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.

 

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

Again, I first formulated Discat Plus in 1966, continued its improvement as research dictated, and continue to use it and make it available to doctors who understand its benefits. Also its use is strengthened by continued research. If interested in this beneficial nutritional addition to the treatment of disc degeneration and spinal stenosis, contact us at www.coxtrc.com and more specifically http://coxtrc.com/supplements/discatplus.html. Thank you!

 

 

Kuo reported that impaired nutrition leads to disc degeneration; therefore, there is a definite need to improve disc nutrition. (1) Zhu stated impairment of different nutrition pathways results in different degenerative patterns in human discs. (2) Shirazi-adl reported disc nutrient concentrations could fall to levels inadequate to maintain cellular activity or viability, resulting in cell death and disc degeneration. Gu states that poor nutritional supply has a long-term effect on disc degeneration. The nutritional level, proteoglycan content, water content, and volume during human disc degeneration in a realistic 3-dimensional finite element model of the human intervertebral disc was developed for the study of nutrition of the disc. (3)

Note that the term proteoglycan content is referred to in the above citation by Gu. What is this proteoglycan so important in maintaining a normal intervertebral disc and preventing disc degeneration? It is glycosaminoglycan which is the proteoglycan in the intervertebral disc that imbibes water to give the intervertebral its normal hydrostatics for weight bearing and normal motion. Glycosaminoglycan is primarily chondroitin sulfate. Schleich states biochemical alterations of spinal discs are present before degeneration of the disc is visible on x-ray or MRI. (4) Glycosaminoglycan (GAG) loss plays a central role in these degenerative processes. GAG content of the nucleus pulposus (np) and annulus fibrosus (af) of the disc showed lower levels of gag content as disc degeneration worsens. Deng found glycosaminoglycan in the nucleus pulposus and annulus fibrosus decreases as disc degeneration increases.  Of great interest is that the depletion of GAG content in degenerative lumbar discs correlated significantly with intervertebral disc herniation.

What can be done to impede disc degeneration and enhance disc regeneration?  Mavroaonatou stated that glycosaminoglycan synthesis stimulated by glucosamine provides a possible promising clinical role for treating disc degenerative disorders. (7) Shostak reported on 30 patients with LBP (mean age 51) who were given chondroitin sulfate (drug structum) 1g/day for 24 weeks. 73% of patients showed pain relief and improved spinal function and structum is included in treatment of low back pain as chondroprotective drug. (5) Seleznova reports that chondroitin sulfate in combination with non-steroidal anti-inflammatory drugs could achieve rapid rehabilitation of patients with locomotor activity and improve quality of life in general for non-specific back pain. (6)

Since 1966 I have researched chondroitin sulfate, the chemical making up glycosaminoglycan within the human intervertebral disc, and have formulated Discat Plus which contains chondroitin sulfate, glucosamine sulfate, and other nutrients found in the disc- calcium, magnesium, zinc, manganese, and potassium.

In clinical practice, I give Discat Plus to patients with disc degeneration, disc herniation, and spine pain. It will, in the future, be a preventive supplement as is the structum formula described above.

Consider the nutritional aspect of treating spine pain, disc degeneration, disc herniation and spinal arthritis. Flexion distraction spinal manipulation which incorporated disc decompression under traction may be a stimulus to enhance imbibition of Discat Plus into the intervertebral disc.

For further information, contact Julie or this link on Discat Plus.

Respectfully submitted,

James M. Cox, DC, DACBR

 

This inaugural blog on the mechanism, diagnosis and treatment of spine and radicular pain appropriately opens with discussion of the most important element of spine care in the United States and the world for that matter – THE PATIENT.

Do you ever empathize with a person in spine pain who is seeking care – the stressful decisions to be made with sometimes with little knowledge of the problem? Can you blame him or her? Fact-filled alternatives are missing for such hard decisions. Just consider the following truths about spine care today.

