Back Pain Series (Part 1)
Updated: May 19
Back pain is the most common reason for doctor’s visits in the U.S. It’s no wonder that it’s a topic on many patient’s minds and misinformation abounds. We are privileged to have back pain/movement specialist, Nathan Kadlecek, DPT, founder of Kadalyst Wellness and Physical Therapy, join us for the newest, back pain blog series!
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Intro and Overview
POP. Sweet relief.
I love getting my back cracked. It feels amazing and causes me to just want to lay there for a few moments and soak it in.
When I was applying to physical therapy programs, my idea of helping and healing people from musculoskeletal issues was that I would be able to diagnose and then treat people based on their specific dysfunction. This could have been a slight positional change in the spine where one segment was rotated more than another, or a pelvis that was rotated too far forward (anterior tilt) or even one of the innominate (hip) bones being rotated more than the other on the sacrum.
I thought I was going to be going to school to fix people and that I, and only I, with my hands could determine what the true dysfunction was.
I was wrong. I had an existential crisis.
**Disclaimer: I am not a manual therapy hater and I use it from time to time.**
We all have biases and beliefs that aren’t very strong if you dive in just past the surface. It’s uncomfortable to question deep seated beliefs.
Don’t confuse usefulness or effectiveness of a technique or treatment plan with the “why it works,” i.e. the mechanism. These are common errors in reasoning I see from patients and practitioners, alike... A few examples:
It rained and then the sun came out. The rain causes the sun to come out.
I got an adjustment/manipulation and now I feel better (true, many people feel better). Adjustments/manipulations put things back into place (is this true? Nope). I feel better, therefore, adjustments definitely put things back into place.
If the second supporting reason given is false, the conclusion cannot be true. Therefore although someone feels better, this doesn’t mean the REASONING for why it happened is correct.
Joints, unless dislocated by trauma, don’t go out of place, especially the spine or pelvis. They certainly can feel off or weird, but this does not correspond to an actual reliably testable positional shift. Ten different healthcare providers will see and feel ten different things when it comes to spine or pelvic position. #unreliable
Why is this important??
False beliefs can be incredibly negative, fear inducing, and self-limiting. I’ve worked with dozens of people who stopped doing incredibly meaningful activities due to the fear that was put into them by well intentioned people saying that “oh, you shouldn’t do that, it’s bad for your back, you’ll throw your back out and be damaged forever.” This is completely avoidable and it’s up to the healthcare providers AND general public to be honest with our own biases and beliefs and to be skeptical of absolutes. Here’s a quick and great read about the relationship between beliefs, self-efficacy, and chronic low back pain in references .
I CAN FIX YOU WITH MY HANDS!
Upon taking my first class in my physical therapy program at Columbia University, I was bright eyed, bushy tailed, and ready to learn exactly how to fix people. This started with in-depth anatomy classes with a lab section for cadaver dissection, physiology to further solidify our undergrad knowledge of each of the bodies internal processes, and various classes specific to neurological conditions, orthopedic conditions (muscle, bone, tendon, ligaments, etc.), pediatrics, geriatrics.
Each of these classes were interesting, however none piqued my curiosity more than the orthopedics courses. These were the courses that would talk about exercise, manual or manipulative therapy, soft tissue mobilization (i.e. massage), and various modalities. In these courses, particularly the spine course, I was fully engaged and soaking all of the information up like a wet sponge.
But, there was a problem. When it came time to start practicing and learning about spinal palpation (feeling spinal segments) and we were asked to perform special tests to determine the difference in rotation of various segments, or the height differences of one innominate bone (hip) from the other, I couldn’t do it. I sucked.
I’ve sucked at things before, I mean, really terrible. I was so bad at field goals my freshman year of high school that I didn’t even get the kicker position (I went on to get a scholarship in college as a punter/kicker). I barely passed neuro in PT school. And wrapping presents… yea it looks like a child did it (although there have been improvements ;) )
This spinal palpation and diagnosis thing though, I couldn’t get it. No matter how much I worked at it or practiced it, I couldn’t feel what the highly experienced professors could feel.
I remember one day I asked, “I really can’t feel the difference, and really, won’t everyone feel something differently, anyways? Isn’t this based on our own perception and confidence?” The response from the instructor was “you just need to practice more and eventually your hands will get more sensitive to the motions.” What’s funny is that I ran into this instructor a few years down the road and found that he doesn’t even believe that, go figure. The educational system is weird.
With the help of some highly skeptical friends, who were older and a bit wiser than I, they helped me build up a healthy set of skepticism towards the palpation of “segmental dysfunction,” and the idea that something was either “out of alignment,” or “mispositioned,” and that it needed to be “corrected,” and that this was somehow the cause of pain. In addition to my skeptical bros, our final ortho class was extremely insightful.
For the entirety of the past two years of PT school I had been under the impression that pain was largely caused by biomechanical faults that could be palpated and corrected by manual therapy. At the beginning of my third year, this paradigm was absolutely crushed and I was left wondering why the hell I even went to school and paid hundreds of thousands of dollars. I was left feeling disillusioned and angry that so much of what we had learned was based on old and outdated evidence. It was exhausting and defeating.
