-08.png)
"My spine feels out of alignment"
You have probably heard it from someone, a family member, a friend, your neighbour; “my spine feels out of alignment, I need to go see profession X too put it back in”.
But what does this actually mean? How does this happen? Does it even happen? Should you be worried it’s happening to you? Is there any science behind it?
We’re going to dive into it below. However, if you want a shorter more entertaining version, please watch the videos by Aaron Kubal (chiropractor) below: https://www.instagram.com/p/CNfQQA6gt9q/?igsh=dTQyaGR1bWF0ZWY5
A little history behind the alignment (subluxation) theory
The subluxation theory is based on the idea that interference of the nerves at the spinal cord is caused by slightly misaligned vertebrae. The founder of this theory, Daniel David Palmer attributed this misalignment and interference of nerve ‘flow’ to almost all existing diseases. He also thought that only spinal manipulations can correct this misalignment.
What does the research say?
Subluxations are not the cause or a contributing factor for any known disease (Cote et al., 2021). There is simply no research to support this, it doesn’t exist.
There is no relationship between pain with spinal curvature and many abnormalities (Christensen & Hartvigsen 2008)(Grob et al., 2008)(Brinjikij et al., 2015)(Tonosu et al., 2017)(Gay 1994)(Balagué & Pellisé 2016). With exceptions being severe scoliosis and other more extreme cases.
Spinal curvatures cannot be accurately or reliably assessed in the clinic by a therapist palpation, observation, photos, or videos (Nolet et al., 2021)(Fausone et al., 2023).
X-rays or other imaging technologies could theoretically be used (and unfortunately do get used) to look for spinal alignment. However, this can actually do far more harm than good (Darlow et al., 2017), which I will expand on below.
Manual therapy and manipulations do not correct spinal curvatures (or change anatomical structures for that matter (Shilton et al., 2015)(Nim et al., 2021)(Bialosky et al., 2018)(Lascurain-Aguirrebeña., 2016)(Sun et al., 2023). Research shows that manipulations can be applied anywhere along the spine and may create the same pain relief (for some people) (Sorensen et al., 2023)(Nim et al., 2021).
This theory has been around for a long time, manipulations have been around for a long time. However, it has not necessarily resulted in better outcomes or better health. Lower back pain numbers are increasing every year (Wu et al., 2020). Spinal manipulations are majority of the time not effective or have very little effect (Rubinstein et al., 2013).
There is no relationship between the subluxation theory and health outcomes or need for interventions (Mirtz et al., 2019).
Conclusion
Looking for a spinal alignment is looking for a problem that does not exist, we can’t assess, and we can’t treat.
So, what do manipulations do? And why do they feel so good?
The very short answer is we don’t completely know (Bialosky et al., 2009)(Bialosky et al., 2018). We know that some factors play a role, for example the placebo effect (link to placebo article), neuromodulation possibly through the descending modulatory system or other temporary changes in the nervous system (Coronado et al., 2012)(Bialosky et al., 2018)(Lascurain-Aguirrebeña et al., 2013).
Why is it even a problem?
So why go through all the trouble to investigate this theory, is it really such a big deal? Well, I am going to make an argument that it is.
Providing manipulations can be helpful for some people. However, the narrative “you’re out of alignment” is the problem and can actually be harmful to people.
Not everyone gets relief, and some even have worse pain (Carnes et al., 2010). I see these people all the time. They have tried manipulation, and it did nothing for their pain although they were promised it would fix them. They since felt helpless, disappointed, frustrated, broken (why didn’t it work for me), upset, which we know can all contribute to pain.
X-rays and imaging when not indicated can be very harmful (Hall et al., 2021)(Darlow et al.,2017)(Sajid et al., 2021). Firstly, they do expose you to radiation (even if it is a small amount). Most importantly they lead to worse outcomes.
These narratives can actually make people feel broken, fragile, and scared to move (Caneiro et al., 2021)(Hohenschurz-Schmidt, 2022). There is a strong relation with these beliefs and pain, read more here (fear avoidance blog). This is my main personal frustration, I see so many people not engaging in their favourite hobbies, sports, physical activities because they are afraid, they will go out of alignment. Which can lead to disuse, deconditioning, disability, less enjoyment of life, social isolation, etc.
It leads to unnecessary and not completely risk-free treatments. Manipulations are generally considered quite safe however, there are still risks involved (and sometimes very serious) (Ward et al 2012)(Carnes et al., 2010).
So why does this theory/narrative still exist?
