Edward F. Owens, Jr. MS, DC
INTRODUCTION
Increased utilization of complementary and alternative medicine (CAM) in the marketplace has been a major force driving acceptance and investigation of unconventional health care models in scientific circles. In part, health care professionals need to understand what benefits lead their patients to seek care outside of the usual channels. It is also vital to determine if there are risks involved with unorthodox health methods about which patients need to be informed.
The increased recognition of the value of different views of health care will perhaps open the door for the chiropractic profession to be accepted as a mainstream health care specialty. In preparation, chiropractic research agenda conferences sponsored by the Health Resources and Services Administration (HRSA) have focused particularly on interdisciplinary projects and mentorship. The goal has been to raise the quality of chiropractic research to a level that would allow it to compete more successfully for funding from the National Institutes of Health (NIH) and hence bolster the science underlying chiropractic.
Still, there are barriers to the acceptance of chiropractic. One barrier is an internal conflict over how the profession defines itself. On one hand, many practitioners and some schools consider the concept of the vertebral subluxation to be the central focus of practice. There is, on the other hand, a perception within the profession that chiropractic might be better accepted as a mainstream health care model if it would get rid of the "subluxation mumbo jumbo." By all means, we should get rid of the mumbo jumbo, but we should keep the vertebral subluxation model as the central focus of chiropractic.
This article will delve into some of the advantages and challenges facing the profession depending on whether we choose to adhere to or reject the vertebral subluxation model as an essential part of chiropractic.
FACTIONS AND PROFESSIONAL OBJECTIVES
There is widespread recognition by chiropractic writers of the fundamental factions represented by the terms "straights" and "mixers." What began in the early days of the profession, perhaps as an attempt by BJ Palmer to maintain control of the profession or to avoid prosecution for practicing medicine without a license, exists today as a fundamental split in the practice objectives of chiropractors. Even though contemporary writers acknowledge the presence of the factions, the straight model of chiropractic has not been well elucidated. For example, straight chiropractic is often viewed as limited in scope: "Doctors of chiropractic, and those closely associated with this science, realize there are at least two major philosophies of chiropractic: straight chiropractic, and health care that incorporates a broader view of what chiropractic physicians can and should provide their patients." 1, pg 21
Often the straight view is presented as simply the concept that there is "a single cause and cure for ailments." 1, pg 21 While some straight chiropractors seem to adhere to this concept, perhaps in honor of chiropractic's "developer," BJ Palmer, or perhaps from dogmatic adherence to an extreme alternative view of health care, some mixer chiropractors also seem to perpetuate the concept of "one cause, one cure," perhaps because it provides an easy target for ridicule. This particular piece of mumbo-jumbo certainly needs to be jettisoned, by straights and mixers alike. Unfortunately, the one cause, one cure concept is so closely associated with chiropractic's model of vertebral subluxation that the vertebral subluxation is in danger of being thrown out with it.
In a more refined view of chiropractic models of health care, there are at least four distinct practice objectives, only one of which is independent of a subluxation model. The practice objective which is independent of a vertebral subluxation model is the use of spinal manipulation for musculoskeletal conditions for which it has been found efficacious through rigorous research. The current list of conditions that are known to respond well to spinal manipulation includes acute low back pain, certain types of headaches, and neck pain. This model of chiropractic will probably fit in well with mainstream health care as a subspecialty of orthopaedics or physical therapy, using manipulation as an alternative treatment for back pain.
The three other models of chiropractic all share a common view that some abnormality of the spinal articulations can lead to disturbed intra-cellular communication over the nervous system. Spinal abnormalities with concomitant neural disturbance are termed vertebral subluxations. Thus, these three distinct practice models all focus on the detection and correction of vertebral subluxation, but differ in how they view the vertebral subluxation in relation to health and disease.
Traditional straight chiropractors rely on anecdotal evidence that patients with a wide array of physical complaints and diagnosed diseases have had remarkable recoveries after receiving chiropractic adjustment. This therapeutic model of vertebral subluxation goes back to the first chiropractic adjustment by DD Palmer and is closely identified with the one cause, one cure phrase. There are, however, other subluxation-centered practice models that use the adjustment as preventive care or in a non-therapeutic mode.
Interestingly, the extreme traditional one cause, one cure model is very much like the musculoskeletal manipulation model. Both use forces applied to the joints as a therapy for certain conditions. Traditional straight chiropractors, however, are willing to apply adjustment for a very wide array of conditions, while musculoskeletal manipulators voluntarily restrict care to a certain set of conditions. In both models, the appearance of symptoms, such as pain and tenderness, or organ dysfunction, indicates the need for care. Diagnosis of a condition dictates the application of the therapy, whether it be manipulation of a fixed joint, or adjustment of a particular spinal articulation because its nerve outflow is linked to a particular organ.
