Bulging Disc, Cox® Technic and Spinal Disc Decompression
By Dr Danica Newbold
B.HSci (Chiro), M.ClinChiro, Ad.Dip Myo.
Certified Cox® Flexion-Distraction Chiropractor
How Do Chiropractors treat Disc Bulge?
Back and neck pain associated with bulging disc (disk), herniated disc (disk) is a common condition, but what does it entail? Here, we explain the basic anatomy, mechanism, signs, symptoms, and treatment of this painful and often debilitating condition. Cox® Certified Chiropractors at Melbourne Spine Clinic and Malvern Chiropractic Clinic have extensive knowledge and training, experience and success in the delivery of effective treatment to manage Bulging discs and Herniated discs. In the USA, where Cox® Technic was developed by Dr James M. Cox, Cox® certified chiropractors are called “back pain specialists”. While this term is not used in Australia, Cox® certified chiropractors have dedicated their ongoing professional development to the treatment of bulging discs and are experts in helping patients to manage this painful condition.
Spinal Discs – what, where, and why?
Spinal discs are the essential cushions between the individual spinal (vertebral) bones. They act as a shock-absorber for the spine and are made up of a thick cartilaginous outer ring (annulus fibrosis) and soft, fluid-like centre (nucleus pulposus). Essentially, think of a spinal disc like a jam doughnut, if you will.
What is a Bulging Disc?
Spinal Disc Bulges, also known as slipped-disc, disc protrusions, herniation or prolapses, can occur at any spinal level in the body. It is defined as, the expansion or movement of the intervertebral disc (IVD) from its defined boundaries that may cause pain and invade the surrounding neurological structures within the spinal column. Not all disc bulges or protrusions cause just back or neck pain. Some may experience only extremity pain such as in the leg or arm.
In more severe cases, disc bulges may herniate, causing the disc to rupture and the inner disc material to spill out into the spinal structures. The seeping material is highly neurotoxic and can place enormous amounts of pressure on the spinal cord and nerves, which causes extreme pain. This is a severe condition and requires immediate medical attention.
The irritation of the spinal nerves caused by bulging discs can create an array of signs and symptoms. These include but are not limited to:
- Back/ Neck pain
- Leg/Foot pain – lumbar or low back disc bulges, i.e., Sciatica
- Arm/ Hand pain – cervical or neck disc bulges
- Burning, Tingling, and/ or Numbness – this can be mild to severe and be located close to the pain source or radiating out into the extremities such as the shoulder, arm or hand in cervical disc bulges; hip, buttock, leg or foot especially in lumbar disc bulges.
- Muscle spasms or weakness
- Decrease mobility/ range of motion.
In more extreme cases, patients may experience altered bowel or bladder function for lumbar or low back disc protrusions. This is a severe condition and requires immediate medical attention in hospital.
What causes Bulging disc (disk) or Herniated disc (disk)?
Bulging or protruding discs may happen for several reasons. Typical reasons might be due to:
- Repetitive strain on the discal compartment creating weakened areas in the annulus fibrosis.
- Rapid or sudden increases in intradiscal pressure due to load or trauma.
- There may even be some instances of genetic predisposition or lifestyle factors.
Repetitive strain can cause microtrauma to the discal compartments. An example of repetitive strain might be poor posture or ergonomics — poor posture when sitting, standing, and working stresses the spinal joint and discs. Sustained postures like slouching, rounded shoulders, forward bending, or translation of the head and neck causes the tensioning of the posterior (back) elements of the spinal compartments. Over time, this can lead to undue stress on the spine and discs that may eventually bulge or protrude outside their typical environment.
Traumatic injury to the spinal discs may include direct or indirect causes. Types of traumatic injuries may include:
- motor vehicle accidents
- spontaneous events – bending, twisting and lifting actions
- violent, excessive, and repetitive sneezing or coughing.
These unexpected loads or torsions of the disc can tear and disrupt the annulus fibrosus hence leading to disc injury.
Lifestyle factors that may be associated with disc injuries can include:
- Insufficient physical activity or sedentary lifestyles – this includes those who predominately work in an office or desk-type occupation.
- Smoking, which emits harmful toxins into the body that have been known to break down disc cartilage.
- Poor diet and obesity – increased weight on the joints and cartilage cushions of the body can accelerate the degenerative process.
- Aging process – as we get older, our joints tend to wear, and the soft tissues of the body (ligaments, tendons, cartilage) lose their moisture and overall structure. For the spinal discs, this means narrowing of the intradiscal spaces, which increases the pressure inside the disc that may lead to disc bulges or protrusions.
How is Bulging disc (disk)or Herniated disc (disk) diagnosed?
The Chiropractors at Malvern Chiropractic and Melbourne Spine Clinic are well trained and educated in all aspects of treating and managing spinal disc bulges using Cox® Technic, which is gentle and low force. When arriving for an initial consultation in the clinic, the Chiropractors conduct an extensive medical history, physical, orthopaedic, and neurological examination of a patient’s condition. If they suspect a disc injury, which as not already been diagnosed, patients are referred for spinal imaging. The most accurate and detailed imaging for disc injuries is an MRI scan. Unlike x-rays, which may identify areas of chronic degenerative change within the spinal joint spaces, MRI scans identify direct injuries of the spinal discs.
