I. LUMBAR SPINE Protocol I and II Instructions

Transcription

1 Prtcl fr Cx Technic Hands On Prtins f Cx Curses (4/24/17) step by step guide instructins fr treating patients with Cx Technic Flexin Distractin & Decmpressin Spinal Manipulatin prepared by James M. Cx, DC, DACBR, FICC, Hn.D.Litt, FACO(H) NOTE: This guide des nt preclude hands n training nr study f the full prtcls presented in the textbk. Please see the textbk, Lw Back Pain: Mechanism, Diagnsis, Treatment, 7 th editin, published by Lippinctt, Williams & Wilkins, 2011, fr the full explanatin and ratinale fr Cx Technic Flexin Distractin & Decmpressin Spinal Manipulatin and the diagnstic wrkup leading t a treatment plan fr each patient yu treat. This set f ntes serves as a simple guide f the prtcls fr training. I. LUMBAR SPINE Prtcl I and II Instructins 1. Patient Psitining Sequence Check that lcks are secure. Assist patient nt table: tighten abdmen and buttcks assist patient nt table have arms rest n arm rests Check patient Placement ASIS 2 frward n thracic piece adjust ankle rest Set spring tensin / pwer balance fr caudal sectin 2. Tlerance Testing (t determine the apprpriate treatment cntact mde side lying, central, lateral, cuff t induce distractin decmpressin and secure the patient during adjustment)* *NOTE: Start at L1 and wrk dwn the lumbar spine t avid engaging a level belw a disc herniatin if sciatica is present. Yu may tlerance test starting at L5 S1 and mve cephalward if n sciatica is present. Release Flexin Extensin Lck Central Distractin Testing by means f tiller bar nly IF PAIN LATERALIZES, ice, acupressure, etc., nly fr a day r tw OR chse t apply side lying. spinus prcess cntact (mammillary cntact ptin) dwnward table mvement till cciput extends r 2 hld fr 4 secnds (mimic applicatin 2 secnds dwn, 2 secnds up) test L1 level and test caudally ne level at a time t the lwest lumbar segment Lateral Distractin Testing by means f hlding each ankle nly IF PAIN LATERALIZES WITH HOLDING ANKLES, then nly mve the table with the tiller bar as in central testing. spinus prcess cntact (mammillary cntact ptin) hld ankle (first uninvlved, then invlved) dwnward table mvement till cciput extends r 2 hld 4 secnds (mimic applicatin 2 secnds dwn, 2 secnds up) test L1 level and test caudally ne level at a time t the lwest lumbar segment Test with cuff n by means f ankle cuffs IF PAIN LATERALIZES WITH THE CUFF ON, then nly mve the table and cntrl the patient by hlding the ankles as in lateral testing. spinus prcess cntact (mammillary cntact ptin) hld ankle (first uninvlved, then invlved) dwnward table mvement till cciput extends r 2 hld 4 secnds (mimic applicatin 2 secnds dwn, 2 secnds up) test L1 level and test caudally ne level at a time t the lwest lumbar segment NOTE: Muscle resistance in the frm f spasm is palpated fr. If any such sign is present, d nt use Cx Technic flexindistractin. If the patient reprts pain n tlerance testing with the cuffs n, adjust withut the cuffs. If the patient reprts pain n tlerance testing while the ankle is held, adjust withut hlding the ankle and just hld the tiller bar which allws just the weight f the legs t be the tractive frce. If the patient reprts pain n tlerance testing with n tractive frce (n ankle hlding r cuffs), ice alne, trigger pint, acupressure, alternating ht/cld and massage may be called fr until lcal irritatin reduces t allw distractin with n signs f discmfrt. Side lying applicatin f frces may be chsen. 1 Cx Technic Prtcls

2 3. Palpatry Cntact fr Increasing Lcal Sft Tissue and Interspinus Tensin Place third digit at the interspinus space t be manipulated. The secnd and furth digits cntact adjacent muscles. Distract the table until the interspinus space feels taut under yur fingertip. At this taut pint the dctr will cntact the spinus prcess with the thenar r thumb index cntact. It is this taut pint that is the starting psitin fr all further table mvement fr distractin and range f mtin f the intervertebral disc and facet jints. Align the dctr hand cntact parallel with the spine in a cephalward directin. D nt cntact the spinus with a perpendicular pressure with the cntact hand; it is a cephalward pressure. Apply distractin with r withut the ankle cuff depending upn patient tlerance results. The end pint f distractin is the interspinus prcess space feeling elastic resistance. When releasing