Your back isn’t “out”

Sometimes as chiropractors we can be so lazy. Especially in how we explain things to patients. We say things like

  • Your spine is out of alignment
  • Your back is too flat/curved
  • Your neck is stuck
  • Your hip is out
  • Your pelvis is tilted
  • One leg is longer than the other
  • Your arches have collapsed
  • Your disc has slipped (see previous post for a big rant on this one!)

As often happens in a healthcare profession (HCP), we’ve developed our own little language to talk to each other about the things we treat. And because we’ve all gone through the same training, we understand what these short-hand terms mean and the implications of them.

But sometimes we make the mistake of assuming that patients know what we mean by this. But some interesting research over a decade ago demonstrated that the use of medical jargon, or even just a poor explanation, can lead to patients getting a very different idea of what is wrong with them. In this study, doctors gave a diagnosis to a patient, and then the patient was asked by researchers afterwards to recall as much as they could about the diagnosis and describe what they thought it meant. Doctors who used the word “neurological” in the explanation (which means anything to do with the nervous system – the brain, spine and nerves in the body) gave patients the impression that their condition was progressive (ie. would only get worse and not better). Patients who heard the word “chronic” (meaning lasting longer than 3 months) interpreted it as “incurable”.

But the real danger in this scenario is not just that the patient mis-understands their condition. The real risk we run is that patients will change their lives based on the information that HCPs give them, and they can end up much worse-off as a result.

We are the problem

Let me tell you about a patient of mine – we’ll call him Paul*. Paul was in his mid-30s when he came to see me. He had been seeing a chiropractor I knew well in another part of the UK, who had recommended he continue his care with me when he moved to Cheshire. When I asked him about his previous treatment, this is what he told me:

“I got some pain in my back while I was running a 10k. When I went to see the chiropractor, he told me both my hips had dislocated and he put them back in again. Since then I’ve had regular treatment and he keeps putting my hips back in place. I’ve stopped running because I don’t want them to dislocate permanently, but my back isn’t really much better.”

As I said before, I know the chiropractor who treated him. He’s a competent, evidence-based and ethical chiropractor. And I know there’s absolutely no way that he told Paul that both his hips were dislocated, but this is what Paul heard from his explanation. As a result, Paul stopped exercising.

A multitude of research tells us that exercise is the best thing you can do for your back and inactivity will almost certainly make back pain worse. Not only that, just think about the impact on Paul’s life when he stopped running. Doubtless his fitness decreased; perhaps gained weight; he may have spent less time in fresh air and nature; and maybe he doesn’t even see his friends from his running group any more.

So there is a real danger when we mis-communicate a diagnosis like this that we change the trajectory of a person’s health. We actually can be the cause of serious problems down the line. If Paul had continued the way he was, he may have put himself at increased risk of cardiovascular disease, diabetes, osteoporosis, several types of cancer and mental health problems.

Chiro-translate

So, returning to that list above, let me give you a translation of what your chiropractor really means! (And you might also want to look at the video explanation on my Facebook page here)

Broadly speaking, the statements fall into 2 categories:

  1. Statements about movement – These are comments about joints being “stuck”, “fixated” or “restricted”, and it might also include comments about joints being “out of alignment”. What is actually happening, is that the joint no longer has a full range of motion so instead of moving 100% of it’s normal motion, it actually moves something like 50-80%. The joint does still move, so it’s not “stuck” or “fixed/fixated” in one placed, and in every other respect the joint is perfectly healthy and does still function, but it probably feels a little stiff. Manual therapy (like the treatments chiropractors do) has been shown to be really effective for restoring movement in these joints. But sometimes we make the patient feel like their spine is fused at that spot, and always will be.
  2. Statements about shape/symmetry – These are comments about spines being too curvy or flat, feet having fallen arches or collapsed arches or high arches, one hip or shoulder being higher than the other, etc. The first thing to say about these measurements is that they’re not very easy to define. For example, there is a huge variety in the shape and size and combination of the 3 arches in a person’s foot. But there isn’t really a fixed definition of how high is too high for an arch. So it falls into the category of the “expert eye”/”looks a bit high/low/flat/collapsed to me” – which can be very different between healthcare professionals. This is sometimes helped by comparing side to side – as in the case of one shoulder or hip being higher than another. The second thing to say is that, when we make statements like this as chiropractors it is VERY rare that we are actually talking about the shape of your skeleton. A lot of times we might just be talking about your general posture, how you hold yourself, or muscle tension in an area making it look bulkier or higher than it actually is. But we run the risk of making patients feel like their skeleton is going to be permanently mis-shapen and lead them to worry unnecessarily.

But the most important thing to say about these 2 categories is that neither of them IN AND OF THEMSELVES are predictive of pain or poor function. When assessing a patient a chiropractor needs to take into account medical history, family history, occupation, hobbies, accidents/injuries… as well as a lot of non-physical factors like the patient’s past experience of healthcare, their beliefs about their pain and their mental health. And after this, the postural and motion assessment forms just one part of a thorough examination.

