Adjustment and Spinal Realignment

Around 10 years ago I had some lower back pain and went to see a chiropractor, as they were offering free assessments. They took photos and x-rays and in my follow up consultation they showed me my x-rays with different coloured lines drawn on them, showing me where my spine sat and where it should have sat if everything was in alignment. I started weekly “treatment” and at my 3-month assessment they took new x-rays and in that follow up they showed me how my spine was much more aligned than it was in my initial assessment.

I understand that the low back pain was fixed by placebo, and I now know that a chiropractor can not physically produce enough force to “adjust” someone’s spine, so I’m thinking that my imaging shouldn’t have shown any difference between the two sets. The way it all happened, it’s obvious that this is part of their usual system, so they are doing this stuff all the time. What, in your opinion, typically accounts for these differences in imaging?

Good question David. This is likely a confirmation bias and searching for “issues” to fix more than anything. I wrote a blog on this topic HERE.
Excerpt:
“Line-Analysis is often given diagnostic credence for vertebral subluxations. Millimeters are measured of spinal movement in comparison to surrounding vertebra and patients are informed those measurable differences are the source of their pain and dysfunction. Again, no evidence supports such claims nor has any research validated the use of line-analysis as a diagnostic tool. In fact, we are realizing more and more imaging doesn’t dictate patient symptoms or a case’s obtainable maximal improvement.”

Here are a few relevant citations:
Weinert, D. J. (2005). Influence of axial rotation on chiropractic pelvic radiographic analysis.*Journal of manipulative and physiological therapeutics, 2,*117–121.

Cakir, B., Richter, M., Käfer W., Wieser, M., Puhl, W., & Schmidt, R. (2006). Evaluation of lumbar spine motion with dynamic X-ray–a reliability analysis.*Spine, 11,*1258–1264.

Coleman, R. R., Cremata, E. J., Lopes, M. A., Suttles, R. A., & Fairbanks, V. R. (2014). Exploratory evaluation of the effect of axial rotation, focal film distance and measurement methods on the magnitude of projected lumbar retrolisthesis on plain film radiographs.Journal of chiropractic medicine, 4, 247–259.

There are a multitude of factors that could influence spinal differences from image to image. A larger confounder is the inability of people to agree upon what they are seeing in imaging (see this study on MRIs).

Overall, the likelihood the same person performed the setup the same exact way each time imaging was taken is likely quite low (meaning reliability is low) and this would likely account for atraumatic differences seen in imagining during shorter follow-ups.

Thanks Michael, that makes sense. I’ll have a read through the linked articles.

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What if the chiropractor can deadlift 600lbs and squat 500lbs?

Jokes aside, they don’t adjust, but rather mobilise the locked vertebra, allowing your body to do the rest to aid recovery. I found that after having my L4 mobilsied, I was able to squat and deadlift within days, compared to when not mobilsing it, taking much longer to get under the bar due to the fact that pain was unbearable, and even breathing hurt…

This is a common mechanistic explanation offered by providers and consumers of manual therapy.

While it may be convenient to assume that a joint is “locked” and thus requires mobilization or manipulation by hand to “release” it, this has not been demonstrated to be true.

This study sought to determine whether spinal manipulative therapy (SMT) confers meaningful change in intervertebral range of motion (IV-RoM) in the cervical spine (I could not locate a similar study for the lumbar spine) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4102240/- The take home message is that no real correlation was found to suggest that SMT confers increased IV-RoM as measured by quantitative fluoroscopy. Interestingly, there was no agreement between the clinical palpation skills of the chiropractic intern/chiropractor and quantitative fluoroscopy in detecting hypo-mobile segments. This comports with the evidence that palpation is not a reliable means of identifying anatomical landmarks https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807681/pdf/jcca-60-1-36.pdf

When we consider this information, we must then question how reliable the practice of detecting and reducing a “manipulable lesion” (https://www.paincloud.com/single-post/2017/05/15/The-tale-of-the-manipulable-lesion) is when the process of identifying large anatomical landmarks by hand is unreliable. Moreover, spinal manipulation is not a specific intervention, meaning you cannot receive a manipulation that specifically mobilizes only your L4 vertebra. We know this given our understanding of the frictionless skin-fascia interface https://www.mskscienceandpractice.com/article/S1356-689X(08)00170-7/pdf?code=msksp-site.

