Will the Real Subluxation Please Stand up?

by John H. Gantner, DC Diplomate, American Board of Chiropractic Orthopedists

 

            Dr. John Gantner is a 40-year chiropractic practitioner, graduating from PCC in 1960. He has been very active in professional affairs during his long career. He is a past president of his local district (Rochester) of the NY State Chiropractic Association. He has served in the NY State Chiropractic Association House of Delegates for over 20 years. He is a past ACA State Delegate for Upstate NY and has served as President of the ACA Council of Delegates and as Vice President of ACA. He is a past member of the Board of Governors of ACA. Dr. Gantner is the only chiropractor in the State of NY ever to be appointed by the Governor (Cuomo) to a Temporary State Commission on Workers Compensation, (1991). He publishes the “NY Comp Letter,” a quarterly newsletter regarding NY State Workers Compensation issues and conducts classes on Workers’ Compensation procedures for NY State Chiropractors. He has published articles in Dynamic Chiropractic, the Digest of Chiropractic of Economics and the ACA Journal of Chiropractic.

 

A recent article about subluxation listings in DC caught my attention. Drs. Cooperstein and Haas wrote the article.l They claim, “..the notion of a specific chiropractic diagnosis (i.e., “listing”) may be more wishful thinking than reality?” With all due respect to Drs. Cooperstein and Haas, two of our finest, there is recent research2,3 that clearly proves that the chiropractic listings such as PRS, PLI-M, etc. are invalid, i.e., vertebrae do not move in that manner. In my view, they are “missing the forest for the trees.”

            I don’t mean that as an insult, but as a level of thinking. Recall back to high school geometry, during which your teacher told you that you couldn’t trisect an angle with a ruler and compass, but you tried anyway! The proof of that theorem is provided in a junior or senior level college course in advanced abstract algebra and cannot be understood in a lower plane of thinking (i.e., plane geometry). Drs. Cooperstein and Haas are two planes of thinking in complexity below the Harrisons. I should say the biomechanics literature, not the Harrisons, for that is what the Harrisons are using. To illustrate my ideas consider the following table with levels of thinking.

            The Harrisons have published numerous articles (in JMPT, Clinical Biomechanics, Spine, Journal of Orthopedic Research, Journal of Spinal Disorders, and the European Spine Journal) about this Table. However, Drs. Cooperstein and Haas continue to use level 1 analysis (“trees = x-ray listings”) instead of realizing the “forest = complex spinal coupling in 3-D” is level 2 and the “continent = postural displacements” is level 3 thinking! Why are two of our most respected chiropractic researchers still studying spinal listings taken from 2-D x-ray thinking instead of the 3-D postural positions that cause these radiographic projected images from which listings are taken? For a simple example, consider three single postures of the thoracic cage compared to the pelvis (+Rz = right lateral bending, +Ry = left posterior rotation, and -Tx = right lateral translation) in Figure 1. Note that in Figure 1, we are looking at the postures from the front view and the x-ray images from behind.

           

Level of Analysis	Engineering Principles
3	Postural Main Motions in 3D, measured as Rotations and Translations
CAUSES
2	Complex Spinal Coupling Patterns in 3D with 6 Degrees of Freedom
CAUSES
1	X-Ray Projected 2D Spinal Images from which Listings are Determined

 

How would you list L4 (1st vertebra off eye level) in Figures 1A, 1B, and 1C? Lumbar #4 is PRI-M right? Wrong! Lumbar #4 has a complicated position due to 3-D coupling from main motion postural displacements, but is projected similarly from three entirely different postures! I can’t draw you L4’s complex coupling patterns; it would take a computer. However, you see my point that three completely different postures have the same listing for L4, which means the same manipulation/adjustment is applied! Cooperstein and Haas might counter that they use other diagnostic tools to determine their listings, however, they have this invalid model of spinal displacement from projected images in their minds.

            Also note that the “P” in PRI-M has been shown by the Harrisons3 to be incorrect at least 75% of the time (i.e., the vertebra go “A” in nine out of 12 loadings).2,3 It’s time for our chiropractic researchers to include an analysis (pre & post with statistics) of every subject’s posture in 3-D as rotations and translations (Rx, Ry, Rz, Tx, Ty, Tz of the head, rib cage, & pelvis). Let’s compare the clinical outcomes to postural outcomes. If no change in posture, then no change in 2-D x-ray listings, so no change in subluxation!

            The chiropractic profession is built around the subluxation, it’s determination, adjustment and correction. Today we see “A-subluxation-based” practices alongside “An ordinary” chiropractic practices.  But does that mean that the subluxation-based doctor uses a special protocol to determine the subluxation? No indeed. Some use simple palpation, others use some sort of instrumentation which registers telltale signs of the subluxation according to their individual protocol(s). 

            This is another way of saying that there is no standardized protocol to determine the vertebral subluxation. Likewise for the adjustment of that subluxation. Does the “A- subluxation-based” doctor offer a different type of adjustment than the “An ordinary” chiropractor? Both are a strictly personal decision. Various guidelines fail to establish the mechanics of subluxation detection or correction. And for the most part, our techniques fail to tell us when the subluxation is gone. Clearly, they do not stand up.

 

            In today’s chiropractic profession, it is not uncommon for two or more DCs to find and adjust a different subluxation in the same patient with the same complaint. And this is true if both doctors were in the same class from the same school.

