervical lordosis per treatment; therefore, on average, it takes 3 treatments to create 1° of lordosis improvement. It is important to acknowledge that this is exactly on par with the results from clinical trials on these methods that show an average of 14° improvement over 30–40 treatments²⁰⁾ (Table 3). Thus, a properly conducted case report may reflect the results from a carefully conducted randomized trial for these methods.

Table 3. Summary of clinical trial details using CBP extension traction in the improvement of cervical lordosis.

Publication details		Cohort & treatment details						Radiographic measures						Pain intensity			Disability scores			Other outcome measures
Author	Year	Condition	Exp/ control	n	Age (SD)	No. of txts	Duration of txt	Pre-post lordosis	Lordosis increase	f/u lordosis	Pre-post AHT	AHT reduction	f/u AHT	Pre-post nk Pain	Pain reduction	f/u pain	Pre-post disability	Disability reduction	f/u disability	Post-treatment & long-term treatment grp	f/u time
Author	Year	Condition	Exp/ control	n	Age (SD)	No. of txts	Duration of txt	Pre-post lordosis	Lordosis increase	f/u lordosis	Pre-post AHT	AHT reduction	f/u AHT	Pre-post nk Pain	Pain reduction	f/u pain	Pre-post disability	Disability reduction	f/u disability	Improvements in other outcome measures	f/u time
RCTs
Moustafa	2021	Asymptomatic	E	40 (15 f)	21.5 (2.7)	30	2.5 m	4.2°/18.1	13.9°	17.9°	24 mm/ 10.1 mm	13.9 mm	11.8 mm	n/a	n/a	n/a	n/a	n/a	n/a	Improved amplitudes of N13, P14, N20, P27,	3 m
Moustafa	2021	Asymptomatic	C	40 (17 f)	23.9 (3.1)	30	2.5 m	4.2°/4.3°	0.1°	5.1°	23 mm/ 22.7 mm	0.3 mm	24 mm	n/a	n/a	n/a	n/a	n/a	n/a	N30 potetials and connduction time N13-N20	3 m
Moustafa	2021	Cervicogenic headache	E	30 (10 f)	43.1 (8)	30	2.5 m	5.6°/18.9°	13.3°	17.7°	25.6 mm/ 6.4 mm	19.2 mm	8.1 mm	n/r	n/r	n/r	78.8/45.8	33	15.6	Improved headache frequency, headache impact	24 m
			C	30 (12 f)	41.9 (7)	30	2.5 m	7.2°/7.1°	−0.1	6.1°	27.2 mm/ 26.9 mm	0.3 mm	28.7 mm	n/r	n/r	n/r	79.9/47.8	32.1	67.3	test-6, daily defined dose	24 m
			C	30 (12 f)	41.9 (7)	30	2.5 m	7.2°/7.1°	−0.1	6.1°	27.2 mm/ 26.9 mm	0.3 mm	28.7 mm	n/r	n/r	n/r	(HDI)	32.1	67.3	test-6, daily defined dose	24 m
Moustafa	2021	Chronic non-specific neck pain	E	55 (25 f)	20 (3)	30	2.5 m	5.3°/20°	14.7°	19.4°	36 mm/ 11 mm	25 mm	13 mm	5.5/1.9	3.6	1.3	33.7/20.6	13.1	10.9	Improved balance, head reposiitioning, smooth	12 m
			C	55 (26 f)	21 (4)	30	2.5 m	5.8°/6.9°	1.1°	5.7°	30 mm/ 29 mm	1 mm	29 mm	5.3/2.1	3.2	4.2	32.2/21.0	11.2	26.1	pursuiit neck torsion, autonomic function	12 m
			C	55 (26 f)	21 (4)	30	2.5 m	5.8°/6.9°	1.1°	5.7°	30 mm/ 29 mm	1 mm	29 mm	5.3/2.1	3.2	4.2	(NDI)	11.2	26.1	pursuiit neck torsion, autonomic function	12 m
Moustafa	2018	Cervical myofascial pain syndrome	E	60 (20 f)	33.1 (8)	30	2.5 m	<25°/n/r	n/r	n/r	n/r	n/r	n/r	5.3/1.4	3.9	0.4	35.7/23.3	12.4	17.4	Improved range of motion, pain-pressure thresholds, cervical posture	12 m
