Published Research

Committees of post-graduate students, practicing clinicians, or college faculty perform reviews of published literature to summarize and critique the findings, validity and accuracy of the published materials. That information and critique is posted and available for review or download by registered users of the organization website.

There are over 400 published studies from peer reviewed resources referenced here in this section regarding radiology associated primarily with biomechanics of the human spine. Additional published literature related to patient preferences and radiation issues are also posted and reviewed in other sections of this website under subsections Clinical Experience, Patient Preferences, and under the Risks and Benefits sections.


Article #Article TitleAuthor & JournalAuthors ConclusionsRadiographic Considerations / Key Points
A Cross-Sectional Study Correlating Cervical Radiographic Degenerative Findings to Pain and Disability. Dennis M. DC, MS, DACBR; Henderson, Charles N. R. DC, PhD Spine:1 December 1996 – Volume 21 – Issue 23 – pp 2747-2751Increasing levels of spinal degeneration are related to increasing chronicity of patient complaints. Spinal degeneration is not related to past trauma or gender. Women, but not men, report higher disability with increasing levels of degeneration. Subjects with past trauma reported more intense pain and disability. Overall, men reported less neck pain and disability than women.Generaly DJD = increased chronic pain. The more segments with DJD the more chronic the pain will be.
A retrospective study to reveal the effect of surgical correction of cervical kyphosis on thoraco-lumbo-pelvic sagittal alignment. (DISCUSS ASSESSING OTHER SPINAL CURVES AND HOW THEY RELATE/COMPENSATE TO EXPLAIN POSSIBILITY AS TO WHY THE LUMBAR SPINE DID NOT CORRECTEur Spine J. 2016 Jul;25(7):2286-93. doi: 10.1007/s00586-016-4392-9. Epub 2016 Jan 25.
Lee DH1, Ha JK1, Chung JH1, Hwang CJ1, Lee CS1, Cho JH2.
Surgical correction of cervical kyphosis affects T1 slope and thoracic kyphosis, but not lumbo-pelvic alignment. These results indicate that the compensatory mechanisms to minimize positive sagittal malalignment of the head may occur mainly in the thoracic, and not in the lumbosacral spine.
A review of biomechanics of the central nervous system--Part I: spinal canal deformations resulting from changes in posture.J Manipulative Physiol Ther. 1999 May;22(4):227-34.
Harrison DE1, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO.
Rotations of the global postural components, head, thoracic cage, and pelvis cause changes in the diameter of the spinal canal and intervertebral foramen. These changes are generally a reduction of less than 1.5 mm in extension, compared with a small increase in flexion of approximately 1 mm. These small changes do not account for the clinical observation of patients having increased neurologic signs and symptoms in flexion.
A review of methods for evaluating the quantitative parameters of sagittal pelvic alignmentSpine J. 2012 May;12(5):433-46. doi: 10.1016/j.spinee.2012.02.013. Epub 2012 Apr 4.
Vrtovec T1, Janssen MM, Likar B, Castelein RM, Viergever MA, Pernuš F.
Normative values for anatomic parameters of sagittal pelvic alignment do not exist because the variability of the measured values is relatively high even for normal subjects but can be predictive for spinal alignment and specific spinopelvic pathologies
A review of methods for quantitative evaluation of spinal curvature. Eur Spine J. 2009;18(5):593-607. Vrtovec T, Pernus F, Likar B. Despite all of the reported limitations, modern imaging techniques help clinicians in making more accurate diagnosis and planning more effective treatment strategies for spinal disorders. Increasing the efficiency of interpretation, reducing human variability and error, and making the interpretation more quantitative are among the most important motivations for developing systems for computer-assisted diagnosis. Computerized quantitative evaluation of spinal curvature in 3D therefore remains a challenging task in the field of medical image processing, analysis and understanding.Despite all of the reported limitations, modern imaging techniques help clinicians in making more accurate diagnosis and planning more effective treatment strategies for spinal disorders. Increasing the efficiency of interpretation, reducing human variability and error, and making the interpretation more quantitative are among the most important motivations for developing systems for computerassisted diagnosis. Even though this article is discussing measurements for surgical intervention, the same considerations should be made for structural correction from a conservative, chiropractic standpoint.
A survey of general practitioners opinions
on the role of radiology in patients with low back pain.
Owens JP, Ruth G, Keir MJ, Spencer H, Richardson D,
Richardson A, et al. Br J Gen Pract 1990;40:98-101.
Ninety general practitioners responded to a questionnaire about the role of radiology in patients with low back pain. Their clinical indications for requesting radiographs were mostly in agreement with the opinions of radiologists, but nearly 80% requested investigations for their own or patients' reassurance. Understanding of the terms used by radiologists was good, although 25% thought that acute disc prolapse could be demonstrated on plain films. Previous training in radiology did not seem to influence knowledge. When general practitioners understood radiological terms they had clear therapeutic and specialist referral preferences. Poorly understood terms and those with which they were familiar but unclear about the implications for management were also identified.
A systematic review of the diagnostic accuracy of
provocative tests of the neck for diagnosing cervical
Rubinstein SM, Pool JJ, van Tulder MW, Riphagen II, de Vet
HC. Eur Spine J 2007;16:307-19.
Future diagnostic studies should include sufficient diseased subjects, and a composite reference standard, consisting of both advanced imaging and electrodiagnostic testing (or consider the diagnostic criteria of Radhakrishnan et al.), in order to ensure correct classification of cervical radiculopathy.
Addition of a Sagittal Cervical Posture Corrective Orthotic Device to a Multimodal Rehabilitation Program Improves Short- and Long-Term Outcomes in Patients With Discogenic Cervical Radiculopathy.Arch Phys Med Rehabil. 2016 Dec;97(12):2034-2044. doi: 10.1016/j.apmr.2016.07.022. Epub 2016 Aug 27.
Moustafa IM1, Diab AA2, Taha S2, Harrison DE3.
The addition of the Denneroll cervical orthotic device to a multimodal program positively affected discogenic CR outcomes at long-term follow-up. We speculate that improved cervical lordosis and reduced AHT contributed to our findings.
Adherence to radiography guidelines for low back pain: a survey of chiropractic schools worldwide.J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):412-8. doi: 10.1016/j.jmpt.2008.06.010.
Ammendolia C1, Taylor JA, Pennick V, Côté P, Hogg-Johnson S, Bombardier C.
This survey suggests that many aspects of radiology instruction provided by accredited chiropractic schools appear to be evidence based. However, there appears to be a disparity between some schools and existing evidence with respect to the role of radiography for patients with acute low back pain without "red flags" for serious disease. This may contribute to chiropractic overutilization of radiography for low back pain.
Adolescent Idiopathic Scoliosis Treatment Using Pettibon Corrective ProceduresMark W Morningstar, DC, Megan N Strauchman, DO, Greg Gilmour DC; J Chiropr Med. 2004 Summer; 3(3): 96–103.
doi: 10.1016/S0899-3467(07)60093-7
Pettibon corrective procedures seemed to be effective at reducing the thoracolumbar scoliosis 15° (43%) after six weeks. The subjective and objective results of this case study warrant further such investigations.Pettibon is a good method for scoliosis management
Alleviation of chronic spine pain and headaches by reducing forward head posture and thoracic hyperkyphosis: a CBP® case report.Fortner MO1, Oakley PA2, Harrison DE3.; J Phys Ther Sci. 2018 Aug; 30(8): 1117–1123.
Published online 2018 Aug 7. doi: 10.1589/jpts.30.1117
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.Case report to relate reduce chornic pain with reducing forward head posture with CBP protocol
Alleviation of neck pain by the non-surgical rehabilitation of a pathologic cervical kyphosis to a normal lordosis: a CBP® case report.Alyssa K. Dennis,1 Paul A. Oakley,2,* Michael T. Weiner,1 Tara A. VanVranken,1David A. Shapiro,1 and Deed E. Harrison; J Phys Ther Sci. 2018 Apr;30(4):654-657. doi: 10.1589/jpts.30.654. Epub 2018 Apr 20.This case illustrates the complete resolution of neck pain and restoration of cervical lordosis in a patient with mid-cervical kyphosis in 10-weeks.Demonstration of a Chiropractic technique (CBP) using xray to show loss of normal curvature of the neck and restoration of curvature. ALso demonstrated that with changes to x-ray and structural curvatures they were able to help with symptomatic complaints.
Alleviation of posttraumatic dizziness by restoration of the cervical lordosis: A CBP® case study with a one year follow-up.Fortner MO, Oakley PA, Harrison DE. Alleviation of posttraumatic dizziness by restoration of the cervical lordosis: A CBP® case study with a one year follow-up. Journal of Physical Therapy Science. 2018;30(5):730-733
Analysis and Adjustment of Vertebral Subluxation as a Separate and Distinct Identity for the Chiropractic Profession: A Commentary.J Chiropr Humanit. 2016 Oct 25;23(1):46-52. eCollection 2016 Dec.
Hart J1.
When a profession's identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and, therefore, might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.
Analysis of accuracy of kyphotic angle measurement for vertebral osteoporotic compression fractures.J Clin Neurosci. 2007 Oct;14(10):961-5. Epub 2007 Jul 23.
Lee SW1, Hong JT, Son BC, Sung JH, Kim IS, Park CK.
The Cobb method 4 showed the best overall reliability. The centroid method and the other Cobb methods using a fractured endplate did not produce an accurate result due to inter- and intraobserver differences in determining the baseline.
Analysis of cervical and global spine alignment under Roussouly sagittal classification in Chinese cervical spondylotic patients and asymptomatic subjects.Yu M1, Zhao WK, Li M, Wang SB, Sun Y, Jiang L, Wei F, Liu XG, Zeng L, Liu ZJ.

Eur Spine J. 2015 Jun;24(6):1265-73. doi: 10.1007/s00586-015-3832-2. Epub 2015 Mar 25.
The cervical alignment correlates with their global spine and pelvic curves. And lordosis is not the only presentation in asymptomatic subjects. The degenerative modification of cervical disc angles was the compensation of global spine degeneration for horizontal gaze. Cervical angles are influenced by their TK angles, occipital-C2 joint and the tilt of T1 vertebral body. The occipital-C2 joint has a compensating mechanism in all Roussouly types in cervical spondylosis.this article did not use specific cervical angles, it is correlating cervical lordosis with spondolyticchanges in the patients
Analysis of compensatory mechanisms in the pelvis and lower extremities in patients with pelvic incidence and lumbar lordosis mismatchGait Posture. 2017 Jul;56:14-18. doi: 10.1016/j.gaitpost.2017.04.041. Epub 2017 May 1.
Cheng X1, Zhang K1, Sun X1, Zhao C1, Li H1, Zhao J2.
Patients with lesser PI-LL mismatch rely more on hip extension to increase pelvic retroversion while those with greater PI-LL mismatch tend to add extra femoral obliquity. When compensating for larger PI-LL mismatch, the importance of hip extension is decreased and the effect of the knee and ankle joint becomes more important by providing greater femoral incline and relatively lesser ankle dorsiflexion respectively.
Analysis of Factors Associated With Sagittal Balance in Normal Asymptomatic Individuals: A Retrospective Study in a Population of East ChinaSpine (Phila Pa 1976). 2017 Feb 15;42(4):E219-E225. doi: 10.1097/BRS.0000000000001782.
Yang M1, Yang C, Zhai X, Zhao J, Zhu X, Li M.
Age, T1 sagittal angle, maxLL, PT, and PI were primary contributors to maintaining sagittal balance in normal asymptomatic subjects, and sagittal balance could be predicted by calculation using the equation derived in this study
Analysis of hip dysplasia and spinopelvic alignment in cerebral palsySpine J. 2014 Nov 1;14(11):2716-23. doi: 10.1016/j.spinee.2014.03.025. Epub 2014 Mar 21.
Suh DH1, Hong JY2, Suh SW3, Park JW1, Lee SH1.
This study found significant differences between CP patients and normal controls in terms of spinopelvic alignment and hip dysplasia. Furthermore, relationships were found between the sagittal spinopelvic parameters and hip dysplasia, and correlations were found between sagittal spinopelvic parameters and pain
Analysis of Spino-pelvic Sagittal Alignment in Young Chinese Patients with Lumbar Disc HerniationOrthop Surg. 2017 Aug;9(3):271-276. doi: 10.1111/os.12340.
Fei H1, Li WS1, Sun ZR1, Ma QW1, Chen ZQ1.
There is no difference in PI between young Chinese patients with lumbar disc herniation and the normal population. Young LDH patients may present flat lumbar and thoracic curves, as well as lower sacral slope. The anteversion sagittal imbalance is regulated by both the spine and the pelvis
Analysis of spinopelvic parameters in lumbar degenerative kyphosis: correlation with spinal stenosis and spondylolisthesisSpine (Phila Pa 1976). 2010 Nov 15;35(24):E1386-91. doi: 10.1097/BRS.0b013e3181e88be6.
Lee JH1, Kim KT, Suk KS, Lee SH, Jeong BO, Kim JS, Eoh JH, Kim YJ.
PI has a direct influence on the variable lumbar curvature in LDK. PI and SS may be complementary factors in determining the subtype of LDK, as PT appears to be relatively constant between the different subtypes of LDK.
Analysis of the cranio-cervical curvatures in subjects withmigraine with and without neck painGabriela Natália Ferracinia, Thais Cristina Chavesb, Fabíola Dachc, Débora Bevilaqua-Grossib, César Fernández-de-las-Pe˜nasd,José Geraldo Physiotherapy 103 (2017) 392–399Subjects with migraine exhibited straightening of cervical lordosis curvature. The presence of neck pain did not influence headposture in subjects with and without migraine.50 patients with migraine and 50 controls were assessed. Measurements included high cervical angle (HCA), low cervical angle (LCA), atlas plane angle (APA), cervical lrdosis Cobb angle (Cobb A), anterior translation distance (ATD), C0 to C1 distance (C0 to C1D), C2 to C7 posterior translation (C2 to C7PT) and hyoid triangle (HT).ubjects with migraine exhibited a straightening of the cervical curve.
Answers to Common Questions About the Use and Safety of CT Scans.Mayo Clin Proc. 2015 Oct;90(10):1380-92. doi: 10.1016/j.mayocp.2015.07.011.
McCollough CH1, Bushberg JT2, Fletcher JG3, Eckel LJ3.
Articles in the scientific literature and lay press over the past several years have implied that computed tomography (CT) may cause cancer and that physicians and patients must exercise caution in its use. Although there is broad agreement on the latter point--unnecessary medical tests of any type should always be avoided--there is considerable controversy surrounding the question of whether, or to what extent, CT scans can lead to future cancers. Although the doses used in CT are higher than those used in conventional radiographic examinations, they are still 10 to 100 times lower than the dose levels that have been reported to increase the risk of cancer. Despite the fact that at the low doses associated with a CT scan the risk either is too low to be convincingly demonstrated or does not exist, the magnitude of the concern among patients and some medical professionals that CT scans increase cancer risk remains unreasonably high. In this article, common questions about CT scanning and radiation are answered to provide physicians with accurate information on which to base their medical decisions and respond to patient questions.Limitations of epidemiological research in assessing cancer risk of CT scans are discussed. There is no conclusive evidence that radiation absorbed doses under about 150 mGy at one exposure will cause cancer. An average effective dosage from CT is between 1 and 10 mSv while average U.S.background environmental exposure is 3 mSv. In conclusion it is recommended to order CT if it will give you the best information.
Anterolisthesis and retrolisthesis of the cervical spine in cervical spondylotic myelopathy in the elderly.J Orthop Sci. 2007 May;12(3):207-13. Epub 2007 May 31.
Kawasaki M1, Tani T, Ushida T, Ishida K.
Degenerative spondylolisthesis is not a rare radiographic finding in elderly patients with CSM, which tends to cause intense cord compression that is seen on MRI scans. Greater mobility of the upper cervical segments may be a compensatory reaction for advanced disc degeneration of the lower cervical segments, leading to the development of degenerative spondylolisthesis. With a similar degree of displacement, anterolisthesis tends to have a greater impact on the development of CSM than retrolisthesis.
Are plain radiographs of the spine necessary during evaluation
after blunt trauma? Accuracy of screening torso computed
tomography in thoracic/lumbar spine fracture diagnosis.
Berry GE, Adams S, Harris MB, Boles CA, McKernan MG,
Collinson F, Hoth JJ, Meredith JW, Chang MC, Miller PR.
J Trauma 2005;59:1410-3.
Admission CAP CT obtained as part of the routine trauma evaluation in these high-risk patients is more sensitive than plain radiographs for evaluation of the TL spine after blunt trauma. In addition, CAP CT can be performed faster. Omission of plain radiographs will expedite accurate evaluation allowing earlier treatment and mobilization.
Are the sagittal cervical radiographic modifiers of the Ames-ISSG classification specific to adult cervical deformity?J Neurosurg Spine. 2018 Nov 1;29(5):483-490. doi: 10.3171/2018.2.SPINE171285.
Bakouny Z1, Khalil N1, Otayek J1, Bizdikian AJ1, Yared F1, Salameh M1, Bou Zeid N1, Ghanem I1,2, Kharrat K1,2, Kreichati G1,2, Lafage R3, Lafage V3, Assi A
CONCLUSIONS The CBVA and TS-CL radiographic modifiers of the Ames-ISSG classification do not seem to be specific to subjects with cervical deformities and can occur in asymptomatic subjects without alteration in HRQOL.This article does not support the use of radiography in regular assessment purposes because the classification system it sought to test, the Ames-ISSG Classification system, did not yield significant information to be used in clinical decision-making.
Are X-rays really safe?Tim Newman. Are X-rays really safe?
Assessment of patients with neck pain: a review of definitions, selection criteria, and measurement tools
Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G. Assessment of patients with neck pain: a review of definitions, selection criteria, and measurement tools. J Chiropr Med 2010; (9):49-59.Different types of definitions appear in the literature based on anatomical location, etiology, severity, and duration of symptoms. Classifications according to severity and duration of pain and the establishment of selection criteria seem to play a crucial role in study designs and in clinical settings to ensure homogeneous groups and effective interventions. A series of objective tests and subjective self-report measures are useful in assessing physical abilities, pain, functional ability, psychosocial well-being, general health status, and quality of life in patients with neck pain. Self-administered questionnaires are commonly used in clinical practice and research projects.Study outlines the use of outcome assessment tools in clinical practice for research purposes in order to improve clinical decision making and quality of care as it pertains to neck pain. Goal of study is to give health care professionals working with neck pain patients more useful information about existing OATs and criteria for selecting the most appropriate ones relating to treatment goals. Looks at intra- and inter-examiner reliability for various ways of measuring neck pain disorders (ROM, muscle strength and endurance, palpation of trigger and tender points)
Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients.J Neurosurg Spine. 2016 Jan;24(1):108-15. doi: 10.3171/2015.3.SPINE141098. Epub 2015 Sep 11.
Scheer JK1, Passias PG2, Sorocean AM2, Boniello AJ2, Mundis GM Jr3, Klineberg E4, Kim HJ5, Protopsaltis TS2, Gupta M4, Bess S6, Shaffrey CI7, Schwab F2, Lafage V2, Smith JS7, Ames CP8; International Spine Study Group.
Patients with thoracolumbar deformity without preoperative CD are likely to have greater improvements in HRQOL after surgery than patients with concomitant preoperative CD. Cervical positive sagittal alignment in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID at 2-year follow-up despite having similar baseline HRQOL to patients without CD. This was the first study to assess the impact of concomitant preoperative cervical malalignment in adult patients with thoracolumbar deformity. These results can help surgeons educate patients at risk for inferior outcomes and direct future research to identify an etiology and improve patient outcomes. Investigation into the etiology of the baseline cervical malalignment may be warranted in patients who present with thoracolumbar deformity.- The results of this study clearly show the strong effect the vestibulospinal tract has on paraspinal musculature and vice versa via surgical intervention. The thoracolumbar spine was surgically modified to fix a current deformity or scoliosis thus changing the cervical lordotic curvature. However, only 50% of patients maintained the correction as the true cause of the patient’s problem (i.e. Vertebral subluxation) was not corrected.
Association of lumbar disc degeneration with osteoporotic fractures; the Rotterdam study and meta-analysis from systematic review.Bone. 2013 Nov;57(1):284-9. doi: 10.1016/j.bone.2013.08.004. Epub 2013 Aug 17.
Castaño-Betancourt MC1, Oei L, Rivadeneira F, de Schepper EI, Hofman A, Bierma-Zeinstra S, Pols HA, Uitterlinden AG, Van Meurs JB.
Male subjects with LDD have a higher osteoporotic fracture risk, in spite of systemically higher BMD.
Association of myelopathy scores with cervical sagittal balance and normalized spinal cord volume: analysis of 56 preoperative cases from the AOSpine North America Myelopathy studySpine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S161-70. doi: 10.1097/BRS.0b013e3182a7eb9e.
Smith JS1, Lafage V, Ryan DJ, Shaffrey CI, Schwab FJ, Patel AA, Brodke DS, Arnold PM, Riew KD, Traynelis VC, Radcliff K, Vaccaro AR, Fehlings MG, Ames CP.
This study is the first to correlate cervical sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment. It is interesting to note that sagittal balance but not kyphosis is tied to myelopathy score. Future work will correlate alignment changes to cord morphology changes and myelopathy outcomes. SUMMARY STATEMENTS: This is the first study to correlate sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment.
Association of myelopathy scores with cervical sagittal balance and normalized spinal cord volume: analysis of 56 preoperative cases from the AOSpine North America Myelopathy studySpine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S161-70. doi: 10.1097/BRS.0b013e3182a7eb9e.
Smith JS1, Lafage V, Ryan DJ, Shaffrey CI, Schwab FJ, Patel AA, Brodke DS, Arnold PM, Riew KD, Traynelis VC, Radcliff K, Vaccaro AR, Fehlings MG, Ames CP.
This study is the first to correlate cervical sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment. It is interesting to note that sagittal balance but not kyphosis is tied to myelopathy score. Future work will correlate alignment changes to cord morphology changes and myelopathy outcomes. SUMMARY STATEMENTS: This is the first study to correlate sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment.
Association of preoperative cervical spine alignment with spinal cord magnetic resonance imaging hyperintensity and myelopathy severity: analysis of a series of 124 casesSpine (Phila Pa 1976). 2015 Jan 1;40(1):11-6. doi: 10.1097/BRS.0000000000000670.
Mohanty C1, Massicotte EM, Fehlings MG, Shamji MF.
Global sagittal alignment and SVA interactively associate with quantitative MRI spinal cord signal abnormalities and worse CSM-related disability. The reciprocal relationships of SVA effect in patients with kyphosis and those with lordosis may reflect an optimal spinal alignment to achieve during surgical management.
Associations between back pain across adulthood and spine shape in early old age in a British birth cohort.Sci Rep. 2018 Nov 5;8(1):16309. doi: 10.1038/s41598-018-34628-9.

Muthuri SG1, Pavlova AV2, Saunders FR2, Hardy RJ3, Gregory JS2, Barr RJ2,4, Martin KR2, Adams JE5, Kuh D3, Aspden RM2, Cooper R3.
In addition, reporting of back pain at ages 53 and/or 60-64 years was associated with smaller L4-5 disc space (lower SM6 scores) in men but not women. These findings suggest that back pain across adulthood may be associated with specific variations in spine shapes in early old age."These findings suggest that back pain across adulthood may be associated with specific variations in spine shapes in early old age". Strong Correlation between spinal alignment and LBP.
Associations between disc space narrowing, anterior osteophytes and disability in chronic mechanical low back pain: a cross sectional study.BMC Musculoskelet Disord. 2017 May 15;18(1):193. doi: 10.1186/s12891-017-1562-9.
Perera RS1, Dissanayake PH2, Senarath U3, Wijayaratne LS4, Karunanayake AL5, Dissanayake VHW6.
Lumbar spondylolisthesis is associated with severity of disability in patients with chronic mechanical low back pain. Associations of x-ray features of LDD with severity of disability and intensity of pain are inconclusive. Female gender and pain radiating into legs are significant confounders.· This study sheds insight into the condition of the lumbar spine apophyseal joints and disc spaces however, the examiners allowed a subjective bias along with the evaluation of the studied area being out of a weight bearing position. Pain as we know is a less than ideal indicator, as it is perceptive in nature and gravity will change lumbar biomechanics. Therefore, future studies should include a weight bearing analysis and functional testing of the lumbar spine to ensure a more accurate representation is developed.
Awareness of radiographic guidelines for low back pain: a survey of Australian chiropractors.Chiropr Man Therap. 2016 Oct 5;24:39. eCollection 2016.
Jenkins HJ1.
Only 50 % of Australian chiropractors report awareness of current radiographic guidelines for low back pain. A poorer awareness of guidelines is associated with an increase in the reported likelihood of use, and the perceived usefulness of radiographs for low back pain, in clinical situations that fall outside of current guidelines. Therefore, education strategies may help to increase guideline knowledge and compliance.The first citation is based on radiography for low back pain in a primary care (medical) office. The guidelines are based on "usual Care" within that setting. The studies and recomendations cited are not within a chiropractic office context of care.
Awareness of radiographic guidelines for low back pain: a survey of Australian chiropractors.Jenkins, H.J. Chiropr Man Therap 24, 39 (2016) doi:10.1186/s12998-016-0118-7Only 50 % of Australian chiropractors report awareness of current radiographic guidelines for low back pain. A poorer awareness of guidelines is associated with an increase in the reported likelihood of use, and the perceived usefulness of radiographs for low back pain, in clinical situations that fall outside of current guidelines. Therefore, education strategies may help to increase guideline knowledge and compliance.
Beyond Pelvic Incidence-Lumbar Lordosis Mismatch: The Importance of Assessing the Entire Spine to Achieve Global Sagittal Alignment.Global Spine J. 2017 Sep; 7(6): 536–542.
Published online 2017 Apr 20. doi: 10.1177/2192568217699405

Robert K. Merrill, BS,1 Jun S. Kim, MD,1 Dante M. Leven, DO,1 Joung Heon Kim, BS,1 and Samuel K. Cho, MDcorresponding author1
Our results demonstrate that PT and TK, and not just PI-LL, play an important role in maintaining sagittal balance when there is a PI-LL mismatch >10°.· This study clearly demonstrated the global effect that a surgical posture correction can have while attempting to achieve sagittal balance throughout the entirety of the spine. It was clear to the researchers that the thoracic spine was relatively a compensatory mechanism for the regions above and below which is what many of us see in our day to day practices. They also stressed the need for measuring sagittal alignment pre/post-operative much like we in the Chiropractic profession do while evaluating vertebral subluxation pre/post-adjustment along with the need to evaluate each patient individually due to the heterogenous nature of spinal biomechanics.
Beyond Pelvic Incidence–Lumbar Lordosis Mismatch: The Importance of Assessing the Entire Spine to Achieve Global Sagittal AlignmentRobert K. Merrill, BS1 , Jun S. Kim, MD1 , Dante M. Leven, DO1 , Joung Heon Kim, BS1 , and Samuel K. Cho, MD,Global Spine J. 2017 Sep; 7(6): 536–542.
Published online 2017 Apr 20. doi: 10.1177/2192568217699405
When there was a normal SVA and PI-LL was >10, the thoracic and cervical spines straightened and the pelvis retroverted. Additionally, when the PI-LL mismatch was small, PT and TK played an important role in maintaining a normal sagittal balance. It is paramount, though, that TK does not overcompensate to pathologic levels or severe complications may occur. Our findings support the concept that sagittal balance involves numerous parameters, namely, PT, TK, and CL. These findings improve our understanding of global sagittal balance and the dynamic relationship of various sagittal parameters in patients with adult spinal deformity. Studies such as this can help direct our goals for corrective osteotomies, guide future prospective studies, and improve our preoperative patient assessment and risk stratification.This study states that "multiple parameters of the spine must be considered when planning deformity correction and the focus should involve the entire spine." This study also compared which compensatory measures were more significant based on the degree of pelvic incidence and lumbar lordosis mismatch either over 10 degrees or under 10 degrees in order to maintain proper Sagittal Vertical Axis. Pelvic Incidence - Lumbar Lordosis miss match under 10 degrees results in more significance in proper thoracic kyphosis and pelvic titl to maintain proper SVA where over 10 degrees results in more significance in Cervical Lordosis and Lumbar Lordosis. Hence structural correction strategies should emphasize the parameters of the entire spine as it relates to correcting posture.
Biomechanical analysis of the lumbar spine on facet joint force and intradiscal pressure--a finite element study.BMC Musculoskelet Disord. 2010 Jul 5;11:151. doi: 10.1186/1471-2474-11-151.
Kuo CS1, Hu HT, Lin RM, Huang KY, Lin PC, Zhong ZC, Hseih ML.
Disc pressures showed a significant increase with preload and changed more noticeably in flexion than in extension or in axial rotation. Compared with the applied preloads, the postures played a more important role, especially in axial rotation; the facet joint forces were increased in the contralateral facet joints as compared to the ipsilateral ones at the same level of the lumbar spine.- This study revealed asymmetries that arise when pre-loading a lumbar spine that is subluxated complicated by genetic expression of each individual’s lumbar anatomy. Moreover, in the absence of subluxation, each vertebral level functions in its own way, varying person to person and even side to side.
Biomechanical analysis of the spino-pelvic organization and adaptation in pathologyRoussouly P1, Pinheiro-Franco JL.
Eur Spine J. 2011 Sep;20 Suppl 5:609-18. doi: 10.1007/s00586-011-1928-x. Epub 2011 Aug 2.

The genuine shape of the spine is oriented by a shape pelvis paramerer, the pelvis incidence (PI). In case of pathology, this constant parameter is the only signature of the original spine shape we have to restore the balance of the patient. It is clear that pelvic anatomy (pelvic incidence) and pelvic positioning (pelvic tilt & Sacral Angle) determines the amplitude of biomechanical stressors placed on different structures in the spine (facets vs. discs). Increased biomechanical stress due to hyperlordosis or hypolordosis of the lumbar spine in relation to pelvic alignment increases risk for intervertebral disc or facet joint degeneration and injury, respectively, as well as degeneration of femoroacetabular. Correction of pelvic positioning (as demonstrated in CBP procedures) in relation to pelvic incidence may be preventative in degenerative conditions. However, "The only way to assess the global spinal sagittal balance and its eventual consequences is the long-standing lateral X-Ray. It is necessary to visualize the whole spine and pelvis, from the skull to the proximal femurs.”
Biomechanics of the cervical spine Part 2. Cervical spine soft tissue responses and biomechanical modeling.Clin Biomech (Bristol, Avon). 2001 Jan;16(1):1-27.
Yoganandan N1, Kumaresan S, Pintar FA.
Experimentally validated models based on accurate geometry, material property, boundary, and loading conditions are useful to delineate the clinical biomechanics of the spine. Both external and internal responses of the various spinal components, a data set not obtainable directly from experiments, can be determined using computational models. Since soft tissues control the complex structural response, an accurate simulation of their anatomic, functional, and biomechanical characteristics is necessary to understand the behavior of the cervical spine under normal and abnormal conditions such as facetectomy, discectomy, laminectomy, and fusion.
Can c7 plumbline and gravity line predict health related quality of life in adult scoliosis?Spine (Phila Pa 1976). 2009 Jul 1;34(15):E519-27. doi: 10.1097/BRS.0b013e3181a9c7ad.

Mac-Thiong JM1, Transfeldt EE, Mehbod AA, Perra JH, Denis F, Garvey TA, Lonstein JE, Wu C, Dorman CW, Winter RB.
Sagittal spinal and global balance was strongly related to the ODI in adults with scoliosis. The observed correlation coefficients were higher than those reported in the only previous study suggesting the detrimental association of positive sagittal balance on ODI in adult spinal deformity. Coronal spinal and global balance did not influence the ODI in the current study cohort. Thisstudy underlines the relevance of C7 plumbline and gravity line in the evaluation of spinal and global balance, and lends further support to the philosophy of achieving adequate sagittal balance in the management of adult spinal deformity, especially in patients older than 50 years old with degenerative scoliosis.Use of xrays to accurately determine the gravity line and C7 plumb line in patients that have scoliosis. Connection is the use of x-ray to accurately determine this relationship which is a paramount indicator of chronic pain.
Center of gravity and radiographic posture analysis: a preliminary review of adult volunteers and adult patients affected by scoliosis. (PROBLEM WITH THIS STUDY IS THE LACK OF LATERAL PELVIC IMBALANCE AND ITS IMPACT ON WEIGHT DISTRIBUTION. THIS WOULD ALTER HOW ONE STANDS IN RELATION TO THE GRAVITY LINE OF THE SPINE ALONG WITH WEIGHT OF INTERNAL STRUCTURES AND SO ONSpine (Phila Pa 1976). 2005 Jul 1;30(13):1535-40.

El Fegoun AB1, Schwab F, Gamez L, Champain N, Skalli W, Farcy JP.
The data analysis of offsets between the gravity line and radiographic parameters revealed a frontal plane mean displacement of the gravity line to the right. In the sagittal plane, a highly significant lack of correlation between the gravity line and plumbline was noted. The plumbline represents a common and convenient visual display of apparent sagittal plane imbalance, but its value as a marker of true postural balance must be questioned.Using the plumbline offset measurement on radiographs is not an effective method to evaluate postural balance - very low coralation to actual postural balance.
Cervical and postural strategies for maintaining horizontal gaze in asymptomatic adultsKhalil N1, Bizdikian AJ1, Bakouny Z1, Salameh M1, Bou Zeid N1, Yared F1, Otayek J1, Kharrat K1, Kreichati G1, Ghanem I1, Lafage R2, Lafage V2, Obeid I3, Assi A4 Eur Spine J. 2018 Sep 7. doi: 10.1007/s00586-018-5753-3Subjects with cervical kyphosis presented with more posterior global alignment and lower TK than subjects with lordosis. In order to maintain horizontal gaze, subjects with cervical kyphosis presented with a more lordotic upper cervical spine than subjects with cervical lordosis. Subjects with straight cervical curvature presented with an intermediate sagittal alignment
Postural analysis only. No relationship to Chiropractic, treatment or radiology.
Cervical Angles in Sleep Apnea PatientsAnnals of Vertebral Subluxation Research, Volume 3
Graham J. Dobson, Robert H. I. Blanks, W.R. Boone, and Harold G. McCoy
The present study was undertaken to evaluate, retrospectively, radiographs from diagnosed Obstructive Sleep Apnea Syndrome (OSAS) patients. Four angles were assessed from the lateral radiographs: (1) atlas/axis, (2) atlas, (3) atlas/occiput, and (4) occiput, which, like the atlas angle, was determined relative to the horizontal plane of the x-ray film. The severity of OSAS was determined by two indices. The first, the standard “Respiratory Disturbance Index” (RDI), indicates the number of apneas and hypopneas per hour of sleep.The second index of OSAS severity, the combined “Sleep Baseline Score” (SBS), was derived from multivariate analysis of a wide variety of sleep parameters. These data were studied through bivariate and multiple regression analyses relative to the level of OSAS severity, sex, and age.Strong correlation between occiupt and cervical flexion and sleep apnea
Cervical coupling during lateral head translations creates an S-configuration.Clin Biomech (Bristol, Avon). 2000 Jul;15(6):436-40.

Harrison DE1, Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ.
Lateral head translations (x-axis) compared to a fixed thoracic cage can be large with a mean of 51 mm to one side. The major spinal coupling was lateral bending which changed direction at C4-C5 resulting in an S-configuration. This might have application in side impacts. All other segmental movements were small, less than 1 mm and 1 degrees.Observing with digitized xray the coupled motion of the cervical spine from an AP view when the patient moves through a lateral translation movement.
Cervical curve restoration and forward head posture reduction for the treatment of mechanical thoracic pain using the Pettibon corrective and rehabilitative proceduresJ Chiropr Med. 2002 Summer;1(3):113-5. doi: 10.1016/S0899-3467(07)60013-5.

Morningstar M.
Restoration of the cervical curve and reduction of forward head posture appears to have beneficial effects beyond the cervical spine. The addition of active rehabilitative procedures seems to enhance the effectiveness of spinal manipulative therapy in the correction of forward head posture and cervical kyphosis.Restoration of the cervical curve has possible benefits in general health beyond the cervical spine
Cervical Hyperlordosis, Forward Head Posture, and Lumbar Kyphosis Correction: A Novel Treatment for Mid-Thoracic PainJ Chiropr Med. 2003 Summer; 2(3): 111–115. Mark W. Morningstara,
doi: 10.1016/S0899-3467(07)60055-X
This comprehensive approach appeared to correct specific posture abnormalities seen on x-ray, and had an apparent positive effect on the patient’s chief complaint. Each procedure in this treatment method needs to be tested separately to determine which procedures had the greatest effect.Posture findings in x-rays has a direct correlation to the patient's cheif complaint. However, this is only a case study.
Cervical instability in cervical
spondylosis patients
Significance of the radiographic index
method for evaluation
Orthopade. 2018 Dec;47(12):977-985. doi: 10.1007/s00132-018-3635-3.

