James Cox DC, DACBR

James M. Cox, D.C., D.A.C.B.R. is a board certified chiropractic radiologist, clinician, and post graduate faculty member of National University of Health Sciences and is in clinical practice in Fort Wayne, Indiana specializing in the diagnosis and treatment of back and extremity pain. He is the developer of the flexion distraction and decompression chiropractic adjusting technic and is a clinical consultant in U.S. federally funded research of his technic. He is author of  the textbook Low Back Pain, Mechanism, Diagnosis, Treatment, 6th edition, by Lippincott publishers and Cervical Spine Pain: Mechanism, Diagnosis, Treatment, third edition. The research, clinical examination and application, and clinical outcome studies on flexion distraction spinal adjusting will be presented in lecture.  

Disc disease may be pain-free or cause low back and extremity pain due to disc herniation, degeneration, instability and spinal stenosis. Its management begins with correlation of clinical and imaging studies.

 

Chiropractic flexion distraction and decompression adjusting protocol I and II procedures for each type of disc disease to include post-surgical disc disease will be detailed.

 

Clinical outcome research data specific to flexion-distraction manipulation in the treatment of 1000 low back and radicular patients with differing types of lumbar disc disease treated in 30 chiropractic clinics will be shared with the number of days and visits required to attain maximum relief (12 visits, 29 days). Federally funded comparison studies of medical care compared to Cox® flexion-distraction decompression chiropractic adjusting for low back and leg pain will be shown as will available statistics from a similar cervical spine comparison study. Clinical adjusting of post-surgical disc disease cases will be covered.

 

Biomechanical changes of intradiscal pressure, foraminal area, disc height, zygapophyseal joint space, facet motion, and neuroreflexive changes within the spine during spinal adjusting will be detailed. Pitfalls and prevention of iatrogenesis in spinal adjusting will be emphasized.

 

Decision making of the appropriateness of chiropractic or surgical medical care based upon clinical diagnosis and the 50% rule will be detailed. Published peer reviewed algorithms of such care will be presented. Co-management benefits will be shown. Consideration of better quality outcomes if referral to chiropractic was sooner in some cases will inspire thought. Finally, other forms of chiropractic care for disc disease will be summarized.

 

Flexion-distraction protocols address two types of patients:

Each of these requires different and exact spinal adjusting methods. Both mandate careful tolerance testing before flexion distraction decompression spinal adjusting is given. Tolerance testing of central, lateral, and cuff applied forces will be presented.

 

Protocol I radicular pain patients are treated simply: pure flexion-distraction and decompression adjusting. The trigger and acupuncture point application for pain relief is added. The electrical stimulation used for the disc and dorsal root ganglion and nerve root inflammation is described. Patient expectations of time and visit requirements will be shown.

 

Protocol II non – radicular patients are treated far more aggressively than Protocol I patients. The flexion-distraction and decompression adjusting is accompanied by mobilization of the facet joint complex. Receptor stimulation with this type of adjusting for pain management will be outlined. 

 

The relief of pain as shown with centralization phenomenon, motor power return, ambulation return, sciatic scoliosis relief, fear avoidance understanding, return to work, and patient education and back school training for understanding and prevention of recurrence of pain will be offered. 

 

Proper diagnosis sets the direction of care. That means differentiating first of all non-mechanical back pain from mechanical back pain. Mechanical back pain is radicular or non-radicular in nature. Progressive neurological deficits requiring immediate surgery are excluded from non surgical care, but the great majority of back and radicular pain patients will be chiropractic patients. Chiropractic adjusting adapts to the definitive diagnosis of spinal conditions of spinal stenosis such as spondylolisthesis and Bertolotti’s syndrome that accompany spinal stenosis caused by disc herniation, ligamentum flavum hypertrophy, facet hypertrophy, endplate hypertrophy, developmental stenosis, spondylolisthesis and Bertolotti’s syndrome. 

 

Co-management between chiropractic physicians and allopaths must be considered when treating some diseases showing overlapping problems such as diabetes, vascular claudication, malignancy, or metabolic diseases.

         

The treatment plan is decided and the rules to follow in reducing treatment visits and conversion of passive to active care must be followed. The 50% rule is closely followed. Questions to consider are: When conservative non-surgical care is not yielding satisfactory relief, when does such care convert to surgical consideration? When is the patient said to have achieved maximum medical improvement? How is this improvement defined? What happens to the patient upon attainment of maximum improvement? Is s/he dismissed to await any future return episodes of the condition or is s/he taught that back pain is not cured, but controlled - thus requiring on-going training and preventive care? These decision making factors from the perspective of chiropractic flexion-distraction protocols will be presented in a published standard of care.