distractin, return t the taut pint nly. 4. PROTOCOL I: Treatment f Sciatic Patients / pain extends belw the knee Prepare the patient as fllws: Patient Psitining Tlerance Testing Cuff n (r ff if patient experiences pain with cuff n r as tlerance testing directs) Mve ankle rest caudally until taut, and lck it in place. Disengage flexin extensin lever. Apply palpatry cntact t set treatment start pint. Apply 3 twenty secnd distractin sets. 5 pumps f 4 secnds each with F/D r lng y axis Depth f caudal distractin = cciput extensin r 2 Trigger Pint Applicatin: Between each 20 secnd sessin, treat apprpriate trigger pint(s) f the affected dermatme (ex: L5 sciatic nerve in gluteus, back f thigh, ppliteal fssa, leg, ankle and ft). 5. PROTOCOL II: Treatment f Nn Sciatica Patient (r sciatic patients wh have 50% relief) / n pain belw knee Full Facet ROM Prepare the patient as fllws: Patient Psitining Tlerance Testing Cuff On (r ff if patient experiences pain with cuff n r as tlerance testing directs) Mve ankle rest caudally until taut, and lck it in place. a. Flexin Disengage flexin extensin lever. Apply palpatry cntact t set new taut treatment start pint. Make spinus prcess cntact with thenar r finger/thumb. (Hand cntact applied in a cephalward directin.) Lift spinus prcess cephalad as table flexes. Apply ne secnd velcity flexin mvements. Amplitude and dsage are applied t patient pain and tlerance levels. Stp caudal table flexin as cciput extends r 2 f dwnward table mvement. Mvement is smth, rhythmical, scillatry mtin. Return table t neutral psitin and secure lcks OR leave unlcked fr lateral flexin. b. Lateral Flexin Perfrm under distractin using flexin (r lng y axis as apprpriate and/r cmfrtable). Disengage levers fr flexin and lateral flexin. Apply palpatry cntact t set taut new treatment start pint in flexin. (Hand cntact applied in a cephalward directin.) Apply flexin t cciput extensin r 2 f dwnward table mvement. Hld spinus prcess between index finger and thumb r use thenar cntact. Apply 1 secnd velcity lateral flexin mvements t each side (right and left). Amplitude and dsage applied t patient pain and tlerance levels. 2 Cx Technic Prtcls

3 Resist spinus prcess with thumb r index finger. Mvement is smth, rhythmical, scillatry. Return table t neutral psitin and secure lcks OR leave unlcked fr circumductin. c. Circumductin Perfrm frm neutral starting psitin (n taut starting psitin set). This mtin cuples flexin/distractin and lateral bending, and it may even cmbine with lng y axis as apprpriate r cmfrtable. Grasp spinus prcess between thumb and index finger r use palmar thenar cntact. (Hand cntact applied in a cephalward directin.) Apply 2 secnd mvements t right and then t left. Amplitude and dsage applied t patient pain and tlerance levels. Mvement is a smth, rhythmical, scillatry mtin. Return the table t neutral psitin, and secure all lcks. d. Extensin Release flexin extensin lever. Cntact SP between index thumb r palmar cntact. Apply anterir pressure as table cmes int extensin. Apply ne secnd repetitins (10 fr test). Amplitude and dsage applied t patient pain and tlerance levels. Mvement is a smth, rhythmical, scillatry mtin. Return table t neutral psitin, and secure all lcks. 6. Getting Patient ff Table / Ending Adjustment sessin Return table t hrizntal/neutral psitin. Check that all lcks are secure. Remve ankle cuffs, if used. Assist patient ff the table (instruct patient t push up ff f the arm rests). This step als allws yu t share tips n hw t get ut f bed at hme and such. II. CERVICAL SPINE Prtcl I and II Instructins Recmmended textbk fr cervical spine mechanism, diagnsis and treatment is Neck, Shulder, Arm Pain: Mechanism, Diagnsis, Treatment, 4th ed. (2014) by James M. Cx, DC, DACBR. IMPORTANT NOTES: Cervical spine flexin distractin and decmpressin spinal adjusting is perfrmed by tw methds: By dctr hand cntact f the vertebral arch f the segment t be distracted Occipital restraint system. Bth methds prduce lng y axis distractin t the individual mtin segment r the entire cervical spine as a clumn. Prtcl I system f distractin manipulatin is fr treating spinal stensis with radicular pain. It utilizes nly lng y axis distractin. When radicular pain is reduced in severity by 50%, Prtcl II is begun as the new treatment prcess. Prtcl II is applicatin f physilgical range f mtin spinal manipulatin fr nn