Thursday, January 19, 2006

What do chiropractic adjustments do to your anatomy?

Last week I visited a chiropractor for the first time since moving to Vermont. I went to him because, for several years now, I've experienced varying degrees of pain or discomfort at various levels of my vertebral column: lower cervical, mid-thoracic, lower lumbar, all on the left side. I have to say, I'm kind of annoyed by the left side of my body. Sure, it carries its weight most of the time, but it doesn't seem to be happy about it. Tingling in the sole of my left foot when I'm wearing certain boots, iliotibial band syndrome (or something like it) in my left lower limb, left gluteal muscles that don't agree with extended periods of sitting. Nothing that prevents me from running or downhill skiing or any of the activities of daily living, but just enough to make me think, "Maybe I should do something about this."

The most annoying problem area is mid-thoracic. Every few months when I least expect it, I have a back attack: sharp yet hard-to-pinpoint pain in my back and lower neck that makes it hurt to turn my head, sit, stand, or really any activity that requires me to be upright. Mercifully the acute phase typically lasts an hour or less, eventually morphing into a more tolerable burning pain that flares up only if I flex my neck too far or turn my head too far to the left. What triggers the back attack is usually a mystery. Sleeping in a bad position? Leaning over a cadaver table in the anatomy lab? Maybe, but more often than not the attack seems unrelated to anything. Stretching, massaging, and ibuprofen can ease the pain, but mostly it's a matter of waiting for the body to heal itself, a "self-limiting" injury as the clinicians like to say. And the discomfort never disappears completely.

So did the chiropractor make a difference? Yes, at least in the neck and midback (the jury is still out on the lumbar region). I notice an increase in neck mobility, especially in turning to the left. I notice substantially reduced pain when I lower my head as far as it can go. I notice that my left arm isn't bothering me now when I run. And I hasten to add that I'm not a chiropractic True Believer. In fact, I'm automatically skeptical of just about everything that comes out of my chiropractor's mouth. Chiropractic seems to have a foundation that is still primarily anecdotal and philosophical, not scientific. That's not to say that it's all baloney. I know there are studies that support its effectiveness for certain conditions in certain patient populations. Whatever. I don't want to get mired here in the devisive "chiropractic vs. allopathic" debate. What I've started wondering is more specific: What exactly happens to your anatomy (joints, muscles, nerves, etc.) during a chiropractic adjustment (or any similar sort of spinal manipulation)?

It turns out that there are a number of reasonable working models and at least a trickle of supporting data. One place to start is a 2002 review article in the Annals of Internal Medicine. It's by William Meeker, DC, MPH, and Scott Haldeman, DC, PhD, MD, FRCPC. Scott Haldeman, a neurologist in Irvine, California, may very well be the only person on Earth with that combination of letters after his name. According to the authors, there are at least five mechanical, anatomical, and/or neurological things that chiropractic manipulations may do (I'm paraphrasing):

  1. Release part of a joint capsule that has become entrapped in facet joints, joints between pairs of vertebrae that have been shown to be very sensitive to pain.
  2. Reposition part of an intervertebral disc (the rubbery disc between successive vertebrae).
  3. Loosen fibrous tissue that formed in a previous injury.
  4. Inhibit overactive reflexes in muscles of the spine or limbs.
  5. Reduce the compression or irritation of nerves.
They also cite studies suggesting that chiropractic adjustments increase the range of joint motion, increase pain tolerance, increase muscle strength, and so on. Lest you get too excited about chiropractic, they also discuss the issue of serious complications from spinal manipulations. Nasty things like vertebral artery dissection and cauda equina syndrome. Such complications are rare but they do happen, and so far there is no way to predict who might have an increased risk.

