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Journal of Manipulative and Physiological Therapeutics Volume 23 Number 9 November/December 2000 0161-4754/2000/$12.

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COMMENTARY
A Normal Spinal Position: Its Time to Accept the Evidence

INTRODUCTION
Recent trends in our chiropractic profession seem to be leading away from wellness care into an exclusive focus on shortterm care for relief of symptoms, especially pain.1 In contrast, some recent articles authored by CBP Nonprot, Inc, researchers express an interest in spinal reconstruction, structural outcomes, and care beyond the mere relief of symptoms.2-6 In a recent commentary, Haas et al7 have taken exception to this approach. A commentary by Haas et al7 concerning one of our recent papers8 expressed a paradigm for chiropractic science and patient treatment that is different from that expressed in our recent literature reviews and original publications. Their views on normal spinal position, radiograph usage, radiograph reliability, and spinal rehabilitation of normal structure, as expressed in their commentary, did not include mechanical engineering principles, which we believe necessary for understanding the stresses and strains in abnormal or asymmetric loading of spinal tissues. In 1998, we had discussed a number critical flaws in 8 commonly held beliefs espoused by some diplomate chiropractic radiologists.8 Thus, given the fact that the conventional wisdom of chiropractic radiologists was challenged, it was not surprising that there were a total of 8 authors and consultants who contributed to the rebuttal commentary of Haas et al.7 What was not expected was the divergence into a critical analysis of Chiropractic Biophysics (CBP) methods and the Harrison spinal model,9 which is used as an anatomical outcome for patients receiving CBP-based treatment. However, we are pleased to both address those raised concerns and present our rebuttal to Haas et als misconceptions about the use of radiography in chiropractic clinical practice. Because this normal spinal model was only self-published until 1992,10-12 some have denied the existence of the Harrison normal spinal model and its implications for physiology. These implications were discussed in a short review of Wolffs law (bone remodels to stress) and Davis law (soft tissue remodels to stress) for abnormal sagittal spinal congurations.3 Because this Harrison model has recently been published in the indexed literature,13-19 its existence can no longer be denied or ignored.
doi:10.1067/mmt.2000.110941

Inasmuch as Haas et al7 had many different topics in their commentary and did provide section titles, it is convenient to respond with reference to those section titles. It is noted that some of their section titles are obscure and certainly not mainstream (eg, their reference to Sackett); nonetheless, the titles are useful as objects for debate. First, however, we present a logical approach to movements in upright posture, from which much about a normal upright position can immediately be derived. It is a basic theorem of physics and engineering that the movement of any object can be decomposed into rotation, translation, and deformation.20 Whereas White and Panjabi21 have used this theorem to describe the 6 degrees of freedom (DOF) of individual spinal segments (rigid bodies), we have used this theorem to express all possible movements of the human head, thoracic cage, and pelvis in 3 dimensions.10-11 Figs 1 and 2 are reprinted from a previous article in the Journal of Manipulative and Physiological Therapeutics.22 These movements will form the basis on which we illuminate a normal postural position. After providing a review of normal upright position in terms of the engineering principles and literature reviews to be presented below, analysis of chiropractic manipulations (which are mostly torsional loads) will lead the reader to conclude that diversied manipulation is inadequate for obtaining a structural change in the neutral resting posture. Thus, precise postural setups (such as those used in the CBP technique) are recommended for the sake of obtaining structural correction in a patients spine after the relief of symptoms.

Biologic Plausibility and Validity


Haas et al1 defined biologic plausibility for us. They appear to have assumed that the only important biologic process is back pain, and on the basis of that view they assume that it is unnecessary to address the upright spinal configuration under gravity. In addition, they state that our model is merely a mathematical description of optimal stress on a static system.7 We now reply that back pain is a multifactorial condition. The process of spinal degeneration and abnormal biomechanics causing mechanical distortions of the central nervous system (CNS) is better characterized as a degenerative disease process. Thus, symptoms appear after the disease process is well advanced (as is the

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Fig 1. Rotational DOF of global body parts. case in heart disease, cancer, and hypertension). In such processes, the emphasis is placed on controlling risk factors. It is suggested that optimizing the spines position to resist the compressive force of gravity is a logical place at which to address an optimal stress risk factor. Of course, the entire oculovestibular, muscle spindle, and mechanoreceptor systems perform this function from moment to moment in upright stance. To imply that this is an unimportant subject regarding spinal mechanics is to ignore a major function of the CNS.

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Fig 2. Translational DOF of global body parts. Haas et al7 believe that there is no compelling evidence to indicate that subluxation exists. However, subluxation has been precisely dened through use of deviations from normal upright posture and our normal spinal model.23 In addition, Haas et al do not appear to appreciate the concept of modeling the spine. A model is used to predict nature; it is a tool. Our models usefulness will be determined in future studies of clinical significance. For such studies to be carried out, the parameters of the models usage must rst be established, and one of these parameters is a measurement methodie,

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Fig 3. A, Vertical position of normal AP posture as agreed on in literature. B, D, Proposed ideal lateral postures. C, Average lateral
posture. Note that differences between Fig 3, B and Fig 3, C are slight.

posture and radiography. Therefore, determining the reliability of the radiographic markings (and posture reliability) is a logical first step. Haas et al claim that we cannot address clinically meaningful conditions, but they want to stop us from attempting such future research by negating our attempts to study the reliability of our methods at the beginning. Clinical signicance can be determined only after one has precise denitions to test and only after one has reliability data established for the measuring methods. Because a normal postural position (outside alignment) and a normal spinal position (inside alignment) are fundamental to our approach to controlling risk factors for spinal dysfunction, a review pertaining to each of these ideas is provided to enable the reader to determine whether Haas et als paradigm matches the biomechanical/biomedical literature.

Normal Upright Posture


There are at least 3 approaches by which one can immediately discover a normal spinal alignment in the anteroposterior (AP) view and the lateral view. Most rigorously, equilibrium equations in the AP view can be used to prove that the postures of Tx, Ry, and Rz in Figs 1 and 2 result in abnormal asymmetric loads on the spinal tissues and lower extremities when these postures are in the neutral resting posture of the subject under investigation. These postures are also asso-

ciated with asymmetric muscle efforts. Numerous electromyographic studies over the past 4 decades add support for this fact.24-34 Because many clinicians7 may be unfamiliar with engineering principles and aspects of upright human stance, 2 other proofs are presented. As a first discussion of normal posture, the readers and Haas et al7 are asked to consider that all chiropractic, osteopathic, physical therapy, and medical colleges teach a plumb line analysis and global ranges of motion, as depicted for Tx, Ry, and Rz in Figs 1 and 2. With regard to the AP view, the following 3 questions come immediately to mind: (1) axial rotation to the left and to the rightfrom where? (2) lateral flexion to the left and to the rightfrom where? (3) lateral translation to the left and to the rightfrom where? Before trying to give an answer that is different from vertical alignment in the AP view, recall that these main postural motions of the head and thoracic cage, Tx, Ry, and Rz, cause spinal coupling patterns for which the movements are known.22,23,35,36 These vertebral coupling patterns are always described as movement away from a vertical normal spinal alignment. Our research team is the first to report spinal coupling for Tx of the head and thoracic cage.35,36 Some authors have argued that slight deviations of the upper thoracic spine are correlated to the side of the dominant arm37 and that a true vertical spine in the AP view there-

