Research

Guehring T, et al.: Disc distraction shows evidence of regenerative
potential in degenerated intervertebral discs as evaluated by protein
expression, magnetic resonance imaging, and messenger ribonucleic acid
expression analysis. Spine. 2006 Jul 1;31(15):1658-65
"Distraction results in disc rehydration, stimulated extracellular matrix gene
expression, and increased numbers of protein-expressing cells."

Komari H, et al.: The Natural History of Herniated Nucleus with
Radiculopathy. Spine 21: 225-229, 1996
77 patients verified on pre-post MRI with signs and symptoms of herniation,
underwent non-surgical intervention including pelvic traction. Changes in
herniation and good-excellent symptomatic improvements were noted in over
82%. The authors draw the conclusion improving the discs contact with the
blood supply accounts for healing of herniation.

Onel,D et. al.: CT Investigation of the effects of Traction on
Lumbar Herniation. Spine 14: 82-90,1989.
30 patients with lumbar herniations were tractioned in a CT scanner at >50%
body weight for -20 min. Hernia retraction occurred in 70% and good clinical
improvements were seen in over 93%. The authors concluded improved blood
flow was the source of healing. Additionally they speculated previous studies
showing traction doesn’t create negative intradiscal pressures perhaps used
too light a force.

Parsons, WB Cumming, JDA: Traction in Lumbar Disc Syndrome. Can
Med Jour 77:7-10,1957.
100 patients with disc syndrome unresponsive to manipulation were treated
with high force traction (+80 lb). 86% of patients had good-excellent
outcomes 12 had poor outcomes but most had pain for an extended
duration.

Saal, JA Saal, JS: Nonoperative Treatment of Herniated Lumbar
Disc w/ Radiculopathy. Spine 14 (4): 431-437, 1989.
58 subjects had an inclusive conservative program including traction (when
initially shown to reduce leg symptoms). Overall 86% had good-excellent
results.

Mathews, JA: Dynamic Discography: A Study of Lumbar Traction. Annls
of Phys Med, IX (7), 265-279, 1968.
3 patients with a ruptured lumbar disc had contrast medium and
radiographic images taken during and after a lumbar traction procedure.
The protrusions were shown to lessen cosiderably with the 30 minute prone
1traction sessions and a dimpling of the outer annulus suggested a negative
intradiscal force was created.

Lidstom, A Zachrisson M: PT of the low back pain and sciatica. Scan
Joul of Rehab Med, 2: 37-42, 1970.
Intermittent supine traction with -+50% body-weight, (10) 20 minute
sessions with added exercises showed considerable improvement in over
90% of the 62 patients.

Hood, LB Chrissman, D: Intermittent Traction in the Treatment of
Ruptured Disc Phys Ther 48: 21, 1968.
40 patients with neurological signs were treated with traction on a friction
free table with 55-70 lbs for 20 minutes. Good-excellent results were seen
in 55%.

Mathews JA et. al.: Manipulation and traction for Lumbago and
Sciatica. Physio Pract 4: 201, 1988.
A controlled trial of traction with manipulative techniques. Traction
force Applied at –100 lbs for 20 minutes leading to substantial relief in
over 85%.

Colachis S, Strohm BR: Effects of Intermittent Traction on
Vertebral Separation. Arch of Phys Med & Rehab, 50: 251-258,
1969.
Subjects were subjected to a supine angled traction force of up to 100
lbs. with x-ray examination. A rope angle of 18 degrees revealed
separation greatest at L4-5 (Note: we speculate a more acute angle -10
degrees affords greater separation at LS-S 1). The separation was
obvious up to T 12-L 1 with total elongation of the spine approaching
+5mm. The vertebra separation is greater on the posterior vs. anterior
aspect of the vertebra.

Constatoyannis C, et. al.: Intermittent Cervical Traction for
Radiculopathy Due to Large-Volume Herniations. JMPT, 25 (3)
2002.
Three weeks of the above described traction method to large
volume herniations resulted in complete resolution of symptoms in 4
patients.

Shealy N, Leroy P: New Concepts in Back Pain Management.
AJPM (1) 20:239-241 1998.
2The application of supine lumbar traction with adherence to several specific
characteristics including progression to a peak force and altering the angle of
pull from 10 degrees (L5 -S 1) to 30 degrees (L3) enhanced distraction at
specific levels.

Gose E, Naguszewski W&R: Vertebral axial Decompression for Pain
associated With Herniated and Degenerated Discs or Facet syndrome:
an Outcome Study. Neuro Research, (20) 3, 186-190, 1997.
A retrospective analysis of over 770 cases, many assumed to be
unresponsive to previous therapies showed a 71 % good-excellent success
rate with -20 treatments on the prone VAX-D traction device. All patients
treated prone with 65-95 lbs. of force 3-5 times per week.

Letchuman R, Deusinger RH: Comparison of sacrospinalis myoelectric
activity and pain levels in patients undergoing static and intermittent
lumbar traction. Spine 18(10): 1361-1365, 1993
This study was used to determine muscular guarding/contraction of Paraspinals
with intermittent vs. static traction. Improved comfort noted in the intermittent
traction group.

