Treating the Elderly with Chiropractic BioPhysics® or CBP® Technique Methods

Jason W. Haas, DC

Private Practice Windsor, CO

Many practitioners are surprised to find out the extent of Chiropractic BioPhysics or CBP Technique methods we employ to treat elderly patients in our facility.  Some colleagues feel that the elderly patients may not be a candidate for treatment due to the fact that they are older, frailer, can have extensive degeneration or many comorbidities.^1-3 These doctors are afraid to attempt to change their spine and posture because the problem is long-standing or they fear they may injure the patient.  However, in our clinical experience treating over 6500 patients in the last eleven years, we have found that the elderly patients respond very well to gentle application of CBP methods and astute clinicians will find that they can have a tremendous positive effect on a patient’s posture, pain, quality of life and overall health.

                  Most of our elderly patients come to us for painful conditions that they have not been able to find relief from using traditional treatments of drugs, surgery or even traditional chiropractic and physical therapy.  These patients are often discouraged with healthcare in general because they are finding that the time they spend with their doctor is less and less and the outcomes of the medicines they are prescribed are less and less effective. This can create a situation of frustration that a well-trained receptionist must contend with in order to get the elderly person feeling comfortable in the office.  A great tour of the office and a compassionate staff can show these folks that the CBP experience will likely be completely different from other chiropractors, medical doctors and other healthcare providers

Our Intake Process & General Exam Procedures

                  Once they see that we offer a different approach to spinal care, we can move them through the process of intake.  The examination is similar to younger patients but may require more time due to a longer health history and multiple concomitant health concerns/conditions.  We will always perform a thorough health history, all pertinent orthopedic and neurological testing, blood analysis if necessary, CBP structural evaluation including spine and extremity films when indicated, Posture Screen™ digital postural analysis and all pertinent outcome measures (all patients receive the SF-36, pain and disability questionnaires), and digital range of motion and strength testing.

                  Once we have the data for our initial assessment we make a determination as to whether they are candidates for CBP Structural Rehabilitation; yes there are some cases that we won't perform CBP care with due to contra-indications.  This assessment involves looking at the evaluated spine films with PostureRay™, and determining if there are any areas that would not respond well to conservative care, and CBP care especially.  If there are areas of suspected instability we will take flexion/extension films or send to my friend Evan Katz,DC for DMX.  Once possible contraindications have been ruled out, we explain the importance of improving sagittal and coronal balance with the patient and discuss the limitations that the care may have.  The discussions on limitations are crucially important because the elderly patients must be aware that osteophytes, disc and ligament degeneration and severe structural abnormalities will likely not return to normal as a result of the care we are providing.  They must know that the goals are better range of motion and strength, better posture (coronal and sagittal) and improvements measured on their outcome measures (SF-36, NDI, etc.) If a patient has an unrealistic expectation of being “fixed” and getting back to completely normal, it’s important to inject some reality and sometimes limit expectations.

Sagittal Plane Alignment & Health Concerns in the Elderly

                  The sagittal plane alignment of the spine and posture and it's connection to human health and longevity is becoming one of the most widely researched topics in spine care today.^4-10 The sagittal plane alignment of the spine and posture in the elderly has been found to correlate to the following health disorders:

1. Increased risk of spinal compression fractures;⁴
2. Increased low back pain and more severe pain;⁵
3. Decreased mobility and increased risk of falls leading to fractures;^6,7,8
4. Increased risk of going into a care giving facility and not being able to take care of one's self in normal activities of daily living;⁹
5. Increased knee or patellar femoral pain;¹⁰
6. Increased disability and impairment due to pain;¹¹
7. Possible increase risk of early death compared to age match corhorts.^12,13

For example, of a few of these important studies are reviewed here. Kobayashi and colleagues⁴ prospectively followed 100 subjects aged 61.9 yrs of age for an additional 12 years (indicating they were about 74 years at follow up). Full spine radiographs were ascertained at initial and long-term follow up in an attempt to identify if sagittal plane radiographic alignment variables play a role in the risk for developing new vertebral compression fractures. In both univariate and multivariate analysis, reductions in lumbar lordosis (Cobb L1-L5) and thoracic kyphosis (Cobb T4-T12) increased the relative risk of developing a new vertebral body compression fracture. Significantly, even curves one standard deviation below the mean value showed statistically significant increased relative risks (RR 3.06). Their⁴ most statistically significant model was multi-variate including pre-existing compression fractures with both the lumbar lordosis and thoracic kyphosis decreased (RR 8.64). Kobayashi and colleagues⁴ suggested that flattened curves reduce the shock absorbing capability of the sagittal curves, increasing the dynamic loads on the vertebral bodies thus increasing the risk of fractures.