Alizada M1, Li RR2, Hayatullah G2.
the authors believe that it is more appropriate
to consider cervical instability as
a stage of the cervical degeneration process.
During this stage, the overall cervical
motion and intervertebral segmental
movement show abnormal pathological
Patients with cervical radiculopathy and or neck pain are more likely to have decreased ROM on lateral flexion extension images and increased cervical instability.
Cervical Position Sense in Forward Head Posture versus Chronic Neck
Pain: A Comparative Study
Rahnama, Leila. (2017). Journal of Clinical Physiotherapy Research. 2. 39-42. The results of the present study showed that patients with CNP have higher HRE,
indicating more cervical proprioceptive dysfunction in such patients compared with those in individuals with FHP. This finding may be of interest
for those researchers investigating the effects of pain and mechanical loads on cervical position sense.
Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy.Ames CP1, Blondel B, Scheer JK, Schwab FJ, Le Huec JC, Massicotte EM, Patel AA, Traynelis VC, Kim HJ, Shaffrey CI, Smith JS, Lafage V.;
Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S149-60. doi: 10.1097/BRS.0b013e3182a7f449.
Cervical deformity correction should take on a comprehensive approach in assessing global cervical-pelvic relationships and the radiographical parameters that effect health-related quality of life scores are not well-defined. Cervical alignment may be important in assessment and treatment of cervical myelopathy. Future work should concentrate on correlation of cervical alignment parameters to disability scores and myelopathy outcomes.Cervical curve should be considered an important acessement for the health of the neck and cervical myelopathy
Cervical sagittal alignment and the impact of posterior spinal instrumented fusion in patients with Lenke type 1 adolescent idiopathic scoliosis.J Spine Surg. 2018 Jun;4(2):342-348. doi: 10.21037/jss.2018.05.17.
Berger RJ1, Sultan AA1,2, Tanenbaum JE2,3,4, Cantrell WA2,5, Gurd DP1, Kuivila TE1, Mroz TE2, Steinmetz MP2,4, Goodwin RC1.
This study demonstrated baseline cervical kyphosis and a trend towards cervical lordosis restoration in patients with AIS and a Lenke type 1 curve who underwent PSIF. This study adds to emerging evidence and, together with further studies, will help estimate the impact of PSIF on the cervical sagittal profile, the effect of CSA on patient reported outcomes, and ways to address cervical sagittal malalignment when undertaking the surgical correction for specific curve types in AIS.There is an improvement of cervical lordosis after scolisis surgery among adolescence by 3.7 degrees
Cervical sagittal alignment in adult hyperkyphosis treated by posterior instrumentation and in situ bending.Orthop Traumatol Surg Res. 2017 Feb;103(1):53-59. doi: 10.1016/j.otsr.2016.10.003. Epub 2016 Nov 23.
Paternostre F1, Charles YP2, Sauleau EA3, Steib JP1.
Two cervical alignment types, lordotic or kyphotic, were observed thoracic hyperkyphosis patients. This alignment was mainly triggered by the amount of thoracic kyphosis and lumbar lordosis, linked to pelvic incidence. Moreover, the inclination of the C7-T1 junctional area plays a key role in the amount of cervical lordosis. The correction of T4-T12 kyphosis induced compensatory modifications at adjacent segments: T1-T4 kyphosis increase (PJK) and L1-S1 lordosis decrease. Global spino-pelvic alignment and head position did not change in the sagittal plane. The cervical spine tented to keep in its preoperative position in most patients.- This study was a basic outline of spinal biomechanics. If you attempt to change the structure at one level without correcting the vertebral subluxation, compensatory mechanisms throughout the entirety of the spine will begin to develop.
Cervical sagittal alignment in idiopathic scoliosis treated by posterior instrumentation and in situ bending.Spine (Phila Pa 1976). 2015 Apr 1;40(7):E419-27. doi: 10.1097/BRS.0000000000000767.
Charles YP1, Sfeir G, Matter-Parrat V, Sauleau EA, Steib JP.
Postoperative adaptive changes occurred at C7 and C2 by shifting anteriorly or posteriorly, resulting in different radiographical cervical shapes. The amount of lumbar lordosis may influence cervical lordosis, which needs to be considered for surgical correction. Adaptive hip movements may influence thoracolumbar and cervical alignment. The amount of proximal thoracic kyphosis influenced cervical lordosis. Global thoracic hypokyphosis might influence cervical alignment, but it was not evidenced.
Cervical Sagittal Alignment in Scheuermann Disease.Spine (Phila Pa 1976). 2015 Dec;40(23):E1226-32. doi: 10.1097/BRS.0000000000001129.
Janusz P1, Tyrakowski M, Kotwicki T, Siemionow K.
Scheuermann disease type has an influence on cervical sagittal balance. Localization of structural kyphosis affects the T1 slope as well as C2-C7 lordosis, cervical tilt, and thoracic inlet angle. Significant difference in C2-C7 lordosis in comparison to similar C0-2 lordosis demonstrates that compensation is present in subaxial cervical spine. Position of the head center of gravity is not dependent on the SD type.
Cervical sagittal balance: a biomechanical perspective can help clinical practice.Eur Spine J. 2018 Feb;27(Suppl 1):25-38. doi: 10.1007/s00586-017-5367-1. Epub 2017 Nov 6.
Patwardhan AG1,2,3, Khayatzadeh S4, Havey RM4,5, Voronov LI4,5, Smith ZA6, Kalmanson O5, Ghanayem AJ4,5, Sears W7.
The results of our biomechanical studies have improved our understanding of the impact of cervical sagittal malalignment on pathomechanics of the cervical spine. We believe this improved understanding will assist in clinical decision-making.A cadaver study that looked at FHP (anterior head translation) and its effects on the muscles, foramen, posture. The stated that this motion increases the size of the foramen and may be an adaptive response to increase patency in cases of compressed nerves. Sub-occipital muscle had incrased work load. NON imaging study on cadavers.
Cervical Sagittal Range of Motion as a Predictor of Symptom Severity in Cervical Spondylotic Myelopathy.(DETERMINE WHY NEUTRAL LORDOSIS DID NOT CORRELATE WITH PAIN IN THIS STUDY BUT DID IN OTHERS)Spine (Phila Pa 1976). 2018 Jul 1;43(13):883-889. doi: 10.1097/BRS.0000000000002478.

Nicholson KJ1, Millhouse PW1,2, Pflug E2, Woods B1,2, Schroeder GD1,2, Anderson DG1,2, Hilibrand AS1,2, Kepler CK1,2, Kurd MF1,2, Rihn JA1,2, Vaccaro A1,2, Radcliff KE1,2.
Static, neutral alignment, including SVA and lordosis, did not correlate with myelopathy or pain symptoms. Greater C27ROM and increased maximal flexion corresponded to milder myelopathy symptoms, suggesting that patients with myelopathy may compensate for cervical stenosis with hyperflexion, similar to that which is observed in the lumbar spine. In a CSM patient population, dynamic motion and compensatory deformities may play a more significant role in myelopathy symptom severity than what can be discerned from standard, neutral position radiographs.
Cervical spine alignment, sagittal deformity, and clinical implications:a review J Neurosurg Spine. 2013 Aug;19(2):141-59. doi: 10.3171/2013.4.SPINE12838. Epub 2013 Jun 14.
Scheer JK1, Tang JA, Smith JS, Acosta FL Jr, Protopsaltis TS, Blondel B, Bess S, Shaffrey CI, Deviren V, Lafage V, Schwab F, Ames CP; International Spine Study Group.
ust as understanding pelvic incidence as it relates to lumbar lordosis was crucial in building our knowledge of thoracolumbar deformities, T-1 incidence and cervical sagittal balance can further our understanding of cervical deformities. Other important parameters that account for the cervical-pelvic relationship are surveyed in detail, and it is recognized that all such parameters need to be validated in studies that correlate HRQOL outcomes following cervical deformity correction.The article, as a review, is thorough and cited by other studies. It formed the foundation of further studies attempting to formulate a more specific classification system. Using an array of sources, the authors sought to review the current clinical appreciation of sagittal plane relationships of the neck.
Cervical Spondylotic Myelopathy.Clin Spine Surg. 2016 Dec;29(10):408-414.
Iyer A1, Azad TD, Tharin S.
This article summarizes the literature regarding the pathophysiology, natural history, and diagnosis of CSM, as well as the various treatment options and their associated risks and indications.
Change and clinical significance of cervical spine sagittal alignment of adolescent idiopathic scoliosisYe F, Shi J, Hu J, Huang B, Qiu H, Chu T.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2016 Mar;30(3):336-42.

[Article in Chinese]
The change of cervical sagittal alignment correlates with the change of thoracic kyphosis. Proper maintenance or restoration of cervical sagittal lordosis alignment should be considered in preoperative evaluation of adolescent idiopathic scoliosis.
Changes in Pelvic Incidence, Pelvic Tilt, and Sacral Slope in Situations of Pelvic RotationClin Spine Surg. 2017 Aug;30(7):E923-E930. doi: 10.1097/BSD.0000000000000444.
Jin HM1, Xu DL, Xuan J, Chen JX, Chen K, Goswami A, Chen Y, Kong QY, Wang XY.
Our study provides insight into the influence of pelvic rotation on the PI, PT, and SS. PI changes with pelvic rotation. The acceptable maximum angle for reliable values of PI, PT, and SS was 17.5 degrees, and the rotation angle of the pelvis on a lateral spinopelvic radiograph can be calculated reliably.
Changes in sagittal alignment after restoration of lower lumbar lordosis in patients with degenerative flat back syndromeJ Neurosurg Spine. 2007 Oct;7(4):387-92.
Jang JS1, Lee SH, Min JH, Maeng DH.
Lower Lumbar Lordosis plays an important role in sagittal alignment and balance. Surgical restoration of lumbar lordosis results in predictable spontaneous correction of the thoracic curve and sacral slope in patients with degenerative flat back syndrome
Changes in Sagittal Lumbar Configuration With a New Method of Extension TractionArch Phys Med Rehabil. 2002 Nov;83(11):1585-91.
Harrison DE1, Cailliet R, Harrison DD, Janik TJ, Holland B.
RECENTLY, THERE HAS BEEN a surge of interest in the biomedical literature about the normal shape and magnitude of the lumbar lordosis. Multiple studies have investigated the normal magnitude and distribution of lumbar lordosis in asymptomatic subjects. These studies have found a species specific shape that is minimally lordotic at T12–L3, with 65% of the total lumbar lordotic angle at L4–S1. Variables such as age (except advanced age), gender, geographic location, and ethnicity have little influence on this species-specific shape. This unique distribution for the lumbar lordosis has been closely modeled with an ellipse.New lumbar traction set up helps patient with chronic LBP with restoration of lumbar lordosis
Changes in sagittal lumbar configuration with a new method of extension traction: nonrandomized clinical controlled trial.Arch Phys Med Rehabil. 2002 Nov;83(11):1585-91.
Harrison DE1, Cailliet R, Harrison DD, Janik TJ, Holland B.
This new method of lumbar extension traction is the first nonsurgical rehabilitative procedure to show increases in lumbar lordosis in chronic LBP subjects with hypolordosis. The fact that there was no change in control subjects' lumbar lordosis indicates the stability of the lumbar lordosis and the repeatability of x-ray procedures. Because, on average, chronic LBP patients have hypolordosis, additional randomized trials should be performed to evaluate the clinical significance of restoration of the lumbar lordosis in chronic LBP subjects.Low back pain is one of the most common presentations in the chiropractic office. A decreased lumbar lordosis, as determined by lateral x-rays, has been found to be a risk factor in the occurrence of low back pain, as well as an increased risk of degenerative changes in the lumbar discs and vertebral bodies. Because of the poor outcome with surgical cases in those with a hypolordosis, conservative treatment, using non-surgical methods, may be favored initially. By utilizing lateral lumbar x-rays to determine degree of hypolordosis, using the posterior tangent, Cobb and Ferguson lines of measurement, proper 3-point traction along with chiropractic care was implemented in this study. Statistically significant positive changes in both the hypolordotic state as well as in pain visual analog scale. Even at a 1 ½ year follow-up, lumbar curvature remained stable.
Changes of cervical sagittal alignments during motions in patients with cervical kyphosis.Zhou L1, Fan J1, Cheng L1, Jiang T1, Yun B1, Tang G1, Yin J2, Fang J1, Yin G1.; Medicine (Baltimore). 2017 Nov;96(47):e8410. doi: 10.1097/MD.0000000000008410.The correction of the cervical kyphosis can be carried out from the apex of the cervical spine that provides a solid theoretical foundation for the correction of the cervical kyphosis.This article is not using the same method that applie to the way CBP does.
Characteristics of sagittal spine-pelvis-leg alignment in patients with severe hip osteoarthritis (DISCUSS HOW COMPENSATIONS CAN OCCUR AS A RESULT OF PELVIC TILT AND INDIRECTLY AFFECT HOA)Eur Spine J. 2015 Jun;24(6):1228-36. doi: 10.1007/s00586-014-3700-5. Epub 2014 Nov 25.
Weng WJ1, Wang WJ, Wu MD, Xu ZH, Xu LL, Qiu Y.
The sagittal morphology of the pelvis in patients with severe HOA was normal and might not be involved in the development and progression of this disorder. Although the whole spine was involved in compensating for the flexed hip joint, the poor ability resulted in severely unbalanced spinal-pelvic alignment in these patients. The forward inclined spine and retroverted femur would contribute to the poor physical activities in these patients. However, the abnormal sagittal spine-pelvis-leg alignment in patients with severe HOA might not be involved in the pathogenesis of low back pai
Characterizing Adult Cervical Deformity and Disability Based on Existing Cervical and Adult Deformity Classification Schemes at Presentation and Following CorrectioNeurosurgery. 2018 Feb 1;82(2):192-201. doi: 10.1093/neuros/nyx175.
Passias PG1, Jalai CM1, Smith JS2, Lafage V3, Diebo BG3, Protopsaltis T1, Poorman G1, Ramchandran S1, Bess S1, Shaffrey CI2, Ames CP4, Schwab F3.
Cervical deformities displayed higher TS-CL grades and different cSVA grade distributions. Preoperative associations with global alignment modifiers and Ames-ACD descriptors were observed, though only cervical modifiers showed postoperative differences.
Chiropractic Biophysics Digitized Radiographic Mansuration Analysis of the Anteroposterior Cervicothoracid View: A Reliability StudyTroyanovich SJ1, Harrison D, Harrison DD, Harrison SO, Janik T, Holland B
J Manipulative Physiol Ther. 2000 Sep;23(7):476-82.
A radiographic measurement procedure that determines projected spinal displacements from true vertical alignment was found to be accurate enough for use in clinical and research applications, meaning its intraclass correlation coefficient value was >0.70.
Clinical and Radiographic Evaluation of Adult Spinal DeformityClin Spine Surg. 2016 Feb;29(1):6-16. doi: 10.1097/BSD.0000000000000352.
Bess S1, Protopsaltis TS, Lafage V, Lafage R, Ames CP, Errico T, Smith JS; International Spine Study Group.
ASD surgical planning must integrate regional, global, and pelvic compensatory/morphologic parameters to adequately correct deformity and thereby provide pain relief and improve function. Radiographic classifications for cervical and thoracolumbar deformities have been developed that utilize the regional and global measures of spinal deformity that are most predictive of patient-reported pain and function. These classifications are aimed to standardize the assessment of ASD to aid in clinical management and to facilitate future research on the evaluation and treatment of ASD.
Clinical guidelines for the management of low back pain in primary care: an international comparison.Koes BW, van Tulder MW, Ostelo R, Burton KA, Waddell G.
Clinical guidelines for the management of low back pain in
primary care: an international comparison. Spine 2001;26:
The comparison of clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations were generally similar. Updates of the guidelines are planned in most countries, although so far produced only in the United Kingdom. However, new evidence may lead to stronger conclusions and enable future guidelines to become even more concordant.Guidelines on when to x-ray, give exercises, what exercises to give, or when/if to recommend spinal manipulation vary from country to country. They are consistent on recommending medications and to avoid bed rest. They all have committees and base their guidelines on literature, but the variance may be based on their interpretation of that literature.
Clinical validation of functional flexion/extension radiographs of the cervical spineDvorák J1, Panjabi MM, Grob D, Novotny JE, Antinnes JA Spine (Phila Pa 1976). 1993 Jan;18(1):120-7.The aim of this study was to determine the clinical validity of functional flexion/extension radiographs of the cervical spine in a defined patient populationPassive flexion/extension xrays were used to evaluate segmental hyper and hypo mobility in patients with either: whiplash, radiculopathy, or DJD. Both hyper and hypomobility have a high correlation to negative patient outcomes.
Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis.Spine (Phila Pa 1976). 2000 Aug 15;25(16):2072-8.
Harrison DE1, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B.
Although both methods are reliable with the majority of correlation coefficients in the high range (ICC > 0.7), from the literature, the posterior tangent method has a smaller standard error of measurement than four-line Cobb methods. Global Cobb angles compare only the ends of the cervical curve and cannot delineate what happens to the curve internally. Posterior tangents are the slopes along the curve and can provide an analysis of any buckled areas of the cervical curve. The posterior tangent method is part of an engineering analysis (first derivative) and more accurately depicts cervical curvature than the Cobb method.
Cognitive Performance and the Alteration of Neuroendocrine Hormones in Chronic Tension-Type HeadachePain Pract. 2018 Jan;18(1):8-17. doi: 10.1111/papr.12574. Epub 2017 May 5.

Qu P1,2, Yu JX3, Xia L2, Chen GH
In this study, our results indicated that patients with CTTHhadanimpairment incognitiveabilityasassessed using the MoCA-C and Nine Box Maze tasks and dysfunction in the neuroendocrine state, with hyperactive HPA and HPG axes, and a hypoactive HPT axis. Higher ACTH levels in the HPA axis indicated poorer generalcognitionandOWM,andahypoactiveHPTaxis (increased TSH, decreased TT3 and TT4) and enhanced GnRH levels suggested an impairment of multimemory systems. These results supported our hypothesis that patients with CTTH had cognitive impairment, specifically memory impairment, which was associated with dysfunction in multiple hypothalamus–pituitary–end organ axes. Furthermore, patients with CTTH exhibited poorer quality of sleep and mood, and the hyperactive HPA axis (elevated CRH and cortisol) and hypoactive HPT axis (enhanced TRH and lowered TT3 and TT4) modulated (mainly deteriorated) the duration of pain, sleepquality,and/ormood.Thus,alteredHPA,HPT,and HPG axes, particularly the HPA axis, may be involved in the pathology of CTTH.There is a corrleation between the cognitive performance of one and the levels of hormones such as CTTH.
Commentary: ethical issues of current health-protection policies on low-dose ionizing radiation.Socol Y1, Dobrzyński L2, Doss M3, Feinendegen LE4, Janiak MK5, Miller ML6, Sanders CL7, Scott BR8, Ulsh B9, Vaiserman A;
Dose Response. 2013 Nov 7;12(2):342-8. doi: 10.2203/dose-response.13-044.Socol. eCollection 2014 May.
Additional negative impacts of LNT-model-inspired radiophobia include: refusal of some patients to undergo potentially life-saving medical imaging; discouragement of the study of low-dose radiation therapies; motivation for radiological terrorism and promotion of nuclear proliferation.2p &2Q
Does low does radiographic procedure pose a long term or short term health risk
What is the linear and non-linear threshold effects of xrays
There is no modernized basis for the linear model of the effects of radiation exposure. Most of the tactics used to discredit the use of xrays are established from political fear mongering as well as evidence based on the prior world war 2 exposure from the atomic bomb. “Unrelated to medical treatment but related to ethics, radiophobia contributes to motivating radiological terrorism and promoting nuclear proliferation.” Referenced from SOCOL et al. 2013
Communication between general practitioners and chiropractors.(standardization may improve communication between chiropractors and GPs)J Manipulative Physiol Ther. 2001 Jan;24(1):12-6.
Brussee WJ, Assendelft WJ, Breen AC.
The results of this study show most general practitioners to have a neutral to positive attitude toward communication with chiropractors. The general practitioners' preferences with regard to the technical aspects of a feedback report concur with the results of similar surveys in the field and can be used as guidelines for written communications. Factors that negatively influence communication between general practitioners and chiropractors seem to be confusing terminology, a limited knowledge of chiropractic, and bad experiences in previous communications. Recognition and illumination of these factors is a prerequisite to the development of good communication.
Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis.(COUPLE WITH STUDY ON HYPOLORDOSIS AND RESTRICTED MOTION)BMC Musculoskelet Disord. 2014 Jul 10;15:229. doi: 10.1186/1471-2474-15-229.
Laird RA1, Gilbert J, Kent P, Keating JL.
On average, people with LBP have reduced lumbar ROM and proprioception, and move more slowly compared to people without LBP. Whether these deficits exist prior to LBP onset is unknown.
Comparison between methods of assessing lumbosacral curve obtained by radiographic image.Acta Ortop Bras. 2015 Mar-Apr; 23(2): 67–71.
doi: 10.1590/1413-78522015230200840

Daiane Aparecida Vacari, 1 Eduardo Borba Neves, 1 and Leandra Ulbricht 1
The correlation and agreement between methods vary considerably. Moreover, the thoracolumbar inflection point should be considered when choosing the method of assessing patients.Scoliosis is a presentation seen regularly in the chiropractic office. There are several methods of determining the severity of the convexity and this study helps to discern the best analytical technique based upon a specific anatomical reference point notably the thoraco-lumbar inflection point. Knowing the most precise degree of convexity can determine not only the severity, but how conservative or aggressive care needs to be for each individual patient. This course of action would be unattainable if specific films are not taken in the chiropractic office and therefore, the patient will not receive the care that is best for their overall case management.
Comparison of Four Radiographic Angular Measures of Lumbar Lordosis. J Neurosci Rural Pract. 2018;9(3):298-304. Okpala FO. In normal patients, there is no significant Pearson's correlation between the mean LSA, LSJA, TRALL and Cobb LL angles, and of the four angles, LSJA is the most reliable angular measure of LL, followed by the TRALL angle, and then, the LSA; the Cobb angle was the least.
This study works to find the most reliable measurment of lumbar lordosis, however these parameteres are measured in a supine which even though has been shown to be not signifcantly different i recumbent posture. This study found of the four angles (LumboSacral Angle, LumboSacral Joint Angle, Cobb Anlge, and tangential radiologic assessment of LL), LSJA is the most reliable angular measure of LL, followed by the TRALL angle, and then, the LSA; the Cobb angle was the least.
Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial(lack of long term relief possibly due to lack of x-ray specific with pending spondylo research and CBP long term results)Pain. 2007 Sep;131(1-2):31-7. Epub 2007 Jan 23.
Ferreira ML1, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshauge KM.
Motor control exercise and spinal manipulative therapy produce slightly better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects, in patients with chronic non-specific back pain.The joint mobilization and spinal manipulative therapy was global manipulation. ***(No radiogoraphy was used to determine how the manipulation was performed???)
Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients.Spine (Phila Pa 1976). 1998 Aug 15;23(16):1750-67.

Jackson RP1, Peterson MD, McManus AC, Hales C.
Lower lumbar lordosis, by the pelvic radius technique, and compensatory sacropelvic translation around a hip axis, in addition to measurements from this axis to the C7 plumb line, were the primary determinates and most reliable radiographic assessments for sagittal balance. Understanding the common and characteristically different compensations that occur with balance in these patients who had specific spinal disorders may help to improve their care.xrays used to determine the proper way to measure lumbar lordosis and to undertand the compensatory role of the pelvis in positioning.
Comprehensive review of therapeutic interventions in managing chronic spinal pain. (Chiropractic not included resulting in potentially unncessessary interventions)Pain Physician. 2009 Jul-Aug;12(4):E123-98.
Manchikanti L1, Boswell MV, Datta S, Fellows B, Abdi S, Singh V, Benyamin RM, Falco FJ, Helm S, Hayek SM, Smith HS; ASIPP.
The indicated evidence for therapeutic interventions is variable from Level I to III. This comprehensive review includes the evaluation of evidence for therapeutic procedures in managing chronic spinal pain and recommendations. However, this review and recommendations do not constitute inflexible treatment recommendations or "standard of care."Chiropractic was excluded and not compared to the interventions in this study.
Configuration of the Connective Tissue in
the Posterior Atlanto-Occipital Interspace
Spine (Phila Pa 1976). 2005 Jun 15;30(12):1359-66.

Nash L1, Nicholson H, Lee AS, Johnson GM, Zhang M.
The connective tissue structures that connect the spinal dura to the RCPm muscle in the PAO interspace are the RCPm fascia and tendinous fibers and perivascular sheathes.Disection study identifying nature of the soft tissue in the posterior antlanto-occipital interspace (PAOI). As the conclusion reads: 'The connective tissue structures that connect the spinal dura to the rectus capitus posterior minor (RCPm) in the PAOI are the RCPm fascia and the tendinous fibers and perivascular sheathes.'
Configuration of the Connective Tissue in the Posterior Atlanto-Occipital Interspace ( NEEDS TO BE COUPLED WITH UPPER CERVICAL STUDY ON MUSCLE/DURAL TENSION)Lance Nash, MSc,* Helen Nicholson, MB, PhD,* Antonio S.J. Lee, MSc,* Gillian M. Johnson, PhD,† and Ming Zhang, MB, MMed, PhD
Spine (Phila Pa 1976). 2005 Jun 15;30(12):1359-66.
In conclusion, the deep layer of the RCPm fascia and theperivascularsheathoftheexternalvertebralplexuses are the main connective tissue components between the RCPm muscle and spinal dura in the posterior craniocervicalregion.TheRCPmfascia,perivascularsheathes, and a small portion of the RCPm tendinous fibers are attachedantero-inferiorlytothespinalduraviathePAO interspace. The morphologic features of the RCPm tendonandfasciaindicatethattheymayhaveanimportant
role in the maintenance of the posterior cranio-cervical stability and the prevention of the dural enfolding and are of anatomic relevance in the debate regarding the etiology of cervicogenic headaches.
role in the maintenance of the posterior cranio-cervical stability and the prevention of the dural enfolding and are of anatomic relevance in the debate regarding the etiology of cervicogenic headaches.
Congruent spinopelvic alignment on standing lateral radiographs of adult volunteers.Spine (Phila Pa 1976). 2000 Nov 1;25(21):2808-15.

Jackson RP1, Hales C.
Of possible clinical importance was the finding that standard measurements for lordosis were dependent on individual pelvic morphology quantitated by the pelvic radius technique.Using xray to determine basic standard measurements of the patient lordosis of the lumbar spine and subsequent pelvic morphology.
Conservative treatment for adolescent idiopathic scoliosis: can it reduce the incidence of surgical treatment?Pediatr Rehabil. 2003 Jul-Dec;6(3-4):215-9.

Maruyama T1, Kitagawa T, Takeshita K, Mochizuki K, Nakamura K.
Twenty of 328 patients (6.1%) with more severe curves to begin with (mean Cobb angle at admission of 48.5 +/- 9.3 degrees ) progressed to 62.2 +/- 8.5 degrees and were treated with spinal fusion by the age of 16.0 +/- 2.6 years. The remaining 308 patients, of comparable age at inception of treatment but with a smaller original mean Cobb angle (32.4 +/- 11.1 degrees ), showed no significant increase in magnitude of curvature (mean 33.6 +/- 11.5 degrees ) by the time of discharge (18.6 +/- 3.1 years). The fact that curvature magnitude was maintained at
Xrays were used to accurately measure and monitor cobb angles on scoliosis patients.
Content and outcome of usual primary care for back pain: a systematic review [with consumer summary]Somerville S, Hay E, Lewis M, Barber J, van der Windt D, Hill J, Sowden G
British Journal of General Practice 2008 Nov;58(556):790-797
Treatment received by patients with back pain was varied and often not in line with back-pain guidelines, particularly with respect to opioid prescription and x-ray investigation. The content of the 'usual care' arm in trials is crucial to interpreting the outcome of studies, but was poorly described in the papers reviewed. Future trials should more fully describe the 'usual care' arm.
Correction of Grade 2 Spondylolisthesis Following a Non-Surgical Structural Spinal Rehabilitation Protocol Using Lumbar Traction: A Case Study and Selective Review of Literature.J Radiol Case Rep. 2017 May; 11(5): 13–26.
Published online 2017 May 31. doi: 10.3941/jrcr.v11i5.2924

Curtis Fedorchuk,1,* Douglas F Lightstone,1 Christi McRae,2 and Derek Kaczor3
This case provides the first documented evidence of a non-surgical or chiropractic treatment, specifically Chiropractic BioPhysics®, protocols of lumbar spondylolisthesis where spinal alignment was corrected. Additional research is needed to investigate the clinical implications and treatment methods.Spondylolisthesis is a presentation found often in the chiropractic office and is found in up to 31% of the adult population. It can cause severe low back pain with subsequent radiculopathy and decrease quality of life. The most non-invasive and least costly way to determine not only the cause the patient’s pain, but also the grade of spondylolisthesis is by performing weight bearing lumbar series, in particular, the lateral lumbar. In most cases, surgical intervention (lumbar fusion) is performed, however, a literature review shows that there is no significant advantage to such a costly procedure as compared to non-surgical interventions. This, as of the publishing date, is the only study that shows not only the structural improvement/correction of the spondylolisthesis, but also a significant decrease in symptomatology using chiropractic care and exercises. Without appropriate imaging, the cause of the patient’s pain could not have been determined and the subsequent structural improvement could not have been quantified.
Correction of pseudoscoliosis (lateral thoracic translation posture) for the treatment of low back pain: a CBP® case report.J Phys Ther Sci. 2018 Sep;30(9):1202-1205. doi: 10.1589/jpts.30.1202. Epub 2018 Sep 4.
Henshaw M1, Oakley PA2, Harrison DE3.
The diagnosis of pseudoscoliosis as opposed to true scoliosis is very important and likely underdiagnosed in common practice. Upright radiographic imaging is essential to differentiate these two spinal disorders and offers no harm to the patient. Comprehensive assessment including routine use of x-ray is recommended to differentiate between spinal disorders.Upright radiographic imagine is essentiel to differentiate true scoliosis from pseudoscoliosis as the treatment will vary dramatically.
Correlation between head posture and proprioceptive function in the cervical regionMin-Sik Yong, PT, PhD,1 Hae-Yong Lee, PT, PhD,2 and Mi-Young Lee, PT, PhD3,* J Phys Ther Sci. 2016 Mar; 28(3): 857–860. FHP is correlated with greater repositioning error than a more upright posture. Our results imply that changes of muscle condition following FHP can lead to disruption of afferent input from the muscle spindles. Thus, it is suggested that this alteration in the muscle spindle plays a major role in the poor proprioceptive function shown in FHP.

Cranio-Vertebral angle was used to measure Forward Head Posture. FHP correlates with flection of the lower cervical and extension of upper cervicals. There is associated weakening of flexors and shortening of extensors. This affects repositioning due to afferentation disruption from muscle spindles.
Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion.Eur Spine J. 2001 Aug;10(4):314-9.

Kumar MN1, Baklanov A, Chopin D.
Patients with normal C7 plumb line and normal sacral inclination in the immediate post operative radiographs had the lowest incidence of adjacent level change compared with patients who had abnormality in one or both of these parameters. The difference was statistically significantUse of folllow up xrays at 5 years to understand the impact of lumbar surgery. Connection is that despite making a successful surgical intervention, xrays were the key tool to determine if there was additional degeneration of the segments of the spine due specifically to lordotic curvature measurements and sacral base angle measurements taken off the radiographs.
Correlation of lumbar disc degeneration and spinal pelvic sagittal balance.Liu H1, Shrivastava SR, Zheng ZM, Wang JR, Yang H, Li ZM, Wang TP, Wang H, Utsab S.
Zhonghua Yi Xue Za Zhi. 2013 Apr 16;93(15):1123-8.
L5/S1 disc degeneration impacts both pelvis overall and pelvis postural parameters. It is also a causative factor of pelvic posterior rotation and compensatory process, as well as trunk imbalance.
Correlation of lumbar disc degeneration and spinal-pelvic sagittal balanceZhonghua Yi Xue Za Zhi. 2013 Apr 16;93(15):1123-8.

Liu H1, Shrivastava SR, Zheng ZM, Wang JR, Yang H, Li ZM, Wang TP, Wang H, Utsab S.
With an important impact on lumbar disc degeneration, PI, either too big or too small, may predispose to the occurrences of lumbar disc degeneration. L5/S1 disc degeneration has a significant impact on pelvis postural parameters (PT, SS). L5/S1 degeneration is a key causative factor of pelvic posterior rotation and compensatory process. L5/S1 disc degeneration has an important impact on pelvis overall parameters (SVA, SPA, C7T). And the degeneration of L5/S1 is a key cause of trunk imbalance
[Article in Chinese]
Lo X, Zhang B, Liu Y, Dai M.
PI of more than normal range may lead to or aggravate lumbar facet joint degeneration at L4,5 and L5, Si; PT and PI are significantly associated with facet joint degeneration at the lower lumbar spine.
Correlations between the feature of sagittal spinopelvic alignment and facet joint degeneration: a retrospective studyBMC Musculoskelet Disord. 2016 Aug 15;17(1):341. doi: 10.1186/s12891-016-1193-6.
Lv X1, Liu Y1, Zhou S1, Wang Q2, Gu H2, Fu X2, Ding Y2, Zhang B3, Dai M4.
Our results indicate that a high PI is a predisposing factor for facet joint degeneration at the lower lumbar spine, and that severe facet joint degeneration may accompany with greater PT at lumbar spine
Correlative analysis of lateral vertebral radiographic variables and medical outcomes study short-form health survey: a comparative study in asymptomatic volunteers versus patients with low back pain. J Spinal Disord Tech. 2002 Oct;15(5):384-90. Korovessis P Dimas A Iliopoulos P Lambiris EThis comparative study showed that the functional status of hard-working patients with chronic LBP is associated with degenerative changes on the lateral radiographs of the lumbosacral spine. Spine surgeons should take into consideration the results of this study in reconstruction of painful degenerative lumbosacral spine.Sagittarius xrays show significant changes in pt’s with LBPn. Pt’s with LBP’n also had significantly lower scores on the SF36 questionnaire. It is theoretical weather correcting lumbar lordosis will improve social function.
Craniocervical Chiropractic Procedures - a precis of upper cervical chiropracticJ Can Chiropr Assoc. 2015 Jun; 59(2): 173–192.
H. Charles Woodfield, III, Craig York, DC, Roderic P. Rochester, DC, Scott Bales, DC, Mychal Beebe Dc, Bryan Salminen DC, Jeffrey N Scholten DC
Using a variety of resources include status of upper cervical or craniocervical chiropractic procedures participating in the international chiropractic association's council on over cervical care. you see T utilizing pyrkal time tested protocols come on now under scientific investigation common for delivering upper cervical chiropractic care. Those truly desiring to explore you see T should pay close attention to the relative abundance of clinical research on the effects of upper cervical care.This articles discusses the relative abundance of clinical research on the effects of upper cervical care as well as the importance of radiographic procedures involved to acquire clinical benefits of Upper Cervical Techniques.
Criteria to restore the sagittal balance in deformity and degenerative spondylolisthesisEur Spine J. 2012 May;21 Suppl 1:S27-31. doi: 10.1007/s00586-012-2236-9. Epub 2012 Mar 13.
Lamartina C1, Berjano P, Petruzzi M, Sinigaglia A, Casero G, Cecchinato R, Damilano M, Bassani R
Relevant parameters of sagittal imbalance have been identified and correlated with clinical outcomes. Methods for calculation of surgical correction of imbalance have been proposed, but not validated in patients with mid-term follow-upThis study states that sagittal imbalance causes pain and decrease in health related quality of life and function. It also states that surgical correction can be complicated by many compensatory factors and frequently resutls in complications resulting in additional surgery. Although it is the result of complex interactions, currently there exist sufficient information to interpret the key aspects of sagittal imbalance in a given patient. A model interpreting sagittal imbalance should include global alignment (measured with C7 plumbline), spinopelvic balance (calculated from lumbar lordosis, thoracic kyphosis, pelvic incidence and age related spinopelvic constant) and adaptative knee flexion, all of which require x-ray analysis to accurately be determined. Several methods exist to calculate the amount of correction needed. Those including all the relevant parameters should be preferred.
Cumulative Radiation Exposure From Imaging Scans Should Be Weighed Against The Benefits Say Researchers Catharine Paddock, Ph.D. August 28, 2009. Cumulative Radiation Exposure From Imaging Scans Should Be Weighed Against The Benefits Say Researchers
Current evidence for spinal X-ray use in the chiropractic profession: a narrative reviewChiropr Man Therap. 2018;26:48. Published 2018 Nov 21. doi:10.1186/s12998-018-0217-8 Jenkins HJ, Downie AS, Moore CS, French SD. The use of spinal X-rays in chiropractic has been controversial, with benefits for the use of routine spinal X-rays being proposed by some elements of the profession. However, evidence of these postulated benefits is limited or non-existent. There is strong evidence to demonstrate potential harms associated with spinal X-rays including increased ionising radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased unnecessary costs. Therefore, in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms. Spinal X-rays should not be performed as a routine part of chiropractic practice, and the decision to perform diagnostic imaging should be informed by evidence based clinical practice guidelines and clinician judgement.This article supports the choosing wisely program based on lack of adequate research and common sense. Several studies in the current literature discuss the effects of poor sagittal spinal alignment in both the young and old, but more severe in the elderly as poor sagittal alignment is correlated with higher rates of disability. The vast majority of the medical model is the "Wait and Monitor" approach, often resulting in surgical intervention for spinal complaints in the future. CBP has demonstrated the benefits of chiropractic care through X-ray analysis in the correction of saggital misalignments of the spine. The concept of increased risk of chronic pain based on feeling helpless as a result of spinal degeneration awareness is more reflective on poor understanding and communication of degeneration from the practicianer as arthritis (unless inflammatory arthritis) does not cause pain in itself but the stresses that generate arthritis do. Explaining that arthritis is a sign of stress in the joint can result in a patient feeling empowered to take control of the situation rather than feeling vitimized. Studies that demonstrate x-rays do not alter patient management are mostly based on primary care providers management of spinal pain which is handcuffed to medications, surgery and general physical therapy. Chiropractic treatment can be individualized based on biomechanical perameters acquired from radiographic imaging.
Current evidence for spinal X-ray use in the chiropractic profession: a narrative review.Jenkins, H.J., Downie, A.S., Moore, C.S. et al. Chiropr Man Therap 26, 48 (2018) doi:10.1186/s12998-018-0217-8In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion.Acta Orthop Suppl. 2013 Feb;84(349):1-35. doi: 10.3109/17453674.2012.753565.

