**8. Clinical evidence of efficacy**

As mentioned, CBP technique has an abundance of clinical evidence supporting its effectiveness in correcting spine deformity and posture [7–10, 15, 42–55]. Recently, systematic reviews have summarized the clinical evidence as reported in the published controlled trials on these methods [56, 57]. We summarize the evidence here in four parts: cervical lordosis, lumbar lordosis, lateral translation (pseudo-scoliosis) postures of the head and thorax, and finally, evolving evidence from case reports/series on other important spine deformities including lumbar spondylolisthesis, cervical spondylolisthesis, thoracic hyperkyphosis, thoracolumbar junctional kyphosis, thoracic hypokyphosis (straight back syndrome), anterior sagittal balance, lumbar kyphosis (flat back syndrome), lumbar hyperlordosis, post-surgical cervical spine fusion and scoliosis.

#### **8.1 Cervical lordosis**

A recent systematic review found that of the RCTs and nRCTs on CBP extension traction methods, a 12–18° improvement in cervical lordosis can be achieved in

10–15 weeks after 30–36 treatment sessions [57]. Most RCTs have used the cervical Denneroll [43–47, 49, 50], and the three nRCTs all used different CET methods (**Table 1**) [7–9].

**Table 1** shows the improvement in degrees per treatment as well as theoretical numbers of treatments for various presenting cervical spine subluxations. On average, there appears to be just less than a half degree improvement per treatment session; obviously, there are patients that will have both more correction and less correction than this. Using this estimation as an initial guideline, evidence-based treatment numbers can be predicted. For example, a patient presenting with a cervical kyphosis of 20° would require over 100 treatments to restore the neck to a curve of 35°.

**Figures 13** and **14** show the long-term outcomes in patients receiving cervical extension traction versus comparative groups not receiving the traction. The patients restoring lordosis via CBP traction methods show improved cervical alignment which is maintained at a years' follow-up (**Figure 13**) whereas, comparative groups receiving various physiotherapeutic treatments less the extension traction do not experience cervical improvement (**Figure 13**) and also show that any initial pain relief regresses back towards baseline levels after the cessation of treatment (**Figure 14**). Patient's with improved lordosis retain their initial pain relief a year later (**Figure 14**). This is alarming as it shows patients receiving various physiotherapeutic treatments who do not improve their cervical lordosis (in hypolordotic patients) will have a future regression of symptoms post-treatment and may be misled by 'apparent treatment efficacy' [5, 57].

#### **Figure 13.**

*Data from five RCTs demonstrates patients achieving cervical lordosis improvement (via extension traction) as well as conventional treatments have lordosis improvements that are sustained for 1 year after stopping treatment versus the cervical curve of comparative groups (controls not achieving lordosis improvement) remain unaffected by conventional treatments (weighted averages from five RCTs [44, 45, 47, 49, 50]). \* indicates a significant group difference as specified in each of the five trials; brackets represent weighted standard deviation.*

*DOI: http://dx.doi.org/10.5772/intechopen.102686 An Introduction to Chiropractic BioPhysics® (CBP®) Technique: A Full Spine Rehabilitation…*

#### **Figure 14.**

*Data from five RCTs demonstrates patients achieving cervical lordosis improvement (via extension traction) as well as conventional treatments have pain reductions that are sustained for 1 year after stopping treatment versus comparative groups (controls not achieving lordosis improvement) who show a regression (increase) of pain intensity towards baseline after stopping treatment (weighted averages from five RCTs [45–47, 49, 50]). \* indicates a significant group difference as specified in each of the five trials; brackets represent weighted standard deviation.*

#### **8.2 Lumbar lordosis**

A recent systematic review found "Limited but good quality evidence substantiates that the use of extension traction methods in rehabilitation programs definitively increases lumbar hypolordosis" [56]. The authors further stated: "Preliminarily, these studies indicate these methods provide longer-term relief to patients with low back disorders versus conventional rehabilitation approaches tested" [56]. On average, a 7–11° increase in lordosis can be achieved over 10–12 weeks after 30–36 treatment sessions (**Table 2**).

It must be mentioned that lumbar extension traction is necessary to increase the lumbar lordosis. Importantly, using the data from published trials [10, 53–55], one can extrapolate approximate treatment duration (**Table 2**). As seen, a mild hypolordotic lumbar spine of 30° (L1-L5 ARA) may only require 32–48 treatments, whereas, a flat lumbar curve would require 127–194 treatments to achieve a normal 40° lordosis.

The same trend as observed in patients receiving cervical lordosis correction versus comparative groups not receiving lordosis improvement is seen in the trials on the lumbar spine [5, 56]. Lordosis increase in patients receiving lumbar extension traction is achieved and maintained at 6-months follow-up (**Figure 15**); these patients also retain their initial pain relief whereas, comparative patient groups not receiving lordosis improvement (**Figure 15**) lose their initial pain relief by 6-months after cessation of treatment (**Figure 16**). Again, this is alarming and shows how active low back treatment, although offering transient pain relief, will likely regress after treatment if not receiving concurrent lordosis correction in those suffering from hypolordotic-related LBP [5, 56].

