I am motivated to write this article for my chiropractic colleagues on this Thursday, December 14, 2017.

In didactic lecture I have taught that the clinical examination is more important than diagnostic imaging in diagnosing a patient’s source of pain; even going so far as to say that MRI should actually confirm the clinical examination impression. Well, this week Karran et al (1) said the same, namely that not to do and MRI of low back pain patients, but rather explain normal MRI findings before ordering the MRI; however explain in detail the clinical examination findings and the clinical impression of what the problem in their spine is. If an MRI is ordered, which is not ordered until 6-8 weeks of specialized spinal manipulation treatment, the patient will see the normal changes seen on an MRI that do not really cause their pain problem. Why is this important? Because 76% of people show disc degeneration and herniation that are not even symptomatic; and to show the patient the MRI and explain all these non contributory findings to their sets up a confused and often depression mental image of their health. DO NOT BLAME PATIENT’S SYMPTOMS ON SPINAL CHANGES THAT DO NOT CAUSE THEIR PAIN. Explain the examination findings in an enhanced reporting strategy. Intervention strategies such as enhanced reporting methods and the provision of quality information (without imaging) have the potential to improve the outcome of patients with recent-onset low back pain. As spinal specialists, we have studied together and I have taught that we treat patients, not mris.

As taught in our certification course, it is the thorough orthopedic, neurological, and physical examination that gives the diagnosis in the majority of patients. Do this examination as we present and all else follows. Ordering MRI or even plain xray diagnostic imaging will decrease as suggested by the Choosing Wisely movement of medicine today.

Respectfully submitted,

James M. Cox, DC, DACBR

(1) Karran EL, Medalian Y, Hillier SL, Moseley GL. The impact of choosing words carefully: an online investigation into imaging reporting strategies and best practice care for low back pain. Peer J. 2017 Dec 6;5:e4151. doi: 10.7717/peerj.4151. eCollection 2017.

Stirred by the acceptance and addition to our paper on the Gemelli Obturator Internus Complex (GOIC syndrome), I write this message.

Lead paper for the December 2017 Cox Research Pearls: Astounding when I look back historically and remember being told by Skeletal Radiology, when I submitted a paper to them for publication, that they only accepted high level research. Also Terry Yochum and I were both told in the 1980’s by Saunders medical publishers that they only published books written by doctors. Wonder how they feel about that statement today?

Doctors, Barclay Bakkum, an excellent anatomist, and I wrote a paper - Cox J, Bakkum BW: Possible generators of retrotrochanteric gluteal and thigh pain: the gemelli obturator internus complex. Journal of Manipulative and Physiological Therapeutics 2005;28(7). Note the following paper uses our named condition – the GOIC syndrome – and did an ultrasound study of the anatomy. It is reference 25 in this new paper.  (1)

This paper studied the GOIC anatomy with ultrasound of the retrotrochanteric bursa and revealed the presence of connective tissue attaching the sciatic nerve to the structures of the gemellus-obturator system at the deep subgluteal space. The amplitude of the nerve curvature during rotating position was significantly greater than during resting position. During passive internal rotation, the sciatic nerve of both cadavers and healthy volunteers transformed from a straight structure to a curved structure tethered at two points as the tendon of the obturator internus contracted downwards. Conversely, external hip rotation caused the nerve to relax. The conclusion is that the sciatic nerve is closely related to the gemelli-obturator internus complex. This relationship results in a reproducible dynamic behavior of the sciatic nerve during passive hip rotation, which may contribute to explain the pathological mechanisms of the obturator internal gemellus syndrome.

I point out that at least a chiropractic paper led to publication in a major medical journal, even though it is somewhat skewed in its course. Nevertheless, our treatment of the GOIC syndrome as delivered in didactic and hand on lecture is a great benefit in relieving sciatic pain. Perhaps these studies will direct chiropractors to study the GOIC syndrome with us.

Following is an anatomical illustration of the GOIC anatomy from Cox/Bakkum paper:

Submitted by

James M. Cox, DC, DACBR

(1) Balius R, Susín A, Morros C, Pujol M, Pérez-Cuenca D, Sala-Blanch X. Gemelli-Obturator Complex In The Deep Gluteal Space: An Anatomic And Dynamic Study. Skeletal Radiol. 2017 Dec 7. Doi: 10.1007/S00256-017-2831-2. [Epub Ahead Of Print]

Stirred by the acceptance and addition to our paper on the Gemelli Obturator Internus Complex (GOIC syndrome), I write this message.