Willems P1.
As the findings of the present thesis show that the currently used tests do not improve the results of fusion by better patient selection, these tests should not be recommended for surgical decision making in standard care. Moreover, spinal fusion should not be proposed as a standard treatment for chronic low back pain. Causality of nonspecific spinal pain is complex and CLBP should not be regarded as a diagnosis, but rather as a symptom in patients with different stages of impairment and disability. Patients should be evaluated in a multidisciplinary setting or Spine Centre according to the so-called biopsychosocial model, which aims to identify underlying psychosocial factors as well as biological factors. Treatment should occur in a stepwise fashion starting with the least invasive treatment. The current approach of CLBP, in which emphasis is laid on self-management and empowerment of patients to take an active course of treatment in order to prevent long-term disability and chronicity, is recommended.In regards to CLBP and treatment options, Spinal Fusion should not be the standard. Being very non-invasive, chiropractic can be an early intervention. Imaging from radiography cannot fully predict pain levels.
Demographic and Physical Characterization of Cervical Spine Curvature and Degeneration JOURNAL OF VERTEBRAL SUBLUXATION RESEARCH, VOL. 1, NO. 2, Michael ShaikewitzWhile numerous studies have described loss of lordosis of the cervical spine and the stages of spinal degeneration, the emphasis has been primarily directed toward these conditions as a result of trauma or other pre-disposing pathological conditions. Although the process of spinal degeneration, primarily as osteoarthritis, and spinal curvature have been investigated, the present author was unable to reference through the literature any specific characterization of cervical spine lordosis and cervical spine degeneration, regardless of etiology, coupled with demographics including such variables as age, gender, and occupation.Author fails to characterize factors other than trauma that causes cervical lordosis
Diagnostic Imaging Guidelines Implementation Study for Spinal Disorders: A Randomized Trial with Postal Follow-ups.Bussières AE 1 , Laurencelle L , Peterson C
The Journal of Chiropractic Education [01 Jan 2010, 24(1):2-18]
Type: research-article, Journal Article
DOI: 10.7899/1042-5055-24.1.2
dherence at follow-up was lower, but mean group differences remained insignificant.Online access to specific recommendations while making a clinical decision may favorably influence the intention to either order or not order imaging studies. However, a didactic presentation alone did not appear to change the perception for the need of diagnostic imaging studies.There is already a high adherence to the current radiolographic guidelines that is being employed by chiropractors for the evaluation of LBP. An integral part of chiropractic edcuation involves extensive training in the field of radiology and application of current evidence based guidelines. At this time it is unclear as to what method of continueing education is the most appropriate for stay up to date with the current guideline; however, online resources regarding imaging recommendations may prove favorable for the appropriate application of a radiographic examination for a patient's complaint.
Diagnostic imaging practice guidelines for musculoskeletal complaints in adults--an evidence-based approach: introduction.J Manipulative Physiol Ther. 2008 Jan;31(1):33-88. doi: 10.1016/j.jmpt.2007.11.003.

Bussières AE1, Taylor JA, Peterson C.
These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision,and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and modified regularly with new information and experience.
Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders.J Manipulative Physiol Ther. 2008 Jan;31(1):33-88. doi: 10.1016/j.jmpt.2007.11.003.
Bussières AE1, Taylor JA, Peterson C.
The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. However, many of them are low-quality studies. We need more high-quality consistent studies for chiropractors to use as clinical guidelines.

***Usual Care, claims without reference ("120x more exposure than chest x-ray)... also look at what they are citing (references 8,9))
Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders.J Manipulative Physiol Ther. 2008 Jan;31(1):33-88. doi: 10.1016/j.jmpt.2007.11.003.
Bussières AE1, Taylor JA, Peterson C.
The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.Recomendations are based on a primary care (medical) model of "usual Care"
Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders.Bussières AE1, Taylor JA, Peterson C. J Manipulative Physiol Ther. 2008 Jan;31(1):33-88. doi: 10.1016/j.jmpt.2007.11.003.Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed.
Diagnostic pediatric computed tomographic scans of the head: actual dosage versus estimated risk.Jaffurs D, Denny A; Plast Reconstr Surg. 2009 Oct;124(4):1254-60. doi: 10.1097/PRS.0b013e3181b59d2d.The authors suggest that published experimental evidence does not support the linear no-threshold model at low linear energy transfer levels similar to the exposure of their patients undergoing computed tomographic scans of the head. In addition, no convincing epidemiologic data exist demonstrating an increase in cancer incidence for doses below 100 mSv.
Diagnostic radiation exposure in children and cancer risk: current knowledge and perspectivesArch Pediatr. 2012 Jan;19(1):64-73. doi: 10.1016/j.arcped.2011.10.023. Epub 2011 Nov 29.

[Article in French]
Baysson H1, Etard C, Brisse HJ, Bernier MO.
The question of the risk of cancer associated with postnatal diagnostic medical exposure involving ionizing radiation in childhood is particularly relevant at the moment given the growing use of diagnostic examinations, especially computed tomography scans, in children. Compared to adults, pediatric patients are more sensitive to radiation and have more years of life expectancy and therefore more years at risk of cancer occurrence as compared to adults. This paper provides a description of diagnostic x-ray exposure in children in France and summarizes epidemiologic studies on subsequent risk of cancer. Overall, this review, based on 12 case-control studies and 6 cohort studies, shows no significant association between exposure to medical diagnostic radiation exposure and childhood cancer risk.
Diagnostic triage for low back pain: a practical approach for primary care.Med J Aust. 2017 Apr 3;206(6):268-273.
Bardin LD1, King P2, Maher CG3.
Back pain is a symptom and not a diagnosis. Careful diagnostic differentiation is required and, in primary care, diagnostic triage of LBP is the anchor for a diagnosis.non-specific LBP (NSLBP), which represents 90 to 95%. Generally speaking, this is directed toward GP (Primary care MD) and how they work with patients presenting with low back pain. It should be noted, it does give a good system of DDX for underlying pathology.
Diagnostic Value of T1 Slope in Degenerative Cervical Spondylotic Myelopathy.Sun J1,2, Zhao HW3,4, Wang JJ3,4, Xun L5, Fu NX1,2, Huang H1.
Med Sci Monit. 2018 Feb 7;24:791-796.
Patients with sagittal imbalance of thoracic inlet parameters have higher risk of DCSM, while T1 slope of less than 18.5° showed significant diagnostic value for the incidence of DCSM.This article uses various measurements such as T1 slope, to relate to the incidence of DCSM, just note that the radiographs in this articles are taken with patient supine
Differences in erect sitting and natural sitting spinal alignment-insights into a new paradigm and implications in deformity correction.Spine J. 2017 Feb;17(2):183-189. doi: 10.1016/j.spinee.2016.08.026. Epub 2016 Aug 22.
Hey HW1, Wong CG2, Lau ET2, Tan KA2, Lau LL2, Liu KG2, Wong HK2.
In a natural sitting posture, the lumbar spine becomes kyphotic and contributes to a single C-shaped sagittal profile comprising the thoracic and the lumbar spine. This is associated with an increase in CL and PT, as well as a constant SVA. These findings lend insight into the body's natural way of energy conservation using the posterior ligamentous tension band while achieving sitting spinal sagittal balance. It also provides information on one of the possible causes of proximal junctional kyphosis or proximal junctional failure.This article used a small and unbalanced (24 male, 4 female) population to study sitting naturally vs. sitting erect vs. standing. Standing posture was used as a control for the test. They answer questions 2 and 3, but more emphasis is placed on topics from question 2. Radiographic measurement of sitting naturally was significant because most patients sit in a position that is not erect, so evaluating how the spine behaves in that state is critical for establishing expectations for healthcare intervention. Sitting in a natural slump compared to erect sitting does appear to change curve measurements and spine-pelvic measurements as well. It also refers to the findings from an earlier study they did (See above article #304).
Differences in male and female spino-pelvic alignment in asymptomatic young adults: a three-dimensional analysis using upright low-dose digital biplanar X-raysSpine (Phila Pa 1976). 2009 Nov 1;34(23):E826-32. doi: 10.1097/BRS.0b013e3181a9fd85.
Janssen MM1, Drevelle X, Humbert L, Skalli W, Castelein RM
These results indicate that the female spine is definitely different from the male spine. The spine as whole and individual vertebrae in certain regions of the normal spine is more backwardly inclined in females than in males. Based on our previous research this signifies that these spinal regions are subjected to different biomechanical loading conditions. These vertebral segments are possibly less rotationally stable in females than in males.This study shows that female spines are more backwardly inclined in both a global spine and individual vertebrae standpoint. This leads to increased posterior shearing of the dorsal aspects of the spine which may contribute to rotational instability overtime and induce deformities both in the growing and in the mature spine. This should be taken into consideration for spinal deformity prevention in women as it relates to radiographic specific treatment plans for prolonged spinal health, as increased lorosis or posterior spinal weight bearing increases spinal deformities,
Dimensions of the cervical neural foramen in conditions of spinal deformity: an ex vivo biomechanical investigation using specimen-specific CT imaging.Eur Spine J. 2016 Jul;25(7):2155-65. doi: 10.1007/s00586-016-4409-4. Epub 2016 Feb 1.
Smith ZA1, Khayatzadeh S2, Bakhsheshian J3, Harvey M1, Havey RM2,4, Voronov LI2,4, Muriuki MG2, Patwardhan AG5,6.
An increase in thoracic kyphosis (T1 tilt) decreased cervical neural foraminal areas. In contrast, an increase in cervical SVA increased the lower cervical neural foraminal areas. Patients with increased upper thoracic kyphosis may respond with increased cervical SVA as a compensatory mechanism to increase their lower cervical neural foraminal area.
Disc degeneration of cervical spine on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers.Eur Spine J. 2011 Apr;20(4):585-91. doi: 10.1007/s00586-010-1644-y. Epub 2010 Dec 3.
Okada E1, Matsumoto M, Fujiwara H, Toyama Y.
As compared to healthy volunteers, patients with lumbar disc herniation showed a higher prevalence of decrease in signal intensity of intervertebral disc and posterior disc protrusion on MRI of the cervical spine. The result of this study suggests that disc degeneration appears to be a systemic phenomenon.Patients with lumbar disc herniation are at a higher risk for cervical disc herniation
Do chiropractors adhere to guidelines for back radiographs? A study of chiropractic teaching clinics in Canada.Spine (Phila Pa 1976). 2007 Oct 15;32(22):2509-14.
Ammendolia C1, Côté P, Hogg-Johnson S, Bombardier C.
The results suggest a strong adherence to radiography guidelines for patients with a new episode of low back pain who presented to chiropractic teaching clinics. Although a high proportion of patients had red flags, radiography utilization was lower than rates reported in previous studies suggesting that adherence to guidelines may help prevent unnecessary radiography.
Do chiropractors adhere to guidelines for back radiographs? A study of chiropractic teaching clinics in Canada.
Ammendolia C, Côté P, Hogg-Johnson S, Bombardier C.
Spine (Phila Pa 1976) [2007]
The results suggest a strong adherence to radiography guidelines for patients with a new episode of low back pain who presented to chiropractic teaching clinics. Although a high proportion of patients had red flags, radiography utilization was lower than rates reported in previous studies suggesting that adherence to guidelines may help prevent unnecessary radiography.There is a high adherence to clincical guidelines recommending the use of radiography for the assessment and management of acute low back pain that is being taught at Canadian Chiropractic college. Despite the occurance of red flags, radiographic evaluation was obtained in only a minor percentage of cases and a trial of conservative care was first utlized. This, however, appears to differ from the higher utilization of radiographic assessments by community chiropractors, who may be more cautious when it comes to the presentation of red flags, have fears about malpractice, or who may not be up to date with the current practice guidelines.
Does cervical lordosis change after spinal manipulation for non-specific neck pain? A prospective cohort study.Shilton M, Branney J, de Vries BP, Breen AC. Does cervical lordosis change after spinal manipulation for non-specific neck pain? A prospective cohort study. Chiropractic & Manual Therapies. 2015;23:33.
Does Imaging Technology Cause Cancer? Debunking the Linear No-Threshold Model of Radiation Carcinogenesis.Siegel JA, Welsh JS; Technology in cancer research and treatment,Technol Cancer Res Treat. 2016 Apr;15(2):249-56. doi: 10.1177/1533034615578011. Epub 2015 Mar 30.the risk:benefit ratio models used to calculate the hazards of radiological imaging studies may be grossly inaccurate if the linear no-threshold hypothesis is wrong. Here, we review the myriad inadequacies of the linear no-threshold model and cast doubt on the various studies based on this overly simplistic model.The current model of radiation carcinogenesis is based on linear transgression of high-dose radiation exposure. Low-dose radiation exposure (
Does improvement towards a normal cervical sagittal configuration aid in the management of cervical myofascial pain syndrome: a 1- year randomized controlled trial.Moustafa IM1,2, Diab AA3, Hegazy F4, Harrison DE5.
Int J Occup Saf Ergon. 2018 Nov 9:1-27. doi: 10.1080/10803548.2018.1544799. [Epub ahead of print]
The addition of the denneroll cervical orthotic to a multimodal program positively affected CMCPS outcomes at long term follow up. We speculate the improved sagittal cervical posture alignment outcomes contributed to our findings.
Does Improvement Towards A normal Cervical Sagittal Configuration Aid in the Management of Fibromyalgia: A randomized controlled trialBMC Musculoskelet Disord. 2018 Nov 12;19(1):396. doi: 10.1186/s12891-018-2317-y.
Moustafa IM1,2, Diab AA3, Hegazy F4, Harrison DE5.
Adding Deneroll cervical extension traction to a multi-modal program has a shortand long-term positive effect on threedimensional spinal posture in patients with FMS
does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects?I Moustafa, AM Diab, D Harrison; J Back Musculoskelet Rehabil. 2017;30(4):937-941. doi: 10.3233/BMR-150464.improved lordosis in the study group was associated with significant improvement in the translational and rotational motions of the lower cervical spine. This finding provides objective evidence that cervical flexion/extension is partially dependent on the posture and sagittal curve orientation. These findings are in agreement with several other reports in the literature; whereas ours is the first post treatment analysis identifying this relationship.Cervical spondylotic radiculopathy, translational, and rotational movements in the cervical spine were corrected. This treatment significantly impacts the CSR community, which is a large percentage of the population. The progress and correction is only seen on radiography. Without diagnostic imaging, this technique would not work and would require patients to seek pain medications or invasive surgery.
Effect of Atlas Vertebrae Realignment in Subjects with Migraine:
An Observational Pilot Study

H. Charles Woodfield III,1 D. Gordon Hasick,2 Werner J. Becker,3
Marianne S. Rose,4 and James N. Scott5 BioMed Research International
Volume 2015, Article ID 630472, 18 pages
These study results suggest that the atlas
realignment intervention may be associated with reduction
in migraine frequency, marked improvement in quality of life
yielding significant reduction in headache-related disability
as observed in this cohort. Utilizes the NUCCA protocol.
High qualitiy study involving university of Calgary and the NUCCA technique to measure Intracranial Compliance Index (ICCI) as a measure of neurological function correlated with migraines and neurological health. This small sample size pilot study showed no significant improvement on ICCI (although some previous case studies did), but there were secondary benefits in patient outcomes.
Effect of disc degeneration on lumbar segmental mobility analyzed by kinetic magnetic resonance imaging.Spine (Phila Pa 1976). 2015 Mar 1;40(5):316-22. doi: 10.1097/BRS.0000000000000738.
Lao L1, Daubs MD, Scott TP, Lord EL, Cohen JR, Yin R, Zhong G, Wang JC.
As disc degeneration developed from the normal to an increasingly severe stage, the motion of lumbar spine progressed from the normal stage to an unstable phase with higher mobility and finally to an ankylosed stage where stability was increased.
EFFECT OF FORWARD HEAD POSTURE ON SENSORIMOTOR INTEGRATIONTaha, Shimaa & Moustafa, Ibrahim. (2017). 4. 118-125. 10.15621/ijphy/2017/v4i2/141952. forward head posture affects SMI through changing the response of CNS to afferent input, as demonstrated by attenuation of cortical STEPS in the group (B) compared with a groupForward head posture is one of the most commonly seen dysfunctions in the cervical spine. FHP causes strain on the neck muscles and changes how the brain processes SMI. Reduced SMI response causes decreased ability to focus, chronic pain, and reduced reflex responses. Analyzing the amount of FHP correction made is only able to be accomplished with diagnostic imaging.
Effect of Lumbar Disc Degeneration and Low-Back Pain on the Lumbar Lordosis in Supine and Standing: A Cross-Sectional MRI Study.Spine (Phila Pa 1976). 2015 Nov;40(21):1690-6. doi: 10.1097/BRS.0000000000001120.
Hansen BB1, Bendix T, Grindsted J, Bliddal H, Christensen R, Hansen P, Riis RG, Boesen M.
Patients may be less lordotic in both the supine and standing position, whereas, change in the lordosis between the positions may be independent of pain. Decreasing lordosis change seems to be associated with age-related increasing disc degeneration in healthy individuals.This study showed changes in Lumbar lordosis that was position dependent and both upright and recumbent MRI showed that decrease lumbar lordosis was associated with LBP. The more degeneration present the less the change in the two positions.
Effect of sagittal alignment on kinematic changes and degree of disc degeneration in the lumbar spine: an analysis using positional MRI.Spine (Phila Pa 1976). 2011 May 15;36(11):893-8. doi: 10.1097/BRS.0b013e3181f4d212.
Keorochana G1, Taghavi CE, Lee KB, Yoo JH, Liao JC, Fei Z, Wang JC.
Changes in sagittal alignment may lead to kinematic changes in the lumbar spine. This may subsequently influence load bearing and the distribution of disc degeneration at each level. Sagittal alignment, disc degeneration, and segmental mobility likely have a reciprocal influence on one another.
Effectiveness of global postural reeducation in the treatment of temporomandibular disorder: case report.J Bodyw Mov Ther. 2013 Jan;17(1):53-8. doi: 10.1016/j.jbmt.2012.05.003. Epub 2012 Jun 21.
Monteiro W1, Francisco de Oliveira Dantas da Gama T, dos Santos RM, Collange Grecco LA, Pasini Neto H, Oliveira CS.
The improvement in postural patterns of the cervical spine provided an improvement in aspects of the EMG signal of the masseter muscle in this patient.
Effects of posture and structure on three-dimensional coupled rotations in the lumbar spine. Cholewicki J, Crisco JJ, III, Oxland TR et al. Spine 1996;21:2421-8.

Intervertebral coupling was partially predicted by lumbar lordosis; however, the inclusion of intrinsic mechanical coupling dramatically improved the simulation of the intervertebral rotations (root mean square error
Epidemiology Without Biology: False Paradigms, Unfounded Assumptions, and Specious Statistics in Radiation Science (with Commentaries by Inge Schmitz-Feuerhake and Christopher Busby and a Reply by the Authors).Sacks B1, Meyerson G2, Siegel JA3.; Biol Theory. 2016; 11: 69–101.
Published online 2016 Jun 17. doi: 10.1007/s13752-016-0244-4
Editors of medical journals now admit that perhaps half of the scientific literature may be untrue. Radiation science falls into that category. Belief in LNT informs the practice of radiology, radiation regulatory policies, and popular culture through the media. The result is mass radiophobia and harmful outcomes, including forced relocations of populations near nuclear power plant accidents, reluctance to avail oneself of needed medical imaging studies, and aversion to nuclear energy-all unwarranted and all harmful to millions of people.Fear of radiographs comes from political, religous or other powerful institutions and no longer has real validity. This is a great article to use towards the Choose Wisely questions addressed and to be researched. The stance that there is radiation everywhere, and in low doses is unharmful as the body.
Etiology of cervical myelopathy induced by ossification of the posterior longitudinal ligament: determining the responsible level of OPLL myelopathy by correlating static compression and dynamic factorsJ Spinal Disord Tech. 2010 May;23(3):166-9. doi: 10.1097/BSD.0b013e31819e9066.
Azuma Y1, Kato Y, Taguchi T.
Cervical OPLL myelopathy is induced by static factors, dynamic factors, or a combination of both. The discriminate formula for symptomatic cervical OPLL myelopathy contains both ROM and SAC.
European guidelines for the diagnosis and treatment of pelvic girdle pain.Eur Spine J. 2008 Jun; 17(6): 794–819.
Published online 2008 Feb 8. doi: 10.1007/s00586-008-0602-4

Andry Vleeming,corresponding author1 Hanne B. Albert,2 Hans Christian Östgaard,3 Bengt Sturesson,4 and Britt Stuge5
As a functional test, the active straight leg raise (ASLR) test is recommended. Mobility (palpation) tests, X-rays, CT, scintigraphy, diagnostic injections and diagnostic external pelvic fixation are not recommended. MRI may be used to exclude ankylosing spondylitis and in the case of positive red flags. The recommended treatment includes adequate information and reassurance of the patient, individualized exercises for pregnant women and an individualized multifactorial treatment program for other patients. We recommend medication (excluding pregnant women), if necessary, for pain relief. Recommendations are made for future research on PGP.
Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists. (lack of posture and chiropractic which can be alleviated by posture/chiropractic understanding, hence the need for chiropractic standardization in xray analysis)Mayo Clin Proc. 2015 Dec;90(12):1699-718. doi: 10.1016/j.mayocp.2015.10.009.
Hooten WM1, Cohen SP2.
Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related indications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence.There is significant research supporting structural based chiropractic in the literature.
Evidence against the use of lumbar spine radiography for low back pain.Van den Bosch MAAJ, Hollingworth W, Kinmonth AL,
Dixon AK. Clin Radiol 2004;59:69-76.
The prevalence of reported lumbar spine degeneration increased with age to 71% in patients aged 65-74 years. The overall prevalence of fracture, possible infection, possible tumour was low in our study population: 4, 0.8 and 0.7%, respectively. Fracture and possible infection showed no association with age. Possible tumour was only reported in patients older than 55 years of age.
Extension traction treatment for patients with discogenic lumbosacralradiculopathy: a randomized controlled trial.Clin Rehabil. 2013 Jan;27(1):51-62. doi: 10.1177/0269215512446093. Epub 2012 Jun 8.
Moustafa IM1, Diab AA.
The traction group receiving lumbar extension traction in addition to hot packs and interferential therapy had better effects than the control group with regard to pain, disability, H-reflex parameters and segmental intervertebral movements.
Factors determining cervical spine sagittal balance in asymptomatic adults: correlation with spinopelvic balance and thoracic inlet alignment.Spine J. 2015 Apr 1;15(4):705-12. doi: 10.1016/j.spinee.2013.06.059. Epub 2013 Sep 8.
Lee SH1, Son ES2, Seo EM3, Suk KS4, Kim KT4.
T1 slope was a key factor determining cervical spine sagittal balance. Both spinopelvic balance and TI alignment have a significant influence on cervical spine sagittal balance via T1 slope, but TIA had a stronger effect than TK. An individual with large T1 slope required large CL to preserve physiologic sagittal balance of the cervical spine. The results of the present study could serve as baseline data for further studies on the cervical spine sagittal balance in various clinical conditions including the surgical reconstruction of lordosis.
Femoral head retroposition as a potential compensatory mechanism in patients with a severe mismatch between pelvic incidence and lumbar lordosisSkeletal Radiol. 2017 Dec;46(12):1679-1685. doi: 10.1007/s00256-017-2663-0. Epub 2017 May 9.
Cheng X1, Zhang K1, Sun X1, Zhao C1, Li H1, Zhao J2.
Femoral head retroposition is an entirely separate compensatory mechanism and, in this study, participated in the compensation for the anterior displacement of the gravity line induced by extra-sagittal spinal malalignment in patients with severe PI-LL mismatch.
Forward Head Posture and Activation of Rectus Capitis Posterior Muscles(USE IN CONJUNCTION WITH "Configuration of the Connective Tissue in the Posterior Atlanto-Occipital Interspace" Scali, Frank & Marsili, Eric & Pontell, Matthew. (2011). (vol 36, pg E1612, 2011). Spine. 36. E1612-4. 10.1097/BRS.0b013e31821129df. Twenty participants were studied. Electromyographic activity collected from RCP muscles was found to increase as the head was voluntarily moved from a self-selected neutral head position (11% of maximum voluntary isometric contraction [MVIC] in RCP minor, 14% of MVIC in RCP major) into a protruded head position (35% of MVIC in RCP minor, 39% of MVIC in RCP major) (P<.001>Forward head posture activates the rectus capitis posterior muscles (which attach to the cervical dura) and may contribute to stabalization of the cranial cervical joints.
Frequency, timing, and predictors of neurological dysfunction in the nonmyelopathic patient with cervical spinal cord compression, canal stenosis, and/or ossification of the posterior longitudinal ligament.(Search for lordosis or motion as a predictor, if not found, make an argument for such)Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S37-54. doi: 10.1097/BRS.0b013e3182a7f2e7.
Wilson JR1, Barry S, Fischer DJ, Skelly AC, Arnold PM, Riew KD, Shaffrey CI, Traynelis VC, Fehlings MG.
On the basis of these results, we provide a series of evidence-based recommendations related to the frequency, timing, and predictors of myelopathy development in asymptomatic patients with cervical stenosis secondary to spondylosis or OPLL. Future prospective studies are required to refine our understanding of this topic
Full-Body Analysis of Age-Adjusted Alignment in Adult Spinal Deformity Patients and Lower-Limb Compensation.Spine (Phila Pa 1976). 2017 May 1;42(9):653-661. doi: 10.1097/BRS.0000000000001863.
Jalai CM1, Cruz DL, Diebo BG, Poorman G, Lafage R, Bess S, Ramchandran S, Day LM, Vira S, Liabaud B, Henry JK, Schwab FJ, Lafage V, Passias PG.
Age-adjusted ideals for sagittal alignment provide targets for patients with ASD. Offsets from actual alignment (more severe sagittal deformity) revealed differential recruitment of lower-limb extension, which varied significantly with age.
Full-spine radiography: a review.J Manipulative Physiol Ther. 1993 Sep;16(7):460-74.
Taylor JA1.
Full-spine radiography and spinographic analysis are controversial procedures in chiropractic. An extensive review of the literature reveals that the role of full-spine radiography is well established. With proper patient selection, careful attention to technical detail and utilization of several technological advancements, full-spine radiography is an effective diagnostic and analytic procedure with an acceptable risk/benefit ratio. Although the reliability of certain spinographic parameters has been established, many questions remain regarding the validity and clinical relevance of those parameters.
Functional radiographic diagnosis of the cervical spine: flexion/extensionDvorak J1, Froehlich D, Penning L, Baumgartner H, Panjabi MM. Spine (Phila Pa 1976). 1988 Jul;13(7):748-55If possible, the functional roentgenogram examination of the cervical spine in the sagittal plane should be performed by including passive movement and the range of motion should be compared with the normal values obtained by passive examination.Study evaluating active and passive flexion/extension images to identify cervical injuries after trauma. No directly beneficial information for our purposes
Further reliability analysis of the Harrison radiographic line-drawing methods: crossed ICCs for lateral posterior tangents and modified Risser-Ferguson method on AP views.Harrison DE1, Holland B, Harrison DD, Janik TJ.; J Manipulative Physiol Ther. 2002 Feb;25(2):93-8.The ICCs assuming random crossed factors understate reliability compared with previously published ICC results assuming nested factors. Reliability of the Harrison modified Risser-Ferguson method of line-drawing analysis on AP views is in the high range, with the majority of ICCs >0.88. For both the Harrison modified Risser-Ferguson method on AP views and posterior tangent method on lateral cervical views, the mean absolute differences of observers' measurements are small.Article may be week in adressing what the Task Force may be looking for as far as reliabliity studies are concerned with line drawing. Error between the Harrison Line drawing of RIsser ferguson and the posterior Tangen method is small.
General practice and chiropractic in Norway: how well do they communicate and what do GPs want to know?(STANDARDIZING X-RAYS AND PROVING WHAT WE DO FROM A POSTURE STANDPOINT MAY HELP GPs UNDERSTAND WHAT WE DO AND RECOMMEND CHIROPRACTORS MORE FOR SPINAL COMPLAINTS)J Manipulative Physiol Ther. 2001 Nov-Dec;24(9):576-81.

Langworthy JM1, Birkelid J.
In general, communications between GPs and chiropractors in Norway are not ideal, particularly with regard to frequency and written quality. However, this is not unique to Norway. With increasing emphasis on multidisciplinary health care, greater understanding and better communication is needed to optimize the benefits of such an approach to patient management. Relevant, timely, consistent reporting on a reciprocal basis, together with a shared vocabulary, should help this process.
General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques.Spine (Phila Pa 1976). 2002 Nov 15;27(22):2538-45; discussion 2546.
Saal JS1.
There are inherent limitations in the accuracy of all diagnostic tests. The tests used to diagnose the source of a patient's chronic low back pain require accurate determination of the abolition or reproduction of the patient's painful symptoms.
Global sagittal axis: a step toward full-body assessment of sagittal plane deformity in the human body.Diebo BG1, Oren JH1, Challier V1, Lafage R1, Ferrero E1, Liu S1, Vira S1, Spiegel MA1, Harris BY1, Liabaud B1, Henry JK1, Errico TJ1, Schwab FJ1, Lafage,J Neurosurg Spine. 2016 Oct;25(4):494-499. Epub 2016 May 20The GSA is a simple, novel measure to assess the standing axis of the human body in the sagittal plane. The GSA correlated highly with spinopelvic and lower-extremities sagittal parameters and exhibited remarkable correlations with HRQOL, which exceeded other commonly used parameters.
Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioningEur Spine J. 2016 Nov;25(11):3644-3649. Epub 2016 Jun 20.
Obeid I1, Boissière L2, Yilgor C3, Larrieu D1, Pellisé F4, Alanay A3, Acaroglu E5, Perez-Grueso FJ6, Kleinstück F7, Vital JM1, Bourghli A8; European Spine Study Group, ESSG.
GT appears to be the most reliable single sagittal plane parameter in ASD. It is the least affected by patient position and incorporates both the pelvic and the spinal alignment within one measure.
GPs opinions and perceptions of chiropractic in Sweden and Norway: a descriptive survey. (Before and after X-Rays may improve GPs perception of chiropractors. Even though this is positive, it can be better!)Chiropr Man Therap. 2013; 21: 29.
Published online 2013 Aug 30. doi: 10.1186/2045-709X-21-29

Daniel Westin,corresponding author1 Tine Tandberg,2 Carol John,1 and Iben Axéncorresponding author3
Swedish and Norwegian GPs agree that chiropractors are competent to treat musculoskeletal conditions. However, there are many differences in GPs perceptions of chiropractic between the two countries and the overall picture indicates that chiropractic is more accepted and recognised as a health care profession in Norway.
Historical influence on the practice of chiropractic radiology: Part I - a survey of Diplomates of the American Chiropractic College of Radiology.Chiropr Man Therap. 2017; 25: 14.
Published online 2017 May 8. doi: 10.1186/s12998-017-0146-y

Kenneth J. Youngcorresponding author
Within the chiropractic profession, there is a continuing belief in radiographically visible subluxations as a cause of suboptimal health. This situation is sustained in part due to the reticence of other chiropractors to report these practices to licensing and registration boards. Investigation into other structures supporting a vitalistic belief system over science in chiropractic is recommended. In addition, it may be useful to explore remunerative systems that move beyond the inherently conflicted fee-for-service model.
Historical influence on the practice of chiropractic radiology: part II - thematic analysis on the opinions of diplomates of the American Chiropractic College of Radiology about the future.Chiropr Man Therap. 2017 May 8;25:15. doi: 10.1186/s12998-017-0145-z. eCollection 2017.
Young KJ1.
The increasing necessity of demonstrating evidence for diagnostic and therapeutic procedures in healthcare makes it likely that chiropractic radiologists and the wider chiropractic profession will need to take a more active position on evidence-based practice. Re-evaluation of guidelines and legislation as well as enforcement policies and practices will be necessary. The consequences of failing to do so may include increased marginalisation and reduced viability as a profession.Relatively low number of respondents (73/190). The opinions were fairly split, and it would be disingenuous to say there was a consensus amongst those that responded.
How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?Wong AYL1, Samartzis D, Cheung PWH, Cheung JPY. Clin Orthop Relat Res. 2018 Nov 13. doi: 10.1097/CORR.0000000000000569. Biopsychosocial factors are associated with the presence and severity of back pain in the AIS population. Our results highlight the importance of considering back pain screening/management for patients with AIS with their psychosocial profile in addition to curve magnitude monitoring. In particular, sleep quality should be routinely assessed. Longitudinal changes and effects of psychotherapy should be determined in future studies.Several factors were found to contribue to the experience of back pain in adolescence with idiopathic scoliosis, including insomina, daytime sleepiness, older age, and larger Cobb angles. In particular, Cobb angles measuring >40 degrees at the throacic curve that persisted into older age was found to be a predictor of chronic back pain in combination with psychosocial factors, such as depression, anxiety, and insomina. For individuals with adolescent idiopathic scoliosis it is improtant to not only monitor curve progression, but to also be aware of lifestyle/psychosocial factors that may be influencing their perseption of pain. Early detection of these factor may help to mitigate the occurance of back pain as an adult.
How do anterior/posterior translations of the thoracic cage affect the sagittal lumbar spine, pelvic tilt, and thoracic kyphosis?Eur Spine J. 2002 Jun;11(3):287-93. Epub 2001 Nov 1.