radicular patients and is carried ut with the cervical and/r cervic thracic spine in lng y axis distractin decmpressin. It is Prtcl I applicatin with the additin f jint mbilizatin. Lng y axis distractin increases the disc space height, drps intradiscal pressures and increases framinal area; this results in greatly reduced pssibility f intrducing spinal stensis within the sseligamentus canal (intervertebral framen) as facet jints are manipulated int their physilgical ranges f mtin. The dctr cntacts with ne hand n the spine and the ther n the tiller bar. Bth tiller bar and spine cntact place equal cephalward frce n the spine. One is nt applied with greater frce than the ther. In applying lng y axis distractin t the cervical segments, the spine is distracted cephalward t the barrier f elastic resistance which is the taut pint where the spinal tissues have n further mtin. Distractin is then 3 Cx Technic Prtcls

4 applied beynd the taut pint. Prtcl I is given fr the radiculpathy patient which is lng y axis distractin nly. Prtcl II has the dctr distract the spine as in Prtcl I fllwed by manipulating the jints f the cervical and cervic thracic spines beynd that barrier f elastic resistance int the physilgical range f mtin f the spinal jints. Patient tlerance is mnitred at all times fr discmfrt. Each mvement is perfrmed t the barrier f elastic resistance as determined by the dctr s tissue tensin sense and taken then slightly beynd that barrier. Patient tlerance is mnitred at all times. Cmbining flexin f the headpiece while lng y axis distractin is executed is a strng frce and is t be administered with reduced distractin frce. If the treating physician chses t d this, s/he must carefully mnitr patient tlerance during this prcedure. The preferred methd is t use nly lng y axis distractin withut flexin added; hwever, sme dctrs find the cmbined applicatin beneficial. In treating ulnar radiculpathy with C8 nerve rt cmpressin r chemical inflammatin, cautin is needed s as t nt apply psterir t anterir pressure n the T1 spinus prcess during lng y axis distractin as this increases intradiscal pressure. Occipital restraint distractin is a gd prcedure t avid increasing intradiscal pressure. Place the ccipital restraint n the patient s cciput, cntact at the T5 level as cephalward distractin is applied n the tiller bar. 1. Patient Psitining Sequence Have the patient lie with the specific area t be treated ver the divisin between the cervical and thracic pieces. The eyes may rest in the eye cututs. If there is need fr mre length f the headpiece, unlck the headpiece lng y axis feature, psitin the head, then lck it. 2. Tlerance Testing *NOTE: Start at C1 and tlerance test each level f the cervical spine t C7. Be sure t nt prduce a psterir t anterir frce n the C7 T1 segments as this increases intradiscal pressure at this level. Always lift the spinus prcess and vertebral arch as lng y axis distractin is applied at the C7 T1 segment. D nt press dwnward n C7 T1 in tlerance testing and/r spinal manipulatin. Cntact cervical spinus prcess transverse prcess with ne hand firmly with a thumb/index cntact while lng y axis tractin with the cervical headpiece is applied with the ther hand n the tractin handle at the head f the table. The headpiece and yur hand cntact mve in parallel with equal frce. (Alternative Plan if the patient expresses lateralizatin f pain: Use the patient s headweight as the tractin frce nly s that very gentle distractin is given if the hand cntact causes pain.) Repeat with each cervical spine level, hlding each spinus prcess transverse prcess segment fr 4 secnds. Ask patient if he/she feels any pain in the neck shulder, arm r thracic spine. NOTE: Muscle resistance in the frm f spasm is palpated fr. If any such sign is present, d nt use distractin. Instead use trigger pint, acupressure, alternating ht/cld and massage until lcal irritatin reduces t allw distractin with n signs f discmfrt. Test the next level mving caudad. 3. PROTOCOL I: Treatment f Radiculpathy Patients / pain extends belw the elbw NOTE: Only lng y axis distractin (with an ptinal slight degree f flexin set at a cmfrt level fr the patient) is used t treat acute radiculpathy. DO NOT REST THE HAND PALM OR PISIFORM CONTACT ON T1. Prepare the patient fr treatment, and perfrm tlerance testing. Apply lng y axis distractin t set treatment start pint which is the pint f tautness f the interspinus space. Apply 3 twenty secnd distractin sets 5 pumps f 4 secnds each with F/D r lng y axis Trigger Pint Applicatin: Between each 20 secnd sessin, treat apprpriate trigger pints f the affected dermatme. 4 Cx Technic Prtcls