Fig 3. ‘Normal’ Lumbar MRI
Fig 4. Multi-level Disc Disease Lumbar MRI
How is Bulging disc (disk) or Herniated disc (disk) treated?
Treatment for disc bulges and protrusions should begin as soon as possible. A trial of conservative, non-invasive, gentle, low – force care is advised, prior to surgery being considered for patients with lumbar disc herniation (1). Any spinal pain management program should address several critical factors.
- Pain reduction or elimination
- Reduce compression on the spinal cord/spinal nerves
- Improve range of motion and mobility.
- Rehabilitation of important spinal/core musculature.
- Address specific personal goals, i.e., returning to work or sports, regular activities of daily living (ADL’s).
How is Cox® Flexion-Distraction and Spinal Decompression Therapy used to treat is Bulging disc (disk) or Herniated disc (disk)?
The practitioners at Malvern Chiropractic and Melbourne Spine Clinic use Cox® Flexion-Distraction and Spinal Decompression therapy. Cox® Flexion-Distraction and Spinal Decompression therapy is a first-line therapy for spinal pain in modern medical practice with more than 40 years of research in successfully treating back pain.
Pioneered by Dr. James (‘Jim’) M. Cox in the USA, Cox® Technic is a well-researched, evidence-based system of Flexion-Distraction and Spinal Decompression. Cox® Technic is well documented in federally funded research in the USA and worldwide. Dr. Cox and his team are continually training and educating Chiropractors, worldwide on becoming Cox® Technic Certified Practitioners. In the USA, Cox® Certified Chiropractors are referred to as “back pain specialists.” Although this term is not used in Australia, Cox® certified chiropractors have extensive training, experience, and success in the delivery of effective treatment in manage bulging discs and herniated discs.
Spinal disc decompression using Cox® Flexion-Distraction and Spinal Decompression Therapy is a safe, low-force, doctor-controlled spinal mobilisation technique performed on a highly specialized Cox®8 Table, which allows the effective administration of flexion-distraction and spinal decompression adjustments. The goal of Cox® Flexion-Distraction and Spinal Decompression is to help the patients go from “pain” to “no pain” as quickly as possible (2).
Spinal disc decompression works by gently stretching the spine. This changes the force and position of the spine and will take the pressure off the spinal discs. Over time, negative pressure from this therapy may cause bulging or protruding discs to retract. The decrease in intradiscal pressure can further reduce compression on the nerves and other structures in the spine. In turn, this helps promote movement of water, oxygen, and nutrient-rich fluids into the discs so they can heal, decrease pain, and increase mobility.
Based on the many years of research, we know Cox® Flexion-Distraction and Spinal Decompression can:
- Decrease intradiscal pressure by up to 192mmHg (millimetres of mercury)
- Improve intervertebral disc height by up to 17%
- Improve spinal nerve openings (foramina) by up to 28%
- Improve range of motion and flexibility
- Decrease pain and sensitivity.
Care for spinal disc bulges is an “active/passive” approach. The passive side of the treatment plan constitutes the treatment received from a Cox® Certified Chiropractor in the clinic. The active participation in the treatment plan is what the patient performs. This can include stretches and rehabilitation/ strengthening exercises as prescribed by the Cox® Certified Chiropractor at precise moments in the overall treatment plan. The exercises and rehabilitation are essential to the overall success of treating back pain conditions, i.e., spinal disc bulges. Failure to do so may slow down or halt any progression of the overall treatment plan. Cooperation between the patient and the Chiropractor is vital to obtain the best clinical outcomes.
Realistic expectations are discussed between the patient and the Chiropractor from the outset. Cox® Flexion-Distraction and Spinal Decompression Technic has several rules and procedures that govern the expectations and outcomes of treatment for bulging and herniated discs. The ‘Rule of 50%’, guides the Cox® Technic treatment under the Cox® Technic protocols. It states:
- 50% reduction in pain symptoms as recorded subjectively (by the patient) and objectively (by the physical tests conducted by the Chiropractor) within the first 30 days.
a. If a 50% reduction in pain is not attained, then referrals for further testing/ imaging may be considered.
- At 50% reduction in pain levels, treatment frequency is reduced by 50%.
b. E.g., If a patient is currently receiving daily treatments, then treatments would be reduced to every two days.
What can I do if I have back pain following surgery for Bulging disc (disk) or Herniated disc (disk)?
Continued back or neck pain following surgery is not uncommon. Failed Back Surgery Syndrome (FBSS) is becoming increasingly prevalent. FBSS is a generalized term used for those patients who have not had an adequate response to spinal surgery interventions. In some cases, patients may have more pain than they had before surgery. Cox® Flexion-Distraction Technic can help alleviate spinal pain symptoms.
