What comes to mind with the title Chiropractor?  Most people, if not all, will think of cracking sounds with manipulations of the body (i.e. adjustments/joint manipulations).  But is this all a Chiropractor is capable of?  A profession will consistently suffer periods of identity-crisis through necessary evolutionary changes to maintain relevance amongst the public.  Chiropractic has been undergoing such an evolutionary change for quite some time, however, there are several hurdles needing to be cleared in order to propel us in the right scientific direction.  One issue in particular is the diagnosis and treatment of “subluxations.”  Vertebral subluxations are viewed as spinal misalignments which interfere with the nervous system.  Chiropractors hypothesize that innate intelligence can be interfered with via vertebral subluxations.

Innate intelligence and vitalism (pseudoscience) are the philosophical beliefs of Straight Chiropractic. Vitalism is an unproven dubious hypothesis that “living organisms are fundamentally different form non-living entities because they contain some non-physical element or are governed by different principles than are inanimate things.”1  Innate intelligence, a term coined by D.D. Palmer (Founder of Chiropractic), is an idea that a life force flows through the nervous system of all living creatures allowing for expression of life via the organization, maintenance, and healing of the body.  Since the nervous system transmits innate intelligence, along with the information for all physiological body processes, ipso facto, removing subluxations equals better expression of innate intelligence equals better functioning of the body.  Chiropractors following this dogma choose to remove vertebral subluxations via spinal adjustments, which should not be confused with joint manipulations.  Adjustments and joint manipulations are viewed as two entirely different interventions. Adjustments encompass accuracy and specificity that release innate intelligence, and Joint Manipulations are non-specific forces being placed into the body.  According to the straight chiropractic philosophy, one is with purpose and the other without.

Straight Chiropractors pride themselves on the 33 principles of chiropractic and firmly believe in the Green Books.2,3  These practitioners mistakenly sit upon a stool comprised 2/3 of philosophy and 1/3 art with no signs of a scientific base.  They value the experience they gain as clinicians as paramount to their success.  If an adjustment doesn’t correct a patient’s ailment, then the skill is flawed in the methodology of identifying a subluxation. The straight chiropractor believes their only job while treating patients is LACVS:  Locate, Analyze, and Correct Vertebral Subluxations.

Like any good scientific endeavor, the premise of an idea must be established first.  Does Subluxation exist?  And if subluxation exists then how do we define it?

A search for “subluxation” on Pubmed, the greatest resource for scientific papers, will yield few actual scientific studies to validate the premise upon which chiropractors base clinical decisions.  An entire sect of healthcare professionals should not be making clinical decisions to treat a non-existent issue.  Better yet, they shouldn’t be paid to do so.

The keystone to scientific rigor is reproducibility of results.  Even if subluxations existed and our sensitivity to detect them was acceptable, we know our specificity to actually adjust the misalignment is horrible.4  However, the problem lies not in correcting vertebral subluxations but instead the complete lack of evidence they exist.

Based on scientific examination, there is no evidence to support subluxation, although an article does exist discussing the medical diagnosis of a radial head subluxation.5  However, the medical field views subluxation differently.  The medical definition of subluxation is that it is a partial dislocation of a joint whereas luxation is a full dislocation.  The premise of vertebral subluxation is that a bone has shifted out of place (but is still normally articulating) and this misaligned vertebra is now impeding nerve flow and subsequently upon bodily functions. Many chiropractic schools teach the 3 prong methodology for Locating, Analyzing, and Correcting Vertebral Subluxations (LACVS):  1) static palpation 2) muscle palpation and 3) motion palpation.  For the most part…these three variables are the crux for many Chiropractor’s utilization of joint manipulations. However, other components such as thermography, nervoscope (Gonstead), muscle testing (Applied Kinesiology), manual “pressure” tests (Torque release and Network Spinal Analysis) are taught.  Then the practitioner will utilize a totality of circumstances to identify where the misalignment has occurred and the direction the force is needed in the body.  This is the core of the subluxation argument and there are literally dozens of construct spin-offs by various Doctors of Chiropractic (DC).  In fact many schools have an entire class dedicated to Subluxation Theories (although theory implies evidential support and none exists for subluxations).  The National Board for Chiropractic Examiners (NBCE – licensing board) even has a section on a board specifically targeted towards testing Subluxation Theories…..which is misworded because theory again implies scientific support. In order to further establish a subluxation does not exist the parameters of finding a subluxation will be examined.

Without scientific support for a construct, the remaining sources for information regarding subluxation are either the schools and/or licensing boards.  The NBCE defines chiropractic as follows: “The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction.  A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability, or illness.  Typically, symptoms of subluxation include one or more of the following:

  • Pain and tenderness
  • Asymmetry of posture, movement, or alignment
  • Range of motion abnormalities
  • Tone, texture, and/or temperature abnormalities of adjacent soft tissues”6

Such a myopic view of treatment has led to the need to question what best practice is for a Chiropractor. If the only tool we have is going to be a hammer we need to be scientifically sure we are only driving nails. If a Chiropractor decides not to utilize Mjölnir for all ailments, then what are their options?  Such a question requires research to find clinical methods not supported by opinions and anecdotal claims but instead firmly based on scientific research.  Most states’ scope of practice for Chiropractors is quite broad and inclusive of science-based interventions like exercise and rehab, which should be more readily utilized. Which brings us to the point of this post: how will the Chiropractic field advance and evolve as a profession?  In order to answer this question, a core, antiquated principle must be evaluated with current evidence for advancement to occur. The above parameters proposed for the detection of subluxations are inherently flawed.