5 4. PROTOCOL II: Treatment f Nn Radicular Patients (r radicular patients wh have 50% relief) / n pain extends belw the elbw) Prepare the patient fr treatment, and perfrm tlerance testing. a. Lng Y Axis Axial Distractin Grasp the spinus transverse prcess f the vertebra at the level f distractin mtin desired. (ex: Grasp C5 t mve the C5 segment.) Release the axial distractin lck. Standing at the side f the instrument, gently push the headpiece axially using the ball handle and the vertebra cntracted with the dctr s hand until tissue tensin sense ntes the barrier f elastic resistance (the treatment start pint). G slightly beynd the barrier f elastic resistance, carefully mnitring patient tlerance. The cntact hand and the instrument s mtin guided by the cervical tiller bar mve parallel. Gently bring back t neutral. Mve t the next level, and repeat. b. Lateral Flexin Grasp the spinus transverse prcess f the vertebra at the level f lateral flexin mtin desired. Unlck the lateral flexin lck. Mve the headpiece int lng y axis distractin. Laterally flex t the left first, then the right. Stabilize the transverse prcess away n the side f lateral headpiece flexin with the cntact hand as the level t be laterally flexed is brught int lateral flexin by the headpiece mtin. Laterally flex the headpiece until tissue tensin sense ntes nrmal physilgical mtin. Gently bring back t neutral. Mve t the next level, and repeat. c. Circumductin (a cmbinatin f lateral flexin and flexin mvement) Grasp the spinus transverse prcess f the vertebra at the level f circumductin mtin desired. Unlck the flexin and lateral lcks. Mve the headpiece int lng y axis distractin. Circumduct t the left, then t the right. Circumduct the headpiece until tissue tensin sense ntes nrmal physilgical mtin. (This is a strng mvement and imprtant t regain mbilizatin f the cervical facets.) Gently bring back t neutral. Mve t the next level, and repeat. d. Extensin Grasp the arch f the spinus transverse prcess f the vertebra at the level f extensin mtin desired. Unlck the flexin extensin lck. Extend the headpiece until tissue tensin sense ntes nrmal physilgical mtin. Gently bring back t neutral. Repeat as necessary at each jint level. Mve t the next level, and repeat. e. Rtatin Grasp the spinus transverse prcess f the vertebra at the level f rtatin mtin desired. Unlck the rtatin lck. Mve the headpiece int lng y axis distractin. Rtate t the left, then t the right. Rtate the headpiece until tissue tensin sense ntes nrmal physilgical mtin by hlding the arch securely while the segment rtates. Gently bring back t neutral. Mve t the next level, and repeat. 5 Cx Technic Prtcls

6 f. Flexin (ptinal Nte that flexin is much strnger than lng y.) Grasp the arch f the spinus transverse prcess f the vertebra at the level f flexin mtin desired. Unlck the flexin extensin lck. Flex the headpiece until tissue tensin sense ntes nrmal physilgical mtin. Gently bring back t neutral. Repeat as necessary at each jint level. Mve t the next level, and repeat. Again nte that this authr prefers lng y axis distractin as applied in Prtcl I t flexin distractin. If flexin distractin is applied, reduce the cephalward frce with the headpiece and carefully mnitr patient tlerance. 5. Ending The Adjustment Sessin Return table t neutral psitin. Check that all lcks are secure. Lwer the tiller bar. Remve ccipital restraint, if used. Instruct patient t push up n the arm rests. Assist patient t upright psitin. III. THORACIC SPINE Prtcls 1. Using Lumbar Attended Autmated Axial Distractin Apply ankle cuffs, if apprpriate. Allw the table t axially distract per yur cntrl during the distractin adjustment and pen the jint space. Mve up the thracic spine, as apprpriate. Using the ftswitch Use a tw handed cntact f the spinus prcess at the apprpriate level. Tap the ft/tapeswitch t allw the table t mve axially. Release the ft/tapeswitch t allw the table t return t neutral. Using the finger buttn Use a ne handed cntact f the spinus at the apprpriate level. With the free hand, tap the finger buttn n the tiller bar beneath the ball handle t allw the table t mve axially. Release the finger buttn t allw the table t return t neutral. Using the cntrl bx On the bx n the side f the table, Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Use a tw handed cntact f the apprpriate spinus prcess at the apprpriate level. NOTE: A high velcity, lw amplitude adjustment may be given during lumbar attended autmated axial distractin as just described. This can be applied at any desired level f thracic spine accrding t patient need and tlerance in a gentle, nn frce manner. 