Content uploaded by Dr. Luigi Albano
Author content
All content in this area was uploaded by Dr. Luigi Albano on Aug 28, 2017
Content may be subject to copyright.
J Can Chiropr Assoc 2017; 61(2) 153
ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2017/153–161/$2.00/©JCCA 2017
Innovative application of Cox Flexion Distraction
Decompression to the knee: a retrospective case
series
Luigi Albano, BSc, DC1
1 Private practice, Windsor, ON
Corresponding author:
Luigi Albano
Walkerville Chiropractic, 1275 Walker Road, Windsor, ON N8Y 4X9
Tel: 519-258-7979
E-mail: dr.luigialbano@gmail.com
© JCCA 2017
Objective: The purpose of this study is to introduce the
application of Cox exion distraction decompression
as an innovative approach to treating knee pain and
osteoarthritis.
Methods: Six months of clinical les from one
chiropractic practice were retrospectively screened for
patients who had been treated for knee pain. Twenty-ve
patients met the criteria for inclusion. The treatment
provided was Cox exion distraction decompression.
Pre-treatment and post-treatment visual analog pain
scales (VAS) were used to measure the results. In total,
eight patients presented with acute knee pain (less than
three months’ duration) and 18 patients presented with
chronic knee pain (greater than three months) including
two patients with continued knee pain after prosthetic
replacement surgery.
Results: For all 25 patients, a change was observed
in the mean VAS scores from 7.7 to 1.8. The mean
number of treatments was 5.3 over an average of 3.0
weeks. Acute patient mean VAS scores dropped from
Objectif : Le but de cette étude est de présenter
l’application de la décompression par exion-distraction
de Cox en tant qu’approche novatrice de traitement de
la douleur au genou et de l’arthrose.
Méthodologie : On a inspecté six mois de
dossiers cliniques d’un cabinet de chiropratique
rétrospectivement pour trouver des patients traités pour
une douleur au genou. Vingt-cinq patients respectaient
les critères d’inclusion. Le traitement fourni était la
décompression par exion-distraction de Cox. On a
utilisé des échelles visuelles analogues (EVA) avant et
après le traitement pour mesurer les résultats. Au total,
8 patients présentaient une douleur aiguë au genou
(depuis moins de 3 mois) et 18 patients présentaient une
douleur chronique au genou (depuis plus de 3 mois),
dont 2 patients avec une douleur toujours présente après
la chirurgie de remplacement de prothèse.
Résultats : Pour les 25 patients, on a observé un
changement des résultats moyens de l’EVA de 7,7 à 1,8.
Le nombre moyen de traitements était de 5,3 sur une
moyenne de 3,0 semaines. Les résultats moyens de l’EVA
des patients atteints de douleur aiguë ont chuté de 8,1 à
1,1 après 4,8 traitements sur 2,4 semaines. Les résultats
154 J Can Chiropr Assoc 2017; 61(2)
Innovative application of Cox Flexion Distraction Decompression to the knee: a retrospective case series
Introduction
The prevalence of knee pain has increased substantial-
ly over a 20 year period, independent of age and body
mass index (BMI).1 It affects approximately 30-40% of
adults by age 65.2 Total knee replacement utilization in
the United States more than doubled from 1999 to 2008.3
Studies have shown that increasing physical activity in
people with osteoarthritis (OA) reduces pain and depres-
sion.4 If a patient has symptoms of OA, such as knee pain
with associated walking disability, he or she may be at
increased risk of premature death from cardiovascular
disease.5 Chiropractic treatment for knee OA is typically
multimodal, involving manipulation, mobilization, soft
tissue techniques, physical therapy modalities, nutritional
counseling, exercise, and orthoses for the knee or foot.6
Cox exion distraction decompression (FDD) of the
spine is an evidence-based, non-surgical spinal care treat-
ment modality, a form of spinal manipulation in which
the human spine is placed in distraction (a type of meas-
ured, controlled traction of the spine) delivered on a spe-
cialized spinal manipulation instrument (the Cox table).7
The main difference between Cox FDD and traction is
that the treatment is manually applied, according to pa-
tient tolerance, with oscillation of the applied forces, all
the while maintaining the joint under decompression (i.e.
