Being shown an X-ray with lines drawn on it, and sold a course of adjustments to straighten you out, is the wrong strategy. Here is why.
Have you seen a practitioner about ongoing back pain and been shown an X-ray with lines drawn across it? Perhaps it even appeared on your clinic letter. It is one of the most common things I encounter, and I want to explain what is wrong with the approach.
The familiar scenario
Every week I see a patient who has been to some form of practitioner for ongoing back pain. They have had an X-ray with lines superimposed on it, supposedly showing their spine, compared against another X-ray representing normal alignment. They are then sold a theory: that a series of adjustments will convert their spine from the first picture to the second, and that this will resolve their chronic pain.
Debunking the premise
Let me start with the underlying myth, which is that your spine must be perfectly aligned to be healthy, or that malalignment is the cause of your back pain.
We know from studies that among people who have never experienced back pain, many have abnormal spinal alignment and are entirely unaware of it.
Sometimes there is an underlying cause of back pain that does place you in malalignment. But it is not the alignment itself that is causing your chronic spinal problem, and that distinction matters enormously.
A good history and thorough clinical examination give us far more information than a plain X-ray ever will. Multiple structures can be the source of back pain, along with various mechanisms and behaviours, and these cannot always be captured on imaging. MRI gives more detail about the structures, but imaging alone still does not tell us what is going on.
What the evidence says about adjustments
A Cochrane review examined the studies on manual therapy and adjustments for chronic back pain, including those comparing them against sham treatments, where one group received the usual adjustments and another received sham massages.
The findings were unremarkable. There was no significant benefit of one over the other, and no powerful study demonstrating one. The same applied when adjustments were compared against traditional treatment such as physiotherapy. The studies that did show a difference were of poor quality and unconvincing.
The nocebo effect
This is the part that concerns me most in clinic.
Patients who have undergone these treatments over long periods, and been shown such X-rays, come to believe their back is fragile or damaged. They then adopt false guarding and protective behaviours:
- Sitting bolt upright, shoulders back, rigidly held, in the belief that this protects the spine
- Bending and moving in a very specific, stiff way for the same reason
Studies have shown that in the long term this does more harm than good.
I am critical of surgeons too
This is not only about non-surgical practitioners.
There is a concept called flat back syndrome, supposedly a cause of a great deal of back pain, with the implication that implanting screws and rods to straighten you will cure it.
The studies supporting this are largely case series: a group of patients underwent the surgery and did well. There is very little comparative data. And in one such study, only a small handful of patients had surgery for flat back syndrome, while the underlying causes addressed were varied. In one of the images, for instance, one bone had slipped forward over another, a spondylolisthesis. That underlying cause was treated surgically, and the patient did well, but that is a rather different proposition.
This has to be weighed against the risks. A study examining all types of thoracic and lumbar deformity found complication rates of up to 55%.
Where alignment does matter
None of this means alignment is irrelevant. If we have identified an underlying problem causing both your back pain and your malalignment, then yes, there is a place for correcting the alignment at that point. Getting it right has been shown to prevent disease at the adjacent segment, and therefore to reduce the likelihood of your needing further surgery later.
The distinction is whether the alignment is being corrected as part of treating a real, identified problem, or pursued as a goal in its own right.
What actually helps
Treatments involving movement and education, learning which exercises and stretches to do from a good physiotherapist or osteopath, consistently beat manual therapy and adjustments.
The key takeaway
If you have long-standing back pain, it is wrong to take an X-ray and sell you a series of adjustments on the false premise that this will improve matters. It is the wrong strategy.
Nothing beats a thorough history and clinical examination from a good clinician, followed by the correct imaging if it is appropriate. Most of the time, no imaging is needed at all.
