N A T I O N A L O F F I C E Suite 2, 36 Woodriff Street

Penrith NSW 2750 Australia

PO Box 335 Penrith NSW 2751

T: 02 4731 8011 F: 02 4731 8088

E: ceo@caa.asn.au www.chiropractors.asn.au

ABN 50 050 096 038

SUBMISSION RELATING TO

CONSULTATION PAPER ON CODES AND

GUIDELINES

TO

DR PHILLIP DONATO, CHIROPRACTOR

CHAIR CHIROPRACTIC BOARD OF AUSTRALIA

FROM

CHIROPRACTORS’ ASSOCIATION OF AUSTRALIA

7 April 2010

For further information contact: Ms Krystina Brown Chief Executive Officer See contact details above Mobile: 0414 514 333

INDEX Page 1 SUBMISSION COVER Page 2 INDEX Page 3 INTRODUCTORY COMMENTS Page 4 -5 GUIDELINES ON ADVERTISING Page 5 GUIDELINES FOR MANDATORY NOTIFICATION Page 5-7 BOARD CODE OF CONDUCT Page 7-8 CODE OF PROFESSIONAL PRACTICE FOR CHIROPRACTORS IN AUSTRALIA Page 8-14 GUIDELINES ON RADIOLOGY Page 14 GUIDELINES ON CONTINUING PROFESSIONAL DEVELOPMENT Page 15-19 APPENDIX I: FURTHER COMMENTS ON DRAFT CODE OF PROFESSIONAL

PRACTICE FOR CHIROPRACTORS IN AUSTRALIA ATTACHMENT 1: NORMAL SPINE MODEL ATTACHMENT 2: RADIOLOGY OF ABNORMAL BIOMECHANICS ATTACHMENT 3: COMPARATIVE PUBLIC BENEFIT OF RADIOLOGY

IN A CHIROPRACTIC PRACTICE

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This submission is in response to the Consultation paper on codes and guidelines prepared by the Chiropractic Board of Australia.

INTRODUCTION The Chiropractors Association of Australia (National) Ltd (CAAN) is the peak body representing chiropractors in Australia. CAAN works at the national level to support chiropractors in practice. We build capacity in chiropractic practice, working at the local level towards a skilled, viable and effective chiropractic sector to improve the health and well-being of Australian communities. The Chiropractors’ Association of Australia, through its state and national branches, provides the organisational interface between government and other stakeholders and chiropractic practice. CAAN’s Code of Professional Conduct for Chiropractors is one of the benchmarks of quality and safety in chiropractic practice and provides future directions for quality improvement. The CAAN Board is pleased to provide this submission to the Chiropractors Board of Australia (CBA). We hope that the committee will consider the CAAN’s feedback provided from across the profession in its ongoing and substantive reviews of the standards. CAAN would greatly appreciate the opportunity to provide experts and industry representation on the CBA's Guidelines Committee. The submission is presented in key themes and with a focus on those standards and criteria where practice improvement might significantly impact on all groups in our community. CAAN appreciates the opportunity to provide input on this submission to the CBA to assist in the development of codes and guidelines for the chiropractic profession in Australia. However, we are concerned that the time allowed for consultation has not facilitated as wide a consultation process as we would have preferred and consequently has not met the CBA’s own standard of “wide ranging consultation”. CAAN believes that with the changes recommended in this submission, the CBA guidelines for the practise of chiropractic could be the finest in the world, protecting both the public and the unique nature of the practice of chiropractic. Please contact our CAAN Chief Executive Officer, Krystina Brown, for any information regarding this submission. Her contact details are on the cover page of the submission.

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GUIDELINES ON ADVERTISING CAAN supports the concept of maintaining high ethical standards in chiropractic advertising. However, we have some concerns with the guidelines for the advertising of regulated health services. 3. Professional Obligations Substantiation of Claims Does the Board now intend for chiropractors to warn of “material risks” associated with chiropractic care in all advertising? Considering the relatively benign nature of the vast majority of abreactions to chiropractic care, this seems overly onerous. In particular, CAAN would have concerns about the requirement to warn about the possibility of VAD/stroke given the recent research by Cassidy, Winterstein et al and others which questions the causal relationship between chiropractic cervical adjusting and VAD/stroke. Many common daily activities have been linked to the onset of stroke. An example of this is drinking from a soft drink can. (Terrett AGJ. Current concepts in vertebrobasilar complications following cervical manipulation. 2001 NCMIC Group Inc., West Des Moines, Ia.) By the proposed standard, sellers of Coca Cola should be required to warn the public of this in their advertising too. Authorising the content of advertising CAAN is concerned that practitioners are expected to be responsible for the editing and editorialising of journalists. Expecting editorial control is unrealistic. Barring practitioners from being involved in media unless they have editorial control is an unreasonable expectation, especially for CAA media spokespeople. Suggested wording: “The chiropractor should take all reasonable steps to ensure accuracy of the reported story.” 5. What is unacceptable advertising? 5b. In health care, there are often “windows of opportunity” for being able to impact on the

health of individuals. In some cases, time pressures exist. Does the Board always consider it unreasonable to use the phrase “Don’t delay” or similar?

eg: Don’t delay getting moles checked? Don’t delay having a blood-pressure assessment? Don’t delay getting your child’s spine and nervous system checked after a fall?

5f. When compared to rates of medical harm chiropractic is comparatively far safer. The safety

record of chiropractic is unequivocally better than that of the medical profession. Medications are more dangerous than chiropractic care by a factor of hundreds. (Rome, CJA 1999; Dabbs and Lauretti, JMPT 1996) Surgical intervention is more dangerous than chiropractic care by a factor of tens of thousands. (Coulter Int J Integ Med, 1999) For the chiropractic profession to be prevented from telling the public these facts constitutes a public health risk. CAAN is deeply concerned that paragraph 5f of this section is both anti-competitive and more importantly, potentially dangerous to the health of the public.

Not to state such figures could be construed as false and misleading! 5j. Again, what health risks does the CBA require practitioners to warn against in their

advertising? 5m. CAAN is of the opinion that there are circumstances in which it is appropriate to encourage

some consumers to undertake a service. We believe that it is unreasonable to suggest that

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this should "not ever" happen in advertising. CAAN agrees, however, that all such information needs to be factual and not written in a scare-mongering way.

6. Specific requirements 6.5 Advertising of price information

After reviewing the ACCC website and the National Law, CAAN fails to understand why practitioners may not advertise time-limited or special offers. We consider that this requires a legal opinion to determine whether this clause constitutes an unlawful restraint of trade.

7. Advertising of Therapeutic Goods

CAAN welcomes this guideline, particularly as it pertains to the use of supplements by chiropractors.

GUIDELINES FOR MANDATORY NOTIFICATION CAAN sees the potential for serious issues with the current structure of the mandatory reporting process. We are absolutely committed to the safety of the public, however there are too many loopholes in this section that may encourage vexatious complaints. CAAN believes that registered health practitioners have a responsibility to approach practitioners who they believe may be breaching guidelines. If that approach fails, then perhaps reporting to a regulatory authority would be the next step? Decision guide: notifying sexual misconduct This flow-chart reads as if a voluntary notification could be made to the board about an allegation of sexual misconduct even though the first practitioner has no evidence or even belief that the second practitioner has engaged in inappropriate sexual activity with a current or former patient. Similar confusion exists with regards to the flow-chart on “departure from accepted professional standards” and “student impairment”. CAAN has reservations about the inflexibility of this section.

BOARD CODE OF CONDUCT CAAN strongly supports the goal of effective health care delivered in an ethical framework. A code of conduct that allows for the values and beliefs of practitioners and their clients and still achieves that goal would be a wonderful addition to the chiropractic profession. In particular, CAAN believes that clear, honest and effective communication between practitioners and their clients is an effective prophylaxis for health consumer complaints. 1.2 Professional values and qualities Practitioners have a responsibility to recognise and work within the limits of their competence

and scope of practice.

CAAN believes that manual spinal care such as the chiropractic adjustment or similar procedures should only be performed by chiropractors or other practitioners of similar training.

1.3 Australia and Australian health care

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As an association with members from a diversity of cultural backgrounds, CAAN supports and encourages awareness and appreciation of the many cultures that exist in Australia.

2. Providing good care

CAAN believes that the best interests of the health consumer are of paramount importance in their relationship with their health care practitioner. CAAN believes that there are, however, times when the “alleviation of symptoms” may not be in the long-term best interests of a client. For instance, it may be necessary to work on painful areas of the body to help in the rehabilitation and repair of injured tissues.

3. Working with patients or clients

CAAN completely concurs with the statement “Relationships based on openness, trust and good communication will enable practitioners to work in partnership with patients or clients.

3.14 Personal relationships

CAAN suggests that most chiropractors would be the primary provider of chiropractic services to their team and family. Does this breach the code? As long as there is good case management, is this a real issue? CAAN recommends the use of section 6.9.2.1 of the CAAN Code of Professional Conduct and Practice for Chiropractors (2005):

“As chiropractic does not involve critical care (such as surgery) and does not involve in-depth exploration of the patient’s psyche (such as occurs in psychology) and as chiropractic has a philosophy that health care is more than the treatment of symptoms and disease and often involves asymptomatic care, it is the policy of the CAA that chiropractors maintain the privilege of providing chiropractic care to their immediate family members and partners, providing that: - adequate records are kept; - confidentiality is maintained; - at all times an option to discontinue care is maintained.”

4. Working with other practitioners

CAAN agrees that a good relationship with colleagues and other health practitioners enhances patient care.

5. Working within the health care system

CAAN concurs that practitioners have a responsibility to contribute to the effectiveness and efficiency of the health care system. We believe chiropractic has a great deal to offer the health care system in this regard. In particular, chiropractors have great potential as primary contact practitioners able to conduct health education, promotion and screening.

6. Minimising risk

CAAN believes that risk minimisation is an important part of the responsibility of all health practitioners. We play an active part in assisting our members to develop and implement appropriate risk management strategies.

CAAN has some concerns about the intention of section 6.3. Is a "professional organisation"

exempt from mandatory reporting? Or do we need to institute a risk management process whereby only non-chiropractors (not bound by the Act or these guidelines) talk to members who are at risk of breaching guidelines. However, does this raise the issue of company directors who ARE chiropractors being prosecuted for failure to notify because we devolved responsibility in these areas to non-chiropractors?

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7. Maintaining professional performance

CAAN fully supports the concept of ongoing professional development to improve chiropractors’ skills in assisting their patients and to keep chiropractors at the forefront of health care delivery. In particular, we are committed to the provision of continuing professional development programs of the highest quality.

8. Professional behaviour

CAAN’s commitment to the highest standards of professional behaviour is reflected in its own Code of Professional Conduct and Practice for Chiropractors.

9. Practitioner Health

CAAN agrees that practitioner health and wellbeing is an important ingredient in the provision of quality health care.

9.2 c) Good practice involves understanding the principles of immunisation against

communicable diseases and being immunised against relevant communicable diseases.

CAAN is concerned that this may threaten the individual rights of practitioners to manage their own health care in the way they see fit. All Australians have these rights under the Australian Charter of Health Care Rights. In particular, the ACHCR states:

“I have the right to be included in decisions and choices about my care. I may join in making decisions about my care and about health service planning.”

10. Teaching, assessing and supervising

CAAN supports and encourages the mentorship, teaching and supervision of practitioners and students as an important part of personal and professional development.

11. Undertaking research

CAAN supports expansion of the knowledge base through quality research conducted in accordance with NH&MRC guidelines.

CODE OF PROFESSIONAL PRACTICE FOR CHIROPRACTORS IN AUSTRALIA CAAN agrees with the CBA’s sentiments that chiropractors have responsibilities and obligations to consumers of their health services, to the chiropractic profession and to the broader community to provide safe, beneficial, responsible and competent health care which meets best practice standards and is responsive to individual, group and community needs, within a context of justice and respect for peoples’ rights. However, CAAN is of the opinion that many sections of this document unnecessarily duplicate the Board Code of Conduct for registered health practitioners. This opinion is supported by the presence of repeated references to the Code of Conduct for Health Practitioners made throughout sections 1, 2, 4 and 5 of the Code of Professional Practice for Chiropractors in Australia. CAAN respectfully suggests that Section 3 - Working within the practice environment - is unnecessary because it simply replicates requirements made in other legislation and therefore adds nothing in the way of guidance to Australian chiropractors over already existing guidelines.

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The CBA is the only registration board of the ten AHPRA boards that has decided to create its own code of professional conduct. All other boards have chosen to use the Code of Conduct for Health Practitioners or supported an existing code of conduct from another body within the health profession they represent. Unless the CBA has evidence that the chiropractic profession needs more guidance in this area than other professions, CAAN recommends that the CBA take the same approach as the Dental, Optometry, Osteopathy, Pharmacy, Physiotherapy and Podiatry Boards of Australia and use the general Code of Conduct for Health Practitioners to protect the public from unprofessional conduct/professional misconduct by registrants. Please see Appendix I for details of CAAN concerns with sections 1 - 5 of the draft Code of Professional Practice for Chiropractors in Australia. CAAN recommends deletion of the profession-specific code of practice for chiropractors, with the exception of specific Guidelines on Radiology and Continuing Professional Development and the retention of sections 2.12 and 2.13. Our recommendations on those areas are as follows: RADIOLOGY CAAN supports the development of Radiology/Radiography guidelines for the chiropractic profession. The CAAN Radiology Committee has reviewed this section of the CBA draft guidelines in detail. The CAAN Radiology Committee consists of the heads of the radiology departments of all three Australian chiropractic teaching institutions as well as a number of field practitioners with a strong interest in the area of chiropractic radiography. CAAN recommendations for amendments to the CBA draft Radiography/Radiology guidelines are those of the CAAN Radiology Committee. Amendment One That chiropractic not be limited to the proposed "red flag" list of parameters currently provided in sections 2.6.2 and 2.6.3 of the draft. CAAN recommends that 2.6.1 reads: “Before a procedure involving exposure of an individual to ionizing radiation is approved or commenced, it must be justified by the chiropractor. Exposure to radiation should not be adopted unless it produces sufficient benefit to the exposed individuals or to society to offset the radiation detriment it may cause.”

We further recommend that section 2.6.1 be rewritten in accordance with “Justification of a medical

radiation procedure”, page 11, from ARPANSA

http://www.arpansa.gov.au/pubs/rps/rps14_draft1.pdf – as follows: 2.6.1 When determining the net benefit of a chiropractic radiation procedure, the chiropractor must

take into account:

(a) the specific objectives of the procedure; (b) the characteristics of the individual involved; (c) the total potential diagnostic or therapeutic benefits, including the direct health

benefits to the patient and the benefits to society in general;

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(d) the individual detriment to the patient that may result from the procedure; (e) the pregnancy status of a female patient if there is the potential for a radiation dose

to the embryo or fetus of more than 0.3 mSv; (f) the breast-feeding status of the female patient to be administered

a radiopharmaceutical if there is the potential for a: (i) radiation dose of more than 1 mSv to a breast-fed child; or (ii) significant radiation dose to the breast glandular tissue of the patient,

(g) the efficacy, benefits and risk of available alternative techniques having the same objectives, either with less exposure to ionizing radiation or in combination with the medical radiation procedure; and

(h) any medical data (such as previous diagnostic information or medical records)

relevant to the medical exposure. Background: CAAN feels that the existing clause lacks clarity as to exactly how a practitioner can "justify any decision" and "demonstrate that any benefit will outweigh the risks associated with ionising radiation." Since section 2.6 requests practitioners specifically comply with the provisions of the Code of Practice for Radiation Protection in the Applications of Ionizing Radiation, (ARPANSA), CAAN recommends that the ARPANSA guideline be directly referenced (as above) to give the practitioner greater guidance. Instead of the list of indications for radiography listed in 2.6.2 and 2.6.3, we propose that the CBA adopt the American College of Radiology (ACR) Guidelines for the Performance of Spine Radiography in Children and Adults (Revised 2007, 2008). http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/pediatric/spine_radiography.aspx Background Indications for radiography from a chiropractic registration board must acknowledge the particular health issues that chiropractors deal with and the particular interventions used by chiropractors. The proposed “red flags” list in sections 2.6.2 and 2.6.3 has been shortened by the standards set by nearly all international guidelines for musculoskeletal radiography. While there is some debate between international guidelines proposed for chiropractic, the ACR Guidelines are from the largest radiology body in the world. The American College of Radiology is an organization of more than 30,000 members. ACR Indications for radiography: A. General indications include, but are not limited to, the evaluation of: 1. Pain or limitation of motion. 2. Spinal trauma (symptomatic or at risk patients). 3. Surgical planning. 4. Previous surgery. 5. Suspected malignancy. 6. Congenital anomalies. 7. Previously detected spinal abnormality. 8. Alignment abnormalities, including scoliosis and kyphosis. B. Specific indications include, but are not limited to, the evaluation of: 1. Shoulder or arm pain from suspected cervical radiculopathy. 2. Occipital headache. 3. Pain radiating around the chest wall. 4. Pain radiating into the buttock, hip, or groin. 5. Compression fractures.

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Please note the 117 studies provided in Attachment 2 supportive of radiographic assessment of mechanical pain or where positive mechanical-based orthopedic findings are found on the initial examination and the 238 studies supportive of radiographic assessment of biomechanical health issues.

Chiropractic radiography guidelines must provide recognition of the needs of a profession that is based on physical interventions, including spinal adjustments, not medical interventions. These guidelines must provide recognition of the needs of a profession primarily assessing and managing mechanical pain and biomechanical health issues. Chiropractic radiographic indications are not specifically limited to the identification of "red-flag" pathologies. Chiropractors manage biomechanical health factors that cause a multi-million dollar drain on the Australian health-care purse. This list of conditions includes thoracic kyphosis, degenerative disc disease and spinal osteoarthritis, scoliosis, spinal canal stenosis, mechanical neck and back pain, radicular pain and headache. We would further argue that chiropractic may offer the public comparatively safer and less expensive protocols of care compared to medical treatment in these health areas. CAAN recommends that section 2.6.3 be removed, as the chiropractic radiographic examination of children is amply covered by the ACR guidelines. Background: Radiology for children deserves very careful consideration. CAAN acknowledges that chiropractors are primary health care professionals trained in diagnosis. We believe that this entitles chiropractors to the same recognition and scope to investigate a presenting complaint and conduct radiographic examination for further investigation when appropriate afforded to other primary health care professionals. There are three important sections to the ACR guidelines regarding children. These guidelines recognise the role radiography may have when an adult or child presents with (a) unexplained pain, (b) pain after trauma and (c) suspicion of congenital anomalies. The ACR guidelines provide specific reference to limiting the number of views for children. The ACR guidelines do not give carte blanche approval for routine radiography of asymptomatic children. Amendment 2 CAAN recommends that section 2.6 formally states and enshrines the importance of the individual clinician’s decision-making. We propose the following paraphrased statement be adopted from the American College of Radiology Guidelines. “The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the chiropractor in light of all the circumstances presented.” The CAAN Radiology Committee also recommends the inclusion of the following statement: “A practitioner must also be able to justify any decision to obtain any diagnostic imaging of a patient. Imaging guidelines are available to assist in this decision making process, but should not be implied to establish the legal standard of care.” Background All radiographic guidelines acknowledge the importance of the individual clinician’s decision-making. (See below.) No clinical guidelines assume that one type of assessment and one type of care must fit all clinicians for all patients all of the time. Chiropractic is a diverse profession with a growing and diverse range of relevant interventions. CAAN notes other radiology guideline examples where the individual clinician’s responsibility to, and

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capacity for, making a clinical decision about the cost/benefit ratio of radiography is acknowledged. 1. The American College of Chiropractic Radiologists (ACCR) Radiography Guidelines "Guidelines address issues common to clinical practice. They are not rules, but guidelines which attempt to define the principles of practice that should generally produce a high quality radiologic procedure. Adherence to radiography guidelines will not assure a successful outcome in every clinical situation. These guidelines are not intended to establish a legal standard of care or conduct, and deviation from a guideline does not, in and of itself, indicate or imply that such practice is below acceptable level of care. The ultimate judgment regarding any specific procedure or course of conduct must be made by the physician/Doctor of Chiropractic in light of all circumstances presented by the individual clinical setting". 2. The Quebec guidelines - http://www.jmptonline.org/article/PIIS0161475407003041/fulltext "These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision, and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and modified regularly with new information and experience.” 3. The PCCRP guidelines - http://www.pccrp.org/preface.htm "The PCCRP Guidelines contained herein are evidence-based suggestions for appropriate radiographic evaluations of patients seeking chiropractic care. No guideline can replace the clinical decisions made by a chiropractic practitioner in the course of treating an individual patient’s health problem. Any approach, by a practitioner, that is different from the PCCRP Guidelines, does not necessarily mean that the approach in question was below the standard of care. However, any chiropractic practitioner, who adopts a course of action different from the PCCRP Guidelines, is advised to keep sufficient patient records to explain why such an action was undertaken". 4. The father of evidence-based medicine, Sackett, points out that “… all levels of evidence and clinical experience should be considered in patient assessment”. [i] [ii] [iii] [iv] [v]

“EBM is NOT restricted to randomized control trials and meta-analysis. It involves tracking down the best external evidence with which to answer our clinical questions”. [v]

“[Evidence-based medicine] means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise, we mean the proficiency and judgment that we individual clinicians acquire through clinical experience and clinical practice".

Sackett goes further: "By best available external clinical evidence, we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough [emphasis added]. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients.”

[i] Sacket DL. Evidence based medicene. Editorial. Spine1998;23(10):1085-86 [ii] Sackett DL, Richardson WS, Rosenburg WHaynes RB. Evidence based medicine:How to practice and teach EBM. New York. Churchill Livingstone 1997 [iii] Sackett DL, Rosenburg WMC, Gray JAM, et al. “Evidence based medicine:what it is and what it isn”t” BMJ 1996;312:71-72 [iv] Sackett DL, Haynes RB, Guyatt GH, Tugwell P. In: Clinical epidemiology: a basic science for

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clinical medicine. 2nd ed.. Boston: Little Brown and Company; 1991;p. 441 [v] Sackett DL, Haynes RB, Tugell PX, Trout KS, Stoddard GL. How to read clinical journals: To learn about diagnostic test. Can Med Assoc J. 1981; 124:703–709 Amendment 3 That section 2.6.4 be re-written as follows: “The use of radiography as a routine clinical procedure for initial assessment or re-evaluation or general screening tool may or may not be inappropriate. X ray may best be considered after the findings of a history, and chiropractic, orthopaedic and biomechanical examination and when clinical decision making is applied to diagnostic considerations, intended interventions or possible contraindications to the type of care considered. Follow-up radiography is only applicable when recognised interventions are recommended for that condition over an appropriate period of time. A radiographic procedure can give a better clinical reliability for certain types of spinal assessment measurements recognised both within orthopaedic medicine and chiropractic and we recognise the poor reliability of alternative measurement methods for specific biomechanical spinal-health presentations. The application of radiographic measurements may include conditions such as segmental instability, scoliosis, thoracic kyphosis, hyper- and hypolordosis of lumbar spine, cervical spine kyphosis and short-leg syndrome. Radiography may provide better clinical utility, reliability and validity for both initial care assessment and the long-term treatment efficacy". Background Radiographic procedures must have clinical relevance. However, the statement in section 2.6.4 falls fundamentally short on clinical provision for a range of biomechanical/postural disorders other than scoliosis. It further fails to provide for the possible need for the measurement of treatment efficacy. Section 2.6 requests practitioners specifically comply with the provisions of Code of Practice for Radiation Protection in the Applications of Ionizing Radiation ARPANSA http://www.arpansa.gov.au/pubs/rps/rps19.pdf Therefore CAAN draws the attention of the CBA to section 3.2.2 of ARPANSA in support the above: “In determining the net benefit from a radiation procedure, the chiropractor must take into account: (a) the specific objectives of the procedure;

(b) the characteristics of the individual involved;

(c) the total potential benefits, including the direct health benefits to the person and, where relevant, the benefits to society in general;

(d) the individual detriment to the client that may result from the procedure; (e) the pregnancy status of a female client of child bearing capacity; (f) the efficacy, benefits and risk of available alternate techniques having the same objectives

with less or no exposure to ionizing radiation" With regard to the above extract from ARPANSA: 1. "In determining the net benefit from a radiation procedure, the chiropractor must take into

account: (a) the specific objectives of the procedure;

A radiographic procedure may at times be required to provide the patient with the correct diagnosis and optimal care. Radiographic investigation may be needed after the findings of an individual patient’s history, chiropractic, orthopaedic and physical examination are considered. The chiropractor has a clinical responsibility to provide every patient with an accurate differential diagnosis for his or her underlying condition and before a sound clinical rationale for physical management can be made. Radiographic procedures are often a required part of this process.