tensile loading plus mechanical stress). This can be per-
formed with or without passive stretch to the specic joint
through various ranges of motion (ROM). Its effects on
the spine are well researched and documented. Cox FDD
has demonstrated a reduction of intradiscal pressure of up
to –192mmHg in the lumbar spine and –502mmHg in the
cervical spine.8,9 It is a non-invasive joint therapy for pa-
tients that allows for continued, reasonable daily activity
or minimal convalescence. Recent research has demon-
strated that articular cartilage has the intrinsic ability to
repair itself when the joint is exposed to distraction with
mechanical stimulation.10,11
The application of exion distraction specically to
the knee with and/or without passive knee exion has
not been well documented. The purpose of this study is
to introduce the application of Cox FDD as an innova-
tive approach to the treatment of knee pain and OA. This
study was designed in retrospect to treatment. Chart re-
view of 25 patients is presented.
Methods
A retrospective search of patient les over six months was
performed from one chiropractic facility. Ethics approval
was obtained by the Research Ethics Board of the Can-
adian Memorial Chiropractic College. Charts that were
included in this study were patients with only knee pain
and having received Cox FDD applied to the knee with
and/or without passive knee exion. VAS scores were
used to assess treatment effectiveness. Thirty-two charts
were selected. Three were excluded on the basis of having
less than three treatments, and four charts were excluded
for not having nal VAS scores, resulting in 25 patient
records. There were no exclusions based on diagnosis.
8.1 to 1.1 within 4.8 treatments over 2.4 weeks. Chronic
patient mean VAS scores dropped from 7.5 to 2.2 within
5.4 treatments over 3.3 weeks. No adverse events were
reported.
Conclusion: This study showed clinical improvement
in patients with knee pain who were managed with Cox
exion distraction decompression applied to the knee.
(JCCA. 2017;61(2):153-161)
key words: knee osteoarthritis, Cox Flexion
Distraction Decompression, knee pain, manual therapy,
manipulation, chiropractic
moyens de l’EVA des patients atteints de douleur
chronique ont chuté de 7,5 à 2,2 après 5,4 traitements
sur 3,3 semaines. Aucun incident indésirable n’a été
déclaré.
Conclusion : Cette étude démontre une amélioration
clinique chez les patients atteints de douleur au genou
qui ont été traités avec la décompression par exion-
distraction de Cox appliquée au genou.
(JCCA. 2017;61(2):153-161)
mots clés : arthrose du genou, décompression par
exion-distraction de Cox, douleur au genou, thérapie
manuelle, manipulation, chiropratique
J Can Chiropr Assoc 2017; 61(2) 155
L Albano
The application of treatment followed similar guidelines
as used in the Cox Technic spinal protocols.8 The treat-
ment involved the patient seated at the Cox Table with the
affected tibiofemoral joint comfortably resting between
the lumbar and dorsal sections of the table (Figure 1). The
dorsal section of the table was placed at an angle between
0-15o below horizontal for comfort and to decrease ham-
string tension. The caudal section was disengaged to al-
low for exion. To create knee joint distraction, the chiro-
practor applied downward forces above the knee and at
the superior aspect of the distal tibiobular joint (Figure
2). The table was distracted to the “taut point” which is
reached when the patient’s knee is distracted to the point
of the barrier of elasticity. This is the starting point of Cox
FDD. The chiropractor controlled the amount of distrac-
tion of the device using a foot switch, applied according
to patient tolerance. The knee was then distracted and
brought to exion and extension as tolerated by the pa-
tient in an oscillatory manner that was smooth and rhyth-
mical for a minimum of 10-15 repetitions (Figures 2, 3,
and 4). Each repetition lasted 2-4 seconds. Total treatment
time with Cox FDD was approximately 1 minute. Most
patients received adjunctive (laser treatment) applied to
the knee joint after each Cox FDD session was complet-
ed. No adverse events were reported.
Results
The age range of the study participants was between 20
and 80 years, with an average age of 57.5. Seventeen of
the eligible charts were considered as chronic with hav-
ing pain greater than three months and eight were con-
sidered acute. Of those, 11 were female and 6 were male.
Fourteen patients (56.0%) had previous knee surgery, all
of which were in the chronic knee pain group: ve me-
niscectomies, two total knee arthroplasties and seven of
unknown surgical type. The acute group was comprised
Figure 1.