Lead paper for the December 2017 Cox Research Pearls: Astounding when I look back historically and remember being told by Skeletal Radiology, when I submitted a paper to them for publication, that they only accepted high level research. Also Terry Yochum and I were both told in the 1980’s by Saunders medical publishers that they only published books written by doctors. Wonder how they feel about that statement today?

Doctors, Barclay Bakkum, an excellent anatomist, and I wrote a paper - Cox J, Bakkum BW: Possible generators of retrotrochanteric gluteal and thigh pain: the gemelli obturator internus complex. Journal of Manipulative and Physiological Therapeutics 2005;28(7). Note the following paper uses our named condition – the GOIC syndrome – and did an ultrasound study of the anatomy. It is reference 25 in this new paper.  (1)

This paper studied the GOIC anatomy with ultrasound of the retrotrochanteric bursa and revealed the presence of connective tissue attaching the sciatic nerve to the structures of the gemellus-obturator system at the deep subgluteal space. The amplitude of the nerve curvature during rotating position was significantly greater than during resting position. During passive internal rotation, the sciatic nerve of both cadavers and healthy volunteers transformed from a straight structure to a curved structure tethered at two points as the tendon of the obturator internus contracted downwards. Conversely, external hip rotation caused the nerve to relax. The conclusion is that the sciatic nerve is closely related to the gemelli-obturator internus complex. This relationship results in a reproducible dynamic behavior of the sciatic nerve during passive hip rotation, which may contribute to explain the pathological mechanisms of the obturator internal gemellus syndrome.

I point out that at least a chiropractic paper led to publication in a major medical journal, even though it is somewhat skewed in its course. Nevertheless, our treatment of the GOIC syndrome as delivered in didactic and hand on lecture is a great benefit in relieving sciatic pain. Perhaps these studies will direct chiropractors to study the GOIC syndrome with us.

Following is an anatomical illustration of the GOIC anatomy from Cox/Bakkum paper:

Submitted by

James M. Cox, DC, DACBR

(1) Balius R, Susín A, Morros C, Pujol M, Pérez-Cuenca D, Sala-Blanch X. Gemelli-Obturator Complex In The Deep Gluteal Space: An Anatomic And Dynamic Study. Skeletal Radiol. 2017 Dec 7. Doi: 10.1007/S00256-017-2831-2. [Epub Ahead Of Print]

Please allow me the privilege of sharing a thought on the growth of chiropractic medicine today.

As you know, the Harvard Health Letter, November 2017, published that low back pain relief can be resolved by a chiropractor or primary care doctor. (1) Now, who utilized chiropractic care?  A newly published paper by Forte and Maiers just answered this question: "Functional limitations in adults who utilize chiropractic or osteopathic manipulation in the United States: analysis of the 2012 National Health Interview survey." Among the 8.5% of U.S. adults who reported receiving manipulation, 97.6% saw chiropractors. Most adults were under age 65 (83.7%), female (56.6%), and white (85.1%). Except for sitting tolerance, functional limitations were significantly higher among older manipulation users compared with younger manipulation users (all p < .001). Older (vs younger) chiropractic/osteopathic users more often reported functional limitations (65.7% vs 37.2%), had difficulty walking without equipment (14.7% vs 2.8%), found it very difficult or were unable to walk one-quarter mile (15.7% vs 3.8%) or climb 10 steps (11.4% vs 2.5%), and needed help with instrumental activities of daily living (6.9% vs 2.0%). Comorbidities differed by age: cardiovascular events/conditions, cancer, diabetes, and arthritis were more common among older adults, and headaches, neck pain, and depression were more frequent in younger adults. Similar proportions of older and younger adults had emergency room visits (23.0% vs 21.7%); older adults reported more surgeries (26.1% vs 15.4%).