This paper describing the effects of manual therapy on the pain experience may be of interest to you What effect can manual therapy have on a patient's pain experience? - PMC

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Although that is your experience, the evidence contradicts anything is being “mobilized”. Altering pain perception is heavily related to therapeutic alliance, contextual effects, and placebo-like expectancy effects. This is not discounting your experience, but rather the outcome - decreased pain perception and ability to train, can be achieved without mobilization, false narratives, and conditioning to an intervention that lacks efficacy.

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mikmir, as JHG referenced above, I am a chiropractor.

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Dr. Ray, would you be willing to post some of the reading suggesting manipulation is not efficacious? I’m sure a lot of the members here would love to read further! I know personally it’s hard to come to a consensus because there’s so much literature out there. I would really appreciate it.

Sure. Please be sure to read through the above citations already mentioned by JHG and myself.

A good starting point regarding the topic is here: https://thelogicofrehab.com/2016/05/…a-black-sheep/.
Ultimately the premise for joint manipulations is flawed. The assumption typically is something (bone) is out of place and we know how to put it back in or where it correctly belongs. There has been a shift from this mechanistic mindset. However, I personally still take issue with passive modalities given the narratives attached attempting to validate the intervention, conditioning (dependency), and learned behavior that comes with their usage. Much of the etiology regarding persistent pain development is centering around self-efficacy and autonomy. If we remove autonomy from a person then we are likely further perpetuating the issue. I’ve also discussed this issue in the pain blog here: https://thelogicofrehab.com/2017/09/…ding-the-path/.

Research (there’s more out there so please feel free to share anything of relevance). This will likely be easier from a research standpoint if we examine the “issues” joint manipulations are being used for but we still need to consider the premise of the intervention and narratives being supplied - this is a similar discussion for other passive modalities (dry needling/acupuncture, k-tape, massage, ultrasound, e-stim):

  1. Not supported for migraines - Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial - PubMed
    Well controlled three arm single blinded RCT on spinal manipulative treatment. The fact they conducted an RCT with SMT is more important than the placebo effects identified. It shows these studies are possible and can be well controlled for bias/error.
    Most likely many more SMT studies will be performed showing similar conclusion for other maladies.
    The reoccurring hypothesis for SMT: "Research has suggested that spinal manipulative therapy may stimulate neural inhibitory systems at different spinal cord levels because it might activate various central descending inhibitory pathways [5–10].” However, based on this study’s results, SMT most likely is placebo. One of their primary findings: “Migraine days were significantly reduced within all groups from baseline to post-treatment (P < 0.001).”

  2. Mediocre study based on not so great studies: http://jamanetwork.com/journa%E2%80%…stract/2616395 (positive takeaway - circumstances surrounding the delivery of SMT -type of clinician and technique - didn’t matter).

  3. Effect of chiropractic treatment on primary or early secondary prevention: a systematic review with a pedagogic approach | Chiropractic & Manual Therapies | Full Text - Doesn’t prevent disease.

From a chiropractic context - subluxations don’t exist as they are described in the chiro profession. If we can’t establish something exists then anything afterwards is nothing more than conjecture and any intervention created to aid with the unsubstantiated issue is theatrics and conditioning patients unnecessarily.

This is a very nuanced topic and I’m happy to discuss further. These studies can get us started. If anyone has any other studies they wish to share for consideration, please post them.

Final thought - we seem to be in a rush to find non-opioid interventions (understandably) and in doing so we may inadvertently condition people to other interventions that lack efficacy. Given the push from the rehab world to say we have THE answer to chronic pain issues, we should be cautious moving forward with these interventions. To be clear, my stance is we are all placebos (clinicians and interventions - some with added benefits we can measure), the question becomes how much are we going to ethically maximize the contextual and expectancy placebo effects without unnecessarily conditioning patients to us and the interventions.

