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\begin{document}

\title{The management of pain due to cervical multilevel disc bulges and spinal
stenosis with a novel wave treatment: A case report.}



\author[1]{Arwa Abuomar}%
\author[1]{Mohammed Albaradie}%
\author[2]{Hussain Aldera}%
\author[3]{Christopher Vannabouathong}%
\author[4]{Lee Bartel}%
\affil[1]{KKT Orthopedic Spine Center}%
\affil[2]{King Saud bin Abdulaziz University for Health Sciences College of Medicine}%
\affil[3]{Neuro Spinal Innovations}%
\affil[4]{University of Toronto}%


\vspace{-1em}



  
  \date{June 18, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
A patient presenting with low back pain received 18 novel treatments of
FDA approved low frequency sound wave stimulation known as Khan Kinetic
Treatment (KKT). Following KKT he demonstrated improvement in pain,
function, quality of life, sleep, and trunk range of motion with no
adverse events.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Back pain is the leading cause of disability worldwide, with up to 80\%
of the population experiencing back pain at some point in their
life.\textsuperscript{1,2} The cost of back pain in the United States of
America (USA) alone is estimated to exceed \$50 billion per
year.\textsuperscript{3} Chronic back pain is complex, and various
treatment options, ranging from conservative therapies to invasive
surgery, exist for the management of these patients.
\textsuperscript{4-7} The Khan Kinetic Treatment (KKT) approach aims to
provide orthopaedic spinal treatment through focused vibroacoustic
treatment (fVAT) and manage the biomechanical aspect of back pain.
Vibroacoustic therapy has been indicated for patients with a range of
musculoskeletal, neurological, and haemodynamic problems demonstrating
positive changes in pain, spasticity, movement control, and specifically
fatigue and anxiety in those with spinal cord or brain injuries.
\textsuperscript{8-13} The musculoskeletal effects specifically include
stimulation of mRNA expression of proteins key to spinal health and a
positive cellular environment for ligament repair. \textsuperscript{12}
KKT involves the application of sine waves, within the audible spectrum,
directed towards the spine. The low-frequency sound waves produce
mechanical vibrations that cause delicate reverberations of the
vertebrae, and minor repetitive stretching and activation of the
attached soft tissues at multiple spine levels. \textsuperscript{14-16}

Treatments for chronic back pain should relieve pain, improve spinal
misalignment, and help heal ligamentous structures, and KKT addresses
all of these factors by: 1) stimulating biosynthesis of intervertebral
disks, 2) correcting abnormal mean axis of rotation of intervertebral
joints, 3) activating spinal cord circuitry that ``gates'' pain
transmission and reducing gamma motor neuron activity, 4) relaxing
paraspinal muscles, ensuring asymmetrical loads on the spine are
minimized, and 5) increasing muscle coordination, due to the decreased
pain, which plays a critical role in spine
stabilization.\textsuperscript{14,15} Clinical evidence from published
reports demonstrated that KKT relieves back and neck pain, corrects
spinal alignment, and enhances the genetic expression of important
proteins in the discs. \textsuperscript{14,15,17,18} The following is a
case report of a young patient who presented with both low back pain and
neck pain, treated with KKT.

\textbf{Case presentation}

\emph{Patient description \& history}

A 23 year old male healthcare worker presented with low back pain
radiating to his right lower limb and neck pain radiating to both
shoulders. His symptoms started three years prior to presentation, which
were aggravated by standing, sitting, walking, neck flexion, neck
extension, and weightlifting. Upon presentation, he stated that the
``pain is as bad as it could be''. He has had diabetes type I since
childhood, taking insulin regularly. He had no history of osteoporosis
or malignancy. Pain medications and conservative therapies did not
improve his pain or sleep. Prior therapies included pregabalin,
meloxicam, and celecoxib, and he complained of worsening symptoms
following physical therapy and massage therapy. The patient provided his
informed consent to publish the results of his treatment.

\emph{Physical examination \& diagnosis}

On physical examination, the patient had severe tenderness over the
lumbosacral and midthoracic spine, moderate limitation in trunk flexion
and extension due to pain, decreased left side patellar reflex, and a
positive straight leg raise (SLR) test on his right side.

