Low Back Pain: Mechanism, Diagnosis and Treatment

752 Pages·1999·35.12 MB·English

by  James Cox

Low Back Pain
Mechanism,
Diagnosis,
and Treatment
Sixth Edition
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Low Back Pain
Mechanism,
Diagnosis,
andT reatment
Sixth Edition
James CMo.x D,. C., D.A.C.B.R.
Director, Cox Low Back Pain Clinic
Fort Wayne, Indiana
Postgraduate Faculty Member
National College of Chiropractic
Lombard, Illinois
Diplomate
American Chiropractic Board of Radiology
Willia&m Wsi lkins
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FOREWORD
In the fall of 1970, I attended a workshop of the American Chi­ provided in a clear and concise manner, leaving a clearly open­
ropractic Board of Radiology. I was a new diplomate, having ended opportunity for the development of new knowledge.
completed my residency program and receiving diplomate sta­ On a personal note, it has been my privilege to know Dr.
tus in that same year. Although not a precise contemporary in James Cox since the mid 1960s and it is with great admiration
our professional, educational studies, Dr. Cox and I neverthe­ and affection that I extend my sincere thanks and deepest ap­
less both became diplomates in radiology in 1970, and it was at preciation for this lifelong dedication to the art and science of
that first workshop that I listened to Dr. Cox present some of chiropractic healing.
his ideas on the acute low back syndrome. Twenty-eight years
James F. Winterstein, D.C.
later, it is my pleasure to write this Foreword and to realize
President
what a great distance has been traveled in that time period.
National College of Chiropractic
Today, Dr. Cox, along with others here at National Col­
lombard, Illinois
lege of Chiropractic, have had the privilege of working in col­
laboration with members of the Stritch School of Medicine at A few years back, a lovely, young woman came to my office
Loyola University, in a federally funded research project to via a referral from Dr. Cox. At the time, I was gathering ma­
study the biomechanics of the lumbar spine in particular as terial for upcoming presentations I was to make, one of which
they relate to the clinical procedure known as "flexion distrac­ was with Dr. Cox. This patient displayed some very interest­
tion." DW'ing the past 28 years, Dr. James Cox has dedicated ing clinical findings, and I thought her case would make for in­
uncounted hours, months, and years to the research, develop­ teresting discussion during my lecture. She seemed approach­
ment, refinement, and application of flexion distraction tech­ able, so I asked her if I could take some slide pictures of her
nique to those patients who suffer the ubiquitous, but elusive radiographs and other imaging and videotape some of her clin­
malady known as low back pain. His success in these efforts is ical examination findings. She started laughing at me, saying I
unparalleled. was too late: Dr. Cox had already done all that. I couldn't help
It is a clear tribute to the vision, purpose, and tenacity of it; I laughed with her. At the next meeting I presented with
Dr. James Cox that the 6th edition of his book titled Low Back Dr. Cox, he was using her as the model for his examination
Pain is now in print. demonstration! My handiwork was demonstrated, too. At the
The condition known as low back pain has been studied by end of the meeting, I found her showing off my "bikini" inci­
thousands of experts, covering uncounted articles, journals, sion in the back of the room, so we both benefitted from the
and books. This vast literature has chronicled the develop­ good work we did for this patient!
ment of diagnosis and treatment of low back syndromes And so goes my longstanding relationship with Dr. Cox.
throughout the last century. Despite all this, the causes of low We have educated each other about our respective fields and
back pain have sometimes eluded the grasp of even the best have worked side-by-side on many cases to the benefit of our
scientists. patients. One of the first patients referred to me on my arrival
In light of this history, I think it is particularly important in Fort Wayne was from Dr. Cox. The patient came to my of­
that Dr. Cox has brought to us, once again, and in a clearly fice with a most concise letter of introduction: accurate his­
enhanced form, not only the thoughts, experiences, and ex­ tory, specific time of pain onset, thorough medical history, de­
periments of many scientists who have studied the phenome­ tailed clinical examination findings, astute results of imaging,
non known as low back pain, but also the more pragmatic art­ and an educated, well-founded diagnosis. I was impressed that
based approach to the treatment of people who suffer from this chiropractic physician knew when to refer the patient to a
this condition, which we refer to in a general way as low back medical specialist, was confident in his diagnosis, and had the
pain, despite its many causes. One cannot help but be im­ desire to do what was best for his patient. Patient satisfaction
pressed by the breadth of coverage of the topic, from the bio­ is high with these types of referrals as they raise confidence in
mechanics of the low back through anatomic to neurologic el­ both practitioners. This case and its letter of introduction
ements. The importance of clinical laboratory diagnosis is helped to establish a good rapport between Dr. Cox and me
carefully defined and the developments of the latest research that has lasted close to 25 years.
