Stalking the "S" Word: A Response to the Sludge Report

The Sludge Report (www.thesludgereport.com) - a new online publication "devoted to the protection of patients from IME abuse and denial of medical benefits") has appeared to paint a picture not unlike Custer's last stand, describing how the concept of subluxation was presented at the recent Fourth Research Agenda Conference (RAC IV) in Arlington Park, Illinois.

Clicking on the "Hot Sludge" link takes you to the unattributed article "Even the Smartest DCs Couldn't Answer This Question." It suggests that the conference organizers and panel chairs had an agenda to disparage the subluxation model and question its relevance, assuming that both the research community and those college presidents attending were probably poised to dispose of the model altogether. If this is so, concluded the report:

In a world where insurance companies are already trying to take every dollar they can from you, the last thing you need are self-appointed leaders of (a) new chiropractic agenda taking away what's left of your professional identity.¹

To paraphrase Mark Twain, I would suggest that reports of or plans for the demise of the subluxation at the conference are greatly exaggerated. The purpose of any scientific conference (RAC IV was no exception) is to weigh evidence in support of or against prevailing concepts, which in this case obviously involved the "s" word.

What happened at RAC IV is that various panelists and individuals from the floor offered their viewpoints of subluxation. RAC IV was never intended to be a loyalty oath to the legacy of B.J. Palmer or whether his precepts were being strictly adhered to. What happened to D.D.? Like any theory in existence for over a century, the subluxation model has undergone and continues to require substantial modification to keep pace with current observations gleaned from experimentation (cohort studies and randomized trials) and observation (clinical practice).

It is important to recall that D.D. Palmer's own concepts of subluxation (approached sometimes as a testable theory and sometimes as a metaphor) went through substantial changes even as this model left the launching pad from 1897 to 1914. Subluxation, according to Palmer, was first described as the result of displaced anatomy being the possible cause of inflammation and disease.²

Beginning in 1903, integrity of neural function rather than the displacement of any body part became central to chiropractic theory; later, the term "educated" was invoked to distinguish a portion of the nervous system from the innate;³ and finally, in 1910, previous references to obstruction of circulation were purged and relegated to the osteopath's domain of interest.⁴ Having been appraised of this shifting concept of subluxation that within just its first 20 years already appears to be nearly kaleidoscopic, we should not feel surprised or threatened by further challenges and changes to the model right up through what was debated at the RAC IV conference last month.

The key, in my opinion, lies with Ian Coulter's statements, which to me were not dismissive of the "non-mercenary" individual from Palmer (as described in the Sludge Report) who questioned the wisdom of heaving the entire concept of subluxation over the railing. Rather, Coulter's statements actually seemed conciliatory. They were directed at the context in which subluxation theory is being maintained. Only when one describes the subluxation as a fully defined anatomical lesion (equivalent, for instance, to an aneurism) does one get into trouble. At this stage, the lesion appears to be not fully defined; rather, the subluxation is a concept put forward to encompass what we believe are the successes of chiropractic health care, compared to the disease-oriented concepts which lie at the epicenter of current models of allopathic medicine. According to Dr. Coulter, the subluxation should be regarded as a working construct rather than a lesion. Should our future research continue to contradict or violate the principles of subluxation as we envision them, then the model (like any scientific theory) should be modified further or discarded.

In no way does this approach deprive chiropractic from pursuing its focus, which at this writing continues to frame subluxation in its current form as a testable theory in its future. Given the facts that:

I. Subluxations cannot be defined by x-rays or other imaging procedures;⁵

II. Interexaminer reliability of identifying motion or end feel restriction at specific segmental levels has been recently shown to vary from good⁶ to poor;⁷ and

III. Both animal models and more circumstantial observations in humans provide the best current evidence linking spinal derangements with pain and/or dysfunction,⁸

we should not find it much of an imposition if we were to insert the word "resumed" in front of our current descriptions of phenomena involving the "s" word. In even the worst case scenario (in which traditional research designs fail to support the subluxation model), it may be that subluxation may be more effective - as Palmer himself suggested a century ago - as a metaphor than as a testable theory. One also needs to be aware that subluxation and medical terminology are not necessarily mutually exclusive. Rather, our concepts of subluxation are an attempt to better understand optimal health, in much the same way that quantum mechanics and Newtonian principles have coexisted for over half a century to further our understanding of wavelike and particulate characteristics of light.

Like Freud's evolving concept of the unconscious, subluxation has required (and will likely continue to require) many transformations and modifications prior to its emergence into a new branch of medicine. In its current state, the subluxation model guides the profession and remains a useful concept with which to approach the patient. However, as Robert Jusino and others who spoke from the floor at the RAC IV conference suggested, the unqualified "s" word presumes a certain arrogance (to say nothing of liability) if it is presented as a finished work - a physical reality without any circumstantial attributes.

The problem at this stage is that the research defining the necessary characteristics of the subluxation is far from complete. Indeed, our entire purpose at FCER is to attempt to rectify this problem with our current oversight of over 40 research projects and over a dozen individuals receiving stipends for postgraduate research. Until such research can be completed, published and correctly interpreted by the public, other professions in health care, and third-party payers, the "s" word will remain in a sort of limbo, bowed but unbroken.

References

1. Hot sludge. Chairperson of the Mercy Steering Committee poses question: should the chiropractic profession abandon the subluxation as its reason to be? Sludge Report August 16, 1999.

2. Palmer DD (ed.) The Chiropractic 1902, #29, Palmer College Archives.

3. Palmer DD (ed.) The Chiropractor: A Monthly Journal Devoted to the Interests of Chiropractic Dec 1904;1(1).

4. Palmer DD. The Chiropractor. Los Angeles, CA: Beacon Light Printing, 1914.

5. Van Schaik JPJ, Verbiest H, Van Schaik FDJ. Isolated spinous process deviations. A pitfall in the interpretation of the lumbar spine. Spine 1989;14(9):970-976.

6. Jull G, Bogduk N, Marshland A. The accuracy of manual diagnosis for cervical zygopophyseal joint pain syndromes. Medical Journal of Australia 1988;148:233-236.

7. Haas M, Panzer DM. Palpatory diagnosis of subluxation. In: Gatterman M (ed.) Foundations of Chiropractic Subluxation. St. Louis, MO: Mosby-Year Book, 1995, pp. 56-67.

8. Rosner A. The Role of Subluxation in Chiropractic. Arlington, VA: Foundation for Chiropractic Education and Research, 1997.