What is CBP® Technique?

In December 1980, CBP® Technique (Chiropractic Biophysics ®) was originally named by Drs. Donald Harrison, Deanne Harrison, and Daniel Murphy for “physics applied to biology in chiropractic”. After a few years, it became apparent that the name was being confused with Biophysics, a field of study usually associated with topics such as energy in molecular bonds. Thus, in the late 1990’s, a new name was derived for a more accurate description of the procedures being utilized, i.e., Clinical Biomechanics of Posture® (CBP®). Since 1980, there have been numerous CBP® Texts written.^1-7

Until 1980, the majority of chiropractors were attempting to adjust single vertebral subluxations with specific lines of drive. While a few upper cervical techniques could demonstrate some before and after x-ray changes, in general, the adjusting of single vertebra did not result in x-ray changes (except in acute antalgic postures). In March 1980, Dr. Don Harrison originated postural set-ups that he coined “Mirror Image®”. Clinically, these adjusting set-ups were found to result in postural and x-ray changes; this impression would be subjected to studies later.

For these new Mirror Image® patient positions, Dr. Don Harrison placed the patient in their opposite posture. These Harrison Mirror Image® positions can be described as “reflecting” the patient’s head, rib cage, and/or pelvis across the median-sagittal plane in the AP view, and positioning the head, rib cage, and/or pelvis across the mid-frontal plane in the lateral view. Prior to performing CBP® Mirror Image® postural set-ups, the patient’s initial presenting abnormal posture(s) must be exactly determined.

            While others have used engineering concepts to describe all vertebral segmental movements as rotations and translations in 3-dimensions,⁸ Dr. Don Harrison was the first to describe abnormal postures of the head, rib cage, and pelvis in this manner. (Figures 1 & 2) For each of these postures illustrated in Figures 1 and 2, Dr. Don Harrison originated drop table adjustments, instrument adjustments (both table and hand-held), and exercises in the Mirror Image® posture as evidenced by his videos and books from 1980-1986. Additionally, for use in difficult cases, he originated Mirror Image® postural traction for several of these rotations and translations of the head, rib cage, and pelvis. Also from 1980-1986, he originated cervical extension traction methods to restore the sagittal cervical curve. These Harrison cervical extension traction methods were improved upon by other CBP® practitioners, such as Dr. Mike Fisk (Spokane, WA), Dr. Dwight DeGeoerge (Saugus, MA) and Dr. Mile Pope (Troy, OH).           

Although CBP® procedures resulted in clinically documented corrections in posture and cervical curve configurations from 1986-1996, methods to restore thoracic and lumbar sagittal curvatures awaited the graduation of Dr. Deed Harrison. Dr. Deed Harrison originated methods of lumbar curvature and thoracic cage postural traction that made routine changes in lumbar lordosis possible. He further refined the CBP® sagittal cervical traction methods with an analysis of head posture, curve configuration, thoracic curvature, gender, and body size.

Figure 1. The possible translations (Tx, Ty, Tz) of the head rib cage and pelvis are depicted in 3-dimensions (the positive x-axis is to the left, positive z-axis is anterior, and the positive y-axis is superior8). In 1980, Dr. Don Harrison termed these pairs on any one axis as Mirror Images®. Whichever postures were found to exist in the patient, these postures would be stressed into their Mirror Image® before a force was applied with an adjusting instrument, drop table, exercise and/or traction. © Dr. Sanghak O. Harrison

Figure 2. The possible rotations (Rx, Ry, Rz) of the head rib cage and pelvis are depicted in 3-dimenesions. In 1980, Dr. Don Harrison termed these pairs on any one axis as Mirror Images®. Whichever postures were found to exist in the patient, these postures would be stressed into their Mirror Image® before a force was applied with an adjusting instrument, drop table, exercise and/or traction. © Dr. Sanghak O. Harrison

Why Traction?

Biomechanical studies have established that long-term biomechanical adaptation requires a constant force over a period of time.⁹ Traction delivers a constant force over a period of time. An important and unique aspect of the CBP® technique is the utilization of traction.  In line with this thinking, long-term corrections of abnormal spinal postural distortions would require a force applied over a period of time, and this can be achieved with traction. Clinical investigations of this premise have proven it to be correct; our traction protocols have proven to result in long-term correction of spinal postural distortions.^10-15 However, CBP® Traction is not the flexion-axial traction encountered in the medical/PT literature; CBP® Traction is to correct posture and to restore the sagittal spinal curvatures.

