The Cervical Lordosis in Health and Disease: Literature Review & The Denneroll 'Home Based' Orthotic

Deed E. Harrison, DC President CBP Seminars, Inc. Vice President CBP Non-Profit, Inc. Chair PCCRP Guidelines Editor—AJCC Private Practice-- Eagle, ID, USA

INTRODUCTION

Since my graduation from Chiropractic College (Life Chiropractic College West) in 1994, I’ve spent much of my 20 years in the clinical and research trenches attempting to understand and improve abnormalities of the cervical lordosis in patient populations. I've personally been involved in many scientific research investigations developing and discussing the evidence for the connection between the cervical lordosis in human health, disease, and spine disorders. In the current article, a brief but focused literature review on the cervical lordosis will be presented; then recommended in office vs. home care methods with the available evidence will be discussed.

The Adult Lordosis

The adult cervical lordosis has received considerable attention in the spine literature; in 1996, both average and idealized values and geometric shape of the cervical lordosis were reported. The average adult cervical lordosis was 34° ± 9° between C2-C7 posterior vertebral body lines.¹ In a follow-up paper in 2004, my colleagues and I² modeled the adult cervical lordosis (using a curve fitting method known as the least squares error) as a piece of a circle from C2-T1. Furthermore, we demonstrated statistically significant differences in adult cervical lordosis between normal subjects, acute neck pain subjects and chronic neck pain subjects.^1,2

The Figure 1. below indicates the representative normal cervical lordosis.

Figure 1. ©Copyright Harrison CBP Seminars. Reprinted with permission.

Literature Review Linking Lordosis to Disorders

            Multiple investigations have been published seeking to understand the association, correlation, or the predictive value of an altered cervical lordosis in different health conditions compared to normal controls. To this end, the majority of these studies have found correlation and predictive validity of the lateral cervical radiographic alignment to a variety of health related conditions including:

1. Acute and chronic neck pain.2-5
2. Headaches.5-8
3. Mental health status.9
4. Whiplash associated disorders (WAD).10-18
5. Degenerative joint disease (DJD).19-30
6. Temporal mandibular joint disorders.31
7. Range of motion and segmental motion patterns.32-34
8. Respiration syndromes.35-39
9. Radiculopathy.40,41
10. Increased probability for soft tissue injury under impact and inertial loads.42-46

Oppositely, a few investigations have found that the lateral cervical alignment measurements do not correlate to and predict the findings in the above 10 categories.^47-52 However, many of these investigations have been found to be internally flawed and detailed reviews of these studies have been performed.^53-57 Thus, it should be obvious that the number (45 studies listed above) and the quality of investigations finding a correlation between the lateral cervical radiographic alignment and the conditions in the above 10 categories is superior to the few negative correlation studies. Over the past 20 years, I personally have concluded that the lateral cervical radiographic alignment has positive correlation and predictive validity for the above 10 categories of spine disorders and health conditions.

In Office Methods vs. At Home Care

Historically, the Chiropractic profession has a long history of interest in attempting to improve or correct alterations in cervical lordosis. Problematically, though many outcome investigations have been performed using a variety of chiropractic procedures, most of the traditional methods of Chiropractic procedures have been shown to have limited success at restoration of the cervical lordosis. Still, taken as a collective whole, these reports indicate that patients benefit by reduced pain, improved range of motion, decreased disability levels, and increased health status following chiropractic procedures that improve the cervical lordosis to near normal values.^58-85

• §  In Office Cervical Extension Traction Methods

According to the literature, Chiropractic BioPhysics® or CBP® Technique cervical extension traction procedures are the best available methods for conservatively, consistently and statistically, improving the cervical lordosis. This 'best' evidence exists as 4 clinical control trials (3 non-randomized and 1 randomized) where cervical extension traction treatment methods were added to and compared against various other chiropractic and physical procedures in treated patients versus control group populations.^58-61 From this data, extension traction procedures have been found to produce average lordosis corrections between 7° (in more severely injured population) and 18° (in typical chronic neck pain populations) following approximately 36 treatment sessions over the course of 9-12 weeks duration.

