A spirited exchange about chiropractic arose in response to a recent post proposing “The Cure” for the legalization of implausible and unproven diagnostic methods and treatments. Some comments pointed to the implausibility of the chiropractic “subluxation” and the lack of robust evidence of efficacy/effectiveness for spinal manipulation, as well as the difficulty of understanding what exactly “chiropractic” is, or does, that distinguishes it from other manual therapists. In response, other comments were posted positing that the Science-Based Medicine blog “is not informed on contemporary chiropractic practice,” that “the profession does not support [the chiropractic] subluxation as a cause of disease,” that chiropractors who treat the chiropractic subluxation are “on the fringe,” and that the chiropractic “subluxation” is no longer taught in chiropractic colleges as a clinically relevant concept, but merely as an artifact of chiropractic history.
However, a review of recent chiropractic literature does not appear to support the latter opinions. The same concerns as raised on SBM are shared by chiropractors themselves and are discussed in articles appearing in peer-reviewed chiropractic journals. Nor is the chiropractic literature as sanguine on the demise of the chiropractic “subluxation” as a clinically relevant condition which is both diagnosable and treatable.
Despite the concerns expressed by chiropractors themselves, the chiropractic literature continues to discuss the chiropractic “subulxation” as if it were a clinically relevant condition subject to diagnosis and amenable to treatment for both non-musculoskeletal and musculoskeletal conditions. This same view of the “subluxation” is taught in chiropractic colleges in North America and Australia.
Chiropractic 101: the subluxation
A June, 2011, article in the journal Chiropractic and Manual Therapies explored, as the title explains, The prevalence of the term subluxation in North American English-language Doctor of Chiropractic Programs. The authors, one from the School of Education at the Indiana Institute of Technology and the other a D.C. on the faculty of Bridgeport College of Chiropractic in Connecticut and the School of Chiropractic and Sports Science at Murdoch University in Australia, studied the academic catalogs of 16 North American chiropractic colleges for use of the term “subluxation.” The authors chose these catalogs as an indication of “what domains of knowledge are taught in the classroom and what domains are evaluated in assuring student competence.”
Their conclusion?
The concept of the subluxation in chiropractic is a controversial subject with a paucity of evidence. With the exception of three schools, all English-language DCPs [Doctor of Chiropractic Programs] in North America mention the concept of the subluxation either in course titles or descriptions and/or their respective missions. Despite the lack of evidence for the subluxation construct, it appears to be very much a key part of chiropractic education.
Some schools may state that they are not subluxation-focused or heavily engaged in the teaching of subluxation. Nonetheless, most schools continue to teach about the subluxation in what seems to be more than just a historical context. We believe that this puts the profession in an awkward position because the skeptic and/or critic of subluxation can point to chiropractic education as outdated and unscientific. Chiropractic education will have to address this issue if the chiropractic education enterprise wishes to become scientifically competitive with other healthcare sciences and produce graduates who are critical thinkers prepared as the evidence changes to change their practice and throughout their careers.
The authors specifically rejected the notion that the subluxation was taught simply as an historical concept:
One might argue that a historical presentation of the subluxation may be all we are finding references to in our research of the DCP curricula. This would be a reasonable argument if the subluxation was mentioned in only one course in a DCP program or if it was only in what was described as a philosophy course. This, in fact, only occurred at two colleges (Texas Chiropractic College and the University of Bridgeport College of Chiropractic), however, with an aggregate average of 13.5 appearances [in the catalogs] and many of those in technique classes it seems unlikely that this is purely to explain the history of [the] term in the chiropractic profession.
In support of their conclusions, the authors referenced other research finding:
- Over 88% of chiropractors surveyed favored retaining the term vertebral subluxation complex.
- Over 70% of chiropractors reported that subluxation is important to their clinical decisions and guides their clinical care of patients.
- A strong majority (over 75%) believed that subluxation was a significant contributing factor 50% or more of visceral disorders.
The article concluded with a prediction that just the sort of examination of current statutory scope of practice for chiropractors I’ve been advocating could occur: “Future research should determine if changes in regulation and research change the prevalence of the use of the term subluxation in chiropractic curricula.” [Emphasis added.]