Harrison DE1, Cailliet R, Harrison DD, Janik TJ.
The findings of this study show that thoracic cage anterior/posterior translations cause significant changes in thoracic kyphosis (26 degrees ), lumbar curve, and pelvic tilt. An understanding of this main motion and consequent coupled movements might aid the understanding of spinal injury kinematics and spinal displacement analysis on full spine lateral radiographs of low back pain and spinal disorder populations.Use of xray to evaluate positioning in a neutral and displaced position. Focus is on the thoracic and lumbar regions to understand better the biomechanics of movement of the spine.
How the neck affects the back: changes in regional cervical sagittal alignment correlate to HRQOL improvement in adult thoracolumbar deformity patients at 2-year follow-up.Protopsaltis TS1, Scheer JK2, Terran JS1, Smith JS3, Hamilton DK4, Kim HJ5, Mundis GM Jr6, Hart RA4, McCarthy IM7, Klineberg E8, Lafage V1, Bess S9, Schwab F1, Shaffrey CI3, Ames CP10; International Spine Study Group; Journal of neurosurgery, Spine.Regional cervical sagittal parameters such as CL and C2-7 SVA are correlated with clinical measures of regional disability and health status in patients with adult thoracolumbar scoliosis. This effect may be direct or a reciprocal effect of the underlying global deformities on regional cervical alignment. However, the partial correlation analysis, controlling for the magnitude of the thoracolumbar deformity, suggests that there is a direct effect of cervical alignment on health measures. Improvements in regional cervical alignment postoperatively correlated positively with improved HRQOL· This study demonstrated a possible interrelationship between the thoracolumbar spine and the cervical spine. By correcting the thoracolumbar spine, the researchers were able to see a normalization in the cervical spine curvature, leading to a documented increase in the patient’s quality of life. Follow up x-rays were at the 2-year mark, limiting the study. Quarterly or bi-annual follow ups would more accurately assess the global shift in curvature, narrowing in on the time taken for the patient’s spine to completely normalize.
How the spine differs in standing and in sitting-important considerations for correction of spinal deformitySpine J. 2017 Jun;17(6):799-806. doi: 10.1016/j.spinee.2016.03.056. Epub 2016 Apr 7.
Hey HWD1, Teo AQA2, Tan KA2, Ng LWN2, Lau LL2, Liu KG2, Wong HK
Sagittal spinal alignment changes significantly between standing and sitting positions. Understanding these differences is crucial to avoid overcorrection of LL, which may occur if deformity correction is based solely on the spine's standing sagittal profile.: This article is strong because of its inclusion criteria, but its limited reach resulted in a small population size that was very imbalanced (50 males and 8 females).
Hyperkyphotic posture and risk of future osteoporotic fractures: the Rancho Bernardo study.Mei-Hua Huang,1 Elizabeth Barrett-Connor,2 Gail A Greendale,1 and Deborah M Kado; J Bone Miner Res. 2006 Mar;21(3):419-23. Epub 2005 Dec 5.Whereas hyperkyphosis may often result from vertebral fractures, our study findings suggest that hyperkyphotic posture itself may be an important risk factor for future fractures, independent of low BMD or fracture history.individuals with hyperkyphosis are at greater risk of fractures
Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study.Kado DM1, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA.
J Gerontol A Biol Sci Med Sci. 2007 Jun;62(6):652-7
Moderate hyperkyphotic posture may signify an easily identifiable independent risk factor for injurious falls in older men, with the association being less pronounced in older with hyerkyphisis in the thoracic region are at hte greatest risk of falling
Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study.Kado DM1, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA. J Gerontol A Biol Sci Med Sci. 2007 Jun;62(6):652-7.Hyperkyphosis was defined as requiring the use of > or = 1 blocks (n = 595, 31.6%). In this cohort, men were more likely to be hyperkyphotic than were women (p <.0001 of="" those="" who="" fell="" were="" hyperkyphotic="" versus="" among="" did="" not="" fall="" older="" more="" likely="" to="" be="" women="" had="" lower="" body="" mass="" index="" exercise="" drink="" alcohol="" and="" poor="" self-reported="" physical="" emotional="" health.="" in="" age-="" sex-adjusted="" models="" with="" hyperkyphosis="" at="" increased="" odds="" experiencing="" an="" injurious="" confidence="" interval="" p=".02)" that="" using="" a="" cutoff=""> or = 2 blocks versus
Those with hyperkyphosis were 1.32 times more likely to have reported a fall. Men wITH HYPER KYPHOSIS were more likely to have reported a fall then women WITH HYPERKYPHOSIS.
Hyperkyphotic Posture Predicts Mortality in Older Community‐Dwelling Men and Women: A Prospective StudyJ Am Geriatr Soc. 2004 Oct;52(10):1662-7. Deborah M. Kado MD, MS Mei‐Hua Huang DrPH Arun S. Karlamangla MD, PhD Elizabeth Barrett‐Connor MD Gail A. Greendale MDHyperkyphotic posture, defined as requiring one or more blocks under the occiput to achieve a neutral head position while lying supine, was more common in men than women (44% in men, 22% of women, P<.0001 in="" age-="" and="" sex-adjusted="" analyses="" persons="" with="" hyperkyphotic="" posture="" had="" a="" greater="" rate="" of="" mortality="" confidence="" interval="" p=".005)." multiply="" adjusted="" models="" the="" increased="" death="" associated="" remained="" significant="" hazard="1.40," ci="1.08-1.81," cause-specific="" was="" specifically="" an="" due="" to="" atherosclerosis.="" conclusion:="" older="" men="" women="" have="" higher="" rates="">
Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework.Implement Sci. 2012 Aug 31;7:82.
Bussières AE1, Patey AM, Francis JJ, Sales AE, Grimshaw JM; Canada PRIme Plus Team, Brouwers M, Godin G, Hux J, Johnston M, Lemyre L, Pomey MP,
Chiropractors' use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.
Imaging in the Diagnosis and Monitoring of Children with Idiopathic ScoliosisShu-Yan Ng* and Josette Bettany-Saltikov The Open Orthopaedics Journal, 2017, 11, (Suppl-9, M5) 1500-1520Radiography, however, enables diagnosis and monitoring of the adolescent idiopathic scoliosis (AIS). It is thus the gold standard in the evaluation and management of scoliosis curves.Within the chiropractic profession, vertebral rotation has been discussed for decades as a disruptor of good health. In this study, it is stated that knowing the extent of vertebral rotation is important clinically. Clinically as apical lumbar vertebral rotation in excess of 33% has been shown to be associated with an increased incidence of low back pain. However, there needs to be research to evaluate stress and increased risk of injury and degeneration to facet joints as well as intervertebral discs with various degrees of rotation over time. This study also discusses increased rates of cancer associated with Adolescent Idiopathic Scoliosis. They attribute this to X-ray utilization without accounting for variables like medications use in surgery at a young age, potential genetic factors, decreased exercise compared to controls. There are too many variables, including a small sample size in comparison to the entire populous, that are not accounted for to confidently conclude the increased rate of cancer to low dose radiation utilization.
Imaging strategies for low-back pain: systematic review and meta-analysisLancet. 2009 Feb 7;373(9662):463-72. doi: 10.1016/S0140-6736(09)60172-0.
Chou R1, Fu R, Carrino JA, Deyo RA.
Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.Many clinicians do routine low back pain x-rays without "Red flags". Research fails to discuss tha physical presentation of no pain does not equal to no need for xrays and the need for x-rays for chiropractic technique analysis.

***Additionally, the term "Usual Care" is used as the comparison standard. Defined as care given through and MD, with or without bed rest and exercise.
Imaging studies in patients with spinal pain: Practice audit evaluation of Choosing Wisely Canada recommendations.Can Fam Physician. 2016 Mar;62(3):e129-37.
Ferrari R.
In the evaluation of nonspecific spinal pain and symptoms, setting and following an a priori threshold for ordering MRI, CT, or bone scans in the spirit of the current Choosing Wisely Canada recommendations has a very low risk of missing a case of a serious cause of back pain.
Imaging the back pain patient.Phys Med Rehabil Clin N Am. 2010 Nov;21(4):725-66. doi: 10.1016/j.pmr.2010.07.004.

Maus T1.
Only when an imaging finding is concordant with the patient's pain pattern or neurologic deficit can causation be considered. The zygapophysial (facet) and sacroiliac joint are thought to be responsible for axial back pain, although with less frequency than the disc. Imaging findings of the structural changes of osteoarthritis do not correlate with pain production. Physiologic imaging, either with single-photon emission CT bone scan, heavily T2-weighted MRI sequences (short-tau inversion recovery), or gadolinium enhancement, can detect inflammation and are more predictive of an axial pain generator
Immediate effects of real-time postural biofeedback on spinal posture, muscle activity, and perceived pain severity in adults with neck pain.Kuo YL1, Wang PS2, Ko PY3, Huang KY4, Tsai YJ5.Gait Posture. 2019 Jan;67:187-193. doi: 10.1016/j.gaitpost.2018.10.021. Epub 2018 Oct 15.Compared with the non-biofeedback condition, the biofeedback condition significantly decreased neck flexion, upper cervical, and lower thoracic angles and lowered the activity of the cervical erector spinae. Self-reported neck pain was not influenced by the application of biofeedback, but significantly increased over the 1-hour typing task.
Impact of dynamic alignment, motion, and center of rotation on myelopathy grade and regional disability in cervical spondylotic myelopathy.J Neurosurg Spine. 2015 Dec;23(6):690-700. doi: 10.3171/2015.2.SPINE14414. Epub 2015 Aug 28.

Liu S1, Lafage R1, Smith JS2, Protopsaltis TS1, Lafage VC1, Challier V1, Shaffrey CI2, Radcliff K3, Arnold PM4, Chapman JR5, Schwab FJ1, Massicotte EM6, Yoon ST7, Fehlings MG6, Ames CP8.
Dynamic motion analysis may play an important role in understanding CSM. Focal parameters demonstrated a significant correlation with worse HRQOL measures, especially increased C-7 sagittal slip in flexion and extension. Novel methods of motion analysis demonstrating reduced motion cones correlated with worse myelopathy grades. More posterior COR and smaller range of motion were both correlated with worse general health scores (SF-36 PCS and Nurick grade). To our knowledge, this is the first study to demonstrate correlation of dynamic motion and listhesis with disability and myelopathy in CSM.
Impact of imaging guidelines on X-ray use among American provider network chiropractors: interrupted time series analysis. (assess for clinical outcome differences, biases in research such as backed by insurance company, number of visits/cost between two groups, patient understanding of injury)Spine J. 2014 Aug 1;14(8):1501-9. doi: 10.1016/j.spinee.2013.08.051. Epub 2013 Oct 4.
Bussières AE1, Sales AE2, Ramsay T3, Hilles SM4, Grimshaw JM5.
Web-based guideline dissemination was associated with an immediate reduction in spine X-ray imaging claims. Sensitivity analysis suggests our results are robust. This passive strategy is likely cost-effective in a chiropractic network setting.Bussières is a chiropractor : no x-ray should be taken if not absolutely necessary
Impact of postural deformities and spinal mobility on quality of life in postmenopausal osteoporosisMiyakoshi N1, Itoi E, Kobayashi M, Kodama H.;Osteoporos Int. 2003 Dec;14(12):1007-12. Epub 2003 Oct 14.We concluded that QOL in patients with osteoporosis was impaired by postural deformities, especially by whole kyphosis, and that spinal mobility has a strong effect on QOL in these patients.this study relates the postural deformities with osteoporosis. This is a great study to for our task force
Implications of spinopelvic alignment for the spine surgeonNeurosurgery. 2012 Mar;70(3):707-21. doi: 10.1227/NEU.0b013e31823262ea.
Mehta VA1, Amin A, Omeis I, Gokaslan ZL, Gottfried ON.

Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery.
Implications of spinopelvic alignment for the spine surgeon.Neurosurgery. 2012 Mar;70(3):707-21. doi: 10.1227/NEU.0b013e31823262ea.

Mehta VA1, Amin A, Omeis I, Gokaslan ZL, Gottfried ON.
Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance.Usng standing lateral full spine xrays to evaluate spinopelvic parameters including: Pelvic Tilt, Pelvic Incidence, Sacral Slope and others and there relationship to spinal health and patient outcomes in spinal surgery. Improving the parameters improved patient outcomes in spinal surgery.
Importance of Sagittal Alignment of the Cervical Spine in the Management of Degenerative Cervical Myelopathy.Neurosurg Clin N Am. 2018 Jan;29(1):69-82. doi: 10.1016/
Buell TJ1, Buchholz AL2, Quinn JC2, Shaffrey CI2, Smith JS2.
Cervical spine sagittal malalignment correlates with worse symptoms and outcomes in patients with degenerative cervical myelopathy (DCM), and should influence surgical management. An anterior versus posterior surgical approach may not significantly change outcomes in patients with preoperative lordosis; however, most studies suggest improved neurologic recovery among kyphotic patients after adequate correction of local sagittal alignment through an anterior or combined anterior-posterior approach. There are no comprehensive guidelines for DCM management in the setting of cervical malalignment; therefore, surgical management should be tailored to individual patients and decisions made at the discretion of treating surgeons with attention to basic principles.
Improvement of Cervical Lordosis and Reduction of Forward Head Posture with Anterior Head Weighting and Proprioceptive Balancing ProtocolsSaunders, E. & Woggon, Dennis & Cohen, Christian & Robinson, David.
(2003) J Vertebral Subluxation Res. 4.
Head weighting may prove to be a useful therapeutic tool in addressing FHP and the concurrent loss of the normal cervical lordosis.Restoration of the cervical lordosis will help with balance issues.
Current Evidence for Spinal X-ray use in the chiropractic profession: A Narrative ReviewChiropr Man Therap. 2018 Nov 21;26:48. doi: 10.1186/s12998-018-0217-8. eCollection 2018.
Jenkins HJ1, Downie AS1, Moore CS2, French SD1,3.
There is strong evidence indicating very little benefit from routine lumbar spine x-rays for all LBP. The GSTG needs to be revised considering the increased risks of radiation exposure and the x-ray costs.In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
Incidence of Foot Rotation, Pelvic Crest Unleveling, and Supine Leg Length Aligment Asymmetry and Their Relationship to Self-Reported Back PainJ Manipulative Physiol Ther. 2002 Feb;25(2):110E.
Knutson GA1.
In evaluating patients with back pain, deviations of posture have long been suspect as an indicator of possible dysfunction.1-4 Postural deviation includes the findings of pelvic unleveling, foot rotation, and leg length inequality (LLI).1,5 LLI is believed to be divided into 2 groups: anisomelia, or actual anatomic asymmetry as a result of injury, disease, or developmental error; and physiologic or functional LLI, which may be the result of hypertonicity in suprapelvic and pelvic muscles causing pelvic torsion in an unloaded condition.6-10 The physiologic/functional LLI is not actually a shortening of leg length, and is best described as leg length alignment asymmetry (LLA).Research shows that supine leg checks can be related to recurring back pain
Increased forward head posture and restricted cervical range of motion in patients with carpal tunnel syndromeDe-la-Llave-Rincón AI1, Fernández-de-las-Peñas C, Palacios-Ceña D, Cleland JA. J Orthop Sports Phys Ther. 2009 Sep;39(9):658-64. doi: 10.2519/jospt.2009.3058.Patients with mild/moderate CTS exhibited a greater FHP and less cervical range of motion, as compared to healthy controls. Additionally, a greater FHP was associated with a reduction in cervical range of motion. However, a cause-and-effect relationship cannot be inferred from this study. Future research should investigate if FHP and restricted cervical range of motion is a consequence or a causative factor of CTS and related symptoms (eg, pain).Quality study correlating forward head posture and decreased ROM with carpal tunnel syndrome (correlation not causation according to authors). No radiography used in this study only photography.
Increased Telomere Length and Improvements in Dysautonomia, Quality of Life, and Neck and Back Pain Following Correction of Sagittal Cervical Alignment Using Chiropractic BioPhysics® Technique: a Case StudyFedorchuk C*, Lightstone DF, McCoy M and Harrison DE; Journal of Molecular and Genetic Medicine. 11. 10.4172/1747-0862.1000269. Our case suggests that correction of cervical lordosis and forward head postures by CBP® Mirror Image® methods improved the sagittal spinal alignment and posture and was temporally associated with lengthened telomeres, improved nocturnal polyuria, neck and mid-back pain, quality of life, and autonomic nervous system adaptability.Shows the ability to correct hypolordotic situations of the spine using CBP and therapy exercises based on xray findings and analysis. Also showed a connection between telomere length changes as well as HRV changes that were measured pre and post chiropractic management.
Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial.J Manipulative Physiol Ther. 2003 Mar-Apr;26(3):139-51. doi: 10.1016/S0161-4754(02)54106-3.
Harrison DE1, Harrison DD, Betz JJ, Janik TJ, Holland B, Colloca CJ, Haas JW.
Neck pain is becoming increasingly prevalent in today’s society. In a recent 10-year follow-up of 200 asymptomatic subjects, Gore reported an incidence of 15% for the development of neck pain. Neck pain has multiple causes including tumor, infection, trauma, spinal degeneration, and mechanical factors. Concerning mechanical factors, the configuration of the sagittal cervical curve has been shown to be an important clinical outcome of health care, especially in cervical postsurgical outcomes. Besides neck pain, loss of cervical lordosis and/or cervical kyphosis has been found to be a factor or cause of tension and migraine headaches.6-8 Intuitively, the relationship between neck pain symptoms and loss…Cervical traction set up helps patients with chronic neck pain with restoration of cervical lordosis
Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial.Harrison DE1, Harrison DD, Betz JJ, Janik TJ, Holland B, Colloca CJ, Haas JW; Journal of Manipulative and Physiological TherapeuticsChiropractic biophysics (CBP) technique's extension-compression 2-way cervical traction combined with spinal manipulation decreased chronic neck pain intensity and improved cervical lordosis in 38 visits over 14.6 weeks, as indicated by increases in segmental and global cervical alignment. Anterior head weight-bearing was reduced by 11 mm; Cobb angles averaged an increase of 13 degrees to 14 degrees; and the angle of intersection of posterior tangents on C2 and C7 averaged 17.9 degrees of improvement.Loss of cervical lordosis has been shown to increase neck pain as well as other committant symptomatology. This presentation is a condition seen regularly in most chiropractic settings. After the analyzation of lateral cervical x-rays in reference to the degree of loss of cervical lordosis and a pre-treatment visual analog pain scale, a 2-way cervical traction procedure with concurrent chiropractic adjustments were implemented. Post-treatment analyzation, which included lateral cervical films and VAS, showed significant improvement in not only lordosis, but pain as well. The significance of the return of lordosis, which can only be quantified via x-ray is imperative to understanding the role proper mechanics relates to pain in the cervical spine.
Influence of T1 Slope on the Cervical Sagittal Balance in Degenerative Cervical Spine: An Analysis Using Kinematic MRI.Spine (Phila Pa 1976). 2016 Feb;41(3):185-90. doi: 10.1097/BRS.0000000000001353.
Weng C1, Wang J, Tuchman A, Wang J, Fu C, Hsieh PC, Buser Z, Wang JC.
An individual with a large T1 slope required large cervical lordosis to preserve physiologic sagittal balance of the cervical spine. Cranial tilt was the cervical parameter most strongly correlated with SVA C2-C7, and thus may be a good parameter to assess decompensation of cervical sagittal balance
Influence of the Occipital
Orientation on Cervical Sagittal
Alignment: A Prospective
Radiographic Study on 335 Normal
Weiguo Zhu, Shifu Sha, Zhen Liu, Yang Li, Leilei Xu, Wen Zhang, Yong Qiu & Zezhang Zhu SCieNTifiC Reports | (2018) 8:15336 | DOI:10.1038/s41598-018-33287-0This study demonstrates the key importance of the occipital orientation in the evaluation of the cervical sagittal alignment.The novel measure, occipital incidence (OI) is considered an anatomic morphology parameter "with no differences between ages and genders." Upper cervical sagittal alignment is mainly compensated by occipital orientation. Lower cervical sagittal is mainly compensated by occipital and thoracic alignments.
Informed appropriate imaging for low back pain management: A narrative review.J Orthop Translat. 2018 Aug 27;15:21-34. doi: 10.1016/ eCollection 2018 Oct.

Wáng YXJ1, Wu AM2, Ruiz Santiago F3, Nogueira-Barbosa MH4.
Diagnostic imaging studies should be performed only in patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition. Radiologists can play a critical role in decision support related to appropriateness of imaging requests, and accurately reporting the potential clinical significance or insignificance of imaging findings.The "6 weeks of conservative care" before imaging is based on PT and Medical Management. Many of the articles cited are discussing the same type of care when coming to the conclusion that there is no significant difference between patients with LBP who do and do not recieve imaging.
Integrative Treatment Using Chiropractic & Conventional Techniques for Adolescent Idiopathic ScoliosisMark Morningstar, D.C. J. Vertebral Subluxation Res. July 9, 2007Using this combined treatment for 90 days, the patients outlined here were able to achieve positive benefits in radiographic, functional, and physiological outcome measures. Limited conclusions can be made due to the study design, however. All patients will be monitored for moderate and long-term assessments.Bracing can help with functional, structural and physiolgical changes in teens with scolosis
Inter and Intra-Examiner reliability of the Upper Cervical X-Ray Marking System: A Third and Expanded LookRochester, RP. Chiropr Res J. 1994; 3(1):23-31The paper concludes measured factors have a very good and acceptable degree of reliability. (See 349)Four Orthopinology practitioner analyzed 10 sets of upper cervical film, consisting of 3 views (30 fils total). The authors concluded that reliability for atlas laterality, odontoid, C2 spinous and lower angle and hight factor measurements are very good. Reliability estimates ranged from 0.83-0.93 for atlas laterality, 0.84-0.96 for odontois, 0.89-0.96 for C2 spinous, and 0.86-0.96 for lower angle. Roatation estimates were worse, at 0.54 to 0.68. This was attributed to possible differences between the computer algorithm and manual processes.
Inter- and Intra-Examiner Reliability of the Upper Cervical X-Ray Marking SystemSigler DC, Howe JW J Manipulative Physiol Ther, 1985; 9(2):75-80The concluded changes seen using this measurement system are just as likely to be from marking error instead of actual relative atlas position changeThe authors study involved twenty x-rays marked by "three experienced upper cervical practitioners." The authors reported that if 80% agreement is acceptable, the range of error is 2.0 degrees, claiming that there is an inability to reproduce measurements. Furthermore, the authors state that measured differences are as likely due to marker error as change in atlas position. However, examination of Pearson ICCs resulted in figures ranging from .70 to .91. This paper has been critcized by other authors, and replicated, infra.  
Inter- and Intra-Examiner Reliabilty of the Upper Cervical X-ray Marking System: A Second LookJackson BL, Barker W, Bentz J, Gambale AG J Manipulative Physiol Ther, 1987;10(4):157-163.The conclude the reliability is at an acceptable level (contradicting Sigler and Howe). (See349Six Pettibon practitioners analyzed 30 x-rays. Reliability estimates ranged from 0.93 to 0.98. This suggests excellent reliability. Differences in examiner proficiency and consistency of analytical procedures may account for the diffent finding, which contradict Sigler and Howe. It is difficult to generalize the results of reliability studies beyond the examiners involved. This is because spinographic analysis is skill-dependent.
Inter- and intra-rater agreement of static posture analysis using a mobile applicationJ Phys Ther Sci. 2016;28(12):3398-3402
David M. Boland, DPT,1 Eric V. Neufeld, BS,1 Jack Ruddell, BS,1 Brett A. Dolezal, PhD,1,* and Christopher B. Cooper, MD1
To determine the intra- and inter-rater agreement of a mobile application, PostureScreen Mobile® (PSM), that assesses static standing posture. [Subjects and Methods] Three examiners with different levels of experience of assessing posture, one licensed physical therapist and two untrained undergraduate students, performed repeated postural assessments of 10 subjects, fully clothed or minimally clothed, using PSM on two nonconsecutive days. Anterior and right lateral images were captured and seventeen landmarks were identified on them. Intraclass correlation coefficients (ICCs) were calculated for each of 13 postural measures to evaluate inter-rater agreement on the first visit (fully or minimally clothed), as well as intra-rater agreement between the first and second visits (minimally clothed). [Results] Eleven postural measures were ultimately analyzed for inter- and intra-rater agreement. Inter-rater agreement was almost perfect (ICC≥0.81) for four measures and substantial (0.60 ICCs greater than 0.60 but less than or equal to 0.80 (0.60) but less than or equal to 0.80 (0.60
Interventional therapies for chronic low back pain(lack of posture and chiropractic which can be alleviated by posture/chiropractic understanding, hence the need for chiropractic standardization in xray analysis)Neuromodulation. 2014 Oct;17 Suppl 2:31-45. doi: 10.1111/ner.12250.
Veizi E1, Hayek S
Implementation of interventional pain procedures in the treatment framework of LBP has resulted in improvement of pain intensity in at least the short and medium terms, but equivocal results have been observed in functional improvement.This article is mostly about interventional therapies... namely various types of inections, dry needlings, and epidurals. Most of the therapies are short term relief, and do not offer long term solutions to CLBP
Is immediate imaging important in managing low back pain?J Athl Train. 2011 Jan-Feb;46(1):99-102. doi: 10.4085/1062-6050-46.1.99.
Andersen JC1.
Available evidence indicates that immediate, routine lumbar spine imaging in patients with LBP and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging. Clinical care without immediate imaging seems to result in no increased odds of failure in identifying serious underlying conditions in patients without risk factors for these conditions. In addition to lacking clinical benefit, routine lumbar imaging is associated with radiation exposure (radiography and CT) and increased direct expenses for patients and may lead to unnecessary procedures. This evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in primary care patients with nonspecific, acute or subacute LBP and no indications of underlying serious conditions. Specific consideration of patient expectations about the value of imaging was not addressed here; however, this aspect must be considered to avoid unnecessary imaging while also meeting patient expectations and increasing patient satisfaction.***Duplicate of #25
Is There a Gender-Specific Full Body Sagittal Profile for Different Spinopelvic Relationships? A Study on Propensity-Matched CohortsSpine Deform. 2016 Mar;4(2):104-111. doi: 10.1016/j.jspd.2015.08.004. Epub 2016 Feb 2.
Vira S1, Diebo BG1, Spiegel MA1, Liabaud B1, Henry JK1, Oren JH1, Lafage R1, Tanzi EM1, Protopsaltis TS1, Errico TJ1, Schwab FJ1, Lafage V2.
With progressive sagittal malalignment, men recruit more knee flexion and women recruit more pelvic tilt and hip extension. Knee flexion is a possible mechanism to gain pelvic tilt for females whereas for males, knee flexion is an independent compensatory mechanism.
Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review.Cho J1, Lee E1, Lee S2. BMC Musculoskelet Disord. 2017 Dec 12;18(1):525. doi: 10.1186/s12891-017-1889-2.Ten studies were included. Four studies were rated as low risk of bias, three at moderate risk of bias and three at high risk of bias. There is a moderate level of evidence of no significant difference in thoracic kyphosis between groups with and without shoulder pain. One study at high risk of bias demonstrated significantly greater thoracic kyphosis in people with shoulder pain (p
Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review.Barrett E1, O'Keeffe M2, O'Sullivan K3, Lewis J4, McCreesh K5.Man Ther. 2016 Dec;26:38-46. doi: 10.1016/j.math.2016.07.008. Epub 2016 Jul 21.Thoracic kyphosis may not be an important contributor to the development of shoulder pain. While there is evidence that reducing thoracic kyphosis facilitates greater shoulder ROM, this is based on single-session studies whose long-term clinical relevance is unclear. Higher quality research is warranted to fully explore the role of thoracic posture in shoulder pain.
It Is Time to Move Beyond the Linear No-Threshold Theory for Low-Dose Radiation Protection.Cardarelli JJ 2nd, Ulsh BA.; ,Dose Response. 2018 Jul-Sep; 16(3): 1559325818779651.
Published online 2018 Jul 1. doi: 10.1177/1559325818779651
Currently, the USEPA uses the linear no-threshold (LNT) model to estimate cancer risks and determine cleanup levels in radiologically contaminated environments. The LNT model implies that there is no safe dose of ionizing radiation; however, adverse effects from low dose, low-dose rate (LDDR) exposures are not detectable. This article (1) provides the scientific basis for discontinuing use of the LNT model in LDDR radiation environments, (2) shows that there is no scientific consensus for using the LNT model, (3) identifies USEPA reliance on outdated scientific information, and (4) identifies regulatory reliance on incomplete evaluations of recent data contradicting the LNT.Linear nothreshold modèle (LNT) should not be used anymore to determine health risks because it creates a society fearful of radiations and carcinogenicity of low radiation doses like thoses associated with medical imaging examinations has not been demonstrated .
Kinematic analysis of diseased and adjacent segments in degenerative lumbar spondylolisthesis.Spine J. 2015 Feb 1;15(2):230-7. doi: 10.1016/j.spinee.2014.08.453. Epub 2014 Sep 8.
Phan KH1, Daubs MD2, Kupperman AI2, Scott TP2, Wang JC2.
There were a similar percentage of patients in each degenerative spondylolisthesis group with lumbar instability. Angular motion decreased at the diseased level with L3-L4 and L5-S1 spondylolisthesis, but increased with L4-L5 spondylolisthesis. Translational motion, however, increased at the diseased level in all three groups. There was compensatory hypermobility at adjacent levels in patients with unstable spondylolisthesis at L3-L4 and L4-L5, but not at L5-S1.
Kinematic analysis of the relationship between sagittal alignment and disc degeneration in the cervical spine.Spine (Phila Pa 1976). 2008 Nov 1;33(23):E870-6. doi: 10.1097/BRS.0b013e3181839733.
Miyazaki M1, Hymanson HJ, Morishita Y, He W, Zhang H, Wu G, Kong MH, Tsumura H, Wang JC.
The present study demonstrated that the changes in sagittal alignment of the cervical spine affect the kinematics. Consequently, it may cause changes in the segment subjected to maximum load for overall motion and accelerate its degeneration.
Kinematic evaluation of cervical sagittal balance and thoracic inlet alignment in degenerative cervical spondylolisthesis using kinematic magnetic resonance imaging.Spine J. 2017 Sep;17(9):1272-1284. doi: 10.1016/j.spinee.2017.04.026. Epub 2017 Apr 26.
Paholpak P1, Nazareth A2, Hsieh PC3, Buser Z4, Wang JC2.
In our study, T1 slope was larger in grade 2 DCS, and the retrolisthesis group had larger T1 slope than the anterolisthesis group. Presence of larger T1 slope was significantly correlated with larger cervical lordosis curvature. Furthermore, cranial tilt was strongly correlated with SVA C2-C7.
Kinetic magnetic resonance imaging analysis of lumbar segmental mobility in patients without significant spondylosis.Eur Spine J. 2012 Dec; 21(12): 2673–2679.
Published online 2012 Jun 7. doi: 10.1007/s00586-012-2387-8

Yanlin Tan,1 Bayan G. Aghdasi,2 Scott R. Montgomery,corresponding author2 Hirokazu Inoue,2 Chang Lu,1 and Jeffrey C. Wang2
In the current study, we evaluated lumbar segmental mobility in patients without significant degenerative disc disease and found that translational motion was greatest in the proximal lumbar levels whereas angular motion was similar in the mid-lumbar levels but decreased at L1-L2 and L5-S1.o The aim of this study was to develop a set of normal ranges concerning segmental lumbar mobility in order to monitor and minimize the natural degeneration that occurs with aging. The topic of utilizing this technology to anticipate the effects that lumbar spinal fusion has on adjacent, unfused segments was also discussed.
Kinetic magnetic resonance imaging analysis of spinal degeneration: a systematic review.Orthop Surg. 2014 Nov;6(4):294-9. doi: 10.1111/os.12137.
Lao LF1, Zhong GB, Li QY, Liu ZD.
Eleven articles (4162 patients) fulfilled the inclusion criteria and were reviewed. It was found that kMRI is more specific and sensitive than conventional MRI regarding relating patients' symptoms to objective findings on imaging that demonstrate pathology and biomechanics. In the kinetic position, kMRI improves detection of disc herniation by 5.78%-19.46% and thus provides a new means of studying the biomechanical mechanism(s) in degenerative spines.o This review focuses on the relevance of functional, weight bearing imaging (kMRI – Kinetic MRI), how it relates to patient outcomes and how it improves the accuracy of a patient’s diagnosis. By evaluating patients in stressed positions (flexion/extension) we can observe spinal joint biomechanics through coupled motion, possibly providing Chiropractors with a means to quantify and measure the effect of treatment from a functional movement standpoint.
Line drawing analyses of static cervical X ray used in chiropractic.J Manipulative Physiol Ther. 1992 Sep;15(7):442-9.
Owens EF Jr1.
Reliability studies exist showing that inter- and intraexaminer reliability are sufficient to measure lateral and rotational displacements of C1 to within +/- 1 degree. This amount of error allows objective analysis of upper cervical X rays to detect changes in the angular positional relationships of radiographic images on the order of those already seen clinically. Methods of cervical analysis that use relative angular measures of skeletal positioning are best able to control the effects of radiographic distortion. The accuracy of the analysis methods has not been ascertained to establish the extent to which angular measurement of vertebral relationships actually reflect three-dimensional movement. It is not known how much of the changes that are seen in pre/post-radiograph sets are due to positioning changes of the patient between radiographic procedure, and how much are due to actual changes of skeletal relationships brought about by adjustment.
Line Drawing Analyses of Static Cervical X-ray Used in Chiropractic.Owens EF. J Manipulative Physiol Ther, 1992; 15(7):442-4491992 Owens publishes a paper that agrees with Jackson’s findings that cervical x-ray analysis could be reliably performed. (See 351)Owen's paper differs from the preceding papers in that it is a review of literature, not an experimental study. A literature search resulted in a list of 15 different x-ray analysis techniques. Owens stated that for an x-ray analysis method to be useful, it must be able to resolve vertebral positions to the nearest 2 degrees; an accuracy of +/- 1 degree would detect most, but not all of the misalignments found in initial examinations of patients.
Longitudinal profiles of back pain across adulthood and their relationship with childhood factors: evidence from the 1946 British birth cohort. (Discuss posture in relation to level arms with taller heights in children with poor posture. Sci Rep. 2018; 8: 16309.
Published online 2018 Nov 5. doi: 10.1038/s41598-018-34628-9

Stella G. Muthuri,corresponding author1 Anastasia V. Pavlova,2 Fiona R. Saunders,2 Rebecca J. Hardy,1 Jennifer S. Gregory,2 Rebecca J. Barr,2,3 Kathryn R. Martin,2 Judith E. Adams,4 Diana Kuh,1 Richard M. Aspden,2 and Rachel Cooper1
These findings suggest that there are different long-term profiles of back pain, each of which is associated with different early life risk factors. This highlights the potential importance of early life interventions for the prevention and management of back pain.Importance of early intervention in early life to prevent back pain later in life.
Low doses of very low-dose-rate low-LET radiation suppress radiation-induced neoplastic transformation in vitro and induce an adaptive response.
Radiat Res. 2008 Mar;169(3):311-8. doi: 10.1667/RR1199.1.
Elmore E1, Lao XY, Kapadia R, Giedzinski E, Limoli C, Redpath JL.
It is concluded that doses of less than 100 mGy delivered at very low dose rates in the range 1 to 4 mGy/day can induce an adaptive response against neoplastic transformation in vitro. When the dose rate drops below approximately 1 mGy/day, this suppression is apparently lost, suggesting a possible dose-rate-dependent threshold for this process.
Low-dose radiation risk extrapolation fallacy associated with the linear-no-threshold model.Hum Exp Toxicol. 2008 Feb;27(2):163-8. doi: 10.1177/0960327107083410.
Scott BR1.
Here, indirect evidence is provided that the excess cancer risk calculated at very low doses of low-LET radiation (e.g., around 1 mGy), based on extrapolating from high dose data for an irradiated human population using the LNT model, is likely a phantom excess risk. Indirect evidence is provided, suggesting that for brief exposures to low-LET radiation doses on the order of 1 mGy, that a decrease below the spontaneous level is many orders of magnitude more probable than for any increase in risk as would be predicted by extrapolating from high to low doses using the LNT model.
Lumbar coupling during lateral translations of the thoracic cage relative to a fixed pelvis.Clin Biomech (Bristol, Avon). 1999 Dec;14(10):704-9.