Chen YG, Li FB, Huang CD: Biomechanics of traction for lumbar disc
prolapse. Chinese Ortho; Jan(1): 40-2, 1994.
Intervertebral pressure was recorded before and during traction. 62% of
prolapsed discs showed negative pressure prior to traction. 64% reduced IDP
with traction and was related to distraction distance. In 19% of prolapsed discs
the pressure actually increased, demonstrating the disruption to the hydrostatic
mechanism occurring with complete annular damage and prolapse.

Nanno M: Effects of intermittent cervical traction on muscle pain. EMG
and flowmetric studies on cervical paraspinals. Nippon Med J;
Apr;61(2):137-47, 1994.
Cervical intermittent traction was shown to be effective in relieving pain,
increasing frequency of myoelectric signals and improving blood flow in effected
muscles.

Chung TS, Lee YJ et al: Reducibility of cervical herniation: evaluation at
MRI during cervical traction with a nonmagnetic device. Radiology Dec;
225(3):895900,2002.
29 patients and seven healthy volunteers had intermittent traction while in
MR. Substantial increase in vertebral length was seen. Full herniation
reduction in 3 and partial in 18 was reported.

3Dietrich M et al: Non-linear finite element analysis of formation
and treatment of disc herniation. Proc Inst Mech Eng; 206(4):225-
31,1992.
The authors analysis shows loads not greater than those occurring in everyday
life cause loss of stability of the disc and allow lateral nucleus displacement.
The model indicates conservative therapy by traction may result in retraction of
hernia by about 40%.

Ramos G, Martin Wm: Effects of axial decompression on intradiscal
pressure. J Neuro 81: 350-353, 1994.
Significant negative pressure (-100mm Hg) was recorded at L4/5 disc in three
volunteers as axial traction was administered. Negative pressure was recorded at -50
pounds tension perhaps representing a minimal threshold force. Patients were prone
and harnessed.

Cox JM: Lumbosacral disc protrusion: a case report. Journal of Manipulative and
Physiological Therapeutics 8(4): 261-266 (December 1985)
A negative myelogram but a positive CT for an L5 disc protrusion is presented. Five
months of medical care preceded chiropractic care; the insurance company
involvement in a case where treatment mode is changed from usual orthodox medical
procedures of epidural steroid injection and physical therapy to chiropractic distraction
manipulation is detailed. Finally, the clinical outcome of the case is provided. At the end of
6 weeks of care the patient returned to his full work duties as a truck driver. His range of
motion of the thoracolumbar spine were full and normal and hi straight leg raises were
positive right at 70 degrees and left at 60 degrees. He had taut hamstring muscle that
required constant stretching so as to not mimic a positive straight leg raise sign. This case
shows that time off work and cost were both reduced by chiropractic care.

Cox, JM, Feller JA, Cox JA: Distraction Chiropractic Adjusting: Clinical Application,
Treatment Algorithms, and Clinical Outcomes of 1000 Cases Studied. Topics in
Clinical Chiropractic 1996; (3)3:45-59, 79-81
An overview of Cox® distraction manipulation protocols is presented including
diagnosis and treatment decision making in low back pain and sciatica cases and
proper utilization of flexion distraction in treating lumbar spine and lower extremity pain. In
addition, the outcome of 1,000 cases involving low back and/or leg pain treated with
chiropractic adjusting (92% utilizing flexion distraction) is presented. A qualitative clinical
and literature review provides the basis of the overview of diagnostic and treatment
protocols. A descriptive case series design was used to collect outcome information on
1,000 patients with low back and/or leg pain; patients were pooled from two separate
studies. Patients were treated by 30 different chiropractors, and a minimum of 20 cases
was supplied by each physician. A descriptive review of cases showed that less than 4%
of patients with low back or leg pain were candidates for surgery. Less than 9% of
patients reached the chronic stage of care. The mean number of days to maximum
improvement under care was 29, and the average number of treatments to maximum
improvement was 12. The results of this study provide some evidence for the use of
4chiropractic management, particularly flexion distraction manipulation, in the treatment of
back pain problems due to a variety of mechanical causes.

Gudavalli MR, Cox JM, Baker JA, Cramer GD, Patwardhan AG: Intervertebral disc
pressure changes during the flexion-distraction procedures for low back pain.
Presented at and in the proceedings of the International Society for the Study of
the Lumbar Spine Meeting, June 1997, Singapore.

Cyriax, Quilette, and Kramer hypothesized that as the vertebrae in the spine are
distracted, a negative pressure develops in the disc, and sucks back a protrusion. The
present study shows that the decrease in the intradiscal pressures may provide the
opportunity for the reduction in the disc bulge during the flexion-distraction procedure.
Ramos et al. reported decreases in the intradiscal pressures during Vertebral Axial
Decompression (VAD) procedure on three patients measured intraoperatively. The result
of the present study are in general agreement with the study reported by Ramos and
Martin. Andersson et al. reported increases in the intradiscal pressures at L3-L4 disc on
four volunteers during active and passive traction. A possible reason for the increase in
the intradiscal pressures could be that the muscles of the in vivo subjects could have
been contracting while under active and passive traction. Work is in progress to monitor
the muscle activity during in vivo situations of treating the patients using the flexiondistraction procedure.