A closer look at Canadian Memorial Chiropractic College
Despite the fact that the study found “no mention of the term subluxation” at Canadian Memorial Chiropractic College [CCMC] another article in the chiropractic literature, Attitudes of clinicians at the Canadian Memorial Chiropractic College towards the chiropractic management of non-musculoskeletal conditions, revealed that “although the concept of chiropractic treatment for non-MSK conditions is controversial, students at the Canadian Memorial Chiropractic College . . . are exposed to a variety of opinions on the subject.” In a survey of clinicians supervising interns at one of six clinics in the Toronto area, all of whom had been educated at CMCC, 50% either “agreed” or “strongly agreed” that chiropractic could be effective for the treatment of asthma, chronic pelvic pain, constipation, dysmennorhea, infantile colic and vertigo.”
This study was published in the Journal of the Canadian Chiropractic Association, which describes itself as “the official, peer reviewed, quarterly research publication of the Canadian Chiropractic Association.”
To understand the significance of 50% figure, one must realize that the referenced treatment of non-MSK conditions by chiropractors is subluxation-based: the detection of spinal “misalignments” and their “correction” through adjustments.” Without ever using the term “subluxation,” this is evident in the article’s explanations for treatment of various non-MSK conditions. [Note also the improper use of “case studies” as “evidence.”]
Asthma:
Chiropractic treatment [that is, adjustments] has been thought to be beneficial in the treatment of this condition as it posited that it may modify the autonomic system and elicit viscerosomatic reactions to it. Additionally, it has been hypothesized that misalignments at the levels of the upper C-spine create spinal reflexes that can induce asthma and correcting the misalignments could potentially alleviate the symptoms.
Constipation:
In a study conducted by Alcantara and Mayer on three pediatric patients, they found successful resolution of the condition after a regiment [sic] of spinal manipulative therapy by observing an increased frequency in bowel movements, with less straining and pain. Similarly, a case study done of a 64 year old Caucasian female demonstrated a positive resolution to chronic constipation after ten treatments of spinal manipulative
therapy.
Infantile colic:
Since an‘adjustment’ theoretically causes sympathetic stimulation which, based on physiology, in turn relaxes the smooth muscle of the gastrointestinal tract, reduces peristalsis, and inhibits bowel function, infantile colic could be effectively treated through manual therapy.
Vertigo:
A retrospective study conducted by Elster showed 100% positive response with either symptoms having improved or completely reversed within one to six months of care using a treatment plan of upper cervical adjustments.
In sum, while the CCMC does not openly mention the chiropractic subluxation in its academic catalog, its students are trained by chiropractors who accept the existence and clinical significance of the subluxation and the utility of detecting and correct it for a variety of conditions, as described in an article which wholly fails to question the concept.
National University of Health Sciences
Another institution which, according to the study of academic catalogs, did not mention the subluxation is the National University of Health Sciences (NUHS), which educates naturopaths and acupuncturists as well as chiropractors. However, had the authors examined a broader range of the school’s literature in divining support for the chiropractic subluxation and its putative effect on human health they would have found it in the form of the Journal of Chiropractic Medicine, published by NUHS and described on the school’s website thus:
Published quarterly, this peer-reviewed indexed journal meets the modern-day chiropractic physician’s need for practical and cutting-edge information with concrete clinical applications.
A review of the first 25 articles, published during 2010-2011 (a full fifteen of which were case reports) appearing in a
PubMed search for the Journal of Chiropractic Medicine, turned up the following:
According to Quackwatch, “applied kinesiology is a pseudoscience based on the anatomically and physiologically impossible notion that muscle-testing enables the practitioner to determine ‘weaknesses’ of organs throughout the body that ‘correspond’ to nutrients placed under the tongue.” Application of various applied kinesiology diagnostic methods and treatments is described in this Journal of Chiropractic Medicine article, including:
Insalvation refers to the fact that the taste buds on the tongue can detect extremely small concentrations of substances within a fraction of a second of stimulation. Oral nutrient evaluations are used in AK because they are clinically useful in the assessment process. Exposure to taste elicits a variety of neurologic, muscular, digestive, endocrine, cardiovascular, thermogenic, and renal responses . . . [T]here is considerable evidence in the literature of extensive efferent function throughout the body from stimulation of the gustatory and olfactory receptors with actual insalivation . . . Insalivation of choline (a component of the neurotransmitter acetylcholine) corrected this finding.” [It is unclear what “finding” was “corrected.”]