There could be so many reasons for it. Here are some possible reasons:
The healthcare professional has not kept up with the evidence (Hartvigsen et al., 2022). There is very little incentive for health care professionals to stay up to date with new evidence, it requires time and money. There is even less incentive to practice using evidence-based practice, as the evidence often does not support the use of shiny tools and gadgets and is often not very glamorous.
The healthcare professional has not come across opposing evidence (Hartvigsen et al., 2022). They may only be subscribed to journals that publish low quality research articles (selective research). They may only follow certain people that confirm their beliefs on social media (confirmation bias).
There are of course more sinister reasons which could be:
Ego, health care professionals have often studied hard for years, made sacrifices in both time and money. Some don’t like to think they can be wrong (Hartvigsen et al., 2022).
Money (Traeger et al., 2021)(Hartvigsen et al., 2022), at the end of the day, private health care is a business, the narrative “you’re out of alignment” is a very simple pitch to sell treatments, sometimes with no end date in sight.
I personally would like to believe that majority of health care professionals are extremely caring and have the best intention to help people.
My take-away for patients:
If manipulations make your pain feel better, you can easily afford them, you are seeing progress. There is nothing wrong with this!
Your body is not a machine or car, it is not made out of individual parts which need to be fixed. The body is actually very robust, can adapt, recover and heal. Take a small cut for example, you cut yourself, your body repairs it without any external input or treatment. A car or machine cannot do this, a blown tyre will not repair itself.
Remain sceptical of narratives that make you feel more broken, fragile, damaged.
Remain sceptical of professionals that will claim to “fix” or “heal” you.
Remain sceptical of any alternative therapies, they are called “alternative” for a reason.
A deeper read and look into the subluxation theory and it’s controversial origin and existence:
And some easier and more entertaining viewings:
References
Balagué, F., & Pellisé, F. (2016). Adolescent idiopathic scoliosis and back pain. Scoliosis and spinal disorders, 11(1), 27. https://doi.org/10.1186/s13013-016-0086-7
Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy, 14(5), 531–538. https://doi.org/10.1016/j.math.2008.09.001
Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach.
The Journal of orthopaedic and sports physical therapy, 48(1), 8–18. https://doi.org/10.2519/jospt.2018.7476
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173
Caneiro, J. P., Bunzli, S., & O'Sullivan, P. (2021). Beliefs about the body and pain: the critical role in musculoskeletal pain management. Brazilian journal of physical therapy, 25(1), 17–29. https://doi.org/10.1016/j.bjpt.2020.06.003
Carnes, D., Mars, T. S., Mullinger, B., Froud, R., & Underwood, M. (2010). Adverse events and manual therapy: a systematic review. Manual therapy, 15(4), 355–363. https://doi.org/10.1016/j.math.2009.12.006
Christensen, S. T., & Hartvigsen, J. (2008). Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. Journal of manipulative and physiological therapeutics, 31(9), 690–714. https://doi.org/10.1016/j.jmpt.2008.10.004
Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis. Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology, 22(5), 752–767. https://doi.org/10.1016/j.jelekin.2011.12.013
Côté, P., Hartvigsen, J., Axén, I., Leboeuf-Yde, C., Corso, M., Shearer, H., Wong, J., Marchand, A. A., Cassidy, J. D., French, S., Kawchuk, G. N., Mior, S., Poulsen, E., Srbely, J., Ammendolia, C., Blanchette, M. A., Busse, J. W., Bussières, A., Cancelliere, C., Christensen, H. W., … Yu, H. (2021). The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature. Chiropractic & manual therapies, 29(1), 8. https://doi.org/10.1186/s12998-021-00362-9
Darlow, B., Forster, B. B., O'Sullivan, K., & O'Sullivan, P. (2017). It is time to stop causing harm with inappropriate imaging for low back pain. British journal of sports medicine, 51(5), 414–415. https://doi.org/10.1136/bjsports-2016-096741
Fausone, D., Doherty, D., Creighton, D., & Roach, V. A. (2023). Variations of spinous and transverse process length in the human lumbar spine. The Journal of manual & manipulative therapy, 31(2), 93–97. https://doi.org/10.1080/10669817.2022.2077604
Gay R. E. (1993). The curve of the cervical spine: variations and significance. Journal of manipulative and physiological therapeutics, 16(9), 591–594.