Static palpation is when the practitioner physically places their hands on the spine of the patient and attempts to identify which way the vertebra has shifted based on the vertebrae above and below.  However, multiple studies have demonstrated our inability to palpate these structures. Most studies regarding palpation are now demonstrating our inability to even agree upon the finding of basic anatomy landmarks critical for some of the necessary adjustments to occur, much less structural anatomy that has shifted out of its normal placement.7  Other studies have demonstrated the inter-rater reliability to locate these minute misalignments in structural anatomy are on par with guessing.8  Now, many chiros will claim this is the “art” of practice but this is the non-scientific aspect of practice and further perpetuates the idea that a patient “needs” a chiro to fix them.

Next up is muscle palpation.  This isn’t just a chiropractic issue but an overall manual therapy issue.  And research again proves we have no premise for what a myofacial trigger point is, much less if one exists and we should be utilizing it as a crux for an intervention.  If agreement can’t be reached regarding the existence of a pathology then is the targeted intervention truly doing anything (or more good than harm)?9,10,11

Finally, motion palpation.  The practitioner will passively move the joint for the patient and then request the patient actively moves the particular segment of the body in question.  Motion palpation research has consistently demonstrated our inability to have inter-rater reliability regarding motion palpation of the spine.12

Some chiropractors choose to rely on postural evaluations as solidification for a patient’s need for treatment.  This is contrary to the literature which currently states posture has minimal impact on pain and/or dysfunction.  Instead there appears to be a broad number of factors to consider in addition to posture.  Additional, it appears abnormal posture is relative and normal exists as a vastly wide range.13,14,15

Lastly, radiological findings have rocketed to the forefront of discussions regarding diagnosis and treatment of spine related issues.  Most Chiropractic schools require several x-ray analysis classes to be taken and boards repeatedly test our ability to read, analyze, and extrapolate diagnosis from imaging.  This isn’t just a Chiropractic issue but an entire physical medicine issue. However, we are the primary culprits for instilling fear in our patients with imaging.  Patients are told spinal curves can be corrected with adjustments, or due to the level of degeneration present they need to have adjustments to prevent further aberrant forces on their spine.  None of these statements are supported in the current scientific literature.  Line-Analysis is often given diagnostic credence for vertebral subluxations.  Millimeters are measured of spinal movement in comparison to surrounding vertebra and patients are informed those measurable differences are the source of their pain and dysfunction.  Again, no evidence supports such claims nor has any research validated the use of line-analysis as a diagnostic tool.  In fact, we are realizing more and more imaging doesn’t dictate patient symptoms or a case’s obtainable maximal improvement.16,17,18

So far, based on the overwhelming lack of scientific evidence, the likelihood a practitioner could identify a subluxation even if it did exist is similar to winning the lottery. Furthermore, classifying a non-existent issue as a health concern perpetuates fear-mongering of patients needing a Chiropractor thus placing the locus of control on the practitioner instead of the patient.  The archaic term “subluxation” must be stricken from our vocabulary.  But where does this leave the field of chiropractic?  We need to demonstrate to the public we are capable of much more than joint manipulations.  Here is how we do that:

Chiropractic is fairly mainstream in today’s options for “alternative medicine.”  But what does alterative medicine mean exactly? Medicine is defined as the science and practice of the diagnosis, treatment, and prevention of disease. What is different about alternative medicine that it warrants its own category in healthcare?  Alternative Medicines’ chosen interventions lack scientific backing; research that has proven its effectiveness.  Alternative Medicine (aka Complimentary/Integrative) exists outside the lines of science.  Alterative medicine is today’s equivalent to snake-oil, and the field is rampant with confirmation bias.  Chiropractic operates here because in the traditional sense Chiropractic is based solely on joint manipulations, which we have proven lacks any sufficient evidence as an intervention.

To quote Edzard Ernst, “Neither prevalence of use nor patient satisfaction are acceptable surrogates for efficacy.”19  Too often in the chiropractic profession both the aforementioned components are invoked as evidence to validate the usage of joint manipulations for subluxations.  Invigorating the entire Chiropractic field to choose abandoning subluxations and joint manipulations is no easy task.  However, the ground work has already been laid to replace the false intervention.  In order to establish ourselves in the healthcare profession we have adopted many integral parts to treating patients.  We are skilled clinicians in taking case histories, performing physical exams, screening for red flags, and diagnosing/treating musculoskeletal disorders.  More importantly, we have direct access to patients; a privilege many fields are still fighting for.  We need to stop abusing this power and begin helping our patients long-term instead of utilizing short-sighted, ill-founded interventions.  We have the allowable scope of practice to perform research supported interventions like exercise through rehab, a field solidified in its efficacy as a valid intervention for nearly one hundred years since World War II.20  This should be our focus: diagnosing/treating patients with interventions proven by science.

As licensed practitioners we have a choice: either perform interventions that have gone through the rigors of scientific testing or utilize ill-founded methodology and obtain a dodgy response at best (i.e. placebo effect).  Would you rather know your intervention is truly doing what you claim it is or simply hope that something positive will occur?  Choose science—it is the only way our field can advance to the forefront of medical practice.

This blog is only the beginning.  Requesting such changes of a field that has been in place for 100 years, clinging to non-evidentiary interventions, will continue to be painstaking.  But we must step back and gain perspective on the field as a whole.  In the meantime, for those choosing science, now is not the time to stand in the darkness quietly waiting for someone else to forge the way.  Accept science instead of dogma and further validate our existence within the medical community.  Our field can coexist amongst science-based medicine.  Our field should be science-based medicine.

 

References:

 

  1. https://mechanism.ucsd.edu/teaching/philbio/vitalism.htm
  1. http://liberationchiropractic.com/wp-content/uploads/research/33ChiropracticPrinciples-Stephenson.pdf)
  1. http://library.palmer.edu/greenbookslist
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