Moustafa	2018	Cervical myofascial pain syndrome	C	60 (24 f)	31.9 (7)	30	2.5 m	<25°/n/r	n/r	n/r	n/r	n/r	n/r	5.1/1.6	3.5	4.2	35.1/24	11.1	28.5		12 m
Moustafa	2017	Cervicogenic dizziness	E	36 (14 f)	49.3 (4.7)	30	2.5 m	7.5°/21.2°	13.7°	20.9°	35 mm/ 0.9 mm	25 mm	14 mm	5.7/3.7	2.0	1.2	47.5/23.2	24.3	6.9	Improved dizziness severity, frequency, DHI, head repositioning accuracy	12 m
Moustafa	2017	Neck pain	C	36 (11 f)	50.4 (4.9)	30	2.5 m	7.2°/6.7°	−0.5°	6.2°	32 mm/ 33 mm	−1 mm	35 mm	5.9/3.6	2.3	6	49.8/24.2	25.6	39.2		12 m
Moustafa	2017	Cervical spondylotic radiculopathy	E	15 (? f)	n/r	30	2.5 m	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	Improved lordosis, pain, DSSEPs, flexion-extension kinematics	3 m
Moustafa	2017	Cervical spondylotic radiculopathy	C	15 (? f)	n/r	30	2.5 m	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r	n/r		3 m
Moustafa	2016	Cervical discogenic radiculopathy	E	30 (11 f)	41.5 (3.7)	30	2.5 m	6.5°/19.7°	13.1°	19.2°	25.4 mm/ 13.0 mm	13.3 mm	15.1 mm	5.1/1.3	3.8	0.5	20.2/7.7	12.5	4	Improved arm pain,DSSEPs, central somatosensory conduction time	12 m
Moustafa	2016	Cervical discogenic radiculopathy	C	30 (12 f)	43.9 (6.2)	30	2.5 m	6.5°/6.7°	0.2°	6.8°	24.4 mm/ 23.5 mm	0.9 mm	24.1 mm	4.7/1.2	3.5	3.9	20.6/12.9	7.7	20		12 m
Moustafa	2013	Fibromyalgia	E	40 (10 f)	54.3 (7)	36	3 m	6.6°/19.4°	12.8°	18.3°	27.9 mm/ 14.5 mm	13.4 mm	14.9 mm	5.2/3.2	2.0	2.9	70.9/44.1	26.8	9.3	Improved 3D posture, algometry, QOL, fatigue, depression, anxiety, sleep, fibromyalgia	12 m
Moustafa	2013	Fibromyalgia	C	40 (12 f)	52.2 (6)	36	3 m	7.5°/7.2°	−0.4°	5.5°	27 mm/ 19.1 mm	7.9 mm	21.2 mm	4.6/3.1	1.5	4.7	71.3/43.6	27.7	47.9		12 m
nRCTs
Harrison	2003	Chronic neck pain	E	33 (14 f)	36.0 (14.2)	38	3.75 m	4.2°/ 22.1°	17.9°	22.0°	24.9 mm/ 15.4 mm	9.5 mm	15.0 mm	4.1/1.1	3.0	n/r	n/r	n/r	n/r		14 m
Harrison	2003	Chronic neck pain	C	30 (14 f)	37.0 (11.1)	0	n/a	10.2°/ 11.1°	0.9°	n/r	23.1 mm/ 22.4 mm	0.8 mm	n/r	3.5/3.4	0.1	n/r	n/r	n/r	n/r		8.5 m
Harrison	2002	Chronic neck pain	E	30 (25 f)	33.1 (14.3)	35	2.25 m	12.4°/ 26.6°	14.2°	22.9°	22.1 mm/ 15.9 mm	6.2 mm	15.3 mm	4.3/1.6	2.7	n/r	n/r	n/r	n/r		15.5 m
Harrison	2002	Chronic neck pain	C	24 (13 f)	35.1 (13.9)	0	n/a	9.9°/ 10.8°	0.9°	n/r	n/r	n/r	n/r	3.6/3.8	−0.2	n/r	n/r	n/r	n/r		8 m
Harrison	1994	n/s(hypolordosis)	E1	35 (11 f)	34.5 (10.9)	60	3 m	14.5°/ 27.7°	13.2°	n/r	19.5 mm/ 12.7 mm	6.8 mm	n/r	n/r	n/r	n/r	n/r	n/r	n/r	Reliability assessment of X-ray markings by 3 examiners	none
			E2	30 (20 f)	35.8 (12.5)	60	3 m	18.7°/ 19.9°	1.2°	n/r	21.3 mm/ 19.3 mm	2.0 mm	n/r	n/r	n/r	n/r	n/r	n/r	n/r		none
			C	30 (17 f)	34.8 (11.1)	0	n/a	18.2°/ 21.2°	2.9°	n/r	20.9 mm/ 20.4 mm	0.5 mm	n/r	n/r	n/r	n/r	n/r	n/r	n/r		none

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RCT: randomized controlled trial; nRCT: non-randomized controlled trial; AHT: anterior head translation; f/u: follow-up; E: experimental group; C: control group.