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Some more…

Sam Homola:

Joel Bialosky:

Eyal Lederman
http://healingbridge.com/wp-content/uploads/2016/08/The-Fall-of-postural-structural-biomechanical-model-in-PT.pdf

To add to Michael’s post, I am attaching studies refuting some of the common claims made by chiropractors who do not practice in an evidenced-based manner. *This also applies to other health care providers who utilize SMT and offer false narratives in their approach.

I would like to preface by stating that this is not a knock on the profession of chiropractic, as SMT is a modality, not a profession in and of itself. SMT has been shown to be effective in modulating nociception Changes in Pain Sensitivity following Spinal Manipulation: a Systematic Review and Meta-Analysis - PMC, and it feels good, but exercise can also modulate nociception, and depending on the type of exercise employed, one may reap other favourable health benefits that SMT or other passive modalities do not confer. I am not totally opposed to the administration of SMT for pain management, but I do take issue with the false narratives that certain clinicians may attach to this modality in order to promote its utilization.

The idea of the vertebral subluxation complex (i.e. hard bone compressing on the soft nerve being the cause of all your health problems), with SMT/adjustments being the only therapy to correct this “malady” is patently false An epidemiological examination of the subluxation construct using Hill's criteria of causation | Chiropractic & Manual Therapies | Full Text So much so, that an appeal has been made to remove such context from chiropractic schools in an effort to deter future graduates from disseminating false information The prevalence of the term subluxation in chiropractic degree program curricula throughout the world - PMC

As Michael indicated above, SMT is not supported for the treatment of migraine headaches.

The claim that SMT is beneficial for scoliosis is unsupported Spinal Manipulative Therapy for Adolescent Idiopathic Scoliosis: A Systematic Review - PubMed

The claim that SMT is curative for asthma is unsupported Spinal manipulation for asthma: a systematic review of randomised clinical trials - PubMed

The claim that SMT lower one’s blood pressure is unsupported Spinal manipulation for the treatment of hypertension: a systematic qualitative literature review - PubMed

The claim that SMT is beneficial for “wellness” or prevention of disease (any disease) is unsupported Effect of chiropractic treatment on primary or early secondary prevention: a systematic review with a pedagogic approach - PMC

The claim that SMT is beneficial for gastrointestinal disorders is unsupported Chiropractic treatment for gastrointestinal problems: A systematic review of clinical trials - PMC

The claim that SMT is beneficial for infantile colic is unsupported Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials - PubMed

The claim that SMT is beneficial for autism spectrum disorders is unsupported [PDF] Clinical effects of spinal manipulation in the management of children and young adults diagnosed with autism spectrum disorder – a systematic review of the literature | Semantic Scholar

The claim that SMT is beneficial for ADHD is unsupported Chiropractic care for paediatric and adolescent Attention-Deficit/Hyperactivity Disorder: A systematic review - PMC

The claim that SMT is beneficial for enuresis is unsupported Chiropractic care of children with nocturnal enuresis: a prospective outcome study - PubMed

The claim that SMT is beneficial for otitis media is inconclusive Otitis media and spinal manipulative therapy: a literature review - PMC , https://jamanetwork.com/journals/jamapediatrics/fullarticle/481422, although my personal bias leans to no

The claim that SMT is beneficial for dysmenorrhoea is unsupported Spinal manipulation for primary and secondary dysmenorrhoea - PubMed

Michael, what did I miss?

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Thanks very much guys! I’m a chiro student currently and I find it very tough sometimes to weed through the BS especially when we talk in class about how it’s supposedly proven with scientific evidence. I appreciate the clarification and look forward to all the learning material you have provided!

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Good stuff Joe. Only a few things to add:

2011 Cochrane review for cLBP - no better than other treatment options: https://www.cochranelibrary.com/cdsr…ct=manipulativ

2012 Cochrane review for acute LBP - no: https://www.cochranelibrary.com/cdsr…ct=manipulativ

2006 Cochrane review for dysmenorrhoea - no: https://www.cochranelibrary.com/cdsr…ct=manipulativ

Not a great study (happy to discuss this) recently in Spine: https://www.thespinejournalonline.co…016-0/fulltext
Letter to the editor regarding this study: https://www.thespinejournalonline.co…088-3/fulltext
Rebuttal to Letter to Editor: Response to Letter to the Editor entitled "Spinal manipulation for chronic low back pain: is it all it is cracked up to be?" concerning "Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis" by Coulter et al. Spine J; doi: 10.1016/j.spinee.2018.01.013 - PubMed

Another common narrative is fertility - I’ve yet to find any evidence regarding SMT on this topic.

