Trauma, especially motor vehicle crashes (MVC), can change an individual’s posture. This will, in turn, affect the victim’s stance and gait, due to soft and hard tissue injuries which cause abnormal function.
Humans adapt in time and need to their environment. The human body must adapt when external forces damage the internal environment. This induced aberrant posture causes the body to function in a minimum, although abnormal, energy state.
The lordotic curves of the spine give the spine strength and stability. Ligament damage to the posterior ligaments found after whiplash causes a loss of the cervical lordosis and forward head posture. This ligament damage is diagnosed as a loss of motion segment integrity.
In a study of motor vehicle patients, Burl Pettibon, DC, and Ray Wiegand, DC, found an abnormal extension malposition of the occiput (C0) on the Atlas (C1).1 This abnormal spinal displacement subluxation results in a loss of cervical lordosis and Forward Head Posture (FHP).
Forward Head Posture is better acknowledged as “Forward Head Syndrome,” and can cause many symptoms, including back pain, headaches, depression, emphysema, intestinal problems, hemorrhoids, varicose veins, osteoporosis, hip and leg deformities, poor health, decreased quality of life, shortened life span, breathing difficulties, hormonal imbalances, spinal pain, headaches, mood swings, high blood pressure, lung and pulse problems, decreased lung capacity and bone changes.2
George Ehni, MD, states, “Ligaments are made of collagen. Collagen fibers can only elongate four percent before they rupture.”3
Ruth Jackson, MD, states, “Ligaments heal with fibrous tissue in an irregular pattern, which is less elastic and less functional. It is different from the origin tissue.”4
When a fractured bone heals, it heals through osteoblastic activity with new bone cells, in four to six weeks. When ligaments are torn, they heal though fibroblastic activity with fibrous or scar tissue. John Kellet said, “The organization of normal ligament tissue has not been approached by the remodeled scar tissue even after forty weeks of healing.”5
In MVC, the cervical spine does not simply go through extension and flexion. The initial phase is compression of the cervical spine followed by traction, with flexion of the upper cervical spine and extension of the lower cervical spine. This produces a kyphotic S-Curve. This is a non-physiological motion of the vertebral segments.6,7
The average car accident occurs in 200 milliseconds. The nervous system reacts in 350 milliseconds. The nervous system does not have enough time to adapt a neuro-muscular protection, and injuries result.
The head experiences initial flexion BEFORE it touches the headrest. The entire spine experiences straightening and compression. At 9.5 km/h or 6 mph, the cervical spine experiences a compressive load of fifty pounds. At the same time, the spine’s shear strain is twenty-two pounds. When the cervical spine is compressed, it loses its ability to withstand shear forces. A forty-pound load reduces facet stiffness by 73%.”7
Calliet explains that, for every inch of forward head posture, the apparent weight of the head increases by ten pounds.8 There also may be serious ligament damage to the posterior longitudinal ligament. This is clearly explained in the AMA’s Guides to the Evaluation of Permanent Impairment, 5th edition, November 2000.9
It is not disputed that many healthy-appearing individuals may have herniated or bulging discs and degenerative changes. The Guides state, “Several reports indicate approximately 30% of persons who have never had back pain will have an imaging study that can be interpreted as positive for herniated disks, and 50% or more will have bulging disks. Further, the prevalence of degenerative changes, bulges and herniations increases with advancing age.” (Page 378)
“While disc problems and degenerative changes are common in the general population, loss of motion segment integrity is rare, unless accompanied by trauma.” Chronic areas will show associated degenerative changes while acute areas will not.
The Guides further state, “When routine X-rays are normal and severe trauma is absent, motion segment alteration is rare; thus flexion and extension X-rays are indicated only when the physician suspects motion alteration from history or findings on routine X-rays.” (Page 379)
“Motion Segment Integrity is defined as two adjacent vertebra, the intervertebral disk, the apophyseal or facet joints, and ligamentous structures between the vertebra. Alteration of motion segment integrity can be either loss of motion segment integrity (increased translation or angular motion) or decreased motion.” (Page 378)
A line is drawn along the posterior bodies of the vertebra below and above the motion segment in question in dynamic (flexion and extension) lateral roentgenograms of the spine. The distance between lines A and B and the distance between lines B and C at the level of the posterio-inferior corner of the upper vertebral body are summed. A value of greater than 3.5 in the cervical spine qualifies as a loss of structural integrity. (See Figure A)
Lines are drawn along the inferior borders of the two vertebral bodies adjacent to the level in question and of the vertebral bodies above and below those two vertebrae. Angles A, B, and C are measured on both flexion and extension X-rays and the measurements subtracted from one another. Note that lordosis (extension) is represented by a negative angle and kyphosis (flexion) is represented by a positive angle. Loss of motion segment integrity is defined as motion at the level in question that is more than eleven degrees greater than at either adjacent level. (See Figure B)
Loss of motion segment integrity (MSI) is defined as “an anteroposterior motion of one vertebra over another that is greater than 3.5 mm in the cervical spine.” (Page 379)
A study published in Spine indicates that angular displacement should be less than seven degrees and that translation (MSI) should be less than .06 mm.10
The Guides further state that this may not show up on a standard examination: “Motion of the individual spine segments cannot be determined by a physical examination but is evaluated with flexion and extension roentgenograms.” (Page 379)
The Guides place a high impairment rating on a loss of motion segment integrity. In the cervical spine, 3.5mm equals 25-28% impairment. This is so important and severe that the Guides equate this damage as equal to a vertebra that has a compression fracture greater than 50%. The reason is that this type of damage to the soft tissue causes abnormal function of the spine and posture!