Thankfully, as time went on, and we continued to learn and push through the final third year, things started to look up. I found that instead of feeling disillusioned from my bias being challenged and destroyed, that I now had more freedom and that many of the patients suffering with chronic pain that I had worked with in the past (who didn’t respond to manual therapy at all) might have some hope after all, to suffer less, that it wasn’t about me ‘fixing’ them.
LAW OF THE ARTERY AND LAW OF THE NERVE
I love reading and studying about beliefs, behavior, bias, fallacies, and many other areas of behavioral economics. This has spurred me on to read numerous different books on the topic, one of my favorites being Thinking Fast and Slow by Daniel Kahneman. If you haven’t read this book, you need to, as you’ll realize you aren’t nearly as smart or bias free as you think.
Due to this love of learning about biases, beliefs, and becoming more skeptical, a curiosity arose. Just like I had wanted to fix people with my hands, many people before me also wanted to do the same; not only Physical Therapists, but Osteopaths and Chiropractors, too. I became curious about how each of these professions started and where in the world did the term “out of alignment,” crop up from. I’d learned and read about the origins before but never as in depth as now.
Before osteopaths, chiropractors, or physical therapists, there were “bone setters”. These bone setters were present in Indonesia, China, Japan, Russia, Hawaii, Nepal, Mexico, and other parts of the world. They performed various techniques of manual manipulation including “adjustments,” “high velocity low amplitude thrusts,” “osteopathic manipulations,” or whatever you’d like to call it. They also reduced actual dislocations of the hip, knee, and shoulders, although they had no formal medical training .
The first Osteopathic Medicine college: 1892, in Kirksville Missouri, Andrew Taylor Still the father of Osteopathic Medicine opened the American Osteopathic College.
Founding belief: Law of the Artery: “He based his theories of disease and dysfunction on the “disturbed artery” in which obstructed blood flow could lead to disease or deformity. This would become known in Osteopathy as the Law of the Artery.”
The first Chiropractic College: 1897, in Davenport, Iowa, Palmer opened The Palmer College of Cure, now known as the Palmer College of Chiropractic.
Founding belief: “...Palmer began to reason that when a vertebra was out of alignment, it caused pressure on nerves. He further reasoned that decreasing nerve impulses would surely affect visceral function leading to disease (the Law of the Nerve).”
The first physical therapy college: 1913, in Otago, New Zealand. The School of Physiotherapy at the University of Otago, NZ.
Founding belief: No particular “founding belief,” as this profession developed organically out of close relationships with orthopedic surgeons. PT’s were originally known as “reconstruction aides,” for injured soldiers during and after World War I (WWI). Mary McMillan was the first and most prominent reconstruction aide, as she was taught by the pre-eminent Sir Robert Jones, a physician in England who co-authored the treatise “Orthopedic Surgery.” Use of massage, corrective exercise, and other modalities were originally utilized.
Prior to the 20th century, much of medicine was still following the motto of “observe and use what helps, avoid what does harm,” which sounds good in theory, but doesn’t always work. This can be evidenced by a procedure to treat fevers back in 1796 and into the 1800's, “bleeding,” using a tool called a lancet (scalpel). It was assumed that if you get rid of the symptom, fever, you solve the problem. So… why not just make people bleed enough to where they become cold. Clearly this wasn’t a great approach and in my mind emphasizes why it’s important to also understand the mechanisms as to why things work so we don’t continue to do incredibly stupid and counterproductive things.
We shouldn’t judge professions based on their beliefs 100 years ago, and we also shouldn’t judge individual people just because they are part of a certain profession. I think this is counterproductive and does not take into account individual beliefs of practitioners and the evolution of professions over time. However we should absolutely hold people accountable when the narratives given to people about pain are incorrect as these can cause serious chronic issues down the road.
FALSE BELIEFS DO CAUSE HARM
“Why should I care about how it works or what they’re telling me, I just want to feel better.” Feeling better at the expense of possibly developing chronic pain down the road is not a healthy trade-off. Like I stated before, manual therapy and adjustments/manipulations/mobilizations all have a positive effect for many people, however the ‘why’ behind it working is also important.
Here is where I have some qualms. Over the past three years of practicing as a physical therapist, i’ve had multiple people, nearly every day, tell me either, “my back is out,” or “my hip popped out,” or “my PT said my hips were WAY off,” and I need to go get it adjusted to get it put back into place. I’ve had more people than I can count, get an adjustment to “put it back in place,” and then who are deathly afraid of exercise because it might “pop it out.” These conversations are frustrating for a few reasons. Disclaimer: *This applies to PTs, Chiros, and Osteopaths. I’m not singling one one profession, so don’t get all bent out of shape ;).*
Joints popping out... DOES. NOT. EXIST... unless you dislocate a joint in which you’ll likely need to get it reduced at the hospital. If people can’t agree on where a joint is out, then how can you know it’s a problem [3,4,5]?
