​I treat a lot of people that have:

• back pain,
• neck pain,
• pelvis pain,
• hip pain.

​Very commonly they’ll tell me something is “out of alignment”. Either that’s what it feels like, or they’ve had treatment from a therapist that has told them that, or they’ve talked to a friend who has said “maybe your ‘X’ is out?” and that makes perfect sense to them.

The concept of something being “out of alignment” is not a paradigm I’ve ever been taught or taught to patients. My understanding of it as an idea is that it comes from an osteopathic and chiropractic model where pain and illness are meant to originate from vertebral “subluxations”. A vertebra is “out of place”. The subluxation model is now being discouraged by chiropractic associations worldwide as not being valid, but it has definitely seeped into public consciousness. A lot of people when they have back pain will try and describe how it feels and come up with the explanation that they’ve “put their back out”. Patients grab hold of a simple idea that seems to makes sense.

When a patient uses this sort of terminology I used to play along with it because I understood what they were saying and I found I upset a lot of patients if I tried to correct them. They had paid good money to see a chiropractor who’s told them their pelvis was out of alignment, they’ve agreed that’s what it felt like so they’ve bought into the idea. When I question the concept directly it can be upsetting. If someone to whom you’ve paid money tells you something, and they’re a nice enough person, and they seem like they care about you and know what they’re talking about, you believe them. To then be the second therapist offering an opinion and say something different can be tricky and I usually word it incorrectly and put the patient right off side.

Anyway, I used to let it slide because it’s easier for everyone, I can get on with treatment using my own paradigm, and I didn’t think any harm was done.

But I’ve now changed my mind on staying quiet. 

I saw a lady today who’s been seeing an osteopath twice a week for a year - thousands of dollars - for a radiculopathy from her lumbar spine which has now progressed to a foot drop. Every session her “pelvis was out”. She doesn’t know how it keeps happening. Her only solution was to pay this “expert” for a “re-alignment”. It’s a very common story. I got so upset today. This lady was in tears - she felt so helpless.

I think this sort of treatment is criminal. It makes someone a helpless victim by diagnosing them with something that they have absolutely no control of themselves - the pelvis just keeps going out mysteriously. And sell a solution: “I can put it back for you. Come in twice a week”. Nothing you can do to help yourself. 

The language is dangerous and damaging and takes advantage of a patient that trusts you are a professional providing an honest service.

When a therapist talks about something being out of alignment I hope they are using the terminology as a euphemism rather than believing something is actually out of place. Because we know it’s not. 

So the therapist is either:

• unknowingly perpetuating an idea that is harmful because they are ignorant,
• or deliberately deceiving patients for financial gain.

​I used to think physios were better than that and the language of alignment was just for other professions. I used to be OK with it because it was Chiro’s and Osteo’s, not physios. But more often these days the language of something being “out” is creeping into physiotherapy. Muscle Energy Technique (MET) is a type of treatment physios are using to treat the hips, sacrum, pelvis, and back pain. “Rotations”, “counter-rotations”, “up-slips”, and “down-slips”. The way they teach it seems like they actually believe it’s a physical/mechanical movement rather than a conceptualised euphemistic explanation. I don’t think it’s a path the physio profession should go down. 

I understand how it happens. An “expert” is in town selling a course. You pay money for the course, you’ve bought the product and are invested in it working, you give it a go with patients and get good results. It’s the same cascade that makes the patient buy in.

Next minute it seems like everyone’s pelvis is twisted. It’s an epidemic.

How can different professions, and even two therapists in the one profession, come up with completely different explanations for what’s going on? I think that speaks to the size of the problem of back pain and there not being a single treatment option that helps everyone. (Well actually there is and that’s exercise - but it’s harder for people to make money from selling exercise.)

This is a bit of a rant and I’m almost nervous to write it down because there are some well respected therapists across a number of professions who are a lot smarter, have better jobs, and earn a lot more money than me, who speak about things being out of alignment.