The clinician conducted a series of physiological tests before each
treatment: (1) cervical range of motion (ROM); (2) the shoulder and
pelvic tilt angle determined to the quarter degree in the coronal plane
with a set of callipers; (3) arm and leg coordinated response to
resistance; (4) supine leg length discrepancy; and (5) deep spinal
palpation for the assessment of tender lesions. Depending on
pre-treatment results, these tests were repeated immediately after each
treatment application. On the initial examination the patient had normal
cervical ROM to the right and mild restriction to the left; the shoulder
angle deviated to the left by one degree and the hip angle deviated to
the left by 1.25 degrees; arm coordinated response to resistance was
reduced on the left (3/5) and on the right (4/5) while legs were 3/5
bilaterally; leg length on the left side was 1cm shorter compared to the
right; and the clinician found 13 tender lesions with considerable pain
at various points along the spine.

The patient had magnetic resonance imaging (MRI) of the cervical spine
and was diagnosed with cervical multilevel disc bulges with mild to
moderate spinal canal stenosis (\textbf{Figure 1} ). Other possible
diagnoses considered were multilevel cervical spondylosis, cervical
intervertebral disc degenerative disease with myelopathy, and muscle
spasm. The patient had a Visual Analogue Scale (VAS) for pain score of
9.85/10, Neck Disability Index (NDI) score of 29/50 (58\%), and
Roland-Morris (RM) score of 8 points.

\emph{Treatment plan \& follow-up}

The KKT treatment device consists of a controller mounted on top of an
impulse delivery mechanism, or device head, which in turn is mounted on
a movable armature to a fixed stand. \textsuperscript{14,15} The device
head may be moved freely in three dimensions. At the base of the device
head, there is a stylus used to deliver the sinusoidal wave forms of
various frequencies and intensities (\textbf{Figure 2} ). The device can
be applied anywhere along the entire spine and related points at the
discretion of the treating physician. Initial treatment parameters are
created on basis of digital data captured through X-rays of the spine.
The treatment plan for the patient was for 12 sessions of KKT on
alternate days followed by six once weekly follow-up sessions along with
physician-recommended lifestyle modifications. \textbf{Table 1}indicates
the anatomical locations at which treatment was administered and the
number of pulses used during each treatment session. The patient was
largely compliant with the 12 treatment schedule, but the first
follow-up treatment was delayed by almost two months.

The patient completed the VAS for pain after every six sessions, while
the NDI and RM questionnaire were recorded at the initial session and
after the final follow-up session.

\emph{Outcomes}

Following the first KKT treatment, the patient's experienced immediate
normalization of his left patellar reflex, trunk flexion, and trunk
extension. He also experienced improvement of pain outcomes. From the 13
painful tender lesions at intake, these were reduced to 5 by treatment 7
and to 0 by treatment 12. The patient's VAS pain score reduced from 9.85
at intake to 3.51 by the final treatment session and 4.48 by the final
follow-up session. His NDI score reduced to 11/50 (22\%) by the final
follow-up session, and his RM score reduced to 6 points. The patient
stated that there was a noticeable improvement in his quality of life
and sleep, and that he could now perform better at work due to his
improvement in physical activity and reduced pain. It is noteworthy that
the patient had a few relapses because of excessive workloads and did
not always adhere to his doctor's recommendations.

Along with improved symptoms, there was also a notable correction in the
biomechanics of his spine and body. Shoulder and pelvic tilts steadily
improved with KKT treatment, until it became neutral from the
5\textsuperscript{th} treatment onwards. After the
7\textsuperscript{th}treatment, the patient had full cervical ROM. After
completing his treatment sessions, MRI imaging showed resolution of
cervical disc bulging. After reviewing all the MRI slices, the
orthopaedic surgeon noticed improvement in disc hydration in all
cervical spine discs, a reduction in spine cord compression at levels
C4-C5 and C5-C6, and no stenosis in in the cervical spine
(\textbf{Figure 3} ). The patient did not experience any adverse events
related to the treatment.