This ligament instability can lead to a loss of cervical and/or lumbar lordosis. This kyphotic spine is an abnormal form and leads to abnormal function. Abnormal anatomy causes abnormal physiology, which results in pathology. This adverse mechanical tension on the central nervous system can lead to a chronic central mediated pain syndrome.
The lordotic curves of the spine give the spine strength and flexibility. Kapandji states that the # curves + 1 = resistance. With the loss of the lordosis, the body loses strength and flexibility.10 Oktenoglu, et al., state, “It is concluded that a loss of lordosis increases the risk of injury to the cervical spine following axial loading.”11
This loss of lordosis has ramifications with regard to health. Shimizu states that progressive kyphosis of the cervical spine results in demyelination of nerve fibers in the funiculi and neuronal loss in the anterior horn due to chronic compression of the spinal cord.12
Previous studies have suggested that spinal cord compression by the vertebral bodies and intervertebral discs during neck flexion causes cervical flexion myelopathy (CFM). Axial MRI/CTM demonstrated flattening of the spinal cord with the posterior surface of the dura mater shifting anteriorly. The findings of this study suggest that degenerative changes of the dura mater may be a characteristic pathology of CFM.13
Giuliano, et al., compared 100 trauma patients with 100 normal subjects, using flexion and extension MRI.14 The ages varied from 18-53, with an average of 35. The patients were 12-14 weeks post injury. In the normal subjects, hypolordosis was found in 4%.
In the trauma patients, hypolordosis with a loss of normal segmental motion pattern was found in 98%. There were 2% asymptomatic disc herniations in the normal group and 28% disc herniations in the trauma patients. “In no instance was disk herniation and spinal stenosis observed in the absence of hypolordosis and segmental motion restriction.”
From this study, it can be stated that individuals with a normal cervical lordosis do not have symptomatic disc herniations. Therefore, the way to correct disc herniations is to restore a normal lordotic curve in the spine.
Ligament damage results in FHP and a loss of the cervical lordosis. Through proper protocols, it is possible to restore the normal lordotic curves of the spine. (See Fig. 1)
A loss of the lordosis causes a stretching of the spinal cord. The diagonal fibers of the dura mater cause a pincer effect when lengthened. Yuan & Marguiles state, “Between a neutral posture and full flexion, the entire cord (C2-C7) elongated linearly with head flexion, increasing 10% and 6% of its initial length along the posterior and anterior surfaces respectively.” Average displacement was 1-3 mm. The upper cord moved caudal and the lower cord cephalad with larger movements on the posterior surface.15
The European Spine Journal, in 2001, indicates a relationship between a loss of lordosis and scoliosis: “A short, unforgiving spinal cord could produce the abnormal rotatory anatomy observed at the apex in scoliosis with, first, lordosis, then lateral deviation and, finally, a rotation of the vertebral column, with the rotation occurring between the canal and the vertebral body, around the axis of the cord.”16 Based upon this, it would also be possible to correct and/or improve scoliosis without bracing and surgery. (See Fig. 2)
These abnormal findings can also be substantiated through the utilization of Myologic computerized muscle testing and range of motion evaluation. This objective outcome assessment is a diagnostic tool that objectively verifies abnormal function as well as determines proper treatment. These changes can be also be verified by CROM, Neck Disability Index, and the Rand 36 activities of daily living / quality of life.
Based on the above, it would appear that rehabilitation and restoration of the cervical lordosis is necessary as a contribution to the health of the individual. The question is then asked, how may this be accomplished?
