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The Basics of CBP Technique
By Deed E. Harrison, D.C.
and
Donald D. Harrison, PhD, DC, MSE
In December 1980, the Chiropractic
Biophysics Technique was created by Drs. Donald Harrison, Deanne Harrison and
Daniel Murphy for “physics applied to biology in chiropractic.”
After a few years, it became apparent that the name was being confused with
biophysics, a field of study usually associated with topics such as energy in
molecular bonds. Thus, in the late 1990s, a new name was derived for a more
accurate description of the procedures being utilized, i.e., Clinical Biomechanics
of Posture (CBP). Since 1980, there have been numerous CBP Texts written.1-7
Until 1980, the majority of chiropractors were attempting to adjust single vertebral
subluxations with specific lines of drive. While a few upper cervical techniques
could demonstrate some before and after X-ray changes, in general, the adjusting
of single vertebra did not result in X-ray changes (except in acute antalgic
postures). In March 1980 Dr. Don Harrison originated postural set-ups that he
coined “Mirror Image.” Clinically, these adjusting set-ups were
found to result in postural and X-ray changes; this impression would be subjected
to studies later.
For these new Mirror Image patient positions, Dr. Don Harrison placed the patient
in their opposite posture. These Harrison Mirror Image positions can be described
as “reflecting” the patient’s head, ribcage and/or pelvis
across the median-sagittal plane in the AP view; and positioning the head, ribcage
and/or pelvis across the mid-frontal plane in the lateral view. Prior to performing
CBP Mirror Image postural set-ups, the patient’s initial presenting abnormal
posture(s) must be exactly determined.
While others have used engineering concepts to describe all vertebral segmental
movements as rotations and translations in three dimensions,8 Harrison was the
first to describe abnormal postures of the head, ribcage, and pelvis in this
manner. (Figures 1 & 2 above). For each of these postures illustrated in
Figures 1 and 2, originated drop table adjustments, instrument adjustments (both
table and hand-held), and exercises in the mirror image posture, as evidenced
by his videos and books from 1980-1986.
Additionally, for use in difficult cases, he originated mirror image postural
traction for several of these rotations and translations of the head, ribcage,
and pelvis. Also from 1980-1986, he originated cervical extension traction methods
to restore the sagittal cervical curve. These Harrison cervical extension traction
methods were improved upon by other CBP practitioners, such as Dr. Mike Fisk
(Spokane, Wash.), Dr. Dwight DeGeoerge (Saugus, Mass.) and Dr. Mile Pope (Troy,
Ohio).
Although CBP procedures resulted in clinically documented corrections in posture
and cervical curve configurations from 1986-1996, methods to restore thoracic
and lumbar sagittal curvatures awaited the graduation of Dr. Deed Harrison.
Dr. Deed Harrison originated methods of lumbar curvature and thoracic cage postural
traction that made routine changes in lumbar lordosis possible. He further refined
the CBP sagittal cervical traction methods with an analysis of head posture,
curve configuration, thoracic curvature, gender and body size.
CBP Goals of Care
Many in chiropractic are turning away from structural outcomes of care to concentrate
on pain reduction, improved ranges of motion (ROM), and other functional outcomes.
In contrast, CBP emphasizes optimal posture and spinal alignment as the primary
goal of chiropractic care, while still documenting improvements in pain and
functional based outcomes.9 Even though
some authors10 in chiropractic claim that
an optimal and average spinal model does not exist, CBP research on this topic,
based on averages of normal subjects, has been published in some of the most
prestigious orthopaedic journals in the Index Medicus.11-16
CBP has published normal shapes, normal global angles (C2-C7, T2-T11, and L1-L5),
and normal segmental angles for each of the sagittal spinal regions (cervical,
thoracic, and lumbar). These are evidence-based models. In fact, the CBP sagittal
lumbar elliptical model12 and the sagittal
circular model16 have been found to have predictive validity in as much as they
can discriminate between normal subjects, acute pain subjects and chronic pain
subjects.
