This page has been written with patient providers in mind. Just as there are different medical procedures to treat the same condition, so it is with chiropractic. This can lead to confusion among patients and medical providers as to what I do as a chiropractor. I view different techniques as different tools in my toolbox. While I still perform traditional manual manipulation in specific cases, I specialize in Cox flexion distraction technic. I am the instructor for this technic at Cleveland University KC as well as a workshop instructor for Dr. Cox.

Much of the skill in its successful application involves the ability to feel tissue tension. I believe the well-known osteopath; Dr. Alan Stoddard describes it best. I have posted a quote from him.

No single profession has a magic treatment for back pain. I hope to increase other providers understanding of what chiropractic has to offer and improve working relationships for the benefit of all our patients.

Much of the skill in its successful application involves the ability to feel tissue tension. The well-known osteopath, Dr. Alan Stoddard, describes it best when he compares this skill to that of a surgeon vs a butcher.

No single profession has a magic treatment for back pain. I hope to increase other providers’ understanding of what chiropractic has to offer and to improve working relationships for the benefit of all our patients.

A Different Method of Spinal Manipulation

Cox Flexion Distraction technique is Low Velocity Low Amplitude (LVLA) manipulation vs traditional High Velocity Low Amplitude (HVLA) manipulation. A flexion-distraction (FD) table is used to decompress specific joints, and then to put those joints through their various physiological ranges of motion. It is a highly-skilled technique that can take years to master.



Cox technic was developed in the early 1960’s by James M. Cox, DC. He combined chiropractic principles with the osteopathic principles as set forth by Alan Stoddard, DO, and John McManis DO. In 1973, Dr. Cox coined the term “flexion-distraction” which is the commonly-used name for Cox technic.


Cox flexion distraction in kc

How is Cox technic different from other forms of traction?

    1. Cox is a skilled, hands-on procedure.
    2. It is specific. Forces are targeted to specific joint levels.
    3. The doctor feels for tissue tension at a specific joint level and then applies a therapeutic degree of force.
    4. Joints are placed through multiple ranges of motion while decompressed.
Cox flexion distraction

Traction tables in various forms typically involve a technician using straps around the area to be treated. A percentage of body weight is calculated to determine the degree of general pulling throughout the spinal column. There is no specific joint isolation and movement is in one plane of motion.

Who we treat

We treat all types of neck and back pain. Personally, I experience the most satisfaction working with the chronic back pain patient. These are the 5% of patients that make up 75% of the cost.

Patients with chronic low back and leg pain can be the most challenging patients to treat for any type of provider, whether it be related to disc herniation, degenerative disc disease, spinal stenosis, or the post-surgical patient. For these patients, we emphasize management of their condition vs cure.

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:

    1. Post-surgical continued pain patients undergoing flexion distraction
    2. Spinal stenosis patients undergoing flexion distraction
    3. 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

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.

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.

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.”



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