Subluxation, Science and the Flat Earth Society

Several articles have recently appeared in both the chiropractic trade press and peer-reviewed journals questioning the very existence of vertebral subluxations.^1,2 A comprehensive review of the evidence supporting vertebral subluxation is beyond the scope of this article. Suffice it to say that entire textbooks from mainstream medical publishers have addressed it.^3-6 At least one peer-reviewed journal indexed in CINAL, MANTIS, and ICL is devoted to the subject.⁷

Several clinical practice guidelines or "best practices" documents have addressed vertebral subluxation and reviewed the scientific literature supporting objective assessment of vertebral subluxation.^8-10 All major chiropractic organizations including the ACA, ICA and WFC have accepted the Association of Chiropractic Colleges Paradigm, which adopted the following statement concerning subluxation:

"Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence."¹¹

An overwhelming majority of chiropractors (at least in North America) accept the term and the concept. Smith and Carber noted that more than 70 percent of chiropractors surveyed report that subluxation is important to their clinical decisions and guides their clinical care of patients.¹² McDonald, et al., reported that more than 88 percent of their surveyed chiropractors favor retaining the term vertebral subluxation complex.¹³

So, what's the problem? A handful of DCs, representing the radical fringe of our profession, are suggesting that the term and concept be abandoned. They seem to think that subluxation-based chiropractic is based on the antiquated monocausal theory espoused by early chiropractors, or the limited model of intraforaminal nerve-root compression. Anyone with even a passing knowledge of the literature knows this is not true.¹⁴ So, what gives? By bantering about terms such as integration and evidence-based practice, members of this fringe element have achieved a degree of success in hijacking some colleges and political organizations in an apparent attempt to pander to third-party payers and fit into the medical system.

I am reminded of an organization known as the Flat Earth Society, whose members stubbornly choose to ignore the overwhelming evidence contrary to their position and deny the spherical nature of the Earth.¹⁵ Ironically, they use Internet technology to propagate this belief. Apparently the Flat-Earth folks have no problem using orbiting communications satellites to spread the word. The subluxation deniers would fit in splendidly. Dogma over data.

What of the notion that DCs should abandon subluxation and the traditional philosophy of chiropractic? The fundamental issues are simple: Are we a profession with a clearly defined mission or are we a profession simply seeking some niche which offers access to a slice of the health care pie? Are we driven by principles or politics? Does our mission statement define our political position or do we grovel to get whatever crumbs the insurance industry tosses our way? Do we have an identity defined by our purpose or are we chameleons who change our colors to blend into the existing environment?

Medical anthropologist EA Morinis wrote, "Only the chiropractic philosophy significantly distinguishes the chiropractic practitioner. And yet the philosophy is kept hidden away. It has done so in fear of being labeled quackery, and this was undoubtedly a good strategy to follow at one time. The public knows next to nothing of [the] chiropractic philosophy of healing and its mechanisms: If hospitals offer spinal manipulation, a chiropractor offers nothing else. This distortion of the chiropractic tradition can only be overcome by a reevaluation of the place of theory in chiropractic. ... Dispossessed of its philosophy, chiropractic is dispossessed of its uniqueness, and perhaps its future."¹⁶

Physiologist I.M. Korr admonished the osteopathic profession to hold fast to its principles: "There are misapprehensions about the source of your strength. Your profession appears to believe that its strength is to be found more in the stamps of approval by self‑appointed magistrates of medicine. ... As a result, you often act as though you believed your strength is to be nurtured by mimicry, by cloaks of protective coloration, by compromise of principles, by organized compliance, by appeasement, and by adaptation to what is prescribed for you by organizations of another profession. ... Recent events loudly proclaim the futility of this approach."¹⁷ Korr also stated, "I think we need, in some way, to re-infuse into the profession an appreciation of the immensity of the idea, of the profession's responsibility to it, and of the vast opportunities to serve it."¹⁸

A visit to the Web site of the American Physical Therapy Association should be required of every DC, particularly those who would abandon the concept of vertebral subluxation.¹⁹ Physical therapy is a profession that has determined the direction it plans to take into the 21st century. One of the most striking proposals is making the entry‑level degree for physical therapists a professional doctorate. The Web site describes the rationale for the entry‑level Doctor of Physical Therapy (DPT) degree:

"(S)ocietal expectations that the fully autonomous health care practitioner with a scope of practice consistent with the Guide to Physical Therapist Practice be a clinical doctor; the realization of the profession's goals in the coming decades, including direct access, 'physician status' for reimbursement purposes."

