Vertebral subluxation

Vertebral subluxation is a term used in chiropractic and should not be confused with the orthopedic subluxation. Chiropractors say vertebral 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."or "a condition in which a vertebra has lost its proper juxtaposition with an adjacent vertebra (to an extent less than a luxation) in such a way as to alter nerve function"[http://www.straightchiropractic.com/index.php?file=language_of_straight_chiropracti.htm. Scientific evidence for vertebral subluxation is lacking.

A subluxation may affect one disc within the spine (degenerative disc disease) or a section of the spine, including the whole spine in some cases. For example, a functional scoliosis, viewed in chiropractic terms, may be due to a vertebral subluxation manifesting as an arch or abnormal curvature.

Chiropractors propose that this condition negatively affects the general health of the body by reducing the proper circulation of either or both of the autonomic and somatic nervous systems, depending on the degree of subluxation and its location. Although not always painful, chiropractors claim that a subluxation interferes with proper function and healing of your body due to the role of the nervous system as a controller and coordinator of most bodily functions.

Modern chiropractic treatment focuses on treating the vertebral subluxation by delivering a chiropractic adjustment to the affected part of the spine to relieve the hindrance to nerve function.

While the orthopedic and conventional medical definition of subluxation includes misalignment and sometimes nerve damage, it is considered a rare occurrance. Medicine disavows the chiropractic contention that minor misalignments can cause organic disease.

Historical definitions

"The possible neurological consequences of subluxation were described by Harrison in 1821, as quoted by Terrett:“When any of the vertebrae become displaced or too prominent, the patient experiences inconvenience from a local derangement in the nerves of the part. He, in consequence, is tormented with a train of nervous symptoms, which are as obscure in their origin as they are stubborn in their nature...”"^*

In the chiropractic system developed by Daniel D. Palmer in the late 1800's, Palmer originally believed that he had discovered the cause of all diseases suffered by mankind - the vertebral subluxation.

"Physiologists divide nerve-fibers, which form the nerves, into two classes, afferent and efferent. Impressions are made on the peripheral afferent fiber-endings; these create sensations which are transmitted to the center of the nervous system. Efferent nerve-fibers carry impulses out from the center to their endings. Most of these go to muscles and are therefore called motor impulses; some are secretory and enter glands; a portion are inhibitory their function being to restrain secretion. Thus, nerves carry impulses outward and sensations inward. The activity of these nerves, or rather their fibers, may become excited or allayed by impingement, the result being a modification of functionating—too much or not enough action—which is disease." Palmer DD (1910) The Science, Art and Philosophy of Chiropractic Portland, Oregon: Portland Printing House Company p20

Chiropractors use and have used various terms to express this concept: subluxation, vertebral subluxation (VS), vertebral subluxation complex (VSC), "killer subluxations," ^*" target="_blank" >or a "bone out of place" (BOOP) [http://www.spinalinjuryfoundation.org/101_new/boop.htm.

More recently, validation of chiropractic’s claims have been raised. National University of Health Sciences (formerly National College of Chiropractic), one of the oldest chiropractic colleges, states: “The Journal of Manipulative and Physiological Therapeutics is the only refereed, internationally indexed chiropractic scientific journal. JMPT was also selected as the official research publication of the American Chiropractic Association.” ^* The phrase appears to have multiple meanings, given different contexts. The most-cited example of research appears in Volume 23, Issue 2, Pages 101-103 (February 2000), titled “Reflex effects of vertebral subluxations: the peripheral nervous system. An update.” The article is preceded by the context: “Presented as an invited presentation at the World Federation of Chiropractic Congress, Auckland, New Zealand, May 20, 1999” by Peter Bolten.

Philip S. Bolton, writes in JMPT, "The traditional chiropractic vertebral subluxation hypothesis proposes that vertebral misalignment cause illness, disease, or both. This hypothesis remains controversial." His objective was, "To briefly review and update experimental evidence concerning reflex effects of vertebral subluxations, particularly concerning peripheral nervous system responses to vertebral subluxations. Data source: Information was obtained from chiropractic or, scientific peer-reviewed literature concerning human or animal studies of neural responses to vertebral subluxation, vertebral displacement or movement, or both." He concluded, “Animal models suggest that vertebral displacements end putative vertebral subluxations may modulate activity in group I to IV afferent nerves. However, it is not clear whether these afferent nerves are modulated during normal day-to-day activities of living end, if so, what segmental or whole-body reflex effects they may have.”