Though cervical extension traction procedures can be considered part of the standard of care for rehabilitation of the cervical lordosis; its wide spread implementation into Chiropractic practices has yet to occur. The likely reasons for this lack of widespread implementation for extension traction is multi-factorial and would include: increased square footage office space needed, increased staff to support implementation, increased patient time in the office, and lack of wide spread technical training for proper applications with indications and contraindications for the various methods. See Figure 2. for in office traction methods.

Figure 2. Various in office cervical extension traction methods. ©Copyright Harrison CBP Seminars. Reprinted with permission.

• §  Home Corrective Orthotics

The use of home corrective orthotic (cervical curve traction) devices as a supplementation to in office treatment programs aimed at rehabilitation of abnormal cervical curvatures has a considerable history in Chiropractic practice. The use of 'at home' cervical extension traction orthotics would seemingly solve several of the key issues with implementation of in office traction methods. Home devices tend to be easier for the patient to use, they are less cumbersome, they are more affordable, and they are likely to be more tolerable. However, at least three main concerns with 'at home' based cervical orthotics must be acknowledged:

There are several different types of home based cervical lordosis corrective orthotics. In Figure 3. a couple of the more popular devices are depicted. Below, I've elected to focus on the cervical denneroll orthotic as it is one of the most applicable, easy to use, and effective (when used properly) home based orthotics today.

Figure 3. Various at home cervical extension traction orthotics: posture regainer, compression extension unit, and cervical denneroll. ©Copyright Harrison CBP Seminars. Reprinted with permission.

The Denneroll Cervical Orthotic

            The cervical Denneroll orthotic device is a simple, yet complex, pillow-like device engineered with curves, angles, and ridges extrapolated, in part, from the CBP evidence based cervical spinal model. Adrian Dennewald, DC (Denneroll Industries in Sydney, Australia) is the developer and owner of the Denneroll orthotic line. In 2008, Dr. Adrian partnered with Chiropractic BioPhysics in an effort to expand the Denneroll product line, to develop proper indications and contraindications for patient care, and to research-test the effectiveness of the Denneroll in improving the cervical lordosis and patient conditions.

            Personally, I was interested in the Cervical Denneroll device as a solution for a low-stress, comfortable mirror-image® traction orthotic to supplement CBP in office care at home.

            To date, the cervical Denneroll, has been tested in a number of case reports and 2 randomized clinical trials. It's been found to improve the cervical lordosis in different patient populations by 7°-14°.^86-91 Thus, the Denneroll orthtoic has been shown to be able to effectively improve the abnormal lordosis of the cervical spine in properly selected cases. Today, the cervical Denneroll products are used worldwide by over 5000 Chiropractors from North America and Australia to the UK, Europe, Asia, and several other international locations.

• Indications for the Denneroll

The Denneroll currently comes in 3 sizes (adult large, adult medium, and pediatric or small) and can be used in many patient conditions and cervical curve configureations. There are three primary placements of the Denneroll cervical orthotic device shown in Figures 4-6. The Denneroll placement should be consistent with both the shape of the cervical curve and the amount/type of sagittal head translation correction that is desired.

• Upper thoracic/lower cervical placement- C7-T2 

This placement of the Denneroll will cause significant posterior head translation, it will increase the upper thoracic curve, and increase the overall cervical lordosis. Specifically, this placement should be used for straightened or kyphotic lower cervical segments with loss of upper thoracic kyphosis and anterior head translation of ≤ 40mm. See Figure 4.

 Figure 4. Abnormal cervical curvatures that fit the inclusion criteria for the application of the Denneroll corrective orthotic in the lower cervical region. These spines must have: • Normal or a mild loss of the upper thoracic kyphosis; • Loss of the lower cervical curve (with or without kyphosis); • Anterior head translation of approximately ≤ 40mm. ©Copyright Harrison CBP Seminars. Reprinted with permission.

