**3. Restoration of lumbar lordosis**

The first clinical trial using CBP methods for the restoration of lumbar lordosis was a non-randomized trial in 2002 [19]. In this trial, 48 patients with chronic low back pain (CLBP) were treated with SMT and extension traction to the lumbar spine for an average of 36 treatment sessions over an average of 12 weeks. There was an average of an 11.3° increase in lumbar lordosis from L1-L5 ARA (9.1° increase from T12-S1 Cobb). A control group of 30 CLBP patients had no pain reduction and no improvement in spine parameters. This trial demonstrated, for the lumbar spine with CLBP patients having hypolordosis, that routine increases in lumbar curvature is achievable; patients who get no treatment have no increase in lumbar curve and remain in pain. Harrison et al. concluded: "This new method of lumbar extension traction is the first nonsurgical rehabilitative procedure to show increases in lumbar lordosis in chronic LBP subjects with hypolordosis."

Since the original trial outlining the CBP extension traction approach for lumbar hypolordosis, two more randomized controlled trials have documented that superior outcomes occur in mechanical LBP and sciatic patients receiving lumbar extension traction as part of comprehensive physiotherapeutic programs versus those who receive the physiotherapy without the extension traction (**Figures 9** and **10**) [25–27]. These results mirror the outcomes as found from the trials on the cervical spine by CBP extension traction methods [24, 28–35]. **Table 2** summarizes the two lumbar trials [25–27].

### **3.1 CBP protocol for restoring lumbar lordosis**

Low back disorder patients who concurrently have lumbar hypolordosis require lumbar extension traction to increase their lumbar structural mal-alignment. **Figure 11** shows three different positions for the application of lumbar extension traction. Although there is not yet enough research to suggest one method over the other, the choice is up to the doctor/therapist. It is suggested that those having high intensity pain and/or those who are older and frail and/or those with balance and locomotor challenges perform lumbar traction in the supine position.

Similar to that discussed for the cervical spine, initial traction should be for 3–5 min and progress to 10–20 min per treatment session [19, 25–27]. Simultaneous physiotherapeutic treatments, including SMT, are in order to provide initial pain relief and improved mobility so that the patient is able to tolerate the traction [36–38].

### *Restoration of Cervical and Lumbar Lordosis: CBP® Methods Overview DOI: http://dx.doi.org/10.5772/intechopen.90713*

### **Figure 9.**

*Data from two RCTs demonstrates patients receiving lumbar 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) remaining unaffected by conventional treatments (Weighted averages from Moustafa et al. [26, 27]).*

### **Figure 10.**

*Data from two RCTs demonstrates patients receiving lumbar extension traction as well as conventional treatments have pain reductions that are sustained for 6-months after stopping treatment versus comparative groups (controls) who show a regression (increasing) of pain intensity towards baseline after stopping treatment (Weighted averages from Moustafa et al. [26, 27]).*


### **Table 2.**

*Summary of two RCTs documenting results in lumbar lordosis improvements corresponding with various pain, disability, quality of life and physiological parameter improvements.*

### **4. Extension traction mechanisms**

Spinal traction has been around for literally hundreds of years. The unique aspect of CBP's traction for the purpose of increasing the physiologic lordosis whether for the cervical or lumbar spinal areas is performing traction in a hyperextended position. The key to significant structural spine alignment changes lays in the viscoelastic creep properties of the intervertebral disk (and ligaments) and myofascial tissues under therapeutic conditions [43].

**Figure 11.** *Lumbar extension traction as preformed in the seated, standing and supine positions (Courtesy: CBP seminars).*

Recently, Harrison and Oakley asked the question: *How does lumbar extension traction increase lordosis?* [44]. It was suggested that lumbar extension traction creates a sustained visco-elastic deformation in the soft tissues (muscles, ligaments, and discs) of the lumbar spine (or cervical spine). It is known that all soft tissues including tendons, ligaments, and discs display visco-elastic properties [45]. It is also known that when the soft tissues of the spine are subjected to a continuous load, the tissues will undergo three processes, "creep," "stress relaxation" and "hysteresis." Creep is the amount of deformation occurring in the tissues, stress relaxation is a reduction in the amount of the internal stress found in the tissues over time, and hysteresis is energy loss in the system from an exothermic reaction likely from the breaking of hydrogen-collagen bonds [45–49].

It is presumed that hyperextension traction targets the anterior portion of the discs, the anterior longitudinal ligament, and anterior column musculature specifically [36, 37]. Traction must be performed in a sustained and continuous manner for creep-relaxation and visco-elastic deformation to occur [45–49]. Thus, the biomechanical elongation of the anterior structures leads to a permanent

*Restoration of Cervical and Lumbar Lordosis: CBP® Methods Overview DOI: http://dx.doi.org/10.5772/intechopen.90713*

structural tissue resting length change and when performed in a frequent manner (i.e., daily or three times per week), a steady and consistent change to the spine alignment will occur as has been demonstrated by CBP for increasing the cervical lordosis by an average of 10–18° [18, 20, 21, 24, 28–35] and lumbar lordosis by an average of 7–11° [19, 25–27, 44] over the duration of 10-14 weeks. Note that the amount of change in the cervical and lumbar lordosis were measured radiographically on follow-up spine X-rays using standardized, reliable, and valid measurement methods [18, 20, 21, 24, 28–35].