It is also important to appreciate that the cases listed in Table 1 represent a diverse population affected by varied pathological conditions. It can be cautiously concluded that extension traction methods aimed to improve the cervical lordosis and reduce AHT as part of a multimodal rehabilitation program appears to be universally successful across genders, adult age groups, and pathological complaints. Further, it appears cervical lordosis and other radiographic parameter improvements as well as the corresponding pain relief and disability improvements are stable and lasting when an average maintenance program of 2× per month is continued after the initial intensive corrective care (Table 2).

Neck pain and headache improvement after cervical spine treatment including improved radiographic sagittal plane alignment has a direct link of causation in the current literature. Harrison et al., for example, were able to differentiate symptomatic neck pain patients from asymptomatic volunteers statistically by discriminant analysis¹³⁾. In their study¹³⁾, chronic neck pain and acute neck pain sufferers had an average cervical lordosis of 22° and 28.6° (C2-7 posterior tangents), respectively. McAviney et al. determined that patients having neck curves (C2-7 posterior tangents) less than 20° had twice the likelihood of experiencing neck pain, and patients having a curve less than 0° (straight and kyphotic curves) had an 18× likelihood of experiencing neck pain¹⁶⁾. Also, forward head position which can occur with loss of lordosis is associated with neck pain⁷²⁾.

Regarding loss of cervical lordosis and anterior head translation being linked to headache, there is accumulating evidence supporting a direct relationship¹⁷^,⁷³^,⁷⁴^,⁷⁵^,⁷⁶⁾. In fact, a review by Mingels et al. found that “contemporary review of neuroanatomical, biomechanical and non-nociceptive pathways, with integration of modern pain neuroscience in tension-type and cervicogenic headache, supports spinal posture as a trigger for episodic headache”⁷⁴⁾. Specifically, they determined that poor posture can activate C1-C3 nociceptors and that “convergence with trigeminal afferents at the trigeminocervical nucleus could explain spinal headache”⁷⁴⁾. It is consistently reported that headache sufferers have loss of cervical lordosis⁷³⁾ and forward head postures⁷⁵^,⁷⁶⁾.

The data summarized in this review points to the cervical lordosis and AHT as being important biomechanical parameters (i.e. biomarkers) that may have implications for the treatment of conditions other than the common craniocervical pathologies of neck pain and headache. One plausible explanation for this is through the biomechanical effects of cervical subluxation on the central nervous system. Any flexion (loss of lordosis) of the cervical spine causes a simultaneous elongation of the cervical spinal canal¹⁰⁾; in turn, an increased strain is exerted onto the ‘pons-cord tract’ which includes the spinal cord, its nerve roots as well as the brainstem including cranial nerves V-XII⁷⁷^,⁷⁸⁾. Under these conditions, normal physiologic tension within the spinal cord may exceed some threshold where normal movements of the head and neck (e.g. flexion) will exert pathologic tension onto the cord, impeding (slowing or altering) its neuro-conduction directly and/or indirectly by limiting its blood flow¹⁰^,⁷⁷^,⁷⁸⁾. Thus, this ‘dynamic strain’ may elicit symptoms consistent with various disease states including radiculopathies, myelopathies, dizziness⁷⁹⁾ or contribute to poor sensorimotor control⁸⁰⁾ and affect balance, gait and other activities of daily living. In support of this mechanical tension phenomenon of altered spinal cord function, Moustafa et al.²¹⁾ recently, using somato-sensory evoked potentials, identified that correction of cervical lordosis and reduction of AHT was linearly related to increased central conduction speed (spinal cord velocity); results were maintained at a 3-month follow up.

Since the diagnosis of alterations of cervical lordosis is not widely recognized by the medical community⁸¹⁾ and due to the fact that many manual therapists do not routinely X-ray their patients, many patients will not be appropriately biomechanically diagnosed with cervical spine subluxation and therefore, their spine deformity will not be treated and it will persist despite short-term relief from ‘black-box treatment’ procedures²⁰^,²⁶⁾. In fact, as discussed recently²⁰^,²⁶⁾, the Moustafa trials have exposed the trend that many physiotherapeutic treatments that provide temporary pain relief fail to provide lasting benefits; in other words, the patients’ pain levels regress towards baseline after treatment cessation. Alternatively, patients who receive treatment that includes a form of extension traction to restore lordotic alignment and reduce AHT, who present with hypolordosis, experience relief of symptoms that remains up to 2 years²²⁾. This trend points to the cervical lordosis and sagittal postural alignment as being important biomechanical biomarkers in those who suffer from craniocervical disorders, as has been suggested in the treatment of headaches³¹⁾, dizziness³⁷⁾ and whiplash associated disorders⁵⁰⁾.