Initial setup.
Figure 4.
Back to neutral.
Figure 2.
Flexion Distraction.
Figure 3.
Returning to neutral with distraction.
156 J Can Chiropr Assoc 2017; 61(2)
Innovative application of Cox Flexion Distraction Decompression to the knee: a retrospective case series
of two females and six males. None of the acute patients
had previous knee surgery.
The reduction in VAS scores for both groups are shown
in Table 1. The total average VAS scores for both groups
dropped from 7.7 to 1.8 (a reduction of 5.9) in an aver-
age of 5.3 treatments over 3.0 weeks. Within the chronic
group, the average reduction in VAS scores was from an
initial VAS of 7.5 to 2.2 (a decrease of 5.3 points) in 5.4
treatments over 3.3 weeks. The average reduction in VAS
within the acute group was from an initial VAS of 8.1 to
1.1 (a reduction of 7.0 points) in 4.8 treatments over 2.4
weeks. There were no patients that reported an increase
in pain. One patient did not report any change. None
of the acute cases required any treatment three months
post-treatment. Most of the chronic cases required on-
going maintenance treatments at a frequency of one
treatment per month. In the chronic group, eight out of
17 (47.1%) patients had undergone previous knee surgery
ranging from arthroscopic meniscectomy (n = 6) to total
knee arthroplasty (n = 2).
The Cox 8 Table allows for real-time force measure-
ments during treatment (Figure 5). Hand pressure, dis-
traction force, table angle and distraction distances are
displayed and recorded in real-time as a visual aid. The
force applied along the y-axis during treatment was with-
in 20-40 lbs and table distraction distance was within 16-
55mm. The treatment exion angle ranged between 0o–
9.1o.
Table 1.
Change in VAS scores for chronic and acute patients.
Group Average Age
(years)
Initial
VA S
Post
VA S
Average
VAS Change
Average No.
Treatment
Average
Time Span (weeks)
Chronic (n=17) 58.1 7.5 2.2 –5.3 5.4 3.3
Acute (n=8) 49.1 8.1 1.1 –7.0 4.8 2.4
Overall (n=25) 57.5 7.7 1.8 –5.9 5.3 3.0
Figure 5.
Cox 8 table forces
graph applied to
the knee.
J Can Chiropr Assoc 2017; 61(2) 157
L Albano
The primary clinical diagnoses of the patients in both
groups were OA, collateral and cruciate ligament sprains,
meniscus tears and sprains, and post-surgical continued
knee pain for partial and total knee arthroplasty. In many
of the cases there was a combination of these diagnoses.
Discussion
Retrospective Case Series Findings
Both the acute and chronic knee pain groups in this case
series responded well to treatment. Almost all of the pa-
tients reported a decrease in pain as measured on the VAS
with Cox FDD. Notably, most patients reported immedi-
ate relief after their rst treatment, that lasted from several
hours up to two days. At last follow-up, almost all patients
reported better mobility, knee joint strength and stability.
The last follow-up was performed at 1 to 3 months after
treatment. No adverse reactions were reported by any of
the patients.
The reduction in VAS scores, number of treatments and
duration of care was similar for both groups. Follow-up
treatment was evaluated for both groups. Thirteen of the
chronic cases returned for follow-up treatments within
four weeks and continued with maintenance treatment
every three to four weeks and/or as needed. In reviewing
the acute group, no patients returned for further treatment
after three months.
Previous Studies of Manual Therapy for OA of the
Knee
The current study demonstrates a reduction in pain level
and treatment duration that are similar with other studies
involving manual therapy, exercise and/or surgery. Van
den Dolder and Roberts demonstrated a reduction be-
tween –8 to –10 mm versus the control group on 100mm
VAS.12 Treatment consisted of transverse friction to the
lateral retinaculum, patellofemoral stretches, and the ap-
plication of sustained medial glide during repeated ex-
ion and extension of the knee. Maher et al.13 showed a
statistically signicant improvement in ROM but no long-
term changes in pain levels using passive knee exion.