are presented in a cogent and coherent process, which makes My undergraduate as well as medical and surgical training
this book not only interesting to read, but particularly useful at Indiana University and residency programs at Georgetown
for the clinician. Medical School and in the U.S. Navy during the Vietnam
Finally, the approach to the treatment of these patients, es­ War prepared me well for medical practice and neuro­
pecially by those who choose to practice the conservative surgery. I started practice knowing the scientific basis of
treatment of low back pain through chiropractic healing, is medicine, down to the molecules and atoms, but soon found
v
vi Foreword
out that not all beneficial care can be explained away by sci­ other physician. Distraction treatment protocols are pre­
entific methods. In developing my practice, which now in­ cisely portrayed in writing and in pictures to help both the
cludes six neurosurgeons (one of whom is my eldest son, Jeff) practitioner perform the distraction technique and the patient
and eight neurologists, all top-notch physicians, I have tried understand how the technique will help manage his or her
to steer them beyond the strictly scientific to acknowledge back pain condition, for, as Dr. Cox states, back pain is rarely
the good that comes from the care beyond traditional scien­ cured but it can be controlled when all parties involved in the
tific explanation. During my training in medicine and neuro­ case work together.
surgery, there was very little talk of alternative care for back After years of collaboration and my seeing the positive re­
pain, or chiropractic care for that matter. Since then, I have sults of chiropractic management, I sent my younger son,
watched alternative care, particularly chiropractic, slowly Kenny, to Dr. Cox's office when he began considering a pro­
come into the mainstream of medicine. Most of medicine is fession, to observe the quality of care that Dr. Cox offers his
more realistic and accepting of alternative therapies, espe­ patients. I now proudly support my son in his choice to become
cially in the realm of back pain management. Most back pain a chiropractor and look forward to working with him and en­
can and should be treated conservatively. I have seen many couraging him to practice chiropractic in the way that Dr. Cox
cases of good chiropractic care result. does, using the gentle, nonforce, distraction protocols for the
Although medicine has slowly come to accept chiropractic, it relief of his patients' pain.
has been a bit too slow in sharing its resources. I am most proud In every profession, be it medical, legal, entrepreneurial, or
of the fact that I have been able to open doors to Dr. Cox in our chiropractic, I have found those who strive to move it forward
local medical community. Dr. Cox has responsibly demonstrated and keep it on the cutting edge. Dr. Cox is one of those peo­
that he knows when to refer patients for further medical and ple, and he shares his knowledge, protocols, and cases within
imaging testing, and I found no reason why he should have to be this text as an example of successful, conservative, chiroprac­
second guessed when sending a patient for tests. I ensure that he tic patient care.
had cooperative, easy access to radiographic and imaging facilities
Rudy Kachmann, M.D.
as needed. Further, as is his reputation, Dr. Cox reads medical
Neurosurgeon
literature voraciously, but occasionally has trouble gaining access
Fort Wayne, Indiana
to it locally. After hearing about his, I made sure that the doors of
local hospital libraries were open to him. I always get a thrill when Low Back Pain, tlle most common reason for seeking help from
I drive into the parking lot at the hospital on Wednesday after­ a health care provider in the dusk of the twentieth century, is a
noons and see Dr. Cox's car with the "L5S 1" license plate framed topic worthy of the persistent penchant of a Dr. James Cox.
