Journal of Manipulative and Physiological Therapeutics
J Manipulative Physiol Ther. 1994 Sep;17(7):454-64.  

The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study.

Harrison DD, Jackson BL, Troyanovich S, Robertson G, de George D, Barker WF.
Chiropractic BioPhysics, Non-Profit, Inc., Harvest, AL 35749.

OBJECTIVE: To experimentally investigate the effect of cervical extension-compression traction combined with diversified chiropractic manipulation and drop table adjusting in establishing or increasing cervical lordosis. DESIGN: Blinded, before and after trial with pre- and postlateral cervical radiographic measurement. SETTING: Primary care private chiropractic clinic in Saugus, MA. SUBJECTS: A) Control group--convenience sample who had no health care for 10-14 wk, 30 persons. B) Treatment group 1, nonrandomized control trial, 35 persons, whose pre- and postlateral cervical radiographs were taken 10-14 wk apart and whose radiographs clearly depicted C1 through C7. C) Treatment group 2, nonrandomized control trial, 30 persons, whose pre- and postlateral cervical radiographs were taken 10-14 wk apart and whose radiographs clearly depicted C1 through C7.

INTERVENTIONS: Treatment group 1: diversified spinal manipulation, drop table adjustments and cervical extension-compression traction five times per week for 10-14 wk (12 wk +/- 2). Treatment group 2: diversified spinal manipulation and drop table adjustments five times per week for 10-14 wk (12 wk +/- 2). MAIN

OUTCOME MEASURES: Anterior head translation millimeters, C2 to C7 absolute rotation angle, angle of C1 to horizontal (atlas plane angle), five relative rotation angles (C2-3, C3-4, C4-5, C5-6, C6-7) and qualitative classification of lordotic configuration. RESULTS: No statistically significant changes existed between the pre- and posttests for the control group except in the C6-7 relative rotation angle. In the treatment group 1, statistically significant differences were found in all X-ray markings. Twenty-nine of 35 members have a lordosis after treatment compared to 11 of 35 before treatment. The C2 to C7 angle changed an average 13.2 degrees, C1 to horizontal changed an average 9.8 degrees, the anterior head translation reduced an average of 6.8 mm, the average relative rotation angle changed: C2-3: 3.1, C3-4: 5.5, C4-5: 4.80, C5-6: 2.7 and C6-7: 1.1. In the treatment group 2, no statistically significant changes existed between the pre- and posttests except atlas angulation to horizontal which increased an average of 3.0 degrees.

CONCLUSIONS: A transformation to a lordotic configuration or increase in lordotic configuration occurred and was measured in the majority of treatment group 1 subjects, while no change in the control group and essentially no change in treatment group 2 was measured. Extension-compression traction combined with diversified chiropractic manipulation and drop table adjusting procedures may improve or partially reestablish the cervical lordosis in 10-14 wk of daily care.

Publication Types:
· Clinical Trial
· Randomized Controlled Trial

PMID: 7989879 [PubMed - indexed for MEDLINE]

CBP Structural Rehabilitaion of the Cervical Spine, Deed E. Harrision, DC, Donald D. Harrison, PhD, DC, MSE, Jason W. Haas, DC, 2002 Harrison CBP Seminars, Inc.  pg. 56, “Cervical Lordosis and Headaches”

     We believe it relevant that several studies have investigated and linked the relationship of altered cervical curve configuration to the presence of chronic headache pain.  In a survey of over 6,000 cases of chronic headache sufferes, Braaf and Rosner found that “complete or segmental loss or reversal of the normal lordotic curve of the cervical spine is the most consistent tension and migraine headaches, Vernon et al. found a high incidence of hypolordosis, straightened and reversed cervical curve configurations.  Also, Nagasawa et al. compared 372 patients with tension headaches to 225 controls matched for age and sex.  They found patients with tension headaches to 225 controls matched for age and sex.  They found statistically significant differences between the two groups, with patients having straightened curve was straight more frequently.  This information contrasts nicely with the findings of Gore et al., where in asymptomatic subjects, the cervical curve increased with age.  Gore et al. found that the average C2-C7 lordosis was 27 degrees in their older asymptomatic patients compared to an average 23 degree for all asymptomatic patients.