\textbf{Discussion}

The management of chronic back pain is complex and continues to be a
leading cause of disability and productivity loss
worldwide.\textsuperscript{1,2,5} Treatment can include a combination of
various medical, psychological, and physical therapies. After these
conservative options fail, more invasive and irreversible surgical
intervention may then be offered to certain patients as a last resort,
for those who qualify. \textsuperscript{4-7} However, spine surgery does
not guarantee long-term symptomatic relief, patient satisfaction, or
return to daily living and is associated with complications,
highlighting the need for less invasive treatment options.
\textsuperscript{19-21}

The KKT approach can fulfill this unmet need by treating patients by
means of precisely directed sound stimulation. The current case study of
a young patient who presented with both low back and neck pain treated
with KKT is consistent with the previously published
evidence.\textsuperscript{14,15,17,18} After completion of his sixth
maintenance session, the patient exhibited improvements in pain and
disability scores, trunk range of motion, quality of life, sleep and
work performance with no reports of adverse effects. Documented
improvement in cervical spine stenosis was noted on MRI.

The use of focused low frequency sound waves in the treatment of spinal
pathologies is a novel medical development which has been largely
spearheaded by the KKT clinical and scientific teams. This particular
case is notable as, in addition to improvement in symptoms and quality
of life, remarkable changes were also seen on MRI following KKT in a
short time period. This case demonstrates the substantial physiological
effect rhythmically pulsed spinal stimulation therapies including sound
waves can play in the nonsurgical management of patients with spinal
pathologies. Although repetitively pulsed electrical stimulation has
demonstrated some promising results in the literature in patients with
lumbar spinal stenosis, \textsuperscript{22,23} less has been reported
with sound wave stimulation. A greater understanding of the
physiological changes that happen to the spine and its surrounding
structures during sound wave treatment is needed. The current RCT
evidence on KKT has demonstrated significantly improved pain and
functional outcomes compared to controls in patients with chronic neck
or low back pain. \textsuperscript{14,15,18} More specially, one of the
earliest studies looking at the clinical effects of this device showed
that a significant number of patients with chronic back and neck pain
experienced significant improvement in pain scores and a decrease in
pain medication requirements. \textsuperscript{18}~Follow up studies
showed that the waves induced beneficial mechanical changes in the
vertebrae, restoring the vertebral column to a more natural
alignment.\textsuperscript{14}~Subsequent studies investigated possible
cellular changes induced by the waves. Animal studies on bovine
intervertebral discs showed that waves from the KKT device induced
upregulation of matrix protein mRNA, such as aggrecan and collagen type
II.\textsuperscript{17}~All of these proteins are associated with disc
hydration and disc health. Continued large-scale studies on the use of
KKT for this indication will assist in validating these findings.

\textbf{Conclusion}

The KKT approach demonstrates promising results, with limited safety
concerns, in a young patient diagnosed with cervical multilevel disc
bulges with mild to moderate spinal canal stenosis. The patient
experienced symptomatic relief and, as a result, improved quality of
life and work performance. Positive structural changes were also seen on
MRI. His improvement is consistent with multiple randomized control
trials showing benefits of the KKT treatment.

\textbf{Acknowledgements}

Dr. Aslam Khan for advice in selecting the case and comments on the
draft of the manuscript. Dr. Peter Dyback for explanatory comments on an
early draft of the manuscript. Dr. Karim Bayanzay for comments on a
draft of the manuscript. Amani AlAmri and Nora AlWahbi for assistance
with the treatments.

\textbf{References}

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2. Rubin DI. Epidemiology and risk factors for spine pain. \emph{Neurol
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3. Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs
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4. Oliveira CB, et al. Clinical practice guidelines for the management
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5. Popescu A, Lee H, Neck Pain and Lower Back Pain. \emph{Med Clin North
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6. Urits I, et al. Low Back Pain, a Comprehensive Review:
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7. Vlaeyen JWS, et al. Low back pain. \emph{Nat Rev Dis Primers} ,
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8. Huang M, Liao LR, Pang MY. Effects of whole body vibration on muscle
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9. Ritzmann R, Stark C, Krause A. Vibration therapy in patients with
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10. R\selectlanguage{ngerman}üütel E, Vinkel I, Eelmäe P. The Effects of Short-Term
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11. Skille O. VibroAcoustic Therapy. \emph{Music Therapy} ,
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12. Bartel L, Mosabbir A. Possible Mechanisms for the Effects of Sound
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13. Campbell EA. Vibroacoustic Treatment and Self-care for Managing the
Chronic Pain Experience: An Operational Model. \emph{JYU Dissertations}
, 2019. \textbf{95} .

