Chiropractic Care

I believe that chiropractors bring something to the table that Big Medicine doesn’t. In my ER, when a patient is diagnosed with back pain, the medical record prompts me at discharge to order consults to physical therapy (PT) and chiropractic. Both are valid options.

I’ve had episodes of severe torso pain—sometimes in my ribs after a collision during ultimate frisbee, sometimes a tightness between my shoulder blades or in my lower back. Sometimes this happens with no apparent injury or trauma. I distinctly remember some severe episodes of low back pain during medical school that would happen when bending over a drinking fountain. My back would become very tense with severe pain for no apparent reason. It was very painful, but these episodes never lasted for more than a few days.

I’ve seen a chiropractor, and it helps. They are able to adjust things and recommend taping in some instances. My pain doesn’t magically go away, but it starts to get better after treatment, and with time, it continues to improve. Life goes on. I don’t expect it to be a chronic problem, and I stay very active.

This is also a frequent reason why patients come to the ER. I have many discussions about musculoskeletal pain related to the back. Low back pain is common, and sharp pain between the shoulder blades is common. Patients are often quite distressed, and many believe that “something must be wrong!” They are often afraid that something deeper or more dangerous is going on. The fact that the torso can cause such severe pain seems like an unacceptable idea to them. They assume it’s something life-threatening or at least something that needs immediate action—a medication, a procedure, a surgery, or to see a spine specialist at 3 a.m.

None of these things are accurate. It’s true that it hurts, but it’s virtually never an actual emergency that has an immediate solution.

Patients refer to their back as being “out of place.” What this actually means is somewhat confusing. We know that the spine can flex and extend both front to back and side to side. That’s obvious. And we know that at each vertebra, there are many points of contact with the vertebra above and below it, as well as the disc that sits between each vertebra. There are ligaments and tendons, fascial layers (connective tissue around muscles), and tiny muscles that connect each vertebra to the ones above and below. Ligaments connect bones to bones; tendons connect muscles to bones. There are nerves that exit the spine at each level and then branch out to the body.

Pain in the legs can often be attributed to a problem related to the nerves being irritated closer to where they exit the spine. When all those points of articulation get irritated—for any number of reasons, often not related to any severe trauma—the pain will extend down the legs. When muscles tighten up, we believe they irritate the nerves. Patients sometimes think the pain is related to something where it actually hurts, which is rarely the case.

Ribs articulate (move) as well. Every time you breathe, there is some motion of the rib cage, which means that at each end of the rib, that joint is moving a little bit. Those joints are not completely static, but the movements are very small. Ribs connect to the spine posteriorly and to the sternum anteriorly. The lower ribs connect by cartilage anteriorly and not directly to the sternum. The bottom two ribs only connect posteriorly.

Besides major trauma, ribs don’t actually get dislocated or “out of place,” at least not as far as Western medicine is concerned. The correct term would be subluxation, which is abnormal movement of a joint but not an actual dislocation. (This gets a little confusing because different joints throughout the body don’t all dislocate or subluxate in the same way.)

I’ve always found it interesting that chiropractors can detect small shifts or nuances with the spine and ribs. They seem to be able to identify when things are slightly out of place. The disconnect is that I get X-rays, CTs, and MRIs of patients every shift. I look at the images myself, and a radiologist will give a report. X-rays show much less detail than CTs and MRIs, but I’ve never seen a report in 20 years that indicates a vertebra or rib is subluxated or just slightly out of place. We just can’t see that level of detail. I’ve seen plenty of spine fractures and a rare dislocated rib, but that is typically only after major trauma. (Minor trauma is enough to cause fractures in patients with risk factors like osteoporosis.)

So I’m left with understanding the idea that it happens, but it’s not something I can find on imaging. It’s frustrating for patients because I don’t have a precise answer for them. We know those things hurt, but I can’t prove what it is that’s hurting, and the best I can offer are pain meds and conservative treatment like PT, chiropractic, heat, cold, massage—anything that makes it feel better until it stops hurting.