Functional theory of vertebral subluxation

As a continuation of the brain, the spinal cord contains nerve tracts which are the neurological pathways thru which the brain communicates with most of the body. While the brain is protected by the skull, the spinal cord is protected by the vertebral column. As nerves branch off the spinal cord, they form the spinal nerve roots which exit the vertebral column thru an opening made by two adjacent vertebrae, called the Intervertebral foramen.

There are several hypotheses on how a misaligned vertebra may cause interference to the nervous system.Strang,V (1984) Essential Principles of Chiropractic Davenport : Palmer College of Chiropractic, OCLC: 12102972

Nerve compression hypothesis: suggests that when the vertebrae are out of alignment, the nerve roots and/or spinal cord can become pinched or irritated. While the most commonly referenced hypothesis, and easiest for a patient to understand, it may be the least likely to occur.
Proprioceptive insult hypothesis: focuses on articular alterations causing hyperactivity of the sensory nerve fibers.
Somatosympathetic reflex hypothesis: all the visceral organ functions can be reflexly affected by cutaneous or muscular stimulation.
Somatosomatic reflex hypothesis: afferent impulses from one part of the body can result in reflex activity in other parts of the body.
Viscerosomatic reflex hypothesis: visceral afferent fibers cause reflex somatic problems.
Somatopsychic hypothesis: the effects of a subluxation on the ascending paths of the reticular activating system.
Neurodystrophic hypothesis: focuses on lowered tissue resistance that results from abnormal innervation.
Dentate ligament-cord distortion hypothesis: upper cervical misalignments can cause the dentate ligaments to put a stress on the spinal cord.
Psychogenic hypothesis: emotions, such as stress, causing contraction in skeletal muscles.

The vertebral subluxation has been described as a syndrome, and as such, the signs and/or symptoms are: altered alignment; aberrant motion; palpable soft tissue changes; localized/referred pain; muscle contraction or imbalance; altered physiological function; reversible with adjustment/manipulation; focal tenderness.^*

The claims for the existence of vertebral subluxations are a matter of controversy, and the chiropractic concept is not recognized by mainstream medicine and science (JMPT, ^*.) The Wilk v. American Medical Association trial transcripts mention this fact:

There was evidence that the chiropractic theory of subluxations was unscientific, and evidence that some chiropractors engaged in unscientific practices. The court did not reach the question of whether chiropractic theory was in fact scientific. However, the evidence in the case was that some forms of chiropractic manipulation of the spine and joints was therapeutic. AMA witnesses, including the present Chairman of the Board of Trustees of the AMA, testified that some forms of treatment by chiropractors, including manipulation, can be therapeutic in the treatment of conditions such as back pain syndrome. ^{PDF of key transcripts}

Treatment of vertebral subluxation

When a chiropractor believes he/she has detected a vertebral subluxation he/she then applies a specific adjustment procedure to the spinal bone considered to be subluxated. While there are a number of different chiropractic techniques, they all can be characterized by the description of having a short-lever, high velocity, low amplitude (HVLA) thrust and specific line of correction.

While chiropractors do attempt to precisely direct treatment at specific movement segments of the spinal column, the one thing that completely separates the chiropractic adjustment from other manipulative techniques is the chiropractic intent - the treatment of vertebral subluxations. No other profession claims to have this intent.

Once these bones or vertebrae are theoretically restored to their proper position, the spinal cord and/or its nerve roots are no longer considered to be hindered or compressed. Thus, without interference from a subluxation, the brain is considered to be enabled to transmit and receive all the messages through the spinal cord and nerve roots to all the parts of the body supplied by those nerves. The spine is considered "in line" and thus it is assumed the body functions in a coordinated manner resulting in increased health.

Still, the traditional chiropractic hypothesis - that vertebral subluxations cause neurological interference that may result in disease, disorder, or dysfunction - remains controversial. The vertebral subluxation is a hypothetical phenomenon and has yet to be empirically evidenced or verified.