2. "In determining the net benefit from a radiation procedure, the chiropractor must take into

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account: (b) the characteristics of the individual involved;

If the management plan for the patient can be determined and will not be affected by the outcome of the radiographs, then radiographs should not be performed. 3. "In determining the net benefit from a radiation procedure, the chiropractor must take into account: (c) the total potential benefits, including the direct health benefits to the person and, where relevant, the benefits to society in general; As previously stated, chiropractic recognises and addresses biomechanical health factors that cause a multi-million dollar drain on the health-care purse. Radiographic examination can be an important part of the clinical examination required to appropriately manage many of these conditions. Sub-section 2.6.4 and the red-flag list in section 2.6.2 ignore these clinical facts. Radiographic examination must be considered if it may provide greater patient and public safety. Radiography may identify a range of clinical contraindications to certain physical interventions or manual spinal adjustments. Chiropractors have a responsibility to provide safe care to patients and the right to take reasonable steps to provide protection from litigation. Please note the 11 studies regarding contraindications in Atachment 2. 4. "In determining the net benefit from a radiation procedure, the chiropractor must take into

account: (d) the individual detriment to the client that may result from the procedure; Full-spine radiography should not be routine. Initial x-ray evaluation and re-evaluation of patients is inappropriate unless the initial examination reveals a recognised spinal biomechanical condition or positive mechanically-based orthopaedic findings. A radiographic procedure can give better clinical reliability for certain types of spinal assessment measurements (see the 37 studies in attachment two). Most of these radiographic measurements are recognised both within orthopaedic medicine and chiropractic. There can be poor reliability of alternative examination or re-examination methods for specific spinal measurements important to spine biomechanical health. Spine-based radiographic measurements are acknowledged within wider orthopaedic health sciences and including the measurement of segmental alignment and instability, scoliosis, thoracic kyphosis, hyper- and hypo-lordosis of lumbar spine, cervical spine kyphosis and short leg syndrome. Radiography may sometimes provide better clinical utility, reliability and validity for both initial care assessment and the long-term treatment efficacy.

Please see ATTACHMENT 1: NORMAL SPINE MODEL

Please see ATTACHMENT 2: RADIOLOGY OF ABNORMAL BIOMECHANICS

SECTION ONE: Provides a list of biomechanical-based spinal health condition/s. These conditions are routinely identified from radiographic investigation after the initial history, initial orthopaedic, neurological and physical examination findings (238 studies)

SECTION TWO: The evidence supportive of how changes in intervention approaches may result (including the management, stabilization or correction) when the above conditions are identified on initial chiropractic radiographs (80 studies).

SECTION THREE: The role of follow-up radiographic evaluation after recognised periods of conservative physical management for specific radiographic findings and conditions thereby establishing and documenting the efficacy of care. (25 studies).

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SECTION FOUR: The role of radiographic evaluation for patients presenting with mechanical pain or a changing symptomatic picture or where positive mechanical-based orthopedic findings are found on the initial examination. (117 studies).

SECTION FIVE: The importance of radiographic evaluation following the initial history and examination of a patient presenting with a history of physical trauma or falling (28 studies).

SECTION SIX: The reliability and repeatability of radiographic positioning and radiographic alignment assessment methods used in medicine and chiropractic. Includes studies confirming the poor reliability of alternative measuring methods. (37 references).

SECTION SEVEN: A radiographic evaluation may commonly reveal clinical information that may contraindicate the safety of certain physical interventions including spinal manipulation (11 studies)

Please see ATTACHMENT 3: THE COMPARATIVE PUBLIC BENEFIT OF RADIOLOGY IN A CHIROPRACTIC PRACTICE

SECTION ONE: Financial cost comparisons of Chiropractic and Medicine (18 studies)

SECTION TWO: Chiropractic clinical relevance/therapeutic comparisons (21 studies)

SECTION THREE: Chiropractic health promotion/patient satisfaction outcomes (6 studies)

SECTION FOUR: Medical harm within musculoskeletal care (38 studies)

GUIDELINES ON CONTINUING PROFESSIONAL DEVELOPMENT CAAN is deeply committed to the process of ongoing improvement through continuing professional development. We support an increased expectation for continuing professional development for chiropractors. We agree with the concept of a mixture of formal and informal learning to achieve professional development outcomes. CAAN stands ready to assist the CBA in the provision of quality CPD to chiropractors and in the administration associated with monitoring practitioner compliance for CPD. CAAN suggests some changes to the CPD guidelines: 1. CAAN assumes that “accreditation activities” involve the CCEA accreditation of chiropractic

programs in Australasia. We agree that this difficult and important work deserves formal CPD credit for those involved.

2. The current draft CBA guidelines for continuing professional development lists a number of

activities as appropriate formal learning activities, including: • Undertaking research and presentation of work • Making presentations of new material

o How does the CBA differentiate between presentation of research findings and

presentation of “new material”? o How would the CBA define “new material”?

CAAN suggests definitions of these terms be included in the guidelines. 3. In regard to Requirement 3.3, CAAN would respectfully request that any changes in CPD

requirements be made with enough notice to enable CPD providers and the organisations recording CPD on behalf of chiropractors sufficient time to alter their systems and procedures to fit those changes made by the CBA.

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APPENDIX 1

FURTHER COMMENTS ON DRAFT CODE OF PROFESSIONAL

PRACTICE FOR CHIROPRACTORS IN AUSTRALIA Within the section on Draft Code of Professional Practice for Chiropractors in the main part of the submission, the following comments are made: The CBA is the only registration board of the ten AHPRA boards that has decided to create its own code of professional conduct. All other boards have chosen to use the Code of Conduct for Health Practitioners or supported an existing code of conduct from another body within the health profession they represent. Unless the CBA has evidence that the chiropractic profession needs more guidance in this area than other professions, CAAN recommends that the CBA take the same approach as the Dental, Optometry, Osteopathy, Pharmacy, Physiotherapy and Podiatry Boards of Australia and use the general Code of Conduct for Health Practitioners to protect the public from unprofessional conduct/professional misconduct by registrants. The following concerns are raised by CAAN in regard to sections 1 – 5 of the draft Code of Professional Practice for Chiropractors in Australia. SECTION 1 Working with the patient, client and consumer CAAN respectfully suggests that the Code of Conduct for Health Practitioners (the Code of Conduct) is sufficient to cover all pertinent points in Section 1 of the draft Code of Professional Practice for Chiropractors in Australia (the Code of Practice). As the Board itself notes, sections 1, 2, 3, 10 and 11 of the Code of Conduct relate to the areas of practice discussed in section 1 of the Code of Practice. Where the Code of Conduct and the Code of Practice deal with the same issues, confusion may arise as to which part of the guidelines are to be followed. For example, section 2.10.7 of the Code of Practice suggests that screenings “… may be associated with harms …”. This may lead practitioners to avoid doing public health screenings. However, section 5.4b of the Code of Conduct states that “Practitioners have a responsibility to promote the health of the community through … education, and where relevant, screening.” We suggest that guidelines should give guidance to the profession rather than become a source of confusion. Feedback from our members suggests that the duplications and contradictions between the Code of Conduct and the Code of Practice is a great source of confusion and concern. Further: 1.1 Rights and responsibilities

o CAAN queries the use of the phrase “… waives the right” in a bullet point in section 1.1.1 on the left side of p.2 of the Code of Practice. An individual may waive their rights, legislation cannot waive an individual’s rights, although it may over-rule those rights.

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o We would suggest that the first bullet point in section 1.1.2 is actually part of the bold text above that bullet point.

1.2 Capacity to give Consent

Consent issues have been covered in detail in sections 3.5, 3.6b (noted as 3.6.2 in the preamble to section 1.2), 3.8 and 3.9b (noted as 3.9.2 in the preamble to section 1.2) of the Code of Conduct.

1.3 Informed Consent

See comments on section 1.2. 1.4 Refusal to provide a service and discontinuation of treatment prior to completion of

course of care

CAAN believes that sections 1-6 of the Code of Conduct more than adequately cover this area of practice.

1.5 Confidentiality and privacy

Section 3.4 of the Code of Conduct covers these issues in full. 1.6 Fees

CAAN believes that the pertinent issues in this section are covered in the guidelines for advertising (sections 4i and 6.5) and the Code of Conduct (sections 1.2, 2.1b, 2.2d, 2.2f, 2.2j, 2.2n, 2.4, 3.2, 3.3, 3.5, 3.6, 5.2, 8.11 and particularly 8.12.).

CAAN believes that there is no peer-reviewed evidence to suggest that care plans and financial arrangements between practitioners and their clients should not exceed 3 months, as stated in section 1.6.7. Particularly in chronic cases, care plans could often be laid out for some months ahead using an understanding of the time-frames involved in rehabilitation of chronic injuries.

We see no reason to limit the time-frames for financial arrangements as long as dealings are conducted in line with the above sections of the Code of Conduct.

1.7 Professional Boundaries

Section 3.4 of the Code of Conduct covers these issues in full. Please note previous comments with regard to section 3.14 of the Code of Conduct.

1.8 Provision of Certificates

Covered fully by section 8.8 of the Code of Conduct. SECTION 2: Working as the practitioner 2.1 Continuing professional development

Covered fully in the detailed Guidelines for Continuing Professional Development. 2.2 Responsibilities of the practitioner

Covered in detail by several areas of the Code of Conduct, particularly section 4.

CAAN has particular concern with the proposed requirement under section 2.2.2 for “… approval by the profession and the relevant health profession board” before a practitioner may “extend their scope of practice through innovation …” Does this mean that every new

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technique and every departure from standard chiropractic technique protocols would require such approval?

2.3 Advertising Covered fully in the detailed Guidelines on Advertising for Health Practitioners.

2.4 Health Records

Covered fully in the Code of Conduct in sections 2.2e, 3.4c, 3.16b and especially 8.4 CAAN would support the use of a practitioner-provided glossary to ensure that records are easily understood by fellow practitioners as per section 2.4.2.

With regards to 2.4.3, we suggest that a detailed notation of subjective and objective responses to care may not always be relevant or necessary on each occasion. This is particularly true in the management of chronic cases.

2.5 Names and titles

Considering the coverage of this issue in the guidelines for advertising for health practitioners and the specificity of the National Law regarding the use of titles, there seems no need for this section.

2.6 Radiology/Radiography – see detailed response above. 2.7 Diagnostic tools, tests and processes

CAAN suggests the deletion of this section because of its lack of clarity and questionable scientific basis. Considering the state of the peer-reviewed literature with regard to inter- and intra-examiner reliability and accuracy of motion palpation and many orthopaedic testing procedures, CAAN suggests that the singling out of “… sEMG, X-ray analysis, thermography, etc” is at best arbitrary.

As such, we recommend the following re-wording of this section:

“The over-reliance on any one diagnostic tool or process increases the risk of health

consumers receiving a misdiagnosis, inappropriate treatment or treatment not necessarily required for their health and well-being.

“Therefore, practitioners should conduct a full and thorough assessment using the tools

most appropriate for the gathering of information necessary to form a diagnosis.” 2.8 Delegation of practice

Covered by the overview of the Code of Conduct, in particular, sections 1.1, 4.3, 6.2, and 10. 2.9 Acupuncture and Dry Needling

CAAN suggests that these procedures do not form part of the core practice of chiropractic. Practitioners using these procedures should be guided by the relevant sections of the guidelines of relevant professional bodies, such as the Chinese Medicine Registration Board of Victoria, the Australian Natural Therapists Association, etc.

2.10 Working with adults and children

Considering the paucity of scientific evidence to support many of the Board’s assertions in this section, CAAN would suggest using section 3.6 of the Code of Conduct to address any issues regarding the chiropractic care of children.

2.11 Duration and frequency of care

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CAAN has serious concerns with many parts of this section.

In particular, we note that health promotion in the chiropractic context is overwhelmingly applied in a one-on-one consultation. To limit one-on-one consultations for this purpose would be to limit chiropractic health promotion "on a population level".

Considering the research by Sarnat et al (JMPT 2007) showing the very significant reductions in health care costs when chiropractors act as portals of entry into the health care system, we believe that section 2.11 may constitute a health risk to the Australian people.

We suggest using components of sections 2, 3, 5, 6 and 8 of the Code of Conduct to address frequency and duration of care issues. In 2.11.1 where reference is made to the “primary goal of chiropractic care…..” the following quotes from the New Jersey State Government statutes for the registration of chiropractors may be useful as definitions within the CBA guidelines:

Chiropractic subluxation: a complex of functional, structural or pathological articular

lesions or a local or systemic aberration of the nervous system caused by pressure, traction, stretch, torsion, chemical or electrical irritation, stimulation or inhibition of the nerve that compromises neural integrity as determined by chiropractic analytical procedures.

Practice of chiropractic: a philosophy, science and healing art concerned with the

restoration and preservation of health and wellness through the promotion of wellbeing, prevention of disease and promotion and support of the inherent or innate recuperative powers of the body.

2.12 Recency of practice

CAAN has made comment on recency of practice standards in previous submissions. 2.13 Professional indemnity and public liability insurance

CAAN supports the CBA fully with regard to PI/PL insurance. Section 3 Working within the practice environment As section 3 of the Code of Practice pertains to standards already required under other Occupational Health and Safety legislation, CAAN believes that it is superfluous. Section 4 Working with other practitioners Considering the presence of guidelines for mandatory notifications, plus sections 4.3, 6.3, 8.1, 8.3, 8.10, 8.11 and 9.3 of the Code of Conduct, CAAN believes that section 4 of the Code of Practice is unnecessary. The use of the term “informed financial consent” may be better replaced with “informed consent” to save further confusion. Section 5 Working with the broader community 5.1 Spinal postural assessment and public place marketing

Concerns about “scientific and clinical relevance” of screening findings and other matters raised in this section can be addressed using the guidelines on Advertising for the health professions.

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CAAN believes that the use of phrases such as “… tout for business …” and the overall pejorative tone of section 5.1 of the Code of Practice may discourage practitioners from fulfilling their responsibilities as outlined in section 5.4b of the Code of Conduct.

5.2 Provision of care to health consumers who are at risk

Sections 6.1-6.2 of the Code of Conduct adequately address these issues. Whilst we support the concept of taking extra care and attention with those clients who are at risk, CAAN suggests that it is an overly onerous requirement that all staff undertake suicide prevention training in the chiropractic context of health care delivery.

5.3 Reporting child abuse

CAAN supports the immediate reporting of suspected child abuse. However, this legal requirement is already covered under other legislation. It is, therefore, unnecessary in this document.

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ATTACHMENT 1: Motion 1 – Stand alone reasons for chiropractic radiography Subheading Question – Provide an overview of patient spinal alignment factors that enable the application of specific chiropractic spinal assessment methods, to better determine, optimise or modify either initial and/or long-term chiropractic management. Craig Moore Introduction: The following summary is primarily an outline of the chiropractic biophysics methodology for spine radiographic assessment and provides 81 references relating to both regional and global subluxation classification types. Average Normal Spinal Alignment Most health care providers accept the average values as “Normal” from a plethora of physiologic, anatomic, and biomechanical measurements (such as normal blood pressure is 120/80). Similarly, average values as “Normal” from healthy subjects for spinal alignment have been determined and published in the scientific literature. Because an average normal spinal model for each region (cervical spine, thoracic sine, and lumbar spine) was not published until recently, the Chiropractic founding fathers did not have access to any such normal values of segmental and/or global alignment. Thus they had only their intuition to guide them. However, this information is available to us at the present time. The journal Spine first published the Chiropractic Biophysics normal spinal model in 1996. From 1996-2003, normal spinal models have been published for each region of the spine.1 2 3 4 5 6 7 These normal spinal models are of two types, average 1 2 3 and ideal. 4 5 6 7 These models have been criticized by persons denying the very existence of subluxation, and have been suggested to be solely ideal or theoretical in character without clinical utility. 8 9 10 11 12 However, average normal spinal models have been developed and published in scientific journals. Furthermore, criticisms addressing these models have been addressed and adequately refuted. 1 2 3 13 In these recent modeling studies of normal individuals, subject x-rays were placed on a view box where a sonic digitizer was used to touch the vertebral landmarks on the x-ray. Specifically, the x-y coordinates of the posterior aspect of the vertebral body landmarks are read and stored in a computer database. These x-y coordinates from digitization of subject films, are then used in modeling of subject spinal alignments. As a result of this ‘curve fitting modeling process’, pieces of circles and ellipses were found to closely approximate the alignment of the posterior body margins and thus this average normal spinal model is actually the path of the posterior longitudinal ligament (PLL) from C1-S1 (Figure 1). It is important to note that chiropractors are not the only health care clinicians that are interested in average models of the spine. Recently, orthopedic surgeons have developed an optimization approach

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to model subject specific sagittal plane spinal curves; application of these models to spinal pain/deformity groups is being done as well. 14 15 16 17 Before presenting average normal values for each motor unit (two adjacent vertebrae), we note that these average normal models have predictive validity in as much as they can discriminate between normal subjects, acute pain subjects, and chronic pain subjects in both the cervical 3 and lumbar spines. 1 In the AP/PA view, the spine should be vertical and all end plate lines should be horizontal including occiput, C1-C7, T1-T12, L1-L5, sacral base, and a line at the tops of the femur heads (Figure 2A). These lines are the Gonstead Technique 18 wedge lines or also they are the endplate lines from which perpendiculars are drawn in the Cobb analysis, i.e., all wedge lines are parallel and all Cobb angles are 0º in the AP or PA spinal radiographic view. Another way to express this AP vertical alignment of the vertebrae is to state that all centers of mass are vertically aligned. In the cervical spine, this is equivalent to stating that the upper angle, lower angle, and CD angle on the nasium view are 90º, 90º, and 0º, respectively (See Section X Nasium X-ray view). In the thoracic and lumbar spines, this is equivalent to stating that all AP Riser-Ferguson angles (in any spinal region) are 0º (See Section X AP Thoracic, AP Lumbar, and AP Ferguson X-ray views). Figure 1. The 2003 Average Normal full Spine Model from C1 to S1 is the path of the PLL. The points shown for C2-S1 are the posterior vertebral body corners. The average normal full-spine model from C1 to T1 is composed of two C1 points (mid anterior arch & mid posterior margin of lateral mass) added to the C2-T1 circular model in Spine 2004. This C1-T1 model is added to the T1-T12 model by superimposing T1. Then the T12-S1 model is added, (from the Journal of Spinal Disorders). The resulting model has near perfect sagittal balance of C1-T1-T12-S1. The vertical line (VAL) for determining sagittal balance is drawn through the origin at posterior-inferior S1. Since a circle is a special ellipse with b/a = 1, this new fullspine model is composed of ellipses in the cervical, thoracic, and lumbar regions, but of different b/a ratios and different height-to length ratios. [Reprinted with permission: Harrison DE et al. Spinal Biomechanics for Clinicians, Vol I., Evanston, WY: Harrison CBP

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In the sagittal view, average normal rotation angles of each motor unit (two adjacent vertebrae) can be derived from drawing lines along the posterior body margins of every vertebrae and measuring the angle of intersection of each pair (Figure 2B). In actuality, these lines represent the slopes in an Engineering analysis of structures taught in Mechanics of Materials. 19 For C1, the sacral base (S1), and the pelvic tilt, lines through these structures are often compared to a horizontal line for an angle of inclination in degrees (Figure 2B). Segmental angles formed at adjacent vertebrae are termed Relative Rotation Angles (RRAs), while global angles (Absolute Rotation Angles are termed ARAs) in each region can be formed by comparing a superior vertebra in a sagittal region to an inferior vertebra. In this way an evaluation of the cervical lordosis (ARA C2-C7), thoracic kyphosis (ARA T1-T12 or ARA T2-T11), and lumbar lordosis (ARA L1-L5) can be measured in degrees. The reliability of these x-ray mensuration procedures will be comprehensively reviewed in Section VIII of the document.

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. Figure 2AB. In A, the vertical alignment of the entire head, spine, and pelvis is shown. One can either express this alignment as (a) all wedge lines (end plate lines) are parallel, e.g., all Gonstead wedge angles are zero and all Cobb angles are zero, or (b) all centers of mass are vertically aligned, e.g., all Nasium upper and lower angles are zero in displacement from 90º and all Risser-Ferguson angles are zero. The Risser-Ferguson lines will meet the sacral base wedge line at 90º. In B, sagittal alignment is measured as intersecting posterior vertebral body tangents, which create segmental angles at each pair of vertebra (RRAs) or global angles (ARAs) in each spinal region. Regional global angles are formed by choosing a superior vertebra and an inferior vertebra to intersect the posterior tangents, e.g., ARA C2-C7, ARA T3-T10, and/or ARA L1-L5. Reprinted with permission from Harrison CBP Seminars Inc., Evanston, WY

5.