Treatment involved the patient laying prone with the knee
exed and the distal femur secured to the table with a sta-
bilization belt and the therapist applied a traction force to
the knee. Pollard et al.8 demonstrated a reduction in mean
VAS scores from 3.3 to 1.9 in their treatment group. The
intervention group received myofascial mobilization and
an impulse thrust procedure. Deyle et al.14,15 demonstrat-
ed in two randomised controlled trials, improvement in
self-reported pain and function when combining manual
therapy with exercise versus exercise alone. The treat-
ment applied was soft tissue mobilization and stretching.
Khademi-Kalantari et al.16 demonstrated signicant relief
of knee pain with sustained knee joint traction. Finally,
Dwyer et al.17 demonstrated improvement but no sta-
tistical improvement between groups when comparing
manual and manipulative therapy (joint mobilization,
manipulation, and soft tissue treatment) with and without
rehabilitation (monitored and/or home program).
Six weeks of continuous knee joint distraction has also
been shown to postpone the need for total knee joint arth-
roplasty in patients younger than age 65.18 Furthermore,
Van der Woude et al.18 have shown that knee articular car-
tilage has the potential to regenerate, in some cases doub-
ling in thickness with continuous knee joint distraction.
Interestingly, these outcomes were maintained even at 5
year follow-up.18 This could help to partially explain the
clinical results observed in the current study.
Knee Physiology
Similarities exist in the physical properties of the knee and
spinal joints. The knee meniscus and intervertebral discs
are responsible for load transmission, force distribution,
shock absorption, and articular cartilage protection.19 Both
structures rely on collagen brils to resist tensile forces.
Articular cartilage and the extracellular matrix (ECM) are
maintained and produced by chondrocytes, specialized
cells derived from mesenchymal stem-cells. Chondrocytes
produce the cartilage matrix and its components such as
proteoglycans (PGs) and glycosaminoglycans (GAGs),
that provide the tissue with hydration and its high capacity
to withstand compressive loads.20 The most abundant PG
in articular cartilage and the ECM is aggrecan which is
composed of a core protein, hyaluronan (HA), and several
side chains of GAGs. The most abundant GAG side chains
are made up of multiple repeating units of chondroitin-sul-
phates, keratin-sulphates and dermatan-sulphates. The
knee meniscus is predominantly a brocartilaginous struc-
ture reinforced by highly ordered collagen bers in a com-
plex orientation. Compressive forces in the intervertebral
discs are predominately handled by the nucleus pulposus
which is also made up of PGs within a loose framework
158 J Can Chiropr Assoc 2017; 61(2)
Innovative application of Cox Flexion Distraction Decompression to the knee: a retrospective case series
of collagen bers. Changes to the viscosity of HA causes
densication of tissue and can modify the function of fa-
scia, nerve receptors, muscle layers (epimysium and peri-
mysium gliding) and hydrodynamic properties of connect-
ive tissue.21 It is suggested by the authour that the use of
Cox FDD to the knee may cause conformational changes
to the synovial capsule and uid, meniscus, articular carti-
lage, tendons and entheses, due to the decreased pressure
induced by treatment similar to that which occurs in the
intervertebral discs.
Increased levels of catabolic enzymes that degrade the
ECM occur in patients with OA and rheumatoid arthritis
(RA).22 Arachidonic acid metabolites (PGs, leukotrienes,
etc.) and cytokine levels are also increased after inam-
matory insult from injury, infection, or in degenerative
diseases such as OA and RA. These metabolites signal
the biosynthesis of specialized pro-resolving mediators
(SPMs) from omega-3 essential fatty acids including
eicosapentanoic acid and docosahexanoic acid.23 SPMs
resolve inammation (catabasis) as opposed to non-ster-
oidal anti-inammatory medications which block certain
steps of inammation. SPMs initiate healing, contain or
limit inammation, prevent and/or reduce the severity of
inammation, and reduce tissue destruction.24,25 SPMs in-
clude lipoxins, resolvins, protectins and maresins and are
known to act as potent regulators of neutrophil inltra-
tion, cytokine and chemokine production, and clearance
of apoptotic neutrophils by macrophages which promote
the return of tissue homeostasis.25 Stretching of connect-
ive tissue reduces the migration of neutrophils and in-
creases SPM resolvin concentrations.24
Passive neurodynamic mobilization has been shown to
promote nerve function by limiting or altering intraneur-
al uid accumulation, preventing the adverse effects of
intraneural edema.26 The use of mobilization techniques,
such as those used in the current study, may promote heal-
ing of the soft tissues by stimulating the functions of the
nervous system to improve adaptability and decrease tis-
sue sensitivity, thereby helping to alleviate symptoms.27,28
Mechanotransduction is the process by which bio-
mechanical signals (physical forces) regulate or affect cel-
lular activity and behaviour.29,30 Paluch et al.29 describes
it as how cells sense physical forces and translate them
into biochemical and biological responses. Biomechan-
ical signals include compression, stretch (decompression
or tension), and shear forces. These forces are converted
into chemical signals at the cell surface, acting on cell sur-
face adhesion-receptors and calcium ion channels. They
are converted into chemical energy at the cell membrane.
