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 

Check out the recorded webinar discussion about the new ICD-10 Codes for Disc Classifications. Dr. Arkfeld shares how the coding is done while Dr. Cox then defines the disc classifications for practical use in clinic. He also shares the positive potential that these codes may allow the chiropractic profession.

Click here to register and watch.  

Join Dr. James Cox for this special hands-on demonstration webinar of live treatment protocol demonstration as the protocols relate to the ICD-10 code classifications. You may also ask questions throughout!

October 28, 2015

12:30pm EST

Wednesday

Register now! 

DC 1: "Flexion distraction. Yeah, I do that. It works great for low back pain and disc herniations."

DC 2: "Have you used flexion distraction for neck pain and arm pain? Cervical spine conditions?"

DC 1: "No. I didn't know it was for that."

DC 2: "The research is amazing, and the technique is so gentle!

Yes, Cox Technic flexion distraction for cervical spine conditions was introduced in 1991 (thanks to Dr. Cox's wife whose C5-6 disc herniation made him venture beyond his beloved L5-S1!). Since then, clinical cases have been published, federally funded studies (both clinical comparison and biomechanical) have been completed, and colleagues have shared their treatment skills with each other formally in workshops and informally in clinics. The Cox Table has also evolved from unwieldy and awkward occipital cups/ropes to simpler long-y axis and straps.

Check out just what Cox Technic flexion distraction offers cervical spine pain patients and their neck pain and arm pain! Then register for a seminar or workshop to learn more.

Certified Cox Technic physician and instructor, Dr. George Joachim, publishes a case report with the Journal of Chiropractic Medicine on his care of a patient with a post surgical C6-C7 spondylotic myelopathy and lumbar radiculopathy occurring together in one patient. Also, his being a chiropractic rehabilitation diplomate, he shares how rehabilitation worked hand-in-hand in this case to help relieve this patient. 

Read the full case study. Share! 

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.

Dr. James Cox had the privilege to present to the 700+ attendees at the ANJC Fall Summit in East Brunswick NJ this past weekend. As he always does, he passionately shares his love of chiropractic and of the research and science behind its art of healing and pain relief. He loves to share his clinical experience over teh past 51 years. At the ANJC, I heard more doctors come up to me and say "I heard your dad / Dr. Cox speak 30 years ago!" While that is awesome, I am so glad they came to hear him again!!! His passion for chiropractic and its science and its art is amazing, and the stories that come after this conversation starter are always interesting. Those are for another blog post...

I have worked with Dad (Dr. Cox) for 22 years. In 22 years, so much has changed and evolved. I was hired to write a newsletter for him and the technique. Today, I get to talk to doctors from around the globe who share their personal patient success stories (which I wish I could get them all to write for me to share with all of you!) and plan training seminars and support our teaching team and coordinate clinicians who want to do research with researchers and connect patients (who are often at the end of their ropes) who need back pain and neck pain relief with Cox Technic certified physicians who can deliver that relief. 

Further, during these 22 years, I have likely sat in over 400 presentations with Dr. Cox and/or other members of our instruction team (Drs. Greenwood, Hazen, Joachim, Kruse, Olding et al). I learn something new at every single course. I hear a new insight or application of a protocol. I hear a new struggle or a new success. I have been on the scene when Dr. Gudavalli has announced reception of a new grant from NIH or HRSA or FCER (when it was in operation) or that a paper about flexion distraction (teaching tools or biomechanical research outcomes or clinical comparison study) is accepted for publication or that he is invited to present flexion distraction to fellow biomechanical engineers and/or chiropractors at conferences in places like Sydney, Dubai, Portugal, California, etc. I am able to watch new doctors to the technique grow in excitement and passion during the course of a seminar. I am honored to hear their stories throughout the course, their personal struggles with back pain and neck pain or those of a loved one, their professional uncertainty as to whether to keep practicing or retire, their journey for finding a better way to help their patients.

What a privilege it's been to be a part of all this excitement that often goes on behind the scenes yet is only known by a few. So thank you to everyone who gives Dr. Cox a second chance - even if it's 30 years later - to share his passion for chiropractic, its science and its art, its research and its clinical application. And I am so glad that you get that chance as he is my dad, and I am so honored to still have him in my life these 30 years, 40 years, almost (!) 50 years. 

I look forward to seeing you at a seminar or lunchtime LIVE webinar or hands-on workshop and hearing your story of hearing Dad teach you 30 years ago (or 2 years ago or 2 months ago!). I am confident you will hear something new to inspire you and your enthusiasm for your chiropractic practice and profession!

- Julie Cox-Cid 

The Musculoskeletal Biomechanics Research Laboratory at the Loyola University Medical Center, endearingly known as the Windy City Lab, is a site of federally funded research into the biomechanical and clinical studies of flexion-distraction, the technique also known as Cox Technic developed by Dr. James M. Cox. The most current project involves the cervical spine.

At the Windy City Lab, Dr. Avinash G. Patwardhan directs a team of orthopaedic surgeons, engineers, medical researchers and statisticians whose publishing credits include over 100 papers in peer-reviewed journals like Spine, J of Bone and Joint Surgery and the J of Biomechanics. It's quite impressive what this small but mighty team has accomplished.

Dr. Ram Gudavalli, chiropractic researcher from Palmer Research Center and director of the chiropractic clinicians and researchers in this particular project under the direction of Christine Goertz, DC, PhD, works closely with Dr. Patwardhan and his team. Consulting chiropractic clinicians who volunteer their time and travel to this project include

• James M. Cox, DC, DACBR
• George Joachim, DC, DACRB
• Ralph Kruse, DC, DABCO
• Robert Rowell, DC 
• Michael Seidman, DC
• Robert Vining, DC

Each time these researchers and clinicians assemble, excitement abounds at the ability to document what happens during this flexion distraction procedure and at the collaborative efforts of all involved.

Please check out the new website for Loyola's Musculoskeletal Biomechanics Research Laboratory, www.WindyCityLab.com. (Watch the image rotator on the homepage to see if you recognize the research team for this flexion distraction research project!)

We have our secure portal and can now start sharing some of the recorded Cox Technic related webinars from the past year. Some are free and presented by Cox Technic Complete (the program for online outreach for flexion-distraction physicians) and some are fee-based as they are academic presentations by Dr. James Cox.

The free webinars include case report presentations of actual patient cases from exam through treatment and outcome as well as discussions of the latest statistics in the world of spinal pain management. Dr. Cox's passion for spinal pain care and research shines in these and his passion will inspire you! Demonstrations of how the Cox Technic Complete program highlights these research and scientific advances and findings for spinal care for the subscriber. Cox Technic Complete pulls it all together from clinical office materials that are downloadable to the website that is personalized for your practice and optimized for internet SEO and localization telling your community that you are a back pain specialist with the treatment to help them get rid of pain.

The educational, academic fee-based webinars are on topics like pathologies in the chiropractic practice, FBSS patients, Cox Technic research studies and patient documentation. Dr. Cox shares his clinical practice style and his passion for chiropractic and research are evident and will likely inspire you.

More online recorded Cox Technic webinars are in the editting stage and will be uploaded over the next few weeks. Enjoy these for now!

Contact us if you have any questions or suggestions for future webinars!