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Reversing thoracic hyperkyphosis: A case report featuring mirror image® thoracic extension rehabilitation

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Jason E. Miller
Jason E. Miller
Jason E. Miller
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Paul A. Oakley
Paul A. Oakley
Scott B. Levin
Scott B. Levin
Scott B. Levin
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Deed Eric Harrison at Chiropractic BioPhysics Technique and CBP NonProfit, Inc. --A Spine Research Foundation in Eagle, ID
Deed Eric Harrison
  • Chiropractic BioPhysics Technique and CBP NonProfit, Inc. --A Spine Research Foundation in Eagle, ID
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Abstract and Figures

[Purpose] To present a case of non-surgical reduction of thoracic hyperkyphosis utilizing a multimodal rehabilitation program emphasizing the mirror image® concept. [Subject and Methods] A 15-year-old female presented to a rehabilitation office suffering from back and neck pains and headaches. The patient was treated sporadically over a period of 13-months. Treatment consisted of anterior thoracic translation and thoracic extension exercises, spinal traction and spinal manipulation. [Results] After 13-months of treatment the patient displayed a significant reduction in hyperkyphosis and a dramatic correction of her overall posture and spine alignment corresponding to the reduction in back/neck pains, headaches and the simultaneous improvement of various other health issues. [Conclusion] Thoracic hyperkyphosis can be reduced through a multimodal rehabilitation program emphasizing mirror image thoracic extension procedures.
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Case Study
Reversing thoracic hyperkyphosis:
a case report featuring mirror image®
thoracic extension rehabilitation
Jason E. MillEr1), Paul a. oaklEy2)*, scott B. lEvi n1), DEED E. Harrison3)
1) Private Practice, USA
2) Private Practice: Newmarket, ON, L3Y 8Y8, Canada
3)CBPNonprotInc.,USA
Abstract. [Pur pose] To present a case of non-surgical reduction of thoracic hyperkyphosis utilizing a multi-
modal rehabilitation program emphasizing the mirror image® concept. [Subject and Methods] A 15-year-old female
presented to a rehabilitation ofce suffering from back and neck pains and headaches. The patient was treated
sporadically over a period of 13-months. Treatment consisted of anterior thoracic translation and thoracic extension
exercises, spinal traction and spinal manipulation. [Results] After 13-months of treatment the patient displayed a
signicant reduction in hyperkyphosis and a dramatic correction of her overall posture and spine alignment cor-
responding to the reduction in back /neck pains, headaches and the simultaneous improvement of var ious other
health issues. [Conclusion] Thoracic hyperkyphosis can be reduced through a multimodal rehabilitation program
emphasizing mir ror image thoracic extension procedures.
Key words: Hyperkyphosis, Posture, Rehabilitation
(ThisarticlewassubmittedMar.17,2017,andwasacceptedApr.5,2017)
INTRODUCTION
Thoracic hyperkyphosis is associated with the incidence of compression fractures1, 2), reduced mobility1, 2), reduced qual-
ity of life3, 4), as well as decreased longevity5–10). In younger adolescent patients it has been determined the greater the
kyphosis curvature, the stronger the negative association to total pain, general self-image, general function, and overall level
of activity11).
Thoracic hyperkyphosis is difcult to treat clinically, and has unique considerations regarding its treatment12). Harrison et
al.13) demonstrated that one cause of thoracic hyperkyphosis is the normal spinal coupling pattern resulting from a posterior
thoracic translation postural shift. They also demonstrated that an anterior thoracic translation postural shift produces the
opposite postural pattern, a attening of the thoracic kyphosis13).
The logical treatment for those with thoracic hyperkyphosis with accompanying posterior thoracic translation posture is
the so-called ‘mirror image®’ approach, a term coined by Dr. Don Harrison14). Examples of the mirror image approach can
include the prescription of thoracic extension postural exercises and spinal traction.
Because of its serious potential/future health impact, the diagnosis of thoracic hyperkyphosis in younger patients deserves
serious attention and treatment aimed at reducing the deformity to prevent future undesirable consequences15). This case
presents the successful reduction of a hyperkyphotic thoracic posture in a 15-year-old suffering from back pains as well as
several other health issues.
J. Phys. Ther. Sci. 2 9: 1264–1267, 2017
*Corresponding author. Paul A. Oakley (E-mail: docoakley.icc@gmail.com)
©2017 The Societ y of Physical Therapy Science. Published by IPEC Inc.
This is an open-access ar ticle distributed under the ter ms of the Creative Commons Attr ibution Non-Commercial No Derivatives ( by-nc-nd)
License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)
The Journal of Physical Therapy Science The Journal of Physical Therapy Science
1265
SUBJECT AND METHODS
A 15-year-old female was brought by her parents to one of our rehabilitation clinics suffering from back and neck pains as
well as headaches. Upon visual inspection, it was obvious she had a pronounced thoracic hyperkyphosis.
The patient reported her pains were rated as 3–5/10 for her neck (0= no pain; 10= worst pain ever), 5–10/10 for migraine
headaches, 4–8/10 for chronic low back pain, 2–5/10 for mid back pain, and 2–4/10 for pain into the ribs and chest. She also
reported to suffer from dizziness, visual disturbances, numbness and tingling into the hands, weakness and coldness in the
left hand, heartburn, heart palpitations, shortness of breath, involuntary breathing patterns, as well as muscle cramps in the
hips, thighs and calves bilaterally.