In terms of the science behind these two methods, the one cause, one cure approach is easy to refute. It is recognized that most diseases, especially chronic ones, have many causes, ranging from genetics and diet, to psychological stress. The observation that organic diseases have spontaneously resolved in some patients under chiropractic care suggests that, in those cases, chiropractic adjustment or contact with the chiropractor may have been just what those patients needed. It does not, however, suggest that all patients who exhibit those symptoms also will benefit from similar care.
Musculoskeletal conditions, on the other hand, are most likely associated with physical trauma or overuse. The manipulation is not related to the cause, but is used to correct a fundamental flaw in the structure by inducing movement in a restricted joint, stimulating joint mechanoreceptors or increasing blood flow into an ischemic area.
The other two subluxation-dependent models of chiropractic might be called preventive or non-therapeutic, based on their objectives. In preventive subluxation care, the vertebral subluxation complex (VSC) describes the whole gamut of tissue and organ level dysfunctions that are associated with spinal lesions.2 Degeneration of tissues is thought to occur in areas of disturbed kinematics, which can eventually lead to arthritic changes in the joints or nerve involvement if the disturbance is not addressed. Care is focused on detecting areas of kinematic dysfunction and correcting them before symptoms arise. In this case, chiropractic care is indicated whether symptoms are present or not.
Non-therapeutic vertebral subluxation-centered care, also called "objective straight chiropractic" by some of its adherents, takes a further step away from using adjustment as a therapy for any condition. As strictly interpreted, there is no inference that vertebral subluxation will necessarily lead to disease later on. Rather, it is pointed out that the vertebral subluxation is already, in some way, interfering with proper functioning of the nervous system, which governs the body's ability to perform and adapt; hence it should be corrected immediately. Once corrected, the spine should be checked for the possible recurrence of vertebral subluxation at regular intervals.
In this model, the influence of vertebral subluxation can be subtle and therefore not necessarily recognizable by the patient. Hence, subluxation should be corrected whether the patient is exhibiting symptoms or not. Since the presence or absence of symptoms of diagnosable disease is seen as not necessarily germane to the location and correction of vertebral subluxation by many objective straight chiropractors, they may place very little emphasis on the diagnosis of health conditions other than those that might be life threatening.
Outlining these two non-therapeutic models of subluxation-centered chiropractic illustrates that the concept of subluxation can be separated from the one cause, one cure model. With their emphasis on the location and correction of vertebral lesions, these models consider the subluxation as a problem in and of itself, and therefore approach its elimination as an issue independent of care given for the treatment of diseases.
It is difficult to estimate the percentage of practicing chiropractors that fall into each of the four practice models outlined above. Certainly there are chiropractic schools that specialize in one area or another, but graduates are free to choose the model that works best for them. In a survey of chiropractors' attitudes toward research, it was found that more than half were interested in seeing the continued research into vertebral subluxation,3 suggesting that practitioner support for one or more of the vertebral subluxation models of practice is significant.
ALTERNATIVE VERSUS COMPLEMENTARY
Both musculoskeletal manipulation and traditional therapeutic chiropractic could be thought of as "alternative" health care, because they offer different therapies for already recognized conditions. Vertebral subluxation care, on the other hand, could be better described as "complementary," since it is not considered a therapy for any condition, but rather serves to enhance the body's natural healing efforts by removing interference to the functioning of the nervous system when it is caused by aberrant spinal kinematics.
Clearly these objectives are different, but a profession that combines both is more diverse and attractive to patients seeking CAM. Jonas and Levin4 outlined several factors that draw patients to utilize CAM methods. For example, the following statements seem to describe vertebral subluxation care very well: "Most CAM systems aim to enhance the body's healing efforts but may not address a known cause. This characteristic of CAM is attractive to patients."4, pg 5 On the other hand, musculoskeletal manipulation as an alternative to drugs and surgery might be described by another statement from the same section of the cited book: "For the majority of patients, the choice to use unorthodox methods is largely pragmatic. They have a chronic disease for which orthodox medicine has been incomplete or unsatisfactory." 4, pg 5 As a health care system, chiropractic can offer both alternative and complementary approaches to health. The two are neither mutually exclusive, nor necessarily in competition with each other.