Mid-low cervical placement - C4-C6.  This placement of the Denneroll will cause slight posterior head translation; however if the larger Denneroll device is used on a small statured individual then it will create some anterior head translation. The cervical spine should have straightened or kyphotic mid cervical regions (apex of the curve). See Figure 5. In cases with significant posterior head translation, as in Figure 5A, the large Denneroll orthotic should be used and a towel can be placed under the Denneroll to increase the height if needed.

Figure 5. Abnormal cervical curvatures that fit the inclusion criteria for the application of the Denneroll corrective orthotic in the middle cervical region. These spines must have: • Normal or a loss of the upper thoracic kyphosis; • Straightening or apex at the mid-cervical curve; • Slight anterior head translation of approximately ≤ 15mm; • In B with Posterior head translation the LARGE Denneroll should be used with a small towel under it to increase height. ©Copyright Harrison CBP Seminars. Reprinted with permission.

Upper to mid cervical placement- C2-C4. This placement of the Denneroll is used for posterior head translation with straightened or kyphotic mid-upper cervical curves. This position allows extension bending of the upper cervical segments while causing slight anterior head translation. See Figure 6. In cases like Figure 6A with significant posterior head translation, where the posterior vertebral bodies are behind the ideal red curved line,7 the large Denneroll orthotic should be used. While in Figure 6B, the small Denneroll should be used.

Figure 6. Abnormal cervical curvatures that fit the inclusion criteria for the application of the Denneroll corrective orthotic in the upper cervical region. These spines must have: • Close to normal lower cervical curvature; • Straightening or apex at the C2-C4-cervical segments; • In B, normal head translation of approximately ≤ 15mm. Here the SMALL Denneroll is used to not create anterior head posture; • In A with Posterior head translation the LARGE Denneroll should be used to create anterior head translation. ©Copyright Harrison CBP Seminars. Reprinted with permission.

• Contra-indications for the Denneroll:

            Quite simply put, no spine orthotic is indicated or should be used in every case presentation. There are both known and proposed risks for extension traction and extension positioning procedures in spine care. The treating -prescribing clinician should perform an examine in every case and perform proper tolerance testing with the patient prior to releasing the patient to use the Denneroll device at home.

            Here's a basic proposed list of contra-indications for Denneroll orthotic patient use:

1. Moderate to severe mid to upper thoracic hyper-kyphosis;
2. Large, rigid anterior head translations that does not reduce with extension;

            For a more complete list of contraindications for the Denneroll device, please consider the cervical Denneroll training DVD series available at this link:  http://chiropractic-biophysics.myshopify.com/collections/denneroll-traction-devices/products/denneroll-box-set-all-5-dvds-cervical-thoracic-lumbar-compression-extension-and-scoliroll-training-videos

Simple Case Report for Understanding Home Care Implementation.

            In this simple / brief case presentation, we have a female that was involved in a frontal collision crash. The subjective complaints were typical complaints seen with whiplash injuries, such as neck pain, sclerotome pain referral to lower neck and upper thoracic spine from probable facet joint injury, headaches, etc. In this case, the patient elected simply not to perform in office traction due to time constraints. In office care consisted of initial coarse of acute care diversified adjusting for 6 visits, then CBP Mirror Image® drop table and instrument based adjustments and Exercises. The patient having such a magnitude of kyphosis, was started as soon as possible with the Denneroll orthotic (on her 7th visit) starting 2x/day at 1 minute and building up to two sessions of 10 minutes, once in morning, and again once at night. Once this goal was achieved, after 2 weeks (4 weeks after injury), she was placed on 1 session of use per day working up to 20 minutes daily. Her initial x-ray was performed on 10/6/2009 then the next post was actually only 2 weeks later, this time on a Digital Motion X-Ray (DMX), dated 10/20/2009.  DMX was chosen as she persisted with headaches and any evidence of ligamentous laxity can be documented. Notice in just 2 weeks of use, the cervical kyphosis is starting to reduce! After 40 sessions of home use, and 36 visits total treatments, with her symptoms and outcome studies showing her nearing pre-injury status, she was prescribed another follow up DMX. The changes on this final follow up x-ray (3-24-2010) were quite amazing as evidenced below in Figure 7.

