The Subluxation Syndrome:
A Condition Whose Time Has Come?This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Chiropractic Humanities 2004; 11: 38–43 ~ FULL TEXT
Christopher Good, MA(Ed), DC
Professor,
New York Chiropractic College
Controversy surrounds the use of the term ‘subluxation’ within the chiropractic profession. This paper suggests that doctors of chiropractic should develop an evidence base that focuses on the clinical entities that are treated in clinical practice. Such effort might include documenting common locally symptomatic subluxations in each joint region and subluxations that cause more distant neurophysiological effects.
From the Full-Text Article:
INTRODUCTION
The chiropractic profession has provided patient care for the detection and removal of vertebral subluxations since DD Palmer’s landmark adjustment over 100 years ago. However, despite the growth of the profession worldwide, it is noted that published research has yet to unequivocally establish the “chiropractic subluxation” as a valid or significant clinical entity. [1] Indeed, there are no large randomized controlled trials (RCTs) that have focused on subluxation and its reduction. Instead, the relevant RCTs typically have utilized manipulation for patients with uncomplicated back or neck symptoms, sometimes described as “mechanical low back pain” or “mechanical neck pain.” Unfortunately, in doing these studies, investigators have not focused on the specific lesion causing the back or neck pain. That is, they did not investigate whether the pain was caused primarily by a myofascial, zygapophysial joint or non-radicular disc lesion. Subsequently, not only have the results been less than impressive when assessing the effectiveness of manipulation in various patient groups, but no data on subluxation, its reduction, and associated changes in the patient’s condition are reported. In the same vein, it is noted there are no peer-reviewed case reports concerning the treatment of a typical “chiropractic subluxation” by adjustment even for the lumbar spine. [2]
Maybe more amazing, is that some chiropractors question the existence of the subluxation, ignoring the basic science publications on the topic found in the data bases Index Medicus and Manual Alternative and Natural Therapy Index System (MANTIS) — and actually compare subluxation to the mythical creature the unicorn. [3] The argument raised here is that even though an entity is defined, does not mean that it exists. Of course the unicorn analogy fails from the start since the horned equid is designated to be “mythical” as per its definition, whereas subluxations (chiropractic or otherwise) are clearly defined as being “real,” the lack of clinical peer reviewed publications not withstanding. However, the argument still raises an important question: what amount of “evidence” is required so that health care providers, as well as the public at large, will come to acknowledge subluxation as a common occurrence among the list of human conditions? Why is it that, despite manipulative therapists having treated countless satisfied patients for “that joint something” over thousands of years, subluxations continue to be vitiated to such a degree, except of course when the most severe form of subluxation is treated by an allopathic physician?
Part of the answer lies in the tenuous neurological hypotheses our profession has associated with subluxation over the years, and our therapeutic claims based on these hypotheses. Proudly we have made great strides in this area, despite the reticence of some to abandon those concepts that are clearly invalidated by the available evidence. However, as to the issue of the existence of subluxation, I would suggest that this is best addressed by appreciating the reality that sometimes joints get stuck and often this is quite annoying. This reality seems clear to those of us who have observed the dramatic symptomatic improvement of patients the moment that a manipulative adjustment occurs (cavitations preferred but not necessarily required). This experience is shared by 90% of US chiropractors who have indicated that they use adjustments for the typical acute mechanical lumbar case, and that the observed benefit was rated as 8, 9, or 10 (with 10 equaling “great benefit”). [4]
It is clear that there is acknowledgement of the reality of the chiropractic subluxation outside the profession, as evidenced by the books written by allopaths and physical therapists concerning finding and manipulating the lesion, as well as the educational opportunities offered by these professions to learn such skills. It would be hard to believe that the learned men and women involved in creating the ICD-9-CM codes would create a category for the “nonallopathic subluxation” if it was doubtful that it existed. Nevertheless, who among us is satisfied with this level of acceptance and understanding of subluxations? Certainly not the 88% of chiropractors who wanted to retain the term “vertebral subluxation complex” and the 90% of us who felt that the adjustment should not be limited only to musculoskeletal conditions (because as a profession we believe that subluxation is a significant contributing factor in 62% of all visceral ailments). [4]
If we are going to get the message successfully communicated and accepted, and thereby increase our cultural authority and utilization rates, part of our professional work must involve developing an evidence base that focuses on the clinical entities that we treat in our offices every day of our practice lives. This means that the extremely common locally symptomatic subluxations in each joint region need to be better defined and characterized, as do the subluxations that cause more distant neurophysiological effects. However, I would suggest that these two categories need to be dealt with as separate entities on their own terms. The beginning steps in this process have already occurred and are there to be built upon. In the meantime, given that less than 25% of the population visits a chiropractor in any given year, [5] maybe the profession should start with pointing out the obvious to the doubters and snoozers among us. Why not make the ubiquitous presence of painful subluxations in the world glaringly clear, and then perhaps shout about it a bit?