Standard medical military traction is performed to open the intervertebal foramina (IVF’s), with no regard to the lordosis. This may actually be detrimental in the long run.
In the chiropractic profession, there has been little research as to what is the best way to rehabilitate the cervical lordosis. Current treatment consists of cervical pillows, cervical roll for spinal molding, Posture Pump, fulcrums, head weights, circular traction, Extension Compression Traction, cervical collar brace, limited vision glasses and specific adjusting procedures.
One of the newest procedures is cervical Vibrating Traction (VT)™. The premise behind the Vibrating Traction™ is simple. Research done by top scientists has suggested that occupational drivers tend to suffer from a higher-than-average incidence of low back pain, due to the effect of the engine’s vibration upon the spinal discs.¹ When the vertebrae of the spine are compressed, as in a sitting position, this vibration “grinds down” the discs, reducing their effectiveness in absorbing the force of gravity. But, if the discs and ligaments are vibrated while they are in an uncompressed, relaxed state, it turns out that the exact same frequency has highly beneficial effects in relaxing ligaments and discs, as well as rehabilitating the spine.17,18,19 (See Fig. 3)
The loss of cervical lordosis and resulting forward head posture is detrimental to the health of the individual. Proper treatment should focus on the restoration of the lordosis. There is much to learn with regard to the spinal rehabilitation of the curves of the spine.
The purpose of CLEAR Institute is to empower the DC who wants to specialize with the patients who have scoliosis and the doctors who treats them.
For Seminar information contact Parker College of Chiropractic at www.parkerseminars.com, or call 1- 800-266-4723.
For information on The Vibe or Vibrating Traction (VT), contact Williams Healthcare Systems at www.williamshealthcare.com or call 1-800-441-4967.
For further information, contact Dr. Dennis Woggon at www.clear-institute.com
1. Burl Pettibon DC. Private Practice Garland Texas, 1994 (anecdotal reference)
2. Dennis Woggon, BSc, DC, CLEAR Institute, Posture, Vol. 1, #1, Dec. 2002
3. George Ehni, MD. Cervical Arthrosis, 1984
4. Ruth Jackson, MD. The Cervical Syndrome
5. John Kellet, Acute Soft Tissue Injuries
6. Grauer, Panjabi et al, Spine, 1997
7. Ono, et al. Society of Automotive Engineers, Strapp Car Crash Conference, 1998
8. Rene Calliet, MD. Neck and Arm Pain.
9. AMA Guides to the Evaluation of Permanent Impairment, 5th edition, November 2000, Chapter 15, pages 378-392
10. Kapandji. Physiology of the Joints, Vol. 3
11. Effects of Cervical Spine Posture on Axial Load Bearing Ability: A Biomechanical Study, Oktenoglu et al, Dept. of Neurosurgery, VKV American Hospital, Instanbul, Turkey, The Cleveland REFERENCES
Clinic Foundation, Cleveland, Ohio, J. Neurosurgey: Spine, Vol. 94, January, 2001
12. A New Model of Kyphotic Deformity Using Juvenile Japanese Small Game Fowls. Spine. 30(21):2388-2392, November 1, 2005. Shimizu, Kentaro MD *; Nakamura, Masaya MD *; Nishikawa, Yuji MD +; Hijikata, Sadahisa MD +; Chiba, Kazuhiro MD *; Toyama, Yoshiaki MD * Abstract:
13. Pathophysiology and treatment for Cervical Flexion Myelopathy. Fujimoto Y, Oka S, Tanaka N, Nishikawa K, Kawagoe H, Baba I. Department of Orthopaedic Surgery, Hiroshima University School of Medicine, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551 Japan. [email protected]
14. The Use of Flexion and Extension MRI in the Evaluation of Cervical Spine Trauma: Initial Experience in 100 Trauma Patients Compared with 100 Normal Subjects” Giuliano et al. Emergency Radiology (October 2002) 9: 249-253
15. In Vivo Human Cervical Spinal Cord Deformation and Displacement in Flexion, Yuan & Marguiles, Spine 1998: 23:1677-83
16. Can a short spinal cord produce scoliosis? Eur Spine J 2001 Feb;10(1):2-9
17. The biomechanics of lumbar disc herniation and the effect of overload and instability, Wilder, Pope, Frymoyer. Journal of Spinal Disorders 1988;1(1):p16-32, Univ. of Vermont, Burlington.
18. Energy Medicine: The Scientific Basis, Oschman. Churchill Livingston Publishing, 2001.
19. Neck muscle vibration induces lasting recovery in spatial neglect, Schindler et al. Clinical Neuropsychology Research Group, City Hospital Bogenhausen, Munich, Germany.