Note the contrast of these papers and the tremendous future for our profession. What I mean by this is – If only 8.5% of U.S. adults utilize chiropractic for low back pain and it is now recommended by such prestigious medical schools as Harvard, imagine the future for chiropractic spine specialists. This percentage will growth rapidly. I see the challenge being for the chiropractors to lead the medical profession in skills to relieve low back pain.

Remember we are dealing with an epidemic of back pain in our country and the world. We are finally being into the arena of best clinical outcome treatment.

Respectfully submitted,

James M. Cox, DC, DACBR

In my 55 years as a chiropractic doctor I have seen great controversy but none greater than that of the role of the nervous system in human disease origin. Nerve compression today is being studied and its conclusions regenerate the early chiropractic concepts of human disease. Let’s look at the following two papers published and in this pearl.

James M. Cox, DC, DACBR, FACO(H)

INTERVERTEBRAL DISC GENERATED PAIN DUE TO SYMPATHETIC NERVE SUPPLY

INTERVERTEBRAL DISC DISEASES (IVDDS) AFFECTING PATHOLOGICAL CHANGES LEADING TO DISC HERNIATION, PROLAPSE AND DEGENERATION AS WELL AS DISCOGENIC PAIN IS STUDIED FOR SYMPATHETIC NERVE INVOLVED IN PAIN SIGNALLING IN IVDD PATIENTS. PIGS WERE GIVEN AN INJECTION OF THE OMINIPAQUE CONTRAST AGENT AND FAST BLUE (FB) RETROGRADE TRACER INTO THE L4-L5 INTERVERTEBRAL DISC AND EUTHANIZED AT 2, 1, AND 3 MONTHS POST INJECTION. FOLLOWING EUTHANASIA, BILATERAL SYMPATHETIC CHAIN GANGLIA (SCHG) TH13 TO C1 WERE COLLECTED. THE PRESENCE, DISTRIBUTION AND NEUROCHEMICAL CHARACTERISTICS OF RETROGRADELY LABELLED SCHG NEURONS WERE EXAMINED. THE MAJORITY (88.8%) OF ALL FB+ CELLS WERE FOUND IN THE L3-L5 SCHG. MOST FB+ NEURONS STAINED FOR DOPAMINE BETA HYDROXYLASE (DBH); ONE-THIRD TO ONE-QUARTER STAINED FOR SOMATOSTATIN (SOM), NEUROPEPTIDE Y (NPY) OR LEU-ENKEPHALIN (LENK); AND ONLY A FEW STAINED FOR GALANIN (GAL). COMPARED WITH THE CONTROL, THE GREATEST DECLINE IN NEUROCHEMICAL IMMUNOSTAINING WAS OBSERVED 2 WEEKS POST INJECTION, AND THE LOWEST DECLINE WAS NOTICED 1 MONTH POST INJECTION. OUR STUDY, FOR THE FIRST TIME, PROVIDES INSIGHT INTO THE COMPLEX PATTERNS OF INTERVERTEBRAL DISC SYMPATHETIC INNERVATION AND SUGGESTS THAT THE BEST TIME FOR NEUROCHEMICAL BALANCE RESTORATION THERAPY WOULD BE 1 MONTH POST-INJURY, WHEN THE NEURONAL CONCENTRATION OF ALL STUDIED SUBSTANCES IS CLOSE TO THE INITIAL PHYSIOLOGICAL LEVEL, THUS PROVIDING FAVOURABLE CONDITIONS FOR SUCCESSFUL RECOVERY.

Barczewska M, Juranek J, Wojtkiewicz J. Origins and Neurochemical Characteristics of Porcine Intervertebral Disc Sympathetic Innervation: a Preliminary Report. J Mol Neurosci. 2017 Jul 31. doi: 10.1007/s12031-017-0956-3. [Epub ahead of print]