2. Using Cervical Axial Distractin Sectin OPTION 1 Manually Applied Apply the ccipital restraint system t stabilize the head. Stand at the head f the table. Use a palmar cntact n the spinus belw the thracic segment t be distracted Pull n the ball handle f the cervical headpiece t distract the segment t the pint f elastic resistance. Mve slightly beynd that pint, minding at all times patient tlerance. Gently return t neutral. Mve caudad t the next thracic spinus, and repeat. 6 Cx Technic Prtcls

7 OPTION 2 Applied in Cnjunctin with Autmated Axial Distractin Caudally Apply the ccipital restraint. Allw the table t axially distract the caudal sectin. Adjust the thracic spine while Using the ftswitch Use a tw handed cntact f the spinus at the apprpriate level. Tap the ft/tapeswitch t allw the table t mve axially. Release the ft/tapeswitch t allw the table t return t neutral. Using the cntrl bx On the bx n the side f the table, Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Use a tw handed cntact f the apprpriate spinus at the apprpriate level. NOTE: A high velcity, lw amplitude adjustment may be given during thracic attended autmated axial distractin as just described. This can be applied at any desired level f thracic spine accrding t patient need and tlerance in a gentle, nn frce manner. IV Autmated Lng Y Axis Distractin Applicatins A. Lumbar Spine Attended Autmated Axial Distractin (nn sciatica patients nly r a sciatica patient wh has attained 50% relief f pain) Prepare patient fr treatment, and perfrm tlerance testing. Using the ftswitch The aut/manual selectr must be in the MAN(ual) mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate frm tlerance testing. Make the cntact with the spinus prcess at the level desired with bth hands r with ne hand and rest the free hand n the ball handle. Tuch the ft/tapeswitch with yur ft. Allw the table t distract as far as necessary t pen the jint space. Release the ft/tapeswitch t allw table t cme back t neutral. Make the next cntact with the spinus prcess at the next level desired & repeat prcedure. Using the finger buttn (n the caudal tiller bar at the back f the bar beneath the ball handle) The aut/manual selectr n the tiller bar must be in the MAN(ual) mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate. Make the cntact with the spinus prcess at the level desired with ne hand. Rest the ther hand n the ball handle cmfrtably enugh that the middle finger is in reach f the buttn. Tuch the buttn with yur finger. Allw the table t distract as far as necessary t pen the jint space. Release the buttn t allw the table t cme back t neutral. Make the next cntact with the spinus prcess at the next level desired & repeat prcedure. Using the cntrl bx The aut/manual selectr n the tiller bar must be in the AUTO mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate. Set the cntrl bx n the side f the table, Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Push the start buttn n the frnt f the cntrl bx. Starting at L5S1 and wrking up the lumbar spine, make a tw handed cntact r ne handed cntact (with the free hand resting n the ball handle) with the spinus prcess at the apprpriate level(s). Once each level has been distracted, ranges f mtin may be cmbined with axial distractin, per instructins as explained in Steps 5a, b, c, and d f the LUMBAR SPINE sectin (page 2), as apprpriate fr the patient and his/her cnditin. Always first distract the spinal segment, then g int the ROM desired. 7 Cx Technic Prtcls