Gudavalli MR, Cox JM, Baker JA, Cramer GD, Patwardhan AG: Intervertebral disc
pressure changes during a chiropractic procedure. Accepted for presentation and
publication at the ASME IMECE 97 Bioengineering Convention, November 16-21,
1997, Dallas, Texas. - Advances in Bioenginneering 1999; BED, vol. 39, pgs 187-
188.
We observed a significant decrease in intradiscal pressure during the flexiondistraction
procedure for low back pain. The pressure has increased during extension motion of the
table. The pressures have increased during right lateral motion whereas the pressures
have decreased during the left lateral motion. During circumduction the pressures have
decreased during the left lateral and flexion motions, where as they have increased
during right lateral and flexion combined motions. In all of the motions the pressures
returned to their original values when the spine was brought back to the initial prone
position. One of the reasons for the increase and decrease during lateral motions is due
to the fact that the transducer was inserted some what right laterally from the center of the
disc. The results clearly show that the pressures are affected during different motions of
the spine associated with the motions of the table. Even though the present study is
limited to one cadaver, the results are very interesting and studies with more number of
cadavers and studies on animals can give further insight into the changes in the
pressures at different regions of the spine.

Gudavalli MR, Cox JM, Baker JA, Cramer GD, Patwardhan AG: Intervertebral Disc
Pressure. Changes During a Chiropractic Procedure. Abstract from the
Proceedings of the Bioengineering Conference, Phoenix.
We observed a significant decrease in intradiscal pressure during the flexiondistraction
procedure for low back pain. When the discs were not pressurized, the pressures went
5below 0 mm Hg. When the discs were pressurized, the decrease in the intradiscal
pressures was much larger, suggesting that in patients with higher intradiscal pressures,
the decrease may be much higher during the treatment. The pressures returned to their
original values when the spine was brought back to the initial prone position. Quilette(2),
and Kramer (3) hypothesized that as the vertebrae in the spine are distracted, a negative
pressure develops in the disc, and sucks back a protrusion. Ramos et al. (4) reported on
the intradiscal pressure during Vertebral Axial Decompression (VAD) procedure on three
patients measured intraoperatively. The results showed that the disc pressures reduced
during the VAD therapy. They demonstrated that the disc pressures can go as low as -
160 mmHg. The results of the present study are in general agreement with the study
reported by Ramos and Martin (4). Anderson at al. (5) reported the intradiscal pressures
at L3-L4 disc on four volunteers during standing, lying, active traction, and passive
traction. The findings showed an increase in the disc pressure during both active and
passive traction. The results from the present study do not agree with the results reported
by Anderson et al. (5). A possible reason could be that the muscles of the in vivo subjects
could have been contracting while under active and passive traction. Work is in progress
to monitor the muscle activity during in vivo situations of treating the patients using
flexion-distraction procedure.

Cox JM et al: Grand Rounds Discussion: Patient with acute low back pain.
Chiropractic Technique 1999; 11(1):1-17
A Grand Rounds discussion of a patient suffering from severe low back pain with pain
radiating into the left thigh. The patient occasionally gets "stuck" in a position where he is
leaning forward and to the right, and he must slowly work out his back in order to
straighten up again. Dr. Cox discusses the examination of the patient, the possible pain
generators for the patient's pain, and the Cox Distraction Adjusting procedures
recommended for the case. Algorithms of decision making and treatment protocol are
presented for Cox® Distraction diagnosis and care of an acute low back pain patient. As
well, discussion of potential sources of the pain is presented. Many references cited.

Cox JM I, Cox JM II: Cox automated axial distraction manipulation. Canadian
Chiropractor 1999; 4(1):26-33
Algorithms of the standard of care for Cox® Distraction are presented and explained.
Automated axial distraction, the newest ability of Cox® Technique protocol, is introduced
in a very technical, step-by-step fashion with illustrations as to hand positioning as well as
instrument use. AAD eases the distraction procedures for the physician and provides a
smooth adjustment for the patient.

Cox JM I, Cox JM II: Cox Distraction Manipulation Procedures for the Cervical
Spine. Florida Chiropractic Association Journal 1999; Jan/Feb: 42-44
Cox® Distraction procedures for the cervical spine and thoracic spine are a natural
outgrowth of its application to the low back. This technical overview of Cox® Distraction
procedures for the cervical and thoracic spine is intended to introduce this form of care for
patients intolerant of classic rotatory thrust techniques due to such anatomical and
pathological findings as degenerative disc disease, vertebral artery syndrome, disc
6herniation, blocked vertebra, occipitalization, scoliosis, other congenital defects, as well
as for patients who just cannot be high velocity adjusted.