Harrison DE1, Cailliet R, Harrison DD, Janik TJ, Troyanovich SJ, Coleman RR.
The clinically common posture of lateral translation of the thoracic cage (lumbosacral list) is often associated with disc herniation. Yet normal lumbar coupling patterns and total range of motion of this movement have not been established in the literature. Normal values for lumbar segmental coupling on anterior-posterior lumbo-pelvic radiographs during trunk list might be important for an analysis of segmental instability since segmental translations were determined to be 1 mm or less.Establishing a standard for lumbar coupled motion during thoracic translation using digitized xrays for analysis.
Lumbar diskogenic pain, provocation diskography, and imaging correlates.Radiol Clin North Am. 2012 Jul;50(4):681-704. doi: 10.1016/j.rcl.2012.04.013.
Maus TP1, Aprill CN.
This article reviews diskogenic pain, the history of provocation diskography, and its current use in the diagnosis of lumbar diskogenic pain. The extensive literature describing imaging features which may predict a positive diskogram, and allow non-invasive diagnosis of diskogenic pain, is examined.
Lumbar Lordosis Minus Thoracic Kyphosis: A Novel Regional Predictor for Sagittal Balance in Elderly PopulationsSpine (Phila Pa 1976). 2016 Mar;41(5):399-403. doi: 10.1097/BRS.0000000000001231.
Yang C1, Yang M, Wei X, Shao J, Chen Y, Zhao J, Zhu X, He D, Li M.
LL-TK was a good regional predictor for sagittal balance in elderly population, especially combined with PI-LL.
Lumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical low back pain: a randomized trial.J Manipulative Physiol Ther. 2012 May;35(4):246-53. doi: 10.1016/j.jmpt.2012.04.021.
Diab AA1, Moustafa IM.
Lumbar extension traction with stretching exercises and infrared radiation was superior to stretching exercises and infrared radiation alone for improving the sagittal lumbar curve, pain, and intervertebral movement in CMLBP.
Lumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical low back pain: a randomized trial.Moustafa IM, Diab AA. J Manipulative Physiol Ther. 2012 May;35(4):246-53. doi: 10.1016/j.jmpt.2012.04.021.Lumbar extension traction with stretching exercises and infrared radiation was superior to stretching exercises and infrared radiation alone for improving the sagittal lumbar curve, pain, and intervertebral movement in CMLBP.
Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based?Ghana Med J. 2017 Mar;51(1):24-29.
Tannor AY1.
There is strong evidence indicating very little benefit from routine lumbar spine x-rays for all LBP. The GSTG needs to be revised considering the increased risks of radiation exposure and the x-ray costs.The article is a brief comparison of 4 different guidelines established by different medical groups. A wide net search was cast through multiple databases, most reputable, and Google was included as well. Although the exclusion criteria were not elaborated, the 4 guidelines selected served the purposes of the author(s). It is worth noting, however, that some of the guidelines are informed by studies that have small populations, but those populations were followed up within 1 year or more frequently in other cases. Other guidelines were informed by more robust studies.

***Intervention was based on "Usual Care" (NSAIDS, Muscle Relaxers, Pain Killers, Rest, Exercis)
Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back painSpine (Phila Pa 1976). 2000 Mar 1;25(5):575-86.
Jackson RP1, Kanemura T, Kawakami N, Hales C.
The pelvic radius technique is recommended for evaluating lordosis to the pelvis because this approach provided not only good measurement reliability on standing radiographs for lumbopelvic lordosis, but also determination of pelvic balance over the hips and the option to assess pelvic morphology quantitatively. Lumbopelvic lordosis and pelvic balance were strongly correlative. This finding, along with higher reliability and lower longitudinal variation on repeated radiographs, indicated greater clinical application for these specific measurements.
Lumbosacral spine imaging: physioanatomic method.Curr Probl Diagn Radiol. 1992 Sep-Oct;21(5):151-213.
Luers PR1.
In a minority of patients the findings on noninvasive imaging either will not correlate with the patient's symptoms or will demonstrate multiple abnormalities that could account for the patient's symptoms. In these patients, invasive techniques are extremely helpful in defining a pain generator or pain generators.(ABSTRACT TRUNCATED AT 400 WORDS).
Magnitude of preoperative cervical lordotic compensation and C2-T3 angle are correlated to increased risk of postoperative sagittal spinal pelvic malalignment in adult thoracolumbar deformity patients at 2-year follow-up.Spine J. 2015 Aug 1;15(8):1756-63. doi: 10.1016/j.spinee.2015.04.007. Epub 2015 Apr 8.
Passias PG1, Soroceanu A2, Scheer J3, Yang S4, Boniello A4, Smith JS5, Protopsaltis T4, Kim HJ6, Schwab F4, Gupta M7, Klineberg E7, Mundis G8, Lafage R4, Hart R9, Shaffrey C3, Lafage V4, Ames C10; International Spine Study Group.
Patients with sagittal spinal malalignment associated with significant cervical compensatory lordosis are at increased risk of realignment failure at 2-year follow-up. Assessment of the degree of cervical compensation may be helpful in preop evaluation to assist in realignment outcome prediction.
Management of a chronic lumbar disk herniation with chiropractic biophysics methods after failed chiropractic manipulative intervention.J Manipulative Physiol Ther. 2004 Nov-Dec;27(9):579.
Paulk GP1, Harrison DE.
This article suggests that successful management of chronic low-back pain symptoms may require a close analysis of a patient's postural deviations and sagittal plane curves. This study suggests that it is possible to restore lumbar lordosis in some cases and this may have an unforeseen benefit to the patient. Further study is warranted into the treatment of chronic low-back pain with chiropractic biophysics methods.Chronic low back pain can have many etiologies and proper diagnosis using diagnostic x-rays is key to understanding the specific cause of the patient’s symptomatology. Postural abnormalities and reduction in lumbar lordosis plays a particular role in the load placed upon discs which leads to pain and deterioration over time. Restoring lumbar lordosis, reducing he load on disc tissue and improving proper motion and movement in the lumbar spine through chiropractic care and prescribed exercises can be obtained. This approach has been shown to significantly improved and/or eliminated symptomology.
Measurement of Occipitocervical AngleSpine (Phila Pa 1976). 2004 May 15;29(10):E204-8.
Shoda N1, Takeshita K, Seichi A, Akune T, Nakajima S, Anamizu Y, Miyashita M, Nakamura K.

The McGregor line is the most reproducible and reliable method for measurement of the occipitocervical angle.
Measurement Variability in the Assessment of Sagittal Alignment of the Cervical SpineSilber JS1, Lipetz JS, Hayes VM, Lonner BS.
J Spinal Disord Tech. 2004 Aug;17(4):301-5.

Measurements of cervical spine sagittal alignment by the Gore method are more reproducible than by the Cobb method.
Measurements of lumbopelvic lordosis using the pelvic radius technique as it correlates with sagittal spinal balance and sacral translation.Spine J. 2002 Nov-Dec;2(6):421-9.

Gardocki RJ1, Watkins RG, Williams LA.
Sacral translation, the C7 plumb line and lumbopelvic lordosis are useful measures for sagittal spinal balance. Lumbopelvic lordosis and sacral translation can be correlated to the sagittal spinal balance. Understanding these measurements and the range of lumbopelvic compensation can be extremely helpful in treating patients with spinal pathology and in avoidance of flatback deformity. Application of these measures would be especially helpful in the treatment of patients with spinal fusion, degenerative spondylosis, disc disease, fractures, and in the prevention of sagittal malalignment.xray analysis of lateral standing postures in a neutral and translated postures to better understand the compensatory movements of the spine.
Methodological quality and outcomes of studies addressing manual cervical spine examinations: A review
Dieter Hollerwöger
Manual Therapy
May 2006 (Vol. 11, Issue 2, Pages 93-98)
The studies demonstrated methodological strength in describing selection criteria and in interpreting results. The studies' outcomes make the claim to be able to detect segmental cervical dysfunction based on a manual assessment only questionable. Further improvements in quality, uniform study designs, and a valid reference standard would be necessary in order to obtain more reliable data in the future.Different examiners utilize different techniques to evaluate segmental dis function. Detecting segmental disfunction manually alone is questionable.
Modeling of the sagittal cervical spine as a
method to discriminate hypolordosis: results of elliptical and
circular modeling in 72 asymptomatic subjects, 52 acute neck
pain subjects, and 70 chronic neck pain subjects.
Harrison DD, Harrison DE, Janik TJ, Cailliet R, Ferrantelli
JR, Haas JW, et al.
Spine 2004; 29:2485-92.
In the normal group, a family of ellipses was found 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 degrees, 28.6 degrees, and 22.0 degrees, C2-C7 Cobb angles were 26.8 degrees, 16.5 degrees, and 12.7 degrees, and radius of curvature were r = 132.8 mm, r = 179 mm, and r = 245.4 mm, respectively.
Molecular biology, epidemiology, and the demise of the linear no-threshold (LNT) hypothesis.Pollycove M1, Feinendegen LE.; Comptes Rendus de I'Academie des sciences,C R Acad Sci III. 1999 Feb-Mar;322(2-3):197-204.The biologic effect of radiation is not determined by the number of mutations it creates, but by its effect on the biosystem that controls the relentless enormous burden of oxidative DNA damage. At low doses, radiation stimulates this biosystem with consequent significant decrease of metabolic mutations. Low-dose stimulation of the immune system may not only prevent cancer by increasing removal of premalignant or malignant cells with persistent DNA damage, but used in human radioimmunotherapy may also completely remove malignant tumors with metastases. The reduction of gene mutations in response to low-dose radiation provides a biological explanation of the statistically significant observations of mortality and cancer mortality risk decrements, and contradicts the biophysical concept of the basic mechanisms upon which, ultimately, the NCRPs confidence in the LNT hypothesis is based.2Q
“The argument that Low dose radiation can induce a genomic instability, which can in turn induce a cancer is not based on convincing data” No significant correlation between sensitivity to radiation-induced genomic instability and cancer induction. Doses of less than 100 mSv, cancer excess is not seen. However it doesn’t rule out the possibility of a smaller effect inducing cancer.
Atomic bomb data does not provide solid arguments for the LNT model. Among humans there is no carcinogenic effects for acute irradiation at doses less than 100mSv and for protracted Irradiation at doses less than 500mSv. Fears associated with LNT at any dose lack scientific justification. If the carcogenic risk exists, it is so small that it is without clinical importance.
Musculo-skeletal and pulmonary effects of sitting position - a systematic review.Szczygieł E1, Zielonka K1, Mętel S2, Golec J1.Ann Agric Environ Med. 2017 Mar 31;24(1):8-12. doi: 10.5604/12321966.1227647.Incorrect sitting posture contributes to many disorders, especially in the cervical and lumbar spine. It also determines the work of the respiratory system. Most authors suggest that maintenance of the physiological curvature of the spine is crucial for the biomechanics of the sitting position, as well as the location of the head and position of the pelvis. It raises awareness of work-related hazards and the introduction of education on the principles of proper seating. It is necessary to draw attention to the risks associated with work performed in a sitting posture, and education on the principles of ergonomical sitting.Slumping leads to decreased deep spinal muscles, serratus ant. and rhomboid. Trap and pec hypertension also noted. This increases strain on discs. It also decreases total tidal volume of lung. The outlined ergonomic recommendations reduce spinal stress lowering occupational risk.
National Emergency X-Radiography Utilisation Study Group.
Validity of a set of clinical criteria to rule out injury to the
cervical spine in patients with blunt trauma.
Hoffman JR, Mower WR, Wolfson AB, Tood KH, Zucker M,
N Engl J Med 2000;343:94-9
A simple decision instrument based on clinical criteria can help physicians to identify reliably the patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients.
Natural history of spinopelvic alignment differs from symptomatic deformity of the spineSpine (Phila Pa 1976). 2010 Jul 15;35(16):E792-8. doi: 10.1097/BRS.0b013e3181d35ca9.
Mendoza-Lattes S1, Ries Z, Gao Y, Weinstein SL.
First, Gradual increase in PI is described throughout the lifespan that is paralleled by an increase in SFD, and is not by an increase in the SS. This represents a morphologic change of the pelvis. Second, Patients with symptomatic deformity of the spine present an increased C7P, thoracic hypokyphosis, reduced LL, and signs of pelvic retroversion (decreased LL and SS; increased SFD)
NHP and natural head orientation: basic considerations in cephalometric analysis and researchEur J Orthod. 1995 Apr;17(2):111-20.
Lundström A1, Lundström F, Lebret LM, Moorrees CF.

A critical judgement of the recorded natural head position and correct head orientation can enhance the reliabilty of cephalometric analysis in clinical practice and research.
No evidence that CT scans, X-rays
cause cancer'
Catharine Paddock, Ph.D. on February 4, 2016. 'No evidence that CT scans, X-rays
cause cancer'.
Non-operative correction of flat back syndrome using lumbar extension traction: a CBP® case series of twoDeed E. Harrison1 and Paul A. Oakley; J Phys Ther Sci. 2018 Aug;30(8):1131-1137. doi: 10.1589/jpts.30.1131. Epub 2018 Aug 7.This is the first successful non-operative correction of flat back syndrome. This approach seems highly effective, is a fraction of the cost of spinal surgery typically used to treat this condition, and offers no health risks including those assumed from radiography necessary for screening and follow-up.This new procedure has been shown to improve posture, relieve chronic pain, and increase ADLs in people who would otherwise require surgery for correction. It prevents invasive surgery by allowing the body to correct itself. Lumbar extension traction necessitates x-rays to determine if a patient is eligible for the procedure and to evalute progress over time.
Non-surgical improvement of cervical lordosis is possible in advanced spinal osteoarthritis: a CBP® case reportJ Phys Ther Sci. 2018 Jan; 30(1): 108–112.
Published online 2018 Jan 27. doi: 10.1589/jpts.30.108

Miles O. Fortner,1 Paul A. Oakley,2,* and Deed E. Harrison3
Although degenerative spondylosis of the cervical spine will have physical limitations to non-surgical correction, this case serves as an example that it is possible to reduce degenerative kyphosis and increase global cervical lordosis corresponding to health improvements in these patients.
Non-surgical relief of cervical radiculopathy through reduction of forward head posture and restoration of cervical lordosis: A case report.Wickstrom BM, Oakley PA, Harrison DE. Non-surgical relief of cervical radiculopathy through reduction of forward head posture and restoration of cervical lordosis: A case report. Journal of Physical Therapy Science. 2017;29(8):1472-1474
Nonoperative management of cervical myelopathy: a systematic review (LACK OF POSTURAL CORRECTION?)Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S55-67. doi: 10.1097/BRS.0b013e3182a7f41d.

Rhee JM1, Shamji MF, Erwin WM, Bransford RJ, Yoon ST, Smith JS, Kim HJ, Ely CG, Dettori JR, Patel AA, Kalsi-Ryan S.
There is a paucity of evidence for nonoperative treatment of cervical myelopathy, and further studies are needed to determine its role more definitively. In particular, for the patient with milder degrees of myelopathy, randomized studies comparing nonoperative with surgical treatment would be particularly helpful, as would trials comparing specific types of nonoperative treatments with the natural history of myelopathy.
Nonsurgical correction of straight back syndrome (thoracic hypokyphosis), increased lung capacity and resolution of exertional dyspnea by thoracic hyperkyphosis mirror image® traction: a CBP® case report.Mitchell JR1, Oakley PA2, Harrison DE3.; J Phys Ther Sci. 2017 Nov;29(11):2058-2061. doi: 10.1589/jpts.29.2058. Epub 2017 Nov 24.This case illustrates that nonsurgical improvement in thoracic kyphosis in a patient with SBS is possible and that this may positively influence lung capacity, health and report focusing on correcting the straight spine syndrome and relifing pain and dyspnea with CBP protocol
Normal patterns of sagittal alignment of the spine in young adults radiological analysis in a Korean populationSpine (Phila Pa 1976). 2011 Dec 1;36(25):E1648-54. doi: 10.1097/BRS.0b013e318216b0fd.
Lee CS1, Chung SS, Kang KC, Park SJ, Shin SK.
The patterns of sagittal alignment could be classified into three types showing that the spinal balance becomes more negative, the lumbar inclination and TLJA increase, the SS and pelvic incidence decrease, and lumbar lordotic curves becomes shorter as the patterns of sagittal curvature move toward type 3. This classification in young adults should be considered individually as a reference for surgeons aiming to restore the lumbar lordosis and sagittal alignment in degenerative lumbar fusion surgery.
Normal variation in sagittal spinal alignment parameters in adult patients: an EOS study using serial imaging.Eur Spine J. 2018 Mar;27(3):578-584. doi: 10.1007/s00586-017-5459-y. Epub 2018 Jan 13.
Hey HWD1, Tan KLM2, Moorthy V3, Lau ET2, Lau LL2, Liu G2, Wong HK2.
Radiographic sagittal parameters vary between serial images and reflect dynamism in spinal balancing. SVA and PT are predisposed to the widest variation. SVA has the largest variation between individuals of low pelvic tilt. Therefore, interpretation of these parameters should be patient specific and relies on trends rather than a one-time assessment
Normative data for parameters of sagittal spinal alignment in healthy subjects: an analysis of gender specific differences and changes with aging in 626 asymptomatic individualsEur Spine J. 2018 Feb;27(2):426-432. doi: 10.1007/s00586-016-4807-7. Epub 2016 Oct 22.
Yukawa Y1,2, Kato F3, Suda K4, Yamagata M5, Ueta T6, Yoshida M7.
Standard values of spino-pelvic sagittal alignment were established in each gender and each decade from 20' to 70'. A remarkable change of spino-pelvic sagittal alignment was seen from 7th decade to 8th decade in asymptomatic subjects.
Normative values of spino-pelvic sagittal alignment, balance, age, and health-related quality of life in a cohort of healthy adult subjectsHasegawa K1, Okamoto M2, Hatsushikano S2, Shimoda H2, Ono M2, Watanabe K,Eur Spine J. 2016 Nov;25(11):3675-3686. Epub 2016 Jul 18.Whole body standing alignment even in healthy subjects gradually deteriorates with age, but is compensated to preserve a horizontal gaze. HRQOL is also affected by aging and spinopelvic malalignmen
Observer agreement in assessing flexion-extension X-rays of the cervical spine, with and without the use of quantitative measurements of intervertebral motion.Taylor M1, Hipp JA, Gertzbein SD, Gopinath S, Reitman CA, Spine J. 2007 Nov-Dec;7(6):654-8. Epub 2007 Jan 12This study suggests that commonly used methods to assess flexion-extension X-rays of the cervical spine may not provide reliable clinical information about intervertebral motion abnormalities, and that validated, computer-assisted methods can dramatically improve agreement among clinicians. The lack of definitions of instability and fusion acceptable to all the clinicians was likely a primary source of disagreement with both manual and computer-assisted assessments.Study shows: Flexion extension films evaluated by individual MDs for assessing injury is not as reliable as new (2007) computer based diagnostics, for evaluating joint instibility etc.
Orthopaedists' and family practitioners' knowledge of simple low back pain management. (standardizing procedures and showing results will help educate other physicians in LBP management strategies)Spine (Phila Pa 1976). 2009 Jul 1;34(15):1600-3. doi: 10.1097/BRS.0b013e3181a96622.
Finestone AS1, Raveh A, Mirovsky Y, Lahad A, Milgrom C.
Both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners. Although the importance of publishing guidelines and keeping them up-to-date and relevant for different disciplines in different countries cannot be overstressed, disseminating the knowledge to clinicians is also very important to ensure good practice.Mostly based on which is the proper prescription for LBP. The "standard of care" guidelines referred to do iterate that the physicians interviewed did not (in general) have understanding of current guidelines.
Pathophysiology and natural history of cervical spondylotic myelopathy (SEARCH IN ARTICLE ABOUT ALIGNMENT AND PATHOPHYSIOLOGY...LINK WITH OTHER ARTICLES ON ALIGNEMENT AND NON-SURGICAL CORRECTION)Karadimas SK1, Erwin WM, Ely CG, Dettori JR, Fehlings MGCSM has unique pathobiological mechanisms that mainly remain unexplored. Although the natural history of CSM can be mixed, surgical intervention eliminates the chances of the neurological deterioration.
Pelvic Incidence Can Be Changed not only by Age and Sex, but also by Posture Used during ImagingKorean J Spine. 2017 Sep; 14(3): 77–83.
doi: 10.14245/kjs.2017.14.3.77
Ji Won Moon, James Ki Shinn, Dalsung Ryu, Se-Yang Oh, Yu Shik Shim, and Seung Hwan Yoon

In this study, pelvic parameters were measured from the same subjects using X-ray and CT. Then, the correlation between pelvic parameters according to examination method was directly compared. In addition, pelvic parameters according to changes in posture were also analyzed. SS was larger by 3.5°, PT was smaller by 6.7°, and PI was smaller by 3.2° when the parameters were measured using CT rather than X-ray. This change in pelvic parameters is likely due to the change from standing position to supine position used for this study. Furthermore, female subjects exhibit a higher PI than do males, which was statistically significant. Furthermore, our results indicated an association between age and PI through linear regression analysis. This association was observed using both X-ray and CT examinations as well as in both male and female subjects; however, the correlation was stronger in female subjects.
Pelvic Incidence Changes Between Flexion and ExtensionSchroeder N1, Noschenko A1, Burger E1, Patel V1, Cain C1, Ou-Yang D1, Kleck C2
Spine Deform. 2018 Nov - Dec;6(6):753-761. doi: 10.1016/j.jspd.2018.03.008.
PI is a dynamic parameter that changes between flexion and extension. Changes in SS are the main factor involved in these changes, implicating movement through the sacroiliac joints as the cause. Obese patients have greater changes in PI from flexion to extension.
Pelvic incidence: a fixed value or can you change it?Spine J. 2017 Oct;17(10):1565-1569. doi: 10.1016/j.spinee.2017.06.037. Epub 2017 Jun 29.
Place HM1, Hayes AM2, Huebner SB3, Hayden AM4, Israel H5, Brechbuhler JL5.
This study demonstrated that for a high percentage of the healthy subjects who participated, the PI changed when the subjects varied their pelvic position. This questions the assumption that PI is a fixed parameter and suggests a potential functional motion at the sacroiliac joint. It also supports the idea that intentionally changing one's posture could lead to a change in PI, an idea that could have ramifications in surgical cases.
Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformitySpine (Phila Pa 1976). 2009 Aug 1;34(17):E599-606. doi: 10.1097/BRS.0b013e3181aad219.
Lafage V1, Schwab F, Patel A, Hawkinson N, Farcy JP.
This study confirms that pelvic position measured via PT correlates with HRQOL in the setting of adult deformity. High values of PT express compensatory pelvic retroversion for sagittal spinal malalignment. This study also demonstrates significant T1-SPI correlation with HRQOL measures and outperforms SVA. This parameter carries the advantage of being an angular measurement which avoids the error inherent in measuring offsets in noncalibrated radiographs.
Pelvic Tilt Evaluation From Frontal Radiographs: The Validity, Interobserver Reliability and Intraobserver Reproducibility of the Sacro-Femoral-Pubic ParameterJ Arthroplasty. 2017 May;32(5):1665-1669. doi: 10.1016/j.arth.2016.11.026. Epub 2016 Nov 23.
Ragsdale MI1, Wong FS2, Boutin RD2, Meehan JP1.
Calculating PT from a frontal radiograph using the equation for the SFP parameter is a valid, reliable, and reproducible formula that may be used to predict sagittal PT
Physiological value of pelvic and spinal parameters of sagital balance: analysis of 250 healthy volunteersRev Chir Orthop Reparatrice Appar Mot. 2003 Oct;89(6):496-506.
[Article in French]
Guigui P1, Levassor N, Rillardon L, Wodecki P, Cardinne L.
This work provided a useful tool for analyzing and understanding anteroposterior imbalance in patients with spinal disease and also a means of calculating corrections to be made with treatment, established from the linear regression equations which were elaborated.
Postural Consequences of Cervical Sagittal Imbalance: A Novel Laboratory Model.Spine (Phila Pa 1976). 2015 Jun 1;40(11):783-92. doi: 10.1097/BRS.0000000000000877.
Patwardhan AG1, Havey RM, Khayatzadeh S, Muriuki MG, Voronov LI, Carandang G, Nguyen NL, Ghanayem AJ, Schuit D, Patel AA, Smith ZA, Sears W.
This study established predictive relationships between radiographical measures of forward head posture, T1 tilt, and postural compensations in the cervical lordosis angles needed to maintain horizontal gaze. The laboratory model predicted that normalization of C2-C7 SVA will reduce suboccipital (C0-C2) hyperextension, whereas T1 tilt reduction will reduce the hyperextension in the C2-C7 segments. The predictive relationships may help in planning corrective strategy in patients experiencing neck pain, which may be attributed to sagittal malalignment.
Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis.Spine (Phila Pa 1976). 2008 Oct 1;33(21):2316-25. doi: 10.1097/BRS.0b013e318186b236.

Mac-Thiong JM1, Wang Z, de Guise JA, Labelle H.
Children and adolescents stand with a relatively constant global sagittal spino-pelvic alignment, regardless of the local lumbosacral deformity. A normal posture is maintained in low-grade spondylolisthesis and in high-grade spondylolisthesis with a balanced sacro-pelvis. Posture is abnormal in high-grade spondylolisthesis associated with a retroverted sacro-pelvis, suggesting that surgical reduction of the local lumbosacral deformity in these patients could be attempted to restore a normal posture.Xrays were taken and analysed for postural positioning as it relates to a standing spine positioning in subjects with Spondys and retroverted pelvis. Connection relates to the need for xrays to view such detail of a spinal issue.
Postural Re-Education of Scoliosis - State of the Art (Mini-review).(SHOWS YOU NEED TO BE SPECIFIC IN YOUR CORRECTIONS)Curr Pediatr Rev. 2016;12(1):12-6.
Borysov M, Moramarco M, Sy N1, Lee SG.
Scoliosis corrective exercises are supported by two randomized controlled trials (RCT) and should regularly be applied in mild scoliosis at risk for progression. Unspecific exercises such as Yoga, Dobomed cannot be regarded as effective as exercises using a well defined scoliosis pattern specific corrective routine.Specific corrective exercises derived from the original Schroth program have demonstrated significant improvement of Cobb's angle by 5 degrees but this improvement has not been assessed beyond 24 weeks. The method requires patients to be involved.
Practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in a provider network offering complementary care in the United States.(Chiropractic schools teach different approaches to xrays)J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):127-42. doi: 10.1016/j.jmpt.2013.04.002. Epub 2013 May 8.
Bussières AE1, Sales AE, Ramsay T, Hilles S, Grimshaw JM.
Chiropractic school attended and practice location were the most influential predictors of spine radiograph utilization among network chiropractors. This information may help to inform the development and evaluation of a tailored intervention to address overuse of radiograph utilization.
Preliminary study for classification of spino-pelvic sagittal alignment in adult volunteersZhonghua Wai Ke Za Zhi. 2013 Jun 1;51(6):522-6.

Yin GH1, Zhu LX, Chen RS, Lü ZD, Lu M, Yan HB, Zhang ZM, Li QC, Jin DD.
LL is the central parameter of the spino-pelvic sagittal balance. The patterns of the spino-pelvic sagittal alignment in adults could be classified into three types, according to LL and IP. The classification could describe the morphological differences and balance of the spino-pelvic sagittal alignment.
Preservation of Thoracic Kyphosis Is Critical to Maintain Lumbar Lordosis in the Surgical Treatment of Adolescent Idiopathic ScoliosisSpine (Phila Pa 1976). 2010 Jun 15;35(14):1365-70. doi: 10.1097/BRS.0b013e3181dccd63.
Newton PO1, Yaszay B, Upasani VV, Pawelek JB, Bastrom TP, Lenke LG, Lowe T, Crawford A, Betz R, Lonner B; Harms Study Group.
In conclusion, posterior selective thoracic fusion and instrumentation decreased thoracic kyphosis and also affects the sagittal alignment of the nonfused lumbar spine with the decrease in lumbar lordosis .The reduction of thoracic kyhosis after the scoliosis surgery is associated with a reduction in the lumbar lordosis.
Preserving the Anti-Scientific Linear No-Threshold Myth: Authority, Agnosticism, Transparency, and the Standard of Care.Dose Response. 2017 Jul 14;15(3):1559325817717839. doi: 10.1177/1559325817717839. eCollection 2017 Jul-Sep.
Sacks B1, Siegel JA2.
This article explores some of the motivations behind, and methods used to assure, the extreme durability of the LNT myth in the face of the preponderance of contrary evidence and the manifest harms of radiophobia. These include subservience to the voice of authority, tactics such as claiming agnosticism on behalf of the entire field, transparent references to contrary evidence while dismissing the findings without refutation, and seeking shelter behind the legally protective medical standard of care.For almost 70 years, the Linear No-Threshold (LNT) Assumption concludes that ALL ionizing radiation, at any dose is harmful and has accumulative effects on the human body increasing the risk of cancer. This assumption has ignored the benefits associated with lose dose and chronic low dose (as with medical imaging) radiation exposure. Overwhelming scientific evidence has repeatedly shown that it induces an adaptive biological response that increases the repair of somatic DNA 1-24 hours post-exposure along with initiating further repair elsewhere in the body. This evidence has yet to dissuade the paradigm of radiophobia of the regulatory agencies as they are not considered independent voices, but “one voice”. The school of thought cannot be allowed to change due to cultural and bureaucratic red-tape. Proponents of LNT continually support their position by only acknowledging the initial damage to somatic DNA less than 1 hour post exposure and completely ignoring the subsequent repair 1-24 hours later.
Prevalence and risk factors associated with musculoskeletal complaints among users of mobile handheld devices: A systematic review.Xie Y1, Szeto G2, Dai J2., Appl Ergon. 2017 Mar;59(Pt A):132-142. doi: 10.1016/j.apergo.2016.08.020. Epub 2016 Sep 11. This review demonstrates that the prevalence of musculoskeletal complaints among mobile device users ranges from 1.0% to 67.8% and neck complaints have the highest prevalence rates ranging from 17.3% to 67.8%. This study also finds some evidence for neck flexion, frequency of phone calls, texting and gaming in relation to musculoskeletal complaints among mobile device users. Inconclusive evidence is shown for other risk factors such as duration of use and human-device interaction techniques due to inconsistent results or a limited number of studies.

Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implicationsJ Manipulative Physiol Ther. 2014 Nov-Dec; 37(9): 678–687.
Published online 2014 Nov 1. doi: 10.1016/j.jmpt.2014.10.003
Robert D. Vining, DC, Eric Potocki, DC, MS, Ian McLean, DC, DACBR, Michael Seidman, MSW, DC, A. Paige Morgenthal, DC, MS, James Boysen, DC, MS, and Christine Goertz, DC, PhD
Moderate-severe disc degeneration, multilevel disc narrowing, and degenerative spondylolisthesis were common in individuals with CLBP with age more than 40 years. Isthmic spondylolisthesis was not more prevalent than what has been reported in other populations. Transitional segmentation was identified in a minority of participants, with some of these exhibiting accessory joints or fusion. Mean sacral slope in individuals with CLBP was not substantially different from mean slopes reported in other populations.There is a high prevalence if dengerative diseases in patients over the age of 40.
Primary prevention in chiropractic practice: a systematic review. (Utilization in X-rays can improve preventative measures via postural analysis, which can explain preventative measures.)Chiropr Man Therap. 2017; 25: 9.
Published online 2017 Mar 20. doi: 10.1186/s12998-017-0140-4

Guillaume Goncalves,corresponding author1,2,3 Christine Le Scanff,1,2 and Charlotte Leboeuf-Yde1,2,3
More research efforts have been put into wellness than into prevention of musculoskeletal disorders or public health-related disorders. It therefore seems that parts of the chiropractic profession are in search of an understanding of various aspects of clinical practice over and above its traditional musculoskeletal role. Interestingly, only a small proportion of chiropractic patients consult for PP, despite the readiness of the profession to offer such services.
Proceedings of the State-of-the-Art Symposium on Diagnostic and Interventional Radiology of the Spine, Antwerp, September 7, 2002 (Part two). Upright, weight-bearing, dynamic-kinetic MRI of the spine: pMRI/kMRI.JBR-BTR. 2003 Sep-Oct;86(5):286-93.
Proceedings of the State-of-the-Art Symposium on Diagnostic and Interventional Radiology of the Spine, Antwerp, September 7, 2002 (Part two).
Jinkins JR1, Dworkin J.
To conclude, the potential relative beneficial aspects of upright, weight-bearing (pMRI), dynamic-kinetic (kMRI) spinal imaging on this system over that of recumbent MRI (rMRI) include: the revelation of occult disease dependent on true axial loading, the unmasking of kinetic-dependent disease, and the ability to scan the patient in the position of clinically relevant signs and symptoms. This imaging unit also demonstrated low claustrophobic potential and yielded relatively high-resolution images with little motion/chemical shift artifact.
Prospective evaluation of criteria for obtaining
thoracolumbar radiographs in trauma patients.
Holmes JF, Panacek EA, Miller PQ, Lapdis AD, Mower
WR. J Emerg Med 2003;24:1-7.
A total of 2404 patients were enrolled. TL spine injuries were identified in 152 patients. Of these 152 patients with spine injuries, all 152 (100%, 95% confidence interval 98-100%) were considered high risk by having at least one of the high-risk criteria. These criteria have a specificity of 3.9%, a positive predictive value of 6.6%, and a negative predictive value of 100%. All of the high-risk criteria but intoxication with ethanol or drugs were important as sole predictors of TL spine injury. The use of high-risk clinical screening criteria identified virtually all blunt trauma patients with acute TL spine injuries. These criteria, however, have poor specificity and positive predictive value.

Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study.Lancet. 2012 Aug 4;380(9840):499-505. doi: 10.1016/S0140-6736(12)60815-0. Epub 2012 Jun 7.
Pearce MS1, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A.
Use of CT scans in children to deliver cumulative doses of about 50 mGy might almost triple the risk of leukaemia and doses of about 60 mGy might triple the risk of brain cancer. Because these cancers are relatively rare, the cumulative absolute risks are small: in the 10 years after the first scan for patients younger than 10 years, one excess case of leukaemia and one excess case of brain tumour per 10,000 head CT scans is estimated to occur. Nevertheless, although clinical benefits should outweigh the small absolute risks, radiation doses from CT scans ought to be kept as low as possible and alternative procedures, which do not involve ionising radiation, should be considered if appropriate.
Radiation Hormesis: The Good, The Bad, The UglyD. Luckey, Lawrence, KS. Dose-Response 4(3):169–190, 2006
Formerly Nonlinearity in Biology, Toxicology, and Medicine
Three aspects of hormesis with low doses of ionizing radiation are presented: the good, the bad, and the ugly.Three aspects of hormesis with low doses of ionizing radiation are presented: the good, the bad, and the ugly. The good is acceptance by France, Japan, and China of the thousands of studies showing stimulation and/or benefit, with no harm, from low dose irradiation. This includes thousands of people who live in good health with high background radiation. The bad is the nonacceptance of radiation hormesis by the U. S. and most other governments; their linear no threshold (LNT) concept promulgates fear of all radiation and produces laws which have no basis in mammalian physiology. The LNT concept leads to poor health, unreasonable medicine and oppressed industries. The ugly is decades of deception by medical and radiation committees which refuse to consider valid evidence of radiation hormesis in cancer, other diseases, and health. Specific examples are provided for the good, the bad, and the ugly in radiation hormesis.
Radiograph use in low back
pain: a United States emergency department database
Isaac DM, Marinac J, Sun C. J Emerg Med 2004; is an increased probability of receiving a radiograph for those patients 40-70 years old, being seen at a metropolitan hospital, having private insurance, and being treated by a resident in training. Multiple factors are associated with the overuse of radiographs for patients presenting with uncomplicated LBP.