History

The neologism "subluxation" was coined by Andrew Still, MD, the founder of osteopathy, and refers to phenomena concerning bodily fluids. Vertebral subluxation is a concept that evolved over decades of research conducted in the chiropractic profession. The term was borrowed from osteopathy, and applied to vertebrae, to designate a disruption of normal nerve activity, theorized to be at the source of noticeable changes in the body. There are historical references going back to Hippocrates to support the long held belief and clinical impression that the function of the spine was a key element in the proper maintenance of health.

In its chiropractic context, the term "subluxation" was first described by Daniel David Palmer, who was possibly inspired by osteopath Andrew Still. Still's model was a disturbance of blood flow to various organs from "osteopathic lesions", resulting in weakening of tissues and organs. Palmer's understanding, based on the scientific knowledge of the time, was that a disturbance of nerve supplies to the same tissues and organs more readily explained the changes produced after correction ("adjustments") of misaligned spinal bones.

The original investigation and research into this newly described entity are shrouded in confusion, due to lack of formal notes, and the political struggle that ensued to establish a stable fountainhead for the entire chiropractic profession. A popular version was that Palmer restored long-lost hearing to a janitor by realigning bones of his spine. Sources from the period claim that chiropractic as a treatment form gained notoriety during the 1918 Flu Epidemic, when it was found that patients receiving "adjustments" had significant lesser mortality than those treated with conventional medical treatments of the day. The impact of subluxation on the immune system has been researched and demonstrated well into the 1980's by other researchers including Ronald Pero, head of the Cancer Prevention Institute in New York.

The search for subluxations has led to one of the most significant contributions of the chiropractic profession to the health sciences: radiography. In an attempt to visualize and analyze spinal misalignment, chiropractors embraced and provided initial interest in an emergent technology that used radiation from a high voltage emitter to produce a shadow of dense bone tissue on light sensitive plates. This allowed the establishment of a stable network of suppliers for hardware, films and chemicals that are now widely used by medical science. Nowadays, x-ray analysis still provides diagnostic and analytic information to chiropractors.

Further osteopathic researchers, like Irwin Korr, investigated and confirmed the influence of nerve involvement in the mechanism of health and disease influenced by osteopathic and chiropractic treatments. However, over the years, the osteopathic and chiropractic professions have diverged in their scope and focus. Whereas chiropractors have retained as their main goal the detection and correction of subluxations, osteopathic education and practice has abandoned the subluxation as a cause of disease and has shifted away toward a more medical, drug and surgery dependent approach to care.

Other medical researchers, like Maigne, a French rheumatologist, have found that spinal bones that displayed normal position but moved abnormally were also producing abnormal changes to tissues away from the spine. His attention was paid to muscles, bones and ligaments affected by motor nerves.

Both the osteopathic "subluxation" and the chiropractic "vertebral subluxation" remain hypotheses that are not universally-accepted within their respective professions, much less outside of them.

Sources of confusion

As the above discussion shows, one of the confusing aspects of "vertebral subluxation" is whether it is a metaphysical concept (as posited in B. J. Palmer's philosophy of chiropractic) or whether it is an actual phenomenon. Another confusion is that, if "vertebral subluxation" is a physical phenomenon, is it also a "scientific" claim? If so, it encounters two immediate problems: (1) empirical verification, and more importantly, (2) an inability to be falsified (the falsifiability requirement).

Karl Popper, the philosopher of science, demands science go beyond empirical phenomena and verification (through repeated experimentation), and further requires any scientific hypothesis, by nature, to be minimally falsifiable. Popper writes, "We say a theory is falsified only if we have accepted basic statements which contradict it. This condition is necessary, but not sufficient; for non-reproducible single occurrances are of no significance to science. Thus a few stray basic statements contradicting a theory will hardly induce us to reject it as falsified. We shall take it as falsified only if we discover a reproducible effect with refutes the theory. . . . requirement that the falsifying hypothesis must be empirical, and so falsifiable, only means that it must stand in a certain logical relationship to possible basic statements; thus this requirement only concerns to the logical form of the hypothesis . . . .[the basic statements play two different roles. On the one hand, we have used the system of all logically-possible basic statements in order to obtain with its help the logical characterization for which we are looking -- that of the form of empirical statements. On the other hand, the accepted basic statements are the basis for the corroboration of hypotheses. If accepted basic statements contradict a theory, then we take them as providing sufficient frounds for its falsification only if the corroborated a falsifying hypothesis at the same time." Popper, "Falsification versus Conventionalism, 1934" in Popper Selections, edited by David Miller (Princeton: Princeton University Press, 1985, 150-1) The obstacle of falsifiability, of course, arises only after the obstacle of verification has been overcome.