CBP Structural Rehabilitaion of the Cervical Spine, Deed E. Harrision, DC, Donald D. Harrison, PhD, DC, MSE, Jason W. Haas, DC, 2002 Harrison CBP Seminars, Inc. Studies Referenced in “Cervical Lordosis and Headaches”

1.  Headache. 1993 Feb;33(2):90-5.  

Roentgenographic findings of the cervical spine in tension-type headache.
Nagasawa A, Sakakibara T, Takahashi A.

Department of Neurology, Nagoya University School of Medicine, Japan.

Roentgenographic studies were carried out on 372 patients with tension-type headache and 225 normal control subjects to determine relationships between straightened cervical spines, low-set shoulders, and cervical spine instability. A great majority of the patients with tension-type headache were found also to have straightened cervical spine. Patients with tension-type headache may have a restricted progression of the cervical spinal lordosis, which results in a straightened cervical spine. The flexor muscles of the head and neck prevent physiological lordosis of the cervical spine, and their sustained chronic contraction may be a principal cause of a straightened neck. The low-set shoulder was frequently seen in patients with tension-type headache, and it may result in traction of the brachial plexus, which gives rise to pain in the neck and shoulders. Cervical spine instability, on the other hand, was rather infrequent in patients with tension-type headache. Its relationship to tension-type headache is unclear and warrants further study. Our results suggest that both a straightened cervical spine and low-set shoulders may play an important role in the pathogenesis of tension-type headache and its accessory symptoms.

PMID: 8458729 [PubMed - indexed for MEDLINE]

2.  J Manipulative Physiol Ther. 1992 Sep;15(7):418-29.  

Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study.

Vernon H, Steiman I, Hagino C.
Center for the Study of Spinal Health, Canadian Memorial Chiropractic College, Toronto, Ontario.

OBJECTIVE: The prevalence and nature of findings of cervicogenic dysfunction is explored in subjects with muscle contraction/tension-type (MCH) headache and common migraine without aura (CM). DESIGN: Descriptive survey. SETTING: Chiropractic outpatient research clinic. PATIENTS: Forty-seven (47) subjects, aged 18-55 with two categories of benign headache, were studied: MCH (tension-type) n = 19 (6 males, 13 females) and CM (without aura), n = 28 (3 males, 25 females). Subjects were recruited as part of an intervention trial and, thus, form a consecutive sample of patients. The present findings were elicited as part of the initial assessment. INTERVENTION: No therapeutic intervention is reported. MAIN OUTCOME MEASURES: Standardized headache history; plain film and dynamic spinal X rays; motion palpation; and pressure algometry. RESULTS: For CM, the most prevalent headache locations were frontal (81%) and occipital (78%). Neck pain and upper back pain accompanied headache in 90% and 41% of subjects, respectively. For MCH, the most prevalent headache locations were occipital (87%) and frontal (81%). Neck and upper back pain accompanied headache in 100% and 27%, respectively, of all subjects. For the total group, 77% of all subjects and 89% of females exhibited a marked reduction, absence or reversal of the normal cervical lordosis. Ninety-seven percent of all subjects exhibited, on dynamic X-ray studies, at least one significant abnormality of segmental mobility from C1 to C7, while 43% exhibited abnormalities at four or more segments. Segmental motion at C0-C1 was reduced in 90% of subjects in flexion and 70% of subjects in extension. On motion palpation, 84% of CM and MCH subjects were found to have at least two major fixations from C0 to C2. On pressure algometry, 92% of CM and 85% of MCH had at least one verifiable tender point (TP) in the upper cervical region. The most common locations for TPs were mid-cervical (C2-C3), lateral occipital and suboccipital. CONCLUSIONS: Both MCH and CM subjects demonstrate high occurrences of: a) occipital and neck pain during headaches; b) tender points in the upper cervical region; c) greatly reduced or absent cervical curve; and d) X-ray evidence of joint dysfunction in the upper and lower cervical spine. These findings support the premise that the neck plays an important, but largely ignored role in the manifestation of adult benign headaches. A case-control study should be conducted to confirm the greater prevalence of cervicogenic dysfunction in headache as compared to nonheadache subjects.