Radiographic analysis of lumbar lordosis: centroid, Cobb, TRALL, and Harrison posterior tangent methods.Spine (Phila Pa 1976). 2001 Jun 1;26(11):E235-42.
Harrison DE1, Harrison DD, Cailliet R, Janik TJ, Holland B.
All four radiographic methods had high reliability and low mean absolute differences of observers' measurements. Because it lacks a segmental analysis, the TRALL method is not recommended. The centroid, Cobb, and Harrison posterior tangent methods provide global and segmental angles. However, the centroid segmental method requires three segments and is less useful for a stability analysis.Comparing 4 radiographic methods for measurement of lumbar lordosis, it has been found that all methods have high interobserver and intraobserver reliability with small mean absolute difference of observer.
Radiographic Analysis of Lumber LordosisHarrison DE1, Harrison DD, Cailliet R, Janik TJ, Holland B.
Spine (Phila Pa 1976). 2001 Jun 1;26(11):E235-42.
All four radiographic methods had high reliability and low mean aboslute differences of observers' measurements. The TRALL method is not recommended. The centroid segmental method is less useful for a stability analysis.
Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects(DISCUSS IMBALANCES CAUSING PAIN IN FUTURE AND NOT RIGHT AWAY)J Bone Joint Surg Am. 2005 Feb;87(2):260-7.
Vialle R1, Levassor N, Rillardon L, Templier A, Skalli W, Guigui P.
This description of the physiological spinal sagittal balance should serve as a baseline in the evaluation of pathological conditions associated with abnormal angular parameter values. Before a patient with spinal sagittal imbalance is treated, the reciprocal balance between various spinal angular parameters needs to be taken into account. The correlations between angular parameters may also be useful in calculating the corrections to be obtained during treatment.
Radiographic anomalies that may alter
chiropractic intervention strategies found in a New Zealand
Ammendolia C. J Manipulative Physiol Ther 2005;28:375.A large percentage of patients presenting for chiropractic care have anomalies present on spinal radiographs. Further research and analysis is necessary to investigate the risk-verses-benefit ratio of spinal radiographs for chiropractic patients.
Radiographic assessment for patients with low back pain.Simmons ED, Guyer RD, Graham-Smith A, Herzog R. Radiographic assessment for patients with low back pain. Spine 1995;20:1839-41.Guidelines for radiographs of the lumbar spine are established. In general, radiographs are not believed to be necessary for a first episode of low back pain present for less than 7 weeks. Exceptions to this include various medical or physical findings, which are listed. In general, anteroposterior and lateral views only should be done initially. Indications for other views are discussed.Paper provides guidelines on when it would be appropriate to take lumbar radiographs on a person with an acute episode of low back pain of less than 7 weeks duration. It suggests that fewer low back x-rays should be taken and not much more can be gained from taking more than simple AP and lateral views (i.e. spot views and obliques) when imaging is indicated at all.
Radiographic assessment for patients with low back pain.Simmons ED, Guyer RD, Graham-Smith A, Herzog R.
Spine 1995;20:1839-41.
Guidelines for radiographs of the lumbar spine are established. In general, radiographs are not believed to be necessary for a first episode of low back pain present for less than 7 weeks. Exceptions to this include various medical or physical findings, which are listed. In general, anteroposterior and lateral views only should be done initially. Indications for other views are discussed.
Radiographic assessment of the cervical
spine in asymptomatic trauma patients.
Neurosurgery 2002; 50(3 Suppl):S30-5.
Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC.
A three-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended for radiographic evaluation of the cervical spine in patients who are symptomatic after traumatic injury. This should be supplemented with computed tomography (CT) to further define areas that are suspicious or not well visualized on the plain cervical x-rays.
Radiographic examination of the lumbar spine in a community hospital: an audit of current practiceHalpin SF, Yeoman L, Dundas DD. BMJ 1991;303:813-5.There is a need to inform doctors of the efficacy of radiological examinations. An awareness of the college's guidelines among general practitioners should be actively promoted by radiologists.
Radiographic predictors for the development of myelopathy in patients with ossification of the posterior longitudinal ligament: a multicenter cohort studySpine (Phila Pa 1976). 2008 Nov 15;33(24):2648-50. doi: 10.1097/BRS.0b013e31817f988c.
Matsunaga S1, Nakamura K, Seichi A, Yokoyama T, Toh S, Ichimura S, Satomi K, Endo K, Yamamoto K, Kato Y, Ito T, Tokuhashi Y, Uchida K, Baba H, Kawahara N, Tomita K, Matsuyama Y, Ishiguro N, Iwasaki M, Yoshikawa H, Yonenobu K, Kawakami M, Yoshida M, Inoue S, Tani T, Kaneko K, Taguchi T, Imakiire T, Komiya S.
Static and dynamic factors were related to the development of myelopathy in OPLL.
Radiographic pseudoscoliosis in healthy male subjects following voluntary lateral translation (side glide) of the thoracic spine.Arch Phys Med Rehabil. 2006 Jan;87(1):117-22.

Harrison DE1, Betz JW, Cailliet R, Colloca CJ, Harrison DD, Haas JW, Janik TJ.
During lateral translation of the thorax (trunk list), coupled lumbar lateral flexion resulted in the appearance of a pseudoscoliosis on AP radiographs. For this trunk list posture, Cobb angles are considerable (16 degrees ) and increase as the magnitude of trunk translation increases. Differentiating true structural scoliosis from this pseudoscoliosis would be clinically important. The small coupled axial rotation in trunk list is in contrast to the considerable degree of axial rotation observed in structural idiopathic scoliosis.xray analysis of the thoracic and lumbar spine to understand basic biomechanics of the spinal joints as they move in a translation movement. Helpful from a DC perspective for being able to better understand scoliosis and what is happening when that is the dx.
Radiography for low back pain: a randomised controlled trial and observational study in primary care.Kerry S, Hilton S, Dundas D, Rink E, Oakeshott P.
Br J Gen Pract
Referral for lumbar spine radiography for first presentation of low back pain in primary care is not associated with improved physical functioning, pain or disability. The possibility of minor psychological improvement should be balanced against the high radiation dose involved.
Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P,
Pringle M. BMJ 2001;322:400-5.
Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.
Radiologic features of dropped head syndrome in the overall sagittal alignment of the spineEur Spine J. 2018 Feb;27(2):467-474. doi: 10.1007/s00586-017-5186-4. Epub 2017 Jun 10.
Hashimoto K1, Miyamoto H2, Ikeda T1, Akagi M1.
The present study has indicated that radiologic feature of DHS in the sagittal alignment of the overall spino-pelvis can be categorized into two types: SVA+ and SVA
Radiological analysis of lumbar degenerative kyphosis in relation to pelvic incidenceSpine J. 2012 Nov;12(11):1045-51. doi: 10.1016/j.spinee.2012.10.011. Epub 2012 Nov 14.
Bae JS1, Jang JS, Lee SH, Kim JU.
The results of this study suggest the importance of the key anatomical parameter, PI, in the determination of sagittal contour in symptomatic LDK patients and normal population. Spinopelvic parameters and pelvic compensatory mechanisms in LDK patients differ according to PI. Identifying the spinopelvic parameters is useful when correcting deformities.
Radiophobia: 7 Reasons Why Radiography Used in Spine and Posture Rehabilitation Should Not Be Feared or Avoided.Oakley PA1, Harrison DE2; Dose Response. 2018 Apr-Jun; 16(2): 1559325818781445.
Published online 2018 Jun 27. doi: 10.1177/1559325818781445
Radiography is a safe imaging method for routine use in patient assessment, screening, diagnosis, and biomechanical analysis and for monitoring treatment progress in daily clinical practice.(This article relates best to Question number 2) Exposure to radiation does not directly correlate to the linear effect on the body as previously founded in research that looked at exposure to the atomic bomb over time. There is a Hormesis effect to radiation that increases and decreases throughout the exposure. 2i- Radiographs are the best clinical affordable option to spinal correction. Especially in determining force vectors through manual manipulation.
Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parametersSpine (Phila Pa 1976). 2015 May 1;40(9):642-9. doi: 10.1097/BRS.0000000000000844.
Diebo BG1, Ferrero E, Lafage R, Challier V, Liabaud B, Liu S, Vital JM, Errico TJ, Schwab FJ, Lafage V
Spinopelvic mismatch is an important driver in SSM. Pelvic retroversion and flattening of TK (reduction) become exhausted with increasing mismatch, at which point there seems to be a steady transfer of compensation toward significant participation of the lower limbs. Further analysis suggests differential recruitment of these compensatory mechanisms based upon age.This article demonstrates that compensation machinery triggered by one of the spinal malalignment drivers such as loss of LL can be seen in thoracic kyphosis, cervical lordosis and lower extremities including knee and hip joints. These adaptations can result in hip, knee and spine degeneration over time. Thus, as stated in the article, evaluation of global sagittal spinal alignment in the presence of increased knee flexion with pain should be considered.
REDUCING THORACIC HYPERKYPHOSIS SUBLUXATION DEFORMITY: A SYSTEMATIC REVIEW OF CHIROPRACTIC BIOPHYSICS® METHODS EMPLOYED IN ITS STRUCTURAL IMPROVEMENOakley, Paul & Harrison, Deed. (2018). 1. 59-66. Although limited, there is promising evidence that the CBP technique approach for the reduction of THK by application of mirror image traction and exercises as a part of a multimodal rehabilitation program may prove very effective. As opposed to the limited evidence offered by monotherapy exercise trials, the application of thoracic hyperextension traction combined with hyperextension exercises is logical from a biomechanics standpoint.
A randomized clinical trial to further evaluate the CBP approach to treat THK is warranted.
A well cited article on CBP and its effectiveness on hyperkyphosis of the thoracic spine. No new direct findings relative to radiography mentioned. Most facts related to radiology were mentioned as conclusions from previous studies. Although the article did clearly outline the benefits of radiography and its safety and cited other articles well.
Reduction of progressive thoracolumbar adolescent idiopathic scoliosis by chiropractic biophysics® (CBP®) mirror image® methods following failed traditional chiropractic treatment: a case report.Haggard JS1, Haggard JB1, Oakley PA2, Harrison DE3.; J Phys Ther Sci. 2017 Nov;29(11):2062-2067. doi: 10.1589/jpts.29.2062. Epub 2017 Nov 24.CBP mirror image exercises and traction are consistent with other successful non-surgical approaches and show promise in treating adolescent idiopathic scoliosis. Performing radiographic stress views to observe the reduction potential in a movement sequenced order of 2 mirror image positions / movements deduced from the initial static AP spinal Radiograph. This method assisted in coordinating the series of exercises traction methods in the order in which they were performed through-out the treatment process.
Regarding the Credibility of Data Showing an Alleged Association of Cancer with Radiation from CT Scans.Socol Y1, Welsh JS;Technol Cancer Res Treat. 2016 Feb;15(1):159-62. doi: 10.1177/1533034614566923. Epub 2015 Jan 23.Computed tomography (CT) scans are of high clinical value as a diagnostic technique, and new applications continue to be identified. However, their application is challenged by emerging concerns regarding carcinogenesis from their radiation. Recent articles made a significant contribution to the above-mentioned concerns by reporting evidence for direct association of the radiation from CT scans with cancer. Such interpretation of the data has already been criticized; there is the possibility of reverse causation due to confounding factors. Nevertheless, such work has had a high impact, with one article being cited more than 300 times from the Web of Science Core Collection within 2 years. However, the data points on cancer relative risk versus CT dose in that article fit straight lines corresponding to the linear no-threshold hypothesis suspiciously well. Here, by applying rigorous statistical analysis, it is shown that the probability of the fit truly being that good or better is only 2%. The results of such studies therefore appear "too good to be true" and the credibility of their conclusions must be questioned.This is a critique of Pearce et al study conclusion there is a statistically significant dependence of relative risk of leukemia and brain tumors from CT scans in childhood. It hypothesizes the conclusions a not consistent with the body of evidence regarding this topic. It also criticized the study for possible faulty mathematical interpretation, it was to good to be true.
Relation between low back pain syndrome and x-ray findings. Magora A: Scand J Rehab Med 1978; 10:135-145.

No direct relation between sacralization, partial or complete, and LBP was found; this was based on interrelation of the LBP and control groups, with or without sacralization, to age, ethnic community, occupation, number of changes of occupation or place of employment, duration of LBP, and physical occupational requirements (sitting, standing, bending, sudden maximal effort). There is some evidence that LBP, when associated with sacralization, may be more severe.
Relationship among Cervical Spine Degeneration, Head and Neck postures, and Myofascial Pain in Masticatory and Cervical Muscles in Elderly with Temporomandibular Disorder.Hong SW1, Lee JK2, Kang JH3. Arch Gerontol Geriatr. 2018 Dec 7;81:119-128. doi: 10.1016/j.archger.2018.12.004.The cerTMD showed higher number of active TrPs in the masticatory and cervical muscles, greater forward head posture, and more severe degenerative changes in the cervical spine than mTMD did. The degenerative changes in each level of the cervical spine had complex interactions with head postures. Cervical degeneration, particularly at level of second to third vertebra appeared to be linked to the development of active TrPs in the masticatory and cervical muscles.It has been recognized by several types of practitioners, including chiropractors, that there is a strong correlation between changes in head posture and TMJ function. Changes in the cervical lordosis and cervical spine degenerate can alter craniocervical angles and predispose a person to a greater risk of developing TrPs in the cervical and TMJ muscles and myofascial pain syndrome. Early intervention to assess, montior, and attempt to prevent these degenerative changes from progressing may reduce the risk of the development of myofascial pain syndrome and associated TMJ dysfunction.
Relationship between craniocercvical orientation and center of force of occlusion in adultsCranio. 2017 Sep;35(5):283-289. doi: 10.1080/08869634.2016.1235254. Epub 2016 Oct 20.
Westersund CD1, Scholten J1, Turner RJ2.

Findings suggest that changes in posture and occlusion can be obserbed after the NUCCA procedure, implying an interconnectivity between the CCJ and an individual's occlusal contacts. NUCCA procedure utilizes detailed X-Ray analysis in order to evaluate and correct Craniocervical Junction alignment. Craniocervical Juntion alignment correlates with the biomechanics of the temporal-mandibular joint as well as occlussal contacts chich can potentially contribute to temporal mandibular dysfunction. This study demonstrates that correction of the craniocervical junction alignment can have a possitive effect on temporomandular biomechanics and thus alleviate symptoms of temporomandibular dysfunction.
Relationship between low back pain and lumbar sagittal alignment after lumbar fusionZhonghua Yi Xue Za Zhi. 2013 Apr 16;93(15):1129-32.
[Article in Chinese]
Hai Y1, Zhao H, Shao N, Lu SB, Yang JC, Liu YZ.
There is a close relationship between back pain after fusion and loss of lumbar sagittal lordosis. And reconstruction of lumbar lordosis should be one important goal for lumbar fusion
Relationship Between Modic Changes and Sagittal Balance Parameters in the Cervical Spine.Med Sci Monit. 2018; 24: 6102–6106.
doi: 10.12659/MSM.909773
Wu JP1, Wang QB2, Feng XJ3, Wang Q1, Cheng MH4;
The present study demonstrated that Cobb C2–C7 (less than 8.5°) is a potential risk factor for the development of Modic ChangesMeasuring the curve of the cervical spine is related to modic change (degenerative changes found on MRI) in the cervical spine.
Relationship between standing posture and stability.Danis CG1, Krebs DE, Gill-Body KM, Sahrmann S. Phys Ther. 1998 May;78(5):502-17.Posture and stability had a low correlation. Subjects with bilateral vestibular hypofunction did not demonstrate a forward head or backward trunk lean, as has been reported anecdotally. Changing from standing with feet apart to feet together increased whole-body movement patterns to control standing stability.
Reliability and validity of head posture assessment by observation and a four-category scaleMan Ther. 2010 Oct;15(5):490-5. doi: 10.1016/j.math.2010.05.002. Epub 2010 Jun 4. Silva AG1, Punt TD, Johnson MI.Head posture (HP) is assessed as part of the clinical examination of patients with neck pain using observation and qualitative descriptors. In research, HP is characterised through the measurement of angles and distances between anatomical landmarks. This study investigated whether the assessment of HP as performed in clinical practice is reliable and valid. Ten physiotherapists assessed forward HP, head extension and side-flexion from images of 40 individuals with and without previous experience of neck pain using a four-category scale. The assessment was repeated twice with a 1-week gap. Physiotherapists' ratings were then compared with angular measurements of the same components of HP. K values for intra-rater reliability varied between 0.22 and 0.81 for forward HP, between 0.19 and 0.69 for head extension and between 0.38 and 0.67 for side-flexion. K values for inter-rater reliability were 0.02 for forward HP, 0.07 for head extension and 0.19 for side-flexion. Correlation coefficients between the ratings and the angular measurements varied between -0.16 and -0.49 for forward HP, between -0.17 and 0.68 for head extension and between -0.04 and 0.37 for side-flexion. The assessment of HP by observation and a four-category scale showed poor reliability and validity.

Reliability assessment of a novel cervical spine deformity classification systemJ Neurosurg Spine. 2015 Dec;23(6):673-83. doi: 10.3171/2014.12.SPINE14780. Epub 2015 Aug 14.
Ames CP1, Smith JS2, Eastlack R3, Blaskiewicz DJ3, Shaffrey CI2, Schwab F4, Bess S5, Kim HJ6, Mundis GM Jr3, Klineberg E7, Gupta M7, O'Brien M8, Hostin R8, Scheer JK9, Protopsaltis TS4, Fu KM10, Hart R11, Albert TJ12, Riew KD13, Fehlings MG14, Deviren V15, Lafage V4; International Spine Study Group.
The proposed classification provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters. The intra- and interobserver reliabilities suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification.The article describes an attempt to assemble and test a classification system for cervical spine deformities. The test for reliability goes moderately well, but also suffers some significant confusion in its implementation. Volunteers for testing the classification appear to have not precisely implemented some of the intended steps of the process, which may have been the source of some of the lackluster results of the test.
Reliability of centroid, Cobb, and Harrison posterior tangent methods: which to choose for analysis of thoracic kyphosis.Spine (Phila Pa 1976). 2001 Jun 1;26(11):E227-34.
Harrison DE1, Cailliet R, Harrison DD, Janik TJ, Holland B.
The centroid, two-line Cobb, and Harrison posterior tangent methods, when applied to measurements of kyphosis, are all reliable and have similar small error ranges. The centroid method does not give an accurate segmental analysis, uses more points and more time in clinical applications, and results in smaller angles of total kyphosis than the Cobb or posterior tangent methods. The posterior tangents are the slopes along the curve.
Reliability of Lateral Bending and Axial Rotation with Validity of a new method to Determine Axial Rotation on Anteroposterior Cervical RadiographsJ Manipulative Physiol Ther. 2001 Sep;24(7):445-8.
Janik T1, Harrison DE, Harrison DD, Holland B, Coleman RR, Payne MR.
A new radiographic measurement method for determinging axial rotations of the cervical segments on AP views had reliability values in the good to excellent range. The new method had an average error of less than 1° and approx. 11.5%.
Reliability of lumbar lordosis measurement in patients with spondylolisthesis: a case-control study comparing the Cobb, centroid, and posterior tangent methods.Spine (Phila Pa 1976). 2010 Aug 15;35(18):1691-700. doi: 10.1097/BRS.0b013e3181c9a75f.
Hwang JH1, Modi HN, Suh SW, Hong JY, Park YH, Park JH, Yang JH.
Posterior tangent method should be used for the global and segmental angle analysis for the LL in cases with spinal instability because of (a) higher correlation coefficient for segmental angle measurements; (b) lower SEM at the instability level than the centroid method despite similar correlation coefficients; and (c) similar to the engineering analysis.Comparing 3 radiographic methods of measurement of lumbar lordosis in patients with spinal instability such as spondylolisthesis, it has been found that 1 method in particular was more reliable ie high interclass and intraclass correlation coefficient.
Reliability of spinal displacement analysis of plain X-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique.Harrison DE1, Harrison DD, Troyanovich SJ.; J Manipulative Physiol Ther. 1998 May;21(4):252-66.X-ray line drawing is reliable. Normal values for the sagittal spinal curvatures exist in the literature. The normal sagittal spinal curvatures are important clinical outcomes of care. Patient positioning and postural radiographs are highly reproducible. When these standardized procedures are used, the pre-to-post alignment changes are a result of treatment procedures applied. Chiropractic radiology education and publications should reflect the recent literature, provide more support for X-ray line drawing analyses and applications of line drawing analyses for measuring spinal displacement on plain radiographs.The dose of an x-ray normaling does not exceed 2-3 mGy (200-300 mrem) for a lumbar image, which is more than 100 times lower than the dose threshold for radiogenic cancer.
Reliability of the Pettibon Patient Positioning System for Radiographic ProductionJackson, B.L., Barker, W.F., Pettibon, B.R., Woggon, D., Bentz, J., Hamilton, D.L., Weigand, M., & Hester, R.L. (2000). Reliability of the Pettibon Patient Positioning System for Radiographic Production.

It appears that Pettibon technique practitioners have empirical justification for the use of pre and post-adjustment radiographs in the course of patient care. The Pettibon patient positioning system exhibits a standard error of measure within the established limits.
Reliability of the Upper Cervical X-ray Marking System: A Replication StudyJackson BL, Barker WF, Gambale AG. J Clin Invest Res, 1988;1(1):10-131988 Jackson replicates the above study with the similar results and conclusions (See 350)Jackson et al sought to replicate study by Sigler and Howe. 38 x-rays were analyzed by three Pettibon practitioners. Reliability estimates were high.Upper and lower angles were measured. The results contradict Sigler and Howe.
Reliability of the Visual Assessment of Cervical and Lumbar Lordosis: How good are we???Spine (Phila Pa 1976). 2003 Aug 15;28(16):1857-9.
Fedorak C1, Ashworth N, Marshall J, Paull H.

Intrarater reliability of the visual assessment of cervical and lumbar lordosis was statistically fair, whereas interrater reliability was poor.
Relief of exertional dyspnea and spinal pains by increasing the thoracic kyphosis in straight back syndrome (thoracic hypo-kyphosis) using CBP® methods: a case report with long-term follow-up.Betz JW1, Oakley PA2, Harrison DE3.; J Phys Ther Sci. 2018 Jan; 30(1): 185–189.
Published online 2018 Jan 27. doi: 10.1589/jpts.30.185
Long-term follow-up confirmed stable improvement in physiologic thoracic kyphosis in this patient. Nonsurgical correction in thoracic hypokyphosis/SBS can be achieved by mirror image traction procedures configured to flex the thoracic spine into hyperkyphosis as well as corrective exercise and manipulation as a part of CBP technique report focusing on correcting the straight spine syndrome and relifing pain and dyspnea with CBP protocol
Repeatability Over Time of Posture, X-ray Positioning, and X-ray Line Drawing: An Analysis of Six Control
Harrison DE, Harrison DD, Colloca CJ, Betz JW, Janik TJ, Holland B. J Manipulative Physiol Ther 2003; 26(2):87-98.Posture, radiographic positioning, and radiographic line drawing are all very reliable/repeatable. When Chiropractic Biophysics standardized procedures are used, any pre-to-post alignment changes in treatment groups are a result of the treatment procedures applied. These results contradict common claims made by several researchers and clinicians in the indexed literature. Chiropractic radiologic education and publications should reflect the recent literature, provide more support for posture analysis, radiographic positioning, radiographic line drawing analyses, and applications of posture and radiographic procedures for measuring spinal displacement on plain radiographs.
Repeatability over time of posture, radiograph positioning, and radiograph line drawing: An analysis of six control groupsJournal of Manipulative & Physiological Therapeutics , Volume 26 , Issue 2 , 87 – 98 Harrison, Deed E. et al.Posture, radiographic positioning, and radiographic line drawing are all very reliable/repeatable. When Chiropractic Biophysics standardized procedures are used, any pre-to-post alignment changes in treatment groups are a result of the treatment procedures applied. These results contradict common claims made by several researchers and clinicians in the indexed literature. Chiropractic radiologic education and publications should reflect the recent literature, provide more support for posture analysis, radiographic positioning, radiographic line drawing analyses, and applications of posture and radiographic procedures for measuring spinal displacement on plain radiographs.
Repeatability over time of posture, radiograph positioning, and radiograph line drawing: an analysis of six control groups.Harrison DE1, Harrison DD, Colloca CJ, Betz J, Janik TJ, Holland B.; J Manipulative Physiol Ther. 2003 Feb;26(2):87-98.Posture, radiographic positioning, and radiographic line drawing are all very reliable/repeatable. When Chiropractic Biophysics standardized procedures are used, any pre-to-post alignment changes in treatment groups are a result of the treatment procedures applied. These results contradict common claims made by several researchers and clinicians in the indexed literature. Chiropractic radiologic education and publications should reflect the recent literature, provide more support for posture analysis, radiographic positioning, radiographic line drawing analyses, and applications of posture and radiographic procedures for measuring spinal displacement on plain radiographs.Thus far, data in positioning for radiographs and posture are very reliable and repeatable. Strong study considering the use of 6 CBP control trials.
Reproducibility of sagittal radiographic parameters in adolescent idiopathic scoliosis-a guide to reference values using serial imaging.Spine J. 2017 Jun;17(6):830-836. doi: 10.1016/j.spinee.2017.01.001. Epub 2017 Jan 5.
Hey HWD1, Wong GC2, Chan CX2, Lau LL3, Kumar N3, Thambiah JS3, Ruiz JN3, Liu KG3, Wong HK
Most radiographic sagittal spinal parameters in AIS patients are generally reproducible with some variations up to a maximum of 4°. This natural variation should be taken into account when interpreting these radiographic sagittal parameters so as to achieve the most accurate results in surgical planning.This retrospective study including a reasonable 138 subject pool; however, due to the nature of adolescent idiopathic scoliosis, the pool was very unbalanced being majority female (110/138). It focused on reliable measurements because of the significance in those measures being possible predictors of outcome (answering Question 2). The entire reason why the study is performed is because changes are expected due to the dynamic nature of the spine, and planning for regular assessments of these changes would be important in addressing mechanical abnormalities in a clinical setting - especially when attempting surgical corrections. However, there was found to be a significant variability related to the posture of the subjects between image acquisition sessions.
Resolution of temporomandibular joint dysfunction (TMJD) by correcting a lateral head translation posture following previous failed traditional chiropractic therapy: a CBP® case report.J Phys Ther Sci. 2018 Jan;30(1):103-107. doi: 10.1589/jpts.30.103. Epub 2018 Jan 27.
Jaeger JO1, Oakley PA2, Moore RR1, Ruggeroli EP1, Harrison DE3.
Abnormal head/neck postures, such as lateral head translation, may be an unrealized source of TMJD and may be explained through the 'regional interdependence' model or by how seemingly unrelated anatomy may be associated with a primary complaint.TMJD affects up to 30% of the adult population and can severely affect overall quality of life. Postural deviations, in particular, lateral head translation, can affect the biomechanics of the TMJ and lead to dysfunction and symptomatology of clicking, pain and malocclusion. This can severely impact overall quality of life. These postural deviations are demonstrated and measured using low-dose x-rays. These precise measurements are used to determine the exact course of care with chiropractic alignments as well as specific exercises according to the patient’s presentation. Several case studies have shown that chiropractic care and specific exercises impart resolution of TMJD symptoms. Pre and post x-ray analysis show that when the lateral head deviation is corrected, we see elimination of the TMJD symptoms and restored proper function of the TMJ.

Variability between lateral spine images in patients with a spine that moves suggests that the spine is capable of changing on short term influence by posture and positioning. This means that standardizing the criteria of pre-correction imaging and measurement is critical as it will serve a basis for follow up measurements in a changing structure. This article seems to reveal a weakness in the study as well a current procedural standardization: The instructions are the same, but the patient’s ability to consistency implement the instructions between sessions can change.
Respiratory Dysfunction in Chronic Neck Pain Patients. A Pilot Study.Kapreli, E., Vourazanis, E., Billis, E., Oldham, J., & Strimpakos, N. (2009). Cephalalgia, 29(7), 701–710The aim of this pilot study was to add weight to a hypothesis according to which patients presenting with chronic neck pain could have a predisposition towards respiratory dysfunction. Twelve patients with chronic neck pain and 12 matched controls participated in this study. Spirometric values, maximal static pressures, forward head posture and functional tests were examined in all subjects. According to the results, chronic neck patients presented with a statistically significant decreased maximal voluntary ventilation (P = 0.042) and respiratory muscle strength (Pimax and Pemax), (P = 0.001 and P = 0.002, respectively). Furthermore, the current study demonstrated a strong association between an increased forward head posture and decreased respiratory muscle strength in neck pateits. The connection of neck pain and respiratory function could be an important consideration in relation to patient assessment, rehabilitation and consumption of pharmacological agents.
Restriction in lateral bending range of motion, lumbar lordosis, and hamstring flexibility predicts the development of low back pain: a systematic review of prospective cohort studiesBMC Musculoskelet Disord. 2017; 18: 179.
Published online 2017 May 5. doi: 10.1186/s12891-017-1534-0

Sean G Sadler,corresponding author1 Martin J Spink,1 Alan Ho,2 Xanne Janse De Jonge,3 and Vivienne H Chuter1
In summary, we found that a restriction in lateral flexion and hamstring range of motion as well as limited lumbar lordosis were associated with an increased risk of developing LBP. Future research should aim to measure additional lower limb musculoskeletal risk factors, have follow up periods of 6-12 months, adopt a standardised definition of LBP, and only include participants who have no history of LBP.This study did not use imaging for the purpose of lateral bending assesment. Multiple other tests and examination procedures were used in the selected studies that were included.
Reversing thoracic hyperkyphosis: a case report featuring mirror image® thoracic extension rehabilitation.Miller JE1, Oakley PA2, Levin SB1, Harrison DE; J Phys Ther Sci. 2017 Jul; 29(7): 1264–1267.
Published online 2017 Jul 15. doi: 10.1589/jpts.29.1264
Thoracic hyperkyphosis can be reduced through a multimodal rehabilitation program emphasizing mirror image thoracic extension procedures.Case study for a 15 year old female succeessfully correct her thoracic kyphosis with CBP EAT protocol
Risk of malignancy associated with head and neck CT in children: a systematic review.Otolaryngol Head Neck Surg. 2014 Oct;151(4):554-66. doi: 10.1177/0194599814542588. Epub 2014 Jul 22.
Chen JX1, Kachniarz B1, Gilani S1, Shin JJ2.
Cohort data suggest that 1 excess brain malignancy occurred after 4000 brain CTs (40 mSv per scan) and that the estimated risk in the 10 years following CT exposure was 1 brain tumor per 10,000 patients exposed to a 10 mGy scan at less than 10 years of age.The risk of malignancy asociated with radiation exposure from a CT scan of the head and neck has shown to be very low. "Cohort data suggest that 1 excess brain malignancy occurred after 4000 brain CTs (40 mSv per scan) and that the estimated risk in the 10 years following CT exposure was 1 brain tumor per 10,000 patients exposed to a 10 mGy scan at less than 10 years of age." A CT scan is roughly 7 times more radiation exposure than from a typical low-dose exposure film study done in a chiropractic setting.
Risk of radiation-induced malignancies from CT scanning in children who underwent shunt treatment before 6 years of age: a retrospective cohort study with a minimum 10-year follow-up.White IK1, Shaikh KA, Moore RJ, Bullis CL, Sami MT, Gianaris TJ, Fulkerson DH; J Neurosurg Pediatr. 2014 May;13(5):514-9. doi: 10.3171/2014.2.PEDS12508. Epub 2014 Mar 14.Previously published models predict a significant number of future cancers directly caused by CT scanning. However, there are very few published clinical data. In the authors' study, zero future radiation-induced malignancies were detected after routine CT scanning in a high-risk group. While the authors do not consider their single-institution study adequate to define the actual risk, their data suggest that the overall risk is low. The authors hope this study encourages future collaborative efforts to define the actual risk to patients.CT scanning has a low risk for developing cancer/tumors, but more powerful studies are necessary. Presently assumptions of cancer risk are extrapolated from data related to exposures after Hiroshima and Nagasaki, therapeutic radiation treatment and nuclear facility employment.
Roentgenographic Measurement of Atlas Laterality and Rotation: A Retrospective Pre- and Post-Manipulation StudyGrostic JD, DeBoer KF. J Manipulative Physiol Ther, 1982;5(2):63-71This study shows the change following care was 1.23 degrees and 1.35 degrees respectively for “Atlas Laterality and Rotation”323 random case records were taken from the files of one practitioner, and analysed for alignment pre and post adjustment. Statistically significant changes were found between the pre and post radiographic measurements. The paper did not assess reliability or validity.
Roentgenologic diagnosis of the cervical spine in childhoodMarkuske H Psychiatr Neurol Med Psychol (Leipz). 1983 May;35(5):257-66The discussion of the results draws attention to their practical value and to the importance of functional radiographical examination of the cervical spine during childhood.Article in GERMAN
Role of pelvic translation and lower-extremity compensation to maintain gravity line position in spinal deformityJ Neurosurg Spine. 2016 Mar;24(3):436-46. doi: 10.3171/2015.5.SPINE14989. Epub 2015 Nov 13.
Ferrero E1,2, Liabaud B1, Challier V1, Lafage R1, Diebo BG1, Vira S1, Liu S1, Vital JM3, Ilharreborde B2, Protopsaltis TS1, Errico TJ1, Schwab FJ1, Lafage V1.
This is the first study to describe full-body alignment in a large population of patients with spinal pathologies. Furthermore, patients categorized based on T1SPi were found to have significant differences in the pelvic shift and lower-limb compensatory mechanisms. Correlations between lower-limb angles, pelvic shift, and ODI were identified. These differences in compensatory mechanisms should be considered when evaluating and planning surgical intervention for adult patients with spinal deformity.
Sacro-femoral-pubic angle: a coronal parameter to estimate pelvic tiltEur Spine J. 2012 Apr;21(4):719-24. doi: 10.1007/s00586-011-2061-6. Epub 2011 Nov 24.
Blondel B1, Schwab F, Patel A, Demakakos J, Moal B, Farcy JP, Lafage V
The pelvic tilt is an essential measure in the context of radiographic evaluation of spinal deformity and malalignment. Given the routinely excellent visibility of coronal films this study established the SFP as a coronal parameter which can reliably estimate pelvic tilt. The high correlation and predictive ability of the SFP angle should prompt further study and clinical application when lateral radiographs do not permit assessment of pelvic parameters.The pelvic tilt is an essential measure in the context of radiographic evaluation of spinal pain and malalignment. There is a need to establish a reporducable coronal plane pelvic parameter which correlates closely with pelvic tilt when pelvic tilt parameters are poorly visualized on lateral film. This study shows that the Sacro-femoral-pubic angle may be utilized in order to predict pelvic tilt involvment in spinal pain or malalignment from a coronal view when pelvic tilt is not properly visualized from the lateral view, in order to determine a more specific treatment plan for spinal complaints.
Sacrum pubic incidence and sacrum pubic posterior angle: two morphologic radiological parameters in assessing pelvic sagittal alignment in human adultsEur Spine J. 2014 Jul;23(7):1427-32. doi: 10.1007/s00586-014-3300-4. Epub 2014 Apr 22.
Wang W1, Wu M, Liu Z, Xu L, Zhu F, Zhu Z, Weng W, Qiu Y
Both SPI and SPPA are reliable parameters for determining the morphology of the pelvis. The SPI is precise in predicting PI and PRS1, while SPPA is reliable in predicting FSPA. The SPI and SPPA will allow further study on lateral spinal-pelvic alignment in patients with hip joint abnormalitiesSixty subjects were assessed using radiographic analysis. Reliability analysis showed high intra- and inter- observer agreement, with ICCs ranging from 0.813 to 0.987. The study is limited by using only two observers and 60 subjects.
Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain.Eur Spine J. 2000 Feb;9(1):47-55.

Lazennec JY1, Ramaré S, Arafati N, Laudet CG, Gorin M, Roger B, Hansen S, Saillant G, Maurs L, Trabelsi R.
Appropriate position of the fused vertebrae is also of paramount importance to minimize muscle work during posture maintenance. The main risk is failing to correct or to causing excessive pelvic retroversion with a vertical sacrum leading to a sagittal alignment that replicates the sitting position. This situation is often accompanied by loss of lumbar lordosis and adversely affects stiff or degenerative hips.Connection is that the use of x-ray to evaluate sacral base angle and lumbar lordosis is important to understand the correlation to pain levels with the musculature supporting normal posture.]
Sagittal alignment of the cervical spine in the setting of adolescent idiopathic scoliosisJ Neurosurg Spine. 2018 Nov 1;29(5):506-514. doi: 10.3171/2018.3.SPINE171263.
Akbar M1, Almansour H1, Lafage R2, Diebo BG3, Wiedenhöfer B4, Schwab F2, Lafage V2, Pepke W
Alignment of the cervical spine is closely related to thoracic curvature and global alignment. In patients with AIS, a hypokyphotic thoracic alignment or posterior global alignment was associated with a global cervical kyphosis. Interestingly, upper cervical and cranial parameters were not statistically different in all investigated groups, meaning that the upper cervical spine was not recruited for compensation in order to maintain a horizontal gaze.The article supports the case that creating a desired mechanical change in the human body first requires a comprehension of the current mechanical status of the subject’s body as well as a means of comparison after the procedure to change the mechanics is completed. Moreover, it sought to test whether changing lower regions of the spine (in scoliosis patients) would positively affect the cervical spine. It is strong in its comprehension of the thoracic regional changes and how they relate to the lower cervicals. It openly admits that it is weak regarding its appreciation of the upper cervical region of the spine. The study was also retrospective pertaining to one institution, meaning its sample size is inherently limited—but for a single-center study it is thorough.
Sagittal balance of the pelvic-spine complex and lumbar degenerative diseases. A comparative study of 85 cases.Eur Spine J. 2007 Sep;16(9):1459-67. Epub 2007 Jan 9
Barrey C1, Jund J, Noseda O, Roussouly P.