Probably the most compelling study I've seen so far is one called The Effects of Side-Posture Positioning and Spinal Adjusting on the Lumbar Z Joints (which, coincidentally, was also published in 2002). With funding from the National Center for Complementary and Alternative Medicine, the authors recruited healthy young volunteers to undergo MRI scans before and after a lumbar manipulation on one side. Data analysis (and rather striking images like the one below) show that the adjustments produced increased separation of the facet joints (also called zygapophysial joints or Z joints). Of course, whether that's good or bad is a matter of debate, one that will hopefully be illuminated by more data.



Two MRI cross-sections of the lumbar spine in the same individual. The bottom of the image is towards the back of the person. R = right; L = left; L5 = fifth (lowest) lumbar vertebra. The first image (c) was taken before the left lumbar side-posture spinal adjustment; the second (d) is after. Notice that the gap of the left facet joint (i.e., the white space between the two dark hamburger-bun shapes directly above the L) is larger after the adjustment. Figure copied from Cramer, et. al (2002). The Effects of Side-Posture Positioning and Spinal Adjusting on the Lumbar Z Joints. Spine 27: 2459-2466.

22 Comments:

At 7/09/2006 9:08 AM, Blogger SAM-I-am said...

My dad visited a chiropractor for years, which provided temporary relief from back pain. It turns out he has an autoimmune disease which causes bone growth in his spine. He wonders if the chiropractor was breaking off very tiny bits of bone growth, although I wonder what would happen to the bone in that case?

 
At 7/18/2007 1:34 PM, Anonymous Anonymous said...

I'm really enjoying your blog! I too am fascinated by anatomy.

I'm curious as to how the results would stack up in a chiropractor v. neuromuscular massage therapist Battle of Facts. I personally have experienced tremendous relief from NMTs, as for 20 odd years I chronically extended/shortened certain muscles (very bad posture and carriage issues) that then compressed nerves and even angled-up my collarbones. (Focusing on a permanent solution to my problems was what got me interested in anatomy)

I can't say why I think that muscular manipulations would relieve more symptoms of the general populace than vertebral "adjustments" (other than it seems more logical - and I know that where anatomy is concerned logic can sometimes be thrown out the window). Certainly they may all be related in some way, but I can't even count the number of people I see on an hourly basis who are perpetually hunched over desk, talking with phones crooked in their neck, leaning over things, etc etc, chronically affecting the muscular jacket that sheaths bones and nerves. It would seem that manipulation of those muscles - to include permanent solutions such as posture improvements - rather than spinal adjustments would seem better-suited to do the trick.

Hrmm.

 
At 9/18/2007 12:09 PM, Anonymous Kevin Phillips, DC said...

To anonymous,

In my chiropractic practice, i have found a combination of muscle work and adjustments do really well. Muscles and joints work together, and can help or hurt each other's functions depending on their status.

As to the scientific studies on chiropractic, i remember reading somewhere how the total money spent studying chiropractic nationwide was less than that spent by one drug company in a year. Science, especially good science, is expensive, and as our society shows us, disease diagnosis and treatment, rather than true health care, is where the health care dollars go. Just look at the top three killers in the U.S. Heart disease, cancer and medicine. All preventable. Isn't it time we begin to listen to our bodies instead of telling them what we want to hear??

I like your site, by the way. Good luck in your studies.

 
At 2/28/2008 9:00 AM, Blogger redburnbj said...

I just love your blog! I really get excited reading about anything medical. I wish I had gone into medicine. (I am able to have fun with an anatomy book)
Great topic!
I too believe there are benefits to chiro, but that it is also loaded with risk.
I was especially horrified when I learned of the risk of vertebral artery dissection, which I had NO IDEA of when I was going to a chiro and getting my neck whipped around!
I am so interested in the mechanical affects of adjustment. I love the pic here, very interesting. Keep up the great blogging!

 
At 4/21/2008 12:11 PM, Anonymous Dr. Zach Wells said...

As a practicing Chiroprator, I can say your site is very informative. As for your mention of risks, I agree there are risks in receiving spinal adjustments. It is important to note the incidence of such risks:

The best estimates of the odds of suffering a serious complication from a chiropractic
neck treatment are about one incident out of every two million treatments.

