Question
QUESTION: I wen to see a chiropractor for back pain on low back right side.  I have been treated in the past for rotated pelvis and mild sublaxation.  I was informed that I needed some major work - femur not going into the socket.  He used x-rays from another doctor that was 5 months old.  He treated me for 3 months and I got worse - severe muscle guarding and constant discomfort.  I went to see an orthopedist who took x-rays and said he saw nothing abnormal and put me in PT.  I did that for ~2 months.  Chiropractor told me it was all muscular at this point and perhaps part of aging.  I went back to orthopedist who referred me to another chiropractor who took x-rays and told me I had a misalignment at L5.  He rated it a grade 3 out of 4 but told me he could treat it.  I have seen him for a week and have a little relief - less muscle guarding.  Is this something that can be corrected and is there anyway to tell if the first chiropractor just made it worse.  Are there other tests I have should have?

ANSWER: Dear Cee Cee,

I'm sorry to say, but what you have experienced is a three-ring-circus of bad treatment.   First of all, there is little reason to take x-rays unless the doctor is looking for a disease like a tumor or infection or a severe form of arthritis.   The concept of bones being out of place has been disproven years ago and all modern, evidence-based practitioners are well aware of this.   There was absolutely no reason to get more x-rays from the orthopedist, and certaninly not again from the second chiropractor.   I don't know how old you are.  I have no idea about your medical history such that it would lead doctors to take x-rays three times.  Even if you had a little osteoarthritis, it would not matter in regards to treatment because it is not something that a DC or PT or MD is going to fix.  Forget about "correction."   Think first about pain relief and regaining your functioning.  Most people that have no great barriers to care (such as tumors, serious arthritic conditions, etc) will find that they improve with treatment week by week, and certainly not get worse over three months.    There are two basic perspectives on back pain: 1) histologic/pathology model.   This is where there is a tissue that is diseased or damaged and is the cause of the pain.  This would be the case if you had a disc protruded against your nerve and it correlated with your symptoms and objective signs/tests.  The other model: 2) functional/kinetic model.  This is where there is no evidence of tissue disease or damage, but there are signs of bodily dysfunction, e.g. things aren't working well.  Your providers must focus on #2 if there is no evidence to support #1.   Orthopedists are well trained to look for #1: disease/pathology, e.g. broken parts.  PT's are supposed to be good at dealing with #2: re-habilitate what doesn't work well (assuming you have a good PT).   DC's are supposed to be good at #1 and #2 unless they have not been keeping up with the clinical literature or coursework over the last 15 years.    I would suggest finding a chiropractor that has a variety of modalities at their disposal: joint manipulation, exercise training, soft tissue procedures, etc.  Seek out someone via www.grastontechnique.com  or Active Release Technique (.com).  If they want to take another x-ray, then don't even bother being there.   You should find improvement within a few weeks, not get worse over a few months.    

'Hope this was helpful.

Dr. G

---------- FOLLOW-UP ----------

QUESTION: Dr. G,

Thank you so much for your timely and honest feedback.  I am 46 years old and have responded well chiropractic in the past.  It is interesting you refer to pain management because the chiro who treated me for 3 months believed there needed to be significant movement to correct my issue as I stated before it has been a very painful time for me.  How can a diagnosis be done without review of x-rays?  Also, how can I tell if permanent damage has been done to my body?  Are there other tests that will tell that?  How does one know if there is disc degeneration or bone spurs or some other underlying complication?

Answer
Hi Cee Cee,

Okay, here goes:  if you took 100 people and x-rayed their spines, you'd find disc and joint degeneration, scoliosis and segment misalignment in a significant number of them.  It would not necessarily correlate with pain or ability.   I've seen pro athletes with degnerated discs and bone spurs (both notable on x-rays) and they have no pain.  I've seen people with discs bulging against nerves (as seen on MRI...you cannot see the disc or nerve on x-ray) and they say they feel fine.  I've seen people with perfectly normal x-rays (and MRI's) and they are in miserable pain.  You cannot CANNOT go by the x-ray in most cases to determine what part of your spine is causing your pain.  That is why current guidelines on the treatment of lower back pain advise against x-rays in most cases.   A big problem is when doctors depend solely on x-ray or MRI to judge what's wrong with you while abandoning their hands-on examination skills.   Much is learned by listening to the patient and carefully and thoroughly examining.  Forget the x-rays.  If you were elderly and your symptomatic complaints ALONG WITH your physical examination pointed to a potential problem such as an aneurysm or cancer, then surely x-rays are appropriate.  If you had this, it would have been suspected and detected long ago.   Odds are you are simply just not getting the right combination of examination and treatment.   About 30% of your body is composed of fascia (go ahead and GOogle this).   Fascial is the connective tissue that binds us together and adds to our structural support.   It is very pain sensitive (Google: myo-fascial pain or plantar fascitis, for example).   What is being done to address your fascia?   If you don't have a tumor or other major disease, and since there is no justification to "alinging your bones," and if you do not have any significant disc disease, then what else is it?   You need to ask your DC these questions.   Also, what kind of chiropractic care are you getting?   Just a quick pop and crack?   What about distractive manipulaion or tractioning?  What about soft tissue therapies like active myofascial release or Graston Technique?   You need to ask your provider these things.   If you cannot get a straight forward and logical answer, then you need to find a new provider.  

I hope this helps!  

Dr. G