**5. Extension traction protocols**

Although strict CBP technique methods incorporate exercises, spinal adjustments and spinal traction (E-A-T), these protocols have been discussed elsewhere [1, 36–38]. We will outline the critical protocol parameters that apply specifically to extension traction.

A patient must be screened for the presence of spinal hypolordosis in the cervical or lumbar spine by standard standing X-ray. External (non-imaging methods) body measurements are not valid for the assessment of the magnitude, segmental contributions, and geometric shape of a patient's lumbar or cervical lordosis. Furthermore, only direct spine imaging allows the visualization and quantification of a patients pelvic and thoracic inlet morphologies which are known variables that influence the magnitude of sagittal curvature that should be present and can be achieved through rehabilitation [37, 39, 40]. In the majority of cases, all radiographs should be taken with the patient in a standardized position, standing freely without support, with arms fully flexed with the hands in the clavicle position [50, 51]. We recommend the feet to be positioned hip-widths apart without any shoes as well as the patient should have their eyes open and be staring straight ahead at eye level. Although full spine 36-inch lateral views may be used, it is recommended that a dedicated lateral cervical be taken to more accurately assess cervical subluxation as the 36-inch view projects the head more posteriorly and the cervical spine flatter [52, 53]. An obvious concern about routine X-rays is the exposure to radiation, we address this issue in the next section.

Although various measurement methods may be used, we recommend the Harrison posterior vertebral body tangent method as it is highly reliable (small standard error of measurement; i.e., <2° for regional measures of C2-7 and L1-5) [12–15]. Although C2-T1 absolute rotation angle (ARA) can be used, typically C2-C7 ARA is standard for measuring the cervical lordosis and L1-L5 ARA for the lumbar lordosis.

A patient may start traction for only 3–5 min initially. Increasing traction time may progress by 1–3 min on subsequent treatments pending their clinical tolerance and response. Total traction time should be between 10 to 20 min maximum. There is no significant benefit to performing traction longer than 20 min as the majority of visco-elastic creep deformation occurs in this time [48].

Typical treatment plans include seeing a patient three-times per week for 10–12 weeks prior to a repeat X-ray and analysis of structural improvement. As outlined in previous works [36–38], a patient may require several rounds of treatments to achieve a spinal alignment in the realm of normal/ideal; this is particularly true for patients having gross spinal deformities, high pain levels, and disability, as demonstrated in the treatment of non-iatrogenic flat back [44]. It is not untypical to treat a Patient three times per week, for 6–12 months in these cases.