In June 2016, the Journal of Chiropractic Medicine reported published an article which showed the clinical outcomes of 69 post-surgical back pain patients. This study investigated the degree of pain reduction while undergoing treatment using Cox® Flexion-Distraction therapy and reported outcomes at 24 months post conservative intervention. Conclusion: Greater than 50% pain relief following Cox® Technic chiropractic distraction spinal manipulation was seen in 81% of postsurgical patients receiving a mean of 11 visits over a 49-day period of Chiropractic care (3).
What does Cox® Flexion-Distraction and Spinal Decompression feel like?
The treatment performed in the clinic by the Certified Cox® Flexion-Distraction Chiropractors at Malvern Chiropractic Clinic and Melbourne Spine Clinic, is a very gentle and safe technique. It is a method of gentle traction, performed as a slow-moving pumping action, and spinal mobilization technique with the assistance of the highly specialized Cox® Table. Overall, it feels like a deep but mild stretching feeling to the spine. All movements are slow and within the patient’s tolerance.
Fig 5. Low Back (lumbar spine) Cox® F/D Treatment
Fig 6. Neck (cervical spine) Cox® F/D Treatment
What does the research tell us?
Spinal manipulation and mobilisation are likely to reduce pain and improve function in chronic low back pain patients (4).
- 80% of cervical and lumbar spine disc herniations helped by flexion-distraction treatment (5).
- 13 of 18 low back patients felt greater positive effects of flexion-distraction over placebo (6).
- A Cochran review of surgical and non-surgical interventions for Lumbar Spinal Stenosis (LSS) was conducted. It revealed that “no clear benefits were observed with surgery versus non-surgical treatment.” However, the author did conclude that the rate of side-effects of undergoing surgery ranged from “10% to 24%”, and that “no side effects were reported for any conservative treatment (7).
What is the prognosis for Bulging disc (disk) or Herniated disc (disk)?
Is there a quick fix for Bulging discs or Herniated discs? no quick fixes when treating spinal disc bulges. Most disc injuries can take several weeks to settle down. It is important to note that spinal disc bulges can remain quite sensitive and vulnerable during the early stages of conservative management. It can take up to six weeks, if not more, to overcome this initial stage. However, things will not always remain this way. The pain and physical limitations associated with spinal disc bulges are not a permanent fixture in one’s life. 91% of low back pain patients treated with Flexion-Distraction achieve maximal improvement in 90 days (8). Commitment to the conservative management program as set forth by the Cox® Certified Chiropractors at Malvern Chiropractic Clinic and Melbourne Spine Clinic is essential to achieving the desired outcomes long term.
(1) Daffner, SD; Hymanson, HJ; Wang, JC. Cost and use of conservative management of lumbar disc herniation before surgical discectomy. Spine 2010; 10 (6): 463-468
(3) Gudavalli, M.R., Olding, K., Joachim, G., Cox, J.M. Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series. J.ChiroMed. 2016, June, vol 15.
(4) Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Suttorp Booth M, Herman PM. Manipulation and Mobilization for Treating Chronic Low Back Pain: a Systematic Review and Meta-Analysis. Spine J. 2018 May; 18(5): 866–879.
(5) BenEliyahu et al. Magnetic Resonance Imaging and Clinical Follow-Up; Study of 27 Patients Receiving Chiropractic Care for Cervical and Lumbar Disc Herniations. JMPT, vol19, 1996
(6) Hawk, C., Azad, A., Phongphua, C., Long, C.R. Preliminary study of the effects of a placebo chiropractic treatment with sham adjustments. JMPT, vol22. 1999
(7) Zaina F, Tomkins‐Lane C, Carragee E, Negrini S: Surgical Versus Non‐Surgical Treatment For Lumbar Spinal Stenosis. Cochrane Database Syst Rev 2016;(1):CD010264
Fig 1. https://www.ehealthstar.com/conditions/bulging-herniated-disc/broad-based-herniatio n
Fig 2. https://www.ehealthstar.com/conditions/bulging-herniated-disc/broad-based-herniation
Fig 3. https://radiopaedia.org/cases/normal-lumbar-spine-mri?lang=us
Fig 4. https://radiopaedia.org/cases/degenerative-changes-and-disc-herniations-in-the-lumbar-spine?lang=us
Fig 5. https://www.coxtechnic.com/patients/treatment
Fig 6. https://www.coxtechnic.com/patients/treatment
About the Author
Dr Danica Newbold is a Chiropractor and Cox® Certified Practitioner at Malvern Chiropractic Clinic and Melbourne Spine Clinic. Dr Newbold completed her Chiropractic studies and graduated from RMIT University in 2016. Prior to this, she had qualified and was working as a Myotherapist. After witnessing a family member undergo the pain and struggle associated with a disc conditions, Danica developed a keen interest in the conservative management and treatment of spinal and disc injuries and diseases. Dr Newbold became fully certified in Cox® Technic in November 2017.
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