Preface
This page is written for physicians and healthcare providers.
Just as there are multiple medical procedures to treat the same condition, there are also multiple chiropractic approaches. From the outside, this can create understandable confusion about what chiropractic actually is — and more importantly, what any individual chiropractor actually does.
I view chiropractic techniques as different clinical tools. While I continue to use traditional manual manipulation when appropriate, my practice is centered on Cox® Flexion-Distraction, a highly specific form of mechanically assisted spinal manipulation designed for disc, nerve root, and degenerative spine conditions. I currently serve as the Cox Flexion-Distraction instructor at Cleveland University–Kansas City and as a national workshop instructor for Dr. James Cox.
Much of the effectiveness of this approach depends on a clinician’s ability to perceive tissue tension, joint resistance, and neurologic response in real time. The late osteopathic physician Dr. Alan Stoddard captured this well when he compared skilled manual care to the difference between a surgeon and a butcher — not in force, but in precision and tactile discrimination.
No single profession holds a monopoly on treating back and neck pain. My goal is to clarify what modern, evidence-based chiropractic can contribute, and to strengthen collaborative relationships with referring providers for the benefit of shared patients.
If you are interested in the current literature on conservative spine care, manual medicine, and non-surgical management of musculoskeletal disorders, I invite you to explore KC Spine Facts — a curated, clinician-focused resource reviewing recently published research relevant to front-line spine care.
A Different Method of Spinal Manipulation
Cox® Flexion-Distraction is a form of low-velocity, low-amplitude (LVLA) mechanically assisted spinal manipulation, in contrast to traditional high-velocity, low-amplitude (HVLA) thrust techniques. Treatment is delivered on a specialized flexion-distraction table that allows segment-specific decompression while guiding spinal joints through their normal physiological ranges of motion.
Unlike traction or generalized mobilization, Cox Flexion-Distraction is a hands-on, clinician-directed procedure. The physician continuously monitors tissue tension, joint resistance, and neurologic response while adjusting force and motion in real time. As with other manual disciplines, proficiency requires extensive training and clinical experience.
Historical Foundation
Cox Flexion-Distraction was developed in the early 1960s by James M. Cox, DC, who integrated chiropractic biomechanics with osteopathic principles articulated by Alan Stoddard, DO, and John McManis, DO. In 1973, Dr. Cox introduced the term “flexion-distraction,” which has since become the accepted name for the procedure.
This osteopathic influence is particularly evident in the emphasis on palpatory diagnosis, tissue response, and controlled therapeutic loading, rather than forceful joint cavitation.
How Cox Flexion-Distraction Differs from Traction
Although Cox Flexion-Distraction involves spinal decompression, it should not be confused with traction therapy.
Traction systems typically use straps and mechanical pulling forces based on a percentage of body weight to apply a generalized longitudinal force across multiple spinal segments, usually in a single plane of motion. Individual joint levels are not isolated, and the clinician has limited ability to adjust force based on real-time tissue response.
By contrast, Cox Flexion-Distraction is:
- Segment-specific — forces are directed to targeted spinal levels
- Hands-on — the physician controls motion and force at all times
- Multiplanar — joints are mobilized through flexion, extension, lateral flexion, and distraction while decompressed
- Tolerance-based — force is continuously adjusted based on patient response
This allows precise mechanical and neurologic input without the uncontrolled forces associated with some thrust or traction-based approaches.
Patient Populations Commonly Treated
Cox Flexion-Distraction is commonly used for patients with neck and back pain, particularly those with chronic or mechanically complex conditions.
Chronic spine patients represent a small percentage of the total musculoskeletal population but account for a disproportionate share of healthcare utilization and cost. In these cases, treatment goals typically emphasize functional improvement and symptom management rather than cure.
This is where precision-based, tolerance-guided spinal decompression and mobilization can be particularly valuable.
Cases Treated by Dr. Patterson
Case 1
I have treated this patient for many years. She was 77 at the time of these films. You can see a two-level fusion from L3-L5. Note the severe degenerative changes at L5/S1 and L2/3. She has severe stenosis measuring 5mm at L2/3 and 7mm at T12/L1. Cox distraction allows me to treat the areas gently and specifically above the fusion as well as pelvis. We help her mange her pain and improve function.
Case 2
These images of a 60-year-old female were taken in 2019. She had suffered with sciatic pain for over 30 years. In 2016 she opted for low back surgery. Note the laminectomies from L2-5. She has severe disc degeneration at L3/4. She received some initial relief from the surgery, but over the course of 3 years, she developed increased left leg pain and new pain in the right buttock. With Cox treatment, her pain began to localize into the buttocks. Her pain levels dropped from 8 and 9/10 to 4/10. We explain to these patients that 50% reduction in pain is a good clinical outcome. We continue to treat her periodically for flares, and she has an occasional injection.