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Since the AP alignment dictates zero degrees displacement in all end plate lines and all lines through centers of mass, it is the average normal sagittal angles (RRAs & ARAs) that are of interest. Below, Tables (1-3) present average normal values for the RRAs and ARAs for the three spinal regions, cervical spine, thoracic spine, and lumbar spine. As expressed previously, these average values are from published average healthy subjects’ spinal modeling studies. 1 2 3

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Structural Spinal Subluxation Assessment The spinal listing is the mechanical description of the subluxation. Historically, spinal listings have been composed of letters of the alphabet to represent the direction in which a vertebra has misaligned, e.g., P = posterior, A = anterior, R = right (spinous movement in PA view), L = left (spinous movement in PA view), S = superior, and I = inferior. These directions of misalignment were observed on spinal radiographs as early as 1910. Without an education in engineering, early Chiropractic Clinicians correctly categorized all the possible movements of a motor unit (listing the top vertebra’s movement relative to the vertebra immediately below) as: axial rotation, lateral bending, flexion-extension, anterolisthesis-retrolisthesis, laterolisthesis, and thin discs. Figure 3 illustrates all twelve possible vertebral misalignments in six degrees of freedom, but with listings expressed in engineering terms as rotations in degrees (Rx, Ry, Rz) and translations in millimeters (Tx, Ty, Tz).3 The origin or right-handed Cartesian coordinate system is adopted from Panjabi et al in 1974. 20

Figure 3. These are the misalignments that early Chiropractors observed on spinal x-rays after 1910. These were later described as rotations and translations in an x-y-z coordinate system in the literature in the 1970s. Using the Panjabi et al.’s coordinate system (Y vertical, X to the left, Z forward), axial rotation is ±Ry, lateral flexion is ±Rz, and flexion-extension is ±Rx, while left and right latero-listheses are ±Tx, vertical translation (thin discs and traction) are ±Ty, and antero- and retro-listheses are ±Tz. Reprinted with permission: Harrison DE et al. Spinal Biomechanics for Clinicians, Vol I., Evanston, WY: Harrison CBP Seminars, 2003

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In 1972, the liberal Chiropractic Colleges’ Houston Medicare Conference 21 chose 17 spinal displacements as spinal subluxations to be used by the US Federal government in defining spinal subluxation for re-imbursement of services to Chiropractors. These were/are: A. Static intersegmental subluxations 1. Flexion malposition 2. Extension malposition 3. Lateral flexion malposition 4. Rotational malposition 5. Anterolisthesis 6. Retrolisthesis 7. Altered interosseous spacing (decrease/increase) 8. Osseous foraminal encroachment B. Kinetic intersegmental subluxations 9. Hypomobility (fixation) 10. Hypermobility 11. Aberrant motion. C. Sectional subluxations 12. Scoliosis and/or alteration of curves secondary to musculature imbalance 13. Scoliosis and/or alteration of curves secondary to structural asymmetries 14. Decompensation of adaptational curvatures 15. Abnormalities of motion. D. Paravertebral subluxations 16. Costovertebral and costotransverse disrelationships 17. Sacroiliac subluxations It is important to note that using the average normal spinal model in Figure 1 and Tables 1-3, these displacements (listings) can be measured in degrees of rotation and millimeters of translation. Additionally, using the methods suggested in Figure 2A (Gonstead, Cobb, Risser-Ferguson, upper and lower angles on the nasium), it is possible to measure “Sectional Subluxations” (regional subluxations) in degrees of displacement from normal. However, these “Sectional Subluxations” are more clearly described in engineering terms as buckling, i.e., snap through buckling = sagittal buckling in harmonics or eigenvalues and their eigensolutions (types of “S”-curves), Elastic buckling of a column, or Euler buckling of a column. 22 23 24 25

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Subluxation Types Using the reference frame from Panjabi et al, 20 there are four types of observed postural and spinal segmental subluxations (displacements), which have been adequately described in mechanical engineering terms and verified by biomechanical investigations. In 1998, Harrison et al 5 presented a detailed review of the literature of these four types. In the current document, we add to the four types of subluxation discussed by Harrison et al 26 and present these as types of structural/mechanical displacements of the spine (“bone out of place”): 1. Segmental subluxations: These are the segmental displacements from C1-S1 measured from the vertebra above relative to an origin located in the vertebra immediately below. These vertebral spinal subluxations are listed in terms of Rx, Ry, Rz, Tx, Ty, Tz), 18 27 28 29 30 (See Figure 3). Triano 27 discussed these segmental displacements in terms of a buckling phenomenon but only discussed their post-buckled behavior (kinematic alterations) while neglecting the fact that these are associated with static displacements described as their respective post-buckled modes. The only valid way to identify these segmental displacements (post-buckled segmental modes or kinematic alterations) is by radiographic means. 18 28 29 30 2. Postural main motion and coupled motion: Postural displacements found in neutral resting stance are completely described as rotations and translation displacements of the head, thoracic cage, and pelvis. The majority of these displacements are concomitantly associated with spinal coupling/displacement patterns. 26 31 32 33 34 35 Each postural displacement has a unique spinal displacement pattern, with which it is normally associated. 3. Snap-through buckling in the sagittal plane: The alterations in the regional sagital curves of cervical or lumbar lordosis to kyphosis and “S”-curves and, to some extent, changes in thoracic kyphosis to hypo-or hyper-kyphosis have been found to be consistent with the engineering Snap-through type of buckling. 36 37 38 39 40 41 42 43 44 45 46 47 48 According to Nightingale et al 39, referring to Chen and Lui 23, “In a column with a fixed base, buckling is evidenced by an abrupt decrease in measured compressive load with increasing deflection and moment. Snap through buckling is characterized by a visible and rapid transition from one equilibrium configuration to another”. Snap through buckling can occur in 1 of 3 ways: a) an abrupt impact load applied to the head, ribcage, or pelvis, b) an overload event such as bending forward and lifting a very heavy object, or 3) an inertial loading event causing rapid acceleration and inertial loads to the spinal segments such as a rear end motor vehicle accident. 36 37 38 39 40 41 42 43 44 45 46 47 48 Increased complexity of the snap-through buckling is delineated in terms of the shape of the curves. An S-shape in any region (cervical, thoracic, lumbar) is the 1st order buckled mode, flexion-extension-flexion in any region is the 2nd order buckled mode, etc. In experiments, 2nd order and higher buckled modes are caused by dynamic loading and are associated with large

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increases in potential energy whereas 1st order buckled modes have been produced under static and quasi-static loading experiments. See Figure 5. 4. Euler buckling in AP/PA view: This type of structural displacement is generally where the structures of the lower most segments in a spinal region experience some failure, e.g., axial rotation and/or lateral flexion of L4 and L5. 26 49 50 51 These displacements are generally localized to the distal spinal regions of the cervical, thoraco-lumbar, and lumbo-pelvic and are generally associated with sub-catastrophic (non-complete tears) and sometimes catastrophic (macro) tears in the surrounding ligaments. These occur under similar loading circumstances as Snap through buckling detailed above. See Figure 6. 5. Scoliosis: Recently, the pathomechanics and perhaps the eitiology of the non-neurogenic forms of scoliosis have been described by a ‘slow-loading’ buckling mechanism. 35 52 There are multiple different types, locations and complexities of scoliosis. 6. Static or dynamic segmental instability: These are the segmental displacements depicted in Figure 3 but are at the limit of or past the limit for range of motion of the functional spinal unit. These are associated with significant ligamentous trauma. This information is detailed in Section X of this document under dynamic imaging and flexion/extension radiography. 53 54 55 56 57 58 59 60 61 These 6 types of subluxation are mechanical descriptions for the allowable spinal displacements that can occur. Using the average normal spinal model, inside normal upright stance, that we precisely defined in Figure 1, these 6 types of displacements can be quantified. It is an important feature that each one of the structural subluxations (except for instability, number 6 above) is a displacement that occurs within the allowable range of motion of the functional spinal motion segment. Thus, these 5 subluxations are static and dynamic mechanical displacements that are sustained within the range of joint motion. Also, we note that the above 6 types of structural subluxation are listed in increasing complexity of the displacement until we reach complete ligamentous failure or instability (number 6).

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Anatomic/Anomaly Variants Affecting Spinal Geometry An important topic when discussing our average spinal models’ application to the human population is a consideration of anatomical variations in a given persons spinal anatomy. There are several known anatomical variants of human spinal anatomy that affect spinal alignment/geometry, however, there are several variants that do not. Significant progress has been made in understanding the correlations between a variety of anatomical variants and spine geometric alterations; Chiropractic clinicians and researchers have played a significant role in this area of investigation. We continue to make progress understanding the context and accommodating for these variants. 12 62 63 64 65 66 For example, in a recent 2005 Chiropractic text, Peterson and Hsu, 12 claim that chiropractic roentgenometric measurement of spinal subluxation is “…controversial within the profession, particularly because the impact of natural and normal asymmetries with the body on these measurements is not known.” In support of their statement, the opinion article by Haas et al 62 and the investigation by Peterson et al 63 are offered. Despite claims, there is no referenced evidence to support the view that ‘natural asymmetry’ of the spinous processes altering spinal geometry in the AP view. In contrast, Farfan 67 found that when the spinous process is asymmetrical, the entire vertebral architecture will change and keep the lamina junction in line with the structural center of the vertebral body. This means the center of mass of the vertebral body will remain approximately the same. Farfan 67 states “It would appear that in the development of the vertebra, asymmetrical body growth is compensated for by asymmetric growth of the neural arch”. The second investigation offered by Peterson and Hsu 12 to criticize the chiropractic clinicians’ use of spinal radiography, is the study by Peterson et al. 63 With a small sample size and no segmental analysis of cervical lordosis, Petersen et al 63 claimed that alterations in the angle of the facet surfaces in the sagittal plane caused a reduction in the magnitude of the cervical lordosis. The claim that facet architecture/angles influence the cervical curve can be traced to a single 1977 self-published text by MacRae. 64 with only Class V evidence given. Winterstein 65 claimed that “short pedicles and vertically facing articular facets predispose to a cervical hypolordosis or kyphosis.” Winterstein offered no references for such statement. Peterson et al were challenged in a letter by Harrison et al 68 Harrison et al 69 performed a much needed investigation using 252 subjects, where the correlation between articular pillar height, facet surface sagittal plane angles, and the shape of the dens and the segmental and total cervical spine curvature was determined. Harrison et al concluded, “In contrast to chiropractic radiology paradigms in the literature, we found no

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statistical correlation with hyperplasia of the cervical facets (superior and inferior facet surfaces that diverge to the posterior) and any segmental or global angle of cervical lordosis. Additionally, there is no correlation with the vertical heights of the cervical facets and any segmental or global angle of cervical lordosis.” There are spinal anatomical variants that do affect the geometry of the spine and these include the following: 1. Sagittal plane wedge angles of the vertebral bodies, 70 71 72 2. Coronal plane wedge angles of the vertebral bodies (hemi-vertebra), 73 3. Anomalies of the skull condyles, 66 74 75 76 77 78 4. Transitional vertebra at L5-S1, 79 80 5. Congenital and surgical blocked vertebra, 81 and 6. Pelvic/sacral morphology. 14 15 16 17 Chiropractic pioneers (clinicians and researchers) and other health care physicians are on the forefront of investigating spinal anomalies, learning to identify them via radiographic means, and developing treatment strategies that account for the anatomical variances. 72 74 75 76 79

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References: 1 Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B. Elliptical Modeling of the Sagittal Lumbar Lordosis and Segmental

Rotation Angles as a Method to Discriminate Between Normal and Low Back Pain Subjects. J Spinal Disord 1998; 11(5): 430-439.

2 Harrison DE, Janik TJ, Harrison DD, Cailliet R, Harmon S. Can the Thoracic Kyphosis be Modeled with a Simple Geometric Shape? The

Results of Circular and Elliptical Modeling in 80 Asymptomatic Subjects. J Spinal Disord Tech 2002; 15(3): 213-220

3 Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW, Ferrantelli J, Holland B. Modeling of the Sagittal Cervical Spine as a Method to

Discriminate Hypo-Lordosis: Results of Elliptical and Circular Modeling in 72 Asymptomatic Subjects, 52 Acute Neck Pain Subjects, and 70

Chronic Neck Pain Subjects. Spine 2004; 29(22):2485-2492

4 Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of Lordotic Cervical Spine Curvatures to a Theoretical Ideal Model of the

Static Sagittal Cervical Spine. Spine 1996; 21(6):667-675

5 Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW. Do Alterations in Vertebral and Disc Dimensions Affect an Elliptical Model of the

Thoracic Kyphosis? Spine 2003; 28(5): 463-469

6 Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca CJ. Evaluations of the Assumptions Used to Derive an Ideal Normal Cervical

Spine Model. J Manipulative Physiol Ther 1997;20(4): 246-256

7 Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE. Can the Sagittal Lumbar Curvature be Closely Approximated by an Ellipse? J

Orthop Res 1998; 16(6):766-70

8 Oakley PA. Its Paul’s Opinion: Triano should stop bad mouthing Harrison’s work and accept it as clinical evidence for the CCPGG Guidelines.

American Journal of Clinical Chiropractic 2005;14(4): 3

9 Oakley PA. It’s Paul’s Opinion: CBP Researchers at 2004 ACC/RAC. American Journal of Clinical Chiropractic 2004; 13(2): 3

10 Triano JJ. Statements during a talk to the Faculty of Cleveland Chiropractic College Kansas City. Kansas City, MO, August 2004

11 Nelson CF, Lawrence D, Triano D, Bronfort G, Perle SM, Metz D, Hegetschweiler K, LaBrot T. Chiropractic as spine care: a model for the profession.

Chiropractic & Osteopathy 2005;13:9

12 Peterson C and Hsu W. Indications for and use of x-rays. Chapter 33. In: Haldeman S., editor, Modern Developments in Chiropractic, 3rd edition. New York:

McGraw-Hill Companies, Inc.,2005; pp. 661-681

13 Harrison DE, Harrison DD, Troyanovich SJ. A Normal Spinal Position, Its Time to Accept the Evidence. J Manipulative Physiol Ther 2000; 23: 623-644

14 Berthonnaud E, et al. Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disorders & Techniques

2005;18(1):40-47

15 Roussouly P, et al. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine

2005;30(3):346-353

16 Vialle R, et al. Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. JBJS Am 2005;87:260-267

17 Vaz G, et al. Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J 2002;11:80- 87

18 Rowe SH, Ray SG, Jakubowski AM, Picardi RJ. Plain Film Radiography in Chiropractic. Chapter 5. In: Plaugher, ed. Textbook of Clinical Chiropractic. A

Specific Biomechanical Approach. Williams & Wilkins, Baltimore. 1993; pages 112-149

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Manipulative Physiol Ther 1998; 21(3): 177-86

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1992;25:17-28

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Fixed Pelvis. Clin Biomech 1999: 14(10):704-709

32 Harrison DE, Cailliet R, Harrison DD, Troyanovich SJ, Janik TJ. Cervical Coupling on AP Radiographs During Lateral Translations of the Head Creates an S-

Configuration. Clin Biomech 2000; 15(6): 436-440

33 Harrison DE, Cailliet R, Harrison DD, Janik TJ. How Do Anterior/Posterior Translations of the Thoracic Cage Affect the Sagittal Lumbar Spine, Pelvic Tilt, and

Thoracic Kyphosis? Eur Spine J 2002; 11(3): 287-293

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radiograph. Spine 1997;22:501-508

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36 Yoganandan N, Pintar FA, Arnold P, Reinartz J, Cusick JF, Maiman DJ, Sances A. Continuous motion analysis of the head-neck complex under impact. J Spinal

Disorders 1994;7:420-428

37 Oktenglu T, Ozer F, Ferrara LA, Andalkar N, Sarioglu AC, Benzel EC. J Neurosurg (Spine 1) 2001;94:108-114

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cervical spine. J Biomechanics 2000;33:191-197

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1996;29:307-318

40 Nightingale RW, McElhaney JH, Richardson WJ, Best TM, Myers BS. Experimental impact injury to the cervical spine: Relating motion of the head and the

mechanism of injury. J Bone and Joint Surgery AM 1996;78-A:412-421

41 Fukushima M, Kaneoka K, Ono K, Sakane M, Ujihashi S, Ochiai N. Neck injury mechanisms during direct face impact. Spine 2006;31:903-908

42 Garcia T, Ravani B. A biomechanical evaluation of whiplash using a multi-body dynamic model. Transactions of ASME 2003;125:254-265

43 Panjabi MM, Pearson AM, Ito S, Ivancic PC, Wang JL. Cervical spine curvature during simulated whiplash. Clin Biom 2004;19:1-9

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(Canada): University of Waterloo;1983

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ATTACHMENT 2: Stand alone reasons for chiropractic radiography.

Subheading – To further establish the current spinal health status of the patient through identification of biomechanical factors where early detection provides patient benefit. The list below tables specific radiological findings which may be modified or managed or stabilised through specific approaches or protocols available within chiropractic-care. These findings therefore provide the justification for the radiography procedure and are findings that may specifically alter patient treatment.

Introduction 1. Overview: Chiropractic radiography is a growing biomechanical science. The previous document has already provided 81 references in support of an accepted normal or ideal spine position and biomechanical alignment for ideal spinal hygiene. Below we now provide the categories and a lengthy list of supportive references, primarily from medical (non-chiropractic) literature, tabling abnormal spinal biomechanics and abnormal alignment identified through radiography. The basis for this literature search was that the data accepted met at least two of the following three criteria:

1. That responsible radiography was identified as an accepted routine method of investigation of the finding/condition.

2. The referenced finding/condition was recognized both within chiropractic and also within the wider medical literature.

3. The finding/condition has clear relevance to specific protocols available to physical non-surgical management or treatment available to a chiropractor.

The vast majority of this literature synthesis was taken from the most respected medical orthopedic journals in the world including Spine Journal, European Spine Journal and Journal of Spinal disorders and 80% from research documented inside the last 20 years. Resources:

Spine journal European Spine Journal Bone and joint surgery journal Arch Phys Med Rehabilitation. Journal of Spinal disorders Journal of American Geriatrics Society. Physical Therapy Journal/journal of physiological therapeutics Medline/Medscape/Pubmed Several others

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Summary of criteria and for chiropractic-radiography beyond red-flags: SECTION ONE: Provides a list of biomechanical-based spinal health condition/s. These conditions may be identified from radiographic investigation after the initial history, initial orthopedic and physical examination findings: a) Scoliosis and pseudo-scoliosis (16 studies) b) Hyper or hypo-lordosis of cervical spine (53 studies) c) Hyper and hypo-kyphosis of thoracic spine (35 studies) d) Hyper or hypo-lordosis of lumbar spine (30 studies) e) Aberrant global spinal sagittal balance (lateral posture) (68 studies) f) Aberrant spinal coronal balance (anterior posture) (10 studies) g) Leg length disparity (26 studies) SECTION TWO: The evidence supportive of how changes in therapeutic approaches may result (including the management, stabilization or correction) when the above conditions when are identified on initial chiropractic radiographs. (80 studies). a) Scoliosis and pseudo-scoliosis b) Hyper or hypo-lordosis or kyphosis of cervical spine c) Hyper and hypo-kyphosis of thoracic spine d) Hyper or hypo-lordosis of lumbar spine e) Aberrant global spinal sagittal balance f) Aberrant spinal coronal balance g) Leg length disparity- pre/post heel orthotic leveling h) Spine related pain SECTION THREE: The role of follow-up radiographic evaluation after recognized periods of conservative physical management for certain specific radiographic findings and conditions thereby establishing and documenting the treatment efficacy (25 studies). SECTION FOUR: The role of radiographic evaluation for patients presenting with mechanical pain or a changing symptomatic picture or where positive mechanical-based orthopedic findings are found on the initial examination. (117 studies). SECTION FIVE: The importance of radiographic evaluation following the initial history and examination of a patient presenting with a history of physical trauma or falling (28 studies). SECTION SIX: The reliability and repeatability of radiographic positioning and radiographic alignment assessment methods used in medicine and chiropractic. Studies confirming the poor reliability of alternative measuring methods (37 references).

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SECTION SEVEN: A radiographic evaluation may commonly reveal clinical information that may contraindicate the safety of certain physical interventions including spinal manipulation (11 studies) SECTION ONE: A full list of biomechanical-based spinal health condition/s. These conditions must only be considered for further radiographic investigation after the initial history, initial orthopedic and physical examination: A) Scoliosis and pseudo-scoliosis

1. Low-Dose Radiography of Scoliosis in Children: A Comparison of Methods Kalmar, John A. MD; Jones, Jerome P. PhD; Merritt, Christopher R. B. MD Spine Journal Apr 1994 Volume 19

2. Radiation Exposure During Scoliosis Screening Radiography WESLEY M. MD; WAUGH, THEODORE R. MD; McMASTER, Spine Journal Oct 1981 Volume 6

3. Assessment of Spinal Flexibility in Adolescent Idiopathic Scoliosis: Suspension Versus Side-Bending Radiography Lamarre, Marie-Eve BEng; Parent, Stefan MD, PhD; Labelle, Hubert MD; Aubin, Carl-Eric PhD; Joncas, Julie RN; Cabral, Anne BEng; Petit, Yvan PhD Spine Journal 15 March 2009 - Volume 34 - Issue 6 - pp 591-597

4. Comparison of Observer Variation in Conventional and Three Digital Radiographic Methods Used in the Evaluation of Patients With Adolescent Idiopathic Scoliosis Mok, James M. MD; Berven, Sigurd H. MD; Diab, Mohammad MD; Hackbarth, Melissa PA-C; Hu, Serena S. MD; Deviren, Vedat MD Spine Journal 15 March 2008 - Volume 33 - Issue 6 - pp 681-686

5. Diagnostic Findings in Painful Adult Scoliosis Grubb, Stephen A. MD; Lipscomb, Hester J. RN, MPH Spine Journal May 1992 Volume 17.

6. Reducing the Lifetime Risk of Cancer From Spinal Radiographs Among People With Adolescent Idiopathic Scoliosis Levy, Adrian R. MSc; Goldberg, Mark S. PhD; Mayo, Nancy E. PhD; Hanley, James A. PhD; Poitras, Benoit MD, FRCP Spine Journal 1 July 1996 - Volume 21 - Issue 13 - pp 1540-1547

7. The Transverse Plane Evolution of the Most Common Adolescent Idiopathic Scoliosis Deformities: A Cross-sectional Study of 181 Patients Asher, Marc A. MD; Cook, Larry T. PhD Spine Journal June 1995 Volume 20

8. Comparison of Cobb Angles in Idiopathic Scoliosis on Standing Radiographs and Supine Axially Loaded MRI Wessberg, Per MD; Danielson, Barbro I. MD, PhD; Willén, Jan MD, PhD Spine Journal Dec 2006 Volume 31

9. The Selection of Operative Versus Non-operative Treatment in Patients With Adult Scoliosis Glassman, Steven D. MD; Schwab, Frank J. MD; Bridwell, Keith H. MD; Ondra, Stephen L. MD; Berven, Sigurd MD; Lenke, Lawrence G. MD Spine Journal 1 January 2007 - Volume 32 - Issue 1 - pp 93-97

10. Scoliosis associated with limb length inequality. Papaioannou T, Stokes I,Kenwright J. J Bone and joint surgery 1982;64(1)59-62.

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11. Measurement of scoliosis by orthopedic surgeons and radiologists. . Wilson MS, Stockwell J, Leedy MG. Aviat Space Environ Med 1983;54:69-71.

12. Degenerative symptomatic lumbar scoliosis. Pritchett JW, Bortel DT. Spine Journal 1993 May;18(6):700-3.

13. The effect of postural scoliosis on lumbar apophyseal joins. Giles LGF, Taylor JR. Scand Rheumatology 1984;13:209-220.

14. Measurement of the Cobb angles on radiographs of patients who have scoliosis.

15. Morrisy RT, Goldsmith GS, Hall EC, Kehl D, Cowie H. J Bone Joint Surg Am 1990;72:320-7.

16. Measurement of scoliosis and kyphosis radiographs: intraobserver and interobserver variation. Carman DL, Browne RH, Birch JG. J Bone Joint Surg Am 1990;72:328-33.