Data suggested that patients with lumbar diseases have variations of sagittal alignment such as less distal lordosis, more proximal lumbar lordosis, and a more vertrical sacrum. It is clear that pelvic anatomy (pelvic incidence) and pelvic positioning (pelvic tilt & Sacral Angle) determines the amplitude of biomechanical stressors placed on different structures in the spine (facets vs. discs). Increased biomechanical stress due to hyperlordosis or hypolordosis of the lumbar spine in relation to pelvic alignment increases risk for intervertebral disc or facet joint degeneration and injury, respectively. Despite pelvic incidence, CBP demonstrates ability to change pelvic tilt, sacral angle and lubar lordosis and thus may be preventative in degenerative conditions, particularly with changes in lumbar lordosis.
Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases.Eur Spine J. 2007 Sep;16(9):1459-67. Epub 2007 Jan 9.

Barrey C1, Jund J, Noseda O, Roussouly P.
the shape of the pelvis appeared well influence the type of degenerative disease observed seeing that patients with disc lesions were characterized by a normal or low PI with straight spine whereas degenerative spondylolisthesis population demonstrated pronounced spinal curves with great PI.xrays used to assess the pelvic positioning to not its relevance in understanding the sacro/pelvic element of spinal degeneration. Connection includes the use of films to better understand spinal decay.
Sagittal equilibrium of the pelvis: analysis of the inclination of the ischio-pubic ramus from the horizontalRev Chir Orthop Reparatrice Appar Mot. 2000 Jun;86(4):390-5.
[Article in French]
Lecoq C1, Jacquemier M, Dutour O, Jouve J, Garron E, Bollini G.
The interdependence of sagittal radiographic parameters of the pelvis and the spine have been largely demonstrated. Certain pathological situations (isthmic spondylolysis with spondylolisthesis, lower back pain, etc.) can be explained by the value of these parameters, particularly incidence. The inclination of the ischio-pubic ramus from the horizontal reflects the periacetabular region. When analyzed in the sagittal plane, it was found to be a more stable parameter, independent of most clinical criteria (particularly age, and etiology) and of the other radiographic parameters studied. The only determining factor appears to be acquisition of the upright position. The consistency of this parameter constrasts with the variability of the other radiographic parameters of the pelvis and the spine, particularly incidence, although the inclination of the ischio-pubis ramus is an expression of a region different than the pelvis. This study suggests that the periacetabular region plays a key role in acquisition of the upright position in humans. The periacetabular region would be a fixed point around which the lower limbs and spine describe varying orientations.
Sagittal lumbar and pelvic alignment in the standing and sitting positions. (USE THIS STUDY TO POINT OUT THAT SITTING FURTHER INCREASES SPINAL STRESS WITH ABNORMAL CURVATURES AND HOW IMPROTANT PROPER SPINAL ALIGNMENT IS FOR PEOPLE WHO SIT A LOT FOR WORK)J Orthop Sci. 2012 Nov;17(6):682-6. doi: 10.1007/s00776-012-0281-1. Epub 2012 Aug 23.

Endo K1, Suzuki H, Nishimura H, Tanaka H, Shishido T, Yamamoto K.
This study showed that LLA decreased by approximately 50 % and PT increased by approximately 25 % in the sitting position compared with the standing position. No significant gender differences were observed for LLA, SS, and PT in the standing position. In the sitting position, however, LLA and SS were markedly larger for women.Use of xray to determine the difference in lumbar lordosis and sacral base angle in a standing and sitting position. Connection is the use of xray to accurately determine these changes was necesary.
Sagittal plane analysis of the spine and pelvis in adolescent idiopathic scoliosis according to the coronal curve typeSpine (Phila Pa 1976). 2003 Jul 1;28(13):1404-9.
Mac-Thiong JM1, Labelle H, Charlebois M, Huot MP, de Guise JA.
Thoracic kyphosis depended mostly on the spinal deformity, whereas lumbar lordosis was influenced mainly by the pelvic configuration. The scoliotic curve type was not associated with a specific pattern of sagittal pelvic morphology and balance. The pelvic incidence found in this study was significantly higher than that reported in the literature for normal adolescents. The role of the pelvic incidence in the pathogenesis of adolescent idiopathic scoliosis needs to be explored in a longitudinal study involving patients with adolescent idiopathic scoliosis and normal adolescents.
Sagittal plane considerations and the pelvis in the adult patientSpine (Phila Pa 1976). 2009 Aug 1;34(17):1828-33. doi: 10.1097/BRS.0b013e3181a13c08.
Schwab F1, Lafage V, Patel A, Farcy JP.
It has become evident that good clinical outcome in the treatment of spinal deformity requires proper alignment. Pelvis parameters play an essential role not only in terms of spine morphotypes but also in regulating standing balance and postoperative alignment. Thus, optimal treatment of a patient with spinal deformity requires integration of the pelvis in the preoperative evaluation and treatment plan.
Sagittal plane segmental motion of the cervical spine. A new precision measurement protocol and normal motion data of healthy adults.Frobin W1, Leivseth G, Biggemann M, Brinckmann P Clin Biomech (Bristol, Avon). 2002 Jan;17(1):21-31Flexion-extension radiographs of the cervical spine are performed to explore potential damage to the bony or ligamentous structure resulting in abnormal, segmental motion patterns. Determining rotational motion gives only an incomplete picture. The new protocol allows for precise quantification of translational motion and classification of segments as hypo- or hypermobile by comparison with normal motion data.137 lateral cervical xrays were evaluated to establish norms for cervical ROM using new electronic measurement methods (2002)
Sagittal spinopelvic alignment and body mass index in patients with degenerative spondylolisthesisEur Spine J. 2011 May;20(5):713-9. doi: 10.1007/s00586-010-1640-2. Epub 2010 Dec 1.
Schuller S1, Charles YP, Steib JP.
The detailed analysis of segmental lordosis revealed that the lordosis increased at the levels above the spondylolisthesis, which might subsequently increase posterior stress on facet joints. The association of overweight and a relatively vertical inclination of the S1 endplate is predisposing for an anterior translation of L4 on L5. Furthermore, the sagittally oriented facet joints do not retain this anterior vertebral displacement.
Sagittal standing posture, back pain, and quality of life among adults from the general population: a sex-specific association.Araújo F1, Lucas R, Alegrete N, Azevedo A, Barros H.
Spine (Phila Pa 1976). 2014 Jun 1;39(13):E782-94. doi: 10.1097/BRS.0000000000000347.
In males, differences in back pain severity were observed only among pelvic tilt/pelvic incidence ratio groups. Females presenting high pelvic incidence and sacral slope exhibited higher odds of severe back pain than those with intermediate values (adjusted odds ratios = 2.21 and 2.15; 95% confidence interval, 1.24-3.97 and 1.21-3.86; respectively). Sagittal vertical axis showed the largest differences in physical quality of life of females: high group had 8.8 lower score than the low group (P
Variance in Sagittal standing posture in males does not predict quality of life outcomes. In females it does.
Scoliosis deformity reduction in adults: a CBP® Mirror Image® case series incorporating the 'non-commutative property of finite rotation angles under addition' in five patients with lumbar and thoraco-lumbar scoliosis.Harrison DE1, Oakley PA2.;J Phys Ther Sci. 2017 Nov; 29(11): 2044–2050.
Published online 2017 Nov 24. doi: 10.1589/jpts.29.2044
This unique treatment approach offers a patient-specific, targeted structural rehabilitative procedure to stress the spine towards a more straightened configuration. Adult lumbar and thoraco-lumbar curves can be reduced and improved by these non-invasive CBP methods.correcting Scolosis with CBP protocol among 5 patients
Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series.Morningstar, M.W., Woggon, D. & Lawrence, G.
BMC Musculoskelet Disord 5, 32 (2004) doi:10.1186/1471-2474-5-32
The combined use of spinal manipulation and postural therapy appeared to significantly reduce the severity of the Cobb angle in all 19 subjects. These results warrant further testing of this protocol.Scoliosis is a fairly common presentation in the chiropractic office. It can be attributed to severe postural imbalances as well as reduced quality of life due to pain and discomfort. By using both specific and physical therapies, scoliosis (Cobb angle) was reduced signficantly within a 4-6 week time frame. In this study, the patient outcome was substantial, however, the reduction of the Cobb angle can only be quantified with pre and post x-rays.
Should Chiro follow the ACA/ABIM recommendations on x-ray?see Dr. Arnone number index21. Should Chiropractic Follow the American Chiropractic Association _ American Board of Internal Medicine’s Recommendations on X-Ray_ - US Chiropractic DirectoryThe visual assessment of cervical and lumbar lordosis is unreliable. In contrast, the reliability of x-ray in morphology, measurements and biomechanics has been determined accurate and reproductible. Based upon the literature, radiation is not cumulative and has rendered no evidence of long term effects. There is no evidence that x-ray has long term health effects. Chiropractors should weigh the adavantages and disadvantages in routine x-ray prescriptions
Slight Head Extension: Does it change the saggital Curve? Authors: Harison D, Harrison D., Janik T, Holland B, Siskin L. Eur Spine J (2001) 10 :149–153
DOI 10.1007/s005860000228
Therefore, when slightly flexed head positions
are visualized on initial radiographs and not on posttreatment
radiographs, surgical and conservative kyphotic
alignment changes verified post-radiographically are likely
due to treatment interventions.
Slight changes in head extention (less than 14 degrees) do not change cervical kyphosis into cervical lordosis. In other words evaluating patients with cervical kyphosis using xray imaging is difficult to manipulate with regard to shifting cervical kyphosis into cervical lordosis using head extension to a degree less than 14 degrees.
Sling-based infant carrying affects lumbar and thoracic spine neuromechanics during standing and walking.Schmid S1, Stauffer M2, Jäger J3, List R4, Lorenzetti S5. Gait Posture. 2019 Jan;67:172-180. doi: 10.1016/j.gaitpost.2018.10.013. Epub 2018 Oct 12.Compared to unloaded walking, carrying the dummy in front was mainly associated with increased lumbar lordosis (standing: (Δ8.8°, p = 0.006; walking: (Δ ≥ 8.2°, 1-100% of gait cycle [%GC], p 
Good article in regards to posture and weight bearing
Space Available for Cord, Motion, and disc degeneration at the adjacent segments level of degenerative cervical spondylolisthesis using kinematic MRI.J Clin Neurosci. 2017 Nov;45:89-99. doi: 10.1016/j.jocn.2017.07.029. Epub 2017 Aug 7.
Paholpak P1, Nazareth A2, Barkoh K2, Lee LV2, Lucas J3, Buser Z4, Wang JC2.
In conclusion, DCS affected cervical spine motion and kinematics. Grade 1 retrolisthesis showed tendency of narrower SAC at the cephalad level more than the same grade anterolisthesis. The likelihood of the adjacent segment disease and spinal cord compression are higher in both grade 2 anterolisthesis and retrolisthesis.
Spinal facet joint biomechanics and mechanotransduction in normal, injury and degenerative conditions. (BIOMECHANICALLY HEAVY BUT ABLE TO TALK ABOUT FACET FORCES WITH DIFFERENT DEGREES OF MOTION, USE TO DEMONSTRATE INCREASED STRESS ON JOINTS WITH MISALIGNMENT)J Biomech Eng. 2011 Jul;133(7):071010. doi: 10.1115/1.4004493.
Jaumard NV1, Welch WC, Winkelstein BA.
Overall, the goal of this review is to present a comprehensive review of the breadth and depth of knowledge regarding the mechanical and adaptive responses of the facet joint and its tissues across a variety of relevant size scales.
Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies.(The results of this study may be in part due to lack of proper X-ray guided treatments)Ann Intern Med. 2003 Jun 3;138(11):871-81.
Assendelft WJ1, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.
There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.
Spinal Posture in the Sagittal Plane Is Associated With Future Dependence in Activities of Daily Living: A Community-Based Cohort Study of Older Adults in JapanThe Journals of Gerontology: Series A, Volume 68, Issue 7, 1 July 2013, Pages 869–875 Kojiro Kamitani, Takehiro Michikawa, Satoko Iwasawa, Norihito Eto, Taichiro Tanaka, Toru Takebayashi, Yuji NishiwakiThis study indicates that spinal inclination is associated with future dependence in ADL among older adults.This study indicates that spinal inclination is associated with future dependence in ADL among older adults. It also lists several complications of poor posture as well as stating a study that shows even mildly positive sagittal balance is somewhat detrimental and the decline in health status increases in a linear ashion with progressive sagittal imbalance. This study also concludes that the incliniaiton is associated with future dependence in ADL among older adults warrants wide attention. Given this information, the chiropractic approach to preventing worsening posture and/or correcting posture can prevent future dependency in ADLs.
Spinopelvic alignment in patients with osteoarthrosis of the hip: a radiographic comparison to patients with low back painSpine (Phila Pa 1976). 2005 Jul 15;30(14):1650-7.
Yoshimoto H1, Sato S, Masuda T, Kanno T, Shundo M, Hyakumachi T, Yanagibashi Y.
These findings suggest that higher PI in the younger individual may contribute to the development of HOA in later life without both lumbar kyphosis and acetabular dysplasia because of the anterior uncovering of the acetabulum. More investigation will be expected to analyze the spinopelvic alignment in patients with hip spine syndrome.
Spinopelvic Parameters in Asymptomatic Subjects Without Spine Disease and Deformity: A Systematic Review With Meta-AnalysisClin Spine Surg. 2017 Nov;30(9):392-403. doi: 10.1097/BSD.0000000000000533.
Noshchenko A1, Hoffecker L, Cain CMJ, Patel VV, Burger EL
The pooled results and developed methodology can be used as diagnostic criteria for evaluation of the spinopelvic parameters, planning of surgical interventions and evaluation of the treatment effectThis study demonstrates the challenges associated with determining optimal postural values in the pelvic and lumbar spine as there are many contributing factors. However, an important concept brought to light in this study is that Pelvic Incidence (PI) has a significant positive correlation with age which is opposite to the age related changes of Lumbar Lordosis. Previous studies have assumed that PI is a constant, unchanging variable, yet this study shows PI is impracted by different physiological, pathological and treatment confounders. This study suggests 2 factors for PI change over time 1) Sagittal rotational displacement of pelvis proportional to decreaseing of Sacral Slope and Reciprocal increasing of Pelvic Tilt and 2) Anterior Displacment of femoral heads due to weakening of pelvic femoral ligaments and msucles. From a chiropractic standpoint, sagittal rotation can be addressed via adjustments and a limitation to these two suggestions is the exclusion of loss of cervical lordosis overtime resulting in compenstion in the pelvic sagittal alignment.
Spinopelvic Parameters: Lumbar Lordosis, Pelvic Incidence, Pelvic Tilt, and Sacral Slope: What Does a Spine Surgeon Need to Know to Plan a Lumbar Deformity Correction?Neurosurg Clin N Am. 2018 Jul;29(3):323-329. doi: 10.1016/
Celestre PC1, Dimar JR 2nd2, Glassman SD2.
The pelvic incidence defines the amount of lordosis required in the lumbar spine, and a lumbar lordosis within 11° of the pelvic incidence defines alignment of the lumbo-pelvic region. Pelvic tilt is a compensatory mechanism that allows patients to achieve sagittal balance in the setting of decreased lumbar lordosis with the primary compensatory mechanisms being hip extension and knee flexion. Planning an adult lumbar deformity operation requires a comprehensive history and physical examination and thorough radiographic evaluation with the goal of restoring alignment between the pelvic incidence and lumbar lordosis and restoring a normal pelvic tilt.
Spontaneous Improvement of Compensatory Knee Flexion After Surgical Correction of Mismatch Between Pelvic Incidence and Lumbar LordosisCheng X1, Zhang F, Wu J, Zhu Z, Dai K, Zhao ,Spine (Phila Pa 1976). 2016 Aug 15;41(16):1303-9. doi: 10.1097/BRS.0000000000001405The PI-LL mismatch would contribute to compensatory knee flexion during standing in patients with lumbar degenerative disease. Surgical correction of the PI-LL mismatch could lead to a spontaneous improvement of compensatory knee flexion. The degree of improvement in knee flexion depends in part on the amount of correction in the PI-LL mismatchIn the results, a strong correlation between knee flexion angle and pelvic tilt confirm that pelvic retroversion is directly associated with knee flexion. Knee flexion can result in some potentiallly adverse effects and is related to the longer duration of knee pain. Chiropractic approaches have been shown to correct lumbar lordosis and pelvic tilt. This article demonstrates that correction of lumbar lordosis and pelvic tilt can improve knee flexion posture and thus potentially decrease the risk of developing adverse outcomes in the knee and possibly relieve knee pain. Also, this article suggests that having a patient straighten the knees during saggital plain radiographs may allow for a more accurate assessment of spinal posture.
Standing working posture and musculoskeletal pain among citrus sinensis workers in a low-income country.France N1, Artwell K1, Tatenda S1.
Int J Occup Saf Ergon. 2018 Nov 9:1-27. doi: 10.1080/10803548.2018.1544799. [Epub ahead of print]
Analyses generally showed statistically significant associations (p  1 in 77.2% of the workers and caused upper arm pain in 66.3%, the association between the upper score and upper pain was statistically significant (χ2 = 20.57; p 
Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms.J Manipulative Physiol Ther. 1998 Jan;21(1):37-50.

Troyanovich SJ1, Harrison DE, Harrison DD.
Because mechanical loading of the neuromusculoskeletal tissues plays a vital role in influencing proper growth and repair, chiropractic rehabilitative care should focus on the normalization/minimization of aberrant stresses and strains acting on spinal tissues. Manipulation alone cannot restore body postures or improve an altered sagittal spinal curve. Therefore, postural chiropractic adjustments, active exercises and stretches, resting spinal blocking procedures, extension traction and ergonomic education are deemed necessary for maximal spinal rehabilitation. Chiropractic studies that demonstrate structural improvements are sorely lacking and needed. The use of passive treatment modalities as the sole means of chiropractic intervention for the management of patients suffering with neuromusculoskeletal dysfunction no longer has a place in modern chiropractic practice after the acute phase of healing has passed.
Subjecting Radiologic Imaging to the Linear No-Threshold Hypothesis: A Non Sequitur of Non-Trivial Proportion.J Nucl Med. 2017 Jan;58(1):1-6. doi: 10.2967/jnumed.116.180182. Epub 2016 Aug 4.
Siegel JA1, Pennington CW2, Sacks B3.
The present work calls for ending the radiophobia caused by those asserting the need for dose optimization in imaging: the low-dose radiation of medical imaging has no documented pathway to harm, whereas the LNTH and ALARA most assuredly do.The linear no-threshold hypothesis (LNTH) has dominated the medical community for decades with no evidence of increased cancer risk in doses under 100mGy used in medical imaging. We are exposed to anywhere from 1-260 mSv from our environment depending on where we live on the planet. Adverse events cannot be found in the literature associated with this regular exposure. The scientific literature actually shows that low-dose exposure increases a protective biological response which repairs DNA above and beyond the initial insult, whereas the high dose can overwhelm this protective response and increase damage. ALARA (as low as reasonably achievable) precedence is simply not based on sound science. This rampant radiophobia not only leads to reduced quality of imaging, but also reduces the likelihood of finding a potential contraindication or adaptation to care in the chiropractic office.
Subluxation induced cervical Myelopath: Pilot Study **McAlpine, James E, DC Chiropractic Research Journal Volume 2, Number 1 1991Although this pper relates the upper cervical subluxation to the postural changes in the spine, resulting in degenerative changes and spondylotic myelopathy it should be obvious that this insult to the central nervous system at this particular level must have a profound effect on the total health picture of each individual.
Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: A prospective, multicenter, cohort studyEriksen et al. BMC Musculoskeletal Disorders 2011, 12:219 our findings need to be confirmed in subsequent randomized studies for definitive risk-benefit assessment, the preliminary data shows that the benefits of upper cervical chiropractic care may outweigh the potential risksThis study demonstrates the effectiveness and low risk of severe adverse reactions with upper cervical techniques that utilize X-ray analysis. Outcome assessments were significantly improved with less than 3 weeks of care with a high level of patient satisfaction. Over a 17-day treatment period, perceived neck disability as related to activities of daily living captured by the NDI improved by 13.3 points (100 point scale) (47.1%) at follow-up. The ODI improved by 11.3 points (100 point scale) (45.0%) difference. The percentage of patients that returned to a sub-clinical status (SCS) at follow-up was reported. Based on NRS for neck pain, 62.2% of the total sample was at a SCS after approximately 2 weeks of UC chiropractic care. Of those that had a baseline of ≥3 neck pain NRS (which is CSS pain), 57.1% achieved SCS. For headache patients the percentages were slightly higher with 68.0% at a SCS on follow-up and for those with baseline pain ≥ 3 NRS, 62.7% reached SCS. Patients that presented with thoracic or lumbar pain reached SCS after a
short trial of UC chiropractic care for 67.9% and 62.1%, respectively for the total sample. At follow-up, 42.2% reached SCS for cervical disability according to the NDI, and 37.6% of those patients with ≥10 points
Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic PopulationsAJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.
Brinjikji W1, Luetmer PH2, Comstock B3, Bresnahan BW4, Chen LE4, Deyo RA5, Halabi S6, Turner JA7, Avins AL8, James K4, Wald JT1, Kallmes DF1, Jarvik JG9.
Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient's clinical condition.Even in patients with no symptoms, many of them have signs of spine dengerations, the risks increase with age.
T1 slope and degenerative cervical spondylolisthesis.Spine (Phila Pa 1976). 2015 Feb 15;40(4):E220-6. doi: 10.1097/BRS.0000000000000722.
Jun HS1, Kim JH, Ahn JH, Chang IB, Song JH, Kim TH, Park MS, Kim YC, Kim SW, Oh JK.
The DCS group was characterized by a greater T1 slope than the control group; therefore, we suggest that a high T1 slope may be a predisposing factor in developing DCS.
Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects.Eur Spine J. 2013 Apr;22(4):708-13. doi: 10.1007/s00586-012-2500-z. Epub 2012 Sep 19.
Matsumoto M1, Okada E, Toyama Y, Fujiwara H, Momoshima S, Takahata T.
Degenerative findings in both the lumbar and cervical spine, suggesting tandem disc degeneration, was common in asymptomatic subjects. These results provide normative data for evaluating patients with degenerative lumbar and cervical disc diseases.Even in patients with no symptoms, many of then have DDD, in the lumbar spine the risk is 84% in the lumbar spine

Journal of Contemporary Chiropractic, 1(1), 9-19. The persistent debate about the validity of spinal
subluxation needs to end. In this day and age the
chiropractic profession needs to be beyond irrelevant
debate and acknowledge that the lack of biomechanical,
engineering and mathematical education is what has
stumped the universal acceptance of contemporary
subluxation concepts – not its inexistence. As presented,
there certainly exists ‘vertebral subluxation,’ albeit various
types; and all of these subluxation types satisfies criteria
required for valid subluxation theory and scientific
inquiry. These validated subluxation models should be
further tested for their impact on patient conditions, for
the most appropriate corrective interventions, and for
their correlations to improved patient outcomes in clinical
The persistent debate about the validity of spinal
subluxation needs to end. In this day and age the
chiropractic profession needs to be beyond irrelevant
debate and acknowledge that the lack of biomechanical,
engineering and mathematical education is what has
stumped the universal acceptance of contemporary
subluxation concepts – not its inexistence. As presented,
there certainly exists ‘vertebral subluxation,’ albeit various
types; and all of these subluxation types satisfies criteria
required for valid subluxation theory and scientific
inquiry. These validated subluxation models should be
further tested for their impact on patient conditions, for
the most appropriate corrective interventions, and for
their correlations to improved patient outcomes in clinical
The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features.Spine (Phila Pa 1976). 2010 Mar 1;35(5):531-6. doi: 10.1097/BRS.0b013e3181aa5b33.
de Schepper EI1, Damen J, van Meurs JB, Ginai AZ, Popham M, Hofman A, Koes BW, Bierma-Zeinstra SM.
We are the first to report different possible lumbar disc degeneration definitions and their associations with LBP. Disc space narrowing at 2 or more levels appeared more strongly associated with LBP than other radiographic features, especially after excluding level L5-S1.
The association between lumbar spine radiographic features and low back pain: a systematic review and meta-analysis.Seminars in Arthritis and Rheumatism
Volume 44, Issue 5, April 2015, Pages 571-585
Raastad J1, Reiman M2, Coeytaux R3, Ledbetter L4, Goode AP5;
A significant association was found between disc space narrowing in both community- and occupational-based populations without significant differences between the associations. A significant strong association was found between spondylolisthesis and LBP among the occupational group but was weakly associated in the community-based group, which supports that spondylolisthesis may contribute a specific cause for LBP.Disc space narrowing and sponylolisthesis were associated with LBP more so than other xray findings such as facet degeneration.
The Canadian cervical spine rule for radiography in alert and stable trauma
Stiell IG, Wells G, Vandemheen KL, Clement CM, Lesiuk H,
De Maio VL, Laupacis A, Schull M, et al. JAMA 2001;286:1841-8
We have derived the Canadian C-Spine Rule, a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients. If prospectively validated in other cohorts, this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography.
The CBP® mirror image® approach to reducing thoracic hyperkyphosis: a retrospective case series of 10 patients.Oakley, Paul & Jaeger, Jason & Brown, John & Polatis, Todd & Clarke, Jeremiah & Whittler, Clint & Harrison, Deed. (2018). The CBP ® mirror image ® approach to reducing thoracic hyperkyphosis: a retrospective case series of 10 patients. Journal of Physical Therapy Science. 30. 1039. 10.1589/jpts.30.1039. 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.This is an amazing article to show case how the CBP protocol reduces thoracic kyphosis. Very god artiicle with iimages and the date of before after measuremtns from 10 patients
The characteristics of spinopelvic sagittal alignment in patients with lumbar disc degenerative diseasesEur Spine J. 2014 Mar;23(3):569-75. doi: 10.1007/s00586-013-3067-z. Epub 2013 Oct 20.
Yang X1, Kong Q, Song Y, Liu L, Zeng J, Xing R.
PI may play a predisposing role in the pathogenesis of lumbar disc degenerative diseases. The secondary structural and compensatory factors would lead to a straighter spine after disc degenerative change
The cohort study for the determination of reference values for spinopelvic parameters (T1 pelvic angle and global tilt) in elderly volunteersEur Spine J. 2016 Nov;25(11):3687-3693. Epub 2016 Feb 1.
Banno T1, Togawa D2, Arima H2, Hasegawa T2, Yamato Y2, Kobayashi S2, Yasuda T2, Oe S2, Hoshino H2, Matsuyama Y2.
We determined reference values for spinopelvic parameters in elderly volunteers. Similar to SVA, TPA and GT correlated with HRQOL. TPA, GT, PT, and PI-LL were worse in women and progressed with age.
The craniocervical junction: embryology, anatomy, biomechanics
and imaging in blunt trauma
Curtis Edward Offiah & Emily Day, Insights Imaging (2017) 8:29–47
DOI 10.1007/s13244-016-0530-5
Imaging of the blunt traumatic injuries to the craniocervical
junction can be challenging but central to improving morbidity
and mortality related to such injury. The radiologist has a
significant part to play in the appropriate management of patients
who have suffered injury to this vital junction between
the cranium and the spine.
A thourough evaluation of craniocervical junction anatomy and injuries of related structures in trauma. Should be required reading for CC junction education.
The degenerative cervical spine.Llopis E1, Belloch E2, León JP2, Higueras V2, Piquer J2. Radiologia. 2016 Apr;58 Suppl 1:13-25. doi: 10.1016/j.rx.2015.11.009. Epub 2016 Feb 12. Plain-film X-rays continue to be fundamental, because they make it possible to evaluate the alignment and bone changes; they are also useful for follow-up after treatment.A brief article focussed on cervical spine anatomy and pathology. It does however state that radiography is essential to evaluate alignement and bone change.
The effect of adding forward head posture corrective exercises in the management of lumbosacral radiculopathy: a randomized controlled study.J Manipulative Physiol Ther. 2015 Mar-Apr;38(3):167-78. doi: 10.1016/j.jmpt.2014.11.009. Epub 2015 Feb 20.
Moustafa IM1, Diab AA2.
The addition of forward head posture correction to a functional restoration program seemed to positively affect disability, 3-dimensional spinal posture parameters, back and leg pain, and S1 nerve root function of patients with chronic discogenic lumbosacral radiculopathy.
The effect of cervical spine subtypes on center of pressure parameters in a large asymptomatic young adult populationDaffin L1, Stuelcken MC2, Sayers MGL Gait Posture. 2018 Oct 1;67:112-116. doi: 10.1016/j.gaitpost.2018.09.032Our data suggest that sagittal plane cervical alignment is a measure capable of distinguishing between the postural control of asymptomatic lordotic and non-lordotic young adult participants on both surfaces types. Furthermore, decreased postural control is present in asymptomatic participants across all non-lordotic subtypes and is not isolated exclusively to those with forward head posture. Consequently, future research endeavours should investigate the clinical significance of these non-lordotic findings in relation to both the potential for early cervical osseous degeneration and the transitional stages of non-specific pain sufferers from previously asymptomatic young adults
The study links decreased postural control with decreased cervical lordosis in asymptomatic patients. No clinical relavence or conclusions within this study.
The effect of normalizing the sagittal cervical configuration on dizziness, neck pain and cervicocephalic kinesthetic sensibility: A 1-year randomized controlled study.SMI Abdl Mageed, EEM Abutaleb, AME Soliman, A Mohamed Labib;
Eur J Phys Rehabil Med. 2017 Feb;53(1):57-71. doi: 10.23736/S1973-9087.16.04179-4. Epub 2016 Aug 30.
The addition of Denneroll™ cervical extension traction to a multimodal program positively affected pain, cervicocephalic kinesthetic sensibility, dizziness management outcomes at long-term follow-up.Denneroll cervical extension traction and a multimodal program can help correct abnormal hypolordosis in the cervical spine providing chronic pain relief, improved posture, and provide dizziness relief. X-rays allow for imaging to document improvement and corrections made. X-rays are required to determine in a patient has any anomalies and rule them in or out for the procedure.

***Check authors listed. Authors attributed to the article (Moustafa, Diab, Harrison) are not the same ones listed on here.
The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study.Moustafa IM1, Diab AA2, Harrison DE3.; Eur J Phys Rehabil Med. 2017 Feb;53(1):57-71. doi: 10.23736/S1973-9087.16.04179-4. Epub 2016 Aug 30.The addition of Denneroll™ cervical extension traction to a multimodal program positively affected pain, cervicocephalic kinesthetic sensibility, dizziness management outcomes at long-term follow-up. Appropriate physical therapy rehabilitation for cervicogenic dizziness should include structural rehabilitation of the cervical spine (lordosis and head posture correction), as it might to lead greater and longer lasting improved function.1a-1g Great article for our use.
Alteration in cervical lordosis and forward head translation causes both a reduction in ROM and altered seg. Cervical spine kinematic patterns. Ultimately this alteration in sagittal cervical spine alignment could potentially lead to altered sensorimotor integration through altered afferent input do to a change in kinematics.
Restoring Cervical lordosis and reducing Forward head posture with extension traction device had positive impact at long-term follow-up in patients with cervicogenic dizziness.
The effect of posture on the fluid content of lumbar intervertebral discs. Adams MA, Hutton WC. Spine 1983;8:665-71.The results showed that "flexed" discs lost more fluid, especially from the nucleus pulposus, than did the "erect" discs. It is concluded that fluid flow in flexed postures can aid the nutrition of the lumbar discsDecreased height of the disc leads to facet loading and DJD as well as a decrease in IVF space and mechanical deficiencies. It also leads to increased incidence of disc prolapse. Slouching accelorates this process. DJD reduces rate of fluid loss. Disc prolaps is more likely in the morning. Movement plays a minor roll in fluid transfusion and prolonged recumbant posture in sleeping restores fluid to the disc.
The effect of posture on the role of the apophysial joints in resisting intervertebral compressive forces. Adams MA, Hutton WC. J Bone Joint Surg.[Br.] 1980;62:358-62.The results show that, after the intervertebral disc has been reduced in height by a period of sustained loading, the apophysial joints resist about 16 per cent of the intervertebral compressive forces in the erect standing posture, whereas in the erect sitting posture they resist none. The implications of this in relationship to degenerative changes and to low backache are discussed.

The effects of bite line deviation on lateral cervical radiographs when upper cervical joint dysfunction exists - a pilot studyStitzel CJ1, Morningstar MW, Paone PR
J Manipulative Physiol Ther. 2003 Sep;26(7):E17.

If a bite line deviation exists, dynamic cervical flexion and extension radiographs should be taken to calculate the max tolerances in the upper cervical spinal joints. These tolerances serve as the limits for variation before the mesasurement of the cervical spin is altered and the liklelihood of measurement error increases to 20.3%
The efficacy of cervical lordosis rehabilitation for nerve root function, pain, and segmental motion in cervical spondylotic radiculopathyMoustafa, Ibrahim & A, Diaab & A, Ahmed & Harrison, Deed & Shousha, Tamer. (2011). Physiotherapy. 97. eS1-eS1638. Improved lordosis in the study group was associated with significant improvements in nerve root function, VAS rating, and translational and rotational motions of the lower cervical spine.
The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial.Clin Rehabil. 2012 Apr;26(4):351-61. doi: 10.1177/0269215511419536. Epub 2011 Sep 21.
Diab AA1, Moustafa IM.
Forward head posture correction using a posture corrective exercise programme in addition to ultrasound and infrared radiation decreased pain and craniovertebral angle and increased the peak-to-peak amplitude of dermatomal somatosensory evoked potentials for C6 and C7 in cases of lower cervical spondylotic radiculopathy.
The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial.
Diab AA1, Moustafa IM. Clin Rehabil. 2012 Apr;26(4):351-61. doi: 10.1177/0269215511419536. Epub 2011 Sep 21.There was a significant difference between groups adjusted to baseline value of outcome at 10 weeks post-treatment for craniovertebral angle, pain, C6 and C7 peak-to-peak amplitude of dermatomal somatosensory evoked potentials P = 0.000, 0.01, 0.000, 0.001 respectively and at follow-up for all previous variables (P = 0.000). Forward head posture correction using a posture corrective exercise programme in addition to ultrasound and infrared radiation decreased pain and craniovertebral angle and increased the peak-to-peak amplitude of dermatomal somatosensory evoked potentials for C6 and C7 in cases of lower cervical spondylotic radiculopathy.MECHANICAL DESTERBASNCES IS ONE OF THE MOST DETERIORATIVE FACTORS FOR CERVICAL SPONDYLOSIS. Posture, mechanics, and nerve root function improved with strengthening the deep cervical flexors and shoulder retractors as well as stretching the cervical extensors and pectoral is muscles along with infrared radiation and ultrasound. Results less with the group who just received ultrasound and radiation.
The efficacy of lumbar extension traction for sagittal alignment in mechanical low back pain: a randomized trial.J Back Musculoskelet Rehabil. 2013;26(2):213-20. doi: 10.3233/BMR-130372.
Diab AA1, Moustafa IM.
Lumbar extension traction in addition to stretching exercises and infrared radiation improved the spine sagittal balance parameters and decreased the pain and disability in CMLBP.
The femoro-sacral posterior angle: an anatomical sagittal pelvic parameter usable with dome-shaped sacrumEur Spine J. 2007 Feb;16(2):219-25. Epub 2006 Mar 17.
Legaye J
The validation of this parameter was performed and compared with the classical published parameters. It showed good inter-observer reliability, even with dome-shaped sacral plate. In spite of lower correlation with the positional parameters than those observed with PI or PR-S1, the FSPA appeared to be reliable and precise for an exact evaluation of the sagittal spino-pelvic balance is case of spondylo-listhesis with dome-shaped sacral endplate.The pelvic tilt is an essential measure in the context of radiographic evaluation of spinal pain and malalignment. There is a need to establish a reporducable measurement of pelvic alignment in those with sacral end plate deformities, particularly of the anterior/middle aspect. This study shows that utilization of the posterior tip of sacral end plate in order to measure pelvic perameters is a reliable assessment in order to determine a more specific treatment plan for spinal complaints when there are sacral end plate deformites.
The Impact of Kyphosis on Daily FunctioningStephen D. Ryan MD, MPH; J Am Geriatr Soc. 1997 Dec;45(12):1479-86.Kyphosis, by both clinical and quantitative assessment, is associated with diminished function, especially performance of mobility tasks. This association should be verified prospectively. If predictive, the impact of kyphosis on physical function should be considered in osteoporosis prevention and treatment counselingThis article is associating kyphosis to decreased physical functions. However, it did not specify which region of the body.
The impact of obesity on compensatory mechanisms in response to progressive sagittal malalignmentSpine J. 2017 May;17(5):681-688. doi: 10.1016/j.spinee.2016.11.016. Epub 2016 Dec 1.
Jalai CM1, Diebo BG2, Cruz DL1, Poorman GW2, Vira S1, Buckland AJ1, Lafage R2, Bess S1, Errico TJ1, Lafage V2, Passias PG3.
With progressive sagittal malalignment, obese patients differentially recruit lower extremity compensatory mechanisms, whereas non-obese patients preferentially recruit pelvic mechanisms. The ability to compensate for progressive sagittal malalignment with the pelvic retroversion is limited by obesity
The impact of positive sagittal balance in adult spinal deformity.Spine (Phila Pa 1976). 2005 Sep 15;30(18):2024-9.