In a swipe at the patient’s pediatrician, the article adds:
The previous treatments did not deal directly with the craniosacral system, nor did they appear to evaluate adequately the sensory input into the nervous system from the musculoskeletal and viscerosomatic system (adrenal glands and lungs). Applied kinesiology theory suggests that to resolve biomechanical, biochemical, psychosocial, and sensory problems, many areas of the body must be examined and corrected to achieve long-lasting symptomatic relief.
Cessation of cyclic vomiting in a 7-year-old girl after upper cervical chiropractic care: a case report. The lead author is an Assistant Professor at Palmer College of Chiropractic. From the abstract:
A 7-year-old girl had a history of cyclic vomiting episodes for the past 4 ½ years. She also had a 2-month history of headaches and stomachache. . . The patient received low-force chiropractic spinal manipulation to her upper cervical
spine. [As described in the article, “The directional misalignment was determined as an anterior-right misalignment by using pediatric Duff analysis on her upper cervical radiographs.”] There was improvement in her symptoms within an hour after the chiropractic manipulation. . . This case study suggests that there may be a role for the use of chiropractic spinal manipulative therapy for treating cyclic vomiting syndrome.
Use of multimodal conservative management protocol for the treatment of a patient with cervical radiculopathy. The author is an Assistant Professor in the Department of Chiropractic at D’Youville College, Buffalo, NY. The article describes chiropractic treatment following “Gonstead chiropractic protocols” of a patient with a disk protrusion at C5-C6. Here’s a description of the Gonstead System from the Gonstead Clinical Studies Society, quoted in Keating JC, Charlton KH, Subluxation: Dogma or Science? Chiropractic & Osteopathy. Vol. 13, August 10, 2005:
Minor displacements of the spinal bones, known as vertebral subluxations, can cause endangering stress to the spinal cord which acts as the main line of intelligence for the whole body. These displacements, or subluxations, are the cause of many of the unwanted health conditions that people suffer from every day. Although there have been many valuable techniques that have been developed in the chiropractic profession, the Gonstead System is considered a ‘gold standard’ for chiropractic techniques because of its record of safety and effectiveness in correcting vertebral subluxation . . .
In addition to the articles describing “subluxation”-based treatment, of these 25 most recent articles in the Journal of Chiropractic Medicine, three discussed diagnostic techniques for the detection of chiropractic “subluxations.”
Standard deviation analysis of the mastoid fossa temperature differential reading: a potential model for objective chiropractic assessment. The author is an Assistant Director of Research at Sherman College of Chiropractic:
The mastoid fossa temperature differential (MFTD) reading is described as having been used in chiropractic since the 1950s. A temperature is obtained, without making contact, in the mastoid fossa area on both sides. An MFTD “is calculated by subtracting the mastoid fossa temperature on one side from the other side.” While “the clinical significance of the MFTD readings has yet to be determined,” nevertheless “one method for interpreting MFTD readings is with pattern analysis, where an abnormal set of baseline readings are identified and thought to be related to the condition known as vertebral subluxation.”
Computer modeling of selected projectional factors of the 84-in focal film distance anteroposterior full spine radiograph compared with the 40-in film distance sectional views. Two of the authors are chiropractors in private practice and also involved in research at the Gonstead Clinical Studies Society:
While acknowledging that the role of the full-spine anteroposterior full spine radiograph is “controversial,” the authors conclude that “working knowledge of the A-P full spine view is important . . . [as it] may be used for scoliosis
evaluation; and additionally, there are doctors of chiropractic who use the A-P full spine as part of their assessment when viewing of the full spine.” And what might they be “assessing” in the “full spine?” Although not specifically
admitted in the article, full-spine radiographs are used by chiropractors for the “detection” of “subluxations.” Peterson DH, Bergmann TF, Chiropractic Technique, Principles and Procedures, 2nd ed. (Mosby 2002), 75-79.
