The Death and Resurrection of Spinal Subluxation:

A CBP® Researcher's Perspective

By Deed Harrison, D.C.

Abnormal postural positions of the human frame and associated spinal displacement patterns has been proposed as the most common type of spinal subluxation.
As such, postural analysis and spinal radiography are important tools for Chiropractic clinicians interested in identification and treatment of vertebral subluxations.1,2 Recently, however, some researchers in Chiropractic have suggested that the traditional concept of spinal displacement originated by DD Palmer, as a component of vertebral subluxation is unreliable, invalid, and outdated.3 As such, many researchers in Chiropractic have
abandoned the “bone out of place” model of vertebral subluxation and have moved toward the concept of a “manipulable lesion” as the primary dysfunction of the spinal column. Consider, for example, the following statements made by some of the most prominent researchers in the Chiropractic profession:
1) “Valid and reliable tests to detect a manipulative lesion have not been established. Therefore, the presence of such lesion remains hypothetical. However, improvements in study designs might improve future evidence, and great efforts are needed to develop, establish and enforce valid and reliable test procedures.” Hestbaek and Leboeuf-Yde WFC, Paris, 2001, May 21-26
2) “At this time, SD (spinal dysfunction-subluxation) cannot be reliably detected using the clinical methods investigated in these studies. Further, a valid operational definition of spinal dysfunction remains elusive. The construct of SD and the existence of a specific manipulable lesion therefore remain speculative.” Crawford and Littlejohn CMCC — WFC Paris 2001, May 21-26
3) “In light of the findings of these studies, there is no doubt that the chiropractic profession must tackle the problems surrounding the detection of ‘manipulable lesions.’ A jury of researchers needs to define this term, design reliable and valid tests, and establish precise standards for using those tests—and the sooner the better.” Feise RJ. JMPT Letter Feb 2001
4) “No study has been conducted to evaluate the validity of the presence of manipulable lesions in the lumbar spine. Manipulable lesions may be a figment of the collective chiropractic, and other physical therapy professions’ imagination.” French et al. JMPT May 2000: 231-238

Now, before blood pressures begin to rise, let me explain why this situation exists and how we can rectify it. First, and foremost, these researchers have no definition of normal or non-lesioned. Second, they have not truly defined what a “manipulable lesion”
is. Because of the above two reasoning errors, there is not any way possible to have reliable, let alone valid, methods to detect this enigma.
How do we, at CBP®, propose to rectify this situation in Chiropractic? The answer itself is simple, but the tasks required to fulfill the requirements are difficult and time consuming: 1) We need to strictly define what normal is, 2) We need to strictly define what abnormal is, 3) We need to have reliable and valid methods for measuring or detecting abnormal, 4) We need to provide evidence that the abnormal(s) cause or are associated with known disorders, 5) We need to develop methods to correct this abnormal
subluxation, 6) We need to use the same valid and reliable methods in the third section to verify the correction of the abnormal, and 7) Finally, we need to document that correcting these abnormals will improve/resolve the known disorders in number four above.
Fortunately, all of these items have been or are being addressed and answered by researchers at Chiropractic Biophysics® Nonprofit, Inc.
Let me explain how we have answered several of items 1-7 above. Concerning Item #1 above, we have written in detail about the normal/ideal alignment of the human spine.1,2,3-7 We, at CBP® Nonprofit, Inc., have developed and published our ideal and average models of the shape and magnitude of the cervical and lumbar lordosis and are currently in the process of revising our average and ideal model of the thoracic kyphosis.6,7 Figure 1 represents this Ideal model of the human spine/frame from both the anterior and lateral perspectives.
Now that we have a strictly defined normal starting position, abnormal alignment (Item #2 above) can be described. Using definitions from mechanical engineering and probability theory in mathematics, all the possible abnormal postural displacements of the head, thorax, and pelvis have been described by Harrison as rotational and translational movements in three-dimensions.8-11 These rotations and translations of the head, thorax,
and pelvis are abnormal postural displacements when present in neutral static upright stance. Further, these postural displacements are always associated with spinal/vertebral displacements (rotations and translations) away from the normal position described in Figure 1.12,13 Actually, any displacement (rotation and/or translation) away from the neutral/normal position in Figure 1 would be described as abnormal.
Item #3: In order to identify or prove that an abnormal spinal or postural displacement is present, there must be valid and reliable methods for measuring such abnormality. Fortunately, measurement devices to detect abnormal skull, thoracic, and pelvic postures, have been found to have high/excellent inter- and intra-examiner reliability, and some of these devices have been found to have appropriate validity.14-27
These devices include simple plumb-line analysis, computerized assessment, and other simple devices for each individual area. Recently, a digital camera, computerized, assessment tool, the BioTonix system, was developed for the assessment of abnormal upright posture. We are currently in the process of studying the reliability and validity of this system. Figure 2 is an example of the BioTonix posterior to anterior view analysis for a patient with right thoracic translation. In addition to posture analysis, x-ray measurement procedures, for the quantification of spinal displacements, have been found to be reliable.28-35 In the lateral view, these measurements are valid, however, in the anterior to posterior view there are some validity concerns that must be appropriately understood. Figure 3 demonstrates the spinal coupling patterns (vertebral displacement) for the posture in Figure 2 and the type of x-ray measurement procedure for the Anterior to posterior lumbo-pelvic spine.
Item #4: The evidence for abnormal spinal postures and spinal configurations being associated with symptoms or known diseases is growing in the literature.1,2
However, there still exists gaps in this information which must be filled before absolute conclusions can be drawn.
Item #5: In the early 1980’s, Harrison developed Chiropractic Biophysics® Technique (CBP®). CBP® technique is based on linear algebra principles.8-11 In order to correct or reduce abnormal postures, each individual rotation and translation of the skull, thorax, and pelvis is placed into its unique inverse. This unique inverse position is termed the “mirror image” and the adjustment is therefore, called Mirror Image® adjusting.
The outcomes of these procedures have not been fully studied to date, however, a few of our recent studies have provided validity for this approach. Figures 4 and 5 demonstrate two of Harrison’s Mirror Image® procedures to correct the abnormal right thoracic translation posture and x-ray coupling pattern depicted in Figures 2 and 3.
Item #6: In order to verify correction of abnormal posture and spinal displacement after application of appropriate treatment, it is obviously necessary to utilize the same valid and reliable posture analytical system and x-ray line drawing methods discussed under item #3.
Item #7: The documentation of improvement in spinal conditions or disease processes following the application of corrective procedures is the most challenging problem of the above listed items. None in Chiropractic research today can claim to have adequately documented this issue. However, if the Chiropractic profession embraced an appropriate model of subluxation, as discussed here, then advancement in this critical area might be made.
In Conclusion, I don’t believe that most Chiropractic clinicians really understand the state of their profession today. If our profession cannot agree on a model of subluxation, cannot find reliable and valid methods of detecting subluxation, then how can we ever document the correction of subluxation and the benefits to our patients?
Some clinicians may believe this issue to be irrelevant to their daily practice, however, rest assured that this issue is of grave concern to all of us. After all, guidelines for “quality
assurance” used to support or limit Chiropractic coverage are based on the studies that Chiropractic research puts forth. In upcoming issues, I will apply the above 7 items to specific postural and spinal displacements in order to familiarize the reader with the benefits of the Chiropractic Biophysics® subluxation model and treatment approach.