CHALLENGES
Challenges exist whenever an alternative method seeks incorporation into mainstream healthcare. By their very nature, alternative methods are in direct competition with other healthcare systems that offer different therapy for the same conditions. If manipulative techniques are to be adopted, they must be shown to be either more effective than competing therapies, or safer with equal efficacy. In the case of chiropractic manipulative therapy, there is already an alternative to allopathy available in the form of osteopathic manipulation. Chiropractic manipulative therapy, as it seeks incorporation into the mainstream, will meet the same paradox that osteopathy has: "The paradox is this: if osteopathy has become the functional equivalent of allopathy, what is the justification for its continued existence? And if there is value in therapy that is uniquely osteopathic — that is, based on osteopathic manipulation or other techniques — why should its use be limited to osteopaths?"5
Another paradox exists as well. As some chiropractors adopt allopathic attitudes in an effort to be more mainstream, these practitioners risk losing the unique features that set them apart from allopathy. Essentially, they may gain acceptance at the cost of identity.
With non-therapeutic vertebral subluxation care being complementary, its practitioners do not meet the challenges of competition. Rather, they must meet the challenge of showing that such care makes a significant enough impact on the lives of patients to be useful. The role of supportive or quality-of-life-enhancing care is still confusing to the public at this time. From the patient's point of view, the question is, Why should someone seek the care of a practitioner who does not address his or her symptoms. Why continue care when the symptoms go away? From a mainstream practitioner's point of view, Why should someone seek care unless they are exhibiting symptoms of illness?
These are issues for both research and education to solve. Research is needed to document that care aimed at the correction of vertebral subluxation can have an impact on health-related quality of life. It also is needed to document that the early correction of vertebral subluxations can lead to their more rapid resolution with fewer complications. With research in hand, public educational programs can be developed to change society's attitudes and therefore its actions regarding spine-related health, in much the same way that research is being disseminated in the media to help people adopt more healthy diets and lifestyles.
ADVANTAGES OF THE CHIROPRACTIC MODELS
Of the four chiropractic models presented here, the manipulative therapy model is perhaps most congruent with orthodox medicine. There are shared diagnostic principles, similar concepts of disease causation and a developing body of research supporting this approach. On the other hand, chiropractic care aimed at the prevention of disease or enhancement of health in a basically healthy population has advantages as well, particularly in access to a greater number of clients. Fig 1 represents a hypothetical evaluation of the types of patients that might access different chiropractic health care models. If you were to evaluate the health or fitness status of all the individuals in a population, it is quite likely that there would be a wide distribution of findings. Some small percentage of individuals would score very high on the health scale and be considered fit, while a nearly equal portion would score low and be considered sick or diseased. Depending on how you define the cutoff, the largest portion of the population would fall between these two extremes, and might be considered neither sick, nor functioning optimally. Allopathic therapeutic health care systems are devoted to propelling individuals from the sick status into the well, or "not too bad" area. The portion of the population that needs such care is limited to that small percentage under the curve to the left of the sick-well cutoff.
A view that being free of vertebral subluxation is of benefit to any individual, regardless of her or his current health status, opens up access to care (or at least evaluation for the presence of vertebral subluxation) to all individuals in the wellness continuum. The concept here is that vertebral subluxation will in some way depress the healing capacity of an individual and tend to move them toward the left (ie, the sick side of the continuum). Whether the effect of the vertebral subluxation is significant enough to propel him or her across the cutoff line, into the sick state, is irrelevant to the appropriateness of vertebral subluxation care.
RESEARCHING VERTEBRAL SUBLUXATION MODELS INDEPENDENT OF SPECIFIC CONDITIONS
The research agenda for chiropractic has received serious attention in the past 4 years, particularly with the advent of annual conferences devoted to that topic. Early conferences featured workshops on diagnostic assessment, but very little discussion on the research status of vertebral subluxation measures. More recently, the main goals have been the enhancement of the research infrastructure and personnel at chiropractic colleges, the development of grantsmanship skills and formation of research alliances with universities outside of the profession. These strategies are helpful in that they tend to mold research in a way that is more congruent with the type of research capable of obtaining government funding.
Until 1999, it appeared that vertebral subluxation theory would play only a small part in chiropractic's basic science research agenda, and hardly any part in its clinical research. The 1999 Research Agenda Conference (RAC IV) was the first one in which a session particularly devoted to chiropractic theory development was organized. The application of theory, in general, to research endeavors was discussed, with special attention payed to vertebral subluxation as an essential model for chiropractic. While no consensus was reached, it was the first time that vertebral subluxation theory was seriously considered in that setting.
Reviews of the literature relative to vertebral subluxation's significance in chiropractic have been carried out recently, particularly from a therapeutic standpoint.6,7 Basic science research using animal models of vertebral subluxation were found to provide significant support for some concepts of the vertebral subluxation model. While a number of case studies were found to suggest a positive role for vertebral subluxation theory in chiropractic, convincing clinical studies are still lacking.