The Subluxation’s New Clothes
I submit that at a very fundamental level the reality of painful subluxations is demonstrated by the experiences of virtually all humans at some time in their lives, and by most people many times a year.
The experience I refer to is the universally common “Ooh, Aah” Phenomenon (OAP).The OAP occurs when a joint becomes painful (“Ooh”), and then becomes immediately “unpainful”
when the afflicted person shakes or twists or pulls on the region and the joint “pops” (“Aah”).
In this sense, the OAP is really just like the wind; you cannot see it, but once you feel it,
you understand that it exists and will recognize it for all time.Unfortunately, we have failed to explain to the world that the OAP is simply the self-reduction of a painful subluxation. If we only talked about the OAP publicly these subluxations would become self-evident, not unlike some of the other common maladies that afflict humans (eg, no one ever bothers anymore to suggest that trigger points do not exist). Surely, there would be a critical mass to acknowledge subluxation when enough people admitted that the OAP had happened to them. Then when faced with the question, “Well, what would you do if it didn’t “pop” on its own?” the logical answer, “Have a chiropractor pop it for you” would open our doors to the world.
In short, the OAP is the overwhelming observation concerning the existence of subluxation that the masses, including all health care professionals, need to be reminded about, and at the same time makes the unicorn discussion mute. Until we speak up, we will continue to scratch our heads and ask, “Are we really living the ultimate Emperor’s New Clothes nightmare? Can’t the rest of the world see the subluxations?” Well, apparently, they cannot see them, and as a matter of honesty and public health, it is up to us to point out the naked truth. Of course, there may be a price to pay for our veracity. We certainly would not want to be pigeonholed into just treating painful subluxations. Treating nonpainful subluxations is potentially just as important, especially when these have a significant deleterious effect on the nervous system or overall biomechanical function and joint health. In addition, over time we have become too good at treating other clinical conditions too (eg, assorted myofascial syndromes, discoradiculopathies, peripheral nerve entrapments, and a huge variety of sprains and strains, etc.) and this certainly has benefited society. However, adding these conditions to our clinical repertoire should not be done in an attempt to distance ourselves from the things we truly excel at treating: the various painful subluxations found in the human skeletal system.
Here, therefore, is one of our real dilemmas. Should the profession ignore the reality of painful subluxations, or should it take a bold new initiative to remind the world about that which obviously exists? I would suggest that we do the latter, based on a better categorization system and explanation of subluxations, and do it soon. For if we do not, or worse yet, if we choose to abandon subluxation due to political expediency, subluxations will continue to be treated, due to public necessity, by some other type of practitioner in our stead. If this occurs, everyone loses.
The Future and Subluxation Syndromes
As the profession faces the political and economic challenges of the new millennium, it is clear that defining and promoting a potent vision of chiropractic is not only important, but is vitally necessary. In the United Stated, other healthcare professionals, namely the physical therapists and osteopaths, have a growing interest in manipulative therapy for subluxations (including those paid for under Medicare) and consistently encroach upon this area of the musculoskeletal domain once held by chiropractors. It is also important that the idea of identifying the lesion causing the mechanical spinal pain is not lost on these professions. [6] Similarly in other parts to the world, primary care physicians have opened their minds to the idea that there are subgroup populations with differing types of lesions among patients with non-specific low back pain. [7]
In the future, healthcare policy decisions involving insurance coverage and especially governmental policies focusing on the uninsured and underinsured masses will continue to be made. Decisions such as these will be made about this profession, either with or without its help, simply because they must be made. So, will the chiropractic profession play its role? Will we be recognized as the experts in the area of joint analysis and manipulation? Will that role involve the subluxation as one of our defining features as currently exists in Medicare policy and some state licensing laws? On the other hand, will subluxation be an obstacle that will continue to divide the chiropractic profession and subsequently confuse our patients, the policy makers, and the other health care players?
Clearly, the internal squabble concerning the chiropractic subluxation is one of the most destructive problems affecting the future of our profession. Consider, for example, that some members of the profession continue to denigrate those who treat painful spinal conditions, that these “medipractors” have somehow debased the profession and are leading it astray. It is as though treating painful subluxations is un-chiropractic and only treating painless subluxations in order to remove “nerve interference” should be allowed. By the way, don’t pain impulses count as a source of nervous system interference?
In addition, there are those who refuse to consider that patients have a right to choose to have their non-painful subluxations treated as well. What fails to be appreciated by both camps is that patients deserve to receive the highest quality care available for their painful subluxations, just as they do for their nonpainful subluxations that may be causing some other effect on the body. These are issues we clearly need to address, because it would seem obvious that when any type of subluxation is ignored or dismissed, our patients, our society, and ultimately our profession, suffer as a result. I submit that the truth (reality) will set us free. If we simply take the time to create a more universally acceptable evidence-based classification system, we will all move forward, society included, to a better place. That better place may begin with the concept of subluxation syndromes.