Goals of Care

            Many in chiropractic are turning away from structural outcomes of care to concentrate on pain reduction, improved ranges of motion (ROM), and other functional outcomes. In contrast, CBP® emphasizes optimal posture and spinal alignment as the primary goal of chiropractic care, while still documenting improvements in pain and functional based outcomes.¹⁶ Even though some authors¹⁷ in chiropractic claim that an optimal and average spinal model does not exist, CBP® research on this topic, based on averages of normal subjects, has been published in some of the most prestigious orthopaedic journals in the Index Medicus.^18-23 CBP® has published normal shapes, normal global angles (C2-C7, T2-T11, and L1-L5), and normal segmental angles for each of the sagittal spinal regions (cervical, thoracic, and lumbar). These are “evidence based” models. In fact, the CBP® sagittal lumbar elliptical model¹⁹ and the sagittal circular cervical model²³ have been found to have predictive validity in as much as they can discriminate between normal subjects, acute pain subjects, and chronic pain subjects.

To establish optimal and average sagittal models, x-ray line drawing procedures were utilized. CBP® protocols require that the doctor measure the patient’s abnormal posture (global Subluxation) and measure the displacements on spinal radiographs (segmental Subluxation). While some in the chiropractic research arena believe x-ray analysis to be unreliable¹⁷, this is the minority position. The CBP® x-ray line drawing procedures have been studied and shown to be reliable.^24-27 The postural and spinal displacements are the determining factors for deriving the patient’s individualized program of care. While our critics claim that posture, x-ray positioning, and x-ray line drawing are not reliable, our published research shows that these procedures are highly repeatable.²⁸

Duration of Care

Initially, patients are given their choice of receiving (1) pain relief care for their symptoms and/or restoration of functional ROM (which usually entails 6-12 visits), or (2) corrective care for their abnormal posture and spinal displacements (usually a minimum of 24-30 visits). Relief care consists of any number of segmental adjusting techniques the Chiropractor prefers to utilize including but not limited to: Diversified, Gonstead, Activator, Applied Kinesiology, Motion Palpation, etc… While Corrective care consists of CBP® exercises, adjustments, and traction performed in the Mirror Image® (referred to as the E.A.T protocol).

To determine if the CBP® E.A.T protocol of corrective care for each individual (based on his/her posture and spinal displacements) is achieving the desired normalization of posture and spinal alignment, re-examinations are suggested at 36 visit intervals. This 36 visit number is not based on personal opinion, but rather is an average duration from six CBP® Clinical Control Trials.^10-15 To arrive at this 36 visit time period, one may have 4 visits per week for 9 weeks or 3 visits per week for 12 weeks. From our six Clinical Control Trials, the average chronic pain patient achieved 50% correction from their initial position towards our radiographic normals (difference between initial and normal in AP and lateral spine studies). This indicates that, on average, a typical chronic pain patient may need 2 blocks of 36 visits of intensive corrective chiropractic care (defined as 3 or 4 visits per week).

The frequency and duration of further care recommended to the patient at the re-evaluation depends on their improvements in structural and functional based outcomes. If the patient achieved a near-normal posture and spinal alignment at the first re-evaluation, then stabilization care is recommended (which is a reduced frequency of visits). However, if at the first corrective care re-evaluation, less than average improvement is attained on comparative radiographs and digital postural photographs, then there is indication that at least another block of 36 visits will be necessary for optimal spinal correction. With CBP®’s six completed Clinical Control Trials, our methods have moved from the clinical opinion arena to having firm foundation in the category of “evidence based” care.

Irrespective of opinion, global Subluxations (postural) & segment Subluxations (spinal) cause an increase in spinal loads (compressive and shear) and spinal stresses. Due to the increased muscle effort required to stabilize abnormal postural/spinal displacements, the actual increase in load on the spine is much higher than merely the displacement itself.^29-33 The presence of mechanosensitive and nociceptive afferent fibers in spinal tissues (intervertebral disc, facet, ligaments, and muscles),^34-37 and the subsequent neurophysiological research demonstrating the role of such afferent stimulation in pain production,^38-39 and coordinated neuromuscular stabilization of the spine^40-41 all provide a substantial theoretical framework supporting the rationale for goals of treatment regimens to include a reduction of stresses on spinal joints in spinal rehabilitation programs.  

