Low Back Pain


Chiropractic Cox Technic Flexion Distraction and Decompression spine manipulation gives positive outcomes and is supported by the literature on back care. Chiropractic spinal manipulation is a standard of care for low back pain and leg pain. Its benefits are well documented in the literature, and research literature citations are discussed here.

Low Back Pain

Any discussion of low back pain must begin with a description of what low back pain means to you, the patient. It may be one or more of the following symptoms:

  1. Pain localized to the low back only
  2. Pain localized to the low back and buttock
  3. Pain localized to the low back, buttock, and thigh
  4. Pain localized to the low back, buttock, thigh and leg and even extending to the foot and toes

All of these descriptions are given to low back pain and are but variations of what is commonly referred to as low back pain. It can be stated accurately that the further the pain extends down the lower extremity, the more serious the spine problem is, and the more difficult it is to relieve. The reason being that with full leg pain -- sciatic nerve pain down the back and side of the thigh, leg, and bottom of the foot or femoral nerve pain down the front of the groin, thigh, leg and foot --  there is irritation of the spinal nerve as it exits the spine in the low back. This is more complex and usually involves disc herniation or spinal stenosis.

The Patient

We will first look at the patient who has only low back pain which may extend to the buttock and thigh but not extend further down the leg below the knee. This condition is largely considered more amenable to relief. Chiropractic flexion distraction spinal manipulation has specific procedures for the various causes of such pain. Those procedures involve spinal manipulation utilizing spinal stretching called distraction and spinal motions like flexion, extension, side-bending and circumduction to regain normal motion to the low back. We also often use frequency specific microcurrent during treatment.

The Effects of Care

The following are the changes in the spine that relieve pain when this form of spinal adjusting is given:

  1. The intervertebral disc space is increased, that is, it is increased in height
  2. The pressure within the intervertebral disc is reduced.
    • This reduces the pressure on the nerve it is compressing.
    • This reduced pressure inside the disc stops the nerve irritation which relieves low back and leg pain.
  3. The size of the nerve opening within the spinal column, called the foramen, is increased up to 28% in size.
  4. The joints of the spine are moved into their normal ranges of motion to regain normal mobility and freedom of motion without pain
The Benefits of Conservative, Spinal Manipulation Care for Low Back Pain
Spinal research literature continues to document positive outcomes of conservative care for low back pain and that surgery may not always be necessary.
  • The United States Public Health Service, U.S. Department of Health and Human Services guidelines state that spinal manipulation is safe and recommended for acute low back pain. (1)
  • 33% of 27,810 people chose chiropractors as their treating physician for low back pain in the National Health and Nutrition Examination Survey (NHANE). (2)
  • Spinal manipulation is recommended for low back pain. (3)
  • Spinal manipulation is recommended by the American Pain Society and the American College of Physicians for primary care of low back pain. (4)
  • Prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective for primary care of low back pain. (4)
  • Epidural steroid injections give short term but not long-term relief of low back pain. (4)
  • Spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. (4)
  • Surgery for leg pain (radiculopathy) with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to non-surgical therapy for low back pain, though the surgical benefits diminish with long-term follow-up. (4)
  • For patients with no leg pain (non-radicular back pain), with disc degeneration, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard non-surgical therapy. (4)
Documented Outcomes of Cox Technic Flexion Distraction and Decompression For Low Back Pain
  • A study of 1000 patients with low back and lower extremity pain treated with Cox Flexion Distraction and Decompression spinal manipulation by 30 chiropractic physicians is shown in the following chart. Note that various diagnoses of low back and leg pain are given such as sprain/strain, spondylolysis, etc., and each of these diagnosed conditions are described elsewhere in this website as to their diagnosis and treatment.
    • The number of visits and days to attain relief of these conditions, regardless of the individual diagnosis, was found.
      • the average number of days was 29 days
      • the number of office visits for spinal manipulation was 12    (5,6,7)