Intervertebral disc diseases (IVDDs) form a group of a vertebral column disorders affecting a large number of people worldwide. It is estimated that approximately 30% of individuals at the age of 35 and approximately 90% of individuals at the age of 60 and above will have some form of disc-affecting pathological changes leading to disc herniation, prolapse and degeneration as well as discogenic pain. Here, we aimed to establish the origins and neurochemical characteristics of porcine intervertebral disc sympathetic innervation involved in pain signalling in IVDD patients. Pigs were given an injection of the Ominipaque contrast agent and Fast Blue (FB) retrograde tracer into the L4-L5 intervertebral disc and euthanized at 2, 1, and 3 months post injection. Following euthanasia, bilateral sympathetic chain ganglia (SChG) Th13 to C1 were collected. The presence, distribution and neurochemical characteristics of retrogradely labelled SChG neurons were examined. The majority (88.8%) of all FB+ cells were found in the L3-L5 SChG. Most FB+ neurons stained for dopamine beta hydroxylase (DBH); one-third to one-quarter stained for somatostatin (SOM), neuropeptide Y (NPY) or leu-enkephalin (LENK); and only a few stained for galanin (GAL). Compared with the control, the greatest decline in neurochemical immunostaining was observed 2 weeks post injection, and the lowest decline was noticed 1 month post injection. Our study, for the first time, provides insight into the complex patterns of intervertebral disc sympathetic innervation and suggests that the best time for neurochemical balance restoration therapy would be 1 month post-injury, when the neuronal concentration of all studied substances is close to the initial physiological level, thus providing favourable conditions for successful recovery.

CHRONIC CONSTRICTION INJURY OF SCIATIC NERVE DORSAL HORNS CHANGES CIRCULAR RNA (CIRCRNA)EXPRESSION IN RAT SPINAL DORSAL HORN TO CAUSE NEUROPATHIC PAIN AT THE LUMBAR ENLARGEMENT SEGMENTS (L3-L5). CIRCRNA MICROARRAYS SHOWED THAT 469 CIRCRNAS WERE DIFFERENTIALLY EXPRESSED BETWEEN CCI AND SHAM-OPERATED RATS. THREE OF THEM (CIRCRNA_013779, CIRCRNA_008008, AND CIRCRNA_003724) OVEREXPRESSED >10 TIMES AFTER CCI INSULT. CCI RESULTED IN A COMPREHENSIVE EXPRESSION PROFILE OF CIRCRNAS IN THE SPINAL DORSAL HORN IN RATS. CIRCRNAS IN THE DORSAL HORN COULD BE HELPFUL TO REVEAL MOLECULAR MECHANISMS OF NEUROPATHIC PAIN.

Cao S, Deng W, Li Y, Qin B, Zhang L, Yu S, Xie P, Xiao Z, Yu T. Chronic constriction injury of sciatic nerve changes circular RNA expression in rat spinal dorsal horn. J Pain Res. 2017 Jul 17;10:1687-1696. doi: 10.2147/JPR.S139592. eCollection 2017.

BACKGROUND: Mechanisms of neuropathic pain are still largely unknown. Molecular changes in spinal dorsal horn may contribute to the initiation and development of neuropathic pain. Circular RNAs (circRNAs) have been identified as microRNA sponges and involved in various biological processes, but whether their expression profile changes in neuropathic pain condition is not reported.

METHODS: To test whether neuropathic pain influences circRNA expression, we developed a sciatic chronic constriction injury (CCI) model in rats. The CCI ipsilateral spinal dorsal horns of lumbar enlargement segments (L3-L5) were collected, and the total RNA was extracted and subjected to Arraystar Rat circRNA Microarray. Quantitative real-time polymerase chain reaction (qPCR) was used to confirm the circRNA expression profile. To estimate functions of differential circRNAs, bioinformatics analyses including gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes Pathway analyses were performed for the top 100 circRNAs and circRNA-microRNA networks were constructed for the top 10 circRNAs.

RESULTS: circRNA microarrays showed that 469 circRNAs were differentially expressed between CCI and sham-operated rats (fold change ≥2). In all, 363 of them were significantly upregulated, and the other 106 were downregulated in the CCI group. Three of them (circRNA_013779, circRNA_008008, and circRNA_003724) overexpressed >10 times after CCI insult. Expression levels of eight circRNAs were verified using qPCR. GO analysis revealed that thousands of predicted target genes were involved in the biological processes, cellular component, and molecular function; in addition, dozens of these genes were enriched in the Hippo signaling pathway, MAPK signaling pathway, and so on. Competing endogenous RNAs analysis showed that circRNA_008008 and circRNA_013779 are the two largest nodes in the circRNA-microRNA interaction network of the top 10 circRNAs.