Glassman SD1, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F.
This study shows that although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms increases in a linear fashion with progressive sagittal imbalance. The results also show that kyphosis is more favorable in the upper thoracic region but very poorly tolerated in the lumbar spine.Xrays were in use to determine lumbar lordosis in respect to the C7 plumb line in a sagital position. Connection is related to understanding with great specificity which is provided by xray, where the plumb line sits and how that affects the lumbar spine.
The impact of spinopelvic morphology on the short-term outcome of pedicle subtraction osteotomy in 104 patients Neurosurg Spine. 2017 Jul;27(1):74-80. doi: 10.3171/2016.11.SPINE16601. Epub 2017 Apr 28.
Eskilsson K1, Sharma D2, Johansson C1, Hedlund
PSO resulted in a substantial correction of sagittal imbalance and improved outcome in most patients in this study. Correction of the global sagittal balance appears to be a necessary precondition for a good outcome. A harmonious spine with a TK and an LL of similar magnitude seems to add to a positive outcome.This article states that degenerative loss in lordosis is generated by age without discussion of postural issues increasing the rate of degeneration over time. This is deceiving as it suggests that loss of lordosis due to degeneration is innevitable. This study discusses how a single Pedicle Subtraction osteotomy can have an effect on global sagittal balance. However, there is no long term follow up and no discussion on biomechanical motion of the spinal segments post surgical intervention. However, this study does demonstrate that a harmonious spine in an upright position limits pain and increases quality of life. Prevention and chiropractic approaches should be discussed as this has been shown to have benefit in people with postural challenges without the risks associated with surgery. Correction of the lumbar lordosis has a clear effect on other aspects of spinal health as well as the health in the lower extremities. Early detection and correction of altered lordosis through a conservative approach may prevent surgical need and should be considered with postural or pain disorders of the spine.
The importance of plain radiography in the evaluation of radiculopathy after failed diskectomy.Bronson WH , Koehler SM , Qureshi SA , Hecht AC
Orthopedics [12 May 2010, 33(5):96-101]
Type: Journal Article, Case Reports
DOI: 10.3928/01477447-20100329-23 The Digital Object Identifier (DOI) System enables identification of digital entities
The patient underwent revision lumbar decompression with attention being paid to the removal of the calcified annulus and disk material that resulted in complete resolution of his symptoms. Although MRI is the diagnostic test of choice in the evaluation of spinal pathology, plain radiographs can provide important additional information that can be vital to the successful outcome of patients undergoing revision spinal surgery.
The importance of spino-pelvic balance in L5-s1 developmental spondylolisthesis: a review of pertinent radiologic measurements.Spine (Phila Pa 1976). 2005 Mar 15;30(6 Suppl):S27-34.
Labelle H1, Roussouly P, Berthonnaud E, Dimnet J, O'Brien M.
Spino-pelvic balance in the sagittal plane can be considered as an open linear chain linking the head to the pelvis where the shape and orientation of each successive anatomic segment are closely related and influence the adjacent segment. Pelvic morphology and spino-pelvic balance are abnormal in developmental spondylolisthesis. These abnormalities should be quantified on lateral standing radiographs of the spine and pelvis and have important implications for the evaluation and treatment of this pathologic condition.X-rays in the chiropractic office are essential for the proper evaluation and treatment of patients entering the office. Developmental spondylolisthesis is an example of such a condition in which the treatment chosen, based upon specific radiographs, determines the very best outcome. Should proper evaluation not occur, patients can further deteriorate, or at worst, given the wrong treatment and have a very poor outcome. According to this study, those that presented with a L5I and slip angle were the only group that responded well to a surgical intervention, the others did not fair as well. This simple, low cost approach to evaluating this condition can not only spare the majority of people with developmental spondylolisthesis from having invasive surgery, but only recommend surgery to those that would benefit.
The influence of thoracic inlet alignment on the craniocervical sagittal balance in asymptomatic adults.J Spinal Disord Tech. 2012 Apr;25(2):E41-7. doi: 10.1097/BSD.0b013e3182396301.
Lee SH1, Kim KT, Seo EM, Suk KS, Kwack YH, Son ES.
The thoracic inlet alignment had significant correlations with craniocervical sagittal balance. To preserve physiological NT around 44 degrees, large TIA increased T1 slope and CL and vice versa. TIA and T1 slope could be used as parameters to predict physiological alignment of the cervical spine. The results of this study may serve as baseline data for the evaluation of sagittal balance or planning of a fusion angle in the cervical spine.
The linear no-threshold relationship is inconsistent with radiation biologic and experimental data.Radiology. 2009 Apr; 251(1): 13–22.
doi: 10.1148/radiol.2511080671

Maurice Tubiana, MD, Ludwig E. Feinendegen, MD, Chichuan Yang, MD, and Joseph M. Kaminski, MD
Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv (,10,,103,,147,,163). Surveys of second primary malignancies in patients who have undergone radiation therapy should provide more information. The fears associated with the concept of LNT and the idea that any dose, even the smallest, is carcinogenic lack scientific justificationThe linear no threshold theory assumes low doses of x-ray have a linear relationship with high doses. It does not take into account DNA repair at low doses(below 100 mSv).
The Lumbar Pelvic Angle, the Lumbar Component of the T1 Pelvic Angle, Correlates With HRQOL, PI-LL Mismatch, and it Predicts Global AlignmentSpine (Phila Pa 1976). 2018 May 15;43(10):681-687. doi: 10.1097/BRS.0000000000002346.
Protopsaltis TS1, Lafage R2, Smith JS3, Passias PG1, Shaffrey CI3, Kim HJ2, Mundis GM4, Ames CP5, Burton DC6, Bess S7, Klineberg E8, Hart RA9, Schwab FJ2, Lafage V2; International Spine Study Group.
LPA correlates with TPA, PI-LL, and HRQOL in ASD patients. LPA can be used as an intraoperative tool to gauge correction with a target LPA of
The Predictable Factors of the Postoperative Kyphotic Change of Sagittal Alignment of the Cervical Spine after the LaminoplastyJ Korean Neurosurg Soc. 2017 Sep;60(5):577-583. doi: 10.3340/jkns.2017.0505.007. Epub 2017 Aug 30.
Lee JS1,2,3, Son DW1,2,3, Lee SH1,2,3, Kim DH1,2,3, Lee SW1,2,3, Song GS1,2,3.
Laminoplasty has a high probability of aggravating sagittal balance of the cervical spine. T1 slope is a good predictor of postoperative kyphotic changes of the cervical spine. Similarly, T1 slope is strongly correlated with C2-C7 SVA.
The prevalence of neck pain in the world population: A systematic critical review of the literatureFejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population: A systematic critical review of the literature. European Spine Journal. 2006 Jun;15(6):834-848
The relationship between changes of cervical sagittal alignment after anterior cervical discectomy and fusion and spino-pelvic sagittal alignment under roussouly classification: a four-year follow-up study.Huang DN1, Yu M1, Xu NF1, Li M1, Wang SB1, Sun Y1, Jiang L1, Wei F1, Liu XG2, Liu ZJ1.; BMC Musculoskelet Disord. 2017 Feb 20;18(1):87. doi: 10.1186/s12891-017-1447-y.The backward movement of head occurs is the compensatory mechanism in cervical sagittal alignment modifications after ACDF. The compensatory alteration of spino-pelvic sagittal alignment varied in different Roussouly type.posterior translation of the head is associated with ACDF (Anterior cervical discectomy and fusion)
The relationship between head posture and severity and disability of patients with neck pain.Yip CH1, Chiu TT, Poon AT. Man Ther. 2008 May;13(2):148-54. Epub 2007 Mar 23.
The CV angle in subjects with neck pain is significantly smaller than that in normal subjects. There is moderate negative correlation between CV angle and neck disability. Patients with small CV angle have a greater forward head posture, and the greater the forward head posture, the greater the disability.Measuring CV angle has high inter examiner reliablility and would be useful to monitor head posture. Small CV angle => forward head posture => neck pain and increased likelyhood of disability.
The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis.Spine J. 2017 Aug;17(8):1180-1191. doi: 10.1016/j.spinee.2017.04.034. Epub 2017 May 2.
Chun SW1, Lim CY2, Kim K2, Hwang J3, Chung SG4.
This meta-analysis demonstrates a strong relationship between LBP and decreased LLC, especially when compared with age-matched healthy controls. Among specific diseases, LBP by disc herniation or degeneration was shown to be substantially associated with the loss of LLC.Demonstrates a strong relationship between LBP and decreased Lumbar Lordotic Curve, especially when compared with age-matched healthy controls. Overall, patients with LBP tended to have smaller Lumbar Lordotic Angles than healthy controls.
The role of forward head correction in management of adolescent idiopathic scoliotic patients: a randomized controlled trial.Clin Rehabil. 2012 Dec;26(12):1123-32. doi: 10.1177/0269215512447085. Epub 2012 Jul 16.
Diab AA1.
A forward head corrective exercise programme combined with conventional rehabilitation improved three-dimensional scoliotic posture and functional status in patients with adolescent idiopathic scoliosis.This study finds that anterior head carriage needs to be considered in scoliosis management. Functional Rating Index improvements lasted longer with muscular exercises targeting the cervical curve. Scoliosis measurements were done with 3d posture parameters using Formetric II device not x-ray. Improvement of craniovertebral angle noted.
The role of radiography in primary care patients with low
back pain of at least 6 weeks duration: a randomised (unblinded)
controlled trial.
KendrickD, Fielding K, Bentley E,Miller P,KerslakeR, Pringle
M. Health Technol Assess 2001;5:1-69.
Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning, severity of pain or overall health status, and is associated with an increase in GP workload. Participants receiving X-rays are more satisfied with their care, but are not less worried or more reassured about serious disease causing their low back pain. CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH: Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients, and the needs of patients and GPs to be reassured about missing serious disease. Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least 6 weeks.
The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial.Health Technol Assess. 2001;5(30):1-69.
Kendrick D1, Fielding K, Bentley E, Miller P, Kerslake R, Pringle M.
Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning, severity of pain or overall health status, and is associated with an increase in GP workload. Participants receiving X-rays are more satisfied with their care, but are not less worried or more reassured about serious disease causing their low back pain. CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH: Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients, and the needs of patients and GPs to be reassured about missing serious disease. Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least 6 weeks.
The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. Health Technol Assess. 2001;5(30):1-69
Kendrick D1, Fielding K, Bentley E, Miller P, Kerslake R, Pringle M.
Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least 6 weeks.Clinicals peform routine low back pain x-rays without "Red flags". Consistency is needed in when to prescribe low back x-rays. While This study reflects that the outcome of care was unimproved by the use of radiographic procedure; there were not practitioners that utilized any form of manipulative or therapeutic care in the study. The only care utilized was perscriptive medications. Of note is that all patients were more satisfied when they recieved radiographs.
The routine use of radiographic spinal displacement analysis: A dissent.Hass M, Taylor JAM, Gillete RG.
J Manipulative Physiol Ther 1999;22:254-9.
Dynamic function is the key to spinal analysis; static radiographs cannot uncover spinal dysfunction for all the stated reasons. My congratulations to the authors for seeing the problems so clearly and stating them so succinctly.

The significance of correlation of radiographic variables and MOS short-form health survey for clinical decision in symptomatic low back pain patients. Stud Health Technol Inform. 2002;91:325-31.Korovessis P Dimas A Lambiris E

SF-36 scores were correlated with distinct lateral roentgenographic variables of the lowermost lumbar spine (L4-S1) in low back patients, and of the whole lumbar spine in asymptomatic individuals. Clinical decision should not be taken on the basis of radiological evidence of pathology because clinical decision seems to be more accurate when is taken on the basis of combined SF-36 and roentgenographic data. However, clinical examination is mandatory to SF-36 questionnaire and radiographic analysis.
The study of correlation between forward head posture and neck pain in Iranian office workers.Meziat-Filho N1, Azevedo E Silva G2, Coutinho ES3, Mendonça R4, Santos V5.J Back Musculoskelet Rehabil. 2017;30(3):467-475. doi: 10.3233/BMR-150339.The prevalence of NP was 48.9%. The ones who watched TV lying supine in bed for 2 hours or more a day yielded an odds ratio (OR) of 6.21 (1.45-26.52) for acute neck pain (ANP). Who watched TV and used the desktop in the slump posture yielded, respectively, an OR of 4.0 (1.63-9.85), and 2.03 (1.23-3.34) for chronic neck pain (CNP). The ones who frequently changed their positions while using the desktop and used it for 2 hours or more a day yielded an OR of 0.34 (0.14-0.85) for ANP.Our findings support the high prevalence of NP in adolescence and raise the association between some HPH and neck pain.
The study of correlation between forward head posture and neck pain in Iranian office workers.Nejati P1, Lotfian S2, Moezy A1, Nejati M3. Int J Occup Med Environ Health. 2015;28(2):295-303. doi: 10.13075/ijomeh.1896.00352.High thoracic and CV angles were positively correlated with the presence of neck pain only in working position (p 0.05). Our findings have revealed that office employees had a defective posture while working and that the improper posture was more severe in the office employees who suffered from the neck pain.
The Superiority of Plain Radiography to Magnetic Resonance Imaging in Determining Lumbar Lordosis Angles in Patients with Disc HerniationJournal of Medical Imaging and Health Informatics, Volume 8, Number 9, December 2018, pp. 1782-1785(4)
Dagistan, Emine
Lumbar disc herniation decreases lumbar lordosis and we suggest that lumbar lordotic angles should be measured by direct plain radiographies in standing position in these patients. Nevertheless, beside a detailed medical history and physical examination, the diagnosis and treatment should be decided by a combination of MRI and standing plain radiograph in subjects with herniated lumbar discs.
The use of the T1 sagittal angle in predicting overall sagittal balance of the spineSpine J. 2010 Nov;10(11):994-8. doi: 10.1016/j.spinee.2010.08.031.
Knott PT1, Mardjetko SM, Techy F.
This analysis shows that many factors influence the overall sagittal balance of the patient, but it may be the position of the pelvis and lower spine that have a stronger influence than the position of the upper back and neck. Unfortunately, to our knowledge, there are no studies to date that have established a normal sagittal T1 tilt angle. However, our analysis has shown that when the T1 tilt was higher than 25°, all patients had at least 10 cm of positive sagittal imbalance. It also showed that patients with negative sagittal balance had mostly low T1 tilt values, usually below 13° of angulation. The T1 sagittal angle is a measurement that may be very useful in evaluating sagittal balance, as it was the measure that most strongly correlated with SVA(dens). It has its great utility where long films cannot be obtained. Patients whose T1 tilt falls outside the range 13° to 25° should be sent for full-column radiographs for a complete evaluation of their sagittal balance. On the other hand, a T1 tilt within the above range does not guarantee a normal sagittal balance, and further investigation should be performed at the surgeon's discretion.
The value of erect radiographs in cervical spine injury.Scher AT S Afr Med J. 1980 Oct 4;58(14):574-5Certain flexion injuries of the cervical spine may be evident radiologically only if the patient is radiographed in the erect position. Because radiographs of an injured patient are usually obtained in the supine position, the abovementioned injuries may be overlooked
TheT1 pelvic angle, a novel radiographic measure of global sagittal deformity, accounts for both spinal inclination and pelvic tilt and correlates with health-related quality of lifeJ Bone Joint Surg Am. 2014 Oct 1;96(19):1631-40. doi: 10.2106/JBJS.M.01459.
Protopsaltis T1, Schwab F1, Bronsard N2, Smith JS3, Klineberg E4, Mundis G5, Ryan DJ1, Hostin R6, Hart R7, Burton D8, Ames C9, Shaffrey C3, Bess S10, Errico T1, Lafage V1; International Spine Study Group.
The T1 pelvic angle correlates with health-related quality of life in patients with adult spinal deformity. The T1 pelvic angle is related to both pelvic tilt and sagittal vertical axis; however, unlike sagittal vertical axis, it does not vary on the basis of the extent of pelvic retroversion or patient support in standing. Since the T1 pelvic angle is an angular and not a linear measure, it does not require calibration of the radiograph. Thus, the T1 pelvic angle measures sagittal deformity independent of many postural compensatory mechanisms, and it can be useful as a preoperative planning tool, with a target T1 pelvic angle of
Thoracic hyperkyphosis non invasively measured by general practitioners is associated with chronic low back pain: A cross-sectional study of 1364 subjects.Villafañe JH1, Bissolotti L2, Zaina F3, Arienti C4, Donzelli S5, Negrini S6. J Bodyw Mov Ther. 2018 Jul;22(3):752-756. doi: 10.1016/j.jbmt.2017.12.001. Epub 2017 Dec 6.Multivariate logistic regression analysis revealed that gender (OR = 1.70), RMDQ score (OR = 0.51) and thoracic hyperkyphosis (C7 + L3 at the plumb-line distance) (OR = 1.57) were associated with CLBP. The final regression model explained 85.6% (R2 = 0.56; P
Thoracic Inlet Parameters for Degenerative Cervical Spondylolisthesis Imaging Measurement.Wang Q1, Wang XT1, Zhu L1, Wei YX; Med Sci Monit. 2018 Apr 5;24:2025-2030.Patients with preoperative sagittal imbalance of thoracic inlet have a statistically significant increased risk of DCS. T1 slope of more than 22.0º showed significantly diagnostic value for the incidence of DCS.Imbalance of the cervical spine in sagittal plane may explain the phenomena for the cases with Degenerative Cervical Spondylolisthesis (DCS). The disc degeneration may result in the slipping and loss of lordosis, which is also the cause of sagittal anterior imbalance. Therefore, anterior translation of the axis of gravity (Anterior Head Carriage) may also result in the sliding force observed for the patients with DCS.
Three-dimensional spinal coupling mechanics: Part I. A review of the literature.J Manipulative Physiol Ther. 1998 Feb;21(2):101-13.
Harrison DE1, Harrison DD, Troyanovich SJ.
Postural rotations and translations, which are the main motions studied in spinal coupling research, and altered configurations of the normal sagittal plane curves are the cause of both normal and abnormal spinal coupling patterns in three dimensions.
Three-years incident of low back pain in an
initially asymptomatic cohort: clinical and imaging risk factors.
Jarvik JG, Hollingworth W, Haegerty PJ, Haynor DR, Boyko
EJ, Deyo RA.
Spine 2005;30:1541-8.
Depression is an important predictor of new LBP, with MRI findings likely less important. New imaging findings have a low incidence; disc extrusions and nerve root contact may be the most important of these findings.
Traction VS Supine side-bending radiographs in determining flexibilitySpine (Phila Pa 1976). 2007 Nov 1;32(23):2604-9.
Watanabe K1, Kawakami N, Nishiwaki Y, Goto M, Tsuji T, Obara T, Imagama S, Matsumoto M.

In addition to a Cobb angle, other factors such as patient age, the level of the apex, and the number of involved vertebrae also influence the conditions under which the corrective ability of traction radiographs is superior to that of side-bending radiographs. Factors such as age, level of the apex and the number of the involved vertebrae have a direct effect on the traction potential of the patient
Treating 'slouchy' (hyperkyphosis) posture with chiropractic biophysics®: a case report utilizing a multimodal mirror image® rehabilitation program.Fortner MO1, Oakley PA2, Harrison DE3; J Phys Ther Sci. 2017 Aug;29(8):1475-1480. doi: 10.1589/jpts.29.1475. Epub 2017 Aug 10.We suggest that the postural correction of those with various pain symptoms be considered as a first line non-pharmalogical, non-surgical rehabilitation approach for those presenting with poor posture.Case study for a 30 year old female succeessfully correct her thoracic kyphosis with CBP EAT protocol
Treatment and ergonomics training of work-related lower back pain and body posture problems for nurses.Jaromi M1, Nemeth A, Kranicz J, Laczko T, Betlehem J. J Clin Nurs. 2012 Jun;21(11-12):1776-84. doi: 10.1111/j.1365-2702.2012.04089.x.The statistical analysis of repeated measures indicated a significant decrease in back pain intensity after the therapy in both groups, compared with measurements before the therapy; however, the BS group showed significantly better results during the six-month and one-year follow-up period. The biomechanical analysis of postures after the therapy in the BS group showed significant improvements over the control group; during the follow-up, the difference was still significant, yet slightly reduced.This study has shown that a significant reduction in the pain intensity and improvement in body posture can be achieved by the usage of the active physical therapy methods (Back School) in nurses who are experiencing chronic lower back pain.Strengthening, stretching, ergonomics training and posture eduction showed significant reduction in LBPn at 12 months. Passive methods showed equal short term benefit, but significantly reduced long term benefits. In essence, chronic poor posture reduces the bodies ability to function optimally and lowers resistance to external and internal universal forces.
Two-dimensional digital photography for child body posture evaluation: standardized technique, reliable parameters and normative data for age 7-10 years.
Scoliosis Spinal Disord. 2017;12:38. Published 2017 Dec 19. doi:10.1186/s13013-017-0146-7 Stolinski L, Kozinoga M, Czaprowski D, et al.In summary, although both the surface topography and the radiological evaluation cannot be replaced with digital photography—the former for the 3D imaging, the latter for skeletal imaging—this technique offers a new additive value to human posture imaging. The development of digital photography technique allows for its regular use in the assessment of body posture. The method of child preparation and positioning described above allows us to avoid incidentally modified posture. The registration of images is simple, quick, harmless and cost-effective. The semi-automatic image analysis has been developed. The choice of postural parameters was based on previous publications and on personal experience and can be modified. The photographic method of body posture assessment developed during this study is characteristic of high reliability of measurements. The five developed and calculated photographic parameters (sacral slope, thoracic kyphosis, lumbar lordosis, chest inclination, and head protraction) describe the child body posture in the sagittal plane and demonstrate good repeatability and reproducibility, which may become a standard for body posture evaluation in children. Performing such a large series of measurements in children resulted in the preparation of normal values and percentile charts for age and sex, making it possible for us to employ the photographic parameters possible in the diagnosis of child posture pathology as well as to monitor the effects of corrective therapy.This article discusses the effects of poor posture and the importance of screening for spinal posture in children and that radiological evaluation cannot be replaced with digital photography. Therefore, strategies to correct spinal misalignment or prevent worsening of spinal posture should, at least initially, be based on radiographic analysis then possible monitored by other postural analysis techniques.
Upper Cervical Manipulation Combined with Mobilization for the Treatment of Atlantoaxial Osteoarthritis: A Report of 10 CasesJ Manipulative Physiol Ther. 2011 Feb;34(2):131-7. doi: 10.1016/j.jmpt.2010.12.005.
Yu H1, Hou S, Wu W, He X.
This case series suggests that some of the signs and symptoms of atlantoaxial facet osteoarthritis, which can occur in the elderly because of degenerative disorder and younger patients because of trauma, may be improved by upper cervical spinal manipulation combined with mobilization with a mechanical device.
Validity of a decision rule to reduce
cervical spine radiography in elderly patients with blunt
Touger M, Gennis P, Nathanson N, Lowery DW, Pollark CV,
Hoffman JR, Mower WR. Ann Emerg Med 2002;40:287-93
he study group consisted of 2,943 (8.6%) geriatric patients, representing 8.6% of the entire NEXUS sample. The rate of CSI was twice as great in these patients as it was in nongeriatric patients (4.59% versus 2.19%). Odontoid fractures were particularly common in geriatric patients, accounting for 20% of geriatric fractures compared with 5% of nongeriatric fractures. The frequency of patients meeting NEXUS criteria was similar in the 2 groups, with 14% of geriatric patients and 12.5% of nongeriatric patient classified as low risk. CSI occurred in only 2 low-risk geriatric patients, and these patients' injuries met our preset definition of a clinically insignificant injury. The sensitivity of the NEXUS decision instrument for clinically significant injury in the geriatric group was therefore 100% (95% confidence interval 97.1% to 100%).

The prevalence of CSI, and especially odontoid fracture, is relatively increased among geriatric patients with blunt trauma. The NEXUS decision instrument can be applied safely to these patients, with an expected reduction in cervical imaging comparable with that achieved in nongeriatric patients.
Views on radiography use for patients with acute low back
pain among chiropractors in an Ontario community.
Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R.
J Manipulative Physiol Ther 2002;25:511-20
There was a 76% response rate to the mailed surveys. Of those who responded, 63% stated they would use radiography on patients with uncomplicated acute low back pain lasting 1 week; 68% stated that radiographs were useful in the diagnostic evaluation of patients with acute low back pain lasting less than 1 month. Most reasons given for use of radiography in this patient population are not supported by existing evidence.
Views on radiography use for patients with acute low back pain among chiropractors in an Ontario community.J Manipulative Physiol Ther. 2002 Oct;25(8):511-20.
Ammendolia C1, Bombardier C, Hogg-Johnson S, Glazier R.
There appears to be a high rate of radiographic use by chiropractors in the study community, which is consistent with findings in previous studies. Many of the reasons given for use of radiography are not supported by existing evidence and may contribute to the gap between current chiropractic practice and available evidence with respect to use of radiography for acute low back pain.Author's conclusions are based on "best practices" within a primary care medical office and their standard "usual care".
When should the
doctor order a spine X-ray? Identifying vertebral fractures for
osteoporosis care: results from the European Prospective
Osteoporosis Study (EPOS).
Kaptoge S, Armbrecht G, Felsenberg D, Lunt M, O'Neill TW,
Silman AJ, Reeve J, EPOS Study Group.
J Bone Miner Res 2004;19:1982-93
A woman 65 years of age with one vertebral fracture has a one in four chance of another fracture over 5 years, which can be reduced to one in eight by treatment. Positive treatment decisions are often contingent on identifying a vertebral fracture. Selective use of lateral vertebral X-rays can be optimized using a 2-minute screening procedure administered by a nurse.
Which parameters are relevant in sagittal balance analysis of the cervical spine? A literature review.Eur Spine J. 2018 Feb;27(Suppl 1):8-15. doi: 10.1007/s00586-018-5462-y. Epub 2018 Jan 13.
Ling FP1, Chevillotte T1, Leglise A1, Thompson W1, Bouthors C1, Le Huec JC2.
The most important parameters to analyse the cervical sagittal balance according to the literature available today for good clinical outcomes are the following: C7 or T1 slope, average value 20°, must not be higher than 40°. cSVA must not be less than 40°C (mean value 20 mm). SCA (spine cranial angle) must stay in a norm (83° ± 9°). Future studies should focus on those three parameters to analyse and compare pre and post op data and to correlate the results with the quality of life improvement.
X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: Radiography Increases Benefits and Reduces Risks.Oakley PA1, Cuttler JM2, Harrison DE; Dose-Response,Dose Response. 2018 Jun 19;16(2):1559325818781437. doi: 10.1177/1559325818781437. eCollection 2018 Apr-JunSpine care guidelines need to be revised to reflect the potential benefits of modern treatments and the lack of health risks from low X-ray doses. This would encourage routine use of radiography in manual spine therapy, which differs from common pharmacologic pain relief practice.(Question 2)2f – Spinal alignment and balance can only be measured adequately from a standing x-ray with regard to sagittal balance and cobb angle. 2p- Does low does radiographich procedure pose a long term or short term health risk. “Low doses of Radiation stimulate many protective systems, including the immune system, it is very unlikely that the low level radiation causes more damage than benefit. Indeed, damage to molecules and cells from low doses can hardly Be observed, while protective mechanisms can be readily seen and quantified. “ p. 5
X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: Radiography Increases Benefits and Reduces Risks. Dose Response.Dose Response. 2018 Jun 19;16(2):1559325818781437. Oakley PA, Cuttler JM, HarrisonChiropractic and manual therapy procedures aimed at the realignment of the structure of the spine can address a wide range of pain, muscle weakness, and functional impairments. Radiographic imaging is necessary to deliver acceptable patient care in the practice of contemporary manual therapy of the spine. Concerns about the risk of cancer are baseless because the dose of a chiropractic spinal X-ray is more than 100 times below the dose threshold for radiogenic leukemia. The threshold for other types of cancer is likely higher. Imaging guidelines need to be updated to reflect current radiobiology and scientific evidence.

Chiropractic and manual therapy procedures aimed at the realignment of the structure of the spine can address a wide range of pain, muscle weakness, and functional impairments. Radiographic imaging is necessary to deliver acceptable patient care in the practice of contemporary manual therapy of the spine. Concerns about the risk of cancer are baseless because the dose of a chiropractic spinal X-ray is more than 100 times below the dose threshold for radiogenic leukemia. The threshold for other types of cancer is likely higher. Imaging guidelines need to be updated to reflect current radiobiology and scientific evidence.

Correlations between Cervical Lordosis, Vital Capacity, T-spine ROM and EquilibriumLee, Yoonmi & Gong, Wontae & Kim, Byungkon. (2011). Correlations between Cervical Lordosis, Vital Capacity, T-spine ROM and Equilibrium. Journal of Physical Therapy Science. 23. 103-105. 10.1589/jpts.23.103.
The Effect of the forward head posture on postural balance in long time computer based workerAnn Rehabil Med. 2012 Feb; 36(1): 98–104. doi: 10.5535/arm.2012.36.1.98 Jung-Ho Kang, Rae-Young Park, Su-Jin Lee, Ja-Young Kim, Seo-Ra Yoon, Kwang-Ik Jung
Kyphosis and incident falls among community-dwelling older adultsMcDaniels, Corinne & Davis, A. & Wing, D. & Macera, Carol & Lindsay, S. & Schousboe, John & Nichols, J. & Kado, Deborah. (2017). Kyphosis and incident falls among community-dwelling older adults. Osteoporosis International. 29. 10.1007/s00198-017-4253-3
Posture Disorders and their causes in rural schools pupilsRadzevičienė, Liuda & Kazlauskas, Andrius. (2016). POSTURE DISORDERS AND THEIR CAUSES IN RURAL SCHOOLS PUPILS. SOCIAL WELFARE: INTERDISCIPLINARY APPROACH. 1. 118. 10.21277/sw.v1i6.241.
Evidence based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture publicationsOakley, Paul & Harrison, Donald & Harrison, Deed & Haas, Jason. (2006). Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. The Journal of the Canadian Chiropractic Association. 49. 270-96.
A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial.Arch Phys Med Rehabil. 2002 Apr;83(4):447-53.
Harrison DE1, Cailliet R, Harrison DD, Janik TJ, Holland B.
Sagittal cervical traction with transverse load at midneck (2-way cervical traction) combined with cervical manipulation can improve cervical lordosis in 8 to 10 weeks as indicated by increases in segmental and global cervical alignment. Magnitude of lordosis at C2-7 remained stable at long-term follow-up.Cervical traction has been used in the chiropractic setting routinely to reduce cervicogenic pain and improve lordosis. To determine pathology, such as loss of disc height, degenerative changes and the degree of loss of cervical lordosis, lateral cervical x-rays are performed and measured using the Cobb method of measurement. 3-point cervical traction accompanied by chiropractic adjustments have been shown to significantly decrease cervicogenic pain and increase cervical lordosis, even up to a 15 ½ month follow up after treatment. Post lateral x-rays, to determine percentage of improvement in cervical lordosis is key to understanding how proper cervical biomechanics plays a role in cervicogenic pain and related symptomatology.
A normal sagittal spinal configuration: a desirable clinical outcome.J Manipulative Physiol Ther. 1996 Jul-Aug;19(6):398-405.
Harrison DD1, Troyanovich SJ, Harrison DE, Janik TJ, Murphy DJ.
The usual, typical or normal configuration of the cervical spine in the sagittal dimension is a lordosis with a range of 16.5-66 degrees when measured as tangent lines along the cervical curve of the posterior vertebral body margins of C2 and C7. An analysis of stresses and strains supports this claim, as do studies from the scientific literature that attempt to measure and classify average cervical configuration from large population bases. The use of normative data as a gauge against which to measure patients' structural health and as an outcome of the degree of success or failure of chiropractic interventions seem to be logical consequences of these findings.
A review of biomechanics of the central nervous system--part II: spinal cord strains from postural loads.J Manipulative Physiol Ther. 1999 Jun;22(5):322-32.
Harrison DE1, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO.
Flexion of any part of the spinal column may generate axial tension in the entire cord and nerve roots. Slight extension is the preferred position of the spine as far as reducing the magnitude of mechanical stresses and strains in the central nervous system is concerned.
A review of biomechanics of the central nervous system--Part III: spinal cord stresses from postural loads and their neurologic effects.J Manipulative Physiol Ther. 1999 Jul-Aug;22(6):399-410.
Harrison DE1, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO.
The most offensive postural loading of the central nervous system and related structures occurs in any procedure or position requiring spinal flexion. Thus flexion traction, rehabilitation positions, exercises, spinal manipulation, and surgical fusions in any position other than lordosis for the cervical and lumbar spines should be questioned.
Analysis of the cervical spine sagittal alignment in young idiopathic scoliosis: a morphological classification of 120 casesYu M1, Silvestre C, Mouton T, Rachkidi R, Zeng L, Roussouly P.
Eur Spine J. 2013 Nov;22(11):2372-81. doi: 10.1007/s00586-013-2753-1. Epub 2013 Apr 12.

see Dr. Arnone number index6. CervicalSagitalangle
The cervical kyphosis in young patients with idiopathic scoliosis is correlated with global sagittal alignment. The morphology of cervical kyphosis can be manifested in wedging-shaped vertebrae and kyphotic inter-vertebral spaces. Cervical sagittal alignment in idiopathic scoliosis is correlated with global sagittal alignment. Compensational spinal coupling in response to cervical saggital alignment appears take place in order to maintain a forward, horizontal gaze. Cervical Non-Kyphotic individules had a more appropriate global saggital alignment as well as pelvic tilt. The more severe the cervical kyphosis the less optimal the thoracic kyphosis which appears to correlate with coronal alignment. This serves to suggest, that correction of cervical kyphosis, along with saggital pelvic alignment, may have a positive impact on global spinal alignment in those with AIS, neither of which may be properly assessed without assistance of diagnostic imaging.
Chiropractic biophysics technique: a linear algebra approach to posture in chiropractic.J Manipulative Physiol Ther. 1996 Oct;19(8):525-35.

Harrison DD1, Janik TJ, Harrison GR, Troyanovich S, Harrison DE, Harrison SO.
The unique inverse functions of rotations, reflections and translations provide a theoretical basis for making postural corrections in neutral static resting posture. Chiropractic biophysics technique (CBP) uses these concepts in examination procedures, manual spinal manipulation, instrument assisted spinal manipulation, postural exercises, extension traction and clinical outcome measures.CBP practitioners explaining the need for more linear equations related to rotations, reflections and translations in the Chiropractic education to better understand misalignment. Xrays were used to measure these misaligments to help with mirror imaging adjusting. It was suggested that post treatment xrays can help with determining success of correction.
Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods.Ferrantelli JR1, Harrison DE, Harrison DD, Stewart D.; J Manipulative Physiol Ther. 2005 Mar-Apr;28(3):e1-8.A patient with chronic WADs and abnormal head protrusion, cervical kyphosis, and disk herniation experienced an improvement in symptoms and function after the use of CBP rehabilitation protocols when other traditional chiropractic and physical therapy procedures showed little or no lasting improvement.1C, 1E structural correction of the cervical spine with CBP rehabilitation may result in Improvement in chronic symptoms. This was a case study so not too high in strentgh but great starting point in the benefit of improvement in chronic pain and posture on quality of life.