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fore cannot be considered normal. Either sight deviations can be ignored because of the minimal amount of asymmetric loading, or unilateral upper extremity exercises on the nondominant side can be prescribed to correct these. In addition, Haas et al7 claim that because of the natural asymmetry of the spinous processes, the sensibility of a true vertical spine in the AP view is questionable. However, more than 2 decades ago, Farfan38 found that the entire vertebral architecture in the lumbar spine will change and keep the lamina junction in line with the structural center of the vertebral body. This means that the center of mass will remain approximately the same. Farfan38 writes (pages 34-5): It would appear that in the development of the vertebra, asymmetrical body growth is compensated for by asymmetric growth of the neural arch. Therefore, the centers of mass in the AP view will still be in line with vertical gravity to minimize loads on the spinal tissues and to be the origin position for postural movements.39-47 Recently, Kiefer et al48 showed that T1, T12, and S1 must be vertically aligned in the lateral view. In the lateral view, the previous argument can be applied to the movements of Rx, Ty, and Tz in Figs 1 and 2. In fact, much research has been conducted on sagittal posture, especially anterior head translation (+Tz) and pelvic posture, by physical therapists.4961 This research indicates that anterior head translation (protrusion) is fundamentally accepted as abnormal and that, in general, posture evaluation is repeatable and reliable. For a second analysis, a statistical evaluation is presented. As always, there is debate in the literature concerning average normal and ideal normal (upright posture). However, the differences in these upright positions are small. In 1973 and 1975, Beck and Killus62,63 used a computer analysis to average upright lateral and upright AP postures of several hundred young adults. They reported on the reliability of their digitizing methods and showed that posture was reproducible even though the x-rays were taken years apart. They critically analyzed all of the previous reports of posture (such as those of Staffel, 64 Goff, 65 Leger, 66 Haglund, 67 Osgood, 68 and Wiles & Lond, 69 which include such terms as flat back , round back , and hollow back ). Beck and Killus 62 found highly pathologic postures, small sample sizes, incorrectly applied statistics, and lack of an origin for measurement included in previous categories of posture. Using a digitizer, they plotted, in graphic form, the coordinates (paths) of the vertebral bodies of all subjects in the AP and lateral views. With 1500 subjects in their 1975 report, 63 they noted that they had one normal distribution in every point of abscissa. They write:
It follows that there is only one ideal type of spinal column. According to our findings the theory of constitutional types (of posture) cannot be conrmed.62

Therefore, the vertical alignment of the global centers of mass in upright posture in both the AP and lateral views has been statistically established for young adults. Fig 3 illustrates this alignment with some additional references applied to the location of the shoulders and lower extremities.

Harrison Spinal Model


Through use of multiple studies and normal distributions with an ideal mean normal center, normal upright posture has been dened in the literature. This normal posture in the AP view correlates with a straight (vertically aligned) spine. In the lateral view of upright normal posture, it is generally accepted that there exist a cervical lordosis, a thoracic kyphosis, and a lumbar lordosis; however, neither the overall sagittal curvatures of the cervical, thoracic, and lumbar areas nor the segmental contributions are generally stated or agreed on. Therefore, when normality is being debated, only the overall geometric shape and segmental angulation of the cervical, thoracic, and lumbar sagittal curvatures are open to debate. This is where our normal Harrison Spinal Model enters the literature. Both our average (400 subjects) and our ideal normal sagittal cervical spine models were published in 1996.14 Our average (derived from 552 subjects) normal lumbar model was published in 1997.18 Our ideal normal lumbar model was published in 1998.13 At this point, it is important to point out that the Harrison Spinal Model is the normal path of the posterior longitudinal ligament along the posterior vertebral bodies. This ideal and statistical average model has a mean and a random error component (variation around the mean). It is a model not of the entire anatomy of the spine but only of the curvature in the sagittal plane. Models of the entire spine require huge computer codes in which finite elements methods are used. The paradigm presented by Haas et al7that abnormal posture has no effect on physiologyis quite puzzling. It is well documented that abnormal spinal loads (forces and moments) over time cause pathoses. This is taught in all chiropractic college physiology courses as Wolffs law (bone remodels to stress) and Davis law (soft tissues remodel to stress). In the light of the foregoing preceding background data and ideas, a response to each of Haas et als topics7 can now be presented.

Clinical Sensibility and Validity Cervical kyphosis is not a normal variant. In their commentary,
Haas et al7 repeat the common misconception that cervical kyphosis is a normal variant. In general, the studies cited by Haas et al 7 are inadequate, being characterized by inappropriate methods, flawed statistical analysis (if any), and/or unsupported conclusions. It is our intent to review the 6 studies 70-75 mentioned by Haas et al and to present an updated literature review focused on cervical kyphosis.

Beck and Killus provided separate graphs of their maximum points of their normal distributions of posture. The spine had the 3 spinal curves with vertical alignment of T1, T12, and S1 in the lateral view.

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To begin, Haas et al7 refer to a 1986 study by Gore et al.70 In 200 randomly selected asymptomatic subjects, Gore et al found an average of 22 degrees of lordosis using Ruth Jacksons angle from C2-C7; they found that a minority (9%) of these subjects demonstrated the presence of a cervical kyphosis. In contrast, Harrison et al76 found that 35% of 250 symptomatic subjects had kyphotic deformities. These data indicate a dramatic increase in cervical kyphosis in symptomatic subjects in comparison with asymptomatic subjects. An additional concern is the cross-sectional study design used by Gore et al. It is common knowledge among health care providers that several life-threatening illnesses and diseases remain asymptomatic throughout their course or are associated with no overt signs or symptoms until the end stages. Harrison et al3 have previously reviewed the shortcomings of the study by Gore et al.70 The second article used by Haas et al7 in their assertion that kyphosis is a normal variant is the study by Maimaris et al,71 who retrospectively assessed 67 asymptomatic and 35 symptomatic whiplash-injured patients. Follow-up was attained an average of 2 years after the injury. Maimaris et al concluded that reversal of the cervical spine to a kyphotic position was not associated with prolonged disability." However, there are several problems with this study. First, only 39 (58%) of the 67 asymptomatic subjects were "clinically examined," whereas 30 (86%) of the 35 symptomatic subjects were examined. This is a large difference in the percentage of subjects examined in each group, and it can lead to inaccurate data analysis between the groups. Second, the lateral cervical spine radiographs were not measured and quantied; they were merely classied into lordotic, straight, or kyphotic. Therefore, no quantifiable statistical analysis was performed to actually address the issue of the amount or type of lateral cervical curvature as it relates to the presence of symptoms. As an example, on page 396, Maimaris et al present two figures, one representing a kyphotic cervical curve and the other representing "loss of the normal lordosis." If one looks at these two radiographs, it is readily apparent that both of these are kyphotic curvatures. Last, in their Table III on page 395, Maimaris et al present the percentage of subjects in each group with radiographic abnormalities. Clinically signicant differences are noted between the symptomatic and asymptomatic groups, with the symptomatic group having higher percentages of straight and kyphotic curves and the asymptomatic group having the highest percentage of lordotic curves. Similarly, Haas et al7 make the claim that Pedersen72 observed that cervical hypolordsis may be a normal variant. However, the study by Pedersen is of insufcient quality for the drawing of such a conclusion. Pedersen compared a treatment group of only 9 patients with a control group of 17 patients. The criterion for inclusion in the control group was as follows: The subject must not have had any history of cervical or cervico-thoracic symptoms prior to 2 months before entry (lasting continuously for more than 3 weeks). This designation was a poor choice, inasmuch as subjects in the control group could either have had pain of