Full spine radiographs were taken and biomechanically analyzed using the PostureRay® Software (Posture Co. Inc.,
Trinity, FL, USA). This system uses the Harrison posterior tangent method for lateral spine images16, 17) and the modied
Riser-Ferguson method for AP spine images17). These measurement methods are repeatable and reliable16–18).
The patient had several postural faults, the larger and notable ones included a forward head posture (35.6 mm vs. <15 mm
normal19), Fig. 1), thoracic hyperkyphosis (T1–T12= 71.3° vs. 43.7° normal20), Fig. 2), and posterior thoracic translation
posture (−59.2 mm vs. 0 mm normal13), Fig. 3).
The patient was treated with a multimodal rehabilitation program14, 21, 22) including mirror image corrective exercises,
spinal traction, and spinal manipulation. Since the patient had a large posterior thoracic translation, the prescribed mirror
image corrective exercises included an anterior thoracic translation exercise as well as a prone back extension exercise on a
PowerPlate® (Northbrook, IL, USA) which intensies the muscular demand23).
The spinal traction was an anterior thoracic position performed for up to 20 minutes in both a supine position (for rst 20
treatments) and then progressed to a standing position utilizing the SRBraceTM (Circular traction, Huntington Beach, CA,
USA) on the PowerPlate (Fig. 4). This positions the thoracic spine into its mirror image (hypo-kyphosis), as well as positions
the posterior thoracic posture into its mirror image (anterior translation). Spinal manipulation was also applied for pain relief.
The patient received 94 treatments over a period of 13-months. The patient and parents consented to the publication of these
results.
RESU LTS
Upon radiographic re-assessment, the patient’s forward head posture reduced (28.8 mm vs. 35.6 mm), the thoracic hyper-
kyphosis reduced (54.3° vs. 71.3°), and the posterior thoracic translation posture corrected (−59.2 mm vs. +4.9 mm). The
patient reported to be 80–100% improved in all of the initial health complaints. The low back pain improved and was rated
as 2–4/10, and the mid back and rib and chest pains a 1–2/10.
DISCUSSION
This case illustrates the successful application of Harrison’s mirror image approach to reduce thoracic hyperkyphosis
deformity and improve posture in a 15 year old with back pains and various other health issues.
There is limited clinical evidence within the manual therapies literature of successful non-surgical treatments for the
reduction of pathologic thoracic hyperkyphosis1, 24). Although many non-surgical approaches may show promise includ-
ing exercise, manual therapy, spinal orthosis, ‘practiced normal posture,’ and taping, the clinical trials used to study these
Fig. 1. Cervical spine radiographs
Left: Initial taken 9/30/2011; Right: Follow-up taken 10/30/2012.
Patient has visible anterior head translation (35.6 mm vs. normal
<15mm19)).
Fig. 2. Thoracic spine radiographs
Left: Initial taken 9/30/2011; Right: Follow-up taken 10/30/2012.
Patient has visible hyper-kyphosis (T1–T12 = 71.3° vs. normal =
43.7°20)).
J. Phys. Ther. Sci. Vol. 29, No. 7, 2017
1266
procedures have been criticized by being small in scale and short in duration24).
The only other documentation of using thoracic mirror image, extension traction in the treatment of thoracic hyperky-
phosis is a case by Jaeger et al.15) This case reported a 23° reduction in thoracic hyperkyphosis in a 24-year-old receiving 48
posture-based treatments (mirror image traction and exercises) over a 7-month period. The patient also performed the two
exercises as described in our case. An 8.5-month follow-up showed the patients spine had remained stable and the patient
had remained well.
Postural fault is frequently found in the adolescent population25). In screening 2,075 pupils aged 10–17 years, Nitzschke
and Hildenbrand26) determined the rate of hyperkyphosis to be 15% and 12% for males and females, respectively. Poor
posture alignment in the sagittal plane creates a non-ergonomic disequilibrium about the gravity line27) that in turn, changes
trunk muscle length-tension relationships28) that eventually lead to stress-strain nociceptive tendencies in the associated
tissues (i.e. muscles, discs, facet joints etc.) that can be reversed with the correction of posture29).
We believe that recognition of the coupled posterior translation posture and thoracic hyperkyphosis is essential to success-
fully treat patients presenting with this pattern of postural fault. Thoracic hyperkyphosis can be reduced through a multimodal
rehabilitation program emphasizing mirror image thoracic extension procedures.
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... The same SOSORT consensus paper (2010) 31) stated that there is "no sound scientific data available" on effective nonsurgical, conservative treatments for thoracic hyperkyphosis. Although this consensus is now dated, there are emerging conservative treatment options that show initial evidence of hyperkyphosis reduction; these include: 32,33) exercise, manual therapy, spinal orthosis, 'practiced normal posture,' taping, and more recently, thoracic extension traction [34][35][36] . ...
... To our knowledge, there have been only three single case reports and one case series (n=3) on the reduction of thoracic hyperkyphosis by extension traction reported in the literature [34][35][36][37] . In these cases, thoracic extension traction was combined with extension exercises and spinal manipulative therapy (SMT). ...