CONCLUSION: CCI resulted in a comprehensive expression profile of circRNAs in the spinal dorsal horn in rats. CircRNAs in the dorsal horn could be helpful to reveal molecular mechanisms of neuropathic pain.

A little history...

Discat plus is a Chondroitin Sulfate formula I developed in 1966 following reading the work of Cole, Ghosh and Taylor in a two volume text entitled “THE BIOLOGY OF THE INTERVERTEBRAL DISC”. This two volume text was far ahead of its time. Following studying it, I gained awareness of stopping disc degeneration, prompting disc regeneration, and a beginning of possibly controlling spine pain with chondroitin sulfate administration to people.

The source of Chondroitin Sulfate I used and still use was perna canaliculus, a green lipped mussel from New Zealand and Australia that is harvested from the ocean. It is the most potent source of Chondroitin Sulfate known. (welburn) The intervertebral disc contains a mucopolysaccharide compound know as glycosaminoglycan that absorbs fluid to give the disc its property of turgor (stiffness) within its cells. Loss of glycosaminoglycan accompanies disc degeneration and disc herniation. Glycosaminoglycan is Chondroitin Sulfate. Thus the relationship between administering Chondroitin Sulfate (Discat Plus) along with Cox® Technic for treating disc degeneration and herniation began.

In 1966 I formulated Discat Plus (with Chondroitin Sulfate). This was twenty to thirty years before commercial ventures like health food stores and commercial television learned of it and started to sell it.  Remember it takes 17 years for a new idea or fact to settle into common knowledge. This was true for chondroitin sulfate.

and today... 

Now we are seeing pain relief as well as the anti-inflammatory benefits of Chondroitin Sulfate (as in Discat Plus). Please read the following relief of tactile allodynia in the mouse model when oral chondroitin sulfate was given. 

Source: Nemoto W, Yamada K, Ogata Y, Nakagawasai O, Onodera K, Sakurai H, Tan-No K. Chondroitin sulfate attenuates formalin-induced persistent tactile allodynia. J Pharmacol Sci Aug 5. pii: S1347-8613(16)30091-3. doi: 10.1016/j.jphs.2016.07.009. [Epub ahead of print]

We examined the effect of chondroitin sulfate (CS), a compound used in the treatment of osteoarthritis and joint pain, on the formalin-induced tactile allodynia in mice. A repeated oral administration of CS (300 mg/kg, b.i.d.) significantly ameliorated the formalin-induced tactile allodynia from day 10 after formalin injection. On day 14, the phosphorylation of spinal p38 MAPK and subsequent increase in c-Fos-immunoreactive dorsal lumbar neurons were attenuated by the repeated administration of CS. These findings suggest that CS attenuates formalin-induced tactile allodynia through the inhibition of p38 MAPK phosphorylation and subsequent up-regulation of c-Fos expression in the dorsal lumbar spinal cord.

CHONDROITIN SULFATE (CS) IS USED IN THE TREATMENT OF OSTEOARTHRITIS AND JOINT PAIN. IT HAS ALSO SHOWN RELIEF OF TACTILE ALLODYNIA IN MOUSE STUDIES. A REPEATED ORAL ADMINISTRATION OF CS (300 MG/KG, B.I.D.) SIGNIFICANTLY AMELIORATED THE FORMALIN-INDUCED TACTILE ALLODYNIA FROM DAY 10 AFTER FORMALIN INJECTION. ON DAY 14, THE PHOSPHORYLATION OF SPINAL P38 MAPK AND SUBSEQUENT INCREASE IN C-FOS-IMMUNOREACTIVE DORSAL LUMBAR NEURONS WERE ATTENUATED BY THE REPEATED ADMINISTRATION OF CS. THESE FINDINGS SUGGEST THAT CS ATTENUATES FORMALIN-INDUCED TACTILE ALLODYNIA THROUGH THE INHIBITION OF P38 MAPK PHOSPHORYLATION AND SUBSEQUENT UP-REGULATION OF C-FOS EXPRESSION IN THE DORSAL LUMBAR SPINAL CORD.

First, what is tactile allodynia? It is pain caused by touch such as clothing against the skin. It is pain caused by so little irritation it would not be considered to cause pain.