 

A Recommendation for In Office & At Home Exercise Warm Up

            It is usually more difficult to re-establish a cervical lordosis in patients that present with a kyphotic cervical curvature and moderate to advanced degenerative joint disease (DJD). These patients usually complain of chronic cervical pain, muscle rigidity and restricted motion. Many of these patients spend much of their day in cervical flexion or anterior head translation and have lost the capacity to truly extend and move their cervical spines. Long term relief for these patients is generally not possible without some form of effective structural and soft tissue rehabilitation. 

            It is for the above reasons that we typically will recommend that patient performs a series of strengthening and flexibility exercises for their cervical spine prior to performing either in office cervical extension traction or at home Denneroll cervical extension traction. Most often we use the Pro-Lordoic Neck Exerciser™ developed by Dr. Don Meyer of California. This device was modified after the cervical neck strap used and taught for this exercise by myself in the CBP Cervical Rehab Seminars for the past several years. Typically we will have the patient perform various forms of cervical exercises using this exercise band for approximately 5-10 minutes prior to performing or using cervical extension traction devices. The Pro-Lordotic exerciser is shown in Figure 8. 

A simple series of exercises with this band are shown on the below youtube links; however, it should be obvious that the treating clinician should select the proper exercises for the individual patient:

Figure 8. The Pro-Lordotic Neck Exerciser™ is a progressive resistance neck exercise device that tractions the normal lordosis into the cervical spine while active extension exercises of the entire cervical spine are performed during the five minute, structural/postural corrective, home or in-office treatment session. For product ordering information see the following link: http://chiropractic-biophysics.myshopify.com/collections/exercise-equipment/products/pro-lordotic-neck-exerciser ©Copyright Harrison CBP Seminars. Reprinted with permission.

SUMMARY

            Discussions of the cervical lordosis has a long history in the spine literature. While nothing is without controversy, the majority of past and present research reports indicate that the cervical lordosis plays a pivotal role in human health, many spine disorders, and several health disorders. While in office treatment programs combining cervical extension traction procedures should be considered the gold standard for consistent, predictable improvements in patients suffering from abnormalities of the cervical lordosis, at home based corrective cervical spine orthotics should be implemented as well. The cervical Denneroll is one of the most applicable, easy to use, most cost effective, and outcome effective home based cervical extension orthotics on the market today. Clinicians should be aware of the indications and contraindications for at home usage of this device. I hope this presentation assists in your delivery of effective patient intervention in the office and with supplementation of at home devices.

Note:

For more information on the Denneroll Orthotic, please visit http://www.idealspine.com/cervical-dennerol/

For information on becoming a denneroll provider in the USA / Canada please visit http://chiropractic-biophysics.myshopify.com/pages/signup.

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79.       Morningstar, M.W.; Strauchman, M.N.; Weeks, D.A.; Spinal Manupulation and Anterior Headweighting for the Correction of Forward Head Posture and Cervical Hypolordosis: A Pilot Study. J Chiropr Med 2003; 2(2):51-54.

80.       Pierce VP. Results I. Dravosburg, PA: CHIRP, Inc., 1981.

81.       Reynolds, C.; Reduction of Hypolordosis of the Cervical Spine and Forward Head Posture with Specific Adjustment and the Use of a Home Therapy Cushion. Chiropractic Research Journal 1998; 5(1):23-7.

82.       Gary Knutson, DC and Moses Jacob, DC. Possible manifestation of temporomandibular joint dysfunction on chiropractic cervical x-ray studies. J Manipulative Physiol Ther: JAN 1999(22:1) Page(s) 32-37.

