When a healthcare practitioner uses the term “alignment” when it refers to your spine, it can be a bit misleading. The reason lies in the fact that the prevalence of people seeing chiropractors has grown tremendously in the last few decades. Twenty-two years ago, when I started in the world of physical therapy, maybe 1 or 2 out of 100 of my clients would have seen a chiropractor. Now it seems that number is much higher. I do view this as an interesting problem. First, usually clients are much worse off after seeing a chiropractor and second for some reason the diagnosis that everyone seems to get after seeing one is the same. Let me guess, you’re “out of alignment” and your spinal curve is too flat and it needs to be “adjusted” to correct your curve and restore your spinal alignment so your pain will go away.
For starters, the term “spinal alignment” tends to connotate that your back problem is out of your control, that you need some external force to help correct it. This couldn’t be further from the truth. In fact, the exact opposite is true. I teach people all day long how to self-treat their own back and get it and keep it well. Additionally, people who see chiropractors continue to see chiropractors; because they get inside your psyche and begin to effectively create a dependence on the “adjustment.” This is very unfortunate because what that does – that repetitive manipulation of your Vertebral Facet joints –very quickly begins to create a segmental hypermobility and eventually instability in your spine. Once that spinal segment begins to develop hypermobility, then the normal wear of the body will begin to put even more mechanical load and stress on the vertebral disc(s). This mechanical stress on the disc occurs because now the disc is being asked to act as a stabilizer and not the shock absorber it was designed to be.
Many years ago, in 1892, when MDs were treating with arsenic, mercury and cinnamon a frustrated physician developed a treatment approach that was completely different than anything in his time. Andrew Taylor Still developed the practice of Osteopathy – later to become known as Osteopathic Medicine and eventually that is where the Doctor of Osteopathy (DO) comes from. The treatment approach he developed was based on the age-old ideas of manipulation of the spine. As time progressed, DO’s unlike their counterpart the MD claimed they were taught a more holistic approach. Some of the modalities they were taught and applications they were using included manual manipulation. Moreover, in the days of Andrew Taylor Still and the early days of Osteopathy it was advocated that manual manipulation could heal and cure diseases and other internal ailments. Now-a-days Schools of Osteopathy have dropped that philosophy. Today DO’s practice essentially as MD’s and are accepted in the same residency and fellowship programs.
At some point in the late 19th century around 1896, another man named D.D. Palmer developed the principle of chiropractic, which was interestingly similar to that of Osteopathy. Of note this development occurred a decade later. Additionally, Palmer wrote that he had taken courses in Osteopathy and that “Chiropractic is osteopathy gone to seed.” I am not sure was he meant by “gone to seed” but it is interesting that both professions developed from the use of manual manipulation.
Modern times have brought about the evolution of the Osteopathic doctors away from the use of manual techniques and manipulation and passed it on to other professions, for all practical purposes. What was learned from the Osteopathic professions and the use of manual manipulation in the early and mid 20th century was that manual techniques and manipulation can be useful in the treatment of musculoskeletal disorders and dysfunction and for the treatment of pain. They also learned that manipulation can be overutilized and needs to be used with caution.
Moreover, in the 1918 Harrison Fryette, DO advanced the treatment principles of Osteopathy and today these principles are known as Fryett’s Laws. Fryett’s laws help the manual practitioner to create specific techniques and stabilization of adjacent spinal segments that protects against parts of the spine that the practitioner does not want to disturb with their manipulation. In 1959 another pioneer in Osteopathic Manual Medicine, Alan Stoddard, DO published the Manual of Osteopathic Technique. Over his decades of practice, he set-out to help refine Osteopathy’s side of manual manipulation away from the more primitive techniques of its origin. Traditionally, Osteopathic Theory primarily named the spinal dysfunction based on positional faults which is an indirect inference to a Vertebral Facet restriction. However, Stoddard studied, identified, developed and postulated that “positional faults are of secondary importance and movement restrictions are the vital feature of the osteopathic spinal lesion” (Stoddard 1982). [Of note the word lesion here was used to denote dysfunction and not some cancerous type lesion.]
Comparatively, Osteopathic theory matured and developed as science and innovation improved, however the theory and practice of Chiropractic relatively remained the same. The premise of “vertebral subluxation” was originally postulated in 1896 by D.D. Palmer, the chiropractic founder, and is still used as the primary premise today. The idea of “vertebral subluxation” also known as the bone out of place (BOOP) concept means that the vertebral position is altered in a way that puts pressure on nerves, and creating a dysfunction in some portion of the body and even visceral dysfunction. The problem with this BOOP concept is that these subluxations are not visible on X-ray, which is contrary to what a chiropractic might tell you at your visit. Even the World Health Organization defines a subluxation as a “significant structural displacement” and is therefore always visible on static imaging studies like X-rays.