Cox JM, Cox II, JM: Chiropractic Treatment of Lumbar Spine Synovial Cysts: A
Report of Two Cases. Journal of Manipulative and Physiological Therapeutics
2005; 28(2):143-147.
Chiropractic distraction manipulation and physiological therapeutic care relieved 2
patients with low back and radicular pain attributed to MRI-confirmed synovial cysts of the
lumbar spine. This treatment may be an initial conservative treatment option for synovial
cysts with careful patient monitoring for progressive neurologic deficit which would
necessitate surgery. Distraction manipulation may be a safe and effective conservative
treatment of synovial cyst causing radicular pain; further data collection of clinical
outcomes is warranted.

Gudavalli R, Cambron JA, McGregor M et al: A randomized clinical trial and
subgroup analysis to compare flexion–distraction with active exercise for chronic
low back pain. European Spine Journal 2006; 15: 1070-1082
Patients with radiculopathy did significantly better with FD. There were no significant
differences between groups on the Roland Morris and SF-36 outcome measures. Overall,
flexion–distraction provided more pain relief than active exercise; however, these results
varied based on stratification of patients with and without radiculopathy and with and
without recurrent symptoms. The subgroup analysis provides a possible explanation for
contrasting results among randomized clinical trials of chronic low back pain treatments
and these results also provide guidance for future work in the treatment of chronic low
back pain.

Cambron GA, Gudavalli MR, McGregor M et al: Amount of health care and self-care
following a randomized clinical trial comparing flexion-distraction with exercise
program for chronic low back pain. Osteopathy and Chiropractic 2006; 14:19
During a one-year followup, participants previously randomized to physical therapy
attended significantly more healthcare visits than those participants who received
chiropractic care.
.
Cambron GA, Gudavalli MR, Hedecker D et al: One-Year Follow-Up of a
Randomized Clinical Trial Comparing Flexion Distraction with an Exercise Program
for Chronic Low-Back Pain. J of Alternative and Complementary Medicine 2006;
12(7): 659-668
In this first trial on flexion distraction care, flexion distraction was found to be more
effective in reducing pain for 1 year when compared to a form of physical therapy.
Kruse RA, Schliesser J, DeBono VF: Klippel-Feil Syndrome with radiculopathy.

Chiropractic management utilizing flexion-distraction technique: A case report. J of
the Neuromusculoskeletal System 2000;8(4):124-31
A 34-year-old female presented to a chiropractic office with severe, unremitting,
cervical, shoulder, and arm pain of several months' duration. Past medical history,
clinical evaluation, and plain-film radiographs revealed findings consistent with Klippel-
7Feil syndrome. The radiographs revealed a C2/3 block vertebrae, atlas assimilation, and
premature degenerative changes consistent with the syndrome. Treatment consisted of
cervical flexion-distraction manipulation and adjunctive therapies. This patient felt relief
after the first treatment and experienced a complete resolution of her symptoms after
eight treatments performed over a period of 2 months. Klippel-Feil syndrome is an
anatomical entity that results in premature cervical degenerative changes, which may
cause radiculopathy. Flexion-distraction manipulation performed to the cervical spine is
a relatively new clinical procedure, which shows great promise for the treatment of
cervical radiculopathy.

Kruse RA, Gregerson D: Cervical Spinal stenosis resulting in radiculopathy treated
with flexion distraction manipulation: A case study. J of the Neuromusculoskeletal
System 2002;10(4):141-7
A 60 year old male presented with complaints of pain and limited motion in his neck,
with pain and weakness in his left shoulder and arm. These symptoms began after a fall
approximately 4 months prior. His previous allopathic care included medication and
physical/occupational therapy, which provided no significant relief. Cervical plain film
radiographs demonstrated degenerative changes and the magnetic resonance imaging
revealed multilevel central stenosis. The patient was treated with flexion-distraction
manipulation, which provided significant relief of his subjective and objective findings.
Cervical stenosis with resultant radicular and neurological complaints may be difficult
to manage with both conventional allopathic and chiropractic treatment. Flexion
distraction manipulative therapy may be an effective treatment option for these often
difficult cases.

Kruse RA, Gregerson D: Cervical Spinal stenosis resulting in radiculopathy treated
with flexiondistraction manipulation: A case study. J of the Neuromusculoskeletal
System 2002;10(4):141-7
A 60 year old male presented with complaints of pain and limited motion in his neck,
with pain and weakness in his left shoulder and arm. These symptoms began after a fall
approximately 4 months prior. His previous allopathic care included medication and
physical/occupational therapy, which provided no significant relief. Cervical plain film
radiographs demonstrated degenerative changes and the magnetic resonance imaging
revealed multilevel central stenosis. The patient was treated with flexion-distraction
manipulation, which provided significant relief of his subjective and objective findings.
Cervical stenosis with resultant radicular and neurological complaints may be difficult
to manage with both conventional allopathic and chiropractic treatment. Flexion
8distraction manipulative therapy may be an effective treatment option for these
oftendifficult cases.

