Functional rehabilitation
As practitioners we are continually dealing with dysfunctional musculoskeletal systems. Typically dysfunction develops and is perpetuated... Read Article
What are misaligned vertebrae (subluxations)
If you have back pain and looking for treatment you will find information on “misaligned vertebrae”, “bones out of place” and “subluxations”. Those terms are wrong and misleading, so the problems they are trying to describe are too often thought of as not real and either dismissed or ignored.
However they are real real problems and ignoring them makes makes treatments for back pain less effective, and can causes long term detriment to people’s spines and their health.
In this article I’ll use plain language and simple diagrams to show you what these problems are and, how they cause back pain. I’ll also show why ignoring them creates so many problems, and most importantly how they should be fixed.
CONTENTS
Part one: do vertebrae become misaligned or go "out of place"
Part two: what problems do these cause
Part three: how are they corrected
Professionals
References
Part One: Do vertebrae become misaligned or go “out of place”?
In most cases these “misaligned vertebrae” or “bones out of place” are actually individual spinal joints that have stiffened, with the vertebrae often sitting a bit crooked or twisted. The correct term for these is dysfunction. Perhaps the easiest way to make this clear is with some pictures.
Normal spinal movement
This diagram shows how the vertebrae normally sit and move. We see that when standing straight all the vertebrae should sit in the neutral position, and when the spine bends they should all move about the same amount.
Normal position for vertebrae
In this diagram we’ve removed the upper vertebrae so we can just look at the bottom one. We can see that this vertebrae is able to move. All three positions can be considered normal, depending on the movement.
On the other hand the vertebrae pictured on the right is genuinely “out of place”. This is not the condition one would see a chiropractor for. Rather, it would be following massive trauma with the person being in very serious trouble.
Abnormal spinal function (dysfunction)
This picture shows the typical problem someone would see a chiropractor for. If you look at the bottom vertebrae you will see that it is tilted to the left and not moving freely. It looks perfectly normal bending to the left. However, you can see that when the spine is standing straight there is an unusual “kink” at the bottom, and when the spine bends to the right the lower vertebrae stays tilted to the left while there is a quite abnormal stress on the ones above (1).
Ignore the stuff about terminology and jump straight to how these affect your body
What are subluxations
Chiropractors sometimes refer to these problems as “subluxations”. Unfortunately chiropractors and medical doctors have different definitions of the word subluxation, which causes confusion. Let's look at how this has come about.
The medical definition of subluxation
The medical definition of subluxation is a partial dislocation, which is like the genuinely “out of place” vertebrae pictured above.
The initial chiropractic usage
Back in the late 1800s when the first chiropractors started making adjustments (their procedure to correct these issues) they probably thought they were dealing with partial dislocations, or simply had no better way of describing things, so they started calling the these problems “subluxations”. As we’ve seen with other words, meanings can change with common usage. As an example, IT people have started calling on-line data storage “clouds”, which is of course different to the way the term cloud has historically been used.
Causing confusion
Nowadays every modern trained chiropractor knows exactly what a spinal dysfunction is, and certainly know that they are not partial dislocations. That’s their core expertise. They study normal spinal function and dysfunction to an incredible level. However, the differing definition and usage creates confusion and misunderstanding. Some parts of the chiropractic profession want to do away with the term subluxation and use terms such as dysfunction. Meanwhile other parts of the profession are saying “hang on, we’re the experts and have been using the terminology for over 100 years. We know what we mean by the term. Why should we change our terminology, to suit people who know far less about spinal function.”
The expanded use: the “subluxation complex”
As you will see later in this article spinal dysfunction can cause a host of secondary issues such as pain, muscle spasm, arthritic changes, and of particular interest to chiropractors: nerve interference. Chiropractors began to use the term “subluxation complex” to describe the underlying dysfunction plus the other commonly associated issues.
Graeme’s comments
This differing use of terminology causes a lot of problems. From the public’s perspective it’s hard to work out what’s going on, and terms such as “bone out of place” create totally the wrong vision. It’s for those reasons that I will use simple diagrams and unambiguous every day language to describe the problem. That way it will be very clear. In the rest of this article I’ll attempt to use the same strategy to clear up a lot of other misinformation: spelling out what these problems do, how because these issues are ignored, many treatments or back pain are terrible, and finally how to fix them.