less than 3 weeks duration before the past 2 months or had pain in the 2-month period immediately before the study. In addition, the sample size was extremely small and subjects in the two groups were not matched for age, weight, height, or sex. Furthermore, Haas et al7 state that in a study of 180 subjects, Borden et al concluded that a straight cervical spine is abnormal only in conjunction with decreased cervical exibility. In actuality, the study by Borden et al73 found that of 180 asymptomatic subjects, 3 (1.7%) had a reversed cervical curve and 13 (7.2%) had a straight cervical spine. Of the 13 subjects with a straight cervical spine, 11 (85.0%) had concomitant degenerative changes. In the 3 subjects with cervical kyphosis, there were generalized hypertrophic degenerative changes and fusion.73 Borden et al concluded that roentgenographically demonstrated loss of the cervical curve, combined with normal thoracic kyphosis and lumbar lordosis, may be indicative of abnormality of the cervical spine.73 In the light of this information, one might wonder how Haas et al7 could possibly believe that this reference supports the position that cervical hypolordosis or kyphosis is a normal variant. Perhaps they were performing secondary referencing and did not read the original paper. Likewise, Haas et al7 believe that the study by Marshall and Tuchin74 indicates that spinal curve alteration itself may not require treatment. However, there are several potential problems with the method used by Marshall and Tuchin.74 The most serious of these is their choice of the C1C7 Cobb angle for lateral cervical curve mensuration. The 4line C1-C7 Cobb angle is not a valid representation of the cervical lordosis.8,77 Therefore, without a segmental analysis, no conclusions can be made concerning the shape and/or magnitude of the cervical lordosis and its clinical significance in that study. Last, Haas et al7 rely on the conclusions of Gay.75 In a 1993 review, Gay concluded that cervical kyphosis is a normal variant. However, before Haas et als7 commentary, the vast majority of the references cited by Gay had previously been critically analyzed and had been found to be inappropriate by us in 1998.8 Thus, no weight can be applied to Gays75 review. Recent and past mechanical, clinical, and surgical studies concerning the cervical lordosis do not support the position that cervical kyphosis is a normal variant. Haas et al7 seem to insinuate that the only supporting reference that we8 offered for the clinical signicance of a normal cervical lordosis was by Cote et al78 (our old reference 1). This clearly was not the case (see references 9-17 in our original manuscript8). However, because Haas et al and many others continue to debate this issue, a thorough review of the literature on cervical kyphosis and its effects is presented here. It is relevant that several studies have investigated and linked altered cervical curve configurations to the presence of chronic headache pain.79-81 In a survey of more than 6000 cases of chronic headache-sufferers, Braaf and Rosner79 found that complete or segmental loss or reversal of the normal lordotic curve of the cervical spine is the most con-

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sistent characteristic feature and very often is the only abnormality found. In 47 subjects with tension and migraine headaches, Vernon et al80 found a high incidence of hypolordosis, straightened cervical curve congurations, and reversed cervical curve congurations. Nagasawa et al81 compared 372 patients with tension headaches and 225 control subjects matched for age and sex; they found statistically significant differences between the two groups, the headache patients having straightened cervical curve congurations and low set shoulders. In addition, with increasing age, the headache patients cervical curve was straight more frequently. This information contrasts nicely with the findings of Gore et al,70 who noted that in asymptomatic subjects, the cervical curve increased with age. Looking into the matter further, we note that when poor outcomes after surgery are considered, several studies have found a good cervical lordosis to be a signicant factor in preventing neurologic decit and/or compromise.82-93 For example, Goto and Kita82 state that postoperative kyphotic malalignment or angulation are factors strongly affecting the outcome of surgery. Yamazaki et al83 compared 2 groups of patients with ossication of the posterior longitudinal ligament (PLL) postoperatively. Group I consisted of patients with no anterior compression of the spinal cord, and group II comprised patients with residual cord compression. The investigators found a lordosis of less than 10.0 degrees or cervical kyphosis correlated with the presence of postoperative spinal cord compression; this result was statistically signicant. Similarly, recent surgical studies have emphasized that operations that leave the patients cervical spines with less lordosis are associated with increased neck, upper thoracic, and shoulder pain and overall poorer health outcomes.94-97 Lowry94 used the average lordosis of 22 degrees found by Gore et al70 to gauge a successful surgical outcome; he claimed that a fixed kyphotic posture of the mid-cervical spine will lead to overall sagittal imbalance manifested by axial pain in the upper to mid-thoracic region as well as in the posterior cervical spine. Katsuura et al95 compared 44 cases treated with anterior cervical plating (a method of ensuring a stable lordotic correction) to 30 patients receiving anterior fusion without plating. These patients were followed for an average of 38 months postoperatively. The magnitude of cervical lordosis was assessed through use of Ruth Jacksons angle (posterior tangents from C2-C7), and intersegmental (2-line) Cobb angles were used for the alignment of the fused segments. Katsuura et al found statistically significant differences in the incidence of neck pain between the two groups, the plated group having less neck pain and a statistically signicant increase in cervical lordosis. Likewise, Kawakami et al96 retrospectively evaluated 60 patients postsurgically. Cervical lordosis was measured with a 4-line Cobbs method from C2-C7 and a segmental (2line) Cobb angle at the fused level. Segmental kyphosis at the level of the fusion and less lordotic curvature were found to statistically predict which patients would develop axial symptoms (neck pain, shoulder pain, and/or stiff neck). The use of 2-line Cobb methods rather than the 4-line Cobb