Case 3
These images are of a 47-year-old male, taken in 2021. Note the disc herniation at L4/5 with bilateral narrowing of the neural foramen and smaller disc herniation at L5/S1. He first noticed low back pain 2 years previously after driving 12-13 hours. He eventually developed pain in the calf and worsening pain within 15 minutes of standing. Prior treatment included 4 months of physical therapy, 3 steroid injections in 2020 and 3 injections in 2021. The last injection only lasted 1 week. One medical doctor recommended surgery and another told him to never have surgery. He responded exceptionally well to Cox treatment. After 7 visits his burning and tingling were gone. He had very little symptoms with standing. He was given exercise and put on a PRN schedule, as he lives 2 hours from our office.
Case 4
This patient presented to my office in 2009, with severe scoliosis with degenerative changes. She rated her pain level as 9/10. Previous treatment included 2 months of PT and oral medication.
She would have had surgery but could not get clearance from her cardiologist because of recent heart attack and stents. Her leg pain resolved with Cox technic, and she was able to return to cardiac rehab.
She has continued be successfully treated with Cox FD since 2009 and avoided surgery. I submitted this as a case report. Here is a link to the complete report.
Who uses Cox distraction?
While 64% of chiropractors report they use flexion-distraction to varying degrees, only 3% of chiropractors have gone through formal training and are actively certified in Cox technic.
Some medical facilities where Cox work is used
Mayo Clinic – Ralph Gay, M.D., D.C. is a researcher and associate professor of Physical Medicine and Rehabilitation
Osher Center for Integrative Medicine – Harvard Medical School and Bringham and Women’s Hospital.
Several VA Hospitals and military medical facilities such as Scott Air Force Base and Central Arkansas Veterans Healthcare System
Cox flexion distraction is a well-researched, evidence-based technic with ongoing studies.
Current studies at Keiser University College of Chiropractic Medicine include:
- Post-surgical continued pain patients undergoing flexion distraction
- Spinal stenosis patients undergoing flexion distraction
- Ultrasound imaging of lumbar spine during flexion distraction
Below are a few highlights from earlier work. A larger list can be found at this link. List of publications by Cox
Early biomechanical research showed the following with Cox treatment:
- Disc pressure in the lumbar spine drops as low as -192mm Hg
- The neural foramen widens by 28%
- Motion is created at the specific level of interest
- Treatment is well within the failure loads of ligaments
1000 case study
All conditions combined:
12 visits over 29 days to reach maximum improvement
70.7% of patients had good to excellent results
Subgroups:
Analysis was then performed by individual diagnosis and specific joint level. Patients with nuclear protrusion required more visits and longer treatment period than conditions like spondylolisthesis, facet syndrome or spondyloarthrosis.
Randomized clinical trial comparing Cox to Physical Therapy using Active Trunk Exercise Program
After 4 weeks of care, both groups had significantly less pain and increased function. Cox flexion distraction (FD) group had significantly greater relief from pain than the exercise group. Patients with radiculopathy did significantly better with FD. Patients with chronic, moderate to severe symptoms improved the most with FD. Patients with recurrent, moderate to severe symptoms did better with exercise.
https://pubmed.ncbi.nlm.nih.gov/16341712/
At 1 year follow-up – FD group had significantly lower pain scores than the exercise group. Over the course of the year, the exercise group had significantly more healthcare visits than the FD group.
https://pubmed.ncbi.nlm.nih.gov/16970536/
Dr. Patterson Comments: This trial is not listed to disparage physical therapy. It indicates that each profession has its strengths when looking at subgroup data. In my opinion, working relationships need to be developed between chiropractors and physical therapists to achieve the best patient outcomes.
Cervical Studies
While the majority of flexion distraction research has involved the lumbar spine, work has been and is continuing to be done in the cervical spine. Early flexion distraction tables had no separate mechanisms to treat the cervical spine. As Cox tables evolved, head pieces were developed to allow the cervical spine to be treated in the same manner as the lumbar spine. We decompress the spine and then put joints through their various ranges of motion. In 2013, the first cervical study using cadaver spines to access intradiscal pressure changes using Cox FD was published.
Alan Stoddard
“The difference between the manipulator with a keen sense of tissue tension and one without such tension sense is as wide as that of the painter of portraits and the painter of houses. It is as wide as the skill of a surgeon and the butcher, the watchmaker and the blacksmith, the sculptor, and the joiner. Herein lies the difference between the osteopath who has spent years of close application to his art and the operator who thinks he can learn manipulation in a few easy lessons.”
Location
11791 W 112th Street #101
Overland Park, KS 66210
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Phone
(913) 345-9247
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drbob@overlandchiro.com