B) Hyper or hypo-lordosis or kyphosis of cervical spine 1. Modeling of the Sagittal Cervical Spine as a Method to Discriminate Hypo-Lordosis: Results of Elliptical and Circular Modeling in 72 Asymptomatic Subjects, 52 Acute Neck Pain Subjects, and 70 Chronic Neck Pain Subjects. Harrison DD, Harrison DE, Janik TJ, et al. Spine Journal. 2004;29:2485–2492. 2. Sagittal Alignment of Cervical Flexion and Extension: Lateral Radiographic Analysis Takeshima, Toshichika MD; Omokawa, Shohei MD; Takaoka, Takanori MD; Araki, Masafumi MD; Ueda, Yurito MD; Takakura, Yoshinori MD Spine Journal 1 August 2002 - Volume 27 - Issue 15 - pp E348-E355 3. Forward Head Posture is the Cause of 'Straight Spine Syndrome' in Many Professionals. Indian Choudhary Bakhtiar S; Sapur Suneetha; Deb P S. J Occupat and Environmental Med 2000 (Jul); 4 (3): 122—124. 4. The association between cervical spine curvature and neck pain. Grob D, Frauenfelder H, Mannion AF (2006) European Spine Journal Nov 18; Epub ahead of print. 5. Is the Sagittal configuration of the cervical spine changed in women with chronic whiplash syndrome? A comparative computer-assisted radiographic assessment. Kristjansson E, et al. JMPT 2002;25:550-555. 6. Cervical lordosis angle measured on lateral cephalograms; findings in skeletal class II female subjects with and without TMD: a cross sectional study. D'Attilio M, Epifania E, Ciuffolo F, Salini V, Filippi MR, Dolci M, Festa F, Tecco S. Cranio. 2004 Jan;22(1):27-44. 7. The relationship between posture and curvature of the cervical spine. JMPT Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW, Ferrantelli J, Holland B (2004)

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1998 Jul-Aug:21(6)388-91 8. Effects of abnormal posture on abnormal ligament elongations in a computational model subjected to whiplash loading. J Biomechanics 2005 jun38(6):1313-23 9. Relationship between forward head posture and diagnosed internal derangement of the temporomandibular joint. J Orofac Pain. Hackney J, Bade D, Clawson A. 1993 Fall;7(4):386-90. 10. Total head excursion and resting head posture: Normal and patient comparisons. Hanten WP, Olson SL, Russell JL, Lucio RM, Campbell AH. Arch Phys Med Rehabil 2000;81:62-66. 11. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Watson DH, Trott PH. Cehpalalgia 1993;13:272-284. 12. Relationship of forward head posture and cervical backward bending to neck pain. Haughie LJ, Fiebert IM, Roach KE. J Manipulative Physiol Ther 1995(3):91-97. 13. Obstructive sleep apnoea: a cephalometric study. Part I. Cervico-craniofacial skeletal morphology. Tangugsorn V, Skatvedt O, Krogstad O, Lyberg T. European J Orthod. 1995 Feb;17(1):45-56. 14. Obstructive sleep apnea: a principal component analysis. Tangugsorn V, Krogstad O, Espeland L, Lyberg T. Int J Adult Orthodon Orthognath Surg. 1999;14(3):215-28. 15. Natural head posture, upper airway morphology and obstructive sleep apnoea severity in adults. Ozbek MM, Miyamoto K, Lowe AA, Fleetham JA. Eur J Orthod 1998;20:133-143. 16. Cervical Angles in Sleep Apnea Patients: A Retrospective Study. Dobson, GJ.; Blanks, RHI.; Boone, WR.; Mccoy, HG.; JVSR 1999; 3(1): 9-23. 17. Obstructive sleep apnea: a principal component analysis. Tangugsorn V, Krogstad O, Espeland L, Lyberg T. Int J Adult Orthodon Orthognath Surg. 1999;14(3):215-28. 18. Obstructive sleep apnea (OSA): a cephalometric analysis of severe and non-severe OSA patients. Part II: A predictive discriminant function analysis. Tangugsorn V, Krogstad O, Espeland L, Lyberg T. Int J Adult Orthodon Orthognath Surg. 2000 Fall;15(3):179-91. 19. Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study Fernández C, et al. Cephalalgia 2006;26(3):314-319. 20. Determining a clinical normal value for cervical lordosis. McAviney J, Schulz D, Richard

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Bock R, Harrison DE, Holland B (2005) J Manipulative Physiol Ther 28:187-193. 21. Cervical spine geometry correlated to cervical degenerative disease in a symptomatic group. Journal of manipulative physiol therapy 2003 Jul:26(6)341-346 22. Spinal kyphosis causes demylination and neuronal loss in the spinal cord: A new model of kyphotic deformity using juvenile japanese small game fowls. Spine Journal 30(21):2388-2392 Nov 1 2005 23. Determining the relationship between cervical lordosis and neck complaints. Jeb McAviney, Dan Schulz, Richard Bock, Deed E. Harrison, Burt Holland Journal of manipulative physiol therapy March 2005 (Vol. 28, Issue 3, Pages 187-193) 24. Evaluation of axial and flexural stresses in the vertebral body cortex and trabecular bone in lordosis and two sagittal cervical translation configurations with an elliptical shell model Deed E. Harrison, E.William Jones, Tadeusz J. Janik, Donald D. Harrison Journal of Manipulative and Physiological Therapeutics July 2002 (Vol. 25, Issue 6, Pages 391-401 25. Cobb Method or Harrison Posterior Tangent Method: Which to Choose for Lateral Cervical Radiographic Analysis Spine Journal 15 August 2000 - Volume 25 - Issue 16 - pp 2072-2078 Harrison, Deed E. DC; Harrison, Donald D. PhD, DC, MSE; Cailliet, Rene MD; Troyanovich, Stephan J. DC; Janik, Tadeusz J. PhD,÷; Holland, Burt PhD 26. Increased Sagittal Plane Segmental Motion in the Lower Cervical Spine in Women With Chronic Whiplash-Associated Disorders, Grades I-II: A Case-Control Study Using a New Measurement Protocol Kristjansson, Eythor PT, BSc; Leivseth, Gunnar MD, PhD, Prof; Brinckmann, Paul Prof Dr rer nat; Frobin, Wolfgang Dr rer nat Spine Journal 1 October 2003 - Volume 28 - Issue 19 - pp 2215-2221

27. Correction of Cervical Kyphosis Using Pedicle Screw Fixation Systems Abumi, Kuniyoshi MD; Shono, Yasuhiro MD; Taneichi, Hiroshi MD; Ito, Manabu MD; Kaneda, Kiyoshi MD Spine Journal 15 November 1999 - Volume 24 - Issue 22 - p 2389

28. Computerized tomographical study of dorsal neck muscles for insertion of EMG wire electrodes Mayoux-Benhamou MA. Electromyo Clin Neurophys 1993;33:161-6. Journal of Electromyography and Kinesiology, Volume 5, Issue 2, Pages 101-107 29. Is the Sagittal configuration of the cervical spine changed in women with chronic whiplash syndrome? A comparative computer-assisted radiographic assessment. Kristjansson E, et al. JMPT 2002;25:550-555. 30. Total head excursion and resting head posture: Normal and patient comparisons. Hanten WP, Olson SL, Russell JL, Lucio RM, Campbell AH. Arch Phys Med Rehabil 2000;81:62-66.

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31. Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA. Cephalalgia. 2006 Sep;26(9):1061-70. 32. Trigger points in the suboccipital muscles and forward head posture in tension-type headache. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Headache 2006;46(3):454-460. 33. Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Headache. 2006 Sep;46(8):1264-72. 34. Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache. Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA. Headache 2007;47(5):662-672. 35. Relationship of forward head posture and cervical backward bending to neck pain. Haughie LJ, Fiebert IM, Roach KE. J Manipulative Physiol Ther 1995(3):91-97. 36. Cervicogenic dysfunction in muscle contraction headache and migraine: A descriptive study. Vernon H, et al. J Manipulative Physiol Ther 1992;15:418-29. 37. The association between cervical spine curvature and neck pain. Grob D, Frauenfelder H, Mannion AF (2006) Eur Spine J Nov 18; [Epub ahead of print]. 38. Apophysial joint degeneration, disc degeneration, and sagittal curve of the cervical spine. Cote P, Cassidy JD, Yong-Hing K, Sibley J, Loewy Spine Journal. 1997;22:859-64. 39. Comparison of axial flexural stresses in lordosis and three dimensional buckled configurations of the cervical spine Deed Harrison, Don Harrison, Tadeusz Janik. E. William Jones, Rene Calliet, Martin Normand Clinical Biomechanics 16 (2001) 276-284 40. Cervical curvature in acute whiplash injuries: a prospective comparative study with asymptomatic subjects. Injury 1998;29 p775-8 41. Kinamatics of cervical spine injury. A functional radiological hypothesis. Eur Spine Journal. 1995;4p126-32 42. The vertical stability of the cervical spine. Pal GP, Sherk HH. Spine.1998;13:p447-8 43. Prediction of load sharing amoung spinal components of a C5-C6 motion segment using the finite element approach. Spine 1998;23:684-91 44. Anatomic basis for the study of constraints to which the cervical spine is subject in the

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sagittal plane. A study of the centre of gravity of the head. Surg Radiol Anat 1986;8:169-73 45. Whiplash produces an S shaped curvature of the neck with hyperextension of the lower levels. Spine 1997;22:2489-94 46. The effects of mechanical forces on bones and joints. Experimental study on the rat tail. Pazzaglia UE, Andrini L, Di Nucci A. J Bone Joint Surg (Am) 1997;79-A:1024-30. 47. Kinematics of cervical spine injury: a functional radiological hypothesis. Penning L. Eur Spine J 1995;130:317-26. 48 .Kinematics of the cervical spine canal: Changes with sagittal plane loads. Chen IH, Vasavada A, Panjabi MM. J Spinal Disord. 1994;7:93-101. 49. A Review of Biomechanics of the Central Nervous System—Part II: Spinal Cord Strains from Postural Loads. JMPT Volume 22 June 1999 Deed E. Harrison, DC, Rene Cailliet, MD, Donald D. Harrison, PhD, DC, Stephan J. Troyanovich, DC, and Sanghak O. Harrison, DC 50. Effect of Neck Exercise on Sitting Posture in Patients With Chronic Neck Pain. J PHYS THER Vol. 87, No. 4, April 2007, pp. 408-417Deborah Falla, Gwendolen Jull, Trevor Russell, Bill Vicenzino and Paul Hodges 51. Line drawing analyses of static cervical X ray used in chiropractic. Owens EF Jr. J Manipulative Physiol Ther. 1992 Sep;15(7):442-9. Review. 52. Head Posture and Neck Pain of Chronic Nontraumatic Origin: A Comparison Between Patients and Pain-Free Persons �Anabela G. Silva, T. David Punt, Paul Sharples, João P. Vilas-Boas, Mark I. Johnson �Archives of Physical Medicine and Rehabilitation �April 2009 (Vol. 90, Issue 4, Pages 669-674) 53. Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study [see comments]. Vernon H, Steiman I, Hagino C. J Manipulative.Physiol Ther. 1992;15:418-29. C) Hyper and hypo-kyphosis of thoracic spine 1. A study of complaints and their relation to vertebral destruction in patients with osteoporosis. Leidig G, Minne HW, Sauer P, Wuster C, Wuster J, Lojen M, Raue F, Ziegler R Bone Miner 1990;8:217-229. 2. Thoracic kyphosis, rib mobility and lung volumes in normal women and women with osteoporosis. Culham, et al. Spine Journal 1994;11:1250-55.

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3. Spinal curvatures and quality of life in women with vertebral fractures secondary to osteoporosis. Cortet B, Houvenagel E, Puisieux F, Roches E, Garnier P, Delcambre B Spine Journal 1999;18:1921-1925. 4. Evaluation of spinal curvatures after a recent osteoporotic vertebral fracture. Joint Bone Spine. Cortet B, Roches E, Logier R, Houvenagel E, Gaydier-Souquieres G, Puisieux F, Delcambre B. 2002 Mar;69(2):201-8. 5. Relationship Between Vertebral Deformities And Allergic Diseases. Takeda Y, Arai S. The Internet Journal of Orthopedic Surgery 2004;2(1): 6. Association of thoracic kyphosis with subjective poor health, functional activity and blood pressure in the community-dwelling elderly. Nishiwaki Y, Kikuch Y, Araya K, et al. Environ Health Prev Med 2007; 12(6):246-250. 7. Hyperkyphotic Posture Predicts Mortality in Older Community-Dwelling Men and Women: A prospective Study. Deborah Kado,MD, MS,Mei-Hua Huang, DrPH,Arun S. Karlamangla, MD, PhD, Elizabeth Barrett-Connor, MD,w and Gail A. Greendale, MD Journal of American Geriatrics Society. Volume 52 Issue 10 Oct 2004 p1662 8. Trunk deformity is associated with a reduction in outdoor activities of daily living and life satisfaction in community-dwelling older people. Takahashi T, Ishida K., et al. Osteoporosis Int. 2005;16: 273-279. 9. Development of spinal posture in a cohort of children age 11 to 22 years. Eur Spine J 2005 Oct:14(8):738-42 10. Hyperkyphotic posture and risk of future osteoporotic fractures: The Ranch Bernado Study. J Bone Miner Res. 2006 Mar:21(3):419-23 11. Impact of postural deformities and spinal mobility on quality of life in post-menopausal osteoporosis. Osteoporosis Int 2003 Dec:14(12):1007-12 12. Thoracic and Thoracolumbar Kyphosis in Adults Macagno, Angel E. MD; O’Brien, Michael F. MD Spine Journal September 2006 - Volume 31 - Issue 19S - pp S161-S170 13. Differences in Thoracic Kyphosis and in Back Muscle Strength in Women With Bone Loss due to Osteoporosis Mika, Anna PhD; Unnithan, Viswanath B. PhD; Mika, Piotr PhD Spine Journal 15 January 2005 - Volume 30 - Issue 2 - pp 241-246

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14. Lumbar Degenerative Kyphosis: Radiologic Analysis and Classifications Jang, Jee-Soo MD, PhD; Lee, Sang-Ho MD, PhD; Min, Jun-Hong MD, PhD; Han, Kyoung-Mi RN Spine Journal 15 November 2007 - Volume 32 - Issue 24 - pp 2694-2699

15. The Natural History of Congenital Scoliosis and Kyphosis Marks, David S. FRCS, FRCS (Orth); Qaimkhani, Saeed A. FRCS (Orth) Spine Journal 1 August 2009 - Volume 34 - Issue 17 - pp 1751-1755

16. Measurement of Spinal Kyphosis: Implications for the Management of Scheuermann's Kyphosis Spine Journal Stotts, Alan K. MD; Smith, John T. MD; Santora, Steven D. MD; Roach, James W. MD; D'Astous, Jacques L. MD 1 October 2002 - Volume 27 - Issue 19 - pp 2143-2146 17. Prediction of Osteoporotic Spinal Deformity Tony S. Keller, PhD, Deed E. Harrison, DC, Christopher J. Colloca, DC, Donald D. Harrison, DC, PhD and Tadeusz J. Janik, PhD Spine Journal 2003 Volume 28, Number 5, pp 455–462 18. How do anterior/posterior translations of the thoracic cage effect the sagital lumbar spine, pelvic tilt and thoracic kyphosis? European Spine Journal 2002: 11(3): 287-293 Deed Harrison, Rene Cailliett, Don Harrison 19. Lumbar coupling during lateral translations of the thoracic cage relative to a fixed pelvis. Clinical biomechanics 1999 14(10):704-709 Deed Harrison, Rene Cailliett, Don Harrison 20. Thoracic Osteoporotic Fracture Without Upper Back Pain Huntoon, Elizabeth MD; Sinaki, Mehrsheed MD, MS American Journal of Physical Medicine & Rehabilitation: September 2004 - Volume 83 - Issue 9 - p 729 21. Influence of Posture on the Range of Axial Rotation and Coupled Lateral Flexion of the Thoracic Spine. Stephen J. Edmondston, PhD, Mathew Aggerholm, Suzanne Elfving, Neil Flores, Christopher Ng, Richard Smith, BPT, Kevin Netto, PhD JMPT Volume 30 Issue 3 Pages 193-199 (March 2007) 22. Thoracic kyphosis, rib mobility and lung volumes in normal women and women with osteoporosis. Culham, et al. Spine 1994;11:1250-55. 23. Scheuermann kyphosis. Wenger DR, Frick SL 1999 Spine Journal 24:2630-2639 24. Scoliosis sagittal alignment. Hilibrand AS et al. J Ped Orthop 1995;p627-32 25. Long-term morbidity and mortality after a clinically diagnosed vertebral fracture in the elderly-a 12 and 22 year follow up. Calcif Tissue Int 2005;76(4)p235-42 26. Thoracic Kyphosis Affects Spinal Loads and Trunk Muscle Force. J PHYS THER

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Vol. 87, No. 5, May 2007, pp. 595-607Andrew M Briggs, Jaap H van Dieën, Tim V Wrigley, Alison M Greig, Bev Phillips, Sing Kai Lo and Kim L Bennell

27. Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength Sinaki, M., Brey, R.H. (et al.) Osteoporosis International, Springer London, 12.11.2004, vol. 16, no. 8, pp. 1004-1010

28. Postural degenerative kyphosis. Griegel-Morris et al. Phys Ther 1992;72:425-431

29. Hyperkyphotic Posture and Risk of Injurious Falls in Older Persons: The Rancho Bernardo Study Deborah M. Kado, Mei-Hua Huang, Claude B. Nguyen, Elizabeth Barrett-Connor, and Gail A. Greendale J. Gerontol. A Biol. Sci. Med. Sci., Jun 2007; 62: 652 – 657 30. Thoracic kyphosis and the prevelance of advanced uterine collapse. Obstst Gynecol 1996;87:605-609 31. The Straight Back Syndrome M. K. DAVIES, P. MACKINTOSH, R. M. CAYTON, A. J. F. PAGE, M. F. SHIU and W. A. LITTLER J Med 1980; 49: 443-460

32. Tracheal Compression Caused by Straight Back Syndrome, Chest Wall Deformity, and Anterior Spinal Displacement: Techniques for Relief H. C. Grillo, C. D. Wright, P. G. Dartevelle, J. C. Wain, and S. Murakami Ann. Thorac. Surg., December 1, 2005; 80(6): 2057 - 2062.

33. Is Mitral Valve Prolapse Due to Cardiac Entrapment in the Chest Cavity?: A CT View . P. Raggi, T. Q. Callister, N. J. Lippolis, and D. J. Russo Chest, March 1, 2000; 117(3): 636 - 642. 34. Can the Thoracic Kyphosis Be Modeled With a Simple Geometric Shape?: The Results of Circular and Elliptical Modeling in 80 Asymptomatic Patients. Harrison DE, Janik TJ, Harrison DD et al. J Spinal Disord.Tech. 2002;15:213-20. 35. The effect of anterior osteophytes and flexural position on thoracic trabecular strain. Toh E, Yerby SA, Bay BK et al. Spine 2001;26:22-6. D) Hyper or hypo-lordosis of lumbar spine

1. Correlative analysis of lateral vertebral radiographic variables and medical outcomes study short-form health survey: a comparative study in asymptomatic volunteers versus patients with low back pain. Korovessis P Dimas A Iliopoulos P Lambiris E J Spinal Disord Tech. 2002 Oct;15(5):384-90.

2. An analytical survey of structural aberrations observed in static radiographic examinations

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among acute low back cases. Reinert OC. J Manipulative Physiol Ther. 1988 Feb;11(1):24-30. 3. Clinical findings as outcome predictors in rehabilitation of patients with sciatica. Nykvist F, et al. International J of Rehabilitation Res 1991;14:131-144. 4. Radiographic analysis of lumbar spine for low-back pain in the general population. Inaoka M, et al. Arch Orthop Trauma Surg 2000;120:380-385. 5. Knee-spine syndrome: correlation between sacral inclination and patellofemoral joint pain. Tsuji T, Matsuyama Y, Goto M, Yimin Y, Sato K, Hasegawa H, Ishiguro N. J Orthop Sci 2002; 7:519-523. 6. A comparative roentgenographic analysis of the lumbar spine in male army recruits with and without lower back pain. Steinberg EL, Luger E, Arbel R, Menachem A, Dekel S. Clin Radiol. 2003 Dec; 58(12): 985-9. 7. Lumbar lordosis in acute and chronic low back pain patients. Evcik D, Yucel A. Rheumatol Int 2003; 23(4):163-5. Epub 2003 Jan 18. 8. Elliptical modeling and sagittal lumbar radiographic alignment variables in normal vs. chronic low back pain subjects: does pelvic morphology explain group lordotic differences? Harrison DE, Harrison DD, Janik TJ, Cailliet R, Holland B. Proceedings of the 34th annual meeting of the International Society for the Study of the Lumbar Spine (ISSLS) 2007; June 10-14, Hong Kong, China:p149. 9. Pelvic morphology affects the sagittal plane alignment of the lumbo-pelvic spine normal subjects and low back pain patients. Harrison DE, Keller TS, Harrison DD, Janik TJ, Colloca CJ. Proceedings of the 34th annual meeting of the International Society for the Study of the Lumbar Spine (ISSLS) 2007; June 10-14, Hong Kong, China:p148. 10. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases. Barrey C, Jund J, Noseda O, Roussouly P. Eur Spine J 2007; 16:1459–1467. 11. Flattening of sagittal curvature as a predictor of vertebral fracture. Kobayashi T. Osteoporos Int 2008;19:65–69. 12. Personal risk factors for first time low back pain. Adams MA, et al. Spine 1999; 24:2497-2505. 13. Epidemiology of low back pain in the elderly: correlation with lumbar lordosis. Tsuji T, Matsuyama Y, Sato Y, Hasegawa Y, Yimin Y, Iwata H. J Orthop Sci 2001; 6:307-311.

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14. "Spondylolisthesis: its cause and effect". Newman PH (1955). Ann Coll Surg Engl 16: 305. 15. Lumbar hyperlordosis of neuromuscular origin: pathophysiology and surgical strategy for correction Raphaël Vialle, Nejib Khouri, Christophe Glorion, Joël Lechevallier, and Christian Morin Int Orthop. 2007 August; 31(4): 513–523. 16. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. Harrison DD, Cailliet R, Janik TJ, et al. J Spinal Disorders. 1998;11:430–439. 17. The Cellular Pathobiology of the Degenerate Intervertebral Disc and Discogenic Back Pain Rheumatology , 2009-01-01 18. Sustained loading generates stress concentrations in lumbar intervertebral discs. Adams MA, McMillan DW, Green TP, Dolan P. Spine 1996;21:434-8. 19. Anterior thoracic posture increases thoracolumbar disc loading. Deed E. Harrison Christopher J. Colloca Donald D. Harrison Tadeusz J. Janik Jason W. Haas Tony S. Keller. Eur Spine J (2005) 14 : 234–242 20. Intervertebral Disc Degeneration Reduces Vertebral Motion Responses Christopher J. Colloca, DC,* Tony S. Keller, PhD,† Robert J. Moore, PhD Robert Gunzburg, MD, PhD,§ and Deed E. Harrison, DC Spine journal 2002 Volume 32, Number 19, pp E544-50 21. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. Torgerson WR, Dotter WE. J Bone Joint Surg Am 1976;58:850-3. 22. Low-back pain in relation to lumbar disc degeneration. Luoma K, Riihimaki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen Spine Journal 2000;25:487-92 23. A cross-sectional study correlating lumbar spine degeneration with disability and pain. Peterson CK, Bolton JE, Wood AR. Spine Journal 2000;25:218-23.

24. Lumbar posture--should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living. Phys Ther 2003 Oct;83(10):907-17.Scannell JP McGill SM

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

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25. Reciprocal angulation of vertebral bodies in the sagittal plane in an asymptomatic Greek population. Spine Journal (Phila Pa 1976). 1998 Mar 15;23(6):700-4; discussion 704-5. Korovessis PG Stamatakis MV Baikousis AG

26. Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back pain. Jackson RP, Kanemura T, Kawakami N, Hales C. Spine 2000; 25: 575-586. 27. Lumbar lordosis in osteoporosis and in osteoarthritis Michael Papadakis, Georgios Papadokostakis, Konstantinos Stergiopoulos, Nikos Kampanis Æ Pavlos Katonis Eur Spine J (2009) 18:608–613 28. Effectiveness of an Extension-Oriented Treatment Approach in a Subgroup of Subjects With Low Back Pain: A Randomized Clinical Trial. J PHYS THER Vol. 87, No. 12, December 2007, pp. 1608-1618David A Browder, John D Childs, Joshua A Cleland and Julie M Fritz

29. Segmental Instability of the Lumbar Spine Julie M Fritz, Richard E Erhard and Brian F Hagen PHYS THER Vol. 78, No. 8, August 1998, pp. 889-896

30. Can the sagittal lumbar curvature be closely approximated by an ellipse? Janik TJ, Harrison DD, Cailliet R et al. J.Orthop.Res. 1998;16:766-70. E) Aberrant global spinal sagittal balance and alignment.

1. An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Gelb DE Lenke LG Bridwell KH Blanke K McEnery KW Spine Journal (Phila Pa 1976). 1995 Jun 15;20(12):1351-8.