Uniqueness of Care

            Unlike the relief care phase (approximately 3 weeks), which includes segmental adjusting procedures from other named techniques, the E.A.T corrective care protocol is unique to CBP®. These are Exercise, Adjustments, and Traction with mirror image® positioning. In combination, these “E.A.T.” methods are unique to CBP® Technique. Exercises, Adjustments, and Traction are performed in the Mirror Image® of the postures depicted in Figures 1 and 2. Additionally, traction is performed in the cervical, thoracic, and lumbar regions based on the configurations of the lordotic and kyphotic curvatures. For examples of CBP®’s E.A.T corrective care protocols, a few postural and spinal subluxations in the coronal and sagittal planes will be provided and discussed. First, however, we must state that CBP® recognizes and teaches four primary types of spinal subluxations.⁴² The reader needs to be aware that these four types can occur singularly or in different combinations. For our purposes here we will only present treatment of the first two types. These four types include:

1)    Postural rotations and translations and their consequent spinal coupling (displacement patterns),

2)    Sagittal plane buckling or snap through causing hypo-lordosis, S-Curves, or complete reversals,

3)    Coronal plane buckling-such as different types of scoliotic curvatures,

4)    Segmental instability such as retrolisthesis, anterolisthesis, etc…

Postural or Global Subluxations

To begin, we will use the example abnormal posture of right lateral head translation. Figure 3A depicts a patient with the posture of right lateral head translation compared to the thorax. Figure 3B depicts the skeletal animation simulating the known spinal displacement patterns (termed coupling patterns) caused by the head translation posture.⁴³ Figure 3C depicts a PA cervico-thoracic x-ray demonstrating the x-ray displacement. In Figure 4A-C, the CBP® Mirror Image® E.A.T procedures are shown. The reader should notice that in each part of Figure 4, the patient is in the opposite translation posture. Importantly, the Mirror Image® E.A.T. procedures have been found to be effective at reducing lateral head translation postures and consequent spinal displacement patterns in chronic neck pain patients.¹⁴

For our second example, we will use the abnormal posture of right lateral thoracic translation, termed trunk list. Figure 5A depicts a patient with the posture of right lateral thoracic translation compared to the pelvis. Figure 5B depicts the skeletal animation simulating the known spinal displacement patterns (coupling patterns) caused by the thoracic translation posture.⁴⁴ Figure 5C depicts a PA lumbo-pelvic x-ray demonstrating the spinal displacement. In Figure 6A-C, the CBP® Mirror Image® E.A.T procedures are shown. The reader should notice that in each part of Figure 6, the patient is in the opposite translation posture. Importantly, the Mirror Image® E.A.T. procedures have been found to be effective at reducing lateral thoracic translation posture and consequent spinal displacement patterns in chronic low back pain patients.¹⁵

In fact, in CBP®’s 2 Clinical Control Trials concerning AP viewed postural translations,^14,15 it was reported that a 50% reduction in lateral translations (side shift) was obtained in 3 months of care with 36 visits. This is a similar percentage of reduction or improvement to the results from the 4 CBP® lateral spine clinical control trials.^10-13

Figure 5. In A, the subject has right lateral thoracic translation. In B, the lumbar segments L1-L5 have lateral flexion to the same side of thoracic translation, and above L1, segments have lateral flexion to the opposite side of translation. In C, a patient’s x-ray, viewed AP, is shown with large translation. Note Ipsilateral bending from L1-L5 and contralateral bending above L1.Ó Harrison CBP® Seminars

Sagittal Plane Buckling or Abnormal Sagittal Plane Curvatures

In CBP®, we make a distinction between postural subluxations as rotations and translations that cause known spinal coupling displacements and true abnormalities of the sagittal curves of the spine. Again, we must emphasize that these types can occur together. For this discussion we will consider these separately. Our third example, will present 3 types (there are multiple types) of sagittal cervical curve subluxations and their respective Mirror Image® Traction corrective procedures.  Using our ideal circular cervical spine model as a reference guide, Figures 7A, 7C, and 7E illustrate three different types of subluxations of the sagittal cervical curve. In Figures 7B, 7D, and 7F, the type of Mirror ImageÒ extension cervical traction method must match both the sagittal head posture and the displacement of George’s Line (posterior longitudinal ligament) relative to our cervical spine model. Of importance, the clinical utility and effectiveness of each of the three traction methods, depicted in Figure 7, has been reported in a clinical trial.^10,11,13 These three methods enable the CBP® Chiropractic clinician to consistently improve the magnitude and geometric shape of the subluxated sagittal cervical curve. There are indications and contraindications for each type of traction method. The Chiropractor must judiciously learn, understand, and apply traction procedures on a case by case basis.

