Regretfully in 2007, "subluxation" remains a topic of contention. This truly is surprising, as we have no objective measurement of "subluxation here" before adjustment and "subluxation gone" after the adjustment. In the modern day, this lack of objective evidence should make us question the importance of subluxation and cause our focus to be directed at various potential outcomes of the spinal manipulation. It certainly is possible that spinal manipulation has beneficial effects that have nothing to do with joint mechanics, and much more to do with the modulation of segmental and suprasegmental neuronal activity that can reduce pain and visceral symptoms in certain patients.1,2
In the previous paragraph, the phrase "certain patients" was highlighted because we all know that adjustments are not clinically beneficial for all patients. Some patients respond to manipulation while others do not. Most students discover this fact in their first year of chiropractic college. And when it comes to back pain and headaches - certain classmates benefit greatly, some have modest improvements, for others there is no effect, and for some, symptoms worsen. This phenomenon need not be confusing; however, it often leads to undue stress. This stress causes some students to begin to doubt their choice of chiropractic as a profession. To prevent such doubt and confusion from becoming a chronic state of mind, it seems there are at least two appropriate measures that should be taken.
Measures to Be Taken
First measure: We need to give up the notion that adjustments have magical or supernatural healing outcomes. This means we need to eliminate the notion of a "killer subluxation" that blocks the full expression of innate intelligence, which requires weekly preventive adjustments. Early on in chiropractic education, students should be informed about which patients are likely to respond best to manipulation. Several clinical prediction rules have been developed that help determine which patients will best respond to manipulation.3-9 If students and doctors are very familiar with these studies, there will be minimal confusion as to why certain patients respond well to manipulation while others do not. With this knowledge, we can painlessly apply the second measure.
Second measure: We need to develop a patient-centered mindset from the start of our education, which translates into the development of proper patient-management skills. We need to focus on what is wrong with the patient, make an appropriate diagnosis and render the care that best fits the needs of the patient and the diagnosis. Two excellent papers recently have been published by Dr. Donald Murphy, which can help train us in this line of thinking.10,11 The full text of each paper is available for free at the link included in each reference.10,11
In short, there are four key pain-generating tissues - the joint, disc, muscle and epineurium - and there are specific diagnostic tests and treatments for each pain generator. Additionally, there are numerous perpetuating factors that can drive the pain generators to express pain, such as fear/avoidance behavior (yellow flags), sensory-motor dysfunction, oculomotor dysfunction, poor ergonomics, constrained postures, functional instability, altered nociceptive processing and a diet-induced, pro-inflammatory state.10,11 Murphy discusses several of the perpetuating factors in detail or provides the appropriate references.
Identifying the pain generator and perpetuating factor typically produces a focused and confident treatment approach that often leads to rapid resolution of spinal pain and headaches. Chiropractors who utilize this approach to patient care often acquire 30 to 80 new patients per month, and many are referrals from medical doctors.
It is time to move beyond subluxation and focus on the development of clinical prediction rules for spinal manipulation and the appropriate application of patient management strategies. This focus should occur in chiropractic education and the postgraduate setting.
References
- Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. JMPT, 1999;18(6):379-97.
- Pickar JG. Neurophysiological effects of spinal manipulation. Spine J, 2002;2(5):357-71.
- Huijbregts P. Clinical prediction rules: time to sacrifice the holy cow of specificity? JMPT, 2007;15:5-8.
- Childs JD, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med, 2004;141:920-28.
- Fritz JM, et al. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following brief spinal manipulation intervention. BMC Family Practice, 2005;6:29.
- Tseng YL, et al. Predictors for the immediate responders to cervical manipulation in patients with neck pain. Man Ther, 2006;11:306-15.
- Cleland JA, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther, 2007;87:9-23.
- Axen I, et al. The Nordic Back Pain Subpopulation Program: can patient reactions to the first chiropractic treatment predict early favorable treatment outcome in nonpersistent low back pain? JMPT, 2005;28(3):153-8.
- Leboeuf-Yde C, et al. The Nordic Back Pain Subpopulation Program: demographic and clinical predictors for outcome in patients receiving chiropractic treatment for persistent low back pain. JMPT, 2004;27(8):493-502.
- Murphy DR. A clinical model for the diagnosis and management of patients with cervical spine syndromes. J Austral Chiro Osteo, 2004;12(2):57-71. Available at: www.coca.com.au/journal/articledetails.asp?ID=167.
- Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskeletal Disorders, 2007;8:75. Available at: www.biomedcentral.com/1471-2474/8/75/abstract.