with the slogan "discover chiropractic." No one knows back lit­ As a resident in radiology and a gross anatomy laboratory as­
erature and research better than Dr. Cox, and I am proud to be sistant at National College of Chiropractic in the early 1970s, I
able to ensure access, access that allows him to stay on top of the had the privilege to assist Dr. Cox in dissecting and pho­
research literature and to share it via his writings and lectures tographing the structures of the low back in preparation for his
arOlmd the world. early lectures. He never tired of the thirst for more knowledge,
I have watched parts of Dr. Cox's lectures before and after a clearer understanding, and a better picture. Tenacity led to
my presentations at his courses and read his books. His presen­ quality, and quality has asserted itself into the work of Dr. Cox
tation of material is the best in back pain management training. in the low back.
Dr. Cox disseminates more knowledge about back pain me­ But what about this "universal joint" of the body, as Dr.
chanics and diagnosis in his seminars than in other medical and Joseph Janse would often make reference? What happened to
neurosurgical CME training courses I have attended. He takes this joint when in the antediluvian periods of the Earth's his­
the highly scientific material he reads weekly and converts it tory, man decided to stand up and be different, or was man
into practical application. this way from the beginning? An answer we must await, but in
Dr. Cox uses that same practical presentation style the meantime, Dr. Cox has taken to a meticulous study of this
demonstrated in lecturing in his writing of this textbook. He incredible feature of upright bipedism. In no other text will
provides all the scientific research findings accurately, de­ you find such complete and complex coverage of the most dif­
scriptively, and practically so that a practitioner-chiroprac­ ficult and challenging clinical and biomechanical marvel of the
tic, medical, or otherwise-can easily relate to the new ma­ human body.
terial. In describing the diagnosis of disc and back problems, The reader will relish the treasures confined within the
Dr. Cox is most vivid, using illustrative x-ray studies and de­ binding of this text. The teacher will have need for no other
tailed case presentations to exhibit the diagnosis protocol. text in helping students master this subject. The student will be
The algorithms of decision-making are in the simplest yet enriched beyond measure for every moment spent digesting
most detailed of formats. The physician following the Cox morsel after morsel of wisdom and intellect. The clinician,
protocol outlined in the algorithms can confidently handle the ever challenged by this clinical syndrome, will return numer­
patient's case without the fear of over-treating or mistakenly ous times to this feast of practical information from which com­
handling a case alone that may need co-management with an- petence and confidence for patient care can be garnered.
Foreword vii
To neglect this text is to cover the candle with a basket. laid bare to their most fundamental elements for each of us
Dr. Cox has placed his candle on the hilltop so we may all see. to learn from and apply our understanding to benefit our
To see we must open our eyes and read what he has prepared patients.
for LIS. The feast is before us but it is our duty and opportu­ Thanks Dr. Cox.
nity to cat. I encourage all to become partakers at the table of
low back pain instruction and reap the benefits provided by a Reed B. Phillips, D.C., Ph.D.
master teacher, an experienced clinician, an empathic suf­ President
ferer, and a sympathetic listener. From each of these per­ los Angeles College of Chiropractic
spectives, the low back and its associated pain syndromes are los Angeles, California
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PREFACE
The sixth edition of Low Back Pain: Mechanism, Diagnosis, and treatment of the patient with low back and sciatic pain.
Treatment contains 8 years of updated research in the care of Chapter 9 is a new and very detailed protocol of the princi­
low back pain. Astounding changes have occurred in that pe­ ples, biomechanics, anatomic changes, and application of
riod, such as evidence that ergonomic programs, after decades distraction adjustments of the lumbar spine for all its diag­
of research, show no clear evidence that they can prevent back noses. It is an anchor of knowledge of this textbook because
pain; little evidence exists that physical therapy provides long­ it represents the clinical application of distraction adjust­
term benefits for chronic musculoskeletal pain sufferers; ments for the doctor of chiropractic. It will be a constant
epidural steroid injections are of questionable value; and plate source of therapeutic advice on manipulation and adjust­
and screw spinal fusions are controversial. Magnetic resonance ment of the low back pain patient. These two chapters rep­
imaging is considered wasteful as a routine procedure. The resent my clinical approach to the diagnosis and treatment
cost of low back care in the United States continues to rise in of low back and sciatic pain.