Figure 6A-C. In A, Mirror Image® Exercise. The patient is instructed to begin with 10 repetitions and gradually increase to 100-200 repetitions per day. In B, a Mirror Image® Adjustment with the Omni drop Table is shown. The pelvis and feet are elevated while the thorax is kept in the left lateral position. The head is kept neutral with the thorax. A thrust is delivered to the thoraco-lumbar region. In C, one type of Mirror Image® translation Traction is shown. The thorax is held in place by restraints and translated to the left. Note: all of these procedures are done in office under direct supervision.

          Our fourth example, will present 2 types (there are multiple types) of sagittal lumbar curve subluxations and 1 type of thoracic kyphosis subluxation and their respective Mirror Image® Traction corrective procedures.  Using our ideal elliptical lumbar and thoracic spine models as a reference guide, Figures 8A, 8C, and 8E illustrate three different types of subluxations of the sagittal lumbar and thoracic curve. In Figures 8B, 8D, and 8F, the type of Mirror ImageÒ lumbar and thoracic traction method must match both the sagittal thoracic and pelvic posture as well as the displacement of George’s Line (posterior longitudinal ligament) relative to the lumbar and thoracic elliptical spine models. Of importance, the clinical utility and effectiveness of lumbar extension traction has been reported in a clinical control trial.¹² Mirror ImageÒ lumbar traction methods enable the CBP® Chiropractic clinician to consistently improve the magnitude and geometric shape of the subluxated sagittal lumbar curve. There are indications and contraindications for each type of traction method. The Chiropractor must judiciously learn, understand, and apply these traction procedures on a case by case basis.

Abnormal Posture Affects Neurology

            In his texts and journal articles, Alf Breig reviewed the Adverse Mechanical Tensions on the Central Nervous System from abnormal postural loads.^45-47 Most doctors are aware of the traction on the hindbrain, cranial nerves 5-12, cervical cord, and spinal nerve roots from flexion of the head and neck, which can be correlated to kyphotic cervical configurations. However, few have read Breig’s work in sufficient detail to realize that he investigated a multitude of different postures and their adverse affects on the CNS. In 1999, Harrison et al. authored a series of reviews of the literature on deformations of the CNS from postural loads.^48-50 It is obvious from these references that abnormal posture affects the nervous system, i.e. abnormal posture is a type of subluxation as it has the necessary two components of spinal misalignment and nerve interference.

In 2002, Koch et al.⁵¹ described the circumstances consistent with the deliverance of a chiropractic spinal adjustment as “an asymmetry in the horizontal and sagittal planes of body posture and motion.” Such asymmetries in posture and motion adversely affect the nervous system through several mechanisms, as follows:

1.      Abnormal afferent input into the central nervous system.⁵² Abnormal afferent input into the central nervous system has been linked to sudden infant syndrome⁵¹, balance problems^52-56, visual disturbances^57-58, tinnitus⁵⁹, imbalance between the sympathetic and parasympathetic nervous systems⁶⁰, and impaired development of the pediatric central nervous system.⁶¹

2.      Tethering (adverse prolonged stretching) of the central nervous system.  This results in spinal cord ischemia and consequent motor, sensory, and autonomic neurological dysfunction.  Tethering of the spinal cord has been linked to demylenating diseases.^46,62

3.      Electrical dysfunction of nerve transmission through stress generated potentials from bone (streaming potentials and piezoelectricity).⁶³  Electrical nerve interference has been linked to altered expression of one’s DNA.⁶⁴

4.      Associated accelerated degenerative spinal joint pathology will eventually adversely affect the nervous system mechanically.^65-66

         All of these influences on the nervous system in items #1-#4 involve the sympathetic arm of the autonomic nervous system. It is established that the sympathetic nervous system is the primary controlling factor in immunity.⁶⁷ Consequently, uncorrected asymmetries in posture and motion adversely impact the individual’s health and well-being. The goal of CBP® technique is to correct these asymmetries to the greatest degree, minimizing spinal degeneration, improve neurological dysfunction, and improve systemic health.