SURGERY CONSIDERATION

Surgery yields varying feelings and opinions by patients and for good reason. Consider the following scientific papers on surgeons’ disagreement on spine surgery. The better trained the surgeon the less spine surgery is performed. More surgery is done by private clinics and 4 times less in academic and teaching institutions. (1) Degenerative lumbar scoliosis has variability in both non-operative and operative management. The appropriateness of surgery and specific surgical procedures have not been defined for this important pathology of the aging spine. (2) Such statistics support the patient’s plight in treatment decision making.

PATIENT CHARACTERISTICS IN CHOOSING CHIROPRACTIC CARE

Patients seeking chiropractic care are known to be intelligent seekers of their best care. In a study of non-Hispanic black patients who went to chiropractors, they tended to be female, be older, be college educated, be employed, and have a positive viewpoint on their interactions with their chiropractor. (3) Other studies have documented this as well. So successful is spinal manipulation that physical therapists now practice all forms of chiropractic manipulation from high velocity to Cox® Technic flexion distraction and publish peer reviewed papers on it. In Germany, study of manual therapy by general medical doctors for nonspecific low back pain benefits is to be conducted. (4)

COX® TECHNIC FLEXION DISTRACTION AND DECOMPRESSION SPINAL MANIPULATION

Cox® Technic flexion distraction and decompression spinal manipulation is a popular and growing form of spine care for people suffering from disc degeneration, disc herniation and spinal stenosis that cause leg pain called sciatica and arm pain and other spinal conditions such as spondylolisthesis, transitional segments, scoliosis, facet disease, pregnancy, spondylolysis, osteoporosis, arthritis, and so many more diagnoses.

Spinal mobilizations - low velocity passive oscillatory movements such as Cox® flexion distraction decompression spinal manipulation - are reported to reduce spinal pain in some patient subgroups by an endogenous pain inhibition system mediated by the central nervous system. Cox® flexion distraction low velocity low amplitude spinal manipulation shows short-term, remote antinociceptive effect similar to clinical findings in a rat study. (5,6) This author financed the building of a Cox® spinal manipulation instrument that is 1/12 the size of a regular Cox® manipulation instrument. It was built at the University of Iowa with input from Ram Gudavalli, PhD, and is used for rat experimentation as described here. Quite exciting to see how many years of study and research can lead to new approaches.

LITERATURE STATISTICS ON BENEFITS OF SPINAL MANIPULATION COMPARED TO SURGERY

Favorable outcomes of back pain and radiculopathy are attained in the vast majority of patients under non-operative care. Surgical intervention is reserved for patients who have significant pain that is refractory, non-responsive to at least 6 weeks of conservative care. This author finds this window of time adequate to reverse back and extremity pain in the majority of cases with Cox® Technic Flexion Distraction and Decompression spinal manipulation. Patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction are surgical candidates but this occurs in a small minority of cases, less than 1% with the condition called cauda equina syndrome. (7)

The Bone And Joint Decade 2000-2010 Task Force On Neck Pain and its associated disorders searched 5 databases from 2000 to 2014 finding 8551 citations for study. New evidence suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, ultrasound) are not effective and should not be used to manage neck pain. (8)

DEPRESSION IN CHRONIC LOW BACK PAIN PATIENTS

Chronic low back pain is known to cause anxiety and depression for the patient. Can you blame them? Suffering without relief will make anyone anxious. The complex, bidirectional correlation between chronic low back pain and generalized anxiety disorder, common in primary care, can increase the risk of inadequate treatment. (9) Chronic low back pain participants have lower working memory performance and higher pain catastrophizing  compared to pain-free controls.  (10) This author finds patient confidence and understanding of their condition reduces depression; some patients state their relief to now just understand their condition as it had not been explained to them by any prior healthcare consultant, doctor or surgeon in an understandable language.