Geometry of colplanar stereoscopic radiographic pairs for analysis of the lateral cervical radiograph: a study using mathematical models. The author is a Research Assistant Professor at Sherman Chiropractic College. The article is of interest only to those who use X-rays to detect the presence of cervical “subluxations.”
In sum, a review of the most recent 25 articles in the NUHS- published Journal of Chiropractic Medicine reveals that NUHS has hardly rejected the chiropractic subluxation, even though its academic catalogue does not mention the term.
Life University College of Chiropractic
A recent article about chiropractic education shows how instruction in the detection and correction of subluxations is part and parcel of the core training of chiropractic students at Life University College of Chiropractic. The article, Self-Perceived Skills Confidence: An Investigative Study of Chiropractic Students in the Early Phases of a College’s Clinic Program, was written by an Associate Professor at this chiropractic school. Categories of student self-assessment surveyed for the article
. . . were those used in the early clinical curriculum. They included radiograph interpretation of the pelvis, occiput, atlas, and vertebral spine, using full-spine listings (Gonstead type) with the spinious process as a reference, and descriptive listings (fixation, malposition, misalignment, restriction) with the vertebral body as a reference, and motion palpation assessment of the corresponding anatomical areas.
Spinal manipulation categories were those used in the clinical curriculum. They included basic manual intersegmental full-spine (Gonstead-type) and diversified procedures . . .
This description is, quite literally, a textbook example of student training in the detection and correction of the chiropractic “subluxation.” Scaringe JG, Gaye, LJ, Palpation: The Art of manual Assessment (Chapter 10), Scaringe JG, Cooperstein R, “Chiropractic Manual Procedures (Chapter 12) in Redwood D, Cleveland CS, eds., Fundamentals
of Chiropractic (Mosby 2003). It was accepted for publication in a peer-reviewed chiropractic journal, the Journal
of Manipulative and Physiological Therapeutics (May/June 2010), and won a chiropractic research reward.
More “subluxation” in recent chiropractic literature
The chiropractic journal articles summarized above demonstrate that the chiropractic “subulxation” is still taught in North American chiropractic colleges as a clinically relevant condition capable of “detection” and “correction.” They also show that the putative “subluxation” is uncritically presented as such in current peer-reviewed chiropractic literature.
Even those chiropractic journals which appear to be more oriented toward an evidence-based assessment of manual therapies have recently published articles which uncritically accept subluxation-based chiropractic diagnostic techniques and therapies. In addition to the articles noted above, we find:
From the Journal of Manipulative and Physiological Therapeutics:
Interexaminer reliability of supine leg checks for discriminating leg-length inequality (2011): Discusses “functional leg-length inequality,” a bogus diagnostic method used to determine “subluxations.”
A retrospective study of chiropractic treatment of 276 Danish Infants with infantile colic (2010): Without ever describing the proposed mechanism of action by which “chiropractic manipulation” is purported to affect infantile colic, reaches the conclusion that “the findings of this study do not support the assumption that effect of chiropractic treatment of infantile colic is a reflection of the normal cessation of this disorder.”
Running posture and step length changes immediately after chiropractic treatment in a patient with xeroderma pigmentosum (2009): “A 5-year-old female patient with XP (type A) volunteered to participate in the experiment with the consent of her parents . . . [T]he patient was assessed for spinal dysfunction and adjusted (full spine) using diversified techniques . . . Adjustments were delivered in an attempt to correct any or all of the spinal dysfunctions that the clinician [a chiropractor] found at the time of the experiment.”
Journal of the Canadian Chiropractic Association:
Chiropractic care for patients with asthma: A systematic review of the literature (2010): States, without criticism of the lack of scientific plausibility underlying the concept, that “in treating asthmatic patients, the objective of chiropractic spinal manipulative therapy (high amplitude, low velocity thrusts) is . . . to affect nervous system activity.”