Schliesser JS, Kruse RA, Fleming Fallon L: Cervical radiculopathy treated with
chiropractic flexion distraction manipulation: a retrospective study in a private
practice setting: JMPT2003; 26(9):592-596
Background: Although flexion distraction performed to the lumbar spine is commonly
utilized and documented as effective, flexion distraction manipulation performed to the
cervical spine has not been adequately studied. Subjective: To objectively quantify data
from the Visual Analogue Scale (VAS) to support the clinical judgment exercised for the
use of flexion distraction manipulation to treat cervical radiculopathy. Design and setting:
A retrospective analysis of the files of 39 patients from a private chiropractic clinic that
met diagnostic criteria for inclusion. All patients were diagnosed with cervical
radiculopathy and treated by a single practitioner with flexion distraction manipulation and
some form of adjunctive physical medicine modality. Main outcome measures: The VAS
was used to objectively quantify pain. Of the 39 files reviewed, 22 contained an initial and
posttreatment VAS score and were therefore utilized in this study. Results: This study
revealed a statistically significant reduction in pain as quantified by visual analogue
scores. The mean number of treatments required was 13.2 ± 8.2, with a range of 6 to 37.
Only 3 persons required more treatments than the mean plus 1 standard deviation.
Conclusion: The results of this study show promise for chiropractic and manual therapy
techniques such as flexion distraction, as well as demonstrating that other, larger
research studies must be performed for cervical radiculopathy.

Kruse RA, Imbarlina F, DeBono VF: Treatment of cervical radiculopathy with flexion
distraction. J Manipulative Physiological Therapeutics 2001;24(3):206-209
Objective: To discuss the nonsurgical treatment of a cervical disk herniation with
flexion distraction manipulation. Clinical Features: A case study of cervical disk
syndrome with radicular symptoms is presented. Magnetic resonance imaging revealed
a large C5-C6 disk herniation. Degenerative changes at the affected level were
demonstrated on cervical spine plain film radiographs.Intervention and Outcome: The
patient received treatment in the form of flexion distraction manipulation and adjunctive
therapies. A complete resolution of the patient's subjective complaints was achieved.
Conclusion: Flexion distraction has been a technique associated with musculoskeletal
conditions of the lumbar spine. Flexion distraction applied to the cervical spine might
be an effective therapy in the treatment of cervical disk herniations. Although further
controlled studies are needed, treatment of cervical disk syndromes with flexion
distraction might be a viable form of conservative care.

Neault CC: Conservative management of an L4-L5 left nuclear disc prolapse with a
sequestrated segment. J of Manipulative and Physiological Therapeutics
1992;15(5):318-321
A case report is discussed in which a clinically diagnosed case of an L4-L5 nuclear disk
prolapse with a sequestrated fragment was certified by computerized axial tomography
and magnetic resonance imaging at the initiation of the treatment period. It was treated
with flexion-distraction manipulation, hot and cold fomentation, positive galvanism, a
9lumbosacral support, nutritional supplementation, and abstinence from sitting and
exercises. Four weeks after initiation of treatment, the patient was asymptomatic. Eight
weeks after initiation of treatment, and 6 weeks after the original scan, magnetic
resonance imaging certified a reduction in the size of the prolapse within the vertebral
canal. An 11 month follow-up examination indicated the patient had no exacerbations of
her condition and all objective findings were negative.

Hayden RA: Multilevel degenerative disc disease: a case study. Georgia
Chiropractic Journal 1996;April: 6-7:34
A case of a 61-year-old female with low back, hip and sciatic pain since for five years
has been bedridden or restricted to the sofa prior to care is presented. Onset of the pain
was gradual and worsened recently, interfering with work, sleep and rest. Lying flat on
her back helped. Pain radiated to both calves at time, left more than right. The physician
diagnosed her as having multi-level disc degeneration and degenerative joint disease
with significant subluxation of the thoracolumbar spine. She was most symptomatic of
a large, medial, contained L5/S1 disc protrusion with S1 nerve root compression.
After four weeks of Cox® Distraction therapy, she reported no leg or back pain. She is
able to walk and function again much to the delight of her family and the confusion of
her friends.

Cox JM, Trier K: Chiropractic adjustment results correlated with spondylolisthesis
instability. J of Manual Medicine 1991;6:67-72
Stable Spondylolisthesis 75% Relieved of Pain with Cox® Distraction
Hawk C, Azad A, Phongphua C, Long CR: Preliminary study of the effects of a
placebo chiropractic treatment with sham adjustments.

J of Manipulative And Physiological Therapeutics 1999;22(7):436-43
13 of 18 Low Back Patients Felt Greater Positive Effect of Flexion Distraction over
Placebo

Snow G: Chiropractic management of a patient with lumbar spinal stenosis. JMPT
2001; 24(4): 300-304
To discuss the case of a patient with severe, multilevel central canal stenosis who was
managed conservatively with flexion-distraction manipulation; to introduce a cautious
approach to the application of treatment, which can reduce the risk of adverse effects
and might make an apprehensive doctor more comfortable treating this condition; and
to propose a theoretic mechanism for relief of symptoms through use of chiropractic
manipulation. Clinical Features: A 78-year-old man had low back pain and severe bilateral
leg pains. Objective findings were minimal, yet magnetic resonance imaging
demonstrated severe degenerative lumbar stenosis at L3-L4 and L4-L5 and to a lesser
degree at L2-L3. Intervention and Outcome: Flexion-distraction manipulation of the
lumbar spine was performed. Incremental increases in traction forces were applied as
the patient responded positively to care. He experienced a decrease in the frequency
and intensity of his leg symptoms and a resolution of his low back pain. These
improvements were maintained at a 5-month follow-up visit. Conclusion: Successful
management of symptoms either caused by or complicated by lumbar spinal stenosis is
10presented. Manipulation of the spine shows promise for relief of symptoms through
improving spinal biomechanics. Further study in the form of a randomized clinical trial
is warranted.

