**2. Restoration of cervical lordosis**

The first clinical trial using CBP methods for the restoration of cervical lordosis was a non-randomized controlled trial (nRCT) published in 1994 [18]. This first trial substantiated two trends: (1) Sagittal cervical alignment could be changed routinely, in patient cohorts receiving extension traction; (2) Spine alignment does not improve following spinal manipulative therapy (SMT) as a comparative group receiving spinal manipulation had no improvement in lordosis. Two other nRCTs were published in 2002 [20] and 2003 [21] confirming the results in the first trial and demonstrated that follow-up of patients experiencing improvements in lordosis by extension traction showed these improvements were relatively stable (small or no loss) at 14 [21] or 15.5 [20] months follow-up. These two latter trials also documented pain reductions coinciding with the lordosis improvements [20, 21] versus no improvements in untreated control groups.

More recently, Moustafa et al. [24, 28–35] has performed multiple RCTs showing improvements in cervical lordosis with extension traction protocols as part of physiotherapeutic treatment programs. These trials have demonstrated superior long-term patient outcomes versus comparative patient groups who only receive the physiotherapy minus the extension traction. In fact, there is now good evidence substantiating CBP cervical extension traction protocols show long-term reduction of anterior head translation (**Figure 5**), long-term improvement in cervical lordosis (**Figure 6**), and long-term reduction in pain levels (**Figure 7**) versus treatments that are 'cookie-cutter' for the purpose of pain-relief.

### **Figure 5.**

*Data from 3 RCTs demonstrates patients receiving cervical extension traction as well as conventional treatments have reduction of anterior head translation that is sustained for 1-year after stopping treatment versus the comparative groups (controls) remaining virtually unaffected by conventional treatments (Weighted averages from Moustafa et al. [28, 30, 31]).*

### **Figure 6.**

*Data from 3 RCTs demonstrates patients receiving cervical 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) remaining unaffected by conventional treatments (Weighted averages from Moustafa et al. [28, 30, 31]).*

### **Figure 7.**

*Data from four RCTs demonstrates patients receiving cervical extension traction as well as conventional treatments have pain reductions that are sustained for 1-year 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. [28, 30, 31, 33]).*

**Table 1** summarizes the main outcomes from eight separate RCTs on CBPs extension traction as part of physiotherapeutic treatment programs versus comparative groups only receiving the physiotherapy and not the extension traction. Notably, and as demonstrated in **Figures 5**–**7**, pain-relief treatment programs (i.e., stretching/strengthening exercises, infrared irradiation, spinal manipulation, myofascial release, TENS, mobilization, hot packs – not including extension traction) do not improve the spinal parameters and only provide short-term pain relief that regresses after the cessation of treatment.

### **2.1 CBP protocol for restoring cervical lordosis**

The classic CBP "E-A-T" protocol includes Exercises, spinal Adjustments, and Traction in a MI application. Corrective exercises for a cervical spine that is hypolordotic/kyphotic includes cervical extension exercises (**Figure 8**). A new patient may begin with head extension exercises in mid-air, and then progress to using a resistance band placed at the mid/low neck at the apex of their curve abnormality. Repetitions may vary but may begin at 25 and increase to 50 or 100. The patient may be instructed to hold each repetition for 3–5 s [36, 37]. After the patient sufficiently demonstrates proficiency, prescription for home exercises should be made.

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


### **Table 1.**

*Summary of eight RCTs documenting results in cervical lordosis improvements and reduction of anterior head translation corresponding with various pain, disability, quality of life and physiological parameter improvements.*

### **Figure 8.**

*Cervical extension traction. Bottom right: Cervical extension exercises with resistance band (Courtesy: CBP seminars).*

The rationale for corrective exercises is to strengthen the weak muscles, and stretch the shortened muscles as presumably the patient has had the spinal misalignment for some time, usually many years, and the soft tissues will have, over time, adapted to the poor posture [41]. It is generally accepted that exercises alone will not lead to any substantial improvement in lordosis or decreased head translation, but are still important in order to provide stability to the spinal area as the patient is being simultaneously treated with passive spinal traction as part of the CBP rehabilitation program.

Although many CBP practitioners provide spinal manipulative therapy, the MI approach to treat a patient having cervical hypolordosis/kyphosis includes cervical hyperextension drop-table adjustments. The rationale for the application of these force vectors are to reset the tone of the postural muscles [42]. More often patients presenting with cervical spine hypolordosis or kyphosis have accompanying anterior head translation. For this reason, it is commonplace for the manual therapist to place the patient in the prone position and elevate the head support to position the patient in the MI. At the same time the patient can extend their neck

backwards (i.e., look forward and place their chin on the head support) to further place the spine into a hyperextended position. The manual therapist would place their contact hand at the mid-neck and/or on the upper thoracic spine and provide a force downwards to engage the drop-piece on a "drop-table."

Spinal traction is applied to increase the cervical lordosis and the spine must be placed in a hyperextended position (**Figure 8**). There are several extension traction variations; each is specific to the actual cervical alignment. For example, a cervical kyphosis with evident anterior head translation requires a posterior head translation and a "2-way" extension traction set-up [20], while a kyphosis without significant anterior head translation could be sufficiently reduced using a "Pope 2-way" extension traction without posterior head translation [21]. A patient having significant AHT having hypolordosis (but no kyphosis) should have sufficient reduction of AHT and increase in lordosis receiving extension-compression extension traction [18]. Initially, traction should be performed for 3–5 min and progress to 10–20 min per treatment session.