I know these ideas of positional fault, subluxation, and Vertebral Facet restriction are a mouthful and a bit technical. But I wanted to detail some history and the interconnectedness of these ideas to bring the conversation back around to the whole idea of spinal alignment. So, let me explain.
The theory of “spinal alignment” is the idea that your Vertebral Facets are “subluxated” or out of position and/or the joints are not symmetrical compared with the right and left sides when palpated. The Vertebral Facet joints are the small articular junctions of one vertebra as it moves on the vertebra above and below it (see picture below). This asymmetry of the Vertebral Facet joints can also be termed a positional fault. The theory states that if an asymmetry is noticed then it causes pain. Furthermore, the asymmetry in theory can be caused by poor posture and poor movement mechanics. It is well documented that Vertebral Facet joints can cause pain when locked, impacted and restricted, that goes without question, but what I would like to challenge is – could there be other structures that can cause this asymmetry chiropractors are visualizing? Maybe even cause the Vertebral Facet upon physical inspection to look asymmetrical. In fact, the Vertebral Facet asymmetry may not be the problem but a symptom of an even bigger issue among other things. Actually, in most cases if your “spinal alignment” is out of alignment (i.e. you have an asymmetry in the palpation of your spine according to your practitioner) then the question that should be asked is “What pathophysiological dysfunction is causing that asymmetry?” Commonly, it is usually something more like a muscle strain, ligament sprain, annular fiber tear, protruding/bulging/herniated disc, or some sort of Vertebral Facet hypo/hyper-mobility or even early stage degenerative changes. If you try to treat the “spinal misalignment” aggressively like let’s say with manipulation (spinal adjustments) then what you’re going to cause is instability in the Vertebral Facet and potentially additional pathophysiology (at least eventually, especially with repetitive use). Once hypermobility and instability have set-in, then the vertebrae will continue to be “misaligned” because the ligaments have lost the structural integrity to hold them rigid and in place. Spinal manipulation is by definition taking that joint beyond its normal range of motion to create a cavitation of the joint. This causes stretching (really over stretching) in the ligaments of those joints. It is not uncommon for even just one thrust manipulation to a hypermobile spinal segment to cause disc herniations and spinal instability.
When a health care professional tells you after looking at your X-ray that they see that you’re “out of alignment”, then you need to run. First off, that health care professional should never be treating the positional fault or asymmetry first. Secondly, there are many anatomical anomalies and dissimilarities in our musculoskeletal systems. (As a side point, it is impossible to try to correct a structural anomaly that might have been that way since childbirth.) That heath care professional is treating your positional fault when postulating spinal misalignment via your X-ray or even by palpation. It has been shown by late century Osteopathic Physicians that treating the positional fault should only come secondarily and many times once the primary movement restriction is treated, like a muscle strain, ligament sprain, disc sprain, annual fiber tear(s), small herniations, then there is really no need to treat the positional fault because many times it corrects itself. Thus, the pain and symptoms disappear and there is no need to continue treating that area if the pain has subsided. In other words, the positional fault should not be the primary focus of treatment, and by treating the way your spine looks on X-ray is by definition treating the positional fault first. A proper treatment plan should incorporate your subjective interview, spinal joint mobility tests, palpation of the muscle tone, muscle length and flexibility using a modern comprehensive and biomechanical paradigm to determine the best treatment options starting with least aggressive first.
After treating spinal patients for over 20 years, I can say this, it seems like the majority of people who are visiting neurosurgeons and opting for surgery these days are the ones who have used spinal manipulation and adjustments regularly or semi-regularly. When it comes to back pain I caution everyone to beware of the use of manipulation and adjustments and to remember that 80% of patients with back pain get better in 6-8 weeks. So, if your back is acting up, injured, spasmed or locked up and you are not sure what to do, first don’t panic – because back issues are very common – 80% of the world’s population deals with a spine issue in their lifetime. Second, don’t run off to the chiropractic for an adjustment. I can’t tell you how many times I have seen patients who wish that had not done that (for the short-term exacerbation and long-term effects). Third, call a skilled physical therapist who has been trained in the art and science of manual evaluation and can develop you a proper biomechanical assessment and get you started on a treatment plan that will not lead to long-term dependence and accelerated degenerative changes.