... In these cases, thoracic extension traction was combined with extension exercises and spinal manipulative therapy (SMT). Jaeger et al. 34) reported a 23° reduction of thoracic curve in a 24 year old with 48 treatments with additional home care over a 6.5-month period, Miller et al. 35) reported a 17° reduction in a 17 year old female with 94 treatments over a 13-month period, Fortner et al. 36) reported a 12° reduction in a 27 year old female with 30 treatments as well as home care, over a 6-month period, and in the series by Fedorchuk et al. 37) , an average reduction of 11° was achieved in three patients after 10-weeks of care. ...
The CBP ® mirror image ® approach to reducing thoracic hyperkyphosis: a retrospective case series of 10 patients
Article
Full-text available
  • Jul 2018
[Purpose] To present a case series demonstrating the reduction of thoracic hyperkyphosis by the Chi-ropractic BioPhysics ® multimodal rehabilitation program. [Participants and Methods] Ten randomly selected files and corresponding radiographs were chosen from recent clinic archives of patients who were treated for thoracic hyperkyphosis. All patients were treated by CBP mirror image ® thoracic extension traction and exercises, as well as spinal manipulative therapy. [Results] Results demonstrated an average reduction in hyperkyphosis of 11.3° over an average of 25 treatments, over an average of 9 weeks. Patients also experienced a reduction in pain levels and disability ratings. [Conclusion] Postural hyperkyphosis is a serious progressive deformity that is related to a plethora of symptoms, syndromes, and early death. Thoracic hyperkyphosis may be reduced/corrected by posture-specific, thoracic extension protocols including mirror image extension traction and exercises, as well as spinal manipulation as part of the CBP multi-modal rehabilitation program.
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... One article investigated the relationship between the cervical spine and occlusal contacts and found that changes in posture and occlusion can be observed after the NUCCA chiropractic procedure based on radiographic interpretation [64]. 6 Three articles reviewed thoracic hyperkyphosis (THK) [65][66][67], and 2 correlated thoracic hypokyphosis with the physiological relationship to lung functions [68,69]. Oakley et al. concluded thoracic hyperkyphosis may be reduced/corrected by posture-specific, thoracic extension protocols including mirror image extension traction and exercises, as well as spinal manipulation based on PROTS [65]. ...
... 12 Evidence continues to surface that conservative spine care may be able to improve biomechanical imbalances that are identified in postural screening and PROTS [60,64,103,105,106,109,123,124]. For example, correcting abnormal thoracic kyphosis has been achievable, which may negate the negative effects of abnormal sagittal balance of the thoracic spine, such as decreased HRQOL, increased risk of falls, decreased forced expiratory volume in the first second, and complications of osteoporosis [65][66][67][68][69]125]. Oakley et al. published a retrospective case series of 10 patients that "demonstrated an average reduction in hyperkyphosis of 11.3° over an average of 25 treatments, over an average of 9 weeks, with a reduction in pain levels and disability ratings" [65]. ...
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While some research supports utilizing plain radiography for measuring biomechanical alignment of the spine for prognosis and treatment, there are contrasting viewpoints regarding both the value and utilization of these procedures in conservative care. Evaluation of both conservative and non-conservative approaches to spinal care revealed vast differences in radiographic utilization and interpretation between orthopedic surgeons, primary care physicians, chiropractic physicians, and physical therapists, which may account for the different viewpoints and rationale in the literature. A research summary is provided regarding the various methods of spinal analysis utilized by these professions to help determine if there is any unique diagnostic or prognostic value associated with radiographic utilization that could assist in advancing conservative spinal assessment and treatment. Understanding any unique value provided through biomechanical assessment utilizing plain radiography of the spine established in the literature may help chiropractic physicians determine the appropriate use of radiographic procedures in clinical practice and how to coordinate efforts with other conservative and non-conservative professions to improve spinal healthcare.
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... Radiographic evaluation of the spinal region was measured cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral slop angle measurements from the anteroposterior and lateral sides of the patient while standing [13] . ...
... In literature exercise approaches showed that thoracic kyphosis angle decreased as a result of 7 and 8 weeks exercise programme including stretching exercises for extremities, strengthening exercises for trunk and extremities in boys with thoracic kyphosis. Miller et al. reported that costoclavicular angle increased, back pain and thoracic kyphosis angle decreased after image corrective exercises, spinal traction and mobilization in 15 years old girl patient with thoracic kyphosis [13] . Feng et al. showed that thoracic kyphosis angle decreased and thoracic range of motion increased after 8 weeks functional exercise programme in 81 adolescent with thoracic kyphosis [14] . ...
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The increase in the prevalence of thoracic kyphosis in childhood and adolescence affects the whole spine, causing posture disruption, decreased muscle strength, and increased back pain and shortness. 7-8 weeks of exercise programs in conservative treatment of thoracic kyphosis are beneficial in reducing pain and correcting posture. In this case report, 9 weeks exercise program including rectus abdominis muscle eccentric strengthening exercise was found to be beneficial in reducing back pain and shortness, increasing muscle strength and correcting posture in a 13 years old girl.
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... During the first week exercises were performed 3-4 times a week and in the following 2-5 weeks were progressed to 6 times a week, thereafter step-by-step in a decreasing manner 5 times a week in 6-10 weeks, 3 times a week in 11-22 weeks and finally 2 times a week in 23-40 weeks. The subject was treated also with 10 minutes soft tissue back massage [6] once a week and monthly with thoracic thrust manipulations [16,25,27,38]. The subject consented to the publication of this report, including pictures. ...