8 Flexin Extensin Lateral flexin Circumductin B. Unattended Autmated Axial Distractin (nn sciatica patients nly) Full Spine Adjusting The aut/manual selectr n the tiller bar must be in the AUTO mde n the caudal tiller bar. Apply ankle cuffs, if apprpriate, OR apply the ccipital restraint, if apprpriate (nt bth at ne time). Set the cntrl bx n the side f the table: Set the time fr the table t run in aut mde. Set the distance fr distractin while yu adjust the patient. Shw the patient where the patient emergency stp buttn is under the right armrest. Explain that it can be pushed if the patient feels pain during the sessin. Allw the table t deliver an unattended tractin therapy sessin as setup. Check in n the patient during the sessin. The thracic restraint belt can be psitined and used t apply specific level unattended lng y axis distractin. Special Cx F/D and distractin adjustment prcedures demnstrated in lecture and vide include Side lying F/D and distractin adjusting fr patients wh cannt lie prne t include pregnancy sclisis treated in the prne, supine, side lying pstures fr Cx prcedures supine sclisis (adlescent and degenerative) cmpressin defects f steprsis hyperkyphsis f the thracic and lumbar spine spndyllisthesis retrlisthesis steprsis DISH spinal stensis aged spine cnditins REFERENCES: Lumbar Spine and Thracic Spine Techniques: Lw Back Pain: Mechanism, Diagnsis, Treatment, 7 th ed, published by Lippinctt Williams and Wilkins, Cervical and Thracic Spine Techniques: Neck, Shulder, Arm Pain: Mechanism, Diagnsis, Treatment, 4 th ed, 2014, privately published, Mechanisms f table descriptins per features n The Cx 8 Table by Haven Innvatin. 8 Cx Technic Prtcls

9 PROTOCOL III COX SPINAL DECOMPRESSION PRINCIPLES AND APPLICATION (as f July 13, 2016) Much discussin surrunds decmpressin f the spine. Since decmpressin is a fundatin f Cx spine manipulatin prcedures and ften a stand alne prcedure, Prtcl III is nw specifically added t the Cx prcedures. This will bring needed research and frce f delivery fr decmpressin f the spine t the clinician in his r her clinical practice. PRINCIPLES OF COX AUTOMATED DISTRACTION DECOMPRESSION SPINE MANIPULATION: 1. Unattended lng y axis distractin decmpressin is utilized after the fllwing prcedures leading t its applicatin: A. Lw back and radicular pain patients were tlerance tested fr being able t accept the Cx lng y axis decmpressin distractin (Prtcl I) withut pain. 1. Fllwing Prtcl I manual Cx lng y axis distractin, the radicular patient has been 50% relieved f lwer extremity pain. 2. At the 50% relief f pain, manually cntrlled autmated lng y axis Cx decmpressin distractin is tested fr tlerance by the patient. Prtcl I and II are administered under attended Cx lng y axis distractin with tlerance test mnitring. 3. Attended Cx lng y axis decmpressin distractin is tested at each level f the spine t be treated AND ALSO the spine as a clumn f vertebrae is tested fr pain tlerance. 4. If tlerance testing each spine level and as a clumn f segments is nt pain prducing fr the patient, unattended Cx lng y axis distractin decmpressin (Prtcl III) is given t the patient withut the ankle cuffs in place. 5. If n pain is present with unattended Cx lng y axis decmpressin distractin withut the cuffs, the cuffs are placed n the ankles and tlerance testing is repeated. 6. If n pain is felt with cuffs in place as Cx lng y axis distractin decmpressin is delivered, the thraclumbar restraint belt is placed n the patient superir t the segments t be distracted and decmpressed. Patient tlerance t the restraint is nw tested. 7. If any discmfrt is reprted by the patient, treat belw the level f frce at the nset f care and nly use f the thraclumbar belt r cuff as the patient tlerates. Fr example, if placing the thraclumbar restraint n the spine caused discmfrt fr the patient, remve the restraint and repeat tlerance testing withut it. If the patient is cmfrtable with n restraint, begin their care withut the restraint. At subsequent visits the restraint can again be tested n the patient and when and if it is fund t nt cause pain, it can be administered. Tlerance testing always directs patient level f treatment. 8. If the patient declares any frm f discmfrt as Cx lng y axis distractin decmpressin is given, treat at lesser frce. If all frms f Cx decmpressin are painful, d nt deliver the treatment. B. Hw t apply the prper frce with Cx lng y axis distractin decmpressin spinal manipulatin in Prtcl III: 1. With r withut the thraclumbar restraint in place n the spine, palpate the interspinus prcess spaces and feel the tautening f the ligament and the slight pening f the interspinus space. Ask the patient if there is any discmfrt. If any discmfrt, treat with a lesser frm f distractin decmpressin such as manual Prtcl I r II. 2. As the patient states their tlerance t the Cx distractin decmpressin, begin with a small level f autmated distractin with the Cx instrument under unattended autmated distractin. A ne inch excursin f the caudal sectin f the Cx instrumented is excellent fr tlerance testing. Test with the thraclumbar restraint n and ff the patient s spine. 