83.       Moore MK. Upper crossed syndrome and its relationship to cervicogenic headache. J Manipulative Physiol Ther: JUL/AUG 2004(27:6).

84.       Dobson GJ. Structural Changes in the Cervical Spine Following Spinal Adjustments in a Patient with Os Odontoideum: A Case Report. JVSR August 1996, Vol 1, No. 1, p 1-12.

85.       Moore MK. Upper crossed syndrome and its relationship to cervicogenic headache. J Manipulative Physiol Ther: JUL/AUG 2004(27:6).

86.       Paris B, Harrison DE. Restoration of an Abnormal Cervical Lordosis Using the DENNEROLL: A CBP® Case Report. American Journal of Clinical Chiropractic (ISSN 1076- 7320) 2010; April Vol.20 (2):14,26. http://www.chiropractic-biophysics.com/clinical_chiropractic/2010/4/12/restoration-of-an-abnormal-cervical-lordosis-using-the-denne.html

87.       Ferrantelli JR. BioPhysics Insights: The Denneroll Orthotic. American Journal of Clinical Chiropractic (ISSN 1076-7320) 2010; July Vol.20 (3): 13-14. http://www.chiropractic-biophysics.com/clinical_chiropractic/2010/9/12/the-denneroll-orthotic-i-didnt-believe-it-till-i-tried-it.html

88.       Ferrantelli JR, Harrison DE. Denneroll Combined with Pope 2-Way Aids Patient Suffering from Chronic Whiplash Associated Disorders & Advanced S.A.D.D. American Journal of Clinical Chiropractic (ISSN 1076-7320) 2010; Oct. Vol.20 (4):13,14. http://www.chiropractic-biophysics.com/clinical_chiropractic/2010/10/22/denneroll-combined-with-pope-2-way-aids-patient-suffering-fr.html

89.       Boyd C, Harrison DE. CBP Chiropractors: We Must Practice What We Teach American Journal of Clinical Chiropractic (ISSN 1076-7320) 2012: http://www.chiropractic-biophysics.com/clinical_chiropractic/2012/4/1/cbp-chiropractors-we-must-practice-what-we-teach.html

90.       Does improvement towards a normal cervical sagittal configuration aid in the management of lumbosacral radiculopathy: a randomized controlled trial. In Review for possible publication.

91.       The Effect of Normalizing the Cervical Sagittal Configuration for the Management of Cervicogenic Dizziness: A 1-Year Randomized Controlled Study. In Review for possible publication.

3-Point Bending Traction for Scoliotic Curvatures Using the New 3-D Denneroll Traction System: A Case Report

INTRODUCTION

In a study from 1893 regarding scoliosis treatment, Bradford and Brackett,¹, stated, “there is not only nothing irrational in the method of treatment by forcible mechanical correction when feasible, but it is manifest that when shortened ligaments in spinal curvatures are situated so that they serve as a check to muscular action.”¹ They continue, “when they [ligaments] are strong enough to withstand muscular action, gymnastics [exercises] alone are inadequate as a system of correction.” ¹ Bradford and Brackett’s¹ mechanical traction protocol required patients to undergo traction for a half-hour daily. Because this study was done prior to the invention of x-ray, reported results were not very accurate. More than a century later, CBP® researchers and clinicians have found agreement with Bradford and Brackett that exercises should be combined with short duration, high-force mechanical traction in order to obtain the most effective results in scoliosis reduction.

• CBP's Mirror Image® Traction for Scoliosis

The traction employed by the CBP® practitioner for scoliosis management requires critical reasoning and a thorough understanding of the displacements of the spine and posture. Generally speaking this traction is of the 3-point-bending type of load application or a transverse load applied at the apex of the curve with and without lateral bending, axial rotation, or other movements depending on the specific case. The traction set-up must always be performed in a pre-determined optimum sequence of movements using stress x-rays to guide the decision making process. Mirror Image® traction sessions and duration should be a minimum of:

• At least 3-5 times per week. If the patient will traction more than 1 time per day this would be beneficial as long as the patient is not becoming overly painful from the increased frequency of treatment.
• Traction duration should be 20-30 minutes. The patient starts with 2-3 minutes and over consecutive sessions progresses in time.