Bergmann TF, Jongeward BV: Manipulative therapy in lower back pain with leg
pain and neurological deficit. J Of Manipulative and Physiological Therapeutics
1998; 21(4):288-294
Chiropractors need a nonsurgical, conservative approach to treat low back pain with
sciatica as an alternative to and before beginning the more aggressive, and potentially
hazardous, surgical treatment. There is some support for the idea that lumbar disc
herniation with neurological deficit and radicular pain does not contraindicate the
judicious used of manipulation. Although significant questions remain for the
evaluation and treatment of lumbar radiculopathy (sciatica) with disc herniations) there
is ample evidence to suggest that a course of conservative care, including spinal
manipulation, should be completed before surgical consult is considered.
Ice was applied to a patient's lower back for 5 minutes, followed by flexion-distraction
mobilization done by placing a hand contact over the L4 spinous process and using the
pelvic section of the table to distract the lumbar spine between the L4-L5 segment. This
procedure was repeated three times with each distractive process held for 20 seconds.
The patient was told to lie on her back at home with her knees bent in a "90/90" position
whenever possible. She was instructed to get up only for bathroom use.
One week after this appointment, she reported that her lower back pain was almost
gone and that the leg pain no longer bothered her. Treatment again consisted of lumbar
flexion distraction and long axis distraction of the lower extremity. At this point, side
posture rotary manipulation was added to her treatment plan.

Husbands DK, Pokras R: 1991 year-end compendium: The use of flexiondistraction in a lumbosacral posterior arch defect with a lumbosacral disc
protrusion: a case study. ACA J of Chiropractic 1991; December, pgs 21-24
The authors present a case of a 24-year-old Hispanic hyperkyphotic male with a
complaint of acute low back pain as the result of a bending and pulling injury. The
patient presented with a marked right laterally flexed antalgic lean and appeared to be in
severe pain. Radiographs revealed an L6 vertebra with hypoplastic lumbosacral
articular facets and spina bifida occulta. The patient also had radicular compression
symptomatology on physical exam. He was treated with flexion distraction for three
treatments with a significant decrease in symptomatology. The significance of this case
is that flexion distraction may also be useful in the treatment of conditions with inherent
instability such as in the case presented.

Hawk C, Long CR: Use of a pilot to refine the design of a study to develop a manual
placebo treatment. JNMS 2000;8(2):39-48
Thirty-two patients with subacute or chronic low back pain were randomly assigned to
group A (flexion-distraction technique and trigger point therapy), group B (sham
adjustment and effleurage massage), group C (flexion-distraction and effleurage), or
group D (sham adjustment and trigger point therapy) for 6 weeks of treatment. The
Roland Morris Questionnaire (RMQ) and the Pain Disability Index (PDI) were the
11outcome instruments of primary interest. RMQ median score changes were similar
across groups. PDI median score changes at week 3 were greatest in group A, less in
groups C and D, and least in group B. At week 6, group B still showed less change than
the others.

Crawford MC: Chiropractic management of acute low back pain. Alternative Th H
1999; 5(1):112
A 36-year-old mother of 2, previously healthy and athletic, presented with low back pain,
sharp shooting pain down the side of her left leg, and a numb feeling in her toes. She
stated that she was unable to toe raise or straighten her left leg at the knee.
The CT scan indicated a central left disk herniation at the L5 to S1 level, which was
abutting the ventral portion of the thecal sac and the left S1 nerve sheath.
Treatment involved 9 therapy sessions over a 3 week period. Each session consisted of
4 modalities. Interferential electrotherapy with moist heat lasting 15 minutes was used
to control pain. The interferential was set at a low frequency, 1 to 15 Hz, with
approximately 20 mA intensity (for patient tolerance) to produce endorphin release and
relieve hypertonicity. Manipulation of the lumbar spine and sacroiliac joints was done with
the patient in side posture. This manipulative technic was well tolerated and not painful
during or after the procedure. Finally, flexion traction of the specific vertebral segments
was accomplished using a Lloyd flexion distraction table, in which a manual traction force
was applied to the L5 spinous process in a cephalad direction while the table was flexed,
producing additional traction force at the specific vertebral segment. The patient improved
with each session. After the 9th session, the patient felt she had improved enough to
discontinue treatment.