What causes spinal dysfunctions
As stated, the fundamental cause is individual spinal joints stiffening. Causes of this include:
- trauma (individual or repeated)
- repeated abnormal stress (eg. bending and twisting)
- prolonged stress (eg. abnormal postures)
- prolonged muscle tightness (eg. sitting at a computer, emotional stress)
- disuse (not getting enough movement and exercise to maintain movement)
Part two: what problems do these spine dysfunctions cause
Now you’ve seen what these “misaligned vertebrae” or “bones out of place” actually are, lets look at what they do to your spine. I’ll be mentioning various parts that can be affected so first a quick introduction to the anatomy of your spine.
Very simply, we see there’s a column of bones called vertebrae, and between each we have discs. At the back we have little sliding joints to help guide the movement. At the side we have holes that nerves come out, and finally you’ve got levers poking out that muscles attach to to move your spine around.
The effects of these dysfunctions
This diagram shows a very common problem chiropractors deal with. The bottom joint has been repeatedly strained, and is now stiffened and tilting to the right. We will look at each of the problems this will cause.
Pressure on joints
We can see that with the bottom vertebrae tilted to the right there’s a lot of extra pressure on the small joint below on the right. There is also a similar problem above on the opposite side because that joint is tilted back the other way to straighten the spine. These joints were never designed to take constant pressure, so this causes (2,3):
- irritation and inflammation of the joints
- makes the joints more prone to being injured
- increases wear in the joints, causing long term degenerative (arthritic) changes.
- to reduce ongoing damage your nervous system will automatically tighten your back muscles to restrict movement.
Implications for treatment
Over time these joints usually become irritated, inflamed or injured. When this happens you will start getting pain in your spine, which may become sharp and pinching when you move around. These issues are too often just treated with rest, anti-inflammatory drugs and maybe injections. These give temporary relief, but of course do absolutely nothing to relieve the abnormal pressure. Further pain and long term deterioration of your spine are usually inevitable.
Tension on muscles to maintain balance
With the bottom vertebrae tilted the spine above will tend to lean to the right. So you do not overbalance the muscles on the opposite side will automatically tighten to straighten and balance your spine.
Implications for treatment
With the muscles constantly tight they will eventually become painful. Massage and/or stretching exercises are commonly used to relieve them. This will give temporary relief, but as long as the bottom vertebrae is tilted your body will automatically re-tighten the muscles on the left hand side.
Compensation
This diagram shows what happens when this spine with the stiffened lower joint tries to bend to the left. The stiffened joint doesn’t move and stays tilted to the right, while the others are forced to do extra to compensate. The joint above the stiffened tilted joint probably ends up bending twice as far as it was designed to do. As you could imagine this is a disaster waiting to happen. That overworked joint is eventually going to be injured, or will deteriorate very quickly.
Implications for treatment
With stiffened joints and tight muscles your movement will be restricted. Exercises will commonly be prescribed to restore movement and relieve pain, oblivious to the underlying cause. These exercises can temporarily stretch the compensating joints a bit more, maybe giving a bit of relief and a bit more flexibility, but I hope you can already see the long term consequences. Those exercises are not going to restore movement to the stiffened joint, and will only further stress the already over stressed compensatory joints. Without correcting the underlying problem, long term these exercises will cause severe joint degeneration and/or catastrophic failure.
Disc problems
Another common issue with back pain is disc problems. As I’ve shown you discs sit between the vertebrae. Structurally they’re a bit like car tyres only filled with jelly rather than air. That allows them to squash down on one side when you bend.
The main problem with discs is, just like a car's tyres, abnormal stress over time can cause the walls to weaken and the jelly inside starts to push through. That’s what’s happened in this picture. When this does happen it can create several problems.
- It can cause pain as the jelly breaks through the outer part of the disc, and
- as it shows in the diagram it can can press on a nerve.
How stiffened joints can cause disc problems
There are two ways a stiffened tilted joint can cause disc probems.
