Another word used in chiropractic that means other things to some is "subluxation." Oh, I know we add all kinds of clarifying elements like "vertebral" and "complex" to try and communicate our perspective that it has something to do with function of the nervous system, but to everyone else it usually just implies a teeny alignment problem. When you consider the difficulty the chiropractic profession itself has had with it over the years, its no wonder that everyone else doesn't get it right the first time either. I like the term, particularly the concept of it as a model of "spinal lesion" of sorts we can adjust. But I'm not sure I like it as a diagnosis per se, because everyone seems to have it (or someone's definition of it) regardless of their observable health status.
When I have to go back in the insurance record of the state of Washington's workers' compensation system (where I work), it's about the only thing coded as a diagnosis for chiropractic patients. Yes, we are restricted by state law to only care for individuals with it, but what happens from an actuarial standpoint is that chiropractors are perceived as "overtreaters." Why? Because for the same condition, there is a huge amount of variation in how it is treated. Some doctors can care for subluxation in a visit or two; others take much, much longer. Red flags abound. With no standard way to account for severity, complexity, and other confounders the patient might have, our care becomes suspect.
Think of dental carries. Most everyone gets them, but dentists vary in the ways they treat them. The range of care, cost, and duration, however, is fairly well-defined, but not so with subluxation. It's all over the map. It's not that subluxation is a bad concept, it's just that it is not very useful as a diagnosis.
Our term "adjustment" also means different things to different people (including chiropractors). An adjustment to one person might be a high velocity manipulation with cavitation of a certain joint; to someone else it might mean being left on pelvic blocks for 15 minutes. What's the problem, you ask? Aren't the terms "surgery" or "medication" guilty of the same variation transgression? Actually no, because surgery and medication always have qualifiers (like "anterior interbody fusion" surgery or "nonsteroidal anti-inflammatory" medication) which help narrow down what they are and how they are being used, even for billing purposes. We're still not there yet with the term adjustment.
And that is the paradox of the term. To us, an adjustment implies precision and specificity (in each chiropractor's own individual view of the world), but everyone else just sees excessive variation. Somehow, we seem to feel a sense of security and identity by being unique, and certainly a distinct syntax contributes to this. But we do have a challenge: syntax alone (and any related belief system) does not insure uniqueness or "nonduplication."
I don't believe for a minute that if large numbers of osteopaths and family physicians get more proficient at providing manipulation for people with nonspecific low-back pain, and can provide it cheaply in a well-defined, predictable fashion, that we will be considered "nonduplication" just because we "adjust subluxations" rather than manipulate articular dysfunction. Unless, of course, we demonstrate through research that our adjustments do something different, better, cheaper or faster than the competition.
So, am I proposing to abandon our syntax in favor of similar nonchiropractic terminology? Not at all, in fact, just the opposite. But I do think we need to understand why everyone else doesn't quite get it. And I do think we need to consider the context in which we use our terminology.
A chiropractor should become "bilingual" and be able to talk intelligently and specifically about similarities and distinctions between his approaches to manipulation/adjusting and those of other chiropractors.
I've listed a few recent publications of this topic that I think every chiropractor should read and be familiar with.
- The Mercy Conference guidelines help clarify some meaningful differences between manipulation, mobilization and adjusting.
- Gatterman and Leach have both edited textbooks that cover important model-building related to chiropractic ideas about subluxation.
- FCER recently published a useful monograph about the role of subluxation in chiropractic.
All are good resources for us to have at our disposal for communicating what we do. I think we should embrace the word "subluxation" as an umbrella term for a multitude of models for vertebral dysfunction and the role it might play in biomechanical and physiological function. I would also recommend caution in using it as a means to convey some kind of vague chiropractic uniqueness or way of life. It's not that I don't support holism, chiropractors as primary care givers, the use of adjustments as part of a healthy lifestyle, wellness, prevention, and all of that. I do -- very strongly. But I think we should be careful not to isolate ourselves from the overall health care system simply because our unique syntax means so many different things to different people.
Our profession has a lot of syntax work ahead of us. The community at large needs clear, definable, and unambiguous terminology to characterize what we do. There is still too little precision and too much variation and emotion in how we use words.
For us to be payable resources in the health care system of the future, I believe we need to be firmly entrenched in the thinking and management side of patient care, not just the procedural and technical side of it. It is easy for others to confine us into a technical or procedural box when we identify ourselves in an absolute fashion with terms that imply a diagnostic condition or procedure.
I suggest that we emphasize our identity as direct access caregivers and boldly embrace our beliefs, models, and approaches to care as tools we use to provide the best care we can. I think we should be careful not to let our emotions make us vulnerable to others turning it the other way around simply because our syntax is "nonstandard." Scott Haldeman has often stated that power in society lies in the hands of the "knowers" rather than the "doers." In chiropractic, we should strive to make sure that we can be both, and are perceived as both.
Some Recent Essential Readings on "Chiropractic Syntax"
- Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg, MD: Aspen, 1993, p. 103.
- Lantz CA. A review of the evolution of chiropractic concepts of subluxation. Top Clin Chiropr 1995; 2(2):1-10.
- Leach R. The Chiropractic Theories, 3rd ed. Baltimore, MD: Williams & Wilkins, 1994.
- Gatterman MI (ed). Foundations in Chiropractic -- Subluxation. St. Louis, MO: Mosby, 1995.
- Phillips RB, Mootz RD. Contemporary chiropractic philosophy. In: Haldeman S (ed). Principles and Practice of Chiropractic, 2nd ed. Norwalk, CT: Appleton-Lange, 1992.
- Rosner AL. The Role of Subluxation in Chiropractic. Arlington, VA: Foundation for Chiropractic Education and Research, 1997.
Robert Mootz, DC
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