You know what I mean?

There really is no excuse for HCPs to be lazy in their approach to communicating with patients. So if your chiropractor or physiotherapist or doctor says something you don’t understand, please feel no embarrassment in interrupting and asking them to make themselves clearer. A clinician worth his salt will not be offended at you attempting to understand your condition better – good ones would welcome it.

Discs Don’t Slip

The intervertebral discs sit between the bones of the spine. They’re composed of a gel-like material (in the picture below this is called the nucleus pulposus) surrounded by a mesh of fibres (the annulus fibrosus). Whenever there’s any movement through the spine, the discs act like little shock-absorbers, to dissipate the force and protect the bones of the spine from any impact.

On either side of the disc, attaching each surface to the adjacent bone, is a cartilagenous endplate (ie, a flat circular structure made of cartilage) This not only firmly anchors the disc to the bone, but also acts as a membrane for water and nutrients to pass from the blood vessels in the bone into the disc. This keeps it hydrated and nourished.

And on top of this, there are a multitude of ligments that run over the spine and the discs. These are made from strong, tough fibres which run parallel to each other, to form a barrier with high tensile strength. These keeps the whole spine sturdy. The picture below shows the multitude of stabilising ligaments in the spine.

Seriously, discs don’t slip

All of this is simply to say that discs don’t slip. They do not slide out of place, or move around in the spine. They are firmly anchored by the end-plate and bound in by ligaments. They simply cannot slip out.

The injury that is often described as a “slipped disc”, is actually a bulge. Sometimes the annulus fibrosus (the outer rings of fibres that hold the gel of the disc contained) can be injured, and this can lead to the softer nucleus pulposus (the gel in the middle) bulging out, usually into the side of the spine. Sometimes this will put pressure on the nerve there, which causes the classic leg pain of sciatica.

Why does it matter?

Surely it’s just terminology? The pain is the same is doesn’t matter what we call it, right?

Actually, that’s not true.

We can’t see our spines. If we hurt our elbow, we would get a lot of visual information about how the injury was progressing. We would see swelling reduce, bruising go down, scratches or wounds healing, etc. In the spine we don’t get this visual information and so we rely a lot on our imagination – we have to visualise in our own minds what we think is happening in our backs. This is how our brain processes and makes sense of an injury.

And so actually the terminology we use has a huge impact on the mental image we draw up of our injury. I have had patients tell me that their “slipped disc” has moved out of their spine and they have no idea where it has gone but it’s left a great big hole in their spinal column.

The downward spiral

Now imagine how a person who thought like this would act. They would avoid anything that might challenge their “unstable”, “weak” or “slippery” spine/discs. They would be less active, they may sit/lie down/rest more. They may stop doing things they love.

All of these are things that are unhelpful to your recovering back. Research shows that movement is important to your spine and bed rest severely slows recovery.

But all this imagery of “slipped” discs will usually make someone more anxious about their back and, as we have discussed before, fear and anxiety about back pain can actually sensitise the nerves and make the back pain worse.

Good news for discs

As we’ve also discussed on this blog, discs DO heal.

So here’s what you should do if someone tells you that you have a “slipped” disc (once you’ve informed them of their mistake and pointed them to this blog – haha!):

  • Don’t put yourself on bed rest
  • Use paracetemol or cocodamol (not both) and/or manual therapy (like a chiropractor, osteopath or physiotherapist) for pain relief and to encourage movement
  • Perform regular gentle movements in the spine in the direction that gives relief (I give my patients the McKenzie exercises)
  • Be patient. Discs do heal but they take time.

Does my disc need surgery?

We’ve talked before on my Facebook page about how discs don’t really slip. But There’s some exciting new research with even more good news for discs!

Disc bulges CAN re-absorb (resorb). That means the bulge can suck itself back in. Spontaneously. With no surgery or treatment necessary.

Here’s a picture from the research to prove it – can you see the disc sucking back in over time?

And not just the little ones. One of the research papers included a lady who had a large disc bulge in her neck and had experienced sudden quadriparesis (noticeable weakness, but not total paralysis, of all four limbs). Her disc bulge and all her symptoms got better by themselves, with no specific treatment, over 28 months.

In fact one study recommends that lateral disc bulges (these are the bulges that go out to the side into the nerve root, rather than backwards into the spinal cord) resolve so frequently that conservative treatment (ie, non-surgical) should be the first port of call. Especially if there is also radicular pain, like sciatica.

So if you are struggling with a disc issue, remember this:

  • Your body is capable of healing
  • Discs spontaneously resorb very frequently
  • Your spine is ultimately very stable
  • You do not need to immobilise your back or put yourself on bed rest