2. Measurements of lumbopelvic lordosis using the pelvic radius technique as it correlates with sagittal spinal balance and sacral translation. Spine Journal 2002 Nov-Dec;2(6):421-9. Gardocki RJ Watkins RG Williams LA

3. Review of scientific literature relevant to structural rehabilitation of the spine and posture: Rationale for treatment beyond resolution of symptoms. Troyanovich SJ, Harrison DE, Harrison DD J Manipulative Physiol Ther. 1998;21(4)252-256 4. A normal spine position: Accepting the evidence. Harrison DE, Harrison DD. J Manipulative Physiol Ther. 2000:23 p623-644 5. Evidence based protocols for structural rehabilitation of the spine and posture: Review of clinical biomechanics of posture Oakly PA, Harrison DD, Harrison DE J. Canadian Chiro assoc 2005;49(4)p268-294

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6. Variability in Cobb angle measurements using reformatted computerized tomography scans. Adam CJ, Izatt MT, Harvey JR, Askin GN, Spine Journal 2005 Jul15;30(14)p1664-9 7. A variability study of computerized sagital spinopelvic radiographic measurements of trunk balance. Berthonnaud E, Labelle H, Roussouly P, Grimard G, Vaz G, Dimnet J. J Spinal Disorders Tech 2005 Feb;18(1)66-71 8. Relationship Between Vertebral Deformities And Allergic Diseases. Takeda Y, Arai S. The Internet Journal of Orthopedic Surgery 2004;2(1): 9. Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back pain. Jackson RP, Kanemura T, Kawakami N, Hales C. Spine 2000; 25: 575-586. 10. Impact of postural deformities and spinal mobility on quality of life in postmenopausal osteoporosis Miyakoshi N. Osteop Int. 2003;14 1007-1012. 11. Impact of positive sagittal balance in adult spinal deformity. Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The Spine 2005;30:2024-2029. 12. Pelvic morphology affects the sagittal plane alignment of the lumbo-pelvic spine normal subjects and low back pain patients. Harrison DE, Keller TS, Harrison DD, Janik TJ, Colloca CJ. Proceedings of the 34th annual meeting of the International Society for the Study of the Lumbar Spine (ISSLS) 2007; June 10-14, Hong Kong, China:p148. 13. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases. Barrey C, Jund J, Noseda O, Roussouly P. Eur Spine J 2007; 16:1459–1467. 14. Clinical measurement of head and shoulder posture variables. Harrison AL, Barry-Greb T, Wojtowicz G. JOSPT 1996;23:353-361. 15. Body posture and hand strength of patients with temporomandibular disorder. Shiau YY, Chai HM. J Craniomand Pract 1990;8:244-251. 16. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Watson DH, Trott PH. Cehpalalgia 1993;13:272-284. 17. Relationship of forward head posture and cervical backward bending to neck pain. Haughie LJ, Fiebert IM, Roach KE. J Manipulative Physiol Ther 1995(3):91-97. 18. Posture in patients with shoulder overuse injuries and healthy individuals. Greenfield B,

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57. Plain film radiography in chiropractic. In, Plaugher G, editor: Textbook of Clinical Chiropractic. A Specific Biomechanical Approach. . Rowe SH. Williams & Wilkins, Baltimore, 1993; pages: 58. A look at Chiropractic Spinal Correction. Cumberland, WI: Toftness Chiropractic, Inc., 1977. Toftness IN. 59. Organ Dosimetry in Spinal Radiography: A Comparison of 3-Region Sectional and Full-Spine Techniques. Cracknell DM, Bull PW. Chiropr J Aust 2006; 36:33-9. 60. Textbook for clinical chiropractic: a specific biomechanical approach. Plaugher G. Baltimore: Williams & Wilkins, 1993. 61. Influence of spine morphology in intervertebral disc loads and stresses in asymptomatic adults: Implications for the ideal spine. Spine Journal 2005 May-June:5(3)297-309. 62. Sustained loading generates stress concentrations in lumbar intervertebral discs. Adams MA, McMillan DW, Green TP, Dolan P. Spine 1996;21:434-8. 63. A Review of Biomechanics of the Central Nervous System—Part II: Spinal Cord Strains from Postural Loads. JMPT Volume 22 June 1999 Deed E. Harrison, DC, Rene Cailliet, MD, Donald D. Harrison, PhD, DC, Stephan J. Troyanovich, DC, and Sanghak O. Harrison, DC 64. The role of spinal flexion and extension in changing nerve root compression in disc herniations. Schnebel BE,Watkins RG, Dillin W. Spine 1989;14:835-7. 65. Active trunk extensor contributions to dynamic posterior/anterior lumbar spinal stiffness Christopher J. Colloca, DC, and Tony S. Keller, PhD J Manipulative Physiol Ther 2004;27:229-237) 66. Lumbar disc degeneration and sagittal flexibility. Burton AK, Battie MC, Gibbons L, Videman T, Tillotson KM. J Spinal Disord 1996;9:418-24. 67. Full-spine radiography: a review. Taylor JA. J Manipulative Physiol Ther. 1993 Sep;16(7):460-74. Review. 68. Attributes and qualities of human posture and their relationship to dysfunction or musculoskeletal pain. Raine S, Twomey L. Crit Rev Phys Rehabil Med 1994;6:409-37. F) Aberrant spinal coronal balance and alignment

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1. Prevalence and risk factors for asymmetric posture in preschool children aged 6-7 years. Juskeliene V, Magnus P, Bakketeig LS, Dailidiene N, Jurkuvenas V. Int J Epidemiol. 1996 Oct;25(5):1053-9. 2. Effects of pelvic skeletal asymmetry on trunk movement :three dimensional analysis of healthy individuals vs patients with mechanical low back pain. Spine 2006 Feb1:31(3)E71-9 3. Assessing Mechanical Integrity of the Spine Using Radiographic Analysis. Part 2: Case Studies Involving Structural Asymmetry of the Pelvis. Dulhunty J. Chiropr J Aust 2003; 33(2):64-71. 9571 4. Lumbar Coupling During Lateral Translations of the Thoracic Cage Relative to a Fixed Pelvis. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Troyanovich SJ, Coleman RR. Clin Biomech 1999:14(10):704-709. 5. A roentgenological evaluation of the relationship between segmental motion and malalignment in lateral bending. Haas M, Peterson D. J Manipulative Physiol Ther. 1992 6. Chiropractic Biophysics digitized radiographic mensuration analysis of the anteroposterior lumbopelvic view: a reliability study. Troyanovich SJ, Harrison SO, Harrison DD, et al. J Manip Physiol Ther 1999;22(5): 309-315. 7. Prevalence of frontal plane pelvic postural asymmetry-part 1. Juhl JH, Ippolito Cremin TM, Russell G. J Am Osteopath Assoc. 2004 Oct;104(10):411-21. 8. Validation of postural radiographs as a way to measure change in pelvic obliquity. Fann AV. Arch Phys Med Rehabil. 2003 Jan;84(1):75-8. 9. Chiropractic biophysics digitized radiographic mensuration analysis of the anterioposterior lumbopelvic view: a reliability study. J Manipulative Physiol Ther 1999;22:309-15. Troyanovich SJ, Harrison SO, Harrison DD, Harrison DE, Payne MR, Janik TJ, et al. 10. Radiologic interpretation of lumbar vertebral rotation. Gunzburg R, Gunzburg J,Wagner J, Fraser RD. Spine 1991;16:660-4. G) Leg length disparity

1. Is Leg Length Discrepancy Associated With the Side of Radiating Pain in Patients With a Lumbar Herniated Disc? ten Brinke, Albert PT; van der Aa, Hans E. MD, PhD; van der Palen, Job PhD; Oosterveld, Frits PT, PhD Spine Journal: April 1999 - Volume 24 - Issue 7 - pp 684-686

2. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Friberg O Spine Journal 1983:Sep;8(6)p643-641

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3. The Effect of Leg Length Discrepancy on Spinal Motion During Gait: Three-Dimensional Analysis in Healthy Volunteers Kakushima, Mototaka MD; Miyamoto, Kei MD, PhD; Shimizu, Katsuji MD, DMsc Spine Journal 1 November 2003 - Volume 28 - Issue 21 - pp 2472-2476

4. Lumbar Spine Structural Changes Associated With Leg Length Inequality GILES, L G F MSc; TAYLOR, J R MB ChB, PhD Spine Journal April 1982 Volume 7

5. The Relationship between Leg Length Discrepancy and Lumbar Facet Orientation FROH, R MD; YONG-HING, K MB, FRCSC; CASSIDY, J D DC, MSc; HOUSTON, C S MD, FRCPC Spine Journal Volume 13 March 1988

6. Disproportionate Body Growth in Girls with Adolescent Idiopathic Scoliosis: A Longitudinal Study UPADHYAY, S. S. BSc DOrth, MS(Orth); DM, L. C. S. HSU, FRCSE, FACS; HO, E. K. W. FRCS, FRACS, J. C. Y. LEONG, FRCS, FRCSE, FRACS; LEE, M. K. Spine Journal Aug 1991 Volume 16

7. Scoliosis associated with limb length inequality. Papaioannou T, Stokes I,Kenwright J. J Bone and joint surgery 1982;64(1)59-62. 8. Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain (Randomized control trial) Arch Phys Med Rehabil. 2005 Nov;86(11):2075-80. 9. Limb length inequality: clinical implications for assessment and intervention. Brady RJ, Dean JB, Skinner TM, Gross MT. J Orthop Sports Phys Ther. 2003 May;33(5):221-34. 10. Prevalence of frontal plane pelvic postural asymmetry-part 1. Juhl JH, Ippolito Cremin TM, Russell G. J Am Osteopath Assoc. 2004 Oct;104(10):411-21. 11. A standardized technique for lower limb radiography. Practice, applications, and error analysis. Siu D, Cooke TD, Broekhoven LD, Lam M, Fisher B, Saunders G, Challis TW. Invest Radiol. 1991 Jan;26(1):71-7. 12. Limb length discrepancies of the lower extremity (the short leg syndrome). Subotnick S J Orthop Sports Phys Ther 1981;3:11-16. 13. Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle. Leppilahti J, Korpelainen R, Karpakka J, Kvist M, Orava S. Foot Ankle Int 1998;19(10):683-687. 14. Radiographic measurement of bow leg deformity: variability due to method and limb rotation. Strickler SJ, Faustgen JP. J Pediatric Orthop 1994;14:147-151.

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15. Amorphous silicon, flat-panel, x-ray detector: reliability of digital image fusion regarding angle and distance measurements in long-leg radiography. Hamer OW, Strotzer M, Zorger N, Paetzel C, Lerch K, Feuerbach S, Volk M. Invest Radiol. 2004 May;39(5):271-6. 16. Leg length inequality and the side of low back pain, a pilot study. Anderson RG, Hayak R, Foggerty MP. Comsig Rev: Jul 1995(4:2) 33-36. 17. Iliotibial band syndrome in cyclists. Anderson RG, Hayak R, Foggerty MP. Am J Sports Med. 1993;21(3):419-424. 18. Risk factors for recurrent stress fractures in athletes. . Korpelainen R, Orava S, Karpakka J, Siira P, Julkko A. Am J Sports Med 2001;29(3):304-310. 19. Gait asymmetry in patients with limb-length inequality. Kaufman KR, Miller LS, Sutherland DH. J Pediatric Orthopaedics 1996;16:144-150. 20. The effect of limb-length discrepancy on gait. Song KM, Halliday SE, Little DG. J Bone Joint Surgery 1997;79-A(11):1690-1698. 21. Leg length discrepancy. Gurney B. Gait and Posture 2000;15:195-206. 22. Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomical leg-length inequality: prevalence, magnitude, effects and clinical significance. Knutson GA. Chiropractic & Osteopathy 2005;13(11):1-10. 23. Leg length inequality in total hip replacement. Hoikka V, Vankka E, Tallroth K, Paavilainen T, Lindholm TS. Ann Chir Gynaecol 1991;80(4):396-401. 24. Leg Length Inequality and the Side of Low back Pain: A Pilot Study. Anderson, R.; Hayak, R.; Foggerty, M. Comsig Review 1995; 4(2):33-6. 25. Risk factors for stress fractures in track and field athletes. Bennell KL, Malcolm SA, Thomas SA, Reid SJ, Brukner PD, Ebeling PR, Wark JD. Am J Sports Med 1996;24(6):810-818. 26. AP Pelvic X-ray Investigation to Determine Heel Lift Intervention based on Anatomical Leg Length Inequality in Chronic Low Back Pain. Defrin R, Ben Benyamin S, Aldubi RD, Pick CG SECTION TWO: The evidence supportive of changes in therapeutic approaches relevant to the management, stabilization or correction of the above spinal health conditions when identified on chiropractic radiographs.

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a) Scoliosis and pseudo scoliosis - treatment and management 1. The Selection of Operative Versus Nonoperative Treatment in Patients With Adult Scoliosis Glassman, Steven D. MD; Schwab, Frank J. MD; Bridwell, Keith H. MD; Ondra, Stephen L. MD; Berven, Sigurd MD; Lenke, Lawrence G. MD Spine Journal 1 January 2007 - Volume 32 - Issue 1 - pp 93-97 2. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: A Retrospective case series Morningstar MW, Woggon D, Lawrence G, BMC Musculoskeletal disorder 2004 Sep14;5:32 3. Reduction of deformity after chiropractic biophysics mirror image care incorporating the non-commutative property of finite rotation angles in five patients with thoracolumbar scoliosis. HarrisonDE, Oakley PA, Harrison DD. J Chiropractic Education 2006;20(1):19-20. 4. Scoliosis treatment using spinal manipulation and the pettibon weighting system: A Summary of 3 atypical presentations. Morningstar MW, Joy T. Chiro and Osteo 2005:14(1):11-12 5. A Systematic Literature Review of Nonsurgical Treatment in Adult Scoliosis Everett, Clifford R. MD, MPH; Patel, Rajeev K. MD Spine Journal 1 September 2007 - Volume 32 - Issue 19 - pp S130-S134 6. Kyphoscoliosis Improvement While Treating a Patient for Adhesive Capsulitis Using the Active Therapeutic Movement Version 2 Clare Lewis, Richard Erhard, George Drysdale Journal of Manipulative and Physiological Therapeutics November 2008 (Vol. 31, Issue 9, Pages 715-722) 7. Non-operative Treatment for Adolescent Idiopathic Scoliosis: A 10- to 60-Year Follow-up With Special Reference to Health-Related Quality of Life Haefeli, Mathias Med Pract; Elfering, Achim Dipl Psych, PhD; Kilian, Reinhold PhD; Min, Kan MD; Boos, Norbert MD Spine Journal 1 February 2006 - Volume 31 - Issue 3 - pp 355-366 8. Radiographic pseudo scoliosis in healthy male subjects following voluntary lateral translation of the thoracic spine DE Harrison, Joseph Betz, Chris Colloca, Rene Cailliet Arch Phys Med Rehab Volume 87, Jan 2006 9. Treatment of idiopathic scoliosis with side-shift therapy: an initial comparison with Brace treatment historical cohort. European Spine Journal 1999;8:406-10 10. Preliminary Report on the Effect of Measured Strength Training in Adolescent Idiopathic Scoliosis Mooney, Vert; Gulick, Jennifer; Pozos, Robert Journal of Spinal Disorders: April

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2000 - Volume 13 - Issue 2 - pp 102-107A 11. Treatment of Adolescent Idiopathic Scoliosis With Quantified Trunk Rotational Strength Training: A Pilot Study Journal of Spinal Disorders & Techniques: July 2008 - Volume 21 - Issue 5 - pp 349-358 McIntire, Kevin L. PhD; Asher, Marc A. MD; Burton, Douglas C. MD; Liu, Wen PhD 12. Scoliosis Reduction Utilizing an Exercise. Golembiewski GV, Catanzaro DJ. JVSR May 2001, Vol 4, No.2. 13. Influence of an inpatient exercise program on scoliotic curve. Weiss HR. Ital J Orthop Traumatol. 1992;18(3):395-406. 14. Conservative treatment of scoliosis. Weiss HR. Pediatr Rehabil. 2003 Jul-Dec;6(3-4):131-2. 15. Curvature progression in patients treated with scoliosis in-patient rehabilitation--a sex and age matched controlled study.Weiss HR, Weiss G Stud Health Technol Inform. 2002;91:352-6. 16. Clinical report. Reduction of minor lumbar scoliosis in a 57-year-old female. Mawhiney RB. Chiropractic 1989. 17. Active correction by side-shift: an alternative treatment for early idiopathic scoliosis. In: Warner JD, Mehta MH (eds.). Mehta MH. Scoliosis Prevention. Proceeding of the P. Zorab scoliosis symposium 1983. Praeger, NY, pp. 126-140.

18. Scoliosis reduction utilizing an exercise. Golembiewski GV, Catanzano DJ. J Vertebral Subluxation Res 2001:4(2):31-36. 19. Spinal Deformity - Adolescent Idiopathic Scoliosis: Nonoperative Treatment. Dickson, Robert A. Spine Journal:15 December 1999 - Volume 24 - Issue 24 - p 2601 b) Cervical spine lordosis- treatment and management 1. Trigger points in the suboccipital muscles and forward head posture in tension-type headache. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Headache 2006;46(3):454-460. 2. Increasing cervical lordosis. Seated combined compression and transverse load cervical traction with cervical manipulation. A non-randomized clinical control trial. Harrison DE, Harrison DD, Haas JW, Betz JW, Janik TK, Colloca C. J Manipulative Physiol Ther. 2003:26(3)p139-151 3. New 3-point bending traction method for restoring cervical lordosis combined with cervical

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manipulation. Non-randomized clinical control trial Harrison DE, Harrison DD, Calliet R, Janik TK, Holland B. Arch Phys Res Med Rehab 2002;83(4)447-453 4. Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache. Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA. Headache 2007;47(5):662-672. 5. Improvement in Forward Head Posture, Cervical Lordosis, and Pulmonary Function with Chiropractic Care, Anterior Head Weighting and Whole Body Vibration: A Retrospective Study. Mark Morningstar DC, DAASP, FRCCM, FAAIM,David Jockers DC, MS, CSCS Journal of Pediatric, Maternal & Family Health - Chiropractic Vol.2009Issue 4 p.1-7 6. Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA. Cephalalgia. 2006 Sep;26(9):1061-70. 7. Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods. Ferrantelli JR, Harrison DE, Harrison DD, Stewart D. J Manipulative Physiol Ther. 2005 Mar-Apr;28(3):e1-8.

8. Exercises for mechanical neck disorders Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G; Cervical Overview Group. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD004250.

9. Manipulation and mobilisation for mechanical neck disorders. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G; Cervical overview group. Cochrane Database Syst Rev. 2004;(1):CD004249.

10. Structural rehabilitation of the cervical spine. Deed E Harrison Published in 2002, Harrison CBP Seminars

11. Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Headache. 2006 Sep;46(8):1264-72. 12. Treatment of cervical kyphosis in children. Francis WR Jr, Noble DP. Spine 1988;13:883-7. 13. Correction of severe cervical kyphosis in ankylosing spondylitis by traction. Mehdian H, Jaffray D, Eisenstein S. Spine 1992;17:237-40. 14. The traction angle and cervical intervertebral separation. Wong AM, Leong CP, Chen CM. Spine 1992;17:136-8. 15. Flexion and traction effects on C5-C6 foraminal space. 29. Humphreys SC, Chase J, Patwardhan A, Shuster J, Lomasney L, Hodges SD. Arch Phys Med Rehabil 1998;79:1105-9.

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16. Cervical spine manipulation: summary report of a systematic review of the literature and a multidisciplinary expert panel. Shekelle PG, Coulter I. J Spinal Disord 1997;10:223-8 17. Improvement of Cervical Lordosis and Reduction of Forward Head Posture with Anterior Head Weighting and Proprioceptive Balancing ProtocolsE. Stephen Saunders, D.C.1 Dennis Woggon B.S, D.C.2 Christian Cohen B.S. D.C.3 David H. Robinson, PhD.4 J. Vertebral Subluxation Res., April 27, 2003 1 C) Thoracic spine kyphosis- treatment and management 1. Application of passive transverse forces in the rehabilitation of spinal deformities: a randomized controlled study. Weiss HR, Heckel I, Stephan C Stud Health Technol Inform. 2002;88:304-8. 2. Strong Back Can Decrease Thoracic Kyphosis in the Osteoporotic Spine Scott, R; Sinaki, M; Gelczer, R; Wollan, P American Journal of Physical Medicine & Rehabilitation: March/April 1996 - Volume 75 - Issue 2 - p 161 3. Correlation of Back Extensor Strength With Thoracic Kyphosis and Lumbar Lordosis in Etrogen-Deficient Women. Sinaki, Mehrsheed MD, MS; Itoi, Eiji MD; Rogers, John W. MD; Bergstralh, Erik J. MS; Wahner, Heinz W. MD American Journal of Physical Medicine & Rehabilitation: September/October 1996 - Volume 75 - Issue 5 - pp 370-374 4. Spinal extension exercises prevent natural progression of kyphosis. JM Ball, P Cagle Osteoporosis International Volume 20 March 2009

5. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clinic 1994;69:1054-1059

6. Stability of Kyphosis, Strength, and Physical Performance Gains 1 Year After a Group Exercise Program in Community-Dwelling Hyperkyphotic Older Women �Sarah B. Pawlowsky, Kate A. Hamel, Wendy B. Katzman �Archives of Physical Medicine and Rehabilitation February 2009 (Vol. 90, Issue 2, Pages 358-361)

7. Changes in Flexed Posture, Musculoskeletal Impairments, and Physical Performance After Group Exercise in Community-Dwelling Older Women �Wendy B. Katzman, Deborah E. Sellmeyer, Anita L. Stewart, Linda Wanek, Kate A. Hamel �Archives of Physical Medicine and Rehabilitation �February 2007 (Vol. 88, Issue 2, Pages 192-199)

8. The Effect of Thoracic Exercise Program on Thoracic Pain, Kyphosis, and Spinal Mobility �Eun-Hee Choi, Jin-Kang Hur, Jung-In Yang, Dong-Sik Park �Archives of Physical Medicine and Rehabilitation �September 2005 (Vol. 86, Issue 9, Page e23)

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D) Lumbar spine - treatment and management 1. Changes in lumbar sagital curve configuration with a new method of extension traction: A non-randomized clinical trial. Harrison DE, Harrison DD, Haas JW, Janik TK, Holland B. Arch Phys Res Med Rehab 2002;83(11)p1585-1591 2. Clinical findings as outcome predictors in rehabilitation of patients with sciatica. Nykvist F, et al. International J of Rehabilitation Res 1991;14:131-144.

3. Lumbar posture--should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living. Phys Ther 2003 Oct;83(10):907-17.Scannell JP McGill SM

4. A structural approach to the post-surgical laminectomy case. Berry RH, Oakley PA, Harrison DE. J Chiropractic Education 2005;19(1):44. 5. Textbook for clinical chiropractic: a specific biomechanical approach. Plaugher G. Baltimore: Williams & Wilkins, 1993. 6. Changes in sagittal lumbar configuration with a new method of extension traction: Nonrandomized clinical controlled trial Deed E. Harrison, Rene Cailliet, Donald D. Harrison, Tadeusz J. Janik, Burt Holland Archives of Physical Medicine and Rehabilitation �November 2002 (Vol. 83, Issue 11, Pages 1585-1591) 7. Core strengthening Venu Akuthota, Scott F Nadler Archives of Physical Medicine and Rehabilitation March 2004 (Vol. 85, Issue , Pages 86-92) 8. Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. M L Walker, J M Rothstein, S D Finucane, R L Lamb Phys Ther April 1987 (Vol. 67, Issue 4, Pages 512-6) 9. Physical therapy to treat spinal stenosis Wunschmann BW, Sigl T, Ewert T, Schwarzkoph SR, Stucki G, Orthopade 2003;32:865-8 10.Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. �E Itoi, M Sinaki �Mayo Clin Proc �November 1994 (Vol. 69, Issue 11, Pages 1054-9) 11. Lumbar Spinal Stenosis: Conservative or Surgical Management? : A Prospective 10-Year Study Amundsen, Tom MD; Weber, Henrik MD, DrMed; Nordal, Helge J. MD, DrMed; Magnaes, Bjørn MD, DrMed; Abdelnoor, Michael MPH, PhD; Lilleås, Finn MD Spine Journal:1 June 2000 - Volume 25 - Issue 11 - pp 1424-1436

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12. Lumbar posture--should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living. Phys Ther 2003 Oct;83(10):907-17.Scannell JP McGill SM

C) Sagital and coronal spinal balance - treatment and management 1. Conservative methods to correct lateral translations of the head. A non-randomized clinical trial. Harrison DE, Harrison DD, Haas JW, Betz JW, Janik TK, Holland B. J Rehab Res Devel 2004;41(4):p631-640 2. Mirror image methods for correcting trunk list: A non-randomized clinical trial. Harrison DE, Harrison DD, Haas JW, Janik TK, Holland B. Euro Spine J 2005:14p155-162 3. The application of therapeutic exercises based upon lateral flexion roentgenography to restore biomechanical function in the lumbar spine. Chiropractic Speiser, R. Aragona R, Heffernan, J. Research J 1990; 1(4):7-17. 4. Textbook for clinical chiropractic: a specific biomechanical approach. Plaugher G. Baltimore: Williams & Wilkins, 1993. 5. A look at Chiropractic Spinal Correction. Cumberland, WI: Toftness Chiropractic, Inc., 1977. Toftness IN. 6. Pathogenesis, presentation, and treatment of lumbar spinal stenosis associated with coronal or sagittal spinal deformities. Fraser JF, Huang RC, Girardi FP, Cammisa FP Jr. Neurosurg Focus. 2003 Jan 15;14(1):e6. 7. Structural rehabilitation of the lumbar spine. Published 2006 by Deed Harrison 8. [Physiological value of pelvic and spinal parameters of sagital balance: analysis of 250 healthy volunteers] Guigui P, Levassor N, Rillardon L, Wodecki P, Cardinne L. Rev Chir Orthop Reparatrice Appar Mot. 2003 Oct;89(6):496-506. 9. Low Back Stability: From Formal Description to Issues for Performance and Rehabilitation. Exercise and Sport Science Reviews. 29, 26-31. 10. Significant reduction in risk of falls and back pain in osteoporotic-kyphotic women through a Spinal Proprioceptive Extension Exercise Dynamic (SPEED) program. Sinaki M; Brey RH; Hughes CA; Larson DR; Kaufman KR�Department of Physical Medicine and Rehabilitation, Mayo Clin Proc. 2005; 80(7):849-55 (ISSN: 0025-6196) D) Leg length disparity- pre/post heel orthotic leveling

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1. Heel lifting as a conservative therapy for osteoarthritis of the hip. Ohsawa S, Ueno R. Prosthet Orthot Int 1997 ;21(2)p153-158 2. Heel lifting as a conservative therapy for osteoarthritis of the hip: based on the rational of Pauwels’ intertrochanteric osteotomy. Ohsawa S, Ueno R. Prosthet Orthot Int 1997;21(2):153-158. 3. Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain. Defrin R, Ben Benyamin S, Aldubi RD, Pick CG. Arch Phys Med Rehabil. 2005 Nov;86(11):2075-80. 4. Effectiveness of orthotic shoe inserts in the long-distance runner. Gross ML, Davlin LB, Evanski PM. Am J Sports Med 1991;19(4):409-412. E) Spine related pain treatment 1. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Bronfort G, Haas M, Evans RL, Bouter LM. Spine J. 2004 May-Jun;4(3):335-56. Review. 2. Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: a retrospective analysis of 100 cases. Aspegren D, Enebo BA, Miller M, White L, Akuthota V, Hyde TE, Cox JM. J Manipulative Physiol Ther. 2009 Nov-Dec;32(9):765-71. 3. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spine (Phila Pa 1976). 1996 Dec 15;21(24):2860-71; discussion 2872-3. Review. 4. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, Hawk C. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74. Review. 5. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Fritz JM, Delitto A, Erhard RE. Spine 2003 Jul 1;28(13):1363-71; discussion 1372.

6. Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis. McMorland G, Suter E. J Manipulative Physiol Ther. 2000 Jun;23(5):307-

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11. 7. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM. Spine (Phila Pa 1976). 2006 Mar 15;31(6):611-21; discussion 622.

8. Exercise and chronic low back pain: what works? Liddle SD, Baxter GD, Gracey JH. Pain. 2004 Jan;107(1-2):176-90. Review. Erratum in: Pain. 2004 May;109(1-2):200-1. 9. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-blinded, randomized clinical trial. Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Spine 1998;23:311-9. 10, Mechanical low back pain: a comparison of medical and chiropractic management within the Victorian work-care scheme Chiro J of Aust 1992;22:p47-53

SECTION THREE: The role of follow-up radiographic evaluation after recognized periods of conservative physical management for certain radiographic findings and conditions and thereby establishing and documenting the treatment efficacy. (25 studies). 1. A retrospective consecutive case analysis of pretreatment and comparative static radiological parameters following chiropractic adjustments. Plaugher G, Cremata EE, Phillips RB. J Manipulative Physiol Ther. 1990 Nov-Dec;13(9):498-506. Comment in: J Manipulative Physiol Ther. 1991 Jun;14(5):334-6. 2. Evidence based protocols for structural rehabilitation of the spine and posture: Review of clinical biomechanics of posture Oakly PA, Harrison DD, Harrison DE J. Canadian Chiro assoc 2005;49(4)p268-294 3. Review of scientific literature relevant to structural rehabilitation of the spine and posture: Rationale for treatment beyond resolution of symptoms. Troyanovich SJ, Harrison DE, Harrison DD J Manipulative Physiol Ther. 1998;21(4)252-256 4. Reliability of spinal displacement analysis on plane x rays: A review of commonly accepted facts and fallacies. Harrison DE, Harrison DD, Troyanovich. J Manipulative Physiol Ther. 1998:21(4)252-256 5. Cervical spine geometry correlated to cervical degenerative disease in a symptomatic group. Journal of manipulative physiol therapy 2003 Jull:26(6)341-346 6. A normal spine position: Accepting the evidence. Harrison DE, Harrison DD. J Manipulative Physiol Ther. 2000:23 p623-644

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7. Upper cervical post x-ray reduction and its relationship to symptomatic improvement and spinal stability. Owens EF, Eriksen K. CRJ: 1997(4:2):10-17. 8. Abnormal Upper Cervical Joint Alignment and the Neurologic Component of the Atlas Subluxation Complex. Knutson GA. CRJ 1997; 4(1). 9. Precision radiologic study: an exposition of specific upper cervical analysis. Kale MU. ICA Rev: JUL/AUG 1991(47:4) 41-45. 10. Comparison Betweeen Upper Cervical X-Ray Listings and Technique Analyses Utilizing a Computerized Database. Eriksen, K.; Chiropractic Research J 1996; 3(2):13-24. 11. Roentgenographic measurement of atlas laterality and rotation: a retrospective pre- and post-manipulation study. Grostic J, Deboer K. J Manipulative Physiol Ther 1982;5(2):63-71. 12. Clinical efficacy of upper cervical versus full spine chiropractic care on children with autism: a randomized clinical trial. Khorshid KA, Sweat RW, Zemba DA, Zemba BN. J Vertebral Subluxation Res 2006; March 9:1-7. 13. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Friberg O. Spine. 1983 Sep;8(6):643-51. 14. Low back pain associated with leg length inequality. Giles LGF, Taylor JR. Spine 1981;6:510-521. 15. Scoliosis associated with limb-length inequality. Papaioannou T, Stokes I, Kenwright J. J Bone Joint Surg Am 1982;64(1):59-62. 16. Persistent low back pain and leg length disparity. Gofton JP. J Rheumatol 1985;12747-750. 17. Effectiveness of orthotic shoe inserts in the long-distance runner. Gross ML, Davlin LB, Evanski PM. Am J Sports Med 1991;19(4):409-412. 18. Heel lifting as a conservative therapy for osteoarthritis of the hip: based on the rational of Pauwels’ intertrochanteric osteotomy. Ohsawa S, Ueno R. Prosthet Orthot Int 1997;21(2):153-158. 19. Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain. Defrin R, Ben Benyamin S, Aldubi RD, Pick CG. Arch Phys Med Rehabil.2005 Nov;86(11):2075-80.

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20. Harrison DE, 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;41(4):631-640. 21. Mirror Image Methods for Correcting Trunk List: A Non-randomized Clinical Control Trial. Harrison DE, Cailliet R, Betz JW, Harrison DD, Haas JW, Janik TJ, Holland B. Harrison Eur Spine J 2005; 14:155-162. 22. Increasing the Cervical Lordosis with CBP Seated Combined Extension-Compression and Transverse Load Cervical Traction with Cervical Manipulation: Non-randomized Clinical Control Trial. Harrison DE, Harrison DD, Betz J, Janik TJ, Holland B, Colloca C. J Manipulative Physiol Ther 2003; 26(3): 139-151. 23. Changes in Sagittal Lumbar Configuration with a New Method of Extension Traction: Non-randomized Clinical Control Trial. Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B. Arch Phys Med Rehab 2002; 83(11): 1585-1591. 24. New 3-Point Bending Traction Method of Restoring Cervical Lordosis Combined with Cervical Manipulation: Non-randomized Clinical Control Trial. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Arch Phys Med Rehab 2002; 83(4): 447-453. 25. Long-term morbidity and mortality after a clinically diagnosed vertebral fracture in the elderly-a 12 and 22 year follow up. Calcif Tissue Int 2005;76(4)p235-42 SECTION FOUR: The clinical role of radiographic evaluation for patients presenting with mechanical-pain, a changing symptomatic picture or positive orthopedic findings requiring further radiographic evaluation. Background: There is a legal and clinical responsibility for the chiropractor to provide the patient with an accurate differential diagnosis for the underlying mechanisms of pain and before a sound clinical rationale for corrective-based physical management can be made under chiropractic-care. This below of 117 references correlates either the: a) The relationship between spine related pain and the role of radiographic assessment. b) The immediate relationship between pain and spinal mechanics directly at the disc and joint level. 1. Best Evidence on Assessment and Intervention for Neck Pain Assessment of Neck Pain and Its Associated Disorders: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders Nordin, Margareta PT, Dr Med Sc; Carragee, Eugene J. MD, FACS; Hogg-Johnson, Sheilah PhD; Weiner, Shira Schecter PT, PhD (Candidate);

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Hurwitz, Eric L. DC, PhD; Peloso, Paul M. MD, MSc, FRCP(C); Guzman, Jaime MD, MSc, FRCP(C); van der Velde, Gabrielle DC; Carroll, Linda J. PhD; Holm, Lena W. Dr Med Sc; Côté, Pierre DC, PhD; Cassidy, J David PhD, Dr Med Sc; Haldeman, Scott DC, MD, PhD Spine Journal:15 February 2008 - Volume 33 - Issue 4S - pp S101-S122 2. The value of medical history and physical examination in diagnosing sacroiliac joint pain. . Dreyfuss P, Michaelsen M, Pauza K, mcLarty J, Bogduk N. Spine Journal 1996;21:2594-2602. 3. Radiographic Anomalies That May Alter Chiropractic Intervention Strategies Found in a New Zealand Population. Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL. J Manipulative and Physiol Ther. 2004;27(9):554–559. 4. Selective Indications for Thoracic and Lumbar Radiography in Blunt Trauma �Carol A Terregino, Steven E Ross, Mary Fran Lipinski, Jane Foreman, Richard Hughes �Annals of Emergency Medicine �August 1995 (Vol. 26, Issue 2, Pages 126-129) 5. Radiograph assessment for patients with low back pain �Edward D Simmons, Richard D Guyer, Arnold Graham-Smith, Richard Herzog �The Spine Journal �May 2003 (Vol. 3, Issue 3, Supplement, Pages 3-5) 6. Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint �Jacob M. Buchowski, Khaled M. Kebaish, Vladimir Sinkov, David B. Cohen, Ann N. Sieber, John P. Kostuik �The Spine Journal �September 2005 (Vol. 5, Issue 5, Pages 520-528) 7. A cross-sectional study correlating lumbar spine degeneration with disability and pain. Peterson CK, Bolton JE, Wood AR. Spine Journal 2000;25:218-23. 8. A cross-sectional study correlating lumbar spine degeneration with disability and pain. Peterson CK, Bolton JE, Wood AR. Spine Journal 2000;25:218-23. 9. Clinical findings as outcome predictors in rehabilitation of patients with sciatica. Nykvist F, et al. International J of Rehabilitation Res 1991;14:131-144. 10. An analytical survey of structural aberrations observed in static radiographic examinations among acute low back cases. Reinert OC. J Manipulative Physiol Ther. 1988 Feb;11(1):24-30. 11. Clinical findings as outcome predictors in rehabilitation of patients with sciatica. Nykvist F, et al. International J of Rehabilitation Res 1991;14:131-144. 12. Radiographic analysis of lumbar spine for low-back pain in the general population. Inaoka

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M, et al. Arch Orthop Trauma Surg 2000;120:380-385. 13. Clinical findings in a population with back pain. Relation to one-year outcome and long-term sick leave. Reigo T, Tropp H, Timpka T. Scand J Prim Health Care. 2000;18(4):208-214. 14. A comparative roentgenographic analysis of the lumbar spine in male army recruits with and without lower back pain. Steinberg EL, Luger E, Arbel R, Menachem A, Dekel S. Clin Radiol. 2003 Dec; 58(12): 985-9. 15. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex and size. Jackson RP, McManis AC. Spine Journal. 1994;19:1611–1618 16. The association between cervical spine curvature and neck pain. Grob D, Frauenfelder H, Mannion AF (2006) Eur Spine J Nov 18; [Epub ahead of print]. 17. Hyperextension strain or "whiplash" injuries to the cervical spine. Griffiths HJ, Olson PN, Everson LI, Winemiller M. Skeletal Radiology 1995; 24(4):263-6. 18. A Multiple Parameter Assessment of Whiplash Injury Patients Undergoing Subluxation Based Chiropractic Care: A Retrospective Study. McCoy HG, Matthew McCoy M. JVSR 1996 Vol 1, No. 3. p 1-11. 19. Traumatic thoracic outlet syndrome. Kai Y, et al. Orthop Traumatol 1998;47:1169-1171. 20. Neurogenic thoracic outlet syndrome in whiplash injury. . Kai Y, et al. J Spinal Disorders 2001;14:487-493. 21. Relationship of forward head posture and cervical backward bending to neck pain. Haughie LJ, Fiebert IM, Roach KE. J Manipulative Physiol Ther 1995(3):91-97. 22. Posture in patients with shoulder overuse injuries in healthy individuals. Greenfield B, Catlin PA, Coats PW, Green E, McDonald JJ, North C. J Orthop Sports Phys Ther. 1995 May;21(5):287-95. 23. Musculoskeletal abnormalities in chronic headache: A controlled comparison of headache diagnostic groups. Marcus DA, et al. Headache 1999;39:21-27. 24. Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study Fernández C, et al. Cephalalgia 2006;26(3):314-319. 25. Myofascial trigger points, neck mobility and forward head posture in unilateral migraine.

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Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA. Cephalalgia. 2006 Sep;26(9):1061-70. 26. Performance of the craniocervical flexion test, forward head posture, and headache clinical parameters in patients with chronic tension-type headache: a pilot study. Fernandez-de-las-Peñas C, Pérez-de-Heredia M, Molero-Sánchez A, Miangolarra-Page JC. J Orthop Sports Phys Ther. 2007 Feb;37(2):33-9. 27. Clinical characteristics of flexed posture in elderly women. J Am Geritric Soc. 2003 Oct: 51(10) 1419-26 28. The impact of positive sagital balance in adult spinal deformity. Spine Journal Volume 30(18). Sept 15 2005 pp2024-2029 29. Determining the relationship between cervical lordosis and neck complaints. Journal of manipulative physiol therapy 2005 (Mar) 8(3): 30. Handbook of clinical chiropractic. Wyatt LH. Gaithersburg (MD): Aspen Publishers; 1992; 31. Low back pain and the lumbar intervertebral disk: Clinical considerations for the doctor of chiropractic �Stephan J. Troyanovich, Donald D. Harrison, Deed E. Harrison�Journal of Manipulative and Physiological Therapeutics �February 1999 (Vol. 22, Issue 2, Pages 96-104) 32. A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up �Donald R. Murphy, Eric L. Hurwitz, Ericka E. McGovern�JMPT�November 2009 (Vol. 32, Issue 9, Pages 723-733) 33. A new computer aided technique for analysis of lateral cervical radiographs in postoperative patients with degenerative disease. Herman AM, Giesler FH, Spine 2004 Aug 15;29(16)p1795-1803

34. Correlative analysis of lateral vertebral radiographic variables and medical outcomes study short-form health survey: a comparative study in asymptomatic volunteers versus patients with low back pain. J Spinal Disord Tech. 2002 Oct;15(5):384-90. Korovessis P Dimas A Iliopoulos P Lambiris E

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

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36. Methodological quality and outcomes of studies addressing manual cervical spine examinations: A review �Dieter Hollerwöger�Manual Therapy �May 2006 (Vol. 11, Issue 2, Pages 93-98)

38. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. Harrison DD, Cailliet R, Janik TJ, et al. J Spinal Disorders. 1998;11:430–439. 39. The Cellular Pathobiology of the Degenerate Intervertebral Disc and Discogenic Back Pain Rheumatology , 2009-01-01 40. Anterior thoracic posture increases thoracolumbar disc loading. Deed E. Harrison Christopher J. Colloca Donald D. Harrison Tadeusz J. Janik Jason W. Haas Tony S. Keller. Eur Spine J (2005) 14 : 234–242 41. Intervertebral Disc Degeneration Reduces Vertebral Motion Responses Christopher J. Colloca, DC,* Tony S. Keller, PhD,† Robert J. Moore, PhD Robert Gunzburg, MD, PhD,§ and Deed E. Harrison, DC Spine journal 2002 Volume 32, Number 19, pp E544-50 42. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. Torgerson WR, Dotter WE. J Bone Joint Surg Am 1976;58:850-3. 43. A. Low-back pain in relation to lumbar disc degeneration. Luoma K, Riihimaki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen Spine Journal 2000;25:487-92 44. A Cross-Sectional Study Correlating Cervical Radiographic Degenerative Findings to Pain and Disability. Marchiori, Dennis M. DC, MS, DACBR; Henderson, Charles N. R. DC, PhD Spine:1 December 1996 - Volume 21 - Issue 23 - pp 2747-2751 45. Investigation of the relation between low back pain and occupation. Magora A: Scand J Rehab Med 1975;7:146-151. 46. Relation between low back pain syndrome and x-ray findings. Magora A: Scand J Rehab Med 1978; 10:135-145. 47. Modeling of the Sagittal Cervical Spine as a Method to Discriminate Hypo-Lordosis: Results of Elliptical and Circular Modeling in 72 Asymptomatic Subjects, 52 Acute Neck Pain Subjects, and 70 Chronic Neck Pain Subjects. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Haas JW, Ferrantelli J, Holland B (2004) Spine Journal 29:2485-2492. 48.Contemporary concepts in spine care: radiographic assessment for patients with low back pain. Simmons ED, Guyer RD, Graham-Smith A, Herzog R. Spine Journal 1995;20:1839-41. 49. Cervical curvature in acute whiplash injuries: a prospective comparative study with

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asymptomatic subjects. Injury 1998;29 p775-8 50. Cervical zygapophyseal joint pain patterns. II: A clinical evaluation. Aprill C, Dwyer A, Bogduk N. Spine Journal 1990;15:458-61. 51. Mechanical initiation of intervertebral disc degeneration. Adams MA, Freeman BJ, Morrison HP et al. Spine 2000;25:1625-36. 52. The effect of posture on the fluid content of lumbar intervertebral discs. Adams MA, Hutton WC. Spine 1983;8:665-71. 53. The effect of posture on diffusion into lumbar intervertebral discs. Adams MA, Hutton WC. J Anat. 1986;147:121-34. 54. The effect of posture on the role of the apophysial joints in resisting intervertebral compressive forces. Adams MA, Hutton WC. J Bone Joint Surg.[Br.] 1980;62:358-62. 55. Sustained loading generates stress concentrations in lumbar intervertebral discs. Adams MA, McMillan DW, Green TP et al. Spine 1996;21:434-8. 56. 'Stress' distributions inside intervertebral discs. The effects of age and degeneration. Adams MA, McNally DS, Dolan P. J Bone Joint Surg.Br. 1996;78:965-72. 57. Comparison of lumbar paravertebral EMG patterns in chronic low back pain patients and non-patient controls. Ahern DK, Follick MJ, Council JR et al. Pain 1988;34:153-60. 58. The prevalence of cervical zygapophyseal joint pain. A first approximation. Aprill C, Bogduk N. Spine. 1992;17:744-7. 59. The role of functional status questionnaires for low back pain. Beattie P, Maher C. Aust.J Physiother. 1997;43:29-38. 60. The innervation of the lumbar spine. Bogduk N. Spine. 1983;8:286-93. 61. On the nature of neck pain, discography and cervical zygapophysial joint blocks. Bogduk N, Aprill C. Pain 1993;54:213-7. 62. The anatomy of the so-called "articular nerves" and their relationship to facet denervation in the treatment of low-back pain. Bogduk N, Long DM. J.Neurosurg. 1979;51:172-7. 63. Percutaneous lumbar medial branch neurotomy: a modification of facet denervation. Bogduk N, Long DM. Spine. 1980;5:193-200.

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64. The human lumbar dorsal rami. Bogduk N, Wilson AS, Tynan W. J Anat. 1982;134 (Pt2):383-97. 65. The Management of Pain. 2 ed. Bonica JJ. Philadelphia: Lea & Febiger, 1990. 66. 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Carragee EJ, Paragioudakis SJ, Khurana S. Spine 2000;25:2987-92. 67. Carrick FR. Cervical radiculopathy: the diagnosis and treatment of pathomechanics in the cervical spine. J Manipulative.Physiol Ther. 1983;6:129-37. 68. An inflammation model of low back pain. Cavanaugh J.M., Yamashita T., Ozaktay A.C. et al 1990. Boston, MA, Proceedings of the International Society for the Study of the Lumbar Spine. 1990.Ref Type: Conference Proceeding 69. Neural mechanisms of lumbar pain. Cavanaugh JM. Spine. 1995;20:1804-9. 70. Sensory innervation of soft tissues of the lumbar spine in the rat. Cavanaugh JM, el-Bohy A, Hardy WN et al. J.Orthop.Res. 1989;7:378-88. 71. Innervation of the rabbit lumbar intervertebral disc and posterior longitudinal ligament. Cavanaugh JM, Kallakuri S, Ozaktay AC. Spine. 1995;20:2080-5. 72. Myo-electric behavior of the trunk muscles during static load holding in healthy subjects and low back pain patients. Chen WJ, Chiou WK, Lee YH et al. Clin.Biomech.(Bristol., Avon.) 1998;13:S9-S15. 73. Motor and somatosensory conduction in cervical myelopathy and radiculopathy. Chistyakov AV, Soustiel JF, Hafner H et al. Spine 1995;20:2135-40. 74. Effects of posture and structure on threedimensional coupled rotations in the lumbar spine. A biomechanical analysis. Cholewicki J, Crisco JJ, III, Oxland TR et al. Spine 1996;21:2421-8. 75. Stabilizing function of trunk flexor-extensor muscles around a neutral spine posture. Cholewicki J, Panjabi MM, Khachatryan A. Spine 1997;22:2207-12. 76. Postural aberrations in low back pain. Christie HJ, Kumar S, Warren SA. Arch.Phys.Med.Rehabil. 1995;76:218-24. 77. The surgical anatomy of thoracic facet denervation. Chua WH, Bogduk N. Acta Neurochir.(Wien.) 1995;136:140-4.

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78. Innervation of "painful" lumbar discs. Coppes MH, Marani E, Thomeer RT et al. Spine 1997;22:2342-9. 79. Chiropractic biophysics technique: a linear algebra approach to posture in chiropractic. Harrison DD, Janik TJ, Harrison GR et al. J.Manipulative.Physiol.Ther. 1996;19:525- 13491 80. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Dwyer A, Aprill C, Bogduk N. Spine. 1990;15:453-7.

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81. Clinical and electrophysiological appraisal of the significance of radicular injury in back pain. Fisher MA, Shivde AJ, Teixera C et al. J Neurol.Neurosurg.Psychiatry 1978;41:303-6. 82. [Innervation of the sacroiliac joint of the human] Z Grob KR, Neuhuber WL, Kissling RO. Rheumatol. 1995;54:117-22. 83. The innervation of the spinal dura mater: anatomy and clinical implications. Groen GJ, Baljet B, Drukker J. Acta Neurochir (Wein) 1988;92(1-4):39-46. 84. North American Spine Society: failure of the pathology model to predict back pain. Haldeman S. Spine 1990;15:718-24. 85. Effects of hydrostatic pressure on matrix synthesis and matrix metalloproteinase production in the human lumbar intervertebral disc. Handa T, Ishihara H, Ohshima H et al. Spine 1997;22:1085-91. 86. Anterior thoracic posture increases thoracolumbar disc loading. Harrison DE, Colloca CJ, Harrison DD et al. Eur.Spine J. 2005;14:234-42. 87. Does long-term compressive loading on the intervertebral disc cause degeneration? [In Process Citation]. Hutton WC, Ganey TM, Elmer WA et al. Spine 2000;25:2993-3004. 89. A comparison of the innervation characteristics of the lateral spinal ligaments between normal subjects and patients with adolescent idiopathic scoliosis. Jiang H, Greidanus N, Moreau M et al. Acta Anat.(Basel.) 1997;160:200-7. 90. The nature and distribution of the innervation of human supraspinal and interspinal ligaments. . Jiang H, Russell G, Raso VJ et al. Spine. 1995;20:869-76. of lumbar spinal dura and longitudinal ligaments. Spine 1998;(23)4;403-411. 91. Possible mechanism of painful radiculopathy in lumbar disc herniation. Kawakami M, Tamaki T, Hayashi N et al. Clin.Orthop 1998;241-51. 92. Experimental lumbar radiculopathy. Behavioral and histologic changes in a model of radicular pain after spinal nerve root irritation with chromic gut ligatures in the rat. Kawakami M, Weinstein JN, Chatani K et al. Spine. 1994;19:1795-802. 93. Experimental lumbar radiculopathy. Immunohistochemical and quantitative demonstrations of pain induced by lumbar nerve root irritation of the rat. Kawakami M, Weinstein JN, Spratt KF et al. Spine. 1994;19:1780-94.