PMID: 1342581 [PubMed - indexed for MEDLINE]

3.  Spine. 2001 Nov 15;26(22):2463-6.  

Roentgenographic findings in the cervical spine in asymptomatic persons: a ten-year follow-up.

Gore DR.
Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

STUDY DESIGN: The lateral roentgenographic findings in 159 initially asymptomatic persons were reviewed at a 10-year interval. A questionnaire was used at the time of the last roentgenogram to determine the incidence of pain. OBJECTIVES: To identify the number of persons who experienced pain during that 10-year period, describe the roentgenographic changes, and determine the association between the development of symptoms and roentgenographic findings. SUMMARY OF BACKGROUND DATA: It is well established that degenerative changes of the cervical spine increase with age and may occur in asymptomatic persons. However, it is unknown whether pain is more likely to develop in persons with degenerative changes than in those with normal roentgenograms. METHODS: Lateral cervical roentgenograms were obtained in 200 asymptomatic persons, 100 women and 100 men, to obtain normal values of cervical lordosis and degenerative changes in persons aged 20-65 years. Ten years later, 159 participants had repeat roentgenograms and were administered a questionnaire regarding the presence or absence of pain. RESULTS: There was an increase in the number of subluxations and an increase in degenerative changes. Pain developed in 15% of participants in the 10-year interval. The presence of degenerative changes at C6-C7 on the initial roentgenogram was a statistically significant predictor of pain. CONCLUSION: With age, there is an increase in the number of subluxations and the incidence and severity of degenerative changes. Pain is more likely to develop in persons with degenerative changes at C6-C7.

PMID: 11707711 [PubMed - indexed for MEDLINE]

Other Studies:
There are several studies indicating cervical kyphosis as a factor predicting por results after whiplash injury.  In a 5-year long-term follow-up of 146 patients’ with whiplash injury.  Hohl identified cervical kyphosis as a factor predicting a poor outcome.  Norris and Watt followed 61 patients involved in motor vehicle accidents for a minimum of six months.  They found that abnormal neck curves “…are more common in patients with a poor outcome.”  In a prospective study, Ettlin et al. found that loss of lordosis was very common (68%) in patients with cerebral symptoms due to whiplash injury.

•  Recently in a prospective study of 110 patients, Kai et al. studied the relationship of neurogenic thoracic outlet syndrome (NTOS) to whiplash injury.  They found an incidence of cervical kyphosis of 44%-46% in the patients with NTOS compared to 11-24% in the subjects without NTOS.  Kai et al. concluded that reversal of the cervical lordosis was abnormal and cervical lordosis is a significant finding after whiplash injury.  Lastly, several studies have demonstrated that whiplash injuries do indeed cause reversals and other changes in the configuration of the cervical lordosis. 

CBP Structural Rehabilitaion of the Cervical Spine, Deed E. Harrision, DC, Donald D. Harrison, PhD, DC, MSE, Jason W. Haas, DC, 2002 Harrison CBP Seminars, Inc.  “Studies indicating Cervical Lordosis is related to pain after Whiplash”

1.  J Bone Joint Surg Br. 1983 Nov;65(5):608-11.  

The prognosis of neck injuries resulting from rear-end vehicle collisions.

Norris SH, Watt I.

Injury of the neck may result when a motor vehicle is run into from behind; such injury is frequently the cause of prolonged disability and litigation. We report a series of 61 patients with these injuries. A classification, based upon the presenting symptoms and physical signs has been evolved. This classification is shown to be a reliable basis for formulating a prognosis. Factors which adversely affect prognosis include the presence of objective neurological signs, stiffness of the neck, muscle spasm, and pre-existing degenerative spondylosis.