CONSIDERATION OF HIGH VELOCITY LOW AMPLITUDE VERSUS LOW VELOCITY VARIABLE AMPLITUDE SPINE MANIPULATION BY SPINE CONDITIONS

Classic side posture high velocity low amplitude spinal manipulation was compared to Cox® flexion distraction non thrust spinal manipulation in a study of 192 participants, mean age 40 years, 54% male with subacute and chronic low back pain. Similar effects in short-term low back pain improvement for both were superior to a wait list control. (11) This author notes the mean age of the 192 patients was 40, and Cox states that the older the patient the more reliable is flexion distraction decompression spinal manipulation due to degenerative spine disease and inability of the patient to tolerate high velocity thrust adjustment. Also no radicular patients were part of this study and radicular patients, show Cox® flexion distraction decompression non thrust adjusting has great superiority because side posture thrust adjusting is not well tolerated and is shown to aggravate disc herniation and spinal stenosis. Here is seen the erudite decision making of the chiropractor in determining spinal manipulation use and application. (11)

CONCLUDING PATIENT INTERESTS IN CHIROPRACTIC MANIPULATION

Lastly, evidence based clinical practice is three entities:

1. research
2. clinical expertise
3. patient satisfaction and preference.

Chiropractic must persist in the research for documentation of its contribution to the epidemic problem of spine pain. Dissemination of this research to the chiropractic field doctor is an absolute necessity so he or she can implement the principles taught. Patient satisfaction with chiropractic research and clinical superiority will maintain the leadership role for chiropractic in spine care management.

Cox® Technic flexion distraction and decompression spinal manipulation has published scientific papers on the biomechanics and clinical outcomes of the technic for spine and radicular pain. Standards of care for cervical, thoracic and lumbar spine spinal manipulation are published as well as tutorials in the application of the flexion distraction and decompression technic. For full study of the work, go to the website www.coxtechnic.com. There you will find copies of the research papers, descriptions of Protocol I and II applications of the technic, clinical outcome studies, and case presentations of spinal conditions such as spinal stenosis, intervertebral disc herniation, spondylolisthesis, Bertolotti’s syndrome, facet syndrome, synovial cyst, Tarlov cyst, scoliosis, and subluxation. Cox Technic Complete® program websites like this one more fully go into the examination, physical, orthopedic, neurological and diagnostic imaging of spine pain patients which are shown in video for patients to study and then arrange care with the physician. These studies are designed to lead to the most prudent diagnosis of the patient’s condition. Study opportunities with Dr. Cox and other certified chiropractors for those interested in the procedures are given. Certification following 32 hours of hands on and didactic study is available for international referral directory opportunities.

Clinical validity of Cox® Technic is shown in the just published Clinical Practice Guideline: Chiropractic Care for Low Back Pain in the Journal of Manipulative and Physiological Therapeutics published online January 19, 2016. (12)  It shares that “currently, the most robust literature regarding manual therapy for low back pain is based primarily on high-velocity, low-amplitude (HVLA) techniques, and mobilization (such as flexion-distraction) therefore, in the absence of contraindications, these methods are generally recommended.” (12) This validation of Cox® flexion distraction decompression spinal manipulation is necessary for developing chiropractic’s role in spine treatment.

It is the leadership of superior spinal manipulation that will ultimately draw the public’s acceptance. It is my opinion that our path of research, clinical application and patient preference is large in the future of expanded chiropractic medicine.

Thank you for studying with me.

Respectfully submitted,

James M. Cox, DC, DACBR, FICC, Hon.D.Litt., FACO(H)

1/26/16 

Dr. James Cox well developed Cox® Technic's reputation for managing low back pain and sciatica. Most everyone who uses it says they'd turn to flexion distraction to manage low back pain and leg pain and disc herniation. But the evolution of Cox Technic to caring for the other regions of the spine has grown! Flexion Distraction Cox® Technic for cervical spine disc herniations and disc degeneration and headache and arm pain is well researched biomechanically and clinically. Its research progresses with federal funding via NIH and HRSA chiropractic research grants at NUHS and Palmer Research with Loyola Stritch School of Medicine/Hines VA Hospital and others like University of Iowa and University of Illinois. It's so exciting!

Check out this video that just shows snippets of lumbar spine flexion distraction application (It will look so familiar!) as well as cervical spine treatment (on The Cox8 Table) and side-lying treatment for pregnant patients (so comfortable and effective!) as well as patients who are in too much pain to  lie on their stomaches. 