... Likewise, application of thoracic extension traction, thoracic extension exercises and manual thoracic mobilizations for 9 weeks resulted in reduced pain and disability among 10 adult patients alongside with improvement in thoracic hyperkyphosis [27]. After treating an adolescent girl for thoracic hyperkyphosis, forward head posture, neck and back pains, headaches, and various other health issues with simultaneous anterior thoracic translation and thoracic extension traction over a period of 13 months, 80-100% improvement in all of the initial health complaints alongside with remarkably improved posture was observed [25]. And, a 32-year-old male subject reported substantial improvement in middle and low-back pain, neck pain, as well the reduction of headaches and dizziness, forward head posture and thoracic hyperkyphosis after cervical and thoracic extension exercises, traction, and manipulation program that lasted for 13 weeks [16]. ...
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The participant of this study was a 40-year-old female, who mainly complained of middle thoracic stiffness and pain in extension at the mid thoracic level with hyperkyphosis, forward head and mild thoracic dextroscoliosis. The subject participated in multimodal home-based physiotherapy program with the duration of 9 months, consisting of posture exercises, soft tissue massage therapy and thoracic manipulations. Comparison of initial and final evaluation revealed the improvement in all evaluated variables, including the reduction of thoracic hyperkyphosis, forward head posture and thoracic dextroscoliosis, freer and less painful thoracic spine extension mobility, no pain in the sacroiliac joint, and increased satisfaction with the posture. There was also notable improvement in the algometry of the paraspinal muscles, equalization of functional lower-leg length and rib-pelvic distance of both sides of body. In conclusion, the proposed physiotherapy protocol can be beneficial in addressing postural faults such as thoracic hyperkyphosis, forward head and scoliosis. However, further research is needed with a larger sample.
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... The early diagnosis and treatment of THK is essential in the prevention of the otherwise associated typical poor health outcomes. Several clinical trials and case reports have documented the successful non-surgical reduction of THK in patients [17][18][19][20][21][22][23][24][25][26] . These methods primarily involve back extension exercise regimens, and more recently thoracic extension traction methods [23][24][25][26] . ...
... Several clinical trials and case reports have documented the successful non-surgical reduction of THK in patients [17][18][19][20][21][22][23][24][25][26] . These methods primarily involve back extension exercise regimens, and more recently thoracic extension traction methods [23][24][25][26] . ...
Alleviation of chronic spine pain and headaches by reducing forward head posture and thoracic hyperkyphosis: a CBP® case report
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  • Aug 2018
[Purpose] This case presents the reduction of both forward head posture and thoracic hyperkyphosis in a young male with chronic back pain and headaches by a comprehensive posture rehabilitation program as a part of Chiropractic BioPhysics® methods. [Participant and Methods] A 32 year old male presented with constant pain and headaches for seven years since he was involved in a work related injury. He had seen five different MDs, undergone multiple imaging tests, and received multiple prescriptions, thirteen steroid injections and was recommended for a spine surgery that he had denied. He was on long-term disability. Upon comprehensive posture and spine assessment, the patient had exaggerated forward head translation and thoracic hyperkyphosis. The patient was treated 36 times over 13-weeks with cervical and thoracic extension exercises, traction, and manipulation. [Results] After treatment the patient reported dramatic improvement in symptoms as indicated on valid disability questionnaires and substantial improvements in posture. [Conclusion] Posture-related pain and disability is not often addressed in allopathic medicine but substantial posture improvements are achievable in short time periods as this case illustrates. Poor postures in young patients should be corrected to avoid long-term consequences. Radiography as used in spinal rehabilitation is safe and reliable.
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... It is important to note that the literature also suggests that many of these radiographic parameters such as sagittal cervical spinal alignment and posture can be corrected with conservative care and these corrections can be corelated with improved function and health outcomes [88][89][90][91][92][93][94][95][96][97][98][99][100][101][102]. Other studies indicate that conservative care can result in radiographic changes to sagittal lumbar spinal alignment and posture, which is correlated with improved pain scores and health-related quality of life (HRQOL) [103][104][105][106][107]. Research has demonstrated that abnormal sagittal thoracic spinal alignment can be corrected, which is correlated with improvement in the risk of falls, headaches, forced expiratory volume, and HRQOL [108][109][110][111][112][113][114][115]. Additional studies have demonstrated that conservative correction of cervical lordosis and forward head posture can be associated with increased HRQOL, reduced back pain, and improved nervous system adaptability [100]. ...
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Full-text available
  • Mar 2023
Plain Radiography of the spine (PROTS) is utilized in many forms of healthcare including the chiropractic profession; however, the literature reflects conflicting opinions regarding utilization and value. Despite being an essential part of Evidence-Based Practice (EBP), few studies assess Doctors of Chiropractic (DCs) clinical opinions and experience regarding the utilization of (PROTS) in practice. In this study, DCs were surveyed regarding utilization of PROTS in practice. The survey was administered to an estimated 50,000 licensed DCs by email. A total of 4301 surveys were completed, of which 3641 were United States (US) DCs. The Clinician Opinion and Experience on Chiropractic Radiography (COECR) scale was designed to analyze survey responses. This valid and reliable scale demonstrated good internal consistency using confirmatory factor analysis and the Rasch model. Survey responses show that 73.3% of respondents utilize PROTS in practice and 26.7% refer patients out for PROTS. Survey responses show that, among US DCs, 91.9% indicate PROTS has value beyond identification of pathology, 86.7% indicate that PROTS is important regarding biomechanical analysis of the spine, 82.9% indicate that PROTS is vital to practice, 67.4% indicate that PROTS aids in measuring outcomes, 98.6% indicate the opinion that PROTS presents very low to no risk to patients, and 93.0% indicate that sharing clinical findings from PROTS studies with patients is beneficial to clinical outcomes. The results of the study indicated that based on clinical experience, the majority of DCs find PROTS to be vital to practice and valuable beyond the identification of red flags.