CASE REPORT       

            The current patient had a history of thoracic pain and had been under chiropractic care for many years which she indicated gave her temporary relief. Now at 13 yrs old, her pain and frequency have worsened over the last 4 months to a stage where she was experiencing daily headaches and thoracic pain rated as severe on a numerical rating scale (7-8 / 10).

• Initial Radiography

1. Primary Right Thoracic curve = 43 degrees (see Figure 1).
2. Secondary Left Lumbar Curve = 28 degrees (see Figure 1).

• 1st in traction x-ray using the Denneroll Table and the Scoli-Roll Fulcrum System

            The first in-traction x-ray showed that the thoracic spine was well effected however the lumbar spine was bending and under the stress in the incorrect direction (see Figure 2). This showed us that we needed to raise the lumbar spine off the table to help stretch the lumbar spine correctly.

• 2nd in traction x-ray

            In response to the first in-traction x-ray, we decided to raise the pelvis to a level of +2 (two blocks under the right hip to address the concerns of the lumbar spine translation. You will see in the 2^nd in-traction x-ray that raising the pelvis height did not decrease the effects of the ScoliRoll under the thoracic spine. This is obviously achievable due to the downward pressure of the two straps pulling on the thoraco-lumbar spine and upper thoracic region. The specific effects of using the block system to raise the pelvis is really evident when you look at the stress x-ray in figure 3.

From these in-traction x-rays we can accurately assess that the block under the pelvis is best for the patient’s spine. It also shows how x-rays are essential in establishing the best possible traction position.

• CHIROPRACTIC INTERVENTIONS

            Due to the positive findings of the stress radiographs, the patient was recommended to undergo corrective chiropractic care including Mirror Image traction on the denneroll table, Mirror image adjusting, and Mirror Image Exercises. She was seen for 3 x week for 1-month (with a couple of interruptions) and was advised on doing home exercises on the days she was not being treated in the office.

•  Mirror Image® Exercises and Adjustments

            We believe that both postural based exercises and adjustments are vital in consolidating the benefits of the effective spine stretching using the denneroll 3-point bending traction table. During the patient's exercise, neurological stimulation was added by impulsing the spine during her exercise movements; thus turning the exercise into the adjustment.

After 5 weeks and 13 sessions, we can see the corrective improvements in the patient’s spine. The patient’s symptoms have been reduced 90%. Thus, she is symptomatically doing very well and began improving after her 1^st session and has reported no symptoms at all for the last 3 weeks.

• 5 weeks-Follow up Radiography

            A one month follow up radiographs of the thoracic and lumbar spines were obtained to identify if the recommended and applied treatment was having the desired effect. Obviously scoliosis of this magnitude might require more frequent and increased numbers of sessions. However, only a follow up radiograph can truly determine what extent more care or different care is required.

            A remarkable reduction of the AP Thoracic scoliotic curve was identified from 41 degrees down to 28 degrees on the post (a 13° net improvement). Similarly, the AP Lumbar curvature demonstrated improvement. See Figure 5.

SUMMARY

            This case presents the initial successful reduction of a primary thoracic scoliosis in an adolescent female with a history of chronic pain. After 5 weeks and 13 sessions, we can see the corrective improvements in the patient’s spine. The patient’s symptoms have been reduced 90%. We believe the results are due to the combined effect of the Mirror Image treatment methods including the 3-point bending traction employed using the 3-D Denneroll Traction Table. The patient is continuing care and perhaps a future article will address her response.

References

1. Bradford EH, Brackett EG. Treatment of lateral curvature by mean of pressure correction. 1893.

CBP Chiropractors: We Must Practice What We Teach

Cindy Boyd, BS, DC

Private Practice of Chiropractic Alameda, CA

Faculty Life Chiropractic College West

&

Deed E. Harrison, DC

President CBP Seminars, Inc.