Overloading the compensating joints
The first is really obvious. Those compensating joints are forced to bend way more than they were meant to which puts tremendous stress on the fibres in the walls of the discs, so over time they will weaken and fail.
Lack of movement
The not so obvious way a stiffened joint can destroy a disc is through a lack of movement. There are no blood vessels inside a disc so it relies on movement to pump through nutrients. If it’s not moving there’s no pumping. With no pumping there’s no nutrients. With no nutrients the inside of the disc dies (3–5).
X/ray changes: degeneration and arthritis
We’ve mentioned how stiffened spinal joints can cause long term arthritic changes. Lets have a look at an example on an x/ray.
On this x-ray the white rectangles are the vertebrae and the discs are the spaces between them. In the normal joint the space between the vertebrae is about the right thickness and it’s even all the way through. It looks like a nice healthy disc.
If we look at the abnormal one below we see that the space is much thinner on the left which means the disc has deteriorated on that side. There are also a couple of things like parrot beaks poking out the side. They are bone spurs, part of arthritic changes.
Misleading information given about x/rays
When patients are shown their x/rays they are often told two things:
- the arthritic changes are the cause of their problem, and
- the changes are due to their age.
Lets look at how ill-informed and misleading these statements are. The key thing to note here is that changes like that take at least 20 years to develop, and they’ve only happened in one spot: the left hand side of that abnormal joint.
- The arthritic changes may be causing pain, but unless there is bone on bone or those arthritic spurs are pressing on something they often don’t cause pain. The real problem is the underlying cause of the abnormal stress.
- The normal joint above is the same age and it is completely normal
Nerves
The last effect of stiffened joints I’ll look at is nerves. As I’ve shown you the nerves come out holes at the side. If there’s tilting of vertebrae that reduces the size of the hole. Also arthritic changes, swelling from inflamed joints, or ruptured discs can also reduce the space for the nerves.
Depending on how the nerves are affected they may cause extra signals (static) or reduced signals (blockage). It is well recognised that this can cause problems when it happens to the nerves that detect pain or control muscles.
- “blockage” can cause numbness and reduced ability to control muscles.
- “static” can cause pain or muscle tightness.
However, the nervous system controls the things shown in this diagram as well, opening up a host of possible consequences of nerve interference.
Graeme’s comments
Back about 100 years ago chiropractors noticed that sometimes seemingly unrelated conditions would improve when spines were adjusted. They started to claim that disease was caused by nerve interference, and by adjusting spines they were curing diseases. Nowadays all chiropractors understand that there are many possible causes of diseases. The overwhelming majority would not claim to be curing diseases, but would acknowledge that interference to the nervous system can cause the body to function abnormally. With this in mind, checking your spine for potential sources of nerve interference is just as sensible as checking for things such as blood pressure and cholesterol levels.
Summary of stiffened joints (dysfunction) and their relationship with other issues
That’s what stiffened tilted joints (dysfunction) can do. The reality with back problems though is that usually many issues happen concurrently. Also, while stiffened joints can cause other problems, other problems can cause stiffened joints (6). However, those stiffened and tilted joints need to be considered central for three very important reasons.
Every back problem has them
First, as a chiropractor for over 27 years every patient with back pain I saw had at least one and usually more of them.
If you don’t fix the dysfunctional joints your spine will continue to have problems
Secondly, as I’ve shown those stiffened and tilted joints can cause all those other problems. If you don’t remedy the joints you can’t fix the other problems, or they keep coming back.
Correcting the dysfunction takes care of a lot of the other problems
Finally, and this is very important. Look what happens if you correct the stiffened tilted joints.
- The muscles no longer need to be tight
- the pressure comes off the over-stressed small joints at the back of your spine
- the overworked compensating joints no longer need to compensate,
- there’s more room for the nerves to come out,
- and finally if there are any arthritic changes causing problems, taking the stress off them may be the difference between them being painful or trouble free.
Part three: How to correct spinal dysfunction
We’ve seen that stiffened and tilted joints are a major part of back pain, so how do we fix them?