Not me. Don’t worry. Your back is strong. Your back is stable. Your back is resilient. It’s sore now, but that is largely unrelated to structure and mechanics. There’s definitely nothing broken, out of place, or alignment.

​Back pain is a big problem.  Everyone gets it.  It's the most common thing I treat.  About a quarter of the patients I see have back pain.  There's a massive disease burden.  It's expensive.

And it can seem complicated.  Everyone's got different advice about what to do.  There's not one thing that fixes it.  It can seem a bit out of control.  And that can make it worse again.  Stupid little things aggravate it.  It doesn't seem fair.  Stress.  Anxiety.

Usually there's not anything magical I can do to give you immediate relief.  We work on little gains that you can achieve regularly by yourself throughout the day and it gradually improves.  It takes a bit of work.

My main goal when you come in for treatment is to give you control.  Once you have a sense of control it doesn't hurt as much.  I frame this as a "BACK PAIN MANAGEMENT PLAN"...

- KNOW WHAT AGGRAVATES IT -

For example, this could be:

• Sitting
• Driving
• Bending
• Lifting
• Twisting
• Running 
• Standing

- KNOW WHAT RELIEVES IT -

This could be:

• Tablets
• Heat
• Massage
• Stretches
• General exercise
• Avoiding prolonged sitting

- KNOW HOW TO PREVENT THE NEXT EPISODE -

This could be:

• Strengthening exercises
• Stretching
• General exercise
• Avoiding prolonged sitting

We need to pick the one or two most important things from each of these lists
​

I quite enjoy the concept of Micromorts & Microlives.  Our average life expectancy can be divided into one-million, half-hour units.  I enjoy the maths of risk.  The things that add or subtract units of our lives.  

For example:

• 2 cigarettes shortens your life by 30 minutes
  
• 1 standard drink adds 30 minutes (the 2nd drink takes it away again)
  
• 20 minutes of moderate exercise adds an hour to life expectancy
  
• 2 hours sitting shortens your life by 30 minutes

There’s been some media over the last couple of years suggesting that “sitting is the new smoking”.

Research now tells us that the number of hours we sit each day is an independent predictor of our health, similar to other factors like age, smoking status, obesity, & exercise.  It turns out that sitting for 10 hours a day is harmful for your health whether or not you exercise, how old you are, whether or not you smoke, & whether or not you’re fat or thin.  Sitting is bad for you.

The longer we sit, the less healthy we are.  There are a couple of reasons…  

Sitting is the primary cause of low back pain, which is a leading cause of disability in the general population (second only to depression), with nearly four million Australians suffering at any one time. Total treatment costs in Australia exceed $4 billion a year.  Back pain is the most common musculoskeletal problem, accounting for one in four patients I see.  

The longer we sit, the less physically active we are. Physical inactivity shortens our lives.  It is the 4th leading cause of death.  Physical inactivity is the second greatest contributor, behind tobacco smoking, to the cancer burden in Australia.  Physical inactivity is estimated to be the main cause for approximately 25% of breast and colon cancers, 27% of diabetes, and approximately 30% of ischaemic heart disease.

From an evolutionary point of view we’ve had 100,000 generations of being hunter-gatherers, moving around, doing different things all day.  We’ve only had 10 generations of industry, where we do the one thing all day, commonly including too much sitting.  Our bodies just aren't used to sitting for long periods of time. 

Sounds terrible? However, the solution is easy…

New research has found that getting up and moving around for two minutes every hour is associated with a 33% lower risk of dying prematurely.  

Breaking up the sitting time appears to be more beneficial to life expectancy than doing daily exercise.  You can eliminate the harmful effects of sitting 10 hours a day by getting up for 2 mins every hour.

Breaking up sitting time also is also good for back pain.  

I’ve spent years trying to get people to sit with better posture to prevent back pain.  It’s super hard to maintain.  It takes continuous deliberate effort, which is almost impossible.  I’ve tried posture -aids, ergonomic chairs, lumbar supports, cushions, Swiss balls, taping.  I’ve given up.  You just can’t sit with perfect posture for long periods of time.  