Clinically, vertebral subluxation research is difficult, especially if it is separated from condition-based research. The double blind randomized controlled trial (RCT) is difficult enough to achieve in chiropractic research, with such challenges as the development of suitable shams and blinding of the care givers and patients. In the case of preventive or non-therapeutic vertebral subluxation research, the RCT is almost meaningless for a number of reasons. First, outcome measures usually depend on the presence of symptoms of disease. In the absence of symptoms as clinical measures, other performance or functional outcome measures need to be developed. Secondly, in vertebral subluxation research, the adjustment is not considered a therapy that can be turned on or off. Rather, the goal of adjustment is to eliminate signs of vertebral subluxation (and presumably, the vertebral subluxation itself). It is more important to monitor the presence of vertebral subluxation as an independent variable, rather than the application of adjustment. There is no guarantee that the adjustment will be successful in eliminating the vertebral subluxation for a significant time period, hence the "adjustment" group in an RCT may not be subluxation free. Likewise, there is no guarantee that members of the control group will exhibit vertebral subluxation through the course of the study. Comparing outcome measures between the control and "adjustment" groups, the typical method of analysis in an RCT, might not be a valid test of any hypothesis relating vertebral subluxation to improved clinical outcome.
Clearly, observational studies are a better option for studying complementary health care methods. Detecting the benefits of preventive measures requires a risk analysis and large numbers of patients. Practice-based studies using surveys of general health and quality of life are promising. 8-11 In a continuing study, now in its third year of data collection, the RAND SF-36 general health survey has been administered to patients of chiropractors specializing in upper cervical specific adjustment, a type of care directed at improving alignment between the atlas and skull. Results to date have shown that patients with a variety of mostly musculoskeletal complaints show statistically and clinically significant improvements in all eight dimensions of the SF-36. The improvements are independent of the chronicity of the complaint, indicating that the changes are not due to the natural course of acute conditions.9 This type of research, while promising, cannot detect whether health gains were due specifically to correction of vertebral subluxation, or if non-specific effects were responsible.
Since the information found through research is tightly bound to the particular questions that are asked, research on vertebral subluxation that is not related to disease incidence, but rather to health, requires a new framework for asking meaningful questions. A vertebral subluxation hypothesis tree is under development at Sherman College of Straight Chiropractic to help identify hypotheses that both derive from philosophical views of vertebral subluxation, and work with current theories about how joint function is related to neural function. This work was originally presented at the RAC IV in Chicago in 1999. A more comprehensive presentation is currently in press.12
Central to any research on vertebral subluxation is the validation of the signs and measures used to assess its presence. There is no shortage of clinical techniques for detecting vertebral alignment or fixation, such as X-ray analysis and palpation. Likewise, a variety of methods is currently in use by chiropractors to assess aberrant neurological functioning, including postural analysis, skin temperature patterns, and leg length difference. While some of these tests are considered reliable, there is no common standard against which to measure validity.
Further research to investigate the impact of vertebral subluxation care needs to advance on three fronts. There should be a continuation of practitioner-based research to show what effect such care has on the health and well-being of patients in a practice setting. Institution-based research should focus on validating subluxation detection methods already in use, and developing new methods for detecting aberrance of spinal kinematics and neurological interference. Basic science is needed to uncover the principles underlying the relationship between spinal articulations and neurology. Perhaps we can apply some advice from Jonas and Levin, namely that "the choice of an adequate research methodology should not be fixed a priori, but should reflect a balance among relevance, scientific rigor and feasibility." 4, pg 68
CONCLUSION
Vertebral subluxation models of the application and effects of chiropractic care do not fit well with conventional medicine. In attempting to blend chiropractic into mainstream health care, it is tempting to define chiropractic in terms of manipulative medicine alone. There is, however, strong support from practitioners for continuing to define the profession in terms of the vertebral subluxation. It should be recognized that chiropractic care can be both alternative, providing therapy for specific diagnosed conditions, and complementary, providing care aimed at the prevention of degeneration or the enhancement of health.
While avenues of research into chiropractic's vertebral subluxation models and complementary aspects might be of little importance to federal granting agencies, they should be pursued for their relevance to the profession. Perhaps we can turn the research agenda of the profession away from molding ourselves to fit in better with orthodox research toward engaging orthodox researchers to help us answer questions meaningful to chiropractic practitioners.
Key Points for Colleges/Students (Including Research Centers)
Article copyright Topics in Clinical Chiropractic.
Key points for Practitioners/Clinics
REFERENCES