First, how not to fix dysfunctional spinal joints
Exercises alone are often prescribed to correct functional spinal problems. However, as we’ve seen it is impossible for exercises to isolate the movement to individual spinal joints, therefore to put it simply stuck joints stay stuck while compensating joints are forced to move even more. This can give temporary relief, but as the x/ray example showed, years later can result in catastrophic failure.
The proper way to correct spinal dysfunction
The way to restore movement to those stiffened joints is by using a force directly on that joint. Looking back at the underlying issue there are two major challenges.
- The stiffened joint may only be “stuck” in one direction.
- There will likely be a compensating joint (about 3cm away) that is already over stressed and moving too far. Applying force to this joint will be very detrimental.
The spinal adjustment (specific manipulation)
Given those challenges the force needs to be very accurately applied so that:
- it moves the fixed joint but not the close by compensating joint, and
- the appropriate amount of force is used, and
- it must be delivered in the direction needed.
As you could imagine this takes a huge amount of training and skill. This is the core expertise of chiropractors who call these procedures adjustments. Other professional such as Osteopaths and therapists with special post graduate qualifications have expertise at this as well, and use slightly different terminology (7–10).
Overcoming adaptions and changes
As well as needing to very specifically induce movement into the stiffened tilted joints, the muscles and soft tissues around them need to be restored. Looking at the basic dysfunction effect diagram shown earlier we can see that with the vertebrae tilting the space between the levers at the bottom of the stiffened joint has closed down on the right and opened up on the left. Over time the muscles and other tissues between these levers change in length to adapt. In order for the joint to go back to normal those muscles and tissues need to change back again. Of course its a bit more complicated because you’ve got things like muscles that have deteriorated due to being tight all the time, and others shortened, stiffened or weakened due to disuse, but I think you get the picture though. Things have to re-adapt over time. You can’t just go snap crackle pop and it’s all like new again.
The role of other therapies
As I’ve discussed, therapies such as massage, exercises or medications alone it will rarely fix anything. However, they can be an extremely important part of the process of restoring your spine.
Massage
As discussed in our article why do trigger points keep coming back muscles that have been tight for long periods of time develop changes that can cause pain, but more importantly inhibit function and can prevent it from returning to normal. Massage is excellent to help restore muscles.
Exercise
We’ve seen that exercises alone will not restore normal spinal movement. However, as a result of the dysfunction, over time many muscles and other tissues will have shortened and weakened. These need exercise to restore. The way this is done is to gradually introduce exercises once chiropractic adjustments (or similar) have restored some movement.
Rest and medication
If your spine is very inflamed rest and medication may be used temporarily to help settle it down in order to allow correction to begin.
Surgery
If there is a catastrophic failure such as a ruptured disc is pressing hard on a nerve surgery may be needed. Too often though after surgery the underlying cause of the catastrophic failure is ignored.
Managing the process of spinal correction
To correct your spine you will need chiropractic adjustments (or similar) plus the coordinated use of other therapies such as massage and exercise. Like the adjustments (or similar), coordinating this process takes a great deal of training. Therefore the process needs to be managed by a professional such as a Chiropractor, Osteopath or a therapist with appropriate post graduate qualifications. That professional may do all those therapies him or herself, or refer some tasks to other appropriately qualified professionals.
Graeme's comments
That’s what I’ve done for over 27 years in practice: correct spines and manage their rehabilitation. I’d like to finish by sharing with you why we developed our massagers to help support this process.
The need for large amounts of massage or soft tissue therapy
For reasons I discuss in our article why do trigger points keep coming back patients usually need large amounts of massage or soft tissue therapy over a long period of time. If all done by professional therapists that can be very expensive. The consequence of that is patients rarely get enough. Our massagers allow patients to supplement their care with quality therapy at home. That way they can get all they need.
The ability to reach important muscles that conventional massage cannot reach
The usually overlooked issue is that, as this diagram shows, the really important muscles that control the movement of the individual vertebrae sit very deep between the levers. As well as being very deep those levers might only be 1cm apart. Because of that it’s physically impossible for a massage therapists to dig in deep enough to massage them.