method is important because the standard error of measurement (SEM) is much lower (<3) and the segmental analysis finds alterations within the curveie, it is not just evaluation of the end segments. According to Haas et al,7 the surgical studies just cited, all of which indicate the clinical signicance of the cervical lordosis, are not appropriate because surgical patients are not typical chiropractic patients who require conservative care. But perhaps this is merely an excuse for not accepting the facts. However, there are several nonsurgical studies indicating cervical kyphosis as a factor predictive of poor results.98-100 In a long-term follow-up of 146 whiplash-injured patients, Hohl98 identified cervical kyphosis as factor predicting a poor outcome. Norris and Watt99 followed 61 patients involved in motor vehicle accidents for a minimum of 6 months; they found abnormal neck curves to be more common in patients with a poor outcome.99 In addition to clinical outcomes of pain and neurologic deficits, several papers focusing on cervical biomechanics indicate that cervical kyphosis is abnormal.101-103 Using an engineering analysis of slope and bending moment, Matsunaga et al101 proved that degeneration and consequent subluxation will develop in abnormal kyphotic configurations, which they termed buckling alignments. In the case of the S-shaped spine, they write, the spine is in a buckling condition, which corresponds to an unreasonable supporting function. With regard to ossication of the PLL, Matsunaga et al102 followed 101 patients for a 5-year period. Using an engineering analysis of strain, they found that ossification of PLL progressed in the areas showing uneven and abnormal strain at the adjacent intervertebral disk and PLL. Specifically, strain in the tensile direction was found to correlate with ossication of the PLL. It is important to note that the only way to increase the tensile strain in the PLL is to have concomitant hypolordosis or kyphosis.104 Several other studies have indicated that loss of cervical lordosis or kyphosis is a cause of or is associated with a high incidence of degenerative changes in the disk and vertebral bodies.70,73,98,105 Because degenerative changes of the cervical spine are a known cause of morbidity,98,99,106 it can be stated with condence that cervical kyphosis is not a normal variant. In a recent 1997 text on the spine, statements by Frymoyer et al109 are clinically significant about cervical kyphosis as a normal variant. In fact, they assert that kyphosis, straightening, and hyperlordosis of the cervical spine may all be seen in conjunction with spondylotic myelopathy, whereas in other patients the normal curvature is preserved and that kyphosis and hyperlordosis may coexist and thus this gives rise to an S-shaped deformity of the spine, causing greater instability and management problems.109 Furthermore, in a 1996 review on the cervical spine surgeries, Lowery94 states that an additional feature of any plate system, whether anterior or posterior, should be to establish a lordotic cervical curvature. The evidence

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against76-107 cervical kyphosis as a normal variant far outweighs the evidence to the contrary.7,70-75 Finally, with regard to the cervical spine, it is noted that many authors (including Haas et al) have neglected to investigate cervical lordosis and child development. It should not have been necessary to present the preceding review indicating that cervical kyphosis is not a normal variant, inasmuch as Bagnall et al108 showed in 1977 that the cervical lordotic curve is formed in intrauterine life (9.5 weeks). Cervical lordosis could thus be considered a primary curve, like the thoracic kyphosis. Any loss of cervical lordosis is due to trauma, repetitive play, or work postural loadings during and/or after birth. Importantly, using skin markers or surface visualization does not correlate with the shape, magnitude, or direction of the sagittal cervical spine.109,110 Therefore, the use of radiography for identication of any abnormal lateral cervical conguration is absolutely mandatory.

Thoracic Kyphosis
In addition to the work of Beck and Killus,62 whose normal graph used a statistical average, multiple studies have investigated thoracic kyphosis. As in cervical skin contour versus radiographic measurements, DOsualdo et al111 found considerable disagreement between radiographic findings and results obtained with an Arcometer. In 1983, Willner and Johnson112 used spinal pantographs based on skin contour to suggest that kyphosis varied in girls and boys. However, using an ISIS scanner for evaluating back shape, Carr et al113 reported no statistically significant differences with respect to age and sex in children, no statistically signicant differences with respect to age and sex in adults, and no differences between children and adults. Using radiography, Voutsinas and MacEwen114 reported in 1986 that the differences between boys and girls were not significant in any group. Some studies have reported a large range of values for thoracic kyphosisfrom 20 degrees to 40 degrees.115-120 One problem in deciphering a normal average thoracic kyphosis is the inability to see T1-T4 on most lateral thoracic views; this has caused different levels of Cobb angle analysis in the literaturewith different angles of kyphosis, of course. For example, the following levels have been used: T5-T12, T4-T12, T3-T12, T2-T12, and T1-T12. This causes wide ranges of values. For example, Propst-Proctor and Bleck117 measured the inferior endplate of T5 to the superior endplate of T12 in 104 normal children who were referred for suspected screening of scoliosis; they reported a normal distribution with a range of 21 to 33 degrees and a mean of 27 degrees. In 22 cases, Singer et al120 reported no difference in thoracic kyphosis in subjects before and after death (T4-T12: ~49 degrees).120 Milne and Williamson121 reported no significant change in thoracic curvature on follow-up radiographs of 261 subjects aged 62-90 years. In 99 Greek men and women, Korovessis et al122 reported that thoracic kyphosis was not gender related, though kyphosis was found to increase with age (mean T4-T12: ~36 9 degrees). In 102

subjects, Bernhardt and Bridwell123 reported a mean Cobb for T3-T12 of ~36 degrees and a mean Cobb for T1-T12 of ~40 degrees. Jackson and McManus124 investigated sagittal balance in 100 patients and 100 volunteers; they reported the same means and ranges for males and females and for patients and volunteers (mean T1-T12: ~43 9 degrees). In 1998, Vedantam et al125 investigated standing sagittal alignment in 88 adolescents (aged 10-18 years); they reported a striking similarity in regional thoracic kyphosis and lumbar lordosis between adolescents and adults. In 1980, Fon et al126 reported that in 316 subjects, thoracic kyphosis increased with age. In 1993, Cutler et al127 reported that hyperkyphosis in women was associated with altered vertebral body shape (anterior wedging), loss of bone density, loss of fitness, decreased muscle strength, and reduced survival; the investigators suggested a correlation between abnormal upright thoracic posture and changing architecture of the spinal column (Wolffs law). In 1996, Kolessar et al128 reported that 69 patients had kyphotic Cobb T5-T12 measurements of >33 degrees, whereas all 24 volunteers had Cobb T5-T12 < 33 degrees. It is interesting to note that studies on thoracic kyphosis with large population groups provide nearly normal distributions. Thus, as noted by Beck and Killus,62-63 statistically there would be one ideal normal at the mean of these distributions. With the few reported values for Cobb T1-T12 and with ratios of values from Cobb T2-T12, T3-T12, T4-T12, and T5-T12, the mean thoracic kyphotic value seems to be between 40 and 50 degrees for a Cobb angle from the top of T1 to the bottom endplate of T12.