References
1. Harrison DE, Harrison DD, Troyanovich SJ. Reliability of Spinal Displacement Analysis on Plane X-rays: A Review of Commonly Accepted Facts and Fallacies with Implications for Chiropractic Education and Technique. J Manipulative Physiol Ther 1998; 21(4):252-66.
2. Harrison DE, Harrison DD, Troyanovich SJ. A Normal Spinal Position, Its Time to Accept the Evidence. J Manipulative Physiol Ther 2000; 23: 623-644.
3. Haas M, Taylor JAM, Gillete RG. The routine use of radiographic spinal displacement analysis: A dissent. J Manipulative Physiol Ther 1999;22(4):254-259
4. Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca CJ. Evaluations of the Assumptions Used to Derive an Ideal Normal Cervical Spine Model. J Manipulative Physiol Ther 1997;20(4): 246-256.
5. Harrison DD, Troyanovich SJ, Harrison DE, Janik TJ, Murphy DJ. A Normal Sagittal Spinal Configuration: A Desirable Clinical Outcome. J Manipulative Physiol Ther 1996; 19(6):398-405.
6. Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of Lordotic Cervical Spine Curvatures to a Theoretical Ideal Model of the Static Sagittal Cervical Spine. Spine 1996;21:667-675.
7. Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE. Can the Sagittal Lumbar Curvature be Closely Approximated by an Ellipse? J Orthop Res 1998;16(6): 766-770.
8. Harrison DD, Janik TJ, Harrison GR, Troyanovich SJ, Harrison DE, Harrison SO. Chiropractic Biophysics Technique: A Linear Algebra Approach to Posture in Chiropractic. J Manipulative Physiol Ther 1996;19(8):525-535.
9. Harrison DD. CBP®? Technique: The Physics of Spinal Correction. National Library of Medicine #WE 725 4318C, 1982-97. Harrison DD. CBP® Technique: The Physics of Spinal Correction.
10. Harrison DD. Spinal Biomechanics: A Chiropractic Perspective. National Library of Medicine #WE 725 4318C, 1982-97. Harrison DD. CBP® Technique: The Physics of Spinal Correction.
11. Harrison DD. Abnormal postural permutations calculated as rotations and translations from an ideal normal upright static spine. In: JJ Sweere, editor, Chiropractic Family Practice. Gaithersburg: Aspen Publishers, pp.6-1:1-22, 1992.
12. Harrison DE, Harrison DD, Troyanovich SJ. Three-Dimensional Spinal Coupling Mechanics. Part I: A Review of the Literature. J Manipulative Physiol Ther 1998; 21(2): 101-113.
13. Harrison DE, Harrison DD, Troyanovich SJ. Three-Dimensional Spinal Coupling Mechanics. Part II: Implications for Chiropractic Theories and Practice. J Manipulative Physiol Ther 1998; 21(3): 177-86
14. De La Huerta F, Leroux MA, Zabjek KF, Coillard C, Rivard CH. Stereovideoographic evaluation of the postural geometry of healthy and scoliotic patients. Ann Chir 1998;52(8):776-83.
15. Leskinen T, Hall C, Rauas S, Ulin S, Tonnes M, Viikari-Juntura E, Takala EP. Validation of Portable Ergonomic Observation (PEO) method using optoelectronic and video recordings. Appl Ergon 1997 Apr;28(2): 75-83.
16. Petersib Dem Blankenship KR, Robb JB, Walker MJ, Bryan JM, Stetts DM, Mincey LM, Simmons GE. Investigation of the validity and reliability of four objective techniques for measuring forward shoulder posture. J Orthop Sports Phys Ther 1997;25(1): 34-42.
17. McLean IP, Gillan MG, Ross JC, Aspden RM, Porter RW. A comparison of methods for measuring trunk list. A simple plumbline is the best. Spine 1996;21(14): 1667-70.