Second, what does phosphorylation of spinal p38 mapk and subsequent increase in c-fos-immunoreactive dorsal lumbar neurons mean?

Let's first review. What are MAPK, ERK, P38 pathways? Cellular responses to many external stimuli involve the activation of several types of MAPK (Mitogen-Activated Protein Kinase) signaling pathways. MAPKs are a family of serine/threonine kinases that comprise 3 major subgroups, namely, ERK (Extracellular signal–Regulated Kinase), p38 MAPK and JNK (c-Jun N-terminal Kinases).

An understanding of kinases is basic. Genetic and protein information on pain and disease involves knowing that protein tyrosine kinase is an enzyme that transfers po4 from ATP to protein in the cell. The released po4 attaches to tyrosine to form tyrosine phosphate which then attaches to serine and threonine and this regulates cell division. If irregular, it will set abnormal cell division – cancer.

Pathways to transmit proteins through the cell wall from receptor to DNA, RNA of nucleus of the cell.  MAPK–ERK pathway conducts the protein such as tyrosine kinase attached to serine and threonine through the cell wall into the nucleus of the cell. The p38 pathway routes chemicals through the cell wall into the nucleus of the cell. In this paper, chondroitin sulfate is found to inhibit the p38 pathway to relieve tactile allodynia.

This represents another potential benefit of chondroitin sulfate as an anti-inflammatory pain control.

For further information, I am also sharing the following paper on attenuating the MAPK p38 pathway for neuropathy pain relief (Chen et al). Please know I am not expert in such deep subject cellular pathways, but this is basic knowledge for your consideration. - JMC

Source: Chen NF, Chen WF, Sung CS, Lu CH, Chen CL, Hung HC, Feng CW, Chen CH, Tsui KH , Kuo HM, Wang HD, Wen ZH, Huang SY. Contributions of p38 and ERK to the antinociceptive effects of TGF-β1 in chronic constriction injury-induced neuropathic rats. J Headache Pain. 2016 Dec;17(1):72. Epub 2016 Aug 19.

HERE IS AN EXAMPLE OF SUPPRESSION OF MAPK, ERK, P38 ARE ANTINOCICEPTIVE FOR CHRONIC CONSTRICTION OF A NERVE BY TRANFORMING GROWTH FACTOR-B. TGF-Β1-INDUCED ANALGESIA DURING NEUROPATHY. Transforming growth factor-βs (TGF-βs) are a group of multifunctional proteins that have neuroprotective roles in various experimental models. intrathecal (i.t.) injections of TGF-β1 significantly inhibit neuropathy-induced thermal hyperalgesia, spinal microglia and astrocyte activation, as well as upregulation of tumor necrosis factor-α.  During persistent pain, activation of MAPKs, especially p38 and extracellular signal-regulated kinase (ERK), have crucial roles in the induction and maintenance of pain hypersensitivity. TGF-β1 markedly inhibited phospho-p38 upregulation in neurons, microglial cells, and astrocytes. However, i.t. injection of TGF-β1 also reduced phospho-ERK upregulation in microglial cells and astrocytes.

CONCLUSIONS: The present results demonstrate that suppressing p38 and ERK activity affects TGF-β1-induced analgesia during neuropathy.

Researchers from Australia's RMIT University and SGE International Pty Ltd state that novel omega-3 polyunsaturated fatty acids extracts from the green-lipped mussel (Perna canaliculus) inhibited leukotriene and cyclo-oxygenase (COX) activity, both of which are involved in the inflammatory process. Chronic inflammation has been linked to a range of conditions like heart disease, osteoporosis, cognitive decline and Alzheimer's, and type-2 diabetes. (http://www.nutraingredients-usa.com/Research/Studies-support-green-lipped-mussel-s-anti-inflammatory-properties)

The functions of CHONDROITIN SULFATE PROTEOGLYCANS (CS-PGs) in the central nervous system can be categorized as the regulation of cell adhesion and migration, neurite formation, polarization of neurons, synaptic plasticity, survival of neurons, etc. Chondroitin sulfate (perna canaliculus) is reported to:

• Repair degraded bone

• Increase absorption and replacement of calcium

• Rebuild damaged bone, cartilage, tendon, ligament, and disc

Why would I tell a patient to "Own your spine. Own your spine pain."? It's the only one he's/she's got! Where is this bluntness coming from? Well, it’s one of those days. A talk with a patient who wants the fix for back pain NOW got my head spinning. I want to share all I know with the patient, assure him that all will be well beyond this pain episode, that if he just embraces his spine for what it can do, all will be well. But pain gets in the way. I get it. Pain turns our rose colored glasses to gray ones in moments like this. Yet reality intervenes with truth, truth that we all must own our own spine as well as its pain on occasion.