Lumbar Lordosis
Haas et al7 have neglected a large body of literature supporting the clinical significance of a normal lumbar lordosis.13,18,19,116,129-158 To date, there have been 10 separate studies in which a similar method was used to investigate the normal shape and magnitude of the human lumbar lordosis.18,115-117,122,129-133 These 10 studies used strict criteria in categorizing men and women as normal subjects. The age range for the subjects was largebetween 10 and 80 years of age. All 10 of these investigations used radiographic analysis in the neutral upright posture, and total as well as segmental lumbar lordotic angles were measured. In all, a total of 755 normal subjects from 10 separate studies were included in the analysis. All of these studies18,115-117,122,129-133 indicate that the upper lumbar curve, T12-L3, is minimally lordotic whereas the distal lumbar curve, L4-S1, accounts for approximately 65.0% of the lumbar lordosis. Haas et al7 claim (believe) that different patient populations (races) have different optimal spinal congurations and that given the natural variation and asymmetry in the human musculoskeletal system, an ideal spinal model is not plausible. Their beliefs are not supported by recent anthropometric clinical and experimental data on the lumbar spine. For example, several studies addressing the shape and magnitude of the

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lumbar lordosis found no differences with respect to geographic location and/or ethnicity.133-137 In a radiographic study of the lumbar lordosis in 16 healthy Chinese men, Chen133 concluded that no obvious interracial differences were found in the geometric data found in this study. Mosner et al134 compared the lumbar lordotic spinal radiographs of 25 black women with those of 27 white women; no signicant differences were found in the lumbar lordosis, as measured with spinal radiographs, though differences were found in external skin contours. This difference in skin contour gives a false impression of increased lumbar lordosis134 in black versus white women. In a 1985 study of 973 adults, Fernand and Fox135 reported that black and white populations demonstrated no significant difference in the mean lumbar lordotic angle. Korovessis et al136 studied the sagittal configuration of the lumbar spine in 120 asymptomatic Greek volunteers. We have shown that there are no differences in the sagittal profile across geographically and ethnically different populations, they write. As regards the natural variation of human anatomy, Janik et al13 have shown that reported small differences in vertebral bodytodisk height ratios, found in different studies, have no effect on their elliptical model of the lumbar lordosis (ie, none of the segmental angles, T12-S1, were found to change more than 1 degree). As regards low back pain and lumbar lordosis, 6 separate studies have found statistically significant differences between patients with low back pain and matched normal control subjects.19,136,138-141 Korovessis et al136 compared homogenous groups of 120 volunteers and 120 patients with chronic low back pain; subjects were matched for age, sex, and ethnicity. Lordosis was measured through use of a 4-line Cobbs method from T12 to S1, and segmental angles (2-line Cobb) were measured through use of endplate lines relative to horizontal. Statistically signicant differences were found between the two groups, the chronic low back pain subjects having a decreased distal lordosis, L4-S1, in comparison with the controls. Harrison et al19 used elliptical modeling to discriminate between a rigorously defined normal group and 3 separate groups of patients with low back pain; that study included (1) 50 normal subjects from a pre-employment physical screening, (2) 50 patients with acute low back pain (first occurrence; less than 6 weeks duration), (3) 50 patients with chronic low back pain (pain of more than 6 weeks duration or a history of recurrent disabling low back pain), and (4) 24 subjects with low back pain and radiographically verified degenerative disorders or pathoses. These 4 groups were matched for age, weight, height, and sex. The investigators found that of 11 angles, 2 distances, and 2 ratios, statistical analysis was significantly different across groups for 12 of these measurements.19 The chronic low back pain and lumbar pathosis group had a decreased lordosis, whereas the acute low back pain group had an increased lordosis in comparison with the normal subjects. In a similar study, Jackson et al138 compared sagittal lumbar radiographs of 50 normal volunteers with those of 50

adult patients with symptomatic degenerative lumbar disk disease, 30 patients with low-grade L5-S1 isthmic spondylolisthesis, and 30 patients with idiopathic or degenerative scoliosis. Again, statistically significant differences between the groups were found in the radiographic measurements.138 Adams et al142 followed 403 volunteer health care workers for a 3-year period. A decreased lumbar lordosis was found to be one of the personal risk factors in predisposing subjects to a first-time episode of low back pain requiring medical evaluation. Itoi143 analyzed lateral lumbar radiographs in 100 postmenopausal female patients with spinal osteoporosis; a statistically signicant increase in low back pain was found in patients with a rounded thoracic spine and lower acute lumbar kyphosis. This lower lumbar kyphosis has been shown to cause an increase in low back pain, perhaps as a result of increased electromyographic activity of the paraspinal musculature.144 Many surgical papers have identied both lumbar hyperlordosis145 and hypolordosis or kyphosis146-152 as risk factors for low back pain requiring surgical correction. Last, several investigators have found statistically significant increases or associations between loss of lumbar lordosis and degeneration of the disk, vertebral body, and ligaments.152-156 With regard to lumbar lordosis, most experts agree that the assessment of spinal curvature is a part of an evaluation in patients with back problems.157 Because surface measurement of spinal curvature represents neither segmental nor total lumbar lordotic alignment, radiographic analysis is a mandatory part of the routine examination of the lumbar spine.134,158 We believe that Haas et als7 negation of the importance of the structural alignment of the spine stems from a neglect of mathematics and engineering analysis. They seem to be reading published papers with just rudimentary 4-line Cobb angle geometry while ignoring papers that analyze spinal alignment with a slightly higher level of mathematics. Papers that use segmental analysis (see the references above), some analytic geometry,13,19 calculus,103,120,153 curve fitting,9,159-161 and finite elements162-164 have shown the importance of normal alignment of the spine.

Pelvis Orientation
Plaugher et al165 have investigated pelvic radiographic measurements and found reproducibility in pelvic positioning and radiographic marking. Troyanovich et al166 have established high intraclass coefficients (ICCs) and low SEMs for pelvic tilt on the lateral lumbopelvic view. Jackson et al138 have reported high Pearson correlation coefcients for pelvic measurements (in degrees) on lateral full spine views; they reported significant differences in pelvic measurements for normal subjects versus 3 patient groups. In 1995, Saji et al167 studied 61 adolescents with idiopathic scoliosis and 33 normal subjects for femoral neck shaft angles and asymmetry of the hips. An angle was

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Table. Partial review of x-ray reliability studies: ICCs and standard errors of measurement for intraobserver error and interobserver
error (in degrees)
Standard error of measurement (degrees)

ICC
Area/Reference AP cervical Troyanovich et al AP thoracic Pruijs et al (1994) Sevastikoglou, Bergquist Beekman, Hall Gross et al (p176) Morrissy et al Carman et al Goldberg et al Desmet et al AP lumbar Troyanovich et al Lateral cervical Phillips et al (1999) Singer et al5 Plaugher et al Cote et al Jackson et al Harrison et alSpine Lateral thoracic Carman et al Voutsinas, MacEwen Jackson et al (1998) Lateral lumbar Jackson et al (1998) Polly et al (1996) Voutsinas, MacEwen Gelb et al Wood et al Troyanovich et al Troyanovich et al Intra Inter >0.90 >0.90 (Spearman > 0.98) >0.70 >0.80 >0.83 >0.90 (Pearson r > .80) >0.70 >0.80 (Pearson r > .82) (Pearson r > .73) >0.81 >0.83 >0.70 >0.80 >0.70 >0.80