                  In a prospective study of 253 chronic LBP patients matched by age and physical characteristics to 253 normal controls between the ages of 50-85 years, Tsuji et al⁵ found a reduced L1-S1 lordosis in the chronic LBP group. Of primary importance, lumbar lordosis was inversely correlated with pain intensity on a visual analog scale (p= 0.025). In other words, as the lumbar lordosis decreased, the pain intensity of the subject was increased.⁵

                  Recently, Kamitami et al⁹, studied the spinal posture in 804 participants (65–94 yrs of age) who were initially independent in their activities of daily living (ADLL) at baseline. These participants were followed for a 4.5-year follow-up period and it was found that 126 (15.7%) of the participants became dependent in their ADLs. Dependence in ADL was defined as admission to a nursing home or need of home assistance to perform basic self care functions. Importantly, inclination of the upper body relative to the pelvis (angle subtended between the vertical and a line joining C7 to the sacrum) was correlated with outcome and lumbar curvature also showed a marginal association. After adjusting for age and sex, it was found that for each 1 unit increase in the quartile of forward inclination that the odds of becoming dependent on ADL's was 1.79 x greater. Indicating that the highest quartile had a risk of 1.79 x 3 = 5.37 times more likely to be dependent. This study is very important for the elderly person wanting to remain able to perform basic care functions.

Chiropractic BioPhysics Mirror Image® Treatment Approach

                  Care of the elderly patient is slightly different in the CBP setting as it requires a gentler; yet still patient centered approach. We are cautious not to use high-velocity manipulation with elderly patients and work primarily on improving their posture with gentle CBP Mirror Image adjustments. The CBP Mirror image exercises are incredibly important in increasing strength and stability of the core postural muscles. We recommend and use the PowerPlate® as this is an exceptional tool for the elderly to perform their Mirror Image exercises while getting maximal benefit from the whole body vibration or acceleration training.

                  The CBP Mirror Imag traction protocols must also be altered for the elderly patients, they must understand why we are using the traction and stressing the analogy that spinal change is a marathon and not a sprint is important to minimize injury.  Most elderly patient in our office have radiculopathy, peripheral neuropathies, disc herniations and osteophytes so the use of distractive traction is often superior to compression traction which can irritate and worsen radiating symptoms.

                  Frequent re-evaluation and re-assessment of the elderly patient is possibly more important than any other age group.  This is due to the fact that they often have significant health complications that ned to be assessed periodically.  In our integrated setting it is easy for them to see our nurse practitioner or medical doctor if new symptoms arise, and for those of you who are not integrated, I would suggest having a close relationship with local providers to manage any health complications that may arise throughout care.

                  Diligent, patient, and compassionate care for the Elderly population can provide this segment with significant health gains, better posture and balance, less pain and a better overall quality of life. IF you would like more information on CBP care and the elderly, please attend any upcoming seminar.

Sample Patient Case:

Age: 87

Initial Complaints:  Low back pain and left leg sciatic pain NRS 8/10

Oswestry:  58% disability. Significant depression due to worsening of pain, poor balance and coordination.

Patient was told by two other chiropractors they could not help her.  She was told by a surgeon that she is not a candidate for surgery due to advanced age.

CBP Treatment:  Mirror Image adjustments prone with the headpiece elevated and instrument adjustment to the spine. Mirror Image exercises; standing with a block in the lower thorax and head and ribcage retraction performed in-office and at home.  Supine thoraco lumbar traction. Fulcrum of traction at thoraco-lumbar junction, 0° angle of pull and leg strapped below the femur heads, sustained for 12 minutes. Cervical Traction consisting of  Pope-2-way type traction with a distractive force of 10 lbs and a finishing front weight of 18 lbs. sustained for 10 minutes.

Total treatments:  30 sessions

Figure 1. Before treatment and after treatment full spine radiographic changes due to CBP mirror image care over the course of 30 visits. Note that the follow up x-rays are taken a minimum of 3 days after the patients last treatment session. Thus, this is not an x-ray immediately after care. In this manner an accurate response to care can be found.

