Resolving back pain through spinal manipulation

When most people think of spinal adjustments, they will most likely associate this with having the vertebrae bones in the spine being “clicked” or “cracked” into alignment by a chiropractor, osteopath or physiotherapist.  There are also different “grades” of adjustment or manipulation ranging on a scale from 1 thru 5, with 5 being the most radical in terms of movement range adjustment and thus requiring the most amount of applied manual force directed at the joint.  Generally, a grade 3, 4 or 5 adjustment will be carried out by a licensed chiropractor, osteopath or physiotherapist and involve moves that are known in the trade as High Velocity Low Amplitude (HVLA) adjustment techniques – also sometimes called High Velocity Thrust techniques depending on the profession you speak to.

What most people don’t realize is that a completely spontaneous physical adjustment of the spine (or any other bone to bone joint for that matter) can occur and often does during a remedial or clinical massage session, or indeed in any situation where the soft tissue interconnecting with the joint in question is being manipulated in a precision and focused manner.  Indeed, you wouldn’t necessarily go to your massage therapist asking them specifically to manipulate or adjust your spine for you in the same way that a chiropractor or osteopath might do for example as it’s usually beyond their scope of training and practice.   However, equally beneficial indirect and spontaneous bone joint adjustments can and do occur during clinical massage and soft tissue work such as fascia release, and as well as being a lot gentler than high velocity thrust adjustments, these spontaneous adjustments themselves occur because a number of other bio-mechanical conditions (as well as mental states) have aligned themselves within that person that has allowed that change to take place – that person and their being was “ready” to allow that particular change.  Sometimes but rarely direct manipulation is required as a last resort, but even among prominent and highly experienced osteopaths and chiropractors, there are those who have ditched this part of their training and instead have exclusively taken to the softly softly approach with consistent success and hardly ever go back to performing direct physical manipulation of bones.

If you have not yet read our articles on the Psoas and Quadratus Lumborum muscles, please feel free to click the aforementioned links to convince yourself that these 2 very major muscles which attach to the spine can have a significant effect on lower back pain symptoms as well as being able to bear significant load on the spine itself and thus causing potential alignment deviation.  Precision massage therapy offered by therapists trained in clinical massage can of course help release and balance tension in these deep muscles of the lower back.

The intrinsic muscles of the spine which we have not devoted specific articles to are the erector spinae and transversospinales muscle groups, below is a diagram showing the complexity of these 2 muscle groups and their relationship with regards to their attachment points on the spinal column plus the other msucles which we have already discussed previously:

Trigger point pain pattern charts and diagrams are included below to complete this discussion on the soft tissue approach to spinal adjustment and alignment:

What’s the difference between an osteopath, chiropractor, physiotherapist and what you do?

Is question I get asked a lot and it is a reasonable question as we can appear to be quite similar in that we all work hands-on the body doing manual therapy techniques to help people with musculoskeletal complaints including chronic pain, repetitive strain, movement difficulties, an old injury, nerve entrapment, and postural alignment issues to name but a few. The answer lies in the basic philosophical approach that each discipline takes in dealing with a particular issue, which then ultimately determines the techniques which will be used.

The definitions looked at here will mainly apply to UK trained practitioners, but more international and generic supplemental information can be found in the links to various related Wikipedia entries at the end of this particular article. Additionally, one should bear in mind that many practitioners once they’ve gained their basic qualification often go on to do any number of post graduate courses and in fact it is not uncommon for osteopaths, chiropractors, physiotherapists, massage therapists, nurses, movement instructors (such pilates) and many other professionals licensed to do hands on manual therapies to be all attending the same courses – as I myself have done numerous times – this has not only enabled me to learn some profoundly effective hands-on therapy skills which build upon my existing knowledge but also gaining a deeper appreciation of what the other practitioners do in their respective modalities. Ultimately, the aim of course at the end of the day is to be able to serve our clients better and more effectively, no mater what therapy we’re practicing.

Physiotherapy

Traditionally, physiotherapy (also known as PT or Physical Therapy in other countries) uses a mixture of hands-on palpation and various client lifestyle assessment strategies to determine an appropriate course of treatment. The treatments strategies can include massage, but most usually will be an appropriate rehabilitation regime designed to strengthen the pertinent areas of the body involved in the patient’s presenting condition. This would probably be a fair basic definition of the type of service that a physiotherapist in private practice might be offering their clients. Unfortunately, I can already hear the voices of those people who have had very disappointingly different experiences of physiotherapy from practitioners operating from within the public National Health Service (NHS), and yes from numerous anecdotal stories I’ve heard assessment is done entirely hands off (due to time constraints of 20 minute appointments for assessment and treatment) and the solution is almost always focused exclusively on getting the client onto a routine of strengthening exercises. This exclusive focusing on strengthening (of muscles) can lead to imbalance problems where already over tight opposing muscles to the damaged area are not being identified as needing to be released first and so are getting even more tense when the imbalance is magnified as the weakened area becomes stronger through the rehab process. Also in the last 10-15 years, hands-on skills in massage work within a typical physiotherapist’s degree training program has been greatly reduced to the point now where even an massage therapist with just the most basic level (ITEC or equivalent) of qualification in the UK will have done more hours of practical training in massage than a more recently qualified physiotherapist. This is in a quite way ironic, as therapeutic and remedial massage for clinical benefit was actually what physiotherapy entirely about at one point in history, nowadays the massage element has been replaced by ultra sound devices and other technological devices. My advice would be to search out a good private physio who has additional training or expertise in the type of issue you are seeking help with, if you have only ever experienced physio on the NHS. I’ve personally learnt some great soft tissue manipulation techniques for the spine which was taught by a practitioner who is both a musculoskeletal physiotherapist, a remedial massage therapist as well as a yoga teacher, all elements feeding into the course she taught including yoga exercises which were indicated as useful rehab exercise for spine issues.