In an article on the chiropractic vertebral subluxation written in 2005^*, the authors had this to say:

"There is nothing inherently dogmatic or anti-scientific in the notion that an articular lesion may have health consequences, or that correction of joint dysfunction may relieve symptoms and/or improve health. Neither does our current inability to predict the effects (if any) of subluxation and/or the benefits of subluxation-correction relegate this hypothetical construct to the dustbin of clinical theories. Indeed, it would be just as inappropriate to dispose of this largely untested theory without data as it is to proclaim its meaningfulness without adequate evidence. On the other hand, as Carl Sagan suggested, extraordinary claims will require extraordinary evidence. With respect to the supposed mechanisms of adjusting, Haldeman reminds us that "What must be avoided... is the unreasonable extrapolation of current knowledge into speculation and presentation of theory as fact." Given the current deficiency of empirical data, the only sound scientific-epistemological position that we can conceive of is to acknowledge our ignorance: we don't know if subluxation is clinically meaningful or not. We suggest that this is a requisite first step toward greater wisdom concerning subluxation."

The concept of vertebral subluxation has been plagued with definitional problems since its inception. One of chiropractic's most staunch defenders of belief in the vertebral subluxation provides this explanation as a possible cause of the confusion:

The vertebral subluxation cannot be precisely defined because it is an abstraction, an intellectual construct used by chiropractors, chiropractic researchers, educators and others to explain the success of the chiropractic adjustment.

This is not a unique state of affairs, abstract entities populate many branches of science...

Subluxations, genes, gravity, the ego and life are all heuristic devices, "useful fictions" that are used to explain phenomenon that are far larger than our understanding. We use them as long as they work for us and discard or limit their application when they become unwieldy or unable to account for new observations...

Critics of chiropractic have incorrectly assumed that chiropractic is based on the theory or principle that vertebral subluxations cause "pinched" nerves that cause disease. They have it backwards. Chiropractic is based on the success of the spinal adjustment. The theory attempting to explain the success of the adjustment (nerve impingement, dis-ease, subluxations) followed its clinical discovery.

Examples of such erroneous criticisms based on this straw-man argument abound in the medical literature. Some examples: "The teachers, research workers and practitioners of medicine reject the so-called principle on which chiropractic is based and correctly and bluntly label it a fraud and hoax on the human race." "The basis of chiropractic is completely unscientific." The theory on which chiropractic is based false, namely that a "subluxation" of a spinal vertebra presses on a nerve interfering with the passage of energy down that nerve causing disease to organs supplied by that nerve, and that chiropractic "adjustments" can alleviate the pressure thereby treating or preventing such disease. There is no scientific evidence for the validity of this theory."

To be fair, statements by some chiropractors have tended to perpetuate this misunderstanding: "Pressure on nerves causes irritation and tension with deranged functions as a result."

When chiropractors declare that "pinched nerves" "nerve impingement" "spinal fixations" or others mechanisms of action explain how subluxations affect the person and how chiropractic works they are making the same mistake medical critics make - assuming chiropractic is based on theory. Mechanisms and theories are useful tools, but their limitations should always be kept in mind. Koren

Whether one accepts the statement, "Subluxations, genes, gravity, the ego and life are all heuristic devices, "useful fictions" that are used to explain phenomenon that are far larger than our understanding," gravity and genes, unlike vertebral subluxations, have been empirically verified. At the present time, "vertebral subluxation" remains a metaphysical construct, posited by chiropractic's philosophy of disease, neither of which have been verified, submitted to double-blind tests, much less are capable of falsifification. Thus, confusion continues.

References

External links

Journal of Vertebral Subluxation Research - A Peer-Reviewed Scientific Journal
Journal of Manipulative and Physiological Therapeutics - A Peer-Reviewed Journal
Chiropractic's Elusive Subluxation - Article by Stephen Barrett, M.D.
Does the Vertebral Subluxation Exist? - Article by Tedd Koren, DC

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