Conclusion

 In our present era, “Evidence-Based” medicine was coined as a means to improve patient outcomes and quality of care. There are a number of types of clinical studies providing “evidence” including different types of Case Studies, Case Series, Cohort, Nonrandomized Control Trials, and Randomized Control Trials. Some of the basic science studies providing “evidence” would include anatomical studies, spinal modeling, evaluations of loads, evaluation of stresses and strains, comparisons of alignment in patients and controls (spine or posture), posture and spinal coupling (main motion and coupled motion), and buckling.

CBP® uses postural and radiographic analysis. From the literature, postural evaluation has reliability and validity.^68-77 Significantly, CBP® has multiple types of Index Medicus publications as “evidence” for its patient treatment methods, reliability of radiographic positioning,²⁸ reliability of radiographic line drawing analysis,^24-27 mathematical basis (Linear Algebra) of CBP® analysis and treatment,⁵³ normal spinal model as a goal of care,^18-23 postural and spinal coupling,^42-44,79-80 stresses in abnormal postures,^29-32 and efficacy studies including case studies^81-85 and six nonrandomized clinical control trials.^10-15 What remains for CBP® is further refinement of technique protocols, as well as to perform the top studies of the evidence hierarchy, the much over-rated Randomized Control Trial.⁸⁶ Not only is CBP® a primary technique practiced by a large number of practitioners,⁸⁷ it is a leader in the chiropractic research arena dedicated to the development, refinement, and study of structural rehabilitative procedures for the human spine.

References

1. Harrison DD. CBP® Technique: The Physics of Spinal Correction. National Library of Medicine #WE  725 4318C, 1982-97. Harrison DD.  CBP® Technique: The Physiscs of Spinal Correction.
2. Harrison DD. Spinal Biomechanics: A Chiropractic Perspective. National Library of Medicine #WE 725 4318C, 1982-97. Harrison DD. CBP® Technique: The Physiscs of Spinal Correction.               
3. Harrison DD. CBP® X-ray Work Book. National Library of Medicine #WE 725 4318C, 1982-97. Harrison DD. CBP® Technique: The Physiscs of Spinal Correction.               
4. Harrison DE, Harrison, DD, Haas JW. CBP® Structural Rehabilitation of the Cervical Spine. Evanston, WY: Harrison CBP® Seminars, 2002.
5. Harrison DE, Harrison, DD, Haas JW, Oakley PA. Spinal Biomechanics for Clinicians, Volume I. Evanston, WY: Harrison CBP® Seminars, 2003.
6. Harrison DE, Harrison, DD, Haas JW, Oakley PA. CBP® Structural Rehabilitation of the Lumbar Spine. Evanston, WY: Harrison CBP® Seminars, 2004.
7. Harrison DE, Betz J, Harrison, DD. CBP® Structural Rehabilitation of the Thoracic Spine. Evanston, WY: Harrison CBP® Seminars, 2004.
8. Panjabi MM, White AA, Brand RA. A Note on Defining Body Parts Configurations. J Biomech 1974; 7:385.
9. White A, Panjabi M, Clinical Biomechanics of the Spine. Philadelphia: Lippincott, 1990.
10. Harrison DD, Jackson BL, Troyanovich SJ, Robertson GA, DeGeorge D, Barker WF.  The Efficacy of Cervical Extension-Compression Traction Combined with Diversified Manipulation and Drop Table Adjustments in the Rehabilitation of Cervical Lordosis. A Pilot Study.  J Manipulative Physiol Ther 1994;17(7):454-464.
11. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. New 3-Point Bending Traction Method of Restoring Cervical Lordosis Combined with Cervical Manipulation: Non-randomized Clinical Control Trial. Arch Phys Med Rehab 2002; 83(4):447-453.
12. Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B. Changes in Sagittal Lumbar Configuration with a New Method of Extension Traction and its Clinical Significance. Arch Phys Med Rehab 2002; 83(11): 1585-1591.
13. Harrison DE, Harrison DD, Betz J, Janik TJ, Holland B, Colloca C. Increasing the Cervical Lordosis with CBP® Seated Combined Extension-Compression and Transverse Load Cervical Traction with Cervical Manipulation: Non-randomized Clinical Control Trial. J Manipulative Physiol Ther 2003; 26(3): 139-151.
14. Harrison DE, Cailliet R, Harrison DD, Haas JW, Betz JW, Janik TJ, Holland B. Conservative Methods to Correct Lateral Translations of the Head: A Non-randomized Clinical Control Trial. J Rehab Res Devel 2004; in press.
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