Vice President CBP Non-Profit, Inc.

Chair PCCRP Guidelines

Editor—AJCC

INTRODUCTION

In previous issues of the AJCC, we have presented a number of articles on the indications and contra-indications of the cervical denneroll orthotic device as a method for restoration of an abnormal cervical lordosis. Also, several patient case studies have been presented describing the successful ability of the cervical denneroll orthotic device in restoring the cervical lordosis and improving patient health disorders as a consequence. In the current case, we report on the improvement in the cervical spine with a large disc herniation and complex injury-buckling of the cervical segments including retro-listhesis, hyper-extension, and flexion at different cervical spine joints. This report represents the actual conditions of one of the authors (CB) and these are her results.

Key Case Features

A 34 year old female presented with chronic neck pain, decreased range of motion, headaches with extension of the head and neck and a recent onset of heart palpitations of unknown etiology. The symptoms were reportedly getting worse over the past few months, and causing the patient to refrain from practicing in her chiropractic clinic providing one on one patient care. After administering 1-2 adjustments on any given day, the symptoms were exacerbated causing disability and significant discomfort.

The patient had a past history of two head and neck injuries. The first direct impact injury was sustained during a bicycle accident that occurred in the spring of 2008. The patient was riding a bicycle at a high speed and traversed over old railroad tracks at an awkward angle causing an immediate crash. Her head hit the pavement with significant force, and unfortunately she was not wearing a helmet. Fractures were ruled out and no lacerations were present. A mild concussion was sustained. Bruising and swelling was present in the right zygomatic region at the site of direct impact. 

Two years later, a double direct impact injury occurred during a snowboarding accident where the patient fell on an ice patch directly landing on the sacrum and a second impact occurred during the same fall when she fell backwards and hit her skull on the ice patch with significant force. This time the patient was wearing a helmet.  

• ·      Health Status, Pain, and Disability Questionnaires

The short form (Sf)-36 health status questionnaire, numerical rating scale for pain intensity and the neck disability questionnaires were administered. The patient had considerable pain, disability, and depressed health. See Figure 1 for the initial NDI and SF-36 abnormalities.

Figure 1. Patient initial neck disability and SF-36 scores indicating considerable pain, disability, and abnormal health status.

• Radiographic Evaluation

Lateral Cervical Radiograph:

On 8/24/11 a digital lateral cervical was obtained. See Figure 2. The radiographic analysis was done using the Posture RayÒ computerized radiographic mensuration system. The patient’s radiographic displacement values are shown in Figure 2B and are compared against normal. Several cervical spine subluxation-displacements are present including: an abnormal kyphosis from C4-C7, a C3-C4 segmental retro-listhesis, and a considerable hyper-extension of C2-C3 were identified. The radiographic and clinical findings indicated a possibility of herniation one or more cervical discs and instability in multiple levels of the cervical spine.  Thus, an MRI was obtained, and the findings confirmed a central/sub-ligamentous disc herniation at C2/C3 and C5/C6 with concomitant instability.

Figure 2. Initial lateral cervical radiograph and abnormal findings of alignment compared to ideal values. The PostureRay™ system was used.

Lateral Thoracic Radiograph:

            On 8/24/11 a lateral thoracic radiograph was also obtained. Figure 3 depicts the patient's lateral thoracic radiograph. Relative to the CBP ideal thoracic elliptical model, the patient's upper and mid-thoracic segments are in a relative subluxated extension position. This is consistent with an extension abnormal postural position of the thorax relative to the pelvis or lumbar spine.

Figure 3. Lateral thoracic radiograph. The green elliptical line is the Harrison ideal thoracic model representing the proper path of the posterior vertebral bodies of the thoracic spine. Note that the patient has extension-backwards bending of the upper-mid thoracic spine relative to the lower thoracic spine.