Morris CE: Chiropractic rehabilitation of a patient with S1 radiculopathy associated
with a large lumbar disk herniation. JMPT 1999; 22(1):38-44
Objective: To describe the nonsurgical treatment of acute S1 radiculopathy from a large
(12 × 12 × 13 mm) L5-S1 disk herniation. Clinical Features: A 31-year-old man presented
with severe lower back pain and pain, paresthesia, and plantar flexion weakness of the
left leg. His symptoms began 5 days before the initial visit and progressed despite
nonsteroidal anti-inflammatory drugs and analgesic medication. An absent left Achilles
reflex, left S1 dermatome hypesthesia, and left gastrocnemius/soleus weakness was
noted. Magnetic resonance imaging demonstrated a large L5-S1 disk herniation.
Intervention and Outcome: Initial treatment of this patient included McKenzie protocol
press-ups to reduce and centralize symptoms, nonloading exercise for cardiovascular
fitness, and lower leg isotonic exercises to prevent atrophy. Counseling was provided
to reduce abnormal illness behavior risk. Later, flexion distraction and side-posture
manipulation were provided to improve joint function. Sensory motor training, trunk
stabilization exercises, and trigger point therapy were also used. He returned to
modified work 27 days after symptom onset. A follow-up, comparative magnetic
resonance imaging (MRI) study was unchanged. He was discharged as asymptomatic
(zero rating on both the Oswestry and numerical pain scales) after 50 days and 20 visits,
although the left S1 reflex remained absent. Reassessment 169 days later revealed
neither significant symptoms nor lifestyle restrictions. Conclusion: This case
demonstrates the potential benefit of a chiropractic rehabilitation strategy by use of
12multimodal therapy for lumbar radiculopathy associated with disk herniation.

Bulbulian R, Dishman JD, Burke J: Neuroreflex modulation of the lumbar spine in
flexion distraction. New York Chiropractic College, Seneca Falls, New York 13148.
Presented at 5th World Federation of Chiropractic in Auckland, New Zealand. May
15-23, 1999
Introduction: Flexion distraction has gained increased credibility as a therapeutic
modality for treatment of low back pain. Although important work in the area has
elucidated the intradiscal pressure profiles during flexion distraction, the
accompanying neural responses have yet to be described. The purpose of this pilot
study was to access neural reflex responses to motion with three degrees of freedom
applied to the lumbar spine and to evaluate H-reflex responses of the soleus.
Methods. Subjects (n=4) were measured for Hmax reflexes determined from stimulus
responses recruitment curves measured in neutral prone position, flexion, left and right
lateral flexion, and axial rotation on a Cox adjusting table. The mean of 10 evoked Hmax
waves expressed as a percentage of maximal M-wave was the criterion measure. Spinal
range of motion was quantified by Metrecom digitization. Results. The data showed
considerable variation in some movement ranges notwithstanding identical table
positioning for all subjects (i.e. Flexion 3-12°). Mean Hmax/Mmax ratios were 65.5+-15,
65.5+-17, 62.8+-12, 59.6+-17 and 65.9+-19 for neutral, flexion, R. Lateral, L. Lateral
flexion and R and L axial rotation respectively. The salient findings in the data were the
non-existent H-reflex changes in lateral flexion and the significant suppression of
neuromuscular activation in flexion (65+-16 vs 60+-15%; p<0.05) and ipsilateral rotation
(65+-16 vs 59+-17%; p<0.05). Slight perturbations in numerous afferent receptors are
known to significantly alter the H-reflex. The absence of measurable changes in lateral
flexion may indicate that both slow and fast adapting receptors could be involved in
lumbar motion. These preliminary findings suggest the need for further dynamic motion
studies of the flexion distraction neurophysiology.

Bulbulian R, Burke J, Dishman JD : Spinal reflex excitability changes after lumbar
spine passive flexion mobilization. Journal of Manipulative and Physiological
Therapeutics 2002; (Vol. 25, Issue 8, Pages 526-532
Background: Flexion distraction has gained increased credibility as a therapeutic
modality for treatment of low back pain. Although important work in the area has
elucidated the intradiskal pressure profiles during flexion distraction, the
accompanying neural responses have yet to be described. Objective: The purpose of
this pilot study was to assess neural reflex responses to motion with 3 degrees of
freedom applied to the lumbar spine and to evaluate H-reflex responses of the soleus.
Methods: Subjects (n = 12) were measured for H-maximum reflexes determined from
stimulus response recruitment curves measured in neutral prone position. The mean of
10 evoked H-waves (at H-maximum stimulus intensity) were measured in neutral
position, flexion, left and right lateral flexion, and axial rotation of the trunk on an
adjusting table. H-reflexes were expressed as a percentage of maximal M-wave for the
criterion measure. Spinal range of motion was quantified by digitization. Results: The
data showed variation in some movement ranges, notwithstanding identical table
positioning for all subjects. Mean H-reflex amplitude was decreased (15.2 ± 5.8 mV to
1313.8 ± 5.8 mV), and the H/M ratio was also decreased in flexion compared with neutral
(55.0% ± 19.1% to 50.3% ± 19.4%; P < .05). Conclusions: Trunk flexion is accompanied
by inhibition of the motor neuron pool. Slight perturbations in numerous afferentreceptors
are known to significantly alter the H-reflex. The absence of measurable changes in
lateral flexion and trunk rotation may indicate that both slow- and fast adapting
receptors could be involved in lumbar motion. These preliminary findings
suggest the need for further dynamic motion studies of the flexion distraction
neurophysiologic condition.