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... Although there is one RCT on CBP methods showing reduction of the deformity, it is yet to be formally published [52]. A systematic review of CBP methods used to reduce thoracic hyperkyphosis was published [73] and summarized the outcomes of several case reports and series [74][75][76][77][78][79]. In Table 2 of the Oakley and Harrison review an average 12° reduction in thoracic kyphosis occurred after 32 treatments over 14.5 weeks from a total of 17 patients [52]. ...
An Introduction to Chiropractic BioPhysics® (CBP®) Technique: A Full Spine Rehabilitation Approach to Reducing Spine Deformities
Chapter
Full-text available
  • May 2022
Chiropractic Biophysics® (CBP®) technique is a full-spine and posture correcting method that incorporates mathematical principles into a unique approach to treat spinal disorders. It considers that the identification of postural rotations and translations of human postures are first evaluated and compared to the radiographic assessment of the spine alignment. Mirror image® postural positions and movements are utilized including spinal extension positions to improve the spine and posture towards a normal/ideal alignment. Specifically, corrective exercises, corrective traction and chiropractic adjustments are performed encompassing a multimodal rehabilitation program with the goal of improving the posture and spine alignment. CBP Rehabilitation programs are typically performed in-office with supportive at-home measures. Repeat assessment including radiographs are used to quantify and monitor structural improvements. CBP technique is an evidence-based approach to treat spine deformities and is supported by all forms of clinical evidence including systematic literature reviews, randomized controlled trials, non-randomized controlled trials, case reports/series as well as is supported by biomechanical posturespine coupling validity, radiographic and posture analysis reliability/repeatability and use of a validated biomechanical spinal model as the outcome goal of care. CBP technique is a proven method to improve pain, disability and quality of life in those with structural deformities.
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Plain Radiography: A Unique Component of Spinal Assessment and Predictive Health
Article
Full-text available
  • Mar 2024
While some research supports utilizing plain radiography for measuring biomechanical alignment of the spine for prognosis and treatment, there are contrasting viewpoints regarding both the value and utilization of these procedures in conservative care. Evaluation of both conservative and non-conservative approaches to spinal care revealed vast differences in radiographic utilization and interpretation between orthopedic surgeons, primary care physicians, chiropractic physicians, and physical therapists, which may account for the different viewpoints and rationales in the literature. A research summary is provided to explore any unique biomechanical parameters identified with plain radiography of the spine (PROTS) and how these measurements may relate to patient health. Understanding any unique value provided through biomechanical assessment utilizing PROTS may help chiropractic physicians determine the appropriate use of radiographic procedures in clinical practice and how to coordinate efforts with other conservative and non-conservative spinal healthcare professions to improve patient health.
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Are Restrictive Medical Radiation Imaging Campaigns Misguided? It Seems So: A Case Example of the American Chiropractic Association’s Adoption of “Choosing Wisely”
Article
Full-text available
  • May 2020
Since the 1980s, increased utilization of medical radiology, primarily computed tomography, has doubled medically sourced radiation exposures. Ensuing fear-mongering media headlines of iatrogenic cancers from these essential medical diagnostic tools has led the public and medical professionals alike to display escalating radiophobia. Problematically, several campaigns including Image Gently, Image Wisely, and facets of Choosing Wisely propagate fears of all medical radiation, which is necessary for the delivery of effective and efficient health care. Since there are no sound data supporting the alleged risks from low-dose radiation and since there is abundant evidence of health benefits from low-doses, these imaging campaigns seem misguided. Further, thresholds for cancer are 100 to 1000-fold greater than X-rays, which are within the realm of natural background radiation where no harm has ever been validated. Here, we focus on radiographic imaging for use in spinal rehabilitation by manual therapists, chiropractors, and physiotherapists as spinal X-rays represent the lowest levels of radiation imaging and are critical in the diagnosis and management of spine-related disorders. Using a case example of a chiropractic association adopting “Choosing Wisely,” we argue that these campaigns only fuel the pervasive radiophobia and continue to constrain medical professionals, attempting to deliver quality care to patients.
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REDUCING THORACIC HYPERKYPHOSIS SUBLUXATION DEFORMITY: A SYSTEMATIC REVIEW OF CHIROPRACTIC BIOPHYSICS® METHODS EMPLOYED IN ITS STRUCTURAL IMPROVEMENT
Article
Full-text available
  • Dec 2018
Objective: Thoracic hyperkyphosis is a serious postural health disorder that is associated with many health conditions including morbidity and mortality. Methods: We reviewed all clinical evidence for the treatment of hyperkyphosis by Chiropractic BioPhysics® technique methods. Seven peer-reviewed papers were located that included 4 case reports, 2 case series, and 1 randomized clinical trial treating the cervical spine reporting reduction of the thoracic curve. Results: Although the amount clinical evidence is small, these studies document successful reduction in thoracic curve by an average of 12° concomitant with the improvement in pain, disability, quality of life measures and in some cases improvement in vital capacity. There was large variation in number of treatments, duration of treatment and age of patients. Although there are some clinical trials demonstrating improvement in thoracic kyphosis primarily by exercise programs, the changes are small and most report on suboptimal mensuration methods that do not directly relate to the gold standard x-ray measurement. Only 2 previous exercise intervention trials have reported pre-post x-ray improvements in thoracic alignment, and this was 3°. Conclusion: If future CBP intervention trials are consistent with the initial CBP patient outcomes for this disorder, the CBP treatment approach may prove to be an effective treatment that may logically lead to reduced mortality rates and improvements in quality of life measures in these patients.
