Case Report: Modified Cox® Flexion-Distraction Spinal Decompression Therapy Assists in Management of Low-Back and Pelvic Pain in a Pregnant Patient

Case Report: Modified Cox® Flexion-Distraction Spinal Decompression Therapy Assists in Management of Low-Back and Pelvic Pain in a Pregnant Patient

Tying Research to Clinical Application

Author: Amelia Pappas, DC/Wednesday, March 2, 2016/Categories: March 2016

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By Amelia Pappas, DC


Low-back pain is highly prevalent in pregnant women. Up to 90 percent will experience back and pelvic pain sometime during the course of their pregnancy.1 Of significant note are the biomechanical changes a pregnant woman’s pelvis undergoes during this time with the loosening of the sacroiliac joint and the pelvis being a possible mechanism of pain throughout pregnancy.2 This case shows the successful treatment of a pregnant patient experiencing low-back and anterior pelvic pain using modified Cox® flexion-distraction spinal therapy.


This case outlines the treatment of a 30-year-old female who is 34 weeks pregnant with her first child and who presented with progressive lowback pain and anterior pelvic pain. The pain had been increasing in duration and intensity over the previous four weeks and had led to difficulty when walking or standing for greater than 10 minutes. Initial numeric rating scale (NRS) pain rating was 7/10 at worst and 3/10 at best. General practitioner advice had been sought and a differential diagnosis of urinary tract infection or pubic symphysis inflammation/separation were suspected and later ruled out through ultrasound imaging.

The pain was described at the lumbosacral junction with an occasional sharp “knife-like” sensation in the region of the pubic symphysis. Pain was aggravated by walking, standing and occasionally, with urination and relieved by resting and wearing a compression belt.


Blood pressure was within normal limits at 129/80. Neurological examination of reflexes, dermatomes and muscle strength were unremarkable. On postural examination, a significant increase in lumbar lordosis and right side pelvic distortion pattern were noted. Orthopedic examinations were positive on the right side with Menell’s test and Patrick’s (Fabere) test. No positive straight leg raise or slump test were noted. Hypertonic and tender gluteal, psoas and piriformis muscles were found.


Ultrasound examination at 34 weeks + 3 days gestation ruled out inflammation/separation of pubic symphysis. No other imaging is available.


The patient was treated with supine SOT pelvic blocking techniques in conjunction with modified, side-lying Cox® flexion-distraction therapy Protocol 2,1 which means all ranges of motion are introduced to the spine (e.g., flexion, lateral flexion, circumduction); whereas in Protocol 1 only one motion, that of flexion-distraction decompression is introduced to the one affected segment. The patient was also treated with short duration supine Y-axis decompression therapy. To perform modified flexion-distraction therapy Protocol 2 for a pregnant patient, the patient is placed in a side-lying position and flexion motion is achieved through the table’s lateral flexion mechanism (see Figure 1), a lateral flexion decompression is achieved using the flexion motion of the table (see Figure 2), and circumduction is achieved by unlocking both lateral flexion and flexion mechanisms on the table (see Figure 3). Each range of motion is repeated as per normal Cox® flexion-distraction Protocol 2 outlines.3 A home exercise program was also prescribed, including pelvic tilts, psoas muscle stretches and pelvic floor contraction exercises.”

Case Outcome

After two treatments, the patient reported significantly decreased pain both in frequency and duration. The patient was now able to walk/stand for more than 10 minutes without onset of pain, and no painful urination had been experienced since treatment. After four treatments over a four-week period, the patient stated that her low-back pain had reduced to a NRS rating of 1/10, and she had not experienced any pain at the pubic symphysis since her third treatment. Three days after her fourth treatment, the patient had an uncomplicated labor and birth, and treatment ceased at this time. Upon antenatal follow-up consultation six weeks after birth, the patient reported a complete resolution of symptoms and no ongoing complications.


Low-back pain and pelvic pain are particularly prevalent during pregnancy with a reported incidence of 61 percent.4 This pain has been associated with the increased mechanical strain on the low back and sacroiliac joints due to the change in the center of gravity experienced by the pregnant patient.5 Conservative management of these conditions is often sought; however, very little actual research has been published. Chiropractic therapy is considered a safe and effective means of treating the mechanical pain of pregnancy; a retrospective case series reports 94.1 percent of cases improving post-chiropractic therapy.4

In this case, Cox® flexion-distraction therapy was used rather than manual joint manipulation due to its wide variety of range-of-motion applications and decompressive forces. Protocol 2 was chosen as no radicular symptoms were present,3 and orthopedic testing had indicated involvement of the facet joints.

Using the hypothesis that pain was generated in part by the stress of the increased lumbar lordosis and increased mechanical pressure through sacroiliac and pelvic structures, a decompressive and mobilizing treatment protocol was applied yielding a particularly successful result in not only the lowback and sacroiliac pain but also in the pain experienced at pubic symphysis. A possible mechanism of this relief is that easing the strain and compression in the posterior compartment and sacroiliac region reflexively reduced the strain on, and improved the articulation of, the pubic symphysis. A relationship has also been noted between secondary impairment of lower sacral nerve root function due to mechanical disorder of the low back, which can account for pelvic pain relieved by flexion-distraction therapy.3

Axial distraction adjusting is thought to stimulate the firing of normo-excitatory spinal reflexes, which inhibits hyper-excitatory impulses that generate pain.3 Supine long-axis decompression was a particularly useful modification of Cox® Technic used for this patient, providing enormous relief to the postural stress and pressure accumulation throughout the lower lumbar facet joints experienced during pregnancy and attributed to the increased lordotic curve.

The pattern of low-back and pelvic pain is commonly experienced in the latter months of pregnancy, and the application of Cox® flexion-distraction spinal therapy in this case provided a helpful and gentle solution to these symptoms.


With chiropractic, 52 percent of 115 recruited pregnant patients with low-back pain improved at one week, 70 percent at one month, 85 percent at three months, 90 percent at six months and 88 percent at one year.6 This patient achieved excellent outcomes from Cox® Technic and is continuing to participate in her active care program. This case highlights the success of modified Cox® flexion-distraction therapy, adjusting for the pregnant patient, particularly with the implementation of a strong home active care program. With the high prevalence of back pain experienced by pregnant women, this case highlights the benefit of the use of low-force mechanical therapy in managing low-back and pelvic pain during pregnancy.


1) Kruse R, Gudavalli S, Cambron J. Chiropractic treatment of a pregnant patient with lumbar radiculopathy. J Chiropr Med. 2007;6(4): 153-158.

2) Anderson C. Exercise and pregnancy. ICA review. 2004; 60(1-2):52-61.

3) Cox JM. Low Back Pain: Mechanism, Diagnosis, Treatment, 6th ed, Philadelphia: Lippincott Williams & Wilkins 1999; 273-285.

4) Lisi A. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. J Midwifery Women’s Health. 2006;51(1):e7-10.

5) Ritchie JF. Orthopedic considerations during pregnancy. Clin Obstet Gynecol. 2003; 46:456-466.

6) Peterson CK, Mühlemann D, Humphreys BK. Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1 year follow-up. Chiropr Man Therap. 2014 Apr 1;22(1):15. doi: 10.1186/2045-709X-22-15.

Julie Cox-Cid is coordinator for Cox® Technic and is available at 800-441-5571,; The featured case report is by Amelia Pappas, DC, a Cox® Technic-certified physician practicing in Melbourne, Australia.


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