In the evolving world of healthcare, it's important to remain informed regarding best-practice methods for injury management. One controversial belief around injury and pain management revolves around the concept of joints being aligned or “out of alignment", usually referring to the precise positioning of individual vertebrae, bones within the pelvis, or joint surfaces on a micro-level. Historically, this concept stemmed from old, unfounded theories that spinal misalignment is the root cause of various ailments and diseases. However, as modern science and research have progressed, it has become increasingly clear that this idea is not only unfounded but potentially harmful.
The Fallacy of Joint Subluxation and Misalignment
The belief that our joints can slip out of place, causing a myriad of health issues, was founded on the early chiropractic theories introduced by D.D. Palmer in the late 19th century. Palmer's concept of "subluxations" proposed that misalignments in the spine causes interference between the brain and body which has an impact on the nervous system and/or organ system function which could be the cause of disease. However, this theory lacked scientific evidence and rigorous validation. Over the years, advancements in medical research and technology have extensively debunked the idea of subluxations as the root cause of illnesses.
It is also increasingly recognised that misaligned joints as the cause of all musculoskeletal pain, a theory likely stemming from early subluxation theories, is a concept which should also be re-evaluated. These diagnoses typically necessitate corrective therapist manipulation in an effort to relieve pain. While certain manual therapies can offer relief, it is now clearly understood that their effectiveness often lies in different, complex neurophysiological mechanisms rather than traditional notion of physically realigning joints. Our current understanding reflects the evolving landscape of healthcare, emphasising evidence-based practices and comprehensive approaches to injury management.
Why does the theory and practice of passively ‘correcting’ subluxations and 'aligning' joints persist?
The persistence of the theory and practice of 'correcting' subluxations and joint alignment through therapist manipulation can be attributed to several factors, including:
Long-standing beliefs: These ideas have deep historical roots and have been ingrained in certain schools of thought within healthcare. Tradition and long-standing beliefs can be powerful influences, even in the face of contrary evidence.
Simple explanations for complex problems: The human body is incredibly complex, and illness, pain and discomfort often have multifaceted origins. It's natural for people to seek simple explanations and solutions for their ailments, leading them to embrace treatments based on longstanding beliefs, even when scientific evidence challenges these notions.
Placebo effect: The placebo effect can be defined as when a person experiences real improvements due to their belief in a treatment's effectiveness rather than the actual efficacy of the treatment. This effect can be very powerful, potentially contributing significantly to symptom relief from any applied treatment method. This can perpetuate the belief in the efficacy of subluxation or alignment correction.
Financial interests: Some individuals and institutions have financial interests tied to these treatments, which can create a vested interest in maintaining the status quo. This financial incentive can influence the promotion and continuation of practices, even in the absence of robust scientific support.
Symptom relief: So-called ‘realignment’ techniques, often joint manipulation or ‘adjustments’ where a ‘pop’ is heard have been proven to provide relief of symptoms in certain musculoskeletal conditions. This relief however is not due to joints being re-aligned. Rather, this symptom relief is related to complex neurological and physiological processes. When joint manipulation or 'adjustments' are performed, especially when accompanied by the audible 'pop' (thought to be the release of ‘gas’ within the joint), it triggers a response within the nervous system. Firstly, it can lead to the release of endorphins, the body's natural painkillers, providing temporary pain relief. Secondly, the sudden movement can stimulate sensory receptors in the joints and muscles, altering pain perceptions. Both of these effects not only lead to temporary symptom relief, but can also temporarily improve joint mobility and reduce muscle tension, contributing to an overall sense of relief.
Understanding these factors, in particular the mechanisms for symptom relief is crucial. It highlights that the effectiveness of joint manipulation lies in its ability to modulate the body's response to pain rather than physically realigning joints. Acknowledging these complexities allows healthcare professionals to utilise these techniques judiciously, integrating them into evidence-based practices.
The Problem with Subluxation and Alignment Theories
Theories which propose joints are out of alignment, need to be professionally assessed and manually adjusted or manipulated present a number of issues, including:
Creating and leveraging fear: Emphasising the idea of joints being constantly misaligned can create unnecessary fear and anxiety in individuals. This fear can lead to a heightened sense of vulnerability, making people susceptible to potentially unnecessary treatments, procedures, and expenses.
Creating therapist dependance: Relying on the concept of perpetual misalignment fosters a sense of dependency on therapists or practitioners. Individuals might feel the need for frequent adjustments, assuming that their joints are always shifting out of place. This dependence can hinder self-reliance and the body's natural ability to adapt and heal.