This is what I’d like to share with my patient...

So why must we face this reality? Let’s look at it.

For many with spine pain (neck, mid back or low back with or without arm and leg pain or headache), there is no cure for the spinal condition, only control of pain with proper daily living habits. Let’s consider some facts…

Let’s start with genetics. You may be born with a spinal condition that will never by “normal”. Such conditions have big names like spondylolisthesis, transitional vertebra in which one has 4 or 6 lumbar vertebrae instead of 5, scoliosis, fused or incompletely formed vertebrae. These conditions will always be yours to contend with. No one can remake your spine. Like a bruise on an apple that remains on the apple, the spine is still whole even after attempts to remake it, but it remembers what was done.

Same with life experiences the spine goes through. Let’s take aging. Amazingly, the human spine normally begins to degenerate in the second decade of life, in the teen years. Some people have greater disc degeneration than others. However, if one is deconditioned, that is, out of good physical shape, and then does lifting, bending and twisting with such a compromised spine, the scene is set for back pain. Most of us develop some spine pain early in life, and the pain recedes often with no treatment. Then we continue the same lifestyle of eating too much, lifting heavy weight in the wrong posture to lift, etc.,  our spines then continue to degenerate while we do nothing or very little to maintain good health. Then, later in life, we develop more severe spine and extremity pain and think something can be done to allow us to continue this lifestyle without change. Some even think surgery will reverse all their problems only to find it can make them worse.

Let’s next consider injury from falls, lifting heavy weight, car wrecks, etc.

Now if you have a spine that may have developed in a weakened state - the body of a patient deconditioned - and then add injury to it, pain results. Now, if you are such a person and you develop pain in the back or extremities or headaches and go to a doctor expecting some form of care to relieve this pain, hopefully a pill, surgery, exercise, nutritional supplement or spinal manipulation, you want it quickly so you can return to what you were doing and have the pain not return. So many factors play into the equation for injury (even for work injuries - is it alway entirely the job's fault for a work injury?): genetics, lifestyle, physical condition, life choices in deciding how to use the body to avoid injury or pain may come into play.

DO YOU SEE THE FOLLY OF THIS ATTITUDE?  There is no cure for many spine problems, only control through maintaining a healthy body, learning what you can and cannot do, exercise, visiting the chiropractor for spinal alignment, spinal decompression, spinal manipulation, and conditioning, and supplementing with nutrition to develop and maintain healthy discs in the spine.  A person with a weak spine cannot expect to nevertheless do anything with that spine that he or she wants without a pain consequence forever.  That is like asking a diabetic person to eat a box of chocolates and not be adversely harmed.

OWN IT.  There is no way for you to make a race horse out of a pony. Be content with what you have, and make it work. Appreciate your spine as it is. You may not like these facts, but can you change them? No. Own your spine, and allow it to perform at its peak performance for you and your lifestyle. That requires honest realization of your limitations and living with them while being in the best physical health you can attain. YOU ARE THE ONE WITH THE MOST TO GAIN. The chiropractor is your back pain specialist, your treating doctor, coach, cheerleader, and guide. Work with the trained and even certified in Cox Technic chiropractic physician who uses flexion distraction to maximize your spine’s usefulness and ability!

Respectfully submitted, James M. Cox, DC, DACBR, FICC, HonDLitt, FACO(H)

Cox Technic Flexion Distraction Decompression Spinal Manipulation is evidence-based spinal care, a form of spinal manipulation in which the human spine is placed in distraction (a type of measured controlled traction of the spine) delivered on a specialized spinal manipulation instrument. The Cox Table is the well-designed instrument of choice.