To establish optimal and average sagittal models, X-ray line drawing procedures
were utilized. CBP protocols require that the doctor measure the patient’s
abnormal posture (global subluxation) and measure the displacements on spinal
radiographs (segmental subluxation). While some in the chiropractic research
arena believe X-ray analysis to be unreliable,10
this is the minority position. The CBP X-ray line drawing procedures have been
studied and shown to be reliable.17-20 The
postural and spinal displacements are the determining factors for deriving the
patient’s individualized program of care. While our critics claim that
posture, X-ray positioning, and X-ray line drawing are not reliable, our published
research shows that these procedures are highly repeatable.21
Duration of Care
Initially, patients are given their choice of receiving 1) pain relief care
for their symptoms and/or restoration of functional ROM (which usually entails
6-12 visits), or 2) corrective care for their abnormal posture and spinal displacements
(usually a minimum of 24-30 visits). Relief care consists of any number of segmental
adjusting techniques the Chiropractor prefers to utilize including but not limited
to: Diversified, Gonstead, Activator, Applied Kinesiology and Motion Palpation.
While corrective care consists of CBP exercises, adjustments, and traction performed
in the Mirror Image (referred to as the E.A.T. protocol).
To determine if the CBP E.A.T protocol of corrective care for each individual
(based on his/her posture and spinal displacements) is achieving the desired
normalization of posture and spinal alignment, re-examinations are suggested
at 36-visit intervals. This 36-visit number is not based on personal opinion,
but rather is an average duration from six CBP Clinical Control Trials.22-27
To arrive at this 36-visit time period, one may have four visits per week for
nine weeks, or three visits per week for 12 weeks. From our six clinical control
trials, the average chronic pain patient achieved 50 percent correction from
their initial position towards our radiographic normals (difference between
initial and normal in AP and lateral spine studies). This indicates that, on
average, a typical chronic pain patient may need two blocks of 36 visits of
intensive corrective chiropractic care (defined as three or four visits per
week).
The frequency and duration of further care recommended to the patient at the
re-evaluation depends on their improvements in structural and functional based
outcomes. If the patient achieved a near-normal posture and spinal alignment
at the first re-evaluation, then stabilization care is recommended (which is
a reduced frequency of visits). However, if at the first corrective care re-evaluation,
less than average improvement is attained on comparative radiographs and digital
postural photographs, then there is indication that at least another block of
36 visits will be necessary for optimal spinal correction. With CBP’s
six completed clinical control trials, our methods have moved from the clinical
opinion arena to having firm foundation in the category of evidence-based care.
Irrespective of opinion, global subluxations (postural) and segment subluxations
(spinal) cause an increase in spinal loads (compressive and shear) and spinal
stresses. Due to the increased muscle effort required to stabilize abnormal
postural/spinal displacements, the actual increase in load on the spine is much
higher than merely the displacement itself.28-32
The presence of mechanosensitive and nociceptive afferent fibers in spinal tissues
(intervertebral disc, facet, ligaments, and muscles),33,34
and the subsequent neurophysiological research demonstrating the role of such
afferent stimulation in pain production, 35,36
and coordinated neuromuscular stabilization of the spine37,38
all provide a substantial theoretical framework supporting the rationale for
goals of treatment regimens to include a reduction of stresses on spinal joints
in spinal rehabilitation programs.
Uniqueness of Care
Unlike the relief care phase (approximately three weeks), which includes segmental
adjusting procedures from other named techniques, the E.A.T. corrective care
protocol is unique to CBP. These are Exercise, Adjustments and Traction (E.A.T.)
with mirror image positioning. In combination, these E.A.T. methods are unique
to CBP Technique. Exercises, Adjustments, and Traction are performed in the
Mirror Image of the postures depicted in Figures 1 and 2. Additionally, traction
is performed in the cervical, thoracic, and lumbar regions based on the configurations
of the lordotic and kyphotic curvatures. For examples of CBP’s E.A.T corrective
care protocols, a few postural and spinal subluxations in the coronal and sagittal
planes will be provided and discussed. First, however, we must state that CBP
recognizes and teaches four primary types of spinal subluxations.39
The reader needs to be aware that these four types can occur singularly or in
different combinations. For our purposes here we will only present treatment
of the first two types. These four types include:
Postural or Global Subluxations
To begin, we will use the example of abnormal posture of right lateral head
translation. Figure 3A depicts a patient with the posture of right lateral head
translation compared to the thorax. Figure 3B depicts the skeletal animation
simulating the known spinal displacement patterns (termed coupling patterns)
caused by the head translation posture.40
Figure 3C depicts a PA cervico-thoracic X-ray demonstrating the X-ray displacement.