#### **8.3 AP head and thorax postures**

Coronal plane lateral translations of the head and thorax also referred to as 'pseudo-scoliosis' each has an nRCT published [15, 42] and many case reports

#### **Figure 15.**

*Data from two RCTs demonstrates patients achieving lumbar lordosis improvement (via extension traction) as well as conventional treatments have lordosis improvements that are sustained for 6-months after stopping treatment versus the lumbar curve of comparative groups (controls not achieving lordosis improvement) remain unaffected by conventional treatments (weighted averages from two RCTs [53, 54]). \* indicates a significant group difference as specified in each of the two trials; brackets represent weighted standard deviation.*

#### **Figure 16.**

*Data from two RCTs demonstrates patients achieving lumbar lordosis improvement (via extension traction) as well as conventional treatments have pain reductions that are sustained for 6-months after stopping treatment versus comparative groups (controls not achieving lordosis improvement) who show a regression (increase) of pain intensity towards baseline after stopping treatment (weighted averages from two RCTs [53, 54]). \* indicates a significant group difference as specified in each of the two trials; brackets represent weighted standard deviation.*

*DOI: http://dx.doi.org/10.5772/intechopen.102686 An Introduction to Chiropractic BioPhysics® (CBP®) Technique: A Full Spine Rehabilitation…*

demonstrating its reduction [16, 58–63]. As discussed earlier, the differentiation from true scoliosis is that the involved vertebrae have minimal to no rotation, whereas, true scoliosis has substantial vertebral rotation (**Figure 6**). Also, the spinal coupling pattern of a laterally translated body mass (head or thorax) will demonstrate the lower involved spinal region to laterally flex towards the side of the translation and the upper involved spinal region to laterally flex back towards the vertical [35, 36].

Based on the data, a laterally translated body mass can be reduced about 7–8 mm after about 35 treatments. On average, correction of a laterally translated head or thorax can be corrected at about 0.2 mm per treatment, or about 1 mm per five treatments. Extrapolations of treatment numbers to patient subluxation presentation are shown in **Table 3**. From the data in each of the nRCTs, an approximate 50% reduction of the initial laterally translated head and thorax postures occurred; therefore, an average patient having an approximate 15 mm translation posture (head or rib cage) requires 6-months of corrective care (approximately 72 treatments). It must also be mentioned that many case reports have demonstrated larger lateral translation postural corrections/reductions with CBP methods in similar time frames [16, 58–63], thus, these serve as approximate treatment extrapolations.

#### **8.4 Other spine deformities**

It is known that the science for manual therapies is lacking [64]. Therefore, lesser forms of evidence must be considered when evaluating various treatment approaches used to treat various spinal conditions by manual therapists [65, 66]; this includes treatment utilizing CBP methods. We now highlight more recent case studies and series showing structural spinal correction for a variety of relatively common disorders.

#### *8.4.1 Lumbar spondylolisthesis*

Fedorchuk et al. [67] reported on an 11 mm reduction (13.3–2.4 mm) of an L4 anterolisthesis in a 69-year old suffering from LBP and leg cramping. Pain relief was achieved after 60 treatments over 45 weeks. This was the first documented report of a reduction of a Grade 2 lumbar spondylolisthesis by CBP methods, as well as any other non-surgical method.

Oakley and Harrison reported on the reduction of multiple retrolistheses from L1-L4 ranging from 4.5 to 5.9 mm in a 32-year old male with LBP [68]. These were all reduced to within normal (<4.5 mm) after approximately 36 treatments over 14-weeks. A 13-month follow-up indicated the patient remained well and reported no back pain and the corrections had remained stable.

Fedorchuk et al. [69] reported on the reduction of L1 (−6.6 to −1.7 mm) and L2 (−6.1 to −2.0 mm) retrolistheses and an L5 anterolisthesis (+6.8 to −2.5 mm) in a 63-year old female bodybuilder with severe LBP and osteoarthritis. Thirty treatments were given over 10-weeks which resulted in normalizing all spondylolistheses as well as a dramatic reduction in pain and an ability to leg press 60 more pounds in the gym.

Fedorchuk et al. reported the complete reduction of an L3 retrolisthesis and L4 anterolisthesis after 50 treatments over a 7-month period [70]. The patient was 57-years old with severe LBP and sciatica. The L3 retrolisthesis reduced from −5.3 to −1.7 and the L4 anterolisthesis reduced from +5.4 to +1.0 mm. After treatment the patient was able to return to playing hockey and experienced full resolution of the back pain which had forced him to retire from sport. A 1-year follow-up showed the patient had remained well and maintained the corrections.