both human suffering and dollars. Chapter 10 covers diagnosiS of the low back pain patient,
In this same period, chiropractic has had a positive response and in this chapter I detail the history, examination, clinical
in the literature, and research studies regarding its benefits and decision-making and therapeutic algorithms, and literature
clinical outcomes have been largely positive. Chapter 1 covers support for the performance and interpretation of standard
the history and future of chiropractic as I view it and includes low back tests in chiropractic today. It focuses on excellence
a briefhistory of the evolution of my work with distraction ad­ of diagnostic testing leading to a Aow chart instruction to ar­
justing of the spine, which is methodically explained. rive at the diagnosis of the patient's condition.
Research has finally advanced in chiropractic with the Chapter 16, written by James M. Cox, II, D.C., clearly il­
awarding of two studies by the Health Resources and Services lustrates the importance of the mental state in treating low
Administration of the Department of Health and Human Ser­ back pain as the psychological side of low back pain is dis­
vices to study the biomechanics and clinical benefits of distrac­ cussed. The depression of chronic low back pain, patient cop­
tion adjustments of the lumbar spine. The first grant was ing strategies, detection, and treatment by the physician arc
awarded in 1994, entitled "Biomechanics of the Low Back shown for practitioner clinical use.
Flexion-Distraction Therapy" and the second was awarded in Chapter 7 is the subject of fibromyalgia, written by Lee J.
1997, entitled "Flexion Distraction vs Medical Care of Low Hazen, D.C. This excellent chapter leads the practitioner in
Back Pain." Both studies are joint grants to National College of an understanding of the neuroendocrine and psychological ba­
Chiropractic and Loyola Stritch School of Medicine. Ram Gu­ sis for this somewhat controversial diagnosis and even more
davalli, Ph.D., of National College, is the principal investiga­ controversial therapeutic condition.
tor of both studies, and in Chapter 8 he describes the research Chapter 15 is a great addition to this textbook because of
that has been completed in these studies at the time of publica­ the rehabilitation interest for the low back pain patient. Scott
tion of this textbook. Dr. Gudavalli's chapter is a historic and Chapman, D.C., gives maximal effort to furnish the general
valuable addition to this textbook and to chiropractic history. practitioner the tools to use for the practical application of re­
In Chapters 2 and 3, I update research literature in the bio­ habilitation in the clinic. This chapter is a very strong addition
mechanics and neurophysiology of low back pain and neural to this sixth edition and is a vital part of today' s managed care
compressive and chemical irritation. Chapter 4 covers the most treatment of back pain.
recent material on the diagnosis, clinical features, and treat­ Sil Mior, D.C., accepted the challenge of bringing the lit­
ment of spinal stenosis. Chapter 6 addresses the transitional erature to the chiropractic practitioner on the sacroiliac joint.
segment, Chapter 13 covers facet syndrome, and Chapter 14 Along with the brilliant anatomy of Chae Song Ro, M. D.,
on spondylolisthesis represents the latest literature on these Ph. D., Dr. Mior furnishes this vital subject in the general prac­
conditions that I have collected during the previous 8 years. tice of chiropractic to the practitioner-the sacroiliac joint
Chapter 11, written by David Wickes, D.C., of National anatomy, biomechanics, and adjusting procedures.
College, furnishes the practitioner a very ready outline of diag­ This book is intended to be a clinical instrument for use by
nostic tests to be ordered for pathologies causing low back pain. the chiropractic physician in daily practice. It is practical,
This chapter is very thorough but clinician friendly and usable. everyday knowledge that can be used to stimulate excellent
It will be appreCiated when laboratory testing is needed and patient care and the best of clinical outcomes. Lastly, it is my
clear steps laid out for the doctor to follow. hope that it serves as a stimulus to other chiropractic doctors
Chapter 12 specifically covers the clinical and home to excel and produce a better seventh edition.
James M. (ox, D.C., D.A.C.B.R.
ix