14. Desmoulin GT, et al. Spinal Intervention Efficacy on Correcting
Cervical Vertebral Axes of Rotation and the Resulting Improvements in
Pain, Disability and Psychsocial Measures. \emph{Journal of
Musculoskeletal Pain} , 2012. \textbf{20} (1): 31-40.

15. Desmoulin GT, Yasin NI, Chen DW. Spinal mechanisms of pain
control.\emph{Clin J Pain} , 2007. \textbf{23} (7): 576-85.

16. Kantor J, et al. Potential of Vibroacoustic Therapy in Persons with
Cerebral Palsy: An Advanced Narrative Review. \emph{Int j environ res
and public health} , 2019. \textbf{16} (20): 3940.

17. Desmoulin GT, Hewitt CR, Hunter CJ. Disc strain and resulting
positive mRNA expression from application of a noninvasive
treatment.\emph{Spine} (Phila Pa 1976), 2011. \textbf{36} (14): E921-8.

18. Desmoulin GT, Yasin NI, Chen DW. Initial Results Using Khan Kinetic
Treatment\selectlanguage{english} as a Low Back Pain Treatment Option. \emph{Journal of
Musculoskeletal Pain} , 2007. \textbf{15} (3): 91-102.

19. Chan CW, Peng P. Failed back surgery syndrome. Pain Med,
2011.\textbf{12} (4): 577-606.

20. Proietti L, et al. Complications in lumbar spine surgery: A
retrospective analysis. \emph{Indian j ortho} , 2013. \textbf{47} (4):
340-345.

21. Rigoard P, et al. Multicolumn spinal cord stimulation for
predominant back pain in failed back surgery syndrome patients: a
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(6): 1410-1420.

22. Chandler GS 3rd, et al. Dorsal column stimulation for lumbar spinal
stenosis. \emph{Pain Physician} , 2003. \textbf{6} (1): 113-8.

23. Costantini A, Buchser E, Van Buyten JP. Spinal cord stimulation for
the treatment of chronic pain in patients with lumbar spinal
stenosis.\emph{Neuromodulation} , 2010. \textbf{13} (4): 275-9;
discussion 279-80.



\textbf{Tables}

\textbf{Table 1} . Location and Number of Treatment Pulses\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Treatment location and \# of pulses}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Treatment location and \# of pulses}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Treatment location and \# of pulses}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Treatment location and \# of pulses}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Treatment location and \# of pulses}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Tx\#}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Cervical}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Sternum}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Thoracic}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Lumbar}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Sacrum/Iliac}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft Sc 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
L5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
C1 80 C5\textsuperscript{+} 40\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
60\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
C5\textsuperscript{+} 40\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S3\textsuperscript{+}60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
C5\textsuperscript{+} 40\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60; Rt Sc 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
T3\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
L5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
T4\textsuperscript{+} 60; T5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Rt PSIS 80; PIIS 80\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft T4 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Rt S1 60; Rt PSIS 80\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft T4 60; T5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S1\textsuperscript{+} 60; Rt PSIS 80\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Periodic follow-up treatments beginning 8 weeks following treatment
12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Periodic follow-up treatments beginning 8 weeks following treatment
12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Periodic follow-up treatments beginning 8 weeks following treatment
12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Periodic follow-up treatments beginning 8 weeks following treatment
12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Periodic follow-up treatments beginning 8 weeks following treatment
12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Periodic follow-up treatments beginning 8 weeks following treatment
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
T5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Rt S1 60, S5 60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
L5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Rt PSIS 60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Lft C1 80 C5\textsuperscript{+} 40 C7\textsuperscript{+} 40\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
L5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Rt PSIS 80\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60; Rt Sc 60; Lft Sc 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
L5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60; Rt Sc 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
L5\textsuperscript{+} 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Rt PSIS 80\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Lft C1 80\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
60; Rt Sc 60\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
S1\textsuperscript{+} 60; Hypogastrium 60\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Lft=left; PIIS = Posterior inferior iliac spine; PSIS = Posterior
superior iliac spine; Rt=right; Sc = sternoclavicular; Tx = Treatment.

\textsuperscript{+}Midline



\textbf{Figures}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1.} MRI of the cervical spine before treatment showing
bulging of the disc between the C3-C4 and C4-C5 regions.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2.} KKT device.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 3.} MRI of the cervical spine after treatment revealing
no stenosis in the cervical spine

\selectlanguage{english}
\FloatBarrier
\end{document}