Chiropractic care of a pediatric patient with symptoms associated with gastroesophageal reflux disease, fuss-cry-irritability with sleep disorder syndrome and irritable infant syndrome of musculoskeletal origin (2008): “it was determined that the patient had spinal segmental dysfunctions of the atlas and the 4th thoracic vertebrae. The atlas was determined to have a right posterior rotation and right laterally malposition with respect to the C2 vertebral body (VB). The 4th thoracic VB had a posterior malposition with respect to C3VB. Following craniosacral technique procedures, cranial distortions of the right parietal and temporal bones were determined as well as aberrant motion of the mandible at the right temporomandibular joint (TMJ).” And so on.
More criticism of chiropractic, by chiropractors
Admirable for their criticism of the “subluxation,” other recent articles in the literature critical of chiropractic reveal the “subluxation’s” continued presence in the current practice of chiropractic in North America and in Australia. As well, they demonstrate that some of the same criticisms of chiropractic posted on SBM have been expressed by
chiropractors themselves.
An article published in Chiropractic and Manual Therapies this year, authored by 3 chiropractic academics, found that “patients searching the Internet for chiropractic wellness information will often find a lot of poorly done, useless
information that will not help them maintain health or become well.” Significant to our discussion here, of the
sample studied:
- 77% of sites contained information on chiropractic “subluxation”
- 60% had information on “innate”
- 34% contained obvious anti-vaccination information
- 34% had information that was anti-drug (prescription or medical use of drugs)
The authors concluded that “the depth of information on the sites analyzed was poor and was
rarely evidence-based.”
Another article, published in Chiropractic and Osteopathy (as the journal Chiropractic and Manual Therapies was formerly named) in 2010 surveyed a sample of non-practicing chiropractors and their reasons for leaving chiropractic practice. Due to the small sample size and low rate of response, the authors state that “generalizations to broader populations should be made with caution.” Yet, the results reveal a notable congruence between the negative opinions about chiropractic expressed on SBM and those who had actually left the practice of chiropractic:
- 80% agreed that business ethics in chiropractic were perceived as questionable.
- 62% disagreed with the statement that chiropractic education is an asset when pursuing another career.
- 60% agreed that dogma and philosophy of chiropractic were reasons to abandon active practice.
- 71% believed that associates in a chiropractic practice are often encouraged to prolong the care
of patients. - 74% believed that the chiropractic profession lacked cultural authority.
- 58% agreed that the political problems in chiropractic were factors in being perceived as a
quality clinician.
This frustration with chiropractic was shared in another recent article in the same journal authored by an Australian chiropractor and based on a lectured delivered at the Annual Conference of the Chiropractic & Osteopathic College of Australasia, in 2010. The author bemoans the fact that
- The Chiropractors Association of Australia (CCA) “actively promotes subluxation based chiropractic.”
- “Chiropractic trade publications and so-called educational seminar promotion material often abound with advertisements of how practitioners can effectively sell the VSC [vertebral subluxation complex] to an ignorant ublic.”
- The CCA and the Australian Spine Research Foundation (ASRF) “are promoting ‘wellness care,’ which involves the detection and adjustment of VSC’s,” noting a recent statement in the ASRF’s newsletter that “. . . it is not possible to be well if vertebral subluxation complex is present as a vertebral subluxation complex represents a non-homeostatic state . . . . which makes a state of wellness impossible.”
- Of the three chiropractic teaching institutions in Australia, the program at RMIT University
promotes what the author calls “the subluxation myth.”
Conclusion
Criticisms of chiropractic on Science-Based Medicine are not the reflection of misunderstanding of contemporary chiropractic practice in that, according to chiropractic literature:
Subluxation dogma continues to be a part the education and training of chiropractors in North American and Australia.
Subluxation-based chiropractic remains an integral part of chiropractic practice in North America and Australia, as demonstrated by the uncritical acceptance of articles discussing its implausible diagnostic methods and treatments in peer-reviewed chiropractic journals, its presence in surveys of chiropractic practice in peer-reviewed chiropractic literature, as well as the aforementioned inclusion in chiropractic education.