Integrins and cadherins are transmembrane proteogly-
cans that channel mechanotransductive forces and stimuli
along the cytoskeletal laments to distant sites within the
cytoplasm and nucleus.22,23 Genetic transcription of chon-
drocytes increase the production of aggrecan when inu-
enced by mechanotransduction.22,23,30 Mechanotransduc-
tion stimulates mesenchymal stem cells, found throughout
joint tissues, to differentiate into chondrocytes. Chondro-
cytes are also mechanosensitive and under joint distraction
they produce increased levels of PGs, GAGs, and increase
ECM.29-31 It has been shown that mechanical stimulation of
chondrocytes antagonizes interleukin-1β and tumor necro-
sis factor-α.22 Mechanotransduction has also been shown
to reduce the levels of ECM degrading enzymes in OA and
RA. Cox FDD, as used in the current study, applies tensile
and compressive loads to the ligaments, tendons, menisci,
articular cartilage and entheses of the knee all while under
reduced joint pressure from distraction.
Cox Flexion Distraction Decompression
Cox FDD was developed by Dr. James M. Cox, DC, DACBR
over 40 years ago32. Cox Technic is an evidence based
non-surgical, chiropractic spinal manipulation that is ap-
plied using the Cox Table, by a certied practitioner. Sev-
eral National Institute of Health funded studies have dem-
onstrated the effectiveness of the technique in its applica-
tion to the spine.9,32 This is the rst study to document the
treatment on the knee. Cox and Bakkum demonstrated the
treatment applied to the hip joint in treating gemelli-ob-
turator internus complex (GOIC).33 Federally funded re-
search has shown that Cox Technic applied to the spine:
1. Decreases intradiscal pressure in the lumbar
spine up to –192mmHg.34
2. Decreases intradiscal pressure in the cervical
spine up to –502mmHg.35
3. Increases intervertebral disc height.34
4. Increases intervertebral foraminal area up to
28%.34
Cramer et al.36 demonstrated that spinal joint xation
leads to degenerative changes of the facet joints. Distrac-
tion of the intervertebral disc increases intervertebral disc
J Can Chiropr Assoc 2017; 61(2) 159
L Albano
height, increases perfusion of nutrients, regenerates the
extracellular matrix and reverses degeneration.37-39 Dis-
traction of the knee can regenerate the articular cartilage
and increase the tibiofemoral joint space.11,12,18 The appli-
cation of exion distraction specically to the knee with
and/or without passive knee exion has not been docu-
mented and may yield similar effects as that observed in
the spine. The results of this study suggest that Cox FDD
may be useful in treating patients with knee pain and OA.
This study had also helped to devise a potential protocol
for clinical treatment.
In the most recent published guidelines for non-sur-
gical management of the knee, manual therapy was not
included. The reason provided was that there was insuf-
cient evidence for inclusion.40 A similar conclusion was
made in a systematic review by French et al.41 The Cox
8 table is capable of recording the forces used, exion
angles and distraction distance for each patient. This in-
formation allows for quantiable, standardized treatment
with reproduction of these parameters as well as tracking
of any changes, information that may be useful in future
investigations
Study Limitations
The results of this retrospective study must be gauged with
scrutiny, based on the limitations of this study. The deci-
sion to apply Cox FDD to the knee was based on necessity
and not investigative study. Bias in this study is a major
caveat since it was performed in one location by the same
practitioner, and patients underwent Cox FDD without a
control group. As such, it is unknown if the treatment re-
sults in the current study were as a result of the treatment
provided or the natural course of the knee pain disorders.