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94. Acute brachial neuropathy--electrophysiological study and clinical profile. . Kim KK. J Korean Med Sci. 1996;11:158-64. 95. The relationship of degeneration of the intervertebral disc to mechanical loading conditions on lumbar vertebrae. Kurowski P, Kubo A. Spine 1986;11:726-31. 96. Lumbar spine pain originating from vertebral osteophytes. Lamer TJ. Reg Anesth.Pain Med. 1999;24:347-51. 97. Spine loading characteristics of patients with low back pain compared with asymptomatic individuals. Marras WS, Davis KG, Ferguson SA et al. Spine 2001;26:2566-74. 98. Extraforaminal entrapment of the fifth lumbar spinal nerve by osteophytes of the lumbosacral spine: anatomic study and a report of four cases. Matsumoto M, Chiba K, Nojiri K et al. Spine 2002;27:E169-E173. 99. Mechanoreceptor endings in human thoracic and lumbar facet joints. McLain RF, Pickar JG. Spine. 1998;23:168-73. 100. Mechanoreceptor endings of the cervical, thoracic, and lumbar spine. McLain RF, Raiszadeh K. Iowa.Orthop J 1995;15:147-55. 101. Minaki Y. An electrophysiological study on the mechanoreceptors in the lumbar spine and adjacent tissues. Neuro-Orthopedics 1996;20:23-35. 102. The relative contributions of the disc and 13603 zygapophyseal joint in chronic low back pain. Schwarzer AC, Aprill CN, Derby R et al. Spine. 1994;19:801-6. 103. Posture affects motion coupling patterns of the upper cervical spine. Panjabi MM, Oda T, Crisco JJ, III et al. J Orthop Res. 1993;11:525-36. 104. Traction osteophytes of the lumbar spine: radiographic-pathologic correlation. Pate D, Goobar J, Resnick D et al. Radiology 1988;166:843-6. 105. Spinal nerve stimulation in S1 radiculopathy. Pease WS, Lagattuta FP, Johnson EW. Am.J Phys Med Rehabil 1990;69:77-80. 106. The pathogenesis of discogenic low back pain. Peng B, Wu Wm Hou S, et al. JBJS [Br] 2005;87(1):62-7. 107. Attributes and qualities of human posture and their relationship to dysfunction or musculoskeletal pain. Raine S, Twomey L. Crit Rev Phys Rehabil Med 1994;6:409-37.

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108. Mechanoreceptors in intervertebral discs. Morphology, distribution, and neuropeptides. Roberts S, Eisenstein SM, Menage J et al. Spine. 1995;20:2645-51. 109. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Schwarzer AC, Aprill CN, Derby R et al. Spine. 1994;19:1132-7. 110. Disc degeneration and angular movement of the lumbar spine: comparative study using plain and flexion-extension radiography and discography. Soini J, Antti-Poika I, Tallroth K et al. J Spinal Disord. 1991;4:183-7. 111. Pain from the lumbar zygapophysial joints: a test of two models. Schwarzer AC, Derby R, Aprill CN et al. J.Spinal.Disord. 1994;7:331-6. 112. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Schwarzer AC, Wang SC, Bogduk N et al. Ann.Rheum.Dis. 1995;54:100-6. 113. Spinal segmental somatosensory evoked potentials in lumbosacral radiculopathies. Seyal M, Sandhu LS, Mack YP. Neurology 1989;39:801-5. 114. The effect of anterior osteophytes and flexural position on thoracic trabecular strain. Toh E, Yerby SA, Bay BK et al. Spine 2001;26:22-6. 115. Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study [see comments]. Vernon H, Steiman I, Hagino C. J Manipulative.Physiol Ther. 1992;15:418-29. 116. Histologic analysis of neural elements in the human sacroiliac joint. Vilensky JA, O'Connor BL, Fortin JD et al. Spine 2002;27:1202-7. 117. Mechanosensitive afferent units in the lumbar facet joint. Yamashita T, Cavanaugh JM, el-Bohy AA et al. J.Bone Joint Surg.[Am.] 1990;72:865-70. SECTION FIVE: The importance of radiographic assessment following the initial history and examination of a patient presenting with a history of physical trauma or falling. 1. Emergency Radiology Giuliano V. 2002;9:249-253. 2. Occult post-traumatic cervical ligamentous instability. Wilberger JE, Maroon JC. J Spinal Disorders 1990Jun:3(2):p156-61

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3. Evaluation of the cervical spine in whiplash injuries. Zatzkin HR, Kveton FW. Radiology 1960;75:577-583. 4. Soft-tissue injuries of the neck in automobile accidents. Hohl M. J Bone and Joint Surgery 1974;56-A:1675-1682. 5. Trauma of the cervical spine as a cause of chronic headache. Braaf MM, Rosner S. J Trauma 1975;15:441-446. 6. The prognosis of neck injuries resulting from rear-end vehicle collisions. Norris SH, Watt I. J Bone and Joint Surgery 1983;65-B:608-611. 8. Hyperextension strain or "whiplash" injuries to the cervical spine. Griffiths HJ, Olson PN, Everson LI, Winemiller M. Skeletal Radiology 1995; 24(4):263-6. 9. A Multiple Parameter Assessment of Whiplash Injury Patients Undergoing Subluxation Based Chiropractic Care: A Retrospective Study. . McCoy HG, Matthew McCoy M. JVSR 1996 Vol 1, No. 3. p 1-11. 10. Traumatic thoracic outlet syndrome. Kai Y, et al. Orthop Traumatol 1998;47:1169-1171. 11. Case study: Acceleration/deceleration injury with angular kyphosis Robert C. Kessinger, DC , Dessy V. Boneva DC JMPT Volume 23, Issue 4, Pages 279-287 (May 2000)

12. Frontiers in Whiplash Trauma, Clinical & Biomechanical Lind, Bengt MD, PhD Spine: November 2001 - Volume 26 - Issue 22 - p 2515 13. Measurement Techniques for Upper Cervical Spine Injuries: Consensus Statement of the Spine Trauma Study Group Bono, Christopher M. MD; Vaccaro, Alexander R. MD; Fehlings, Michael MD; Fisher, Charles MD; Dvorak, Marcel MD; Ludwig, Steven MD; Harrop, James MD Spine:1 March 2007 - Volume 32 - Issue 5 - pp 593-600 14. Whiplash produces an S shaped curvature of the neck with hyperextension of the lower levels. Spine 1997;22:2489-94 15. The effects of mechanical forces on bones and joints. Experimental study on the rat tail. Pazzaglia UE, Andrini L, Di Nucci A. J Bone Joint Surg (Am) 1997;79-A:1024-30. 16. Kinematics of cervical spine injury: a functional radiological hypothesis. Penning L. Eur Spine J 1995;130:317-26. 17. American Geriatrics SocietyBritish Geriatrics SocietyAmerican Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2000;49:664–672.

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18. Imaging suspected cervical spine injury: Plain radiography or computed tomography? Systematic review �Gavin Cain, Jane Shepherdson, Vicki Elliott, Jon Svensson, Patrick Brennan �Radiography �February 2010 (Vol. 16, Issue 1, Pages 68-77)

19. The epidemiology of falls and syncope. Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002;18:141–158

20. Biomechanics of falling. Tencer AF. Mayo Clin Proc 2005 80:847-848 21. Transverse sacral fractures , 05 November 2007 �Luis A. Robles �Spine Journal �January 2009 (Vol. 9, Issue 1, Pages 60-69)

22. A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers. Brauer SG, Burns YR, Galley P. J Gerontol. 2000;55:M469–M476.

23. A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients. Thomas JI, Lane JV. Arch Phys Med Rehabil. 2005;86:1636–1640

24. Predicting the probability of falls in community-dwelling older adults. Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Phys Ther. 1997;77:812–819

25. Clinical predictors of unstable cervical spine injury in multiply injured patients. Ross, S., K. O'Malley, W. DeLong, C. Born, and C. Schwab. Injury: British Journal of Accident Surgery, 23: 317-319, 1992. 26. Prospective analysis of acute cervical spine injury: a methodology to predict injury. Jacobs, L., and R. Schwartz. Ann Emerg Med, 15: 44-49, 1986. 27. Cervical curvature in acute whiplash injuries: a prospective comparative study with asymptomatic subjects. Injury 1998;29 p775-8 28. Kinamatics of cervical spine injury. A functional radiological hypothesis. Eur Spine Journal. 1995;4p126-32 SECTION SIX: The reliability and repeatability of radiographic positioning and radiographic alignment assessment methods used in medicine and chiropractic. The poor reliability of alternative measuring methods. 1. The (“poor”) correlation between surface measurement of head and neck posture and the anatomic position of the upper cervical vertebrae. Johnson GM. Spine 1998 Apr 15;23(8):921-7.

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2. The relationship between surface contour and vertebral body measures of upper spine curvature. (“poor reliability”) Refshauge KM, Goodsell M, Lee M. Spine 1994;19:2180-5. 3. The value of measurement from T5-T12 as a screening tool in detecting abnormal kyphosis. Kolessar DJ, et al. J Spinal Disord 1996;9:220-222. 4. Body posture photographs as a (“poor”) diagnostic aid for musculoskeletal disorders related to temporomandibular disorders (TMD). Zonnenberg AJ, Van Maanen CJ, Oostendorp RA, Elvers JW. Cranio. 1996 Jul;14(3):225-32. 5. Implications for the Use of Postural Analysis as a Clinical Diagnostic Tool: (“poor”) Reliability of Quantifying Upright Standing Spinal Postures From Photographic Images Nadine M. Dunk, BSc Jennifer Lalonde, BSc, Jack P. Callaghan, PhD JMPT Volume 28, Issue 6, Pages 386-392 (July 2005)

6. Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients. Jackson RP, Peterson MD, McManus AC, Hales C. Spine 1998; 23:1750-1767. 7. Chiropractic Biophysics Digitized Radiographic Mensuration Analysis of the Anteroposterior Lumbopelvic View: A Reliability Study. Stephan J. Troyanovich, DC, Sanghak O. Harrison, DC, Donald D. Harrison, PhD, DC, Deed E. Harrison, DC, Mark R. Payne, DC, Tadeusz J. Janik, PhD, and Burt Holland, PhD JMPT Volume 22 June 1999 8. Chiropractic Biophysics Digitized Radiographic Mensuration Analysis of the Anteroposterior Cervicothoracic View: A Reliability Study Stephan J. Troyanovich, DC, Deed Harrison, DC, Donald D. Harrison, DC, PhD,c Sanghak O. Harrison, DC, Tadeusz Janik, PhD, and Burt Holland, PhD JMPT Volume 23 September 2000 9. The reliability of postural x-rays in measuring pelvic obliquity. Fann AV, Lee R, Verbois GM. Arch Phys Med Rehabil 1999;80:458-461. 10. Short Leg Correction: A clinical trial of Radiographic vs. (“poor reliability”) Non-Radiographic Procedures. Aspegren Dd, Cox Jm, Trier Kk. J Manipulative Physiol Ther: Oct 1987(10:5) 232-38. 11. Comparison Of Leg Length Inequality Measurement Methods As Estimators Of The Femur Head Height Difference On Standing X-Ray. Bishop Pa, Mansfield Er, Rhodes Dw. J Manipulative Physiol Ther: Sep 1995(18:7) 448-452. 12. Validation of postural radiographs as a way to measure change in pelvic obliquity. Fann AV. Arch Phys Med Rehabil. 2003 Jan;84(1):75-8.

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13. Accuracy and precision of clinical estimation of leg length inequality and lumbar scoliosis: comparison of clinical and radiological measurements. Friberg O, Nurminen M, Korhonen K, Soininen E, Manttari T. Int Disabil Stud. 1988;10(2):49-53. 14. The Validity Of The Prone Leg Check As An Estimate Of Standing Leg Length Inequality Measured By X-Ray. Bishop Pa, Mansfield Er, Rhodes Dw. J Manipulative Physiol Ther: Jul/Aug 1995(18:6) 343-346. 15. Lumbar Degenerative Kyphosis: Radiologic Analysis and Classifications Jang, Jee-Soo MD, PhD; Lee, Sang-Ho MD, PhD; Min, Jun-Hong MD, PhD; Han, Kyoung-Mi RN Spine Journal 15 November 2007 - Volume 32 - Issue 24 - pp 2694-2699 16. Evaluation of spinal curvatures after a recent osteoporotic vertebral fracture. Joint Bone Spine. Cortet B, Roches E, Logier R, Houvenagel E, Gaydier-Souquieres G, Puisieux F, Delcambre B. 2002 Mar;69(2):201-8. 17. Measurement of scoliosis and kyphosis radiographs: intra-observer and inter-observer variation. Carman DL, Browne RH, Birch JG. J Bone Joint Surg Am 1990;72:328-33. 18. A comparison of three methods for measuring thoracic kyphosis: implications for clinical studies S. Goh, R. I. Price, P. J. Leedman and K. P. Singer Rheumatology 2000; 39: 310-315

19. (“Poor”) Reliability and Validity of Four Instruments for Measuring Lumbar Spine and Pelvic Positions PHYS THER Vol. 66, No. 5, May 1986, pp. 677-684 Ray G Burdett, Kathryn E Brown and Michael P Fall 20. Repeatability over time of posture, radiograph positioning, and radiograph line drawing: an analysis of six control groups. Harrison DE, Harrison DD, Colloca CJ, Betz J, Janik TJ, Holland B. J Manipulative Physiol Ther. 2003 Feb;26(2):87-98. Erratum in: J Manipulative Physiol Ther. 2003 Mar-Apr;26(3):211. 21. Reliability of spinal displacement analysis of plain X-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique. Harrison DE, Harrison DD, Troyanovich SJ. J Manipulative Physiol Ther. 1998 May;21(4):252-66. 22. Back surface curvature and measurement of lumbar spinal motion. (“poor reliability”) Stokes IAF, Bevins TM, Lunn RA. Spine 1987;12:355-61. 23. Interrater and intrarater reliability in the measurement of kyphosis in postmenopausal women with osteoporosis. Lunden KM, Li AM, Bibershtein S. Spine 1998;23:1978-85.

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24. Intra and inter-examiner reliability of the chiropractic biophysics lateral lumbar radiographic mensuration procedure. Troyanovich SJ, Robertson GA, Harrison DD, Holland B. J Manipulative Physiol Ther 1995;18:519-24. 25. Accuracy of the sagittal vertical axis in a standing lateral radiograph as a measurement of balance in spinal deformities. Van Royen BJ, Toussaint HM, Kingma I, Bot SD, Caspers M, Harlaar J, Wuisman PI. Eur Spine J. 1998;7(5):408-12. 26. Measurement of lumbar sagittal mobility: a comparison of methods. Salisbury PJ, Porter RW. Spine 1987;12:190-3. 27. A comparison of actual (“radiographic”) and apparent lumbar lordosis in black and white adult. Mosner EA, Bryan JM, Stull MA, Shippee R. Spine Volume 14 March 1989 28. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. Harrison DD, Cailliet R, Janik TJ, et al. J Spinal Disorders. 1998;11:430–439. 29. Lumbopelvic lordosis and pelvic balance on repeated standing lateral radiographs of adult volunteers and untreated patients with constant low back pain. Jackson RP, Kanemura T, Kawakami N, Hales C. Spine 2000; 25: 575-586. 30. A variability study of computerized sagital spinopelvic radiographic measurements of trunk balance. Berthonnaud E, Labelle H, Roussouly P, Grimard G, Vaz G, Dimnet J. J Spinal Disorders Tech 2005 Feb;18(1)66-71 32. Roentgenographic analysis of posture in spinal osteoporotics. Itoi E. Spine Journal 1991;16:750-756. 33. Evaluation of a functional position for lateral radiograph acquisition in adolescent idiopathic scoliosis. Faro FD, Marks MC, Pawelek J, Newton PO Spine. 2004;29(20): 2284-9. 34. Computer-assisted assessment of spinal sagittal plane radiographs. Rajnics P, Pomero V, Templier A, Lavaste F, Illes T. J Spinal Disord. 2001 Apr;14(2):135-42. 35. Measurement variance in limb length discrepancy: clinical and radiographic assessment of interobserver and intraobserver variability. Terry MA, Winell JJ, Green DW, Schneider R, Peterson M, Marx RG, Widmann RF. J Pediatr Orthop. 2005 Mar-Apr;25(2):197-201. 36. Measurement of lower limb alignment using long radiographs. Wright JG, Treble N, Feinstein AR. J Bone Joint Surg. 1991 Sep;73(5):721-3.

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35. The reliability of patient positioning for evaluating static radiographic parameters of the human pelvis. Plaugher G, Hendricks AH, Doble RW, Bachman, TR, Araghi HJ, Hoffart VM. J Manipulative Physiol Ther 1993;16:517-522. 36. Further reliability analysis of the Harrison radiographic line-drawing methods:crossed ICCS for the lateral posterior tangents and modified riser-ferguson method on A-P views JMPT feb 2002Deed E. Harrison, DC,a Burt Holland, PhD,b Donald D. Harrison, PhD, DC,c and Tadeusz J. Janik, PhDd 37. A Review of (“the poor”) Intraexaminer and Interexaminer Reliability of Static Spinal Palpation: A Literature Synthesis �Michael T. Haneline, Morgan Young�Journal of Manipulative and Physiological Therapeutics �June 2009 (Vol. 32, Issue 5, Pages 379-386) SECTION SEVEN: A radiographic evaluation may commonly reveal clinical information that may contraindicate certain physical interventions including spinal manipulation. 1. Relative and absolute contraindications to spinal manipulative therapy found on spinal x-rays. Proceedings of the World Federation of Chiropractic 7th Biennial Congress; Orlando, FL, May 2003, page 376. Bull PW. 2. Radiographic findings that may alter treatment identified on radiographs of patients receiving chiropractic care in a teaching clinic. J Chiropractic Education 2006;20(1):93-94. Pryor M, McCoy M. 3. Radiographic Anomalies That May Alter Chiropractic Intervention Strategies Found in a New Zealand Population. J Manipulative and Physiol Ther 2004; 27(9):554-559. Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL.

4. Fluctuating Asymmetry and Vertebral Malformation: A Study of Palmar Dermatoglyphics in Congenital Spinal Deformities. Spine: 1 April 1997 - Volume 22 - Issue 7 - pp 775-779 Goldberg, Caroline J. MD; Fogarty, Esmond E. FRCSI, FRACS; Moore, David P. FRCSI, MCh, Orth; Dowling, Frank E. MCh, FRCSI 5. Anomalies Associated with Vertebral Malformations. Beals, Rodney K. MD; Robbins, James R. MD; Rolfe, Bruce MD Spine: August 1993 Volume 18 Issue 10

6. Is systematic radiography needed before spinal manipulation? Ann Readapt Med Phys. 2007 Mar;50(2):111-6; discussion 117-8. Epub 2006 Oct Recommendations of the SOFMMOO 7. Nonvascular complications following spinal manipulation. Jefferey S Oppenheim, Daniel E Spitzer. Spine Journal Nov 2005 Volume 5 Issue 6

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8. Herniated disc with radiculopathy following cervical manipulation:non surgical management. Donald R Murphy Spine Journal July 2006 Volume 6 Issue 4 9. Prospective investigations into the safety of spinal manipulation. Edzard Ernst Journal of pain and symptom management March 2001 Volume 21 Issue 3 10. Safety of spinal manipulation in the treatment of lumbar disk herniations; A Systematic review and risk assessment. Drew Oliphant JMPT March 2004 Volume 27 Issue 3

11. Predictors of adverse events following chiropractic care for patients with neck pain. Sidney M Rubenstein, Charlotte Leboef-yde, Dirk Knol, Tammy Koekkoek JMPT Feb 2008 Volume 31 Issue 2

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ATTACHMENT 3: The comparative public benefit of radiography in a chiropractic practice.

How radiography kept within a chiropractic office may provide the public with a safer, less expensive “one-stop” patient-centered musculoskeletal management approach, from diagnosis through to treatment. Below is a review of the international studies that favorably compare chiropractic financial cost of care to equivalent medical cost of care and the comparative risk of harm from comparable treatment interventions.

While chiropractic will not always replace the need for surgery or medication, this data does recognize the:

a) relevant clinical treatment role for chiropractic with the listed condition b) comparative benefit financially for this condition under chiropractic c) potential reduction in patient harm from treatment when under chiropractic vs medical

care.

Introduction:

Any analysis regarding the risk of any clinical assessment procedure (radiography) cannot be disconnected from the risk vs. benefit of the subsequent treatment protocols that follow. Here we provide a more complete disclosure of the comparative benefit-risk ratio of chiropractic vs. medical treatment options for the same patient presenting with the same condition. The relevance here is that these presenting conditions are commonly assessed through chiropractic radiography and medical radiography. The list includes neck pain, back pain, spinal stenosis, whiplash, disc protrusion, cervical spine radicular pain, sciatica”.

The document by the US Department of Health and Human Services, Agency for Health Care Policy and Research; Chiropractic in the United States: training, practice, and research (32) states“ recent evidence-based review of conservative and surgical interventions for acute back pain failed to identify any interventions supported by multiple high-quality scientific studies. Thus despite the poor quality of many of the studies evaluating its effectiveness, there is as much or more evidence for the effectiveness of spinal manipulation as for other non-surgical treatments for back pain. At present, however, comparative data for these largely low-risk (manipulative) therapies (in relation to surgery) are not available.

Anthony L. Rosner Phd (31) summarized the dangers of chiropractic care by outlining “more precise estimates of serious complications from cervical manipulations have recently been estimated to be 6 per 10 million manipulations, with fatal occurrences estimated at the rate of 3 per 10 million manipulations. (79) This rate pales in comparison to NSAID-related gastropathies resulting in death; assuming that each patient receives an average of 10 manipulations in treatment, death rates after cervical manipulations calculate to anywhere between 1/100 to 1/400, the rates seen in the use of NSAIDs for the same

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condition. (52) (53) It is also far below the risk of death from such voluntary and everyday activities as power boating, pregnancy, taking contraceptive pills, or automobile driving. (80) One would imagine that we have lost our perspective on the entire issue of benefit-to-risk ratios here”. He further added, “ the risks of surgery to the spine are often ignored. Some authors present selective information that fails to account for the fact that death rates for lumbar spine operations have been reported to be 300 times higher than the rate produced by cerebrovascular accidents in spinal manipulation (54) (55) for cervical surgeries, recent death rates have been estimated to be 700-fold greater”. (54) “With the recent association of cerebrovascular accidents with rotational maneuvers applied to the upper neck, (81) (82) accident rates produced by spinal manipulations in this region may now be anticipated to decrease. The accident rate in using medications (decidedly non-chiropractic), on the other hand, is often shown to have increased rising 2.5-fold for hospital inpatients and jumping 8.5-fold for outpatients. (83)

The actual number of iatrogenic complications specifically ascribed to chiropractic has been shown in the literature to be significantly overestimated, because of the fact that the practitioner actually involved is in many cases was a non-chiropractor. Rather, a major portion of these accidents has occurred at the hands of a practitioner with inadequate professional training but incorrectly represented in the medical literature as a chiropractor (57)

Content: SECTION ONE: Financial cost study comparisons (18 studies) SECTION TWO: Chiropractic clinical relevance/therapeutic comparisons (21 studies) SECTION THREE: Chiropractic health promotion/patient satisfaction outcomes (6 studies) SECTION FOUR: Medical harm in musculoskeletal-care (38 studies) SECTION FIVE: Excessive reliability on external randomized control trials (10 studies)

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SECTION ONE: Favorable financial cost study comparisons 1. Comparing the costs between provider types of episodes of back pain care. Rosner A. Spine Journal. 1995;20:2595–2598. 2. Cost per case comparison of back injury claims of chiropractic versus medical management of conditions with identical diagnostic codes. J Occup Med. Jarvis KB, Phillips RB, Morris EK. 1991;33:847–852.

3. Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to health services. Manga P. Report to the Ontario Ministry of Health. 1998;.

4. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. Carey TS, Garrett J, Jackman A, MacLaughlin C, Fryer J, Smucker DR, et al. N Engl J Med. 1995;333:913–917.

5. Cost Minimization Analysis of Low Back Pain Claims Data for Chiropractic Vs Medicine in a Managed Care Organization Brian Grieves, J. Michael Menke, Kevin J. Pursel Journal of Manipulative and Physiological Therapeutics November 2009 (Vol. 32, Issue 9, Pages 734-739) 6. The Selection Effects of the Inclusion of a Chiropractic Benefit on the Patient Population of a Managed Health Care Organization Craig F. Nelson, R. Douglas Metz, Thomas M. LaBrot, Kenneth R. Pelletier Journal of Manipulative and Physiological Therapeutics March 2005 (Vol. 28, Issue 3, Pages 164-169)

7. Chiropractic and medical costs of low back care. Stano M, Smith M. Med Care. 1996;34:191–204.

8. Mechanical low-back pain: a comparison of medical and chiropractic management within the Victorian WorkCare Scheme. Ebrall P. Chiropr J Austr. 1992;22:47–53.

9. The effectiveness and cost-effectiveness of chiropractic management of low-back pain. Papadopoulos C, Swan W. Richmond Hill: Kenilworth; 1993; 10. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. Carey TS, Garrett J, Jackman A, MacLaughlin C, Fryer J, Smucker DR, et al. N Engl J Med. 1995;333:913–917

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11. The Manga Report; A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain Funded By The Ontario Ministry Of Health written by: Pran Manga, Ph.D.�Douglas E. Angus, M.A.�Costa Papadopoulos, MHA�4 William R. Swan, B.Comm. August 1993

12. Comparative Analysis of Individuals With and Without Chiropractic Coverage: Patient Characteristics, Utilization, and Costs Antonio P. Legorreta; R. Douglas Metz; Craig F. Nelson; Saurabh Ray; Helen Oster Chernicoff; Nicholas A. DiNubile Arch Intern Med, Oct 2004; 164: 1985 - 1992. 13. The AMI Study 1999-2002, found decreases of: 43 percent in- hospital admissions per 1,000; 58.4 percent in hospital days per 1,000; 43.2 percent in outpatient surgeries and procedures per 1,000; and, 51.8 percent in pharmaceutical costs. It noted that: "The AMI experience seems to indicate that a non-pharmaceutical/nonsurgical orientation can reduce overall health care costs significantly and yet deliver high quality care." 2003-2005. The results of the original study were confirmed, with demonstrated decreases of 60.2 percent in in-hospital admissions, 59 percent in hospital days, 62 percent in outpatient surgeries and procedures, and 85 percent in pharmaceutical costs.

14. The Stano Study: Oakland University Economics Professor Dr. Miron Stano, Journal of Manipulative and Physiological Therapeutics June 1993 found that, when costs of advanced imaging and referrals to physical therapists and other providers were added, chiropractic care costs for chronic patients were 16 percent lower than medical care costs. If the study would have included hospitalization or surgical costs, two very expensive medical treatments for low-back pain, or over-the-counter medications, the savings from chiropractic would have been even greater. Additionally, chiropractic patients showed an advantage over medical patients in pain, disability, and satisfaction outcomes. 15. The Procedures Study: This study demonstrates that chiropractic care leads to lower costs by reducing the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs in patients with low-back and neck pain. The study examined the claims data from a managed care health plan over a four-year period. The use rates of the high-cost procedures mentioned above were compared between employer groups with and without a chiropractic benefit. For patients with both low back and neck pain, the use rate of all four of these categories was lower in the group with chiropractic coverage. The study concludes: "Among employer groups with chiropractic coverage compared with those without such coverage, there is a significant reduction in the use of high-cost and invasive procedures for the treatment of back pain." 16. Spinal Manipulation Gives Value for Money: British Medical Research Council (MRC) Trial Finds Adding Spinal Manipulation and Exercise to GP Care Provides Relief

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(and Cost-effectiveness) for Back Pain British Medical Journal 2004 (Dec 11); 329 (7479) 17. Cost-Effectiveness of Chiropractic Care in a Managed Care Setting. American Journal of Managed Care Study Carrie D. Mosley; Ilana G. Cohen, DC; Roy M. Arnold, MD, MHA Published Online: February 29, 1996 18. The Utah Study: compared the cost of chiropractic care to the cost of medical care for conditions with identical diagnostic codes and found that cost was almost 10 times higher for medical than for chiropractic claims. Also, the number of work days lost was nearly ten times higher for those who received medical care. SECTION TWO: Chiropractic clinical relevance and therapeutic comparisons: 19. Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders Eric L. Hurwitz, Eugene J. Carragee, Gabrielle van der Velde, Linda J. Carroll, Margareta Nordin, Jaime Guzman, Paul M. Peloso, Lena W. Holm, Pierre Côté, Sheilah Hogg-Johnson, J. David Cassidy, Scott Haldeman Journal of Manipulative and Physiological Therapeutics February 2009 (Vol. 32, Issue 2, Pages S141-S175) 20. Nonsurgical Interventional Therapies for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline Chou, Roger MD; Atlas, Steven J. MD, MPH; Stanos, Steven P. DO; Rosenquist, Richard W. MD Literature Review Spine Journal 1 May 2009 - Volume 34 - Issue 10 - pp 1078-1093 21. The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: Findings from the UCLA Low Back Pain Study Eric L. Hurwitz, Hal Morgenstern, Philip Harber, Gerald F. Kominski, Thomas R. Belin, Fei Yu, Alan H. Adams Journal of Manipulative and Physiological Therapeutics January 2002 (Vol. 25, Issue 1, Pages 10-20) 22. Acute low-back pain problems in adults. Rockville, Md: Agency of Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; Bigos S, Bowyer O, Braen G, et al. 1994; Clinical Practice Guideline No. 14 AHCPR publication no 95–0642.

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23 An Examination of Musculoskeletal Cognitive Competency in Chiropractic Interns B. Kim Humphreys, Andrew Sulkowski, Kevin McIntyre, Mark Kasiban, A. Neil Patrick Journal of Manipulative and Physiological Therapeutics January 2007 (Vol. 30, Issue 1, Pages 44-49) 24. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. Carey TS, Garrett J, Jackman A, MacLaughlin C, Fryer J, Smucker DR, et al. N Engl J Med. 1995;333:913–917 25. Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: A practice-based feasibility study �Joanne Nyiendo, Mitchell Haas, Peter Goodwin �Journal of Manipulative and Physiological Therapeutics �May 2000 (Vol. 23, Issue 4, Pages 239-245) 26. Back pain. Report of a Clinical Standards Advisory Group Committee on Back Pain. Rosen M. London: HMSO; 1994;. 27. Characterization of Health Status and Modifiable Risk Behavior Among United States Adults Using Chiropractic Care as Compared With General Medical Care Harrison T. Ndetan, Sejong Bae, Marion Willard Evans, Ronald L. Rupert, Karan P. Singh Journal of Manipulative and Physiological Therapeutics July 2009 (Vol. 32, Issue 6, Pages 414-422) 28. Spinal manipulation for low-back pain. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Ann Intern Med. 1992;117:590–598 29. Chronic spinal pain syndromes: A clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation �Lynton G.F. Giles, Reinhold Müller �Journal of Manipulative and Physiological Therapeutics �July 1999 (Vol. 22, Issue 6, Pages 376-381) 30. Outcome of low back pain in general practice: a prospective study. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Br Med J. 1998;316:1356–1359. 31. Chiropractic in the United States: training, practice, and research. xi:Rockville, Md: US Department of Health and Human Services, Agency for Health Care Policy and Research; Cherkin DC, Mootz RD editor. 1997;p. 1; 3, 6. 32. The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care for Neck

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Pain: A Prospective, Multicenter, Cohort Study Journal of Manipulative and Physiological Therapeutics, Volume 30, Issue 6, Pages 408-418 S. Rubinstein, C. Leboeuf-Yde, D. Knol, T. de Koekkoek, C. Pfeifle, M. van Tulder 33. Manipulation in the Presence of Cervical Spinal Cord Compression: A Case Series �Donald R. Murphy, Eric L. Hurwitz, Amy A. Gregory �Journal of Manipulative and Physiological Therapeutics �March 2006 (Vol. 29, Issue 3, Pages 236-244) 34. Management of acute lumbar disk herniation initially presenting as mechanical low back pain �L.G.F. Giles�Journal of Manipulative and Physiological Therapeutics �May 2000 (Vol. 23, Issue 4, Pages 294-296) 35. A Nonsurgical Approach to the Management of Patients With Cervical Radiculopathy: A Prospective Observational Cohort Study �Donald R. Murphy, Eric L. Hurwitz, Amy Gregory, Ronald Clary �Journal of Manipulative and Physiological Therapeutics �May 2006 (Vol. 29, Issue 4, Pages 279-287) 36. Chiropractic management and manipulative therapy for MRI documented cervical disc herniations. Journal of Manipulative and Physiological Therapeutics 1994;17:177-185 37. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis �Gert Bronfort, Mitchell Haas, Roni L. Evans, Lex M. Bouter �The Spine Journal �May 2004 (Vol. 4, Issue 3, Pages 335-356) 38. Recruitment Methods and Costs for a Randomized, Placebo-Controlled Trial of Chiropractic Care for Lumbar Spinal Stenosis: A Single-Site Pilot Study �Jerrilyn A. Cambron, Jennifer M. Dexheimer, Mabel Chang, Gregory D. Cramer�Journal of Manipulative and Physiological Therapeutics �January 2010 (Vol. 33, Issue 1, Pages 56-61) 39. A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up �Donald R. Murphy, Eric L. Hurwitz, Ericka E. McGovern�Journal of Manipulative and Physiological Therapeutics �November 2009 (Vol. 32, Issue 9, Pages 723-733) 39b. The Selection of Operative Versus Non-operative Treatment in Patients With Adult Scoliosis Glassman, Steven D. MD; Schwab, Frank J. MD; Bridwell, Keith H. MD; Ondra, Stephen L. MD; Berven, Sigurd MD; Lenke, Lawrence G. MD Spine Journal 1 January 2007 - Volume 32 - Issue 1 - pp 93-97

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SECTION THREE: Chiropractic health promotion and patient satisfaction outcomes: 40. Patient evaluations of care from family physicians and chiropractors. Cherkin DC, MacCornack FA. West J Med. 1989;150:351–355 41. Patient satisfaction: a valid concept?. Williams B. Soc Sci Med. 1994;509–516.

42. Patient evaluations of care from family physicians and chiropractors. Cherkin DC, MacCornack FA. West J Med. 1989;150:351–355

43. Chiropractic Maintenance Care and Quality of Life of a Patient Presenting with Chronic Low Back Pain �Adrian B. Wenban, Michelle K. Nielsen �Journal of Manipulative and Physiological Therapeutics �February 2005 (Vol. 28, Issue 2, Pages 136-142) 44. Why patients use alternative medicine: results of a national study. Astin JA. JAMA. 1998;279:1548–1553.

45. Complementary medicine in Europe. Fisher P, Ward A. Br Med J. 1994;309:107–111. 46. Maintenance care: Health promotion services administered to US chiropractic patients aged 65 and older, Part II Ronald L. Rupert, Donna Manello, Ruth Sandefur Journal of Manipulative and Physiological Therapeutics January 2000 (Vol. 23, Issue 1, Pages 10-19) SECTION FOUR: Comparitive Medical harm in musculoskeletal care (risks) 47. Randomized Trial A Randomized Placebo-Controlled Trial of Single-Dose IM Corticosteroid for Radicular Low Back Pain Friedman, Benjamin W. MD, MS; Esses, David MD; Solorzano, Clemencia RPh; Choi, Hong K. MD; Cole, Michael MD; Davitt, Michelle MD; Bijur, Polly E. PhD; Gallagher, E J. MD Spine Journal 15 August 2008 - Volume 33 - Issue 18 - pp E624-E629 48. Nonsteroidal Anti-Inflammatory Drugs: Balancing Benefits and Risks Saag, Kenneth G. MD; Cowdery, John S. MD Spine Journal July 1994 - Volume 19 - Issue 13 - ppg 1530-1534

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49. Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey (“low risk”) Thiel, Haymo W. DC, PhD; Bolton, Jennifer E. PhD; Docherty, Sharon PhD; Portlock, Jane C. PhD Spine 1 October 2007 - Volume 32 - Issue 21 - pp 2375-2378 50. Safety of Chiropractic Interventions: A Systematic Review (“low risk”) Gouveia, Liliana Olim MD; Castanho, Pedro MD; Ferreira, Joaquim J. MD Spine Journal 15 May 2009 - Volume 34 - Issue 11 - pp E405-E413 51. Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study (“low risk”) Cassidy, J David DC, PhD, DrMedSc; Boyle, Eleanor PhD; Côté, Pierre DC, PhD; He, Yaohua MD, PhD; Hogg-Johnson, Sheilah PhD; Silver, Frank L. MD, FRCPC; Bondy, Susan J. PhD Spine Journal :15 February 2008 - Volume 33 - Issue 4S - pp S176-S183 52. Risk of serious gastrointestinal complications related to the use of nonsteroidal anti-inflammatory drugs: a meta-analysis. (“high risk”) Gabriel SE, Jaakkimainen L, Bombardier C. Ann Intern Med. 1991;115:787–796. 53. A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain. (“low risk”) Dabbs V, Lauretti W. J Manipulative Physiol Ther. 1995;18:530–536. 54. Morbidity and mortality in association with operations on the lumbar spine. (“high risk”) Deyo RA, Cherkin DC, Loesser JD, Bigos SJ, Ciol MA. J Bone Joint Surg Am. 1992;74A:536–543.

55. Treatment of sciatica: a comparative survey of the complications of surgical treatment and nucleolysis with chymopapain. (“high risk”) Boullet R. Clin Orthop. 1990;251:144–152. 56. Magnetic Resonance Imaging Findings as Predictors of Clinical Outcome in Patients With Sciatica Receiving Active Conservative Treatment �Tue Secher Jensen, Hanne B. Albert, Joan S. Sorensen, Claus Manniche, Charlotte Leboeuf-Yde �Journal of Manipulative and Physiological Therapeutics �February 2007 (Vol. 30, Issue 2, Pages 98-108) 57. Increase in US medication-error deaths between 1983 and 1993. (“high risk”) Phillips DP, Christenfeld N, Glynn LM. Lancet. 1998;351:643–644

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58. Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. Terrett AGJ. J Manipulative Physiol Ther. 1995;18:203–210. 59. Health Services Research Prescription of Nonsteroidal Anti-inflammatory Drugs and Muscle Relaxants for Back Pain in the United States Luo, Xuemei PhD; Pietrobon, Ricardo MD; Curtis, Lesley H. PhD; Hey, Lloyd A. MD, MS Spine Journal 1 December 2004 - Volume 29 - Issue 23 - pp E531-E537 60. Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis Julia Hippisley-Cox, Carol Coupland, BMJ 2005;330:1366 (11 June), doi:10.1136/bmj.330.7504.1366

61. Analgesic Usage for Low Back Pain: Impact on Health Care Costs and Service Use (“high risk”) Vogt, Molly T. PhD; Kwoh, C Kent MD; Cope, Doris K. MD; Osial, Thaddeus A. MD; Culyba, Michael MD; Starz, Terence W. MD Spine Journal 1 May 2005 - Volume 30 Issue 9 - pp 1075-1081

62. The Stroke Issue: Paucity of Valid Data, Plethora of Unsubstantiated Conjecture Journal of Manipulative and Physiological Therapeutics, Volume 27, Issue 5, Pages 368-372 J.Chestnut 63. Risk of Death or Reinfarction Associated With the Use of Selective Cyclooxygenase-2 Inhibitors and Nonselective Nonsteroidal Antiinflammatory Drugs After Acute Myocardial Infarction Gunnar H. Gislason, MD; Søren Jacobsen, MD, DMSc; Jeppe N. Rasmussen, MD; Søren Rasmussen, MSc, PhD; Pernille Buch, MD; Jens Friberg, MD, PhD; Tina Ken Schramm, MD; Steen Z. Abildstrom, MD, PhD; Lars Køber, MD, DMSc; Mette Madsen, MSc; Christian Torp-Pedersen, MD, DMSc Circulation. 2006;113:2906-2913.)�© 2006 American Heart Association, Inc.

64. Increased Mortality and Cardiovascular Morbidity Associated With Use of Nonsteroidal Anti-inflammatory Drugs in Chronic Heart Failure Gunnar H. Gislason, MD, PhD; Jeppe N. Rasmussen, MD, PhD; Steen Z. Abildstrom, MD, PhD; Tina K. Schramm, MD; Morten L. Hansen, MD; Emil L. Fosbøl, MB; Rikke Sørensen, MD; Fredrik Folke, MD; Pernille Buch, MD, PhD; Niels Gadsbøll, MD, DMSc; Søren Rasmussen, MSc, PhD; Henrik E. Poulsen, MD, DMSc; Lars Køber, MD, DMSc; Mette Madsen, MSc; Christian Torp-Pedersen, MD, DMSc Arch Intern Med. 2009;169(2):141-149.

65. Non-steroidal anti-inflammatory drugs and cardiac failure: meta-analyses of observational studies and randomised controlled trials Paul A Scotta, Gabrielle H. Kingsleyb,c and David L Scottb,d,* European Journal of Heart Failure 2008 10(11):1102-

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1107;

66. Complications and side effects of cervical and lumbosacral selective nerve root injections �Christopher W. Huston, Curtis W. Slipman, Cyndi Garvin �Archives of Physical Medicine and Rehabilitation �February 2005 (Vol. 86, Issue 2, Pages 277-283)

67. Chronic Pain and Opiates: Balancing Pain Control and Risks in Long-Term Opioid Treatment (“high risk”) �Rollin M. Gallagher, Lisa J. Rosenthal �Archives of Physical Medicine and Rehabilitation �March 2008 (Vol. 89, Issue 3, Supplement 1, Pages S77-S82)

68. Chronic Pain and Opiates: A Call for Moderation (“high risk”) �R. Norman Harden �Archives of Physical Medicine and Rehabilitation �March 2008 (Vol. 89, Issue 3, Supplement 1, Pages S72-S76) 69. A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up �Donald R. Murphy, Eric L. Hurwitz, Ericka E. McGovern �Journal of Manip Physiol Thera �November 2009 (Vol. 32, Issue 9, Pages 723-733) 70. The Relationship Between Repeated Epidural Steroid Injections and Subsequent Opioid Use and Lumbar Surgery (“high risk”) �Janna Friedly, Isuta Nishio, Michael J. Bishop, Charles Maynard �Archives of Physical Medicine and Rehabilitation �June 2008 (Vol. 89, Issue 6, Pages 1011-1015) 71. Defining "Complications" in Spine Surgery: Neurosurgery and Orthopedic Spine Surgeons' Survey. Lebude B, Yadla S, Albert T, Anderson DG, Harrop JS, Hilibrand A, Maltenfort M, Sharan A, Vaccaro AR, Ratliff JK. J Spinal Disord Tech. 2010 Jan 27. 72. A Review of Medicolegal Malpractice Suits Involving Cervical Spine: What can we Learn or Change? Epstein NE. J Spinal Disord Tech. 2010 Jan 16 73. Comparison of 3 Physical Therapy Modalities For Acute Pain in Lumbar Disc Herniation Measured by Clinical Evaluation and Magnetic Resonance Imaging �Zeliha Unlu, Saliha Tascı, Serdar Tarhan, Yuksel Pabuscu, Serap Islak �Journal of Manipulative and Physiological Therapeutics �March 2008 (Vol. 31, Issue 3, Pages 191-198) 74. Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. JB,

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Heavner JE. Rampersaud YR, Moro ER, Neary MA, et al. Spine Journal (Phila Pa 1976). 2006 Nov 1;31(23):2758. 75. Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment �Drew Oliphant �Journal of Manipulative and Physiological Therapeutics �March 2004 (Vol. 27, Issue 3, Pages 197-210) 76. Far-Lateral disk herniation: case report, review of the literature, and a description of nonsurgical management �Richard E Erhard, William C Welch, Betty Liu, M Vignovic �Journal of Manipulative and Physiological Therapeutics �February 2004 (Vol. 27, Issue 2, Pages 123-128 77. Chiropractic management of a patient with lumbar spinal stenosis �Gregory J. Snow �Journal of Manipulative and Physiological Therapeutics �May 2001 (Vol. 24, Issue 4, Pages 300-304) 78. A Randomized Controlled Trial Comparing 2 Types of Spinal Manipulation and Minimal Conservative Medical Care for Adults 55 Years and Older With Subacute or 68. Chronic Low Back Pain �Maria A. Hondras, Cynthia R. Long, Ying Cao, Robert M. Rowell, William C. Meeker �Journal of Manipulative and Physiological Therapeutics �June 2009 (Vol. 32, Issue 5, Pages 330-343) 79. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Spine Journal 1996;21:1746–1760 80. The reality and acceptance of risk. Dinman BD. JAMA. 1980;244:1226–1228 81. Safety in chiropractic practice, part I: the occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978– 1988. Klougart N, Leboeuf-Yde C, Rasmussen LR. J Manipulative Physiol Ther. 1996;19:371–377

82. Safety in chiropractic practice, part II: treatment to the upper neck and the rate of cerebrovascular incidents. Klougart N, Leboeuf-Yde C, Rasmussen LR. J Manipulative Physiol Ther. 1996;19:563–569 83. Increase in US medication-error deaths between 1983 and 1993. Lancet. Phillips DP, Christenfeld N, Glynn LM. 1998;351:643–644

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84.Complications in Disk Surgery Clinical Orthopaedics and Related Research: July/August 1967 - Volume 53 - Issue - ppg 13-20 REYNOLDS, FRED C. M.D. 85. Complications of lumbar disc surgery Serdar Ozgen Deniz Konya M.Necmettin Pamir Volume 3, Issue 5, Supplement, Page 155 (September 2003)

SECTION FIVE: Limits to external randomized control trials The following studies and publications present critical argument that evidence based care is not limited to external randomized control trials and meta-analysis but must include individual clinician decision-making. 86. What Constitutes Evidence for Best Practice? John J. Triano Journal of Manipulative and Physiological Therapeutics November 2008 (Vol. 31, Issue 9, Pages 637-643) 87. Demanding medical excellence: doctors and accountability in the information age, and its relevance to CRNAs and nursing. Gunn IP. A critique of Michael L. Millenson's book, AANA J. 1998;66:575–582. 88. Jurisdictional control of conservative spine care: chiropractic vs medicine [dissertation]. Dallas (Tex): University of Texas; 2006. McGregor M. 89. Where is the wisdom…? The poverty of medical evidence. Smith R. Br Med J. 1991;303:798–799. 90. Second opinion: what's wrong with Canada's health care system and how to fix it. Rachlis N, Kuschner C. Toronto: Collins; 1989;

91. Fables or foibles: inherent problems with RCTs Anthony Rosner Journal of Manipulative and Physiological Therapeutics September 2003 (Vol. 26, Issue 7, Pages 460-467)

92. Accounting for EBM: notions of evidence in medicine. Lambert H. Soc Sci Med. 2006;11:2633–2645.

93. Evidence-based medicine. Interpreting studies and setting policy. Woolf SH, George JN. Hematol Oncol Clin North Am. 2000;14:761–784

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94. Introduction to and techniques of evidence-based medicine. Fisher CG, Wood KB. Spine Journal. 2007;32(19 Suppl):S66–S72

95. The role of evidence in alternative medicine: contrasting biomedical and anthropological approaches. Barry CA. Soc Sci Med. 2006;11:2646–2657.

96. Demanding medical excellence: doctors and accountability in the information age, and its relevance to CRNAs and nursing. Gunn IP. A critique of Michael L. Millenson's book, AANA J. 1998;66:575–582.