There are limitations to this review. The fact that we included only case studies/series in this review, dictated that no statistical analysis could be performed other than simple averages. Also, the case studies documented real clinical practice and therefore, multiple treatments were performed concurrently on the patient. This conceals which specific aspects of the treatment regimen contributed to the improvement in lordosis, reduction in AHT, and also to the relief of the patient. As previously mentioned, and discussed elsewhere²⁶⁾, the series of randomized trials by Moustafa and colleagues has proven that targeted cervical extension traction results in lordosis and AHT improvements as well as long-lasting symptomatic relief in patients despite discontinuing treatment.

Further limitations include the distinction between primary conditions treated versus clinical outcomes achieved. For instance, a patient with osteoarthritis of the cervical spine may have had a successful outcome (i.e. improved lordosis, less pain) but remains osteoarthritic (i.e. Fortner et al.⁵¹⁾). Alternatively, many patients did have improvement or ‘cure/remission’ to their primary complaint, for example Breton et al.⁴³⁾ (carpal tunnel syndrome), Fortner et al.⁴⁹⁾ (Dizziness), etc; these distinctions must be carefully determined from studying the Table 1−‘Other outcomes’. Obviously, caution should be taken to not assume a long-term resolution of the patient condition particularly when no follow-up was reported. Last, since this review simply summarized reports using averages, cautious interpretation of results are suggested, particularly as these cases are not ‘controlled’ as in higher evidential controlled trials.

Future case reports describing CBP protocols used to increase cervical lordosis and reduce AHT should ensure use of standardized symptom, disability, and functional rating scales, fully describe the traction method and other treatment procedures and include a follow-up period of at least 6-months to a year. Cases should also report all radiographic measurements including lordosis, anterior head translation and atlas plane line. Further, future cases should also characterize the cervical lordosis in relation to both the T1-sagittal slope and to the thoracic inlet morphology which is a unique anatomical variable known to influence the amount of cervical lordosis that a given spine can achieve. The thoracic inlet morphology and T1-slope relative to the cervical lordosis are known alignment variables that predict initial and post treatment outcomes. In fact, no CBP case reported a modification to the cervical lordosis goal of care in order to provide a patient-specific customization from the default ‘ideal’ curve⁸²^,⁸³⁾. This is perhaps the most significant criticism of more recent case reports. Last, future cases should report on 3–10 consecutive patients with the same condition, the same general age and gender, and follow the same protocols and procedures; this would make the outcomes more meaningful having greater evidential impact.

Conflict of interest

Dr. Paul Oakley (PAO) is a paid consultant for CBP NonProfit, Inc.; Dr. Deed Harrison (DEH) teaches chiropractic rehabilitation methods and sells products to physicians for patient care as used in this manuscript.

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[r1] 1.Scheer JK, Lau D, Ames CP: Sagittal balance of the cervical spine. J Orthop Surg (Hong Kong), 2021, 29: 23094990211024454. [DOI] [PubMed] [Google Scholar]

[r2] 2.Scheer JK, Lau D, Smith JS, et al. : Alignment, classification, clinical evaluation, and surgical treatment for adult cervical deformity: a complete guide. Neurosurgery, 2021, 88: 864–883. [DOI] [PubMed] [Google Scholar]

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Structural rehabilitation of the cervical lordosis and forward head posture: a selective review of Chiropractic BioPhysics^® case reports

Paul A Oakley, DC, MSc

Sean Z Kallan, BSc

Deed E Harrison, DC

Abstract

INTRODUCTION

METHODS

RESULTS

Table 1. Details of case reports showing improved cervical lordosis in the treatment of patients with various pathological disorders.

Table 2. Details of the cases that reported a follow-up after the initial corrective care to restore cervical lordosis.

DISCUSSION

Table 3. Summary of clinical trial details using CBP extension traction in the improvement of cervical lordosis.

Conflict of interest

REFERENCES

ACTIONS

PERMALINK

RESOURCES

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PERMALINK

Structural rehabilitation of the cervical lordosis and forward head posture: a selective review of Chiropractic BioPhysics® case reports

Paul A Oakley, DC, MSc

Sean Z Kallan, BSc

Deed E Harrison, DC

Abstract

INTRODUCTION

METHODS

RESULTS

Table 1. Details of case reports showing improved cervical lordosis in the treatment of patients with various pathological disorders.

Table 2. Details of the cases that reported a follow-up after the initial corrective care to restore cervical lordosis.

DISCUSSION

Table 3. Summary of clinical trial details using CBP extension traction in the improvement of cervical lordosis.

Conflict of interest

REFERENCES

ACTIONS

PERMALINK

RESOURCES

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Structural rehabilitation of the cervical lordosis and forward head posture: a selective review of Chiropractic BioPhysics^® case reports