Journal of Manipulative and Physiological Therapeutics
Volume 27, Issue 2 , Pages 133-134, February 2004

Lateral cervical curve changes in patients receiving chiropractic care after a motor vehicle collision: a retrospective case series

123 Second St, Elko, NV 89801, USA

New Port Richey, FL, USA

Palmer College of Chiropractic, 1000 Brady St, Davenport, IA, USA

Article Outline

 

To the Editor:

Coleman et al1 reported a mean increase of 6.4° in the lateral cervical radiographs of 13 cervical acceleration deceleration (CAD) injured subjects following “chiropractic care.” Admittedly, the authors1 included subjects with at least 4 interventions.

We have several concerns to which we would appreciate a response. In Table 1, for patients receiving Activator Adjusting Instrument (AAI) adjustments per Activator Methods Chiropractic Technique protocols, plus C7 PA, without stretching exercises (subjects 4 and 13), the practitioners1 obtained 4.5° divided by 2 subjects or 2.25° improvement. By comparison, for patients receiving all 4 interventions, including stretching exercises, a total of 78.5° divided by 11 subjects, or an average of 7.14° improvement was documented. This indicates that AAI alone resulted in 2° improvement, which is about the average error of the method of drawing on the posterior bodies of C2 and C7.2, 3 It appears that the stretching accounts for the improvement of lordosis. The authors1 failed to comment on this important issue. Moreover, it is not apparent from the article exactly what motions of the skull were performed during these “stretching methods,” as the authors state only that, “These stretches were mild in nature and did not involve cervical extension.”

The authors1 inaccurately summarized the study by Harrison et al4 when they asserted that no change in the cervical lordosis following Chiropractic Biophysics (CBP) adjusting procedures was found. In actuality, Harrison et al4 found 2.9° increase in the C2-7 lordotic angle in the control group and 1.2° in patients receiving posteroanterior (PA) drop table adjustments at midneck (without traction). For patients receiving PA drop table adjustments (without traction), Harrison et al4 reported a change in atlas angulation of 3° (control group 0.8°) and reduction of anterior weight bearing of 2 mm (control group 0.5 mm). In other words, CBP adjusting produced the same magnitude of cervical lordosis improvements as compared with Activator adjusting in the current manuscript, albeit within the error of the measurement system.

Coleman et al1 stated that neutral resting posture is repeatable, and utilize this statement to conclude a 6.4° increase in lordosis is likely a treatment effect. However, we find it necessary to point out that radiograph positioning is repeatable in nonwhiplash injured control subjects5 but not in whiplash patients. Head position sense has been reported to be altered and not repeatable in recent whiplash injured subjects.6, 7 Accordingly, the authors' finding of 6.4° increase in cervical lordosis may, in fact, be solely due to head positioning errors in their whiplash patient sample.

Harrison et al8 found a mean increase in the cervical lordosis of 7° as a result of 14° or less or head extension on second lateral cervical radiographs in 40 neck pain subjects. Similarly, Hellsing9 found that 20° of increased skull extension caused only a 10° change in cervical lordosis. Since Coleman et al1 did not provide head extension measurements on their preradiographs and postradiographs, it is likely that their subjects' 6.4° improvement in cervical lordosis is due to slight positional differences on the 2 sets of radiographs.

In 2 separate studies with more than 1 year follow-up, Harrison et al10, 11 have found that subjects receiving a dosage of 36 to 38 treatments of combined manipulation, CBP extension traction, and warm-up extension exercises have increased head extension in association with increased cervical lordosis on posttreatment lateral cervical radiographs. However, because Harrison et al10, 11 provided head extension angles, total lordosis angles, and all segmental angles, they were able to show that the improvements in cervical lordosis were 3 to 5 times greater than that expected from increased head extension alone.

Because of these shortcomings, the data from Coleman et al1 do not show that chiropractic care can increase lordosis. At best, their data1 suggest that stretching might be responsible for increased lordosis but that adjusting with the AAI is not. More likely, the changes reported by Coleman et al1 are due to head positioning errors on the preradiographs and postradiographs because the magnitude of lordosis increase is within that found from head extension alone. While we applaud the attempt by Coleman et al1 to find alternate methods to increase a reduced cervical lordosis, we submit that due to faulty methods, no reliable conclusions can be drawn from this paper. In fact, their methods fall short of the “gold standard” of CBP cervical extension traction.4, 10, 11

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References 

  1. Coleman RR, Hagen JO, Troyanovich SJ, Plaugher G. Lateral cervical curve changes receiving chiropractic care following a motor vehicle collision (a retrospective case series). J Manipulative Physiol Ther. 2003;26:352–355
  2. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B. Cobb method or Harrison posterior tangent method (which is better for lateral cervical analysis?). Spine. 2000;25:2072–2078
  3. Harrison DE, Holland B, Harrison DD, Janik TJ. Further reliability analysis of the Harrison radiographic line drawing methods (crossed ICCs for lateral posterior tangents and AP modified Risser-Ferguson). J Manipulative Physiol Ther. 2002;25:93–98
  4. Harrison DD, Jackson BL, Troyanovich S, Robertson G, de George D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis (a pilot study). J Manipulative Physiol Ther. 1994;17:454–464
  5. Harrison DE, Harrison DD, Colloca CJ, Betz J, Janik TJ, Holland B. Repeatability over time of posture, radiograph positioning, and radiograph line drawing (an analysis of six control groups). J Manipulative Physiol Ther. 2003;26:87–98
  6. Loudon JK, Ruhl M, Field E. Ability to reproduce head position after whiplash injury. Spine. 1997;22:865–868
  7. Rubin AM, Woolley SM, Dailey VM, Goebel JA. Postural stability following mild head or whiplash injuries. Am J Otol. 1995;2:216–221
  8. Harrison DE, Harrison DD, Janik TJ, Holland B, Siskin L. Slight head nodding (does it reverse the cervical curve?). Eur Spine J. 2001;10:149–153
  9. Hellsing E. Changes in the pharyngeal airway in relation to extension of the head. Eur J Orthod. 1989;11:359–365
  10. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. New 3-point bending traction method of restoring cervical lordosis combined with cervical manipulation (non-randomized clinical control trial). Arch Phys Med Rehabil. 2002;83:447–453
  11. Harrison DE, Harrison DD, Betz J, Janik TJ, Holland B, Colloca C. Increasing the cervical lordosis with CBP seated combined extension-compression and transverse load cervical traction with cervical manipulation (non-randomized clinical control trial). J Manipulative Physiol Ther. 2003;26:139–151

PII: S0161-4754(03)00234-3

doi:10.1016/j.jmpt.2003.12.012

Journal of Manipulative and Physiological Therapeutics
Volume 27, Issue 2 , Pages 133-134, February 2004

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