Moreover, the only distinguishing characteristics between
the different types of knee pain in this study were based
on the classication of acute versus chronic knee pain.
Specic diagnoses of the source of the knee pain were
not part of the inclusion criteria. The groups were not fur-
ther categorized or compared based on individual clinical
diagnosis. The only measure of any changes in pain level
was by the use of VAS which is completely subjective.
Objective tests and standardized questionnaires such as
ROM, WOMAC (Western Ontario McMaster Universities
Arthritis Index) and Stair Climb Test (x-step SCT) would
have provided more reliable measurable data. In addition,
follow-up review for the chronic group in this study was
based on patients returning for care for their knee pain or
other conditions. All of the acute cases were contacted by
telephone or were interviewed during treatment for other
conditions unrelated to the knee by the same clinician.
Telephone follow-up does not provide for actual physical
observation. As well, it skews the pain level by not utiliz-
ing the VAS references for the patient.
All of the patients in this study were also given advice
regarding bracing, exercise and nutrition (an anti-inam-
matory/gluten free diet) . Unfortunately record-keep-
ing of compliance with these recommendations was not
maintained as the patients were not provided or sold any
products by the treating practitioner.
Currently, a 20-patient randomized controlled study is
underway in collaboration with the University of Wind-
sor Faculty of Human Kinetics which uses ROM, WO-
MAC and the Step Test, and patients will be evaluated
before and after treatment. The author also applies Cox
FDD treatment to the hip, shoulder and ankle in his clin-
ical practice. Investigation of the effects on these joints
has not been performed but similar clinical results to the
knee have been observed. Future studies are also planned
in order to investigate the effects of Cox FDD therapy on
knee joint space, specically the meniscus and articular
cartilage, measured via weight-bearing x-ray and MRI.
Conclusion
The results of this study suggest that Cox FDD of the
knee joint may offer benet for patients with knee pain
and/or OA. The use of the Cox 8 table may allow for more
standardized and reproducible treatments. The outcomes
of this study nevertheless necessitate further research in
the form of larger, prospective observational and/or con-
trolled studies to conrm similar results.
Acknowledgments
I thank Dr. James M. Cox, DC, DACBR and Julie Cox-Cid
for their encouragement and recommendation to investi-
gate and publish the ndings of this study.
Funding sources and potential conict of interest
No funding sources were offered or provided for this
study. Dr Luigi Albano is a chiropractor in private prac-
tice and is a certied Cox Technic provider.
160 J Can Chiropr Assoc 2017; 61(2)
Innovative application of Cox Flexion Distraction Decompression to the knee: a retrospective case series
References
1. Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT.
Increasing prevalence of knee pain and symptomatic knee
osteoarthritis. Ann Intern Med. 2011; 155(11): 725–732.
2. van den Dolder PA, Roberts DL. Six sessions of manual
therapy increase knee exion and improve activity in
people with anterior knee pain: a randomized controlled
trial. Aust J Physiother. 2006; 52: 261-264.
3. Losina E, Thornhill TS, Rome BN, Wright J, Katz JN.
The dramatic increase in total knee replacement utilization
rates in the United States cannot be fully explained by
growth in population size and the obesity epidemic. J Bone
Joint Surg Am. 2012; 94(3): 201-207.
4. Penninx BWJH, Rejeski WJ, Pandya J, Miller ME,
Di Bari M, Applegate WB, Pahor M. Exercise and
depressive symptoms: a comparison of aerobic and
resistance exercise effects on emotional and physical
function in older persons with high and low depressive
symptomatology. J Gerontol B Psychol Sci Soc Sci. 2002;
57(2): P124-P132.
5. Nüesch E, Dieppe P, Reichenbach S,Williams S, Iff S,
Jüni P. All cause and disease specic mortality in patients
with knee or hip osteoarthritis: population based cohort
study. BMJ. 2011;342:d1165
6. Law A. Diversied chiropractic management in the
treatment of osteoarthritis of the knee: a case report. J Can
Chiropr Assoc. 2001; 45(4): 232-240.