It’s important to note there are a lot of studies on SMT that simply are not of great quality and usually involve overblown conclusions. These poor quality studies are often utilized to rationalize SMT for a variety of issues. This is why clinicians stating they are “evidence based” is not sufficient for trust but rather we need to assess the quality of evidence being put forth for claims.

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Here’s a study that just came out about maintenance care The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain—A pragmatic randomized controlled trial which is another talking point of many chiropractors (I’m also a chiropractor). What’s interesting is that the main claim is roughly 13 less days with low back pain for the SMT group which is only a bit over 1 day a month. I’m not sure what the MCID is for back pain frequency but 1 day a month doesn’t seem like it would be it. Also, when you look at the follow up after 52 weeks, there’s no difference in pain intensity, RMDQ, effect of LBP on disability or general health (EQ5D). Aside from 1 less day per month of bothersome LBP (which could be accomplished by other means as well), maintenance care didn’t do much at all but this will be shouted from the rooftops of chiro clinics everywhere.

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One of the best contextual studies on the role of SMT in care is the review by Menke from Spine in 2014. Do manual therapies help low back pain? A comparative effectiveness meta-analysis - PubMed Once again, we are typically horrendous at thinking in terms of probability but to circle by to Mike’s early comment of us all being placebos (I see this statement as paradoxical, but understand what you mean Mike). The Menke study showed of 84% of acute pain variance, 81% is due to “nonspecific factors” while only 3% was due to the specific treatment. The thing is, nonspecific is getting more specific and likely better worded as “multifactorial.” We now know the role of therapeutic alliance, clinical equipoise, and expectations can have on the outcome of treatment. Maximizing those variables (many clinicians do this without being aware) far supersedes any effect of specificity of treatment. When everyone can claim to have the best “method” for treatment the bigger effect may be in the claim over the method itself.

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I want to be careful to not derail this balanced and evidence-based discussion into a rant, but as patients we need to be vigilant and aware to ensure we are not conned into treatments that are costly and frankly deceptive. A while ago (before BBM) I visited a chiropractor who pulled out a surface electromyography (SEMG) device to demonstrate my “vertebral subluxation complex”. A bunch of red arrows showed up on the screen and the solution was a series of treatments over the course of weeks that would amount to a significant amount of money. “Pay upfront for a reduced rate, we will bill your insurance at full rates to reduce your annual deductible…” I told them I’d think about it.

It seems it would be very difficult to take an SEMG reading that provides useful information in this situation, or to take readings in a consistent environment to show improvements over time. In my case the reading was taken while standing up, on an uneven surface (one foot on a mat, the other off) with the chiropractor adding pressure to use the SEMG device on my back. Obviously he could manipulate the severity of my “vertebral subluxation”. I am certain patients frequently fall for this trick.

Since I’ve started learning from the BMM team I’ve been more conservative in my reliance on a chiropractor (zero visits to date!) to manage my lower back pain that occurs from time to time. I’ve now learned that I’m able to use a barbell to produce very similar results compared to which I previously thought I needed a chiropractor for. Understanding pain better has taught me that I don’t need to be afraid of it anymore; I can use weight to work with the pain, not against it, to move through a full ROM and the relief is almost instantaneous.

Much respect for you all on this thread. Thank you and please keep educating us.

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Hi There

I have a bone spur in the back of my leg near the calf which isolates the muscles that should move properly. Therefore I walk incorrectly. My hips seem to slip into bad places. Where my hip may hurt when I Walk with it. Or it goes into a place where I can’t stretch it because it causes a sharp pain, if I don’t go to the chiropractor it stays there or gets worse. Would chiropractic be wrong in this situation?

I’d also be interested in hearing your replies to @JHG in order to appropriately answer your questions. Also - what is the chiropractor doing during your visits?