Less than 90 days

More than
91 days

More than 20 visits

More than 30 visits









L4 - 56%
L5 - 36%
L4 - 30%
L5 - 30%














L4 - 31%
L5 - 30%
L4 - 19%
L5 - 19%




L4 - 55%
L5 - 27%
L4 - 31%
L5 - 10%







29 days

12 treatments

  • In a comparison study of Cox Flexion Distraction and Decompression spinal manipulation to active exercises for chronic low back pain with and without lower leg pain (sciatica), a total of 235 subjects were studied; 123 were assigned to Cox Flexion Distraction and 112 to active trunk exercise protocols.
    • Subjects randomly allocated to the flexion distraction group had significantly greater relief from pain than those allocated to the exercise program.
    • Subjects categorized as chronic, with moderate to severe symptoms, improved most with the Flexion Distraction protocol.
    • Patients with radiculopathy (leg pain) did significantly better with Flexion Distraction.
    • Overall, Flexion Distraction provided more pain relief than active exercises. (8)
  • Applying axial distraction to the spine is shown to decrease disc stress on the anulus and nucleus. This is anticipated to reduce the compressive disc stresses in back pain. (10)
Reasons to Try Conservative Care for Low Back Pain Before Surgery
  • 95% of patients with low back pain and leg pain will resolve within 1 to 12 months with non-surgical care. (9)
  • A trial of conservative non-operative care is advised before surgery for patients with lumbar disc herniation. 95% of low back pain and leg pain patients are well in a time period of one to 12 months without surgery. (11)
  • A comparison of surgically treated with non-surgically treated patients with chronic low back pain of 349 chronic low back pain patients aged 18-55 years showed no evidence that surgery was any more beneficial than intensive rehabilitation. Surgery cost more, had potential risks, and was not cost effective. (12)
  • Cost and clinical outcome comparisons of chiropractic versus medical care for low back and leg pain showed that chiropractic care is less expensive when care extends beyond primary care. (13)
  • Spinal manipulation provided better short and long-term functional improvement as well as more pain relief in the follow-up than either back school or individual physiotherapy in a study of 210 patients with chronic, non-specific low back pain.
    • Spinal manipulation was associated with higher functional improvement and long-term pain relief than back school or individual physiotherapy.
    • Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy. (14)
  • Traction with relatively low magnitude was found to have significant beneficial effect in maintaining disc height of degenerated disc. (15)
  • Under conservative care, quality of life for lumbar radiculopathy (leg pain) patients improves. (17)
  • There are currently no clear indications for surgery in non-specific low back pain. (18)
  • Chronic low back pain patients without severe neurological deficits can be treated with manipulation, acupuncture, exercise, education, self care. (19)
  • Chiropractic care of worker’s compensation patients shows acute, subacute and chronic back and neck pain patients showed improved subjective and functional status under chiropractic spinal manipulation. (20)

60-80% of health-care consulting patients will continue to have pain after a year. Some say that 90% of back and leg pain patients will be well in 90 days if no treatment is given. This simply is not true as studies show that a third to 72% of them will have pain a year later. Chiropractic treatment is needed and recommended. (21) Conservative, chiropractic care has a place in healthcare for effective, cost-effective, documented treatment for low back pain relief.

  1. Bigos SJ et al: Acute Low Back Problems in Adults. Clinical Practice Guideline No 14, Agency for Health Care Policy and Research Publication No. 95-0642, Public Health Service, U.S. Dept of Health and Human Services, December, 1994
  2. Deyo R et al: Spine 12(3): 1987
  3. Chou R: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147:478.2007
  4. Chou, R et al; Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.  Spine May, 2009; 34 (10)
  5. Cox JM, Shreiner S: Chiropractic manipulation in low back pain and sciatica: statistical data on the diagnosis, treatment and response of 576 consecutive cases. JMPT 7(1):1-11;1984
  6. Cox JM, Feller JA: Chiropractic treatment of low back pain: a multicenter descriptive analysis of presentation and outcome of 424 consecutive cases. J of  Neuromusculoskeletal System;1994:2(4)
  7. Cox, JM. Low Back Pain: Mechanism, Diagnosis, Treatment. 6th edition. Lippincott, Williams & Wilkins 1999
  8. Gudavalli, MR, Cambron, JA, 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(6):1072-82
  9. Legrand E: et al. Disc herniation induced sciatica: medical or surgical treatment?. Revue Du Praticien 2008;58(3):285-93
  10. Hussain, M; Gay, RE; An, KN. Reduction in disk and fiber stresses by axial distraction is higher in cervical disk with fibers oriented toward the vertical rather than horizontal plane: a finite element model analysis. Journal of Manipulative and Physiological Therapeutics 33 (4). MAY 2010. p.252-260
  11. Daffner, SD; Hymanson, HJ; Wang, JC. Cost and use of conservative management of lumbar disc herniation before surgical discectomy. SPINE JOURNAL 10 (6). JUN 2010. p.463-468
  12. Fairbank, J et al: Randomized controlled trial to compare surgical stabilization of the lumbar spine with an intensive rehabilitation program for patients with chronic low back pain. The MRC stabilization trial. British Med J 330(7502):May 28, 2005,p1233-39
  13. Grieves, B; Menke, JM; Pursel, KJ. Cost minimization analysis of low back pain claims data for chiropractic vs medicine in a managed care organization. JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS 32 (9 SP ISS). NOV-DEC 2009. p.734-739
  14. Cecchi, F; Molino-Lova, R; Chiti, M. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. CLINICAL REHABILITATION 24 (1). JAN 2010. p.26-36
  15. Lai, Alon PhD; Chow, Daniel H. K. PhD. Effects of Traction on Structural Properties of Degenerated Disc Using an In Vivo Rat-Tail Model. Spine2010:35(14):1339-45
  16. deleted
  17. Boskovic, K; Todorovic-Tomasevic, S; Naumovic, N. The quality of life of lumbar radiculopathy patients under conservative treatment. VOJNOSANITETSKI PREGLED 66 (10). OCT 2009. p.807-812
  18. Weiner, SS; Nordin, M. Prevention and management of chronic back pain. BEST PRACTICE & RESEARCH IN CLINICAL RHEUMATOLOGY 24 (2). APR 2010. p.267-279
  19. JM; Haldeman, S; Tricco, AC; Dagenais, S. Management of Chronic Low Back Pain in Active Individuals. CURRENT SPORTS MEDICINE REPORTS 9 (1). JAN-FEB 2010. p.60-66
  20. Aspegren, D; Enebo, BA; Miller, M; White, L; Akuthota, V; Hyde, TE; Cox, JM. Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: a retrospective analysis of 100 cases. Journal of Manipulative and Physiological Therapeutics 32 (9 sp iss). Nov-Dec 2009. p.765-771
  21. Hayden, JA; Dunn, KM; van der Windt, DA; Shaw, WS. What is the prognosis of back pain? Best Practice & Research in Clinical Rheumatology 24 (2). APR 2010. p.167-179 
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