4-line Cobb
Intra 3.2 4.9, 3.8, 2.8 1.9 4.5 2.9 2.2* 10.0 2.1* Inter 3.2, 2.0* 3.1 4.2* 2.3 7.2, 6.3, 6.3 3.8* 2.5 1.1, 1.3* 4.2 9.1, 8.3 3.3* 10.0

2-line Cobb
Intra Inter

Mod. Risser-Ferg
Intra <2.0 <2.0 Inter <1.5 <2.0

Post. tangent
Intra 1.2 2.3 1.5 1.7 Inter 1.2 2.4 1.7 1.8

<2.7 3.6, 3.2 2.2, 2.7 3.0* 3.0* 1.1

ICC, Intraclass coefcient; Intra, intraobserver error; Inter, interobserver error. *Only average difference was reported (not standard error of measurement). Standard error of measurement was reported. First value is for C1-C7; second value is for C2-C7.

formed by lines through the femoral shaft and neck. Intraobserver and interobserver reliability were assessed. There were no significant differences between the measurements of a single observer or between the measurements of different observers. Standard errors of measurement were small (intraobserver, 1.6 degrees; interobserver, 1.9 degrees). Saji et al discovered that a normal femoral neck-shaft angle was approximately 135 degrees, the scoliosis subjects having a much higher value for this angle (straightened femur). Levine and Whittle168 studied the effects of pelvic tilt on lumbar lordosis. They reported that flexion of the pelvis increased lumbar lordosis and that extension of the pelvis was associated with hypolordosis. Similarly, Harrison et al19 reported that their subjects with acute low back pain had exed pelvises and lumbar hyperlordosis whereas their subjects with chronic pain had extended pelvic positions and lumbar hypolordosis.

Reliability
Haas et al7 make the following statement: To date, there is little convincing evidence for the reliability of radiograph-

ic analysis of spinal displacement. We have published 5 radiographic line drawing analysis reliability studies and have another in review.77,166,169-172 In other chiropractic publications, the reliability of line drawing analysis on the nasium view and pelvis, additional AP, and lateral views have been reported.165,173-176 Curiously, in regard to the nasium and AP lumbopelvic radiographic views, Haas et al make the following inaccurate statement: There are no grounds for generalizing from studies on pelvic height and the cranium to the repeatability of analyzing spinal curves and segmental displacement.7 Perhaps Haas et al are unaware that the nasium radiograph includes the cervical spine and that its alignment in comparison with the cranium has been subjected to several reliability studies.173,174 For the various Cobb methods (2-line and 4-line), numerous reliability studies have been done on AP lumbar, AP thoracolumbar, and AP thoracic, lateral lumbar, lateral thoracic, and lateral cervical views.9,159-161,177-192 Furthermore, the measurement of pelvic rotation and sagittal segmental translations has been reported as reliable.193-195 In 1992, Capasso et al196 reported high Pearson correlation (r > 0.90) for both

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intra and intergroup correlations among orthopedic surgeons for 3 types of spondylolisthesis radiographic measurements. Similar to Tallroth et als194 findings for lumbar flexion/extension, the findings of Lind et al197 for cervical flexion/extension were high examiner reliability and low intraobserver error of measurement (<1.8 degrees) for lateral cervical segmental flexion angles. Gross et al198 (1983) and Goldberg et al199 (1988) revisited AP Cobb angle reliability and reported smaller errors of measurement (between 1.9 and 3.2 degrees) than most studies. Similarly, DeSmet et al200 reported small interobserver errors of the differences (<1.2 degrees) for Cobb angles. The multitude of studies just cited (a total of 35) reporting high radiographic reliability (those with ICCs report the majority of ICCs to be in the >0.75 range) is sufficient to establish the reliability of radiographic analysis of spinal displacement to the satisfaction of any well-informed reader. Perhaps the high variability of SEM (ranging between 3 and 10 degrees) with the 4-line Cobb methods are of concern. Inasmuch as the Harrison posterior tangent method has smaller SEMs (<2 degrees), this method is suggested to Haas et al7 as well as to clinicians and other researchers for the analysis of the sagittal spine. However, until recently (the 1990s), most investigators reported only means, SDs, and SDs of differences in readings and rereadings (Table). Because the SEM has SD in its formula, the low means and SDs for measurement differences indicate good-to-excellent reliability. However, before 1990, authors rarely provided proper statistical analyses with Pearson r, intrarater ICC, interrater ICC, 95% CI, and SEM values. The vast majority of medical investigators have stated that the low means and SDs for differences in drawing and redrawing radiographic lines (Table) sufce for a claim of adequate reliability. After all, it is merely Euclidean geometry! In 1999, Phillips et al201 reported high correlation coefcients (0.83, 0.91, 0.89, 0.91, 0.88, 0.87) and low SEMs (2.45 degrees, 2.71 degrees, 1.69 degrees; 1.22 mm, 1.32 mm, 1.48 mm) when measuring the occipital-C2 angle and distances on neutral, exion, and extension radiographs. For measuring spinal canal dimensions and cord size in a 1999 review article, Rao and Fehlings202 reported that 7 studies provided interobserver and intraobserver reliability of radiographic measurements (0.82 < ICC < 0.99). In 1997, with means and SDs for measurement differences on AP thoracic views, it was reported that the rib vertebral angle could be reliably measured (intraobserver mean, 4.4 degrees; interobserver mean, 3.6 degrees).203 In 1996, Omeroglu et al204 reported that both intraobserver and interobserver error risks were insignicant for use of the Perdriolle torsionmeter to measure vertebral axial rotation in scoliosis on AP radiographs.204 In 1994, Gilliam et al205 reported high ICCs for both intertester (ICC > 0.86) and intratester (ICC > 0.92) pelvic radiographic measurements. Also in 1993, Hamberg et al206 reported that the x-ray measurements showed high reliability for pelvic tilt analysis.