Grob, D., Frauenfelder, H., & Mannion, A. F. (2007). The association between cervical spine curvature and neck pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 16(5), 669–678. https://doi.org/10.1007/s00586-006-0254-1
Hall, A. M., Aubrey-Bassler, K., Thorne, B., & Maher, C. G. (2021). Do not routinely offer imaging for uncomplicated low back pain. BMJ (Clinical research ed.), 372, n291. https://doi.org/10.1136/bmj.n291
Hartvigsen, J., Kamper, S. J., & French, S. D. (2022). Low-value care in musculoskeletal health care: Is there a way forward?. Pain practice : the official journal of World Institute of Pain, 22 Suppl 2(Suppl 2), 65–70. https://doi.org/10.1111/papr.13142
Hohenschurz-Schmidt, D., Thomson, O. P., Rossettini, G., Miciak, M., Newell, D., Roberts, L., Vase, L., & Draper-Rodi, J. (2022). Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect. Musculoskeletal science & practice, 62, 102677. https://doi.org/10.1016/j.msksp.2022.102677
Lascurain-Aguirrebeña, I., Newham, D., & Critchley, D. J. (2016). Mechanism of Action of Spinal Mobilizations: A Systematic Review. Spine, 41(2), 159–172. https://doi.org/10.1097/BRS.0000000000001151
Mirtz, T. A., Morgan, L., Wyatt, L. H., & Greene, L. (2009). An epidemiological examination of the subluxation construct using Hill's criteria of causation. Chiropractic & osteopathy, 17, 13. https://doi.org/10.1186/1746-1340-17-13
Murphy, D. R., Schneider, M. J., Seaman, D. R., Perle, S. M., & Nelson, C. F. (2008). How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropractic & osteopathy, 16, 10. https://doi.org/10.1186/1746-1340-16-10
Nim, C. G., Downie, A., O'Neill, S., Kawchuk, G. N., Perle, S. M., & Leboeuf-Yde, C. (2021). The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review. Scientific reports, 11(1), 23415. https://doi.org/10.1038/s41598-021-02882-z
Nolet, P. S., Yu, H., Côté, P., Meyer, A. L., Kristman, V. L., Sutton, D., Murnaghan, K., & Lemeunier, N. (2021). Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review. Chiropractic & manual therapies, 29(1), 33. https://doi.org/10.1186/s12998-021-00384-3
Rubinstein, S. M., Terwee, C. B., Assendelft, W. J., de Boer, M. R., & van Tulder, M. W. (2013). Spinal manipulative therapy for acute low back pain: an update of the cochrane review. Spine, 38(3), E158–E177. https://doi.org/10.1097/BRS.0b013e31827dd89d
Sajid, I. M., Parkunan, A., & Frost, K. (2021). Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ open quality, 10(3), e001287. https://doi.org/10.1136/bmjoq-2020-001287
Shilton, M., Branney, J., de Vries, B. P., & Breen, A. C. (2015). Does cervical lordosis change after spinal manipulation for non-specific neck pain? A prospective cohort study. Chiropractic & manual therapies, 23, 33. https://doi.org/10.1186/s12998-015-0078-3
Sørensen, P. W., Nim, C. G., Poulsen, E., & Juhl, C. B. (2023). Spinal Manipulative Therapy for Nonspecific Low Back Pain: Does Targeting a Specific Vertebral Level Make a Difference?: A Systematic Review With Meta-analysis. The Journal of orthopaedic and sports physical therapy, 53(9), 529–539. https://doi.org/10.2519/jospt.2023.11962
Sun, Y., Zhang, Y., Ma, H., Tan, M., & Zhang, Z. (2023). Spinal Manual Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. BioMed research international, 2023, 7928429. https://doi.org/10.1155/2023/7928429
Tonosu, J., Oka, H., Higashikawa, A., Okazaki, H., Tanaka, S., & Matsudaira, K. (2017). The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PloS one, 12(11), e0188057. https://doi.org/10.1371/journal.pone.0188057
Traeger, A. C., Soon, J., O'Keeffe, M., Décary, S., Michaleff, Z. A., & Zadro, J. R. (2021). Overcoming Overuse Part 4: Small Business Survival. The Journal of orthopaedic and sports physical therapy, 51(1), 1–4. https://doi.org/10.2519/jospt.2021.0101
Wand, B. M., Heine, P. J., & O'Connell, N. E. (2012). Should we abandon cervical spine manipulation for mechanical neck pain? Yes. BMJ (Clinical research ed.), 344, e3679. https://doi.org/10.1136/bmj.e3679
Wu, A., March, L., Zheng, X., Huang, J., Wang, X., Zhao, J., Blyth, F. M., Smith, E., Buchbinder, R., & Hoy, D. (2020). Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Annals of translational medicine, 8(6), 299. https://doi.org/10.21037/atm.2020.02.175
This blog was written by Samuel Bulten
Comments