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Analysis of muscle activation in each body segment in response to the stimulation intensity of whole-body vibration
Article
Full-text available
  • Feb 2017
[Purpose] The purpose of this study was to investigate the effects of a whole-body vibration exercise, as well as to discuss the scientific basis to establish optimal intensity by analyzing differences between muscle activations in each body part, according to the stimulation intensity of the whole-body vibration. [Subjects and Methods] The study subjects included 10 healthy men in their 20s without orthopedic disease. Representative muscles from the subjects’ primary body segments were selected while the subjects were in upright positions on exercise machines; electromyography electrodes were attached to the selected muscles. Following that, the muscle activities of each part were measured at different intensities. No vibration, 50/80 in volume, and 10/25/40 Hz were mixed and applied when the subjects were on the whole-vibration exercise machines in upright positions. After that, electromyographic signals were collected and analyzed with the root mean square of muscular activation. [Results] As a result of the analysis, it was found that the muscle activation effects had statistically meaningful differences according to changes in exercise intensity in all 8 muscles. When the no-vibration status was standardized and analyzed as 1, the muscle effect became lower at higher frequencies, but became higher at larger volumes. [Conclusion] In conclusion, it was shown that the whole-body vibration stimulation promoted muscle activation across the entire body part, and the exercise effects in each muscle varied depending on the exercise intensities.
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Non-surgical Reduction of Thoracic Hyper-kyphosis in a 24-year Old Music Teacher Utilizing Chiropractic BioPhysics® Technique
Article
Full-text available
  • Jan 2016
Background: Thoracic hyper-kyphosis is a postural deviation that is associated with morbidity and mortality. There is limited evidence for the non-surgical reduction treatment for this condition. Objective: To describe the successful case of conservative reduction in thoracic hyper-kyphosis utilizing thoracic extension traction methods as performed in Chiropractic BioPhysics (CBP®) Technique. Clinical Features: On May 8, 2009 a 24-year old female music teacher reported to a spine clinic in Las Vegas seeking treatment while suffering from neck, mid, and low back pain as well as headaches. The major postural condition was determined to be a hyper-kyphotic thoracic spine Case Study Jaeger et al.; BJMMR, 11(7): xxx-xxx, 2016; Article no.BJMMR.20639 2 with concomitant posterior thoracic translation. Intervention and Outcome: This patient was treated with full CBP® protocol with the unique application of thoracic extension traction. Although the treatment was interrupted by her involvement in a motor vehicle collision, a clinically significant reduction in her kyphosis occurred bringing her spine to within normal limits. She had simultaneous improvements in her clinical symptoms, neurologic and orthopedic tests. Discussion: Traditional conservative treatment options for thoracic hyper-kyphosis have included exercise, manual therapy, spinal orthosis, 'practiced normal posture,' and more recently, taping. All of these procedures, however, have been criticized because despite these methods as showing promise for improving health outcomes in patients with hyper-kyphosis, the trials used to evaluate them have been " small in scale, and most short in duration. " Since this deformity is associated with osteoporosis and worsening of kyphosis it is well advised to treat this condition earlier rather than later. Conclusion: Although traditional approaches to non-surgical treatment for thoracic hyper-kyphosis has weak supportive evidence, we propose extension traction for this condition will prove to be an effective treatment option.
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Vertebral Fractures and Mortality in Older WomenA Prospective Study
Article
Full-text available
  • Jun 1999
  • ARCH INTERN MED
Background Osteoporotic fractures, including clinically detected vertebral fractures, are associated with increased mortality. However, only one third of vertebral fractures are diagnosed. It is unknown whether vertebral fractures, whether clinically apparent or not, are associated with greater mortality.Objectives To test the hypothesis that women with prevalent vertebral fractures have greater mortality than those without fractures and to describe causes of death associated with vertebral fractures.Design Prospective cohort study with mean follow-up of 8.3 years.Setting Four clinical centers in the United States.Participants A total of 9575 women aged 65 years or older and enrolled in the Study of Osteoporotic Fractures.Measurements Vertebral fractures by radiographic morphometry; calcaneal bone mineral density; demographic, medical history, and lifestyle variables; blood pressure; and anthropometric measures. In a subset of 606 participants, thoracic curvature was measured during a second clinic visit.Main Outcome Measures Hazard ratios for mortality and cause-specific mortality.Results At baseline, 1915 women (20.0%) were diagnosed as having vertebral fractures. Compared with women who did not have a vertebral fracture, women with 1 or more fractures had a 1.23-fold greater age-adjusted mortality rate (95% confidence interval, 1.10-1.37). Mortality rose with greater numbers of vertebral fractures, from 19 per 1000 woman-years in women with no fractures to 44 per 1000 woman-years in those with 5 or more fractures (P for trend, <.001). In particular, vertebral fractures were related to the risk of subsequent cancer (hazard ratio, 1.4; 95% confidence interval, 1.1-1.7) and pulmonary death (hazard ratio, 2.1; 95% confidence interval, 1.4-3.0). In the subset of women who underwent thoracic curvature measurements, severe kyphosis was also related to pulmonary deaths (hazard ratio, 2.6; 95% confidence interval, 1.3-5.1).Conclusion Women with radiographic evidence of vertebral fractures have an increased mortality rate, particularly from pulmonary disease and cancer.