3. With n cmplaint f discmfrt frm the patient, set the Cx instrument t deliver lng y axis distractin decmpressin withut the restraint r with the restraint placed abve the spine level frm which distractin decmpressin f the inferir vertebrae is desired. The dctr will either use the thraclumbar restraint r nt depending upn patient cmfrt. Islatin f the decmpressin distractin frce is best with the thraclumbar restraint in place. Use the ankle cuffs as patient tlerance allws. Patients desire distractin 9 Cx Technic Prtcls

10 with the cuff and thraclumbar restraint in place and the mst cmfrtable distance f distractin determined fr best decmpressin. 4. Depending n the patient bdy habitus and tissue stretching ability, set the caudal sectin f the Cx instrument t distract the desired distance. Tw inches f distractin is a very cmmn amunt f distractin distance. Time the delivery f the decmpressin frce at the desired degree f distractin distance. The time is cmmnly 12 minutes and this is fllwed with Prtcl II spinal manipulatin. 5. Detente f the caudal sectin f the Cx instrument as lng y axis distractin decmpressin is capable f being set. Pressing the elevatin buttn n the tiller bar will set the distractin t hld frm ½ t 4 secnds. This distractin cnstant frce allws hysteresis and stretching f the spinal muscles, ligaments, facet jints, intervertebral disc and tendns; this stimulates afferentatin t the central nervus system and encurages circulatin int the intervertebral disc. 6. As yu start with Cx unattended lng y axis distractin decmpressin at a lw interval such as ne inch, the distractive distance can be increased by ½ inch increments until the desired cmfrt level f distractin fr the patient is attained. 7. Physilgical therapeutic applicatins as electrical stimulatin, acupuncture, heat, cld, etc. can be administered during unattended lng y axis Cx distractin decmpressin. 8. The instrument is equipped with a stp switch that the patient can press t stp the table if any discmfrt is felt. Other call devices can be used fr patient attentin gaining needs. WHAT ARE THE INDICATIONS FOR UNATTENDED LONG Y AXIS COX DISTRACTION DECOMPRESSION SPINAL MANIPULATION PROTOCOL III? A. Disc degeneratin and the accmpanying arthritic disc and facet jint and ligament pathlgies that accmpany it. B. Spinal Stensis. This may be due t disc herniatin r degenerative spine disease such as ligamentum flavum hypertrphy, endplate hypertrphy, facet arthrsis, disc space narrwing, ligament calcificatin r mst cmmnly the cmbinatin f all these factrs. C. Sclisis. Adlescent idipathic sclisis r degenerative sclisis which usually is accmpanied with the cnditins nted in pints A and B. D. Chrnic lw back pain. Patients ften state it wuld feel gd t have their spine pulled apart. Based n the research f Cx Technic, five factrs are in place and benefited with Cx lng y axis distractin decmpressin spinal manipulatin: 1. Increase disc space height 2. Decrease intradiscal pressure 3. Increase the intervertebral framinal area by 28% 4. Restre physilgical range f mtin t the vertebral jints and 5. Afferentatin f pain relieving nerve pathways t the central nervus system. E. Lw back and lwer extremity pain such as sciatica are treated with this prcedure per the abve instructins. WHAT ARE THE CONTRAINDICATIONS TO COX LONG Y AXIS DISTRACTION DECOMPRESSION SPINAL MANIPULATION? A. Any patient cmplaining f spine r extremity pain when tlerance tested prir t using Cx distractin decmpressin prcedures B. Acute fracture, active malignant disease, cauda equine syndrme, prgressive neurlgical disease In didactic lecture and certificatin curses in Cx lng y axis distractin decmpressin spinal manipulatin, cmputer frces generated with the abve prcedures will be taught fr further exactness and cmpetence in delivering Cx unattended autmated lng y axis distractin decmpressin t the spine. Submitted fr Prtcl III by James M. Cx, DC, DACBR 10 Cx Technic Prtcls