Suboptimal outcomes: Overemphasis on constant realignment can lead to suboptimal outcomes. Instead of addressing the root causes of pain or discomfort, focusing solely on joint alignment at a micro level might overlook other essential factors, such as muscular imbalances or weakness, ergonomic factors, repetitive and sustained postures, flawed movement patterns or overall lifestyle choices and general health. Consequently, this tunnel vision approach can delay proper diagnosis and appropriate, evidence-based interventions, potentially prolonging recovery and exacerbating issues.
Does joint alignment have any place in the management of musculoskeletal injury?
Theories which attribute spinal subluxation as the cause of disease, beyond musculoskeletal ailments, have no basis for support and therefore these ideas should not be preached to potentially vulnerable individuals. Consideration of joint alignment in a more global, postural sense can however have a role in the management of certain musculoskeletal injuries (although even this is now being debated). Take the example of lifting a very heavy load, in the context of a sporting environment, we can use a heavy deadlift as an example. Utilising a lifting technique which emphasises rigid maintenance of a neutral spinal curve throughout the lift is thought to reduce potentially injurious forces on the spine which reduces injury risk. This may also be pertinent to lower-load, repetitive activities such as sitting at a desk. Moving away from neutral spinal curves for prolonged periods, beyond what the body has been able to adapt to may over time lead to pain and injury.
Similarly, we can consider lower body alignment using foot posture as an example. Overpronation (when your foot excessively rolls in) might lead to knee valgus (when your knee tracks excessively inwards). In many joint kinematic and kinetic studies, this is thought to increase the strain on certain structures within your knee, potentially increasing your risk of developing an injury. However, it's essential to balance this understanding. Although studies show increasing joint forces with certain postural alignments, many people with these postural impairments will never go on to experience pain or injury as a result. This highlights that while these factors should be considered, it's equally important to recognise the body's adaptability. Muscles, tendons, and ligaments can strengthen and adjust over time, mitigating potential issues. Therefore, joint alignment, viewed through a lens of biomechanics, remains a valuable consideration in injury management, but always in conjunction with an awareness of the body's remarkable capacity to adapt.
Less appreciated factors contributing to pain and injury
The influence of our general physical health and fitness as well as our psychosocial health has an under-appreciated impact on musculoskeletal well-being. Two of the most important contributing factors include:
Physical Health and Fitness: Our body's overall physical health and fitness play a significant role in the well-being of our musculoskeletal system. Regular exercise not only strengthens muscles and joints but also promotes proper circulation, ensuring essential nutrients reach the bones and tissues. Moreover, maintaining a healthy weight is crucial. Increased abdominal fat, in particular, is linked to chronic inflammation. This inflammation not only affects the cardiovascular system but also negatively impacts joint health. Studies have shown that adipose tissue secretes pro-inflammatory substances, leading to joint discomfort and potentially contributing to conditions like osteoarthritis. By focusing on physical fitness and weight management, individuals can significantly reduce the risk of inflammation-related musculoskeletal issues.
Psychosocial Health: Psychosocial factors, including stress and mental well-being, are intricately connected to musculoskeletal health. Stress, whether it's due to work pressures, emotional challenges, or lifestyle factors, can exacerbate pain responses in the body. When stressed, our body releases stress hormones which heighten our response to pain. Moreover, these stress hormones can, over time, negatively impact the body's immune system, making it harder for the body to recover from injuries. Chronic stress has been linked to various musculoskeletal conditions and even exacerbation of conditions like rheumatoid arthritis. Addressing stress through relaxation techniques, mindfulness practices, or professional counselling not only promotes mental well-being but also alleviates physical strain, allowing the body to heal more effectively.
Incorporating stress management practices and regular physical activity into daily routines can significantly enhance musculoskeletal health. By appreciating the interconnection between physical fitness, psychosocial well-being, and the musculoskeletal system, individuals can take proactive steps towards preventing injuries, managing pain, and fostering a healthier, more balanced lifestyle. This comprehensive approach to well-being not only promotes a pain-free life but also contributes to overall vitality and longevity.
The Holistic Approach to Injury Management and Remaining Injury Free
The concepts discussed above underscore the significance of embracing a holistic approach to injury rehabilitation and prevention. This involves shifting our focus away from minute details of vertebral and pelvic alignment and considering the broader physical and psychosocial factors influencing the pain experience. It requires an understanding of general posture, joint alignment, and both physical and psychosocial health, all while recognising the body's remarkable capacity to adapt, heal, and flourish in diverse situations. This comprehensive perspective not only enhances our understanding of musculoskeletal health but also empowers individuals to make informed choices, promoting overall well-being and resilience.