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Equilibrium of the human body and the gravity line: the basics
Article
Full-text available
  • Aug 2011
  • EUR SPINE J
Bipedalism is a distinguishing feature of the human race and is characterised by a narrow base of support and an ergonomically optimal position thanks to the appearance of lumbar and cervical curves. The pelvis, adapted to bipedalism, may be considered as the pelvic vertebra connecting the spine to the lower limbs. Laterally, the body's line of gravity is situated very slightly behind the femoral heads laterally, and frontally it runs through the middle of the sacrum at a point equidistant from the two femoral heads. Any abnormal change through kyphosis regarding the spinal curves results in compensation, first in the pelvis through rotation and then in the lower limbs via knee flexion. This mechanism maintains the line of gravity within the base of support but is not ergonomic. To analyse sagittal balance, we must thus define the parameters concerned and the relationships between them. These parameters are as follows: for the pelvis: incidence angle, pelvis tilt, sacral slope; for the spine: point of inflexion, apex of lumbar lordosis, lumbar lordosis, spinal tilt at C7; for overall analysis: spino-sacral angle, which is an intrinsic parameter.
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7th SOSORT consensus paper: Conservative treatment of idiopathic & Scheuermann's kyphosis
Article
Full-text available
  • May 2010
  • Scoliosis
: Thoracic hyperkyphosis is a frequent problem and can impact greatly on patient's quality of life during adolescence. This condition can be idiopathic or secondary to Scheuermann disease, a disease disturbing vertebral growth. To date, there is no sound scientific data available on the management of this condition. Some studies discuss the effects of bracing, however no guidelines, protocols or indication's of treatment for this condition were found. The aim of this paper was to develop and verify the consensus on managing thoracic hyperkyphosis patients treated with braces and/or physiotherapy. The Delphi process was utilised in four steps gradually modified according to the results of a set of recommendations: we involved the SOSORT Board twice, then all SOSORT members twice, with a Pre-Meeting Questionnaire (PMQ), and during a Consensus Session at the SOSORT Lyon Meeting with a Meeting Questionnaire (MQ). There was an unanimous agreement on the general efficacy of bracing and physiotherapy for this condition. Most experts suggested the use of 4-5 point bracing systems, however there was some controversy with regards to physiotherapeutic aims and modalities. The SOSORT panel of experts suggest the use of rigid braces and physiotherapy to correct thoracic hyperkyphosis during adolescence. The evaluation of specific braces and physiotherapy techniques has been recommended.
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The rehabilitation of hyperkyphotic posture in the elderly
Article
Full-text available
  • Dec 2009
  • Eur J Phys Rehabil Med
The angle of thoracic kyphosis tends to increase with age resulting in hyperkyphosis in some individuals. While the term "kyphotic" is occasionally used to describe someone with accentuated thoracic curvature, hyperkyphosis is preferred since kyphosis itself refers to the normal sagittal angle of thoracic curvature. Epidemiolo-gic studies have demonstrated that age-related hyperkyphosis commonly affects the elderly population with estimates ranging from 20% to 40%. In addition, hyperkyphosis affects a substantial number of older men. Apart from being a cosmetic deformity, older persons who suffer from hyperkyphosis are at increased risk for a variety of adverse health outcomes that include poor physical function, pulmonary compromise, falls, fractures, and even earlier mortality. Most clinicians and patients have assumed that thoracic hyperkyphosis is a result of underlying spinal osteoporosis, but approximately two thirds of those who are most hyperkyphotic don't have vertebral fractures. Over the past few years, there has been increased awareness and focus on potential effective treatments for age-related hyperkyphosis. Of these treatments, exercise based interventions and spinal orthoses are conservative rehabilitation management techniques that have shown promise in potentially improving health outcomes for affected patients. To date, all of these types of trials have been small in scale, and most short in duration. In the future, larger rigorously designed clinical trials will be needed to test and confirm the efficacy and feasibility of the most promising treatments for age-related hyperkyphosis. This invited review will discuss hyperkyphosis in terms of its etiology, clinical associations, and treatment in elderly individuals.