Ref:
Terrett AGJ: Current Concepts in Vertebrobasilar Complications following Spinal
Manipulation. West Des Moines, IA: NCMIC Group, Inc., 2001

Klougart N, Leboeuf-Yde C, Rasmussen LR: Safety in chiropractic practice part I: The
occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from
1978-1988. J Manipulative Physiol Ther 1996; 19;371.

essentially this means one in 25 chiropractors may see this once over the course of a 40 year career.
I hope this sheds some light on the risks.

 
At 6/24/2008 12:03 AM, Blogger Anesha said...

Hi Nice Blog . I don't really know a lot about Human Anatomy study or art, but that's just my 2 cents. Really great job though, Krudman! Keep up the good work!

 
At 9/09/2008 1:49 PM, Anonymous Anonymous said...

Stumbled across your post from a google search. Just curious, have you ever heard of John Sarno? I think you might benefit from his book. Check out the reviews of "Healing Back Pain" on Amazon.com (there are over 300 reviews):
http://www.amazon.com/review/product/0446392308/ref=pd_bbs_sr_1_cm_cr_acr_txt?%5Fencoding=UTF8&showViewpoints=1

 
At 2/06/2009 6:15 PM, Anonymous Anonymous said...

As a neuromuscular massage therapist that works with a chiropractor, I agree that adjustments work well with muscle work. I have found the best results when starting with muscle work, then going to adjustments, then back to more muscle work. This is because muscles need to be in a relaxed state to receive the most benefit from adjustments, and then after an adjustment the muscles can quickly tense back up and pull everything out of sync, unless you relax them again. It's just my opinion but I think that instead of comparing which is more beneficial, you should use a combination of both for the best results.

 
At 7/27/2009 11:10 AM, Blogger Wellness Warrior Dean said...

I showed this to my chiropractor and he said it was a good article. That sold me so I am going to post this on my blog.
http://wellnesswarriordean.blogspot.com I hope you don't mind.

 
At 10/08/2009 11:47 AM, Anonymous Anonymous said...

hey brad im experienceing the same problems as you. could you email me so we could further talk at AllStarPotts@aol.com...thank you i would greatly apprecciate it

 
At 2/15/2010 4:20 PM, Blogger xenia elizabeth said...

Thanks for the great blog post. I'm a Life Drawing professor and love anatomy though most people these days think the only artists interested in anatomy lived during the Renaissance! I just had my first chiropractic adjustment in five or six years--mid-thoracic and a few cervical.

I asked the chiropractor what exactly she was "fixing" when she did the adjustments and she answered by giving me the name & number of the vertebrae she adjusted.

!

I want to know what exactly, is happening. The photo you posted of L5 helps some.

I wish more doctors talked so thoroughly to patients, explaining things, rather than watering them down.

Thanks!

 
At 3/30/2011 11:45 AM, Anonymous Anonymous said...

Just joined in very interested in anatomy i feel the same way i would like to know what they are adjusting and what happens internally. My problems are a slanted pelvic area left side of course i asked if i was born with this or was it from an injury. Chir did not know. I brought my daughter another time because of ear infections i guess it worked or did she grow out it. I also went back again with my wife and daughter and we did a family plan yippee. It was my turn i told the chiro i was ok but he insisted on checking so i lay face down and he bends my legs up and tells me i am off 3 " on the left side lol... I said no way i would walk with a tilt or need a kickstand to hold myself up. He chuckles and tells me he is serious. I get the adjustment done and i feel like crap my left side is so far out of whack.

 
At 3/31/2011 1:40 PM, Anonymous buy viagra said...

I can't believe than I reading this... I'm just going after work.. my back it's killing me the same as my nee, and I know that session it's gonna hurt a lot...
Thanks

 
At 8/18/2011 8:01 AM, Anonymous Anonymous said...