7. Gudavalli MR, Cox JM, Baker JA, Cramer GD,
Patwardhan AG. Intervertebral disc pressure changes
during the Flexion-Distraction procedure for low back
pain. Abstract from the Proceedings of the International
Society for the Study of the Lumbar Spine, Singapore
1998.
8. Pollard H, Ward G, Hoskins W, Hardy K. The effect of
a manual therapy protocol on osteoarthritic knee pain: a
randomised controlled trial. J Can Chiropr Assoc. 2008;
52(4): 229-242.
9. Cox JM. Low back pain: mechanism, diagnosis and
treatment. Seventh Edition. Lippincott, Williams and
Wilkins, 2011: 20-29, 362-383.
10. Lafeber F, Intema F, van Roermund P, Marijnissen A.
Unloading joints to treat osteoarthritis, including joint
distraction. Curr Opin Rheumatol. 2006 18:519-525.
11. Wiegant K, van Roermund P, Intema F, Cotofana S,
Eckstein F, Mastbergen S, et al. Sustained clinical and
structural benet after joint distraction in the treatment of
severe knee osteoarthritis. Osteoarthritis Cartilage. 2013
21:1660-1667.
12. Van den Dolder PA, Roberts DL. Six sessions of manual
therapy increase knee exion and improve activity in
people with anterior knee pain: a randomised controlled
trial. Aust J Physiother. 2006;52: 261-264.
13. Maher S, Creighton D, Kondratek M, Krauss J, Qu X. The
effect of tibio-femoral traction mobilization on passive
knee exion motion impairment and pain: a case series.
J Manipulative Physiol Ther. 2010; 18(1):29-36.
14. Deyle GD, Henderson NE, Matekel RL, Ryder MG,
Garber MB, Allison SC. Effectiveness of manual physical
therapy and exercise in osteoarthritis of the knee. Ann
Intern Med. 2000;132:173-180.
15. Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM,
Gohdes DD, et al. Physical therapy treatment effectiveness
for osteoarthritis of the knee: a randomized comparison
of supervised clinical exercise and manual therapy
procedures versus a home exercise program. Phys Ther.
2005; 85: 1301–1317.
16. Khademi-Kalantari K, Aghdam SM, Baghban AA,
Rezayi M, Rahimi A, Naimee S. Effects of non-
surgical joint distraction in the treatment of severe knee
osteoarthritis. J Bodywork Movement Ther. 2014; 18(4):
533-539.
17. Dwyer L, Parkin-Smith GF, Brantingham JW,
Korporaal C, Cassa TK, Globe G, Bonnen D, Tong V.
Manual and manipulative therapy in addition to
rehabilitation for osteoarthritis of the knee: assessor-
blind randomized pilot trial. J Manipulative Physiol Ther.
2015;38(1): 1-21.
18. Van der Woude JT, van Heerwaarden RJ, Wiegant K,
van Roermund PM, Saris DB, Mastbergen SC, Lafeber FP.
Six weeks of knee joint distraction: sufcient for cartilage
tissue repair. Ann Rheum Dis. 2015;74:371.
19. Beauls P, Verdonk R. The Meniscus. Heidelberg,
Dordrecht. Springer 2010.
20. Fox AJS, Bedi A, Rodeo SA. The basic science of human
knee menisci. Sports Health. 2012; 4(4): 340-351.
21. Stecco A, Gesi M, Stecco C, Stern R. Fascial components
of the myofascial pain syndrome. Curr Pain Headache
Rep. 2013;17:352.
22. Leong DJ, Hardin JA, Cobelli NJ, Sun HB.
Mechanotransduction and cartilage integrity. Ann N Y
Acad Sci. 2011; 1240:32-37.
23. Berrueta L, Muskaj I, Olenich S, Butler T, Badger GJ,
Colas RA, Spite M, Serhan CN, Langevin HM. Stretching
impacts inammation resolution in connective tissue.
J Cell Physiol. 2016; 231(7): 1621-1627.
24. Serhan C. Novel pro-resolving lipid mediators in
inammation are leads for resolution physiology. Nature.
2014 Jun 5; 510(7503): 92-101.
25. Duvall MG, Levy BD. DHA- and EPA-derived resolvins,
protectins, and maresins in airway inammation. Eur J
Pharmacol. 2016; 785: 144-155.