Drs. Gatterman and Hansen have given us the basis for this classification system when they took on the Herculean task of trying to get some consensus among chiropractors and our curious lexicon. They asked a broad collection of doctors of chiropractic their opinions of the various words and definitions used within our profession, and then published the results. Amazingly there was strong consensus within the profession (81% agreement or better for each term), and among the list were the words subluxation (with an understandably broad definition), subluxation complex (the theoretical model from which to teach and investigate), and subluxation syndrome (the clinical entity that is treated). [8]
Dr. Gatterman continued with this work in her text Foundations of Chiropractic: Subluxation, and entire chapters were devoted to the different types of subluxation syndromes chiropractors have come to manage over the years. [9] This makes fascinating reading, not only because it focuses on the unique types of subluxations in each spinal region, but more so because it categorizes them into what they really are clinically: an aggregate of signs and symptoms that relate to dysfunction of spinal, pelvic or peripheral joints. The beauty of this approach is the recognition that each joint region potentially contains one or more subluxation syndromes that have a welldefined list of signs and symptoms and are easy to differentially diagnose from other conditions. For example, if a patient says, “Sharp pain in the mid back just next to the spine…hurts to take a deep breath…feels like someone stuck a knife in there,” and then the patient says “Ooh” when the costotransverse joint is palpated over, the doctor, having excluded the other relevant possibilities, says, “Rib subluxation syndrome.” This is both easy and very powerful. Best of all, if well publicized, this subluxation syndrome will not be treated as angina ever again (assuming the editors of the Merck’s Manual are paying attention).
Table 1. Spinal subluxation syndromes (adapted from Gatterman. [9])
- Upper Cervical Subluxation Syndrome
- Lower cervical Subluxation Syndrome
- Cervicogenic Sympathetic Syndrome
- Cervicogenic Cerebral Dysfunction Syndrome
- Cervicogenic Dorsalgia Syndrome
- Cervicothoracic Subluxation Syndrome
- Thoracic Outlet Subluxation Syndrome
- Thoracic Subluxation Syndrome
- Costovertebral/costotransverse Subluxation Syndrome
- Thoracolumbar Subluxation Syndrome
- Lumbar Subluxation Syndrome
- Sacroiliac Subluxation Syndrome
- Coccygeal Subluxation Syndrome
Table 1 lists the typical subluxation syndromes encountered in the spine. All of these can be defined, studied, and become the focus of published research papers. The most common subluxation syndromes that have localized musculoskeletal signs and symptoms would be the obvious place to start in this campaign, since they would be the easiest to document and hence gain the quickest acceptance and utilization (our group intends to start with the cervicothoracic subluxation syndrome as part of a series of case reports). Those subluxation syndromes that involve more distant effects (organic or systemic) like the “upper cervical subluxation with associated somtaovisceral effects” would seemingly take longer to document well and involve more difficult levels of investigation. However, if we are truly dealing with real clinical conditions and effective treatment procedures, it will simply be a matter of time, not a matter of luck.
The health care world as we know it is acknowledging the reality of myofascial syndromes that can be treated with ischemic compression or Active Release Technique and disc syndromes treated successfully by flexion-distraction techniques. Surely, health care is ready for painful subluxation syndromes treated by manipulative adjustments. And, happily enough, this venture will not be a matter of chiropractic philosophy…it will really just be a matter of stating the facts, and improving the health of the world as we do it.
However, maybe the real question is this: Is the chiropractic profession ready to step up, document and promote the reality of subluxations (painful and otherwise), and receive the credit it deserves before somebody else does?
References:
Keating, JC, Cleveland, CS III, and Menke, M.
in: Chiropractic history: a primer.
Association for Chiropractic History, Davenport, IA; 2004: 37–39Keating JC.
How to hunt the subluxation: clinical research considerations.
New York State Chiropractic Association fall convention; Sep 2003. p.7.Kranz, KC.
Response to letter to editor from C Good.
On the Agenda (New York State Chiropractic Association newspaper). 2003 March; p. 10.McDonald W.P., Durkin K.F., Pfefer M.
How Chiropractors Think and Practice: The Survey of North American Chiropractors
Seminars in Integrative Medicine 2004; 2 (3): 92–98Hawk, C and Long, CR.
Factors affecting use of chiropractic services in seven midwestern states of the United States.
J Rural Health. 1999; 15: 233–239Young, S, Aprill, C, and Laslett, M.
Correlation of clinical examination characteristics with three sources of chronic low back pain.
Spine J. 2003; 3: 460–465Kent, P and Keating, J.
Do primary-care clinicians think that nonspecific low back pain is one condition?.
Spine. 2004; 29: 1022–1031Gatterman, MI and Hansen, DT.
Development of chiropractic nomenclature through consensus.
J Manipulative Physiol Ther. 1994; 17: 302–309in: MI Gatterman (Ed.)
Foundations of chiropractic: subluxation.
Mosby, St. Louis; 1995: 306–469
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