Expert: Scott F. Gillman, DC, DACBSP - 1/30/2010

Question
QUESTION: I am 29 years old and for as long as I can remember have had problems with lower back pain. When I was a child, in dance class, it would bother me. As a teenager, while playing basketball, certain drills would cause excruciating pain. The most recent flare up of back pain came about when I started working out with a trainer. After a group class that concentrated heavily on lower back exercises I have had constant back pain (going on over 3 mos).
As a result of this back pain I started physical therapy and just finished my sixth week (totaling 18 sessions). The physical therapist diagnosed me with a torqued pelvis which seems to have some validity to it since I feel immediate relief after he has corrected it. In addition to these manipulations/corrections, I have been doing daily stretches and exercises to stretch and strengthen my back muscles. However, it tends to torque again with any moderate or intense exercise (ex. Zumba, kickboxing, volleyball, or even the elliptical at times).  
I’m wondering if a tilted/torqued pelvis tends to be a chronic issue that needs periodic manipulations or if this is a condition someone can totally recover from and have no recurrences. With this kind of a background is there hope that this is a condition that I can totally recover from or will I most likely be dealing with this periodically?

ANSWER: Sue,

You can try chiropractic pelvic manipulations as it likely will be different than what the PT does.  And, chiropractors have way more training and experience doing joint manipulation.  Also, you need to be checked for spinal instability via the Prone Instability Test (http://www.physio-pedia.com/index.php5?title=Prone_Instability_Test).    If unstable, then you have to to core stability exercises.   Stop all ab' crunches!!!   There is a good chance that your torqued pelvis has nothing to do with you pelvis, and instead is a lumbar spine instability or disc problem (or both).   If your disc gets irritated, it will cause muscle spasm that will torque your pelvis.  Again, this needs to be assessed.   Also, if you can find a sports chiropractor with good soft tissue skills (see:  www.acbsp.com) then other variables can be assessed, e.g. adhesions in your psoas muscle, SI joint ligament issues, etc.   Remember, PT's are not doctors and sometimes do not have the training to diagnose.  Conversely, in all fairness, many DC's forget their schooling and lose the ability to be a good diagnostician.   The ACBSP.com site is a good place to start to find quality providers, as is www.westhartfordgroup.com   

'Hope this helps.

Dr. G

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

QUESTION: Thanks for the quick reply...I forgot to mention that I had x-rays done that showed nothing significant and then an MRI that showed a "Tiny herniated disc" that both the physical therapist and Neurosurgeon found to be inconsequential. Their response was that an MRI rarely comes back with a 100% clean bill of health. The MRI also showed that I have degenerative disc disease (which I'm still uncertain what significance it has to my back pain) and a dehydrated disc (not sure if this is the "degenerative disc disease"). I had tried a chiropractor before I started physical therapy and immediately following the adjustment my pain skyrocketed and I had to take Vicodin just to endure the pain for the following 3 days. After two sessions with the same results I stopped going. This chiropractor had taken x-rays and his diagnosis echoed that of the physical therapist...torqued pelvis, with one hip higher than the other.
I checked both recommended websites and unfortunately there are no chiropractors listed in my area. Any other recommendations?

Answer
Sue,

I am very familiar with the clinical literature on this topic.   First, there is correlation between disc degeneration and pain as noted in some, but not all studies.   If there is disc degeneration and signs of "end plate sclerosis" or "marrow edema" changes seen at the vetebral bones that approximate the disc, then clearly this correlates with pain.   These changes are called "Modic Signs."   Some radiologists will comment on Modic Signs and some will not.  Otherwise, most folks have a little bulging or protruding of discs with no pain or problems.  In one study of elite horseback riders with back pain compared to non-riding controls, both groups had the same amount of disc and degenerative changes, but higher body weight was a factor.  Yet one other recent study of identical twins showed that the overweight twin had healthier looking discs!  Empirically, from what I've seen in 19 years of practice, the significantly degenerated disc is a likely cause of back issues.   As for the x-rays: everyone has some deviation of normal - and - there is absolutely no correlation between what the DC or PT or MD believes they see as misaligned and pain.  I can show you torqued and twisted spines in people that have no pain.   I can show you beautifully aligned spines and pelvis x-rays in people that are in miserable pain.   Current, evidence-based guidelines recommend not taking x-rays for this very reason.  [Aside: PT's have no radiolgy training and should not comment on your x-rays!]   As for MRI, there also are many cases where the MRI looks great but the patient is in a lot of pain, and visa versa.    Also, the MRI exam is obtained with you laying flat on your back.   This static view has come into question for diagnosing disc-related instability problems that only show up when the spine is upright and bearing weight.   There are two upright MRI scanners in CT in New Haven. There are others in various other places, but the bottom line is that if you signs of instability, as determined by physical exam (and by the details of what provokes your pain episodes), then you must try a core stability program.   This would involve exercises like: "Bird Dog," prone plank, side plank, supine bridge (on back with feet on floor, then progressing to feet on ball).   You can google these exercises, or google "core stability exercises for back pain."    Ask your DC (or find a new one) if they have a Flexion-Distraction or "Cox" distraction table.   Ask if they are familiar with and/or have the textbooks by Stuart McGill or Craig Liebenson on back pain and rehab.  Ask if they are familiar with a prone instability test, and if not then present the web site or article to them.   If your DC is unfamiliar with these items, then you need a new DC.  

Good luck with this.   Let me know if I can be of further help.  

Dr. G