26. Kroeber M, Unglaub F, Guehring T, Nerlich A, Hadi T,
Lotz J, Carstens C. Effects of controlled dynamic disc
distraction on degenerated intervertebral discs: an in vivo
study on the rabbit lumbar spine model. Spine. 2005;
30(2): 181-187.
27. Gilbert KK, Smith MP, Sobczak S, James CR, Sizer PS,
Brismée JM. Effects of lower limb neurodynamic
J Can Chiropr Assoc 2017; 61(2) 161
L Albano
mobilization on intraneural uid dispersion of the
fourth lumbar nerve root: an unembalmed cadaveric
investigation. J Man Manip Ther. 2015; 23(5): 239-245.
28. Jeong UC, Kim CY, Park YH, Hwang-Bo G, Nam CW.
The effects of self-mobilization techniques for the sciatic
nerves on physical function and health of low back pain
patients with lower limb radiating pain. J Phys Ther Sci.
2016; 28(1): 46-50.
29. Paluch EK, Nelson CM, Biais N, Fabry B, Moeller J,
Pruitt BL, Wollnik C, Kudryasheva G, Rehfeldt F,
Federle W. Mechanotransduction: use the forces.
BMC Biology. 2015; 13:47.
30. Wang N, Tytell JD, Ingber DE. Mechanotransduction at a
distance: mechanically coupling the extracellular matrix
with the nucleus. Nature Reviews Molecular Cell Biology.
2009; 10(1): 75-82.
31. Tiku ML, Sabaawy HE. Cartilage regeneration for
treatment of osteoarthritis: a paradigm for nonsurgical
intervention. Ther Adv Musculoskel Dis. 2015; 7(3):
76-87.
32. Cox JM. Blog #6 – What Is Cox® Flexion Distraction
Decompression Spinal Manipulation?
http://www.coxtechnic.com/blog/ March 9, 2016.
33. Cox JM, Bakkum BW. Possible generators of
retrotrochanteric gluteal and thigh pain: the gemelli-
obturator internus complex. J Manipulative Physio Ther.
2005; 28(7): 534-538.
34. Gudavalli MR, Cox JM, Baker JA, Cramer GD,
Patwardhan AG. Intervertebral disc pressure changes
during the exion-distraction procedure for low back pain.
Abstract from the Proceedings of the International Society
for the Study of the Lumbar Spine, Singapore 1998.
35. Gudavalli MR, Potluri T, Carandang G, Havey RM,
Voronov LI, Cox JM, Rowell RM, Kruse RA,
Joachim GC, Patwardhan AG, Henderson CNR, Goertz C.
Intradiscal pressure changes during manual cervical
distraction: a cadaveric study. Evid Based Compl Alt Med.
2013: 2013: 954134.
36. Cramer GD, Fournier JT, Henderson CNR, Wolcott CC.
Degenerative changes following spinal xation in a small
animal model. J Manipulative Physiol Ther. 2004; 27(3):
141-154.
37. Hee HT, Chuah YJ, Tan BHM, Setiobudi T, Wong HK.
Vascularization and morphological changes of the endplate
after axial compression and distraction of the intervertebral
disc. Spine. 2011; 36(7): 505-511.
38. Hee, HT; Zhang, JT; Wong, HK. Effects of cyclic
dynamic tensile strain on previously compressed inner
annulus brosus and nucleus pulposus cells of human
intervertebral disc-an in-vitro study. Jour Orth Research 28
(4) Apr 2010. p.503-9.
39. Guehring T, Omlor GW, Lorenz H, Engelleiter K,
Richter W, Carstens C, Kroeber M. Disc distraction
shows evidence of regenerative potential in degenerated
intervertebral discs as evaluated by protein expression,
magnetic resonance imaging, and messenger ribonucleic
acid expression analysis. Spine. 2006; 31(15): 1658-1665.
40. McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI
guidelines for the non-surgical management of knee
osteoarthritis. Osteoarthritis Cartilage. 2014; 22(3):
363-388.
41. French HP, Brennan A, White B, Cusack T. Manual
therapy for osteoarthritis of the hip or knee: a systematic
review. Man Ther. 2011; 16(2): 109-117.