Cox Technic is most effective biomechanically and clinically for lumbar spine back pain conditions. Check out what it offers the cervical spine related neck and arm pain conditions, the "newest" application of Cox Technic since 1991. Check out this video.

Disc degeneration starts young, so too should the supplementation start young to combat it! Aging, mechanical stresses, and the cells affect the spinal discs. It's not just a passive process of "wear and tear" on the spinal discs. Their nutrition is important, especially in this day and age when researchers are writing about being able to slow and even reverse disc degeneration.

Discat Plus has the building blocks of minerals found in the spinal disc as well as glucosamine sulfate, chondroitin sulfate (via perna canaliculus which is also a great anti-flammatory!). Introduced in the 1960's and evolved over the past 40+ years, Discat Plus supports spinal disc and cartilage heath.

Consider the article by Zhao that actually talks about working "to retard or reverse disc degeneration" and "to repair and regenerate the degenerated disc" by addressing the nutrient and biomechanical factors. These researchers recommend "a very early intervention" because "onset of human disc degeneration occurs as early as by adolescence."

Discat Plus supports the spinal discs, their nutrition and potential regeneration. When combined with distraction chiropractic adjusting, disc degeneration may be welled handled!

Contact your chiropractic physician for Discat Plus or contact CTRC for a doctor near you.

Glycosaminoglyan in disc cartilage is well-documented. This set of researchers wanted to find out what happens to the glycosaminoglycan if the disc is damaged.

So, they punctured the lumbar annulus fibrosus.

After 5 weeks, they performed an MRI  to estimate disc volume and glycosaminoglycan distribution.

The results show that the disc volume increased significantly at 4 weeks after the puncture.

The disc’s nucleus pulposus (center) displaced from annulus fibrosus (surrounding rings) increased T1 weighting of disc and glycosaminoglycan significantly decreased. So basically if there is damage to a disc, glycosaminoglycan leaves the damaged disc,  and the disc changes.

Nutritional and chiropractic treatment seems logical to help repair the damage.

Read more about this research, the check out the Discat Plus formulation for disc health and Cox Technic for disc herniation treatment and relief.

Chiropractic and Back Pain. Chiropractic and Neck Pain. Chiropractic and Spine Pain. The public thinks of chiropractic for back pain by and large.

• 33% of 27,810 people chose chiropractors as their treating physician for low back pain in the National Health and Nutrition Examination Survey. (NHANE) [in Deyo R: Spine 12(3)]
• Spine care delivery is 60% by the medical model and 40% by the chiropractic model. [Saal, Spine 22(14)]
• The total number of US adults who went to a chiropractor increased 57% from 2000-2003. [Davis, Health Svcs Research 45(3)]
• Paid costs for back pain care started with a chiropractor were 40% less than care started with a MD. [Liliedahl, JMPT 33(9)]

Chiropractic is reknown for its back pain care. Chiropractic has evidence-based technique to relieve and control back pain like Cox Technic.

The federally funded studies document Cox Technic Flexion-Distraction and Decompression's biomechanical effects on the spine as well as its clinical outcomes:

• intradiscal pressure drops to as low as -192mm Hg in the lumbar spine
• 28% widening of the area of the intervertebral canal
• flexion distraction is superior in relieving pain due to radiculopathy (leg pain) compared to medical care. (Gudavalli, Euro Sp J 2006) 
• 29 days and  12 visits are the averages for relief of low back pain when not taking into account specific conditions of back pain. [Cox, Topics in Clinical Chiropractic 1996, 3(3)]
• 13.2 treatments is the average for relief of neck pain radiculopathy. [Schliesser, Kruse, JMPT 26(9)]

Back pain and chiropractic fit together. The chiropractic physician is skilled in the diagnosis, examination and treatment of back pain as well as its prevention with nutrition, exercise and lifestyle choices. The chiropractic back pain research continues to evolve in support. Chiropractic physicians train specially to keep abreast of the latest research and Cox Technic treatment application in seminars. Back pain patients find Cox Technic physicians for their back pain relief when they search the referral directory of certified Cox Technic physicians.

Research leads the way in evidence-based care and in Cox Technic.

Contact Cox Technic if you have any questions.