Final Complaints:  Very rare low back pain (NRS2/10)  Sciatica resolved, Depression significantly reduced and the patient states she feels better now than she has in decades. Oswestry: 8%.

Perspective on Patient Outcome:

                  It is my opinion that the improvement in the patient's condition, outcome measures, and self reported ability to function was due to the considerable improvement in the sagittal plane alignment of the patient's thoraco-lumbar curvatures and sagittal-forward balance. The references^4-13 provided below provide evidence based support for this anecdotal but clinically obvious statement.

Reference Links

1. http://www.ncbi.nlm.nih.gov/pubmed/25436061
2. http://www.ncbi.nlm.nih.gov/pubmed/23307577
3. http://www.ncbi.nlm.nih.gov/pubmed/25533322
4. http://www.ncbi.nlm.nih.gov/pubmed/?term=Kobayashi+T+Osteoporos+Int++2008
5. http://www.ncbi.nlm.nih.gov/pubmed/11479757
6. http://www.ncbi.nlm.nih.gov/pubmed/21198460
7. http://www.ncbi.nlm.nih.gov/pubmed/24715607
8. http://www.ncbi.nlm.nih.gov/pubmed/20480146
9. http://www.ncbi.nlm.nih.gov/pubmed/?term=Kamitami+2013
10. http://www.ncbi.nlm.nih.gov/pubmed/12355123
11. http://www.ncbi.nlm.nih.gov/pubmed/15972617
12. http://www.ncbi.nlm.nih.gov/pubmed/19451575
13. http://www.ncbi.nlm.nih.gov/pubmed/15450042

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.

PostureRay®: Better Software Based on the Best Structural Science!

This year we have released many exciting updates to our PostureRay® Radiographic EMR system.  In addition to its already exhaustive list of features geared to stimulate patient referrals and bullet proof your documentation, we have again added EVEN MORE requested features.  Here is a glimpse of the latest additions.

Pediatric Age-Related Segmental and Global Analysis:  Yes, you heard correct, we have released our modeling research findings in our software for inclusion of age-related specific normal for the pediatric/adolescent populations.  Earlier this year, Deed Harrison, DC, Tad Janik, PhD, and myself revisited our ideal and normal modeling studies to extrapolate age related normal using our published modeling for the Harrison Posterior Tangent Methods.  This again, is available nowhere else but in the PostureRay® CBP® module.

Updates Instability Analysis: We have included an optional upgrade to the Endplate (Cobb) analysis for instability pioneered originally by White and Panajbi – which was adopted by the AMA Guides.  In addition, we have also added Penning’s Analysis to better evaluate total instability within total range of motion.  This is crucial for doctors that work on patients involved in MVC’s and other injuries where cervical instability is to be assessed.

Lateral Full Spine Analysis:  Now available in PostureRay® you can digitize a lateral fullspine view and overlay the copyrighted CBP® elliptical fullspine model allowing much more accurate assessment of a patient’s true sagittal plane balance.  This has never been possible, and obviously is not available in any other software package on the market.

Phrase Builder – Since our system is geared as a Structural Based Radiographic Specific EMR, this unique addition will drastically reduce reporting by doctors to both educate patients as well as add impressions to a pathology report using our state of the art macro phrase builder/reporting system.

Nasium Analysis – New to PostureRay® is inclusion of the CBP® Nasium analysis, adding the completion of upper cervical analysis specific to CBP® Methods.

Support for 3^rd Party EMRs / PACs– We are currently partnering with all major vendors of documentation EMRs as well as 3^rd party PACs systems to allow tighter integration with patient demographic implementation and calling up of our QuickView Module.

Updated QuickView and Image Exporting: Doctors now have ability to display and export different variations of our analysis, especially for scoliosis cases.  This allows for adding overlay of annotated findings with impression report lines (such as Risser-Ferguson/Cobb Analysis/ or “patient  friendly” assessment lines 

Impression Report Updates with citations:  Since CBP® originally authored countless index medicus papers on x-ray reliability, validity, as well as the modeling studies, we have used this expertise, to generate specific reports and references to aid your documentation of your x-ray findings.  Again, this available no where else.

If you would like to learn on how the PostureRay® radiographic analysis EMR solution can benefit your practice, please call 866.577.7297, email sales@postureco.com or visit www.postureco.com