PMID: 6643566 [PubMed - indexed for MEDLINE]
2. J Neurol Neurosurg Psychiatry. 1992 Oct;55(10):943-8.  

Cerebral symptoms after whiplash injury of the neck: a prospective clinical and neuropsychological study of whiplash injury.

Ettlin TM, Kischka U, Reichmann S, Radii EW, Heim S, Wengen D, Benson DF.

University Clinics, Basel, Switzerland.

Twenty one unselected patients with an acute whiplash injury of the neck had neurological and neuropsychological assessment, cervical x rays, EEG, BAEP, MRI, and an otoneurological examination within two weeks of the injury. Subjectively, 13 patients reported concentration deficits, 18 reported sleep disturbances, 9 had symptoms of depression, and 7 female patients told of menstrual irregularities. Neuropsychological examination revealed significantly lower performance in tests related to attention and concentration compared to sex, age and educational matched control subjects. Otoneurological examination showed abnormalities in 9 of 17 whiplash subjects. EEG showed questionable changes in 8 of 18 recordings. MRI and BAEP were normal in all patients. Repeat neuropsychological testing in 15 patients at three months showed that attention deficits had improved but were still shown in 12 of 14 and the concentration deficits in 8 of 13 patients. At one year all patients had returned to work, 16 to full and 5 to part time employment. In 4, cognitive dysfunction remained the only significant problem. These findings are discussed as being compatible with possible damage to basal frontal and upper brain stem structures after whiplash injury of the neck.

PMID: 1431958 [PubMed - indexed for MEDLINE]

3. J Spinal Disord. 2001 Dec;14(6):487-93.  

Neurogenic thoracic outlet syndrome in whiplash injury.

Kai Y, Oyama M, Kurose S, Inadome T, Oketani Y, Masuda Y.

Orthopaedic Surgery, Fukuoka City Hospital, Fukuoka, Japan.

A prospective study of 110 patients was carried out to determine the pathogenic significance of trauma to the upper body in the development of neural compressive irritation at the thoracic outlet. Twenty-nine patients were reviewed as cervical strain injuries (N group), 25 patients as probable neurogenic thoracic outlet syndrome (NTOS) (PT group), 39 patients as definite NTOS (T group), and 17 patients as NTOS associated with cervical disc disease (CD-T group). The time lapse between accident and diagnosis and the duration of treatment were significantly longer in T patients or CD-T patients than those in the N group. Radiography of NTOS patients also showed a higher percentage of cervical spine-length/height ratio. Traumatic NTOS would suggest two types related to direct damage of scalene muscles that included some physical aspects of cervical disc disease. Pathogenesis provided a key to the resolution of more complex posttraumatic problems of whiplash injury.

PMID: 11723397 [PubMed - indexed for MEDLINE]

4. Am J Med. 2001 Jun 1;110(8):651-6.  
Whiplash: a review of a commonly misunderstood injury.

Eck JC, Hodges SD, Humphreys SC.

University of Health Sciences, College of Osteopathic Medicine, Kansas City, Missouri, USA.

Whiplash injury is a relatively common occurrence, but its mechanism and optimal treatment remain poorly understood. It is estimated that the incidence of whiplash injury is approximately 4 per 1,000 persons. The most common radiographic findings include either preexisting degenerative changes or a slight flattening of the normal lordotic curvature of the cervical spine. Computed tomography and magnetic resonance imaging are generally reserved for cases of neurologic deficit, suspected disc or spinal cord damage, fracture, or ligamentous damage. Biomechanics studies have determined that after rear impact C6 is rotated back into extension before movement of the upper cervical vertebrae. Thus, the lower cervical vertebrae were in extension while the upper vertebrae were in a position of relative flexion, producing an S shape in the cervical spine. It is believed that this abnormal motion pattern might play a role in the development of whiplash injuries. Historically, a soft cervical collar has been used early after the injury in an attempt to restrict cervical range of motion and limit the chances of further injury. More recent studies report rest and restriction of motion to be detrimental and to slow the healing process.
PMID: 11382374 [PubMed - indexed for MEDLINE]