What will the new "doctor" be offering in the way of services? An article in the journal Physical Therapy is instructive: "Many interventions used by physical therapists in the management of patients with low back pain (LBP) lack evidence supporting their effectiveness. For example, interventions such as thermal modalities, electrical stimulation, and biofeedback have not been studied sufficiently, whereas interventions such as transcutaneous nerve stimulation, mechanical traction, and ultrasound have been studied and found to be ineffective. ... Spinal manipulation is one intervention for LBP that is supported by evidence."²⁰

One can go from high school to DPT in fewer than six years. A high school grad in Davenport, Iowa, can become a DPT in five‑and‑a‑half years. Prerequisite: One year of high-school biology and chemistry.²¹ It's a very attractive deal for a career shopper. No onerous 90‑hour or BS prerequisite, virtually guaranteed employment upon graduation, medical acceptance and the option of a direct-access private practice. This could all but guarantee the end of chiropractic if we don't have something to offer other than manipulation and PT for NMS symptoms.

How many prospective students will choose to go the DC route if both professions claim to offer the same services? We must make sure everyone understands vertebral subluxation, wellness, and our unique approach to unleashing human potential. Or, like the Soviet Union, the chiropractic profession as we know it could die with barely a whimper. The alternative is being the champions of a different approach to our health care priorities and playing a major role in the rescue of a failing health care system. Are you up to the task?

References

1. Murphy DR, Schneider MJ, Seaman DR, et al. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropractic & Osteopathy, 2008;16:10.
2. "Person of the Year: Dr. Thomas Hyde."  Dynamic Chiropractic, Dec. 16, 2008. www.dynamicchiropractic.com/mpacms/dc/article.php?id=53544
3. Eriksen K. Upper Cervical Subluxation Complex: A Review of the Chiropractic and Medical Literature. Baltimore: Lippincott Williams & Wilkins, 2004. 
4. Masarsky CS, Todres Masarsky M, Eds. Somatovisceral Aspects of Chiropractic: An Evidence-Based Approach. New York: Churchill Livingstone, 2001. 
5. Ruch WJ. Atlas of Common Subluxations of the Human Spine and Pelvis. Boca Raton, Fla.: CRC Press, 1997. 
6. Gatterman M. Foundations of Chiropractic. Subluxation. Second Edition. St. Louis: Mosby, 2005.
7. Journal of Vertebral Subluxation Research.
8. Council on Chiropractic Practice. Vertebral Subluxation in Chiropractic Practice.
9. Practicing Chiropractors' Committee on Radiology Protocols for Biomechanical Assessment of Spinal Subluxation in Chiropractic Clinical Practice. 
10. International Chiropractors Association. Best Practices and Practice Guidelines.  
11. Association of Chiropractic Colleges. Chiropractic Paradigm.
12. Smith M, Carber LA. Survey of US chiropractor attitudes and behaviors about subluxation. Journal of Chiropractic Humanities, 2008;15:19-26. 
13. McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Ada, Ohio: Institute for Social Research. Ohio Northern University, 2003.
14. Kent C. Models of vertebral subluxation: a review. Journal of Vertebral Subluxation Research, 1996;1(1):1-7.
15. The Flat Earth Society. www.theflatearthsociety.org/forum
16. Morinis EA. Theory and practice of chiropractic: an anthropological perspective. J Can Chiropr Assoc, 1980;24(3):114-9.
17. Korr IM. The Andrew Taylor Still memorial lecture: research and practice - a century later. J Am Osteopath Assoc, 1974;73(5):362-70.
18. Korr IM. "What 'Osteopathic Medicine' and 'the Osteopathic Concept' Mean to Me." (1962) The Collected Papers of Irvin M. Korr. Indianapolis: American Academy of Osteopathy, 1979.
19. American Physical Therapy Association. www.apta.org
20. Fritz JM, Whitman JM, Flynn TW, et al. Factors related to the inability of individuals with low back pain to improve with spinal manipulation. Physical Therapy, 2004;84(2):173‑88.
21. St. Ambrose University. Application and Admissions Procedures for Track I High School Students.