The only thing I can sugguest to anyone who reads this page is make sure your chiropractor is taking Xrays..so many people go to chiropractors and want one of two things...an instant adjustment that makes them instantly better...or an extensive treatment plan that involves 5 kinds of therapies and treatment meds...This is not what you should be looking for in a chiropractor...A good chiropractor will take two sets of films...an AP and a LAT...(If the chiropractor doesn't know what these mean find another chiropractor!!) What these do is give him/her two looks at your spine..and side view to see disc inflammation and nerve pinching and also tiny curves and even big curves in the spine...And the a frontal view of your spine...this allows him to see where exact adjustments are needed. He can calculate exactly where your pain is coming from or what could cause you more pain in the future. A chiropractor that doesn't do Xrays is working blind...he/she is adjusting your spine where they understand the problem area is..not where the root problem is coming from, which can cause more treatment and sometime more pain! The important thing to remember is don't give up! Going to a chiropractor is the same as taking pills for a cold, or being sick...You don't just take one pill and it's magically better, you take a regime of the pill for a week or two and it helps the bad things to work out of your body! Chiropractic is just the same...make sure to stick with your plan and by the time its over your spine will be back in place and it will help prevent many other aches and pain from occuring as well!...I've been going to a chiropractor over 10 years now and i love it. I get adjusted now mainnly for maintnance and the little minor aches and pains that come from acvtitvies of daily living...I beleive in chiropractic I just recently became a Chiropractic Assistant and cannot believe I see the difference it makes everyday in people lives!

 
At 9/02/2011 7:45 AM, Anonymous Carlos M Gonzalez DC said...

As a practicing Chiropractor of 21 years I found your site interesting. Some of the comments also bring up some good points but I will have to disagree with the one who said X-rays are a must. They are NOT. There is no need to expose someone to ionizing radiation for every little thing. I have done wonders for many patients while as that person called it "working blind". There are times when the benefits outweigh the risks and so I order X-rays, MRI's, Cat Scans or whatever is appropriate for the individual patient. I could write a page or two but let me suggest something I discovered by accident and it changed my life and the lives of thousands of my patients as well. It's called Inversion. You may have seen the an older man, Roger Teeter, doing his infomercial...hanging upside down. Gravity compresses the spine and discs and inverting reverses that. It's as simple as that and many people are blown away by how it takes their pain away. You may need to invert everyday for a week or two BEFORE you notice the difference. Also having a Chiropractor that can give a really good spinal adjustment/manipulation makes a big difference. I've written two books. One contains a chapter titled How To Find The Right Chiropractor For You. The other book is on Inversion Therapy (IT). After 20 years of using IT in my practice on thousands of patients and myself I searched and could not find a book on Inversion Therapy so I wrote it. There is some limited information on my website at http://www.DrCarlosMGonzalez.com.

 
At 9/06/2011 7:16 PM, Anonymous Anonymous said...

Just started going to a chiropractor was uneven and could tell from laying in bed helped me out greatly.Area of pain smaller and less intense.Yes he took xrays first.Going back for more.The questionI have is he uses a tool instead of hands is this ok?

 
At 9/25/2011 3:52 PM, Anonymous Anonymous said...

Great article! But, I have to respond to one of the posts on x- raying everyone. Sorry to degrade your page.

I am a chiropractor that works with MD’s and PT’s and have to fight an uphill battle every day. The chiro’s that xray everyone and sets them up on the same 3 times a week treatment plans are a joke. They give the rest of us a bad name. I specialize only in low back and neck pain with radiculitis. Not asthma, ear infections and bacterial infections.