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Modeling of the Sagittal Cervical Spine as a Method to Discriminate Hypolordosis
Article
  • Nov 2004
Study Design. Computer analysis of digitized vertebral body corners on lateral cervical radiographs. Objectives. Using elliptical and circular modeling, the geometric shape of the path of the posterior bodies of C2–C7 was sought in normal, acute pain, and chronic pain subjects. To determine the least squares error per point for paths of geometric shapes, minor axis to major axis elliptical ratios (b/a), Cobb angles, sagittal balance of C2 above C7, and posterior tangent segmental and global angles. Summary of Background Data. When restricted to cervical lordotic configurations, normal, acute pain, and chronic pain subjects have not been compared for similarities or differences of these parameters. Conventional Cobb angles provide only a comparison of the endplates of the distal vertebrae, while geometric modeling provides the shape of the entire sagittal curves, the orientation of the spine, and segmental angles. Methods. Radiographs of 72 normal subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects were digitized. For normal subjects, the inclusion criteria were no kyphotic cervical segments, no cranial-cervical symptoms, and less than ± 10 mm horizontal displacement of C2 above C7. In pain subjects, inclusion criteria were no kyphotic cervical segments and less than 25 mm of horizontal displacement of C2 above C7. Measurements included segmental angles, global angles of lordosis (C1–C7 and C2–C7), height-to-length ratios, anterior weight bearing, and from modeling, circular center, and radius of curvature. Results. In the normal group, a family of ellipses wasfound to closely approximate the posterior body margins of C2–C7 with a least squares error of less than 1 mm per vertebral body point. The only ellipse/circle found to include T1, with a least squares error of less than 1 mm, was a circle. Compared with the normal group, the pain group’s mean radiographic angles were reduced and the radius of curvature was larger. For normal, acute, and chronic pain groups, the mean angles between posterior tangents on C2–C7 were 34.5°, 28.6°, and 22.0°, C2–C7Cobb angles were 26.8°, 16.5°, and 12.7°, and radius of curvature were r = 132.8 mm, r = 179 mm, and r = 245.4 mm, respectively. Conclusions. The mean cervical lordosis for all groups could be closely modeled with a circle. Pain groups had hypolordosis and larger radiuses of curvature compared with the normal group. Circular modeling may be a valuable tool in the discrimination between normal lordosis and hypolordosis in normal and pain subjects.
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Die Epidemiologie des Rundrückens bei Schulkindern
Article
  • Jan 1990
An fünf Bochumer Schulen wurde eine Reihenuntersuchung der 5. bis 10. Klasse zu Fehlhaltungen bzw. Fehlformen der Wirbelsäule durchgeführt. Insgesamt erfolgte die Untersuchung an 2075 Schülern im Alter von 10 - 17 Jahren und der Kyphosegrad wurde mit Hilfe des Kyphometers nach Debrunner bestimmt. Als Rundrücken galt ein Kyphosewinkel mit 40 Grad oder mehr. Die Rate an Rundrücken betrug 12% bei Mädchen und 15,3% bei Jungen. Zum Vergleich wurde der Rundrückengruppe eine zufällig ausgewählte Gruppe haltungsunauffälliger Kinder gegenübergestellt. Beide Gruppen wurden anhand eines halbstandardisierten Fragebogens zu allgemeinen Lebensumständen, Sportverhalten, orthopädischer und Familienanamnese befragt. Dabei zeigte sich, daß Kinder mit Rundrücken weniger Sport treiben, mehr orthopädische Beschwerden haben und auch in der Familie mehr Rundrücken und Wirbelsäulenprobleme vorhanden sind.
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Effect of Spinal Deformity on Adolescent Quality of Life: Comparison of Operative Scheuermann Kyphosis, Adolescent Idiopathic Scoliosis, and Normal Controls
Article
  • Jan 2013
  • SPINE
Study design: A prospective multicenter study and retrospective chart review. Objective: To compare health-related quality of life (HRQOL) measures and sagittal deformity in operative Scheuermann kyphosis (SK), operative adolescent idiopathic scoliosis (AIS), and normal populations. Summary of background data: No study to date has evaluated patient reported HRQOL measures before surgery in operative patients with SK. Methods: HRQOL data were prospectively collected pretreatment for operative patients with SK using the SRS-22 outcomes instrument and visual analogue scale (VAS). Comparison was made with the SRS-22 from operative AIS and normal populations. Eighty-six patients with SK enrolled in the prospective study were compared with 184 patients with AIS from a prospective database and 31 normal controls. To study the correlation between T5-T12 kyphosis magnitude and SRS-22 score, patients with AIS and SK were pooled together to create a larger continuum of kyphosis. Analysis of covariance, Pearson correlation analysis, and Bonferroni pairwise comparisons were used to determine statistical differences between group demographics, HRQOL indicators, and radiographical variables. Results: Patients with SK had significantly lower scores in all domains of the SRS-22 than patients with AIS. Patients with SK with a thoracolumbar apex reported significantly lower mean scores in the pain domain than those with a thoracic apex. Significant negative correlations were found between all domains of the SRS-22 and T5-T12 kyphosis-the self-image domain demonstrated the highest correlation (r = 0.37). VAS score in the SK population correlated negatively to the pain, self-image, and mental health domains. Conclusion: Increasing sagittal plane deformity as a result of SK has a significant impact on HRQOL as determined by the SRS-22 outcome instrument. In this study, patients with SK reported significantly decreased (worse) scores in all subdomains of the SRS-22 compared with patients with AIS. Level of evidence: 1.
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Survival of healthy old people
Article
  • Jan 1977
  • Br J Prev Soc Med
The purpose of this study was to discover any relationships which might exist between measurable variables recorded when a healthy group of men and women, aged 70 years and over, were examined and their subsequent survival time. It was found that height, body weight, systolic and diastolic blood pressures, haemoglobin, hand grip power, cardiothoracic ratio, and pulse rate are of no predictive value in the estimation of survival time. Survival is not influenced by marital status or occupational class. For both sexes the degree of kyphosis and age are useful predictive criteria in respect of survival time. However, much research work requires to be done to explain why many people die at the time they do.
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