Lumbar Spine - Clinical Outcomes

Cox® Technic Flexion Distraction and Decompression has enjoyed a long history under its developer, Dr. James Cox, and the chiropractic physicians who use flexion distraction to relieve lower back pain and leg pain in their patients. The initial published studies documented the clinical outcomes of patients treated with the technique. One by one the articles were written and published by Dr. Cox and independent practitioners. A large 1000 cases data collection was produced. Then the Health Resources and Services Administration program for chiropractic research started in the 1990's which brought in more chiropractic researchers, biomechanists and clinicians to produce randomized controlled trials. This history of independent physician publishing and formal research project publishing continues excitingly today.

Rowell RM, Rylander SJ. Low-Back Pain, Leg Pain, and Chronic Idiopathic Testicular Pain Treated with Chiropractic Care. J Altern Complement Med. 2012 Apr 10. [Epub ahead of print] 
  • 36 year old man with 5 years of lower back pain, right leg pain testicular pain
  • 19 treatments with Cox® Technic (flexion distraction) in 8 weeks
  • Testicular pain – improved at 1 visit; gone in 3 weeks; still gone at 6 month follow up
  • Low back pain (lumbar spine pain) – decreased at 4 weeks
  • Leg pain – gone at 4 weeks 
  • 75 year old man with low back pain and right anterior thigh and left posterior leg pain of 3 years’ duration is relieved with Cox® Technic (flexion distraction).
    • 4 visits – no right or left leg pain
    • 3 months of 16 visits – low back and buttock pain are minimal with no leg pain
    • 80% relief
  • 49 consecutive patients with disc herniation confirmed on MRI with pain and disability for an average of 60.5 weeks were treated 2-3 times a week initially for 3 weeks with flexion distraction manipulation.
  • Flexion Distraction manipulation, neurodynamic techniques, joint manipulation, myofascial technic and exercise were utilized.
  • Clinical outcome at end of treatment and 14.5 months later showed
    • Clinically meaningful improvement of pain and disability in
      • 79% and 70% of patients respectfully at end of treatment
      • 79% and 73% respectfully at 14.5 months follow-up


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

  • 29 days to maximum improvement (mean) regardless of condition treated
  • 21 visits to maximum improvement (mean) regardless of condition treated
  • Disc herniations take longer than sprain/strains
  • 91% of patients relieved within 90 days, keeping them from the chronic pain stage
  • Results


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 [results of HRSA funded federal grant project between National University of Health Sciences, Loyola Stritch School of Medicine, University of Iowa, University of Illinois, and others]

  • Comparison of flexion distraction (FD) to physical therapy/active exercise (ATEP) for low back pain
  • Both groups improved significantly (measured by VAS and RM) after treatment
  • Patients assigned to FD did better than ATEP (VAS)
  • Patients with radiculopathy improved significantly better with FD therapy (VAS)
  • Results


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 follow-up, participants previously randomized to physical therapy attended significantly more healthcare visits  for low back pain than those participants who received chiropractic care.
    • 38% of flexion–distraction patients sought care
    • 54% of physical therapy patients sought 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

  • Flexion distraction was found to be more effective in reducing pain for 1 year when compared to a form of physical therapy.


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

  • 2 patients with low back and radicular pain attributed to MRI-confirmed synovial cysts of the lumbar spine
  • Relief after treatment with flexion distraction and physiological therapeutics


Snow G: Chiropractic management of a patient with lumbar spinal stenosis. JMPT 2001; 24(4): 300-304

  • severe, multilevel central canal stenosis in a 78-year-old man
  • low back pain and severe bilateral leg pain
  • MRI - severe degenerative lumbar stenosis at L3-L4 and L4-L5 and at L2-L3 (less so)
  • Treatment - flexion-distraction manipulation of the lumbar spine
  • Outcome - 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.


Morris CE: Chiropractic rehabilitation of a patient with S1 radiculopathy associated with a large lumbar disk herniation. Journal of Manipulative and Physiological Therapeutics 1999; 22(1):38-44

  • 31 y/o man with severe lbp, plantar flexion weakness of left leg, absent Achilles reflex, hypesthesia S1 dermatome, MRI large L5-S1 HNP
  • Cox decompression distraction adjustment was part of the treatment resulting in RTW in 27 days.
  • Repeat MRI showed no change
  • 20 visits over 50 days with total remission. Absent Achilles maintained.


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 due to lumbar intervertebral disc herniation
  • Flexion/distraction allowed patient to avoid surgery.


Hayden RA: Multilevel degenerative disc disease: a case study. Georgia Chiropractic Journal 1996; April: 6-7:34

  • 61-year-old female with low back, hip and sciatic pain
  • five years bedridden or restricted to the sofa
  • 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, Hazen LJ, Mungovan M: Distraction manipulation reduction of an L5-S1 disc herniation. Journal of Manipulative and Physiological Therapeutics 1993; 16(5):342-346

  • A computed tomography (CT)-confirmed L5-S1 disk protrusion causing sciatica and low back pain
  • Relieved with flexion-distraction chiropractic manipulation, electrical stimulation, exercises, nutrition advice and low back wellness school class


Hazen LJ, Cox, JM: Lumbar intraspinal extradural synovial cyst: a case study. J of Neuromusculoskeletal System 1993; 1(4):167-169

  • Lumbar intraspinal extradural synovial cyst
  • Managed non-surgically with flexion-distraction and physical therapy modalities (galvanism)


Hubka MJ, Taylor JAM, Schultz GD, Traina AD: Lumbar intervertebral disc herniation: chiropractic management using flexion, extension, and rotational manipulative therapy. Chiropractic Technique 1991; 3(1):5-12

  • large herniation of the L5-S1 intervertebral disc
  • 16-days of flexion distraction mobilization, rotational manipulations, and extension mobilizations
  • Stretching, strengthening, and coordination
  • Dramatic subjective and objective improvement followed chiropractic management.
Gay RE, Bronfort G, Evans RL. Distraction manipulation of the lumbar spine: a review of the literature. J Manipulative Physiol Ther. 2005;28:266–273
  • Further research is needed to establish the efficacy and safety of distraction manipulation and to explore biomechanical, neurological, and biochemical events that may be altered by this treatment.
  • A discussion of nucleus pulposus movement is presented. 
  • A comparison study 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 is presented.


For a complete list of publications on Cox® Technic, click here.

For information on federally funded studies - description, status, funding - click here.