Practitioners who continue to tell people their hips are “off,” or their spine is “out of alignment,” have not taken the time to analyze the evidence. They have not grown as an evidence informed clinician over their time in practice, and they are doing their patients/clients a huge disservice. Yes, these practitioners will likely help many people who were likely to find symptom resolution anyway, BUT, there is also a second order consequence that many of these people now believe that their body is fragile.
Informed opinion incoming. Based on various clients I've had who believe these statements due to healthcare providers misinformation, I posit that we have a MUCH greater % of the population that is now suffering from chronic pain. Yep, I said it. I believe, and again, this is my opinion, that if we are providing this misinformation to the public that makes them feel feeble, weak, fragile, and out of control, requiring an external force to save them, that we are in fact feeding the chronic pain epidemic .
There are approximately 50 million people with chronic pain in this country and millions more living with what’s defined as “high-impact chronic pain,” which is defined as chronic disabling pain that prevents one from working and highly impacts their social life and well-being.
Clearly, we have a problem. The amount of individuals suffering with chronic pain continues to increase, and seemingly, the amount of people who still believe outdated information from the 1800’s is HUGE. I will state it again, just because something has been around for 100’s or thousands of years, and has some positive effects, does not explain WHY.
This “why” is important because it’s now understood that this is a huge contributing component of who will suffer from a chronic musculoskeletal pain condition, and who will not.
SO… IF MY BACK AND HIPS DON’T GO OUT, WHAT’S GOING ON?
There is no doubt that oftentimes our back or hip feels a bit or very ‘off.’ If you really dig deep into your first experience of this feeling and who was the first few people to give you advice on it, it’s likely you’ll remember somebody who said “oh, you need to be careful,” or “you should go get adjusted,” or “wow, your hips are WAY out,” or “your L5 vertebra is way out of place by 2mm.”
Oftentimes we feel and experience pain, and immediately we tap into our memory to see if this is something similar. If it’s not something familiar that we’ve experienced before we’ll go search it up and see if we can figure it out. This is typically when someone will get told that “oh, it’s because your back is out of place,” lemme just pop it back in…
Back pain itself, especially the kind where we feel something is off, that nasty muscle spasm and grabbing feeling, or sciatica, are multifactorial. The irritated structure could be a nerve, muscle, tendon, ligament, disc, or something else, but, there may be a better way to think about this. Rather than trying to find an exact diagnosis (when there typically is not one), what if you thought about pain as what it’s NOT vs. what it is.
If you can rule out that the pain is not due to a fracture, kidney stone, infection, cancer, gall stone, and some other rare conditions, then chances are, with a program to stay moving, and working on your self-efficacy and healthy body beliefs, that things are going to be okay.
Perception is reality, however reality can be warped. If your perception is that your back hurts, therefore your back is out, then your reality that you’ve created is (likely) that every time your back hurts, it’s because your back is out. When really, this is not happening, for reasons cited above. Our perception of situations and events is usually horribly flawed. We are incredibly irrational actors, and the sooner we can accept that and become a little more skeptical and use a few more sources, the sooner we will be able to make a dent in this massive problem that is chronic and persistent pain.
Check out Part 2 to see when imaging is needed and tips on working that pain away!
What do YOU think? As always, please leave your wonderful comments below or respond directly to me via email with your love mail or hate mail :). Email me
AND for a much more in depth review of this topic please visit https://www.painscience.com/articles/structuralism.php -- it's really an epic document! VERY detailed and rational.
Some extra reading:
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Nathan is a powerlifter and physical therapist who’s helped hundreds of people recover from injury and get strong, including iron man competitors, ultra-marathoners, weekend warriors, and high level baseball players. He completed his B.Sc degree of Exercise Science in Arkansas at Harding University and Doctor of Physical Therapy education at Columbia University in New York City.
Nathan thrives on solving large, complex problems and is on a mission to fix America’s broken healthcare system by educating people about pain, self-efficacy, and self-determination.
He’s a movement optimist
A health resiliency evangelist
Baird A, Sheffield D. The Relationship between Pain Beliefs and Physical and Mental Health Outcome Measures in Chronic Low Back Pain: Direct and Indirect Effects. Healthcare (Basel). 2016;4(3) https://www.ncbi.nlm.nih.gov/pubmed/27548244
Pettman, E. (2007). A history of manipulative therapy. Retrieved May 12, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565620/
Seffinger MA, Najm WI, Mishra SI, et al. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine. 2004;29(19):E413-25. https://www.ncbi.nlm.nih.gov/pubmed/15454722
French SD, Green S, Forbes A. Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low-back pain. J Manipulative Physiol Ther. 2000;23(4):231-8.
Walker BF, Koppenhaver SL, Stomski NJ, Hebert JJ. Interrater Reliability of Motion Palpation in the Thoracic Spine. Evid Based Complement Alternat Med. 2015;2015:815407.
Baird A, Sheffield D. The Relationship between Pain Beliefs and Physical and Mental Health Outcome Measures in Chronic Low Back Pain: Direct and Indirect Effects. Healthcare (Basel). 2016;4(3)