18. Gross MT, Burns CB, Chapman SW, Hudson CJ, Curtis HS, Lehmann JR, Renner JB. Reliability and validity of rigid lift and pelvic leveling device method in assessing functional leg length inequality. J Orthop Sports Phys Ther 1998;27(4): 285-94.
19. Brouwer B, Culham EG, Liston RA, Grant T. Normal variability of postural measures: implications for the reliability of relative balance performance outcomes. Scand J Rehabil Med 1998;30:131-27.
20. Dao TV, Labelle H, Le Blanc R. Intra-observer variability of measurement of posture with three-dimensional digitization. Ann Chir 1997;51(8):848-53.
21. Baker CP, Newstead AH, Mossberg KA, Nicodemus CL. Reliability of static standing balance in nondisabled children. Pediatr Rehabil 1998; 2(1): 15-20.
22. Ployon A, Lavaste F, Maurel N, Skalli W, Dubousset J, Zeller R, Rolland Gosselin A. A protocol of in vivo 3D experimental evaluation of global posture and motion of the spine. Rev Chir Orthop Reparatrice Appar mot 1997;83(8): 719-29.
23. Harrison AL, Barry-Greb T, Wojtowicz G. Clinical measurement of head and shoulder posture variables. J Orthop Sports Phys Ther 1996;23(6): 353-61. Med Phys Fitness 1995;35(4): 289-94.
24. Lundstrom A, Lundstrom F, Lebret LM, Moorrees CF. Natural head position and natural head orientation: basic considerations in cephalometric analysis and research. Eur J Orthod 1995;17(2):111-20.
25. Garrett TR, Youdas JW, Madson TJ. Reliability of measuring forward head posture in a clinical setting. J Orthop Sports Phys Ther 1993;17(3): 155-60.
26. Alviso DJ, Dong GT, Lentell GL. Intertester reliability for measuring pelvic tilt in standing. Phys Ther 1988;68(9): 1347-51.
251. Vernon H. An assessment of the intra-and inter-reliability of the postureometer. J Manipulative Physiol Ther 1983;6(2): 57-60.
27. Raine S, Twomey LT. Head and shoulder posture variations in 160 asymptomatic women and men. Arch Phys Med Rehabil 1997; 78(11):1215-23.
28. Jackson BL et al. Chiroparctic Biophysics Lateral Cervical Film Analysis Reliability. JMPT 1993; 16(6):384-91.
29. Troyanovich S et al. Intra- and Interexaminer Reliability of the Chiropractic Biophysics Lateral Lumbar Radiographic Mensuration Procedure. JMPT 1995; 18(8):519-24.
30. Troyanovich S et al. A Further Analysis of the Reliability of the Posterior Tangent Lateral Lumbar Radiographic Mensuration Procedure: Concurrent Validity of Computer Aided X-Ray Digitization. JMPT 1998; 21(7):460-67.
31. Troyanovich S et al. Chiropractic Biophysics Digitized Radiographic Mensuration Analysis of the Anteroposterior Lumbar View: A Reliability Study. JMPT 1999; 22(5):309-15.
32. Troyanovich S et al. Chiropractic Biophysics Digitized Radiographic Mensuration Analysis of the Anteroposterior Cervicothoracic View: A Reliability Study. JMPT 2000; 23(7):476-82.
32. Harrison DE et al. Cobb Method or Harrison Posterior Tangent Method: Which is Better for Lateral Cervical Analysis? SPINE 2000; 25(16):2072-78.
33. Harrison DE et al. Centroid, Cobb, or Harrison Posterior Tangents: Which to Choose for Analysis of Thoracic Kyphosis? SPINE 2001; 26:E235-E242
34. Harrison DE et al. Determination of Lumbar Lordosis: Cobb Method, Centroidal Method, TRALL or Harrison Posterior Tangents? SPINE 2001; 26:E227-E234.
35. Harrison DE et al. Further Reliability Analysis of the Harrison Radiographic Line Drawing Methods: Crossed ICCs for Lateral Posterior Tangents and AP Modified Riser-Ferguson. JMPT 2001; 24:in Press.

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