Recently, computer-aided spinal radiographic measurements have been shown to be highly reliable. For example, in 1996, Rosol et al207 reported a high Pearson correlation for vertebral morphometry (r = 0.96) and low mean coefficients of intraobserver variability (4%) and interobserver variability (2%). We have already mentioned the recent (1998) study of sagittal balance with normal subjects and 3 patient groups conducted by Jackson et al.138 They reported high Pearson correlation coefcients in the vast majority of their interobserver and intraobserver reliability measures (13 measures in their Tables 8 and 9, most being greater than 0.75).138 In addition to the pelvic measurements, they also reported signicant differences in the normal subjects and the 3 patient groups for a multitude of lateral spine measurements. In 1997, Hardacker et al208 studied lateral cervical reliability with segmental Cobb angles and reported only 3 values of interobserver and intraoberver Pearson correlations less than 0.83 for 8 measurements of segmental lordosis (0.64 < r < 0.92). In 1994, Pruijs et al209 used a Spearman correlation coefficient for measurements of Cobb angles on AP thoracic radiographs. They reported high coefficients (>0.98) for both interobserver and intraobserver variation with small SDs of differences (<3.2 degrees). In 1996, Levine and Whittle168 measured pelvic tilt and lumbar lordosis using a television/computer system that obtained 3-dimensional (3-D) coordinates of markers on the pelvis and spine at 20-ms intervals. ICCs for 3 readings of pelvic tilt and lumbar lordosis were 0.78 < ICCs < 0.95. The investigators reported that altering the pelvic tilt signicantly changed the angle of lumbar lordosis. In 1995, Saji et al167 studied 61 idiopathic scoliosis adolescents with 33 normal subjects for femoral neck shaft angles and asymmetry of the hips. An angle was formed by lines through the femoral shaft and neck. They also performed Cobb angle measurements. Intraobserver reliability and interobserver reliability were assessed; there were no signicant differences between the measurements of a single observer or between the measurements of different observers. SEMs were small (intraobserver, 1.6 degrees; interobserver, 1.9 degrees). In addition, the investigators reported a signicant difference in the obtuse femoral angles in normal versus scoliotic subjects, the latter having much larger obtuse angles. In 1985, Tibrewal and Pearcy210 assessed measurement of disk heights from lateral radiographs. They reported a maximum error of 0.7 mm for intraobserver and interobserver measurements. Since 1990, many chiropractic studies have included statistical analyses that are extensive in comparison with those of previous studies. For our 6 CBP radiography reliability studies, we consulted with Burt Holland, PhD, a professor in the Department of Statistics at Temple University. With his aid, our studies have reported complete statistical analyses with a majority of intraobserver and interobserver ICCs greater than 0.75 and small SEMs (<2 degrees). It is interesting to note that ICC > 0.60 is the set of values that Haas et

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Fig 4. Four types of loads with inherent stresses. al7 have declared to be in the good-to-excellent range for chiropractic studies.211 This range is close to the excellent range suggested by Shrout and Fleiss212 (poor < 0.4; 0.4 < fair to good < 0.75; excellent > 0.75). It would be a great surprise to every mathematician, physicist, and engineer to find that radiographic line drawings of all types are not highly reliable. After all, it is nothing more than Euclidean geometry, which is the basis of every human-made structure in our industrial lives.

Posture Reproducibility, Reliability, and Validity


There is in the literature a plethora of posture reliability and reproducibility studies performed by ergonomists, medical doctors, chiropractors, and physical therapists. Posture

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B
Fig 5. A, Diversified technique is limited; lumbar roll is a torsional load applied to lumbar segments by twisting pelvis relative to xed thoracic cage. B, Cervical rotary-break is a torsional load applied to head in lateral flexed and forward flexed positions. These loads are applied to every subject; patients abnormal pretreatment posture is disregarded.

has been studied with patients lying,213 sitting,214 standing,215 lifting,216 working,217 walking,218 engaging in daily routine performance,219 and running.220 Postural stress has been correlated with scoliosis,221 ofce work,222 work-related lifting injuries,223 driving,224 sitting,225 space flight,226 sports injuries,227 and back pain.228 Posture as a valid outcome of care is universally accepted by almost all health care sciences.229-231 Virtually every body part has been studied for its posture in normal subjects versus injured individuals; included are the postures of the head,232 shoulders,233 upper extemity,234 trunk,235 pelvis,236 lower extremity,237 and short leg,238 as well as the whole body posture.239-251 The vast majority of these studies report high interobserver and intraobserver reliability. In 1990, in a study of 86 Chinese subjects, Dai and Gu252 found no significant differences in posture for males and females and no signicant differences in posture between groups of old-aged subjects and middleaged subjects with eyes open, though they did find a difference in posture between groups of old-aged subjects and middle-aged subjects with eyes closed. In a 1997 study of 160 men and women, Raine and Twomey253 found no significant gender differences for each of head and shoulder posture measurements. For a review of the normal alignment of the lower extremities, the reader is referred to the 1996 review by Riegger-Krugh and Keysor,254 who noted that pathology of structures results from skeletal malalignment. Adolescents postural faults have been established as the cause of pain syndromes in adulthood.255 Anatomical short leg inequality has received much attention in the literature. True anatomical leg length inequality causes a recognizable abnormal posture. For a review, the reader is referred to the 1983 review by the American Academy of Osteopathy256 and to recent articles by Beaudoin et al257 and Keppler et al.258 In terms of validity, posture as a valid outcome in the health care sciences is well accepted. In fact, the editor of this Journal has made the following statement: That posture can lead to low back pain will come as a surprise to no one.259

Last, inasmuch as Fialka-Moser et al255 reported that adolescents postural faults have been established as the cause of pain syndromes in adulthood, we are bewildered that chiropractic state licensing boards are being inuenced by the paradigm promoted by Haas et al7 and others, as cited in a recent review.8 For example, in August 1999 the Nevada Board of Chiropractic Examiners told practitioners that it was against Board ruling to take radiographs of children and that posttreatment radiographs were unwarranted. The selective information (countered in our preceding review) generally generated and disseminated by chiropractic radiologists and academicians is adversely affecting chiropractic clinicians ability to provide the best possible service to the patients who seek our care.

Clinical Utility and Appropriateness


Haas et als7 negation of structure (spinal alignment) as a clinical outcome seems to be based on a few controlled clinical trials that failed to demonstrate the effectiveness of chiropractic manipulation in conditions such as asthma260 and nocturnal enuresis.261 These studies used spinal manipulation as the intervention (treatment). Because manipulation seemed to be beneficial for headaches, neck pain, and back pain but not for other diseases or spinal displacement, Haas et al prefer to see chiropractic as merely a temporary treatment regimen for the relief of spinal aches and pains. There are many flaws in this line of reasoning, and most of these aws are derived from a complete void in an engineering education. At least two topics can be applied to Haas et als faulty reasoning: (1) exclusive use of torsional loads in spinal manipulation and (2) neglect of CNS biomechanics. This whole discussion of posture and radiographic line drawing reliability/validity omits a very important clinical factor when any of the postural rotations and translations in Figs 2 and 3 are present for long periods, especially flexed segments in the cervical and lumbar areas. Deformations of the CNS, which result from abnormal postural loads, were recently reviewed in this Journal.262-264

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Fig 6. In these examples, torsional loads make subjects posture worse. A, Patients initial posture is left head lateral exion with contralateral right thoracic bending (low shoulder at right). B, Patients head is right laterally translated with contralateral translation of thoracic cage. Y-axis torsional loadings (seen in Fig 5) will not correct this posture and will in fact add other abnormal postural loads.

Thus, of the two topics, only that of torsional loads in spinal manipulation needs to be presented here.