In Figure 4A-C, the CBP Mirror Image E.A.T procedures are shown. The reader
should notice that in each part of Figure 4, the patient is in the opposite
translation posture. Importantly, the Mirror Image E.A.T. procedures have been
found to be effective at reducing lateral head translation postures and consequent
spinal displacement patterns in chronic neck pain patients.26
Figure 3. In A, the subject has right lateral head translation. In B, the cervical segments C5-C7 have lateral flexion to the same side of head translation and the C0-C4 segments have lateral flexion to the opposite side of head translation. In C, the patient’s X-ray, viewed PA, is shown with large translation. Note: C5-T4 Ipsilateral bending and contralateral bending from C0-C4. ” Photos courtesy Harrison CBP Seminars
Figure 4. In A, Mirror Image Exercise. The patient is instructed to begin with 10 repetitions and gradually increase to 100-200 repetitions per day. In B, Mirror Image Adjustment with the CBP instrument is shown. The patient is positioned with her median-sagittal plane of the head translated left compared to the median-sagittal plane of the rib cage. A light-moderate thrust is delivered to the upper cervical region. In C, one type of Mirror Image translation traction is shown. The head is held in place by two padded restraints and translated to the left. Note: all of these procedures are done in office under direct supervision. Photos courtesy Harrison CBP Seminars
For our second example, we will use the abnormal posture of right lateral thoracic
translation, termed trunk list. Figure 5A depicts a patient with the posture
of right lateral thoracic translation compared to the pelvis. Figure 5B depicts
the skeletal animation simulating the known spinal displacement patterns (coupling
patterns) caused by the thoracic translation posture.41 Figure 5C depicts a
PA lumbo-pelvic X-ray demonstrating the spinal displacement. In Figure 6A-C
(below), the CBP Mirror Image E.A.T procedures are shown. The reader should
notice that in each part of Figure 6, the patient is in the opposite translation
posture. Importantly, the Mirror Image E.A.T. procedures have been found to
be effective at reducing lateral thoracic translation posture and consequent
spinal displacement patterns in chronic low back pain patients.27
Figure 5.
In A, the subject has right lateral thoracic translation. In B, the lumbar segments
L1-L5 have lateral flexion to the same side of thoracic translation, and above
L1, segments have lateral flexion to the opposite side of translation. In C,
a patient’s X-ray, viewed AP, is shown with large translation. Note ipsilateral
bending from L1-L5 and contralateral bending above L1.
Photos courtesy Harrison CBP Seminars
Figure 6 In A, Mirror Image Exercise. The patient is instructed to begin with 10 repetitions and gradually increase to 100-200 repetitions per day. In B, a Mirror Image Adjustment with the Omni drop Table is shown. The pelvis and feet are elevated while the thorax is kept in the left lateral position. The head is kept neutral with the thorax. A thrust is delivered to the thoraco-lumbar region. In C, one type of Mirror Image translation Traction is shown. The thorax is held in place by restraints and translated to the left. Note: all of these procedures are done in office under direct supervision. Photos courtesy Harrison CBP Seminars
Sagittal Plane Buckling or Abnormal Sagittal Plane Curvatures
In CBP, we make a distinction between postural subluxations as rotations and
translations that cause known spinal coupling displacements and true abnormalities
of the sagittal curves of the spine. Again, we must emphasize that these types
can occur together. For this discussion we will consider these separately. Our
third example, will present 3 types (there are multiple types) of sagittal cervical
curve subluxations and their respective Mirror Image Traction corrective procedures.
