Is My Back “Out of Alignment”????
Is My Back “Out of Alignment”????
As a physical therapist, I obviously encounter droves and droves of people who struggle with back pain. After all, according to the Mayo Clinic it is the third most common reason for a primary care doctor’s visit in the United States. Low back pain (LBP) affects at least 80% of us some time in our lives, perhaps 20-30% of us at any given time.(3) In one study a team of researchers from Duke Medical Center found that patients suffering from back pain consume more than $90 billion annually in health-care expenses, with approximately $26 billion of that amount directly attributable to treating the back pain. Immense costs are associated with LBP, including lost productivity and income from work, the expense of medical, rehabilitation, and surgical interventions, and the costs of disabling pain and limited daily function.
However, this isn’t an article about back pain statistics, specific pathology, or specific treatments of back pain. The question this article will address is whether or not your back is out of alignment, said alignment issue is causing your pain, or for that matter any other health condition.
In clinic I get asked or hear a comment almost on a daily basis about needing to get the back “adjusted, re-aligned, put back in place”. The concept of your back bones or “vertebrae” being out of place/alignment goes back a long time in history. It has dominated the general public’s idea of back pain as well as being the entire basis for certain professions. Chiropractors for instance, at least traditionally, base their entire profession and treatment techniques on the theory of spinal subluxation. This theory suggests that mal-alignments in the spine are the main cause of back pain. Additionally it suggests that various other health conditions of multiple organ systems are due to compression on nerves which leads to significantly impaired function throughout the body. This treatment of all organ systems is why Chiropractors refer to themselves as physicians. Physical therapists on the other hand (though we now have a doctorate level education- DPT or Doctorate in Physical Therapy) typically just refer to themselves as therapists or at most Doctors of PHYSCIAL THERAPY due to the fact that we primarily focus on the neuro-musculo-skeletal systems.
With that being said, I would like to address some of the shortcomings of the subluxation theory with the following points:
First, we must address what a subluxation actually is. In medicine a true orthopedic subluxation, is a partial dislocation or a bone/joint. In the spine this can be caused by disc degeneration, curvatures, spondylolysis, and structural abnormalities such spondylolithesis . A subluxation may or may not be mechanically symptomatic and CAN NOTbe seen on a plain x-ray image.
It should also be pointed out that the spinal nerves that arise from each vertebral level primarily supply musculoskeletal structures, and that the body’s organs are supplied predominantly by autonomic nerve ganglia and plexuses located outside the spinal column. Examples of these are the cervical sympathetic ganglia, vagus nerve, phrenic nerve, and the thoracic sympathetic ganglia.
Second, subluxation theory says the spine is responsible for ALL illnesses. According to that theory, germs do not cause disease. Everything is caused by your back. In fact, BJ Palmer who was the son of founder of Chiropractic Medicine DD Palmer, was quoted as saying
"Chiropractors have found in every disease that is supposed to be contagious, a cause in the spine. In the spinal column we will find a subluxation that corresponds to every type of disease. If we had one hundred cases of small-pox, I can prove to you where, in one, you will find a subluxation and you will find the same conditions in the other ninety-nine. I adjust one and return his functions to normal... . There is no contagious disease... . There is no infection... . There is a cause internal to man that makes of his body in a certain spot, more or less a breeding ground [for microbes]. It is a place where they can multiply, propagate, and then because they become so many they are classed as a cause." -- B.J. Palmer, The Philosophy of Chiropractic, V. Davenport, IA: Palmer School of Chiropractic; 1909
***I think with the advancement of modern medicine, antibiotics, vaccines, imaging, etc we can all agree that this quote is just a little bit off.
Next, in all scientific research that has been completed to date, no-one has ever been able to locate a "subluxation" through X-Rays, MRI or any other diagnostic test.
Mirtz TA et al. An epidemiological examination of the subluxation construct using Hill's criteria of causation." Chiropractic & Osteopathy 2009, 17:13, 2009
"No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal, this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.” (1)
Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther. 1995;18:379-397.
Finally, to further decrease the validity of the spinal subluxation theory it has been shown that there is no change in resting joint position after spinal manipulation (adjustment) is performed.(8)
If it were true, then those that suffer from scoliosis (true mal-alignment of the spine) would certainly be doomed to have tremendous pain and dysfunction throughout the entire body right? However, the prevalence of scoliosis is between 5-10% for adolescent boys and girls respectively.(2) Most often, these people that have scoliosis do not even know it, have absolutely no symptoms, and are healthy perfectly functioning individuals!
Anyone who has actually experienced true neural compression/irritation can confirm that the symptoms are not mysterious lurking health issues such as asthma/vertigo/bedwetting/allergies,/PMS/etc which are among just a handful of the ones I’ve personally heard. Instead, they experience tingling, numbness, burning, shooting pain, decreased reflexes, and muscle weakness distal to the compression site of the nerve. Symptoms that do not resolve until the inflammatory process leading to these symptoms can be addressed by medication, positioning, neural mobility exercises, time, or as a last resort surgery.
Many people will argue that “if isn’t out of place then why does it pop and crunch so much when it gets pressed on”? Well, it is currently still theory, but in the leading theory of cavitation theory it is postulated that a rapid increase in the joint volume occurs during manual manipulation of the joint. This subsequently drops the partial pressure of CO2 within the synovial fluid and allows it to be released as a gaseous bubble into the joint cavity. (5, 6, 7)
The take home point of this article is to inform people that your spine does not pop and shift out of place willy nilly like some would have you believe. The spine is an extremely strong and robust structure that can take on an immense amount of force without deformity/injury. Imagine what a football player’s spine would look like after a long hard game if it were that easy to “get out of alignment”.
In fact, the more we learn through diagnostic imaging research studies, we find that degeneration in the spine (and other joints as well) does not directly correlate to pain or dysfunction at all. These degenerative changes are most often just a side effect of aging and are often present for years before we ever realize we have a “bone on bone degenerated back problem”.
I would also like to take the opportunity to express that I am by no means trying to bash the chiropractic profession. There are many good practitioners out there who do not subscribe to the subluxation theory and practice very effective primary care musculoskeletal medicine. Though, in the area I live and practice in (very close to Parker Chiropractic College) the prevalence of subluxation based practitioners is more dense than most places due to the fact that Parker continues to teach and promote this theory to students. (4)
Always try to be an informed patient and remember to stay skeptical my friends!
-Jarod Hall PT, DPT, CSCS
References:
1. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769-81.
2. Mirtz TA et al. An epidemiological examination of the subluxation construct using Hill's criteria of causation." Chiropractic & Osteopathy 2009, 17:13, 2009
3. Carter OD, Haynes SG. Prevalence rates for scoliosis in US adults: results from the first National Health and Nutrition Examination Survey. Int J Epidemiol. 1987;16(4):537-44.
4. http://parker.edu/academics/doctor-of-chiropractic/
5. Unsworth A, Dowson D, Wright V: Cracking joints - a bioengineering study of cavitation in the metacarpophalangeal joint. Ann Rheum Dis1971, 30:348–358.
6. Herzog W, Zhang YT, Conway PJ, Kawchuk GN: Cavitation sounds during spinal manipulative treatments. J Manipulative Physiol Ther 1993, 16(8):523–526.
7. Watson P, Kernohan W, Mollan R: A study of the cracking sounds from the metacarpophalangeal joint. J Engineering Med 1989, 203:109–118.
8. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine. 1998;23(10):1124-8.
9. Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther.1995;18:379-397.
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