Torsional Loads
Let us revisit the postural DOF in Figs 1 and 2, which are based on the engineering concepts of rotations and translations in 3 dimensions. There are 12 single movements in 6 DOF for each of the head, thoracic cage, and pelvis. Through use of permutations in probability theory, it can be determined that there are 728 possible postures (singles, doubles, triples, . . . sextuples) of each of the head, thoracic cage, and pelvis in 3 dimensions, for a total of 7283 or 385,828,352 possible upright human postures!12 This is such an overwhelming number that it is best to restrict our discussion to the individual postures depicted in Figs 1 and 2. These 36 postures (12 singles each for head, thoracic cage, and pelvis) can be recategorized into the 4 types of loads taught in junior-level engineering courses on the mechanics of materials (Fig 4). In mechanics of materials, engineers study the material properties, design, loadings, deections, stresses, and strains of structures.265 The y-axis rotations in Fig 1 are caused by torsional loads, whereas the x-axis (exion/extension) and zaxis (lateral exion) rotations are examples of pure bending. The y-axis translations are examples of axial loads, whereas the x-axis and z-axis translations are examples of transverse

loads. After being exposed to some anatomy and ranges of motion, any engineer can visualize the stresses (forces/area) and strains (measurements of deformation) in these postures. For example, in lateral exion, the exural stresses are compression on the concave fibers and tension on the convex fibers. For the paraspinal tissues, these stresses/strains are directly associated with Wolffs law and Davis law, especially for the application of these abnormal loads over long periods. The previous discussion now illuminates a glaring deciency in applying diversied loadings to patients spines. The vast majority of diversified maneuvers are torsional loads (Fig 5). It might seem that these loadings will have a probability of being only 11% effective (of the 18 DOF illustrated in Figs 1 and 2, head and thoracic torsions are only 2 DOF). However, when considering the total permutations of posture, these diversified torsional loads are 4 out of 385,828,352 possible human postures, which amounts to approximately 0% of specificity in matching the patients abnormal posture. Haas et al7 seemingly do not understand the necessity of matching the patients individual posture because they do not have a realization that these (rotated and translated postures) are mathematical functions in linear algebra, which is fundamental to an engineering education. Linear algebra is the study of linear transformations.266 There are 4 important linear transformations in 3-D geometry: (1) rotations, (2) reections, (3) projections, and (4) transla-

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tions. Because of a complete void in chiropractic education, clinicians and academicians are unaware that rotations, reections, and translations have unique inverses (ie, only one load will correct them) and that rotations, translations, and reections are the only 3-D rigid body movers (this is a theorem in mathematics). From linear algebra, one deduces that there must be a normal (origin) from which to measure the displacements caused by rotations, reections, and translations. From the study of linear algebra, it becomes apparent that y-axis torsional loads are inappropriate interventions in the vast majority of patients. Actually, in most cases (ie, most postural positions of the patient), y-axis torsional loads make the patients posture worse (adding a new position not present in the initial posture). For the sake of brevity, we provide only 2 examples. Suppose the new patient has either head lateral flexion to the right and thoracic lateral flexion to the left or contralateral lateral translations of the head and rib cage (Fig 6). A cervical rotary break, as in Fig 5, A , will cause increased lateral flexion and the addition of head rotation, whereas a lumbar roll will not correct the thoracic lateral bending to the left but will add a y-axis rotation posture to the patient. The torsion stresses cause deformation of the mechanoreceptors in the disks, ligaments, and muscle spindles (these reflexes reduce pain), but they do not alter the initial and ongoing postural loads on the subjects paraspinal tissues. (This simple example, like the preceding discussion on outside posture, neglects the configurations of the sagittal cervical, thoracic, and lumbar curves on the inside.)

However, the complete void of mechanical engineering in their reasoning has led them to a paradigm of chiropractic treatment that we do not accept. Their paradigm of treatment, based on torsional loads, is detrimental to the patients well-being in the longitudinal sense. They seem to be interested only in temporary patient happiness outcomes7 of chiropractic care, whereas we are interested in the long-term effects of abnormal postural loads. We nd it paramount to measure the patients structure on the outside (posture) and use radiography for the segmental alignments on the inside (spine). The measurements gathered are used to uniquely determine the specific interventions chosen for each individual patient. We cannot accept the paradigm of applying general torsional loads to every patient. Deed E. Harrison, DC Private Practice of Chiropractic 123 Second Street Elko, NV 89801 Donald D. Harrison, DC, PhD Stephan J. Troyanovich, DC Stacy Harmon, DC, MD

REFERENCES
1. Haldeman D, Peterson D, Chapman-Smith D. Guidelines for chiropractic quality assurance and standards of practice. Gaithersburg, Md: Aspen Publishers; 1992. 2. 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. J Manipulative Physiol Ther 1994;17:454-64. 3. Harrison DD, Troyanovich SJ, Harrison DE, Janik TJ, Murphy DJ. A normal sagittal spinal conguration: a desirable clinical outcome. J Manipulative Physiol Ther 1996;19:398-405. 4. Troyanovich SJ, Harrison DD. Chiropractic biophysics (CBP) technique. Chiropr Technique 1996;8:1-6. 5. Troyanovich SJ, Harrison DE, Harrison DD. Review of the scientic literature relevant to structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998;21:37-50. 6. Troyanovich SJ, Harrison DD, Harrison DE. Low back pain and the lumbar intervertebral disc: clinical considerations for the doctor of chiropractic. J Manipulative Physiol Ther 1999;22:96-104. 7. Haas M, Taylor JAM, Gillete RG. The routine use of radiographic spinal displacement analysis: a dissent. J Manipulative Physiol Ther 1999;22:254-9. 8. Harrison DE, Harrison DD, Troyanovich SJ. Reliability of spinal displacement analysis on plane X-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique. J Manipulative Physiol Ther 1998;21:252-66. 9. Harrison DD, Janik TJ, Harrison GR, Troyanovich SJ, Harrison DE, Harrison SO. Chiropractic biophysics technique: a linear algebra approach to posture in chiropractic. J Manipulative Physiol Ther 1996;19:525-35. 10. Harrison DD. CBP technique: the physics of spinal correction. National Library of Medicine #WE 725 4318C, 1982-97. 11. Harrison DD. Spinal biomechanics: a chiropractic perspective. National Library of Medicine #WE 725 4318C, 1982-97.

CONCLUSION
A thorough review of normal upright posture, normal spinal modeling, structural spinal alignment as a clinical outcome, and radiograph reliability has been provided. It is up to the reader to evaluate whether it is the present authors or Haas et al7 who (1) have been guilty of omitting of relevant studies, the misrepresentation of evidence, and the disregard of the rules of evidence7 and/or (2) may have presented a bits and pieces approach to the literature, selective extracting and manipulating that which could be construed to be supportive of their position and ignoring the rest.267 The reader may compare the literature cited by Haas et al7 and Morgan267 (a total of 49 references) with the literature cited in this review and a 1998 review 8 (a total of 434 references) to determine whether published studies have been misrepresented and/or neglected. A detailed response to the criticisms of Haas et al concerning biological plausibility, clinical sensibility, and so on has been provided here. Finally, Haas et al and Morgan have questioned our integrity and have become personal in their attack on our credibility. For example, Morgan267 claims that the Harrison et al approach to the topic of spinal displacement appears much less as research and much more as promotion. Science requires critique of ideas, but personal attacks have no place in a scientic debate.

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