Also, as discussed in our article Percussion vs vibration massage, percussion massagers such as massage guns attempt to massage by driving their heads in like jackhammers. There is no way they can jackhammer their heads in that far either. On the other hand the vibrations from a proper vibration massager penetrate deeply and can easily go between bones to get to tight spots that are otherwise impossible to reach. All you need to do is place the head of the massager beside the vertebrae directly over the muscles. For those clinicians who haven’t used a vibration massager like this before here are three very useful pieces of advice.
Vibration can be used very specifically
The first is by placing the head very specifically you can direct the vibrations to the muscles that need it. For example you can direct them at the muscles associated with the stiffened joints while avoiding the ones associated with compensating joints.
Vibration can help relax muscles, allowing movement
Secondly, those tight muscles can work against trying to restore movement, but if you use the vibration massager on them before hand it removes a lot of resistance.
Vibrations can help restore movement
Finally, with some movement restored the vibrations will further relax the muscles and help stimulate the circulation of nutrients. We’ve also got chiropractic adjusting instruments that apply repetitive thrusts into joints in order to “free them up”. Examples include Arthrostim and Impulse Chiropractic Adjusting Instruments. As well as having a much broader effect (including muscles) it is likely the vibration massager will further help restore movement as well.
In practice we find that when applying the massager post adjustment, pre and post checks of movement usually show an excellent increase in movement. Of course we have no way of knowing whether the increase was caused by the relaxation of the muscles around the spine, a similar effect to those chiropractic adjusting instruments, or both. We are just happy that the movement is a lot better.
How to choose a vibration massager
For how to choose an quality massager that will do a great job and that you will be extremely happy with please see our article How to choose a massager, or you can go straight and check out our economical, easy to use professional standard machines: the General Purpose Massager or our Ultimate Quad Head Massager.
Professionals
DrGraeme massagers were originally built by Dr Graeme for use in his clinic, and to prescribe to his patients for additional self use at home. Now these are used by colleagues and other professionals for similar purposes. If you are a professional and wish to know more about this therapy, or possibly get a sample massager to trial please check out our practitioner page.
References
- Rey-Eiriz G, Alburquerque-Sendín F, Barrera-Mellado I, Martín-Vallejo FJ, Fernández-de-las-Peñas C. Validity of the Posterior-Anterior Middle Cervical Spine Gliding Test for the Examination of Intervertebral Joint Hypomobility in Mechanical Neck Pain. J Manipulative Physiol Ther. 2010;33(4):279–85.
- Jaumard N V., Welch WC, Winkelstein BA. Spinal facet joint biomechanics and mechanotransduction in normal, injury and degenerative conditions. J Biomech Eng. 2011;133(7):1–31.
- Merlo JA. Onset, location, and progression of facet joint articular cartilage degeneration following lumbar spinal hypomobility. ProQuest Diss Theses . 2016;30:118.
- Saunders HD. Classification of Musculoskeletal Spinal Conditions. J Orthop Sport Phys Ther. 1979;1(1):3–15.
- Cramer GD, Fournier JT, Wolcott CC, Henderson CNR. Degenerative changes following spinal fixation in a small animal model. J Manipulative Physiol Ther. 2004;27(3):141–54.
- Fernández-De-Las-Peñas C. Interaction between trigger points and joint hypomobility: A clinical perspective. J Man Manip Ther. 2009;17(2):74–7.
- Clealand J et. al. Short-term effects of thrust versus nonthrust mobilisation/manipulation at the thoracic spine in patients with neck pain: a randomised clinical trial. Phys Ther. 2007;87(4):431–40.
- Lau HMC, Wing Chiu TT, Lam TH. The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain - A randomized controlled trial. Man Ther . 2011;16(2):141–7.
- González-Iglesias J, Fernández-De-Las-Peñas C, Cleland JA, Gutiérrez-Vega MDR. Thoracic spine manipulation for the management of patients with neck pain: A randomized clinical trial. J Orthop Sports Phys Ther. 2009;39(1):20–7.
- Krauss J, Creighton D, Ely JD, Podlewska-Ely J. The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: A randomized clinical trial. J Man Manip Ther. 2008;16(2):93–9.
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About Dr Graeme
Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more