I must have been absent that day in Chiropractic school, when they taught us how to read disc inflammation, nerve pinching and other soft tissues on a radiograph. But, hey that is why I order an MRI! Ask the chiro’s who xray everyone, does it change the way you treat? According to this guys a “subluxation” is the root of all evil and it must be corrected. But, are they going to treat any different with an x ray? The answer is, no they are not. 3 times a week until they make the patient hypermobile, then back off to 1 time a week until the patient dies. The true reasons most of these chiro’s x ray people, are so they can do a sub-par history and physical exam and it was a good money maker. Not anymore. Insurance companies are not paying anymore.
According to the American College of Physician guidelines
Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).
There is no evidence that routine plain radiography in patients with nonspecific low back pain is associated with a greater improvement in patient outcomes than selective imaging (41–43). In addition, exposure to unnecessary ionizing radiation should be avoided. This issue is of particular concern in young women because the amount of gonadal radiation from obtaining a single plain radiograph (2 views) of the lumbar spine is equivalent to being exposed to a daily chest radiograph for more than 1 year
(http://www.annals.org/content/147/7/478.full)
How about we actually diagnose a patient, treat conservatively, and then if things are getting worse or not improving get the appropriate advanced imaging.

Dr. Chris

 
At 11/28/2011 8:03 AM, Blogger Dr. G said...

@ Dr. Chris...I do agree that with your statement, "The chiro’s that x-ray everyone and sets them up on the same 3 times a week treatment plans are a joke."

X-ray's are a vital tool and can detect things like osteoporosis, tumors, fractures, soft tissue inflammation and much more. I guess you were absent when they taught the signs of disc inflammation, nerve impingements due to arthritic spurs or misalignments on x-ray. Or maybe they did not teach it at the Chiropractic School you went to.

If you don't treat asthma, ear infections or bacterial infections that's your choice. I treat my patients with all the knowledge I have accumulated and suggest natural alternatives to anti-biotics or having ear tubes put in their kids ears. It's amazing what soft tissue & spinal manipulation and diet correction can do. The surgery can be a last resort if needed which in most cases is not.

X-rays may help change the way I treat. I look at every patient as a seperate individual and I do not routinely x-ray every patient. I totally agree with your last statement " diagnose a patient, treat conservatively, and then if things are getting worse or not improving get the appropriate advanced imaging."

 
At 4/17/2012 4:13 PM, Blogger Jerry Peterson said...

I usually don't have back problems, although an x-ray of my back did show that I have a significant curvature to my spine below the ribcage. I guess I'm fortunate for that. However, a few weeks ago, with no obvious cause, my lower back went out. For a couple of days I was not able to bend over at all without excruciating pain. It was obvious to me that a vertebrae had gotten out of place and was pressing on a nerve when certain movements were made.

The doctors at Chiropractic Naperville got me in, relieved the pain and with just a few treatments restored most of the flexibility I had previously enjoyed.

They are now helping me with other problems, such as reducing my weight. I have to say, my chiropractor has been much more helpful than any medical doctor I have visited.

 
At 10/16/2012 5:04 PM, Blogger John Kyneur said...

Dear Doctor, Great website.The 2 most fascinating areas of the chiropractic related anatomy are the sacro-iliac and the upper cervical. I've been working with these areas for over 30 years. There's a lot of information to be known. On my website, www.haberfieldchiropractic.com.au I have details on the various "Categories" that back conditions fall into - as well as a long list of conditions that arise from having each vertebral segment misaligned.

Kind Regards from Australia,

Dr John

 
At 11/02/2012 9:16 AM, Blogger Brad said...

Great blog! I appreciate the debate and agree that we are all continuing to learn about the affect of spinal manipulation. The involvement of mechanoreceptors and their affect on pain, alpha motor neurons and the descending inhibitory pathway are what fascinate me the most. Other studies are suggesting improved neuromuscular recruitment after manipulation, which would be ideal before active therapy. We are integrating these techniques in our clinic. You can take a look at our practice model and techniques at www.hickoryspine.com. We are striving to integrate with medical physicians and educate them on the safety and efficacy of spinal manipulation in an integrative healthcare model. Thanks, and keep up the great work!

 
At 10/20/2014 8:28 AM, Blogger Hanna Mae said...

I have been to the chiropractor a few times. The adjustments made my neck and lower back feel a lot better. That's the only experience I have had with a chiropractor. Don't know much about it. But the minor adjustments made me feel wonderful! http://www.thespinaladjuster.com

 

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