James M. Cox

Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series

PURPOSE The purpose of this case series is to report on changes in pain levels experienced by 69 postsurgical continued pain patients who received Cox Technic Flexion Distraction (CTFD). METHODS Fifteen doctors of chiropractic collected retrospective data from the records of the postsurgical continued pain patients seen in their clinic from February to July 2012 who were treated with CTFD, which is a type of chiropractic distraction spinal manipulation. Informed consent was obtained from all patients who met the inclusion criteria for this study. Data recorded included subjective patient pain levels at the end of the treatments provided and at 24 months following the last treatment. RESULTS Fifty-four (81%) of the patients showed greater than 50% reduction in pain levels at the end of the last treatment, and 13 (19%) showed less than 50% improvement of pain levels at the end of active care (mean, 49 days and 11 treatments). At 24-month follow-up, of 56 patients available, 44 (78.6%) had continued pain relief of greater than 50% and 10 (18%) reported 50% or less relief. The mean percentage of relief at the end of active care was 71.6 (SD, 23.2) and at 24 months was 70 (SD, 25). At 24 months after active care, 24 patients (43%) had not sought further care, and 32 required further treatment consisting of chiropractic manipulation for 17 (53%), physical therapy, exercise, injections, and medication for 9 (28%), and further surgery for 5 (16%). CONCLUSION Greater than 50% pain relief following CTFD chiropractic distraction spinal manipulation was seen in 81% of postsurgical patients receiving a mean of 11 visits over a 49-day period of active care.

A Randomized Controlled Trial Comparing 2 Types of Spinal Manipulation and Minimal Conservative Medical Care for Adults 55 Years and Older With Subacute or Chronic Low Back Pain

To the Editor: Hondras et al reported on comparison of low-velocity, low-amplitude spinal manipulation (Cox flexion distraction) to high-velocity, low-amplitude adjusting (side-lying lumbar roll adjustment) to minimal conservative medical care for adults older than 55 years with subacute or chronic nonradicular low back pain. The reported result was both forms of manipulation yielded equal clinical relief with lowvelocity, low-amplitude adjusting (eg, Cox technique) having significant improvement in mean functional status over medical care. However, patients were excluded from the study “if they had low back pain associated with frank radiculopathy or neurological signs such as altered lower extremity reflex, dermatosensory deficit, progressive unilateral muscle weakness or motor loss, symptoms of cauda equina compression, or computed tomography or magnetic resonance imaging evidence of anatomical pathology (eg, abnormal disk, lateral or central stenosis).” It seems nearly impossible to find patients without disk degeneration. Disk diseases of degeneration, herniation, and spinal stenosis causing low back and lower extremity pain are the most painful and challenging cases seen in chiropractic practice. Failed back surgical syndrome patients are also included with these patients, and this is an ever-increasing patient load. These cases are growing in numbers in chiropractic offices because of the “baby boomer” influx of older Americans who develop spinal stenosis as a part of the degenerative aging process. They are the 5% of the cases of back pain that absorb 75% of the cost in back care in the United States today. It is not a question of using only one adjustment form or the other but rather how they complement one another to gain the best clinical outcome for the patient. Nearly 60% of chiropractors use flexion distraction in their practices, using it on 23.5% of their patients—those patients for whom the doctor feels it to be most indicated to give the best clinical outcome. Patients with severe low back and radiculopathy were excluded from this study. In the real world of clinical chiropractic, it is the excluded patients from this study that represent the greatest challenge, and flexion distraction becomes the most important spinal adjustment. Gudavalli authored the article showing superiority of flexion distraction decompression adjusting over medical care (physical therapy) in treating low back and radicular pain patients. Had the article of Hondras included the severe low back and radicular patient with spinal stenosis and disk herniation disease, the outcomes could have better revealed the place and need for flexion distraction spinal manipulation and side posture adjusting as determined by clinical relief and improved patient tolerance. Selection of patient conditions for such studies needs input from field practitioners as to the type of patients presenting the greatest clinical challenge. In this authors opinion, the exclusions in this study would not have been selected had such been done. It is the field practitioner who depends on this type of study for clinical guidance in patient care. The excluded conditions from this study make its conclusions limited in value via exclusion of the most difficult problems seen in clinical practice.

Three-dimensional force sensor based feedback device in the treatment of low back pain

The objective of this paper was to develop a real time computer controlled feedback apparatus to the doctor of chiropractic while delivering the treatment forces. A portable system consists of a three-dimensional force transducer, laptop computer, and a custom developed software. The program allows the doctor to view graphically and quantitatively the forces being applied using his hand and can change the amount of applied forces in real time. The system was used in training the new doctors of chiropractic. The device has been useful in improving the delivery of treatment forces by these inexperienced chiropractic students and chiropractors.