I’ve now moved to trying to get people to get up and move for a couple of minutes every 20 minutes.  You can get away with sitting with the worst posture imaginable if you don’t stay there too long.  Overall it takes a lot less thought and effort for a much better result.

I think the change to less sitting needs to be driven by employers over the next few years, similar to how smoking was fazed out of work places.  I think we will see more stand-up desks, stand-up meetings, "walk-around" meetings, and possibly enforced limits on sitting time. 

So whether or not we do it for our backs or for a long life, we need to sit less & move more.

More information

In Australia a lot of money is wasted on unnecessary medical tests.  This means testing to confirm a diagnosis that is already obvious, and tests where the results won’t change the course of treatment.  

A physio example is MRI for knee injuries. Clinical tests I do in the rooms give an accurate diagnosis.  An MRI usually isn’t necessary & can be reserved for cases where the surgeon needs to decide on the type of operation to perform.  If the knee is not a candidate for surgery, then an MRI isn’t going to change the course of rehabilitation.

Similarly with back and neck pain.  Low back pain is the most commonly imaged musculoskeletal complaint.  A healthcare professional may send you for an x-ray / CT / MRI to confirm a diagnosis or “rule out” something serious.  Unfortunately the imaging rarely adds any additional information, and can actually make things worse.

Back pain is very common. It’s the most common musculoskeletal injury, and essentially everyone will have a sore back at some stage in their lives.  Because it’s so common, we know a lot about it.

In nearly all cases, back pain is not serious and we can reach an accurate diagnosis without needing scans.

We can rule out the scary, “worst case” diagnoses like fractures, infections, & tumours with some simple questions.  We can test for potentially serious “structural” injuries with some simple tests in the rooms. 

However, back pain is rarely anything structural or serious, and imaging doesn’t add any useful information.  Research tells us having a scan doesn’t change the treatment you need, or how fast you recover. We know nearly everyone recovers from back pain without needing a scan.

“Is imaging just a waste of time & money?”

If you’ve got time and money, “what’s the harm?”. Well firstly, X-rays and CT scans expose you to radiation that can potentially cause cancers, so should only be performed when there is a clear benefit. Back X-rays deliver about 65 times more radiation than a chest X-ray.  Back CTs expose you to 100 - 500 times the radiation of a chest X-ray.  Would you volunteer for 500 X-rays if there wasn’t a clear benefit?

Possibly a bigger concern is, when we start scanning body parts, we see things.

MRIs can look nasty. There’s way too much detail. We see disc degeneration, disc bulges, degenerative joint disease, osteoarthritis, narrowing.  But all of this is normal.

A study of adults without any back pain found that two-thirds of us have bulging discs or other spinal abnormalities on MRI scans. No pain. Bulging discs. So the bulging discs we see if we MRI your back pain are normal, and not something to worry about.

Imaging for back pain shows us a lot of incidental findings that are unrelated to the pain.  The changes we see on a scan don’t require any treatment. The radiologist writes a big long list of “problems”, however, they are just normal changes that were most likely there before you had your pain, and will most likely still be there once your pain has gone. 

Seeing these normal changes on the scan causes stress and anxiety, and potentially unnecessary follow-up tests and procedures, that add to the severity of the injury.

Studies have found that back pain sufferers who had an MRI, compared to similar people with the same severity of injury:

• consumed higher doses of pain-relief medicines
  
• were off work, on average almost 6 times longer
  
• if the pain was severe, were 8 times more likely to have surgery
  
• if the pain wasn’t severe, were 33 times more likely to have surgery than those who did not have an MRI. 
  

Even though they had the same symptoms. Just because they’ve had a scan.  A lot of reasons not to get a scan.

Once we’ve seen something on a scan our expectations of recovery change, and that becomes self-fulfilling. If you think your back pain is serious it becomes more painful and takes longer to get better.

More information available here, here, & here.

A nice video here.