Gallucci G [1438 S.O.M. Center Road, Mayfield Heights, OH 44124 -- (216)461-4848]:
The effectiveness of chiropractic treatment for disc syndrome. A Study by Blue
Cross and Blue Shield of Ohio and Physicians First, Inc. (1996)
A study was conducted as a joint venture between Physicians First, an established
chiropractic clinic, and Blue Cross and Blue Shield of Ohio. The purpose was to
compile statistics on the effectiveness of chiropractic treatment of back injuries that
might otherwise require surgical intervention. The study was composed of a total of 10
patients with diagnosed intervertebral disc syndrome. All 10 subjects had received
treatment from a medical doctor for the diagnosed conditions. The subjects were
treated under a twelve week plan which included the utilization of Cox Distraction
Technique. Post-treatment surveys revealed that all 10 patients reported improvement
in the frequency and severity of symptoms.

Guadagnino MR: Flexion-distraction manipulation of a patient with a proven disc
herniation. J Of The Neuromusculoskeletal System 1997; 5(2):70-73
Lumbar radicular symptoms can be caused by lumbar intervertebral disc herniations. If a
disc injury is positively established through diagnostic imaging, surgery is a commonly
recommended approach. Flexion/distraction manipulation is a therapeutic alternative that
may offer relief for subjective complaints and elimination of objective signs. Success with
this technique might spare the patient an operative procedure. This is a case report of
one such incidence. Flexion/distraction manipulation is a treatment developed by James
M. Cox. It is often used for lumbar disc injuries (herniation, bulges, etc.), and for other low
back and lower extremity radicular conditions. The technique involves the use of a
specialized table which allows for passive distraction, flexion, lateral bending, and
rotation. These different planes of motion, along with the use of appropriate adjunctive
therapy and exercises, allow for reduction of symptoms attributable to lumbar disc
syndromes. Contraindications and indications for flexion/distraction manipulation have
been identified and enumerated. Flexion/distraction manipulation is a treatment that
should be investigated as a part of the algorithm for presurgical therapies of lumbar
intervertebral disc injuries. This alternative in conservative care may be of benefit to a
large number of patients. The surgical option for treating intervertebral disc herniations
might be reduced with propagation of flexion/distraction manipulation.

Eyerman, E. Simple pelvic traction gives inconsistent relief to herniated lumbar
disc sufferers. Journal of Neuroimaging. Paper presented to the American Society
of Neuroimaging, Orlando, Florida 2-26-98.
14"Serial MRI of 20 patients treated with the decompression table shows in our
study up to 90% reduction of subligamentous nucleus herniation in 10 of 14.
Some rehydration occurs detected by T2 and proton density signal increase.
Torn annulus repair is seen in all."

Shealy, N. et al.: Decompression, Reduction, and Stabilization of the
Lumbar Spine: A Cost-Effective Treatment for Lumbosacral Pain. American
Journal of Pain Management Vol. 7 No. 2 April 1997
"Eighty-six percent of ruptured intervertebral disc (RID) patients achieved 'good'
(50-89% improvement) to 'excellent' (90-100% improvement) results with
decompression. Sciatica and back pain were relieved." "Of the facet arthrosis
patients, 75% obtained 'good' to 'excellent' results with decompression."

Gionis, T. et al.: Surgical Alternatives: Spinal Decompression. Orthopedic
Technology Review. 2003; 6 (5).
"Results showed that 86% of the 219 patients who completed the therapy
reported immediate resolution of symptoms, while 84% remained pain-free 90
days post-treatment. Physical examination findings showed improvement in 92%
of the 219 patients, and remained intact in 89% of these patients 90 days after
treatment."

Gundersen, B, et al.: A Clinical Trial on Non-Surgical Spinal
Decompression Using Vertebral Axial Distraction Delivered by a
Computerized Traction Device. The Academy of Chiropractic Orthopedists,
Quarterly Journal of ACO, June 2004
"All but two of the patients in the study improved at least 30% or more in the first
three weeks.""Utilizing the outcome measures, this form of decompression
reduces symptoms and improves activities of daily living."

Yochum, et al.: Treatment of an L5-S1 Extruded Disc Herniation Using a
DRX-9000 Spinal Decompression Unit: A Case Report. Chiro Econ, Vol 53:
Issue 2.
Spinal Decompression Therapy "...allowed imbibition and complete reduction of
the visualized herniation." "Spinal decompression therapy provided an effective
means of treatment for this patient's symptoms resulting from discal herniation
(extrusion) with associated impingement of the adjacent nerve root." "MR
imaging proved to be a useful and non-invasive technique in monitoring the
efficacy of decompression therapy as it applies to this case." "Decompression of
the spine proved to be superior to the other forms of conservative care when
applied to our patient. The patients' results were both subjectively favorable and
objectively quantified."

Research

Take Action

Learn More