Chiropractic

Most people associate chiropractors as being people who adjust, manipulate and crack the bones of the spine in order to re-align it. Chiropractors adjust the spine not only to benefit the physical posture of a person, but also because they view the spine as being the organizing focal point of health because all the nerves supplying control and feedback pathways from the brain out to the major organs and peripheral limbs of the body emanate from the spine. Therefore, any entrapment of nerves due to pressure from misaligned vertebral bones of the spine could also affect the person’s health due to misfiring nerve signals (or be contributing to musculoskeletal issue). Chiropractors in the UK in common the UK trained osteopaths go through a 5 year training program which covers the exact same level of anatomy, physiology and pathology training that a GP (General Practitioner) would receive, except that there is considerably less training in pharmacology (training in the use of pharmaceutical drugs) and instead this is replaced with the techniques and philosophies pertaining to that particular modality’s way of treatment. Chiropractors (as with osteopaths) are also trained to give nutrition as well as other life style advice, although for some reason this is not an area I’ve heard people mention when they go for a chiropractic visit, it’s always about the adjustment! For those that have been to a chiropractor already or have yet to go, but either way are put off by all the forced crunching and clicking I would urge you to think again and look up the McTimoney Chiropractic approach. McTimoney chiropractors are so different in their approach to performing adjustments as to be almost polar opposite when compared to traditional chiropractors, McTimoney practitioners still make adjustments to the spine but do so in a much more subtle, gentle, less force but still effective manner. I’ve actually been an on-looker observing a McTimoney trained chiropractor at work, and it is indeed hard to believe some of the moves which passed for adjustment procedures were so subtle and gentle could be having the kind of effect they were supposed to be having, but the proof was indeed in the pudding for the person who was on the table at the time!

Osteopathy

In common with chiropractors, osteopaths are best known for the adjustments that they make between joints using what are known as high velocity thrust (HVT) techniques, what are usually referred to as the adjustment or cracking and clicking. A generalization to differentiate chiropractic from osteopathy, is that whilst chiropractors concentrate on the spine, osteopaths concentrate on all bony joints and junctions in order to align the physical structure of a person for optimal health. This alignment strategy, as with chiropractic looks at not only the bones but the nerves and fluids flowing between the bony junctions. Osteopathy itself when you look into the various schools can be quite wide ranging and eclectic once you get passed the core principles. There is a branch of osteopathy which deals with the subtle movement and manipulation of the individual bones of the skull known as cranial osteopathy. A further development of cranial osteopathy is cranial sacral therapy which take the underlying soft tissues and fascia (connective tissue) of the brain and spinal chord as well as the fluid (CSF – Cerebral Spinal Fluid) surrounding these structure to be a kind of respiratory system in its own right which can be worked on and so affecting health in the wider body. Yet another popular branch of osteopathy is visceral osteopathy (also sometimes known as visceral manipulation or visceral release therapy), where organs of the abdominal cavity can be gently coaxed and released into a more optimal suspensory state within its own (but not totally isolated) web of connective tissue, this in turn can have significant impact on musculoskeletal issues which can then be traced back via certain predictable physical interconnection routes. Visceral manipulation in common with craniosacral therapy both work with the fascia system of the body and are both modalities that I have trained in as they involve working with the fascia (connective tissue of the body), which is in turn soft tissue related work and so finally leads me nicely on to what I do…

Soft Tissue Therapy

Soft tissue therapy is not one thing but a eclectic collection of tools, but in common all these tools are hands-on techniques that are designed to work with, affect or manipulate the muscles, fascia and other soft tissues of the body. The soft tissue therapist’s approach is to work with the soft tissues of the body in whatever way is appropriate, this could be light massage to encourage circulation, precision deep tissue massage, soft tissue manipulation, fascia release work, trigger point work, facilitated stretching, etc. The approach then is to release tension in the soft tissues which in return could cause a release of a stuck junction between bone joints if appropriate. The approach that a chiropractor or osteopath often uses is to manipulate the bone or joint itself directly and have the soft tissue follow along (hopefully correctly) afterwards. Emotional or physical trauma as well as unremitting stress is often imprinted in the cellular memory of soft tissue structures experiencing dysfunction and unease, soft tissue therapy due to its non aggressive approach encourages not only a physical release or unwinding of ravelled tension to happen under the guidance of your body’s innate intelligence system (the same intelligence that causes a cut or wound to heal), but also can spontaneously cause the previously locked in emotions or trauma to safely release, this is also often a missing link in the recovery process that wouldn’t otherwise be addressed by other means. As there is more soft tissue in the body than bony tissue, it is often the case the probably as much as 85% or more of issues can be resolved more effectively using a soft tissue approach as a first port of call, and then further follow up with physiotherapy (for strengthening work), osteopathic or chiropractic work if necessary for bony manipulation work or more intractable issues.

Useful links and resources

http://en.wikipedia.org/wiki/Osteopathy
http://en.wikipedia.org/wiki/Chiropractic
http://en.wikipedia.org/wiki/Physiotherapy
http://en.wikipedia.org/wiki/Soft_tissue_therapy

Soft Tissue Therapy Practitioner in Exeter (Devon), UK –
http://www.isca-therapies.co.uk