Using our ideal circular cervical spine model as a reference guide, Figures
7A, 7C, and 7E (below) illustrate three different types of subluxations of the
sagittal cervical curve. In Figures 7B, 7D, and 7F (below), the type of Mirror
Image extension cervical traction method must match both the sagittal head posture
and the displacement of George’s Line (posterior longitudinal ligament)
relative to our cervical spine model. Also of importance, the clinical utility
and effectiveness of each of the three traction methods, depicted in Figure
7, has been reported in a clinical trial.22,23,25
These three methods enable the CBP chiropractic clinician to consistently improve
the magnitude and geometric shape of the subluxated sagittal cervical curve.
There are indications and contraindications for each type of traction method.
The chiropractor must judiciously learn, understand, and apply traction procedures
on a case by case basis.
Figure 7 A-F. Three different subluxations of the cervical curve and their respective Mirror Image traction methods. In A, hypolordosis with mild anterior head translation requires compression extension traction in B. In C, slight kyphosis with posterior head translation requires 2-way non-compression traction in D. In E, reversal of the upper cervical curve with mild anterior head translation requires compression extension 2-way traction in F. Photo courtesy Harrison CBP Seminars
Our fourth example, will present 2 types (there are multiple types) of sagittal
lumbar curve subluxations and 1 type of thoracic kyphosis subluxation and their
respective Mirror Image Traction corrective procedures. Using our ideal elliptical
lumbar and thoracic spine models as a reference guide, Figures 8A, 8C, and 8E
(below) illustrate three different types of subluxations of the sagittal lumbar
and thoracic curve. In Figures 8B, 8D, and 8F, the type of Mirror Image lumbar
and thoracic traction method must match both the sagittal thoracic and pelvic
posture as well as the displacement of George’s Line (posterior longitudinal
ligament) relative to the lumbar and thoracic elliptical spine models. Of importance,
the clinical utility and effectiveness of lumbar extension traction has been
reported in a clinical control trial.24
Mirror Image lumbar traction methods enable the CBP chiropractic clinician to
consistently improve the magnitude and geometric shape of the subluxated sagittal
lumbar curve. There are indications and contraindications for each type of traction
method. The chiropractor must judiciously learn, understand, and apply these
traction procedures on a case by case basis.
Figure 8 A-F. Two different subluxations of the lumbar curve and one of the thoracic curve and their respective Mirror Image traction methods. In A, lumbar kyphosis with anterior thoracic translation requires 3-point bending extension traction in B (shown standing). In C, slight lumbar kyphosis with posterior thoracic translation requires 3-point bending in D (shown supine). In E, hyper-kyphosis of the thoracic curve requires 3-point bending thoracic traction in F (shown standing). Photo courtesy Harrison CBP Seminars
Conclusion
In our present era, “evidence-based” medicine was coined as a means
to improve patient outcomes and quality of care. There are a number of types
of clinical studies providing evidence including different types of case studies,
case series, cohort, nonrandomized control trials, and randomized control trials.
Some of the basic science studies providing evidence would include anatomical
studies, spinal modeling; evaluations of loads; evaluation of stresses and strains;
comparisons of alignment in patients and controls (spine or posture); posture
and spinal coupling (main motion and coupled motion); and buckling.
CBP uses postural and radiographic analysis. From the literature, postural evaluation
has reliability and validity.42-51 Significantly,
CBP has multiple types of Index Medicus publications as evidence for its patient
treatment methods, reliability of radiographic positioning,21
reliability of radiographic line drawing analysis,17-20
mathematical basis (linear algebra) of CBP analysis and treatment,52
normal spinal model as a goal of care,11-16
postural and spinal coupling,39-41,53-54
stresses in abnormal postures,28-31 and
efficacy studies including case studies55-59
and six nonrandomized clinical control trials.22-27
What remains for CBP is further refinement of technique protocols, as well as
to perform the top studies of the evidence hierarchy, the much over-rated Randomized
Control Trial.60 Not only is CBP a primary
technique practiced by a large number of practitioners,61
it is a leader in the chiropractic research arena dedicated to the development,
refinement, and study of structural rehabilitative procedures for the human
spine. For more information, visit idealspine.com.
References
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