            The absence of standardized criteria to establish the presence (and absence) of the subluxation arises from the varying views of our pre and postgraduate instructors and from our personal experiences. It follows that once you have a license to practice chiropractic you can call anything a subluxation. That license also makes you the only authority on where your patient’s subluxation exists, when it is present and when it is gone. Bottom line, outside of the doctor's personal opinion, it is impossible to make a strong case for treatment. One soon learns that an individual doctor’s subjective view of the need for treatment often fails to stand up.

            Yes, there are the x-ray descriptors of the subluxation that were created for Medicare documentation during the 70’s.  These are for x-ray analysis only and we all know that those are rarely what we palpate and not all what we adjust in most Medicare patients. 

            Clearly, the subluxation has us running in circles, like a cat chasing its tail. And like the cat, all we do is burn up energy that could be better used elsewhere.

            After over a century of effort and argument, it is obvious that the individual vertebral subluxation is impossible to standardize. This fact has spawned various techniques, each leading to any number of different treatment protocols.  How long can we go on this way? We simply cannot support a mature profession on the basis of hearsay. It simply doesn’t stand up.

            Is there an answer? In my view, there is. It lies with the chiropractic literature. This is written regularly in JMPT and other publications by authors who have taken the time to study our work and offer answers.  But most of these are supported by anecdotal evidence such as case studies and/or letters to the editor.  A serious study reveals that literature created by Harrison establishes the normal cervical, thoracic and lumbar lordosis.  This work is scientifically based and respected by thinking people in other professions. Respected researchers in Biophysics endorse its findings. It is therefore beyond hearsay or subjective determinations. In other words, it stands up.

            This impressed me and here’s why: CBP® has based its research and its clinical protocols, not upon the determination of a specific vertebral subluxation but upon clear deviations in posture.  CBP® texts list hundreds of possible postural deviations — the sort of thing we each see (but often ignore) every day. It postulates further that the decay of our posture — for any of a number of reasons —  is responsible for a loss of juxtaposition of more than individual vertebra —  but of contiguous areas of the spine.

            The clinical experience of any chiropractor is that many patients get better from adjustments alone. This aligns perfectly with the strong contention of many of our “principled” colleagues and we have no quarrel with that. But all chiropractors have had the experience of seeing a patient recover with adjustments but, once discharged from care,  worsened again. Why?  Was something overlooked? Was the treatment you offered less than effective? Did your adjustments simply remove fixations which for some reason, returned again.

            Our philosophy teaches us to rationalize these to patients who require supportive treatment, often forever.  This may or may not be true. Supportive treatment based only on our opinion that the patient’s symptoms will not stay away causes us to get a bad name from insurance carriers. They feel we treat too long. It’s time we looked a little harder at why these patients worsen without treatment.

            What’s wrong? Simple. We have adjusted the vertebrae as we saw fit until the symptoms went away. That’s fine. But maybe we never completely removed whatever it was that caused the pain (is pain = subluxation?). It’s time to address that. One thing that can be responsible for the return of symptoms is postural stresses. This is consistent with the findings of chiropractic research done by Harrison. CBP® offers the tools to understand and correct these postural stresses in the form of  Mirror Image® adjusting and  corrective exercises which address the specific postural deviations that the patient presents.

            One discovers that posture is something that lends itself to study more easily than the specific vertebral subluxation. Whereas the vertebral subluxation is characterized (and determined) in many proprietary ways, posture can be (and has been) quickly standardized. In the literature, posture is termed the MAIN motion and vertebral displacements are the COUPLED motions, i.e., posture causes spinal displacements. Working on the basis of posture the task for the chiropractic clinician then becomes uniform: to analyze the posture. This can be categorized and measured. Postural changes are both obvious and are treated the same by any doctor familiar with CBP® protocol.  If that sounds like standardization of our work, you are correct.

            Using this line of reasoning, one can see that a cervical spine can subluxate on the thoracic spine — or the lumbar spine to subluxate on the pelvis. There are other (many) possibilities, each requiring specific corrective techniques. The bottom line is that for the first time in history a chiropractor can restore a cervical lordosis, for instance, and on purpose! Better than that, the doctor can use this data to make a case for long term treatment using the same protocols. This is no longer a private (subjective) opinion, it is a realistic and objectively based opinion consistent with the literature.

            Is the use of posture consistent with the literature? Indeed it is. Posture has been studied by various health care professionals for more than a century.  Reliability and validity of using posture has been established in the literature. Harrison has categorized posture in terms of engineering, i.e., as rotations and translations of the head, rib cage, and pelvis in 3-D. In fact, also it was Harrison, a chiropractor, who set forth the normal values for the sagittal spinal curves, for cervical, thoracic and lumbar lordoses.

            More than a few DC’s throughout the world currently use CBP® techniques to help their patients, especially those that tend towards recidivism. Some learned it in school as an elective,4 others in post graduate study. With time CBP® protocols are proving to be a reasonable, logical and effective approach to chiropractic practice. They can be duplicated. They are standardized. They don’t just “work” as some of our “principled” colleagues tell us about what they do — it works for a reason that can be clearly explained and understood. That’s far better than simple belief. It puts us squarely where we belong, within a respected discipline — one that stands up!

 

REFERENCES

1.         ‑‑Cooperstein R, Haas M. The listings continuum: Driving a truck through a paradox. Dynamic Chiropractic 2001;19(20): 28-29, 36.

2.         Harrison DE, Harrison DD, Troy-anovich SJ. Three-Dimensional Spinal Coupling Mechanics. Part I: A Review of the Literature. J Manipulative Physiol Ther 1998; 21(2): 101-113.

3.         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.

4          At this time, most Chiropractic colleges have resisted placing CBP® technique into their Core Curricu-lum. By making it an elective, the student must often pay extra for it. This discourages more than a few students from receiving such training.