Denneroll Stress Radiography:

These values and findings indicate the patient’s candidacy for the Denneroll Cervical Orthotic. Based on MRI findings and significant abnormal segmental cervical translation measurements, Denneroll stress X-rays were taken using the large cervical Denneroll. Figure 4 depicts the lateral stress x-ray. Based on the initial radiographs, it was determined additional upper thoracic flexion and translation was needed in this setup to make a considerable correction in the injured and postural distorted regions. Thus, a 10 millimeter foam block was used under the denneroll device to increase the height of the orthotic in order to induce additional upper thoracic flexion and translation during the stress study.  The peak of the denneroll was placed in the lower cervical spine. Particular attention was given to the hyperextended upper cervical segments, and another block measuring 10 millimeters in height was placed under base of the skull during the stress analysis. Further, to limit the amount of skull extension and upper cervical extension, the patient was asked to actively flex-tuck her chin (although painful) at the time the radiograph was taken. Figure 2 shows the upper cervical spine extension on the initial patient x-ray. 

The stress analysis study showed considerable correction in the cervical abnormal values including the segmental translations and relative rotation angles that were present on the neutral lateral cervical study.

Figure 4. Denneroll stress lateral thoracic radiograph to ensure proper location of the denneroll peak and if the denneroll is effectively improving the cervical alignment.

• Denneroll Cervical Orthotic Intervention

Based on the outcomes of the stress radiographic analysis, the patient agreed to participate in a study to determine the outcome of cervical curve correction using the Denneroll home traction device.  No other forms of treatment were administered. Spinal manipulation, CBPÒ drop table adjustments, Mirror ImageÒ exercises and in office traction types, were all avoided during this particular patient treatment phase with the Denneroll. 

The large cervical Denneroll was used at a frequency of 1-2 times daily, 4-6 days a week for a 30 day period. Each home session involved the patient lying supine on the large cervical Denneroll with a 10 millimeter block under the device. Refer to Figure 4 for the denneroll setup. In addition, a 10 millimeter block was placed under the skull to limit the amount of upper cervical extension.  The patient was also instructed to actively flex the chin while on the device. The amount of upper cervical hyperextension and thoracic extension measured on the lateral cervical and thoracic radiographs warranted the degree of specificity in this setup. Between the dates of 8/24/11-9/22/11 approximately 36 home Denneroll sessions were performed at a duration of 10-18 minutes each.

A follow up lateral cervical x-ray was taken on 9/22/11 to determine if the intervention had made any significant changes.

• Case Outcome

      Subjectively, at the end of the 1-month treatment phase, the patient was asymptomatic including the disappearance of the heart palpitations, headaches and pain.  There were significant improvements in the SF-36 and neck disability outcomes. The follow up lateral cervical radiograph exam showed significant improvements in all cervical regions that were abnormal initial. Figure 5 and Table 1 describe these results.

Figure 5. One-month follow-up lateral cervical. Note that this x-ray was taken a minimum of one day with no treatment interventions. There are considerable improvements in all radiographic abnormalities.

RRA’s (-) values = extension (+) = flexion		Segmental Translation (-) values = posterior	Translation C2-C7
C2/C3	12°	-1.6 mm	21.6mm
C3/C4	-1.7°	-2.4mm
C5/C6	0°	-0.8 mm
ARA C2-C7	-26°

CONCLUSION

            This case report represents the actual conditions of one of the current study authors (C.B.). The uniqueness of this case lies in the severity of the cervical spinal displacements and the concomitant improvements in structural and functional abnormalities using the cervical Denneroll as the exclusive treatment intervention. While the patient's follow-up radiograph is still not considered to be within normal limits and further care is warranted, the improvements over the course of one-month are promising. The patient (C.B.) has committed to continuing her Denneroll intervention program to continue rehabilitating her cervical spine. Afterall, as a CBP Chiropractor, we must practice for ourselves what we teach our patients to do.