Five specific changes in spine mechanics occur in the intervertebral disc and nerve openings with this procedure (1):

1. The height of the intervertebral disc is increased.
2. The size of the nerve opening which is called the intervertebral foramen is increased up to 28% in area.
3. The pressure within the intervertebral disc which is created by the fluid within the disc is reduced from a positive pressure to a negative pressure gradient. This aids in dropping the pressure on the pain sensitive nerves within the disc and the pressure on the nerve which lies behind the disc which causes sciatic or leg pain when compressed over 20 mm of mercury pressure.
4. The movements of the spine are restored. A specific spinal vertebral level (consisting of the intervertebral disc and the moveable joints lying behind the disc) is placing into its normal physiological ranges of motion. Remember that loss of spinal mobility is a part of back pain whether it be acute or chronic. Restoring normal spinal mobility offers improved activities of daily living and diminishing spinal stress that causes back pain.
5. Nervous system tracts of nerves from the spine to the human brain are stimulated when spinal manipulation is administered. These nerve tracts respond to touch, motion, temperature, and pressure to initiate nerve reflexes that relieve pain and allow for normal spinal motion. Such nerve tracts can also affect balance and equilibrium that are so often affected with spinal pain.

The goal of Cox® distraction spinal manipulation is summarized as follows: Attain and maintain physiological range of spine motion with the greatest relief of pain. It is also vital to note that some spinal conditions are not cured, that is to say all the pain is relieved and the person can do any activity without pain recurrence. NO, some spinal conditions that are congenital (born with) or acquired from injury or degenerative spine changes are controlled not cured. In such cases it is important that the patient follow the training given by the chiropractor concerning proper ergonomics (how to move, bend, lift, twist the spine) to avoid pain, perform the specific exercise program developed for your spine condition, and in many cases have dedicated times for undergoing Cox® distraction spinal manipulation so as to maintain relief. Cox Flexion Distraction may well be a beneficial alternative to back surgery for back pain patients.

Respectively submitted,

James M. Cox, DC, DACBR

Tremendous growth in the use of spinal manipulation to treat human spine pain conditions is reported in the literature today. Chiropractic, osteopathy, physical therapy, and allopathy all research and document these benefits; let’s look at some of these benefits.

Physical therapists find tension type headache patients were relieved by suboccipital inhibitory pressure and suboccipital spinal manipulation (upper neck and base of the skull area) in a combined use. It is effective at changing different dimensions of quality of life, and the results support the effectiveness of treatments applied to the suboccipital region for patients with tension type headache. (1)

Treatment of 455 low back pain patients with osteopathic manipulation treatment showed substantial improvement which was defined as 50% or greater reduction of pain at week 12 compared with baseline. Patients with higher pain levels actually showed the greatest relief. In another study, 6 osteopathic spinal manipulation treatments over an 8 week period gave significant and clinically relevant recovery of chronic low back pain. Interestingly, patients without depression were more likely to recover from chronic low back pain with osteopathic manipulation therapy.  A trial of osteopathic manipulation may be useful before progressing to other more costly or invasive interventions in the medical management of patients with chronic low back pain. (2)

Patient age can determine the best form of spinal manipulation to be administered. The American Academy of Osteopathy studied the use of osteopathic spinal manipulative treatment (OMT) in 3 age groups of patients: <65 years, 65-79 years, and ≥80 years.  Osteopathic spinal manipulative treatment can be used to address serious conditions affecting older persons (≥65 years). Spinal manipulation was  used equally in all 3 age groups but varied in the type of spinal manipulation given. Over age 65, more gentle spinal manipulation procedures are used while more vigorous types of spinal manipulation can be delivered in patients under age 65. Respiratory and neurologic conditions were often treated with spinal manipulation. (3)

Chiropractic spinal manipulation showed 86% of low back pain patients showed relief following 12 spinal manipulation treatments given over an average of 29 days. The type of spinal manipulation used was Cox® flexion distraction decompression. (4)

Spinal manipulation is first line treatment for low back pain. (5) When considering treatment for low back pain and sciatic pain, note that epidural steroid injections are reported no better than a placebo for sciatica and spinal stenosis.  These facts can aid a patient in choosing their treatment for headache or low back pain with or without leg pain.

Respectfully,

James M. Cox, DC, DACBR