Editor's note: The following is excerpted from Dr. Flynn's Joseph Janse Lecture, presented at the recent annual meeting of the Federation of Chiropractic Licensing Boards.
"The word subluxation has been daubed in a kaleidoscope of colors with a multitude of meanings by chiropractors during the past 100 years.To some it has become a holy word; to others an albatross to be discarded. Currently, subluxation continues to be the most loved and hated, hotly debated, and consecrated term used by chiropractors. To add to the confusion, more than 100 synonyms for subluxation have been used. Why then do we persist in using the term ... when it has become so overburdened with clinical, political and philosophical significance ... that the concept that once helped to hold a young besieged profession together now divides it and keeps it quarrelling over basic semantics?"
- Dr. Meridel Gatterman, Foundations of Chiropractic: Subluxation
Why indeed? The obvious answer is that the concept of vertebral subluxation is central to chiropractic.
In 1996, 16 college presidents signed a position paper defining subluxation as "a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health." Twelve years later, can we say this definition is biologically plausible and scientifically tested?
The subluxation is part of chiropractic history and is our language. Our physician service in Medicare, as defined in 1972, states that the chiropractic benefit is the correction of a subluxation. You might find it interesting to see what the American Physical Therapy Association's chief executive officer testified when PTs were attempting to provide the chiropractic service in Medicare managed-care plans:
"Contrary to the claims made by the American Chiropractic Association in its memorandum in opposition, physical therapists, as explained below, can and do perform manual manipulation of the spine to correct subluxations, where clinically indicated."
Physical therapists do not typically use the term subluxation, in part because it is ambiguous and has a variety of different meanings. Medical dictionaries define subluxation to mean an incomplete or partial dislocation of a joint, and this is the definition generally accepted by physicians and most other health care practitioners.
The use of the term subluxation by chiropractors has evolved over time. At one time, chiropractors used the term narrowly - essentially to describe a misalignment of a vertebra causing a pinching of a nerve, which chiropractors viewed as the root cause of all disease. Many chiropractors now use the term so broadly that it essentially includes any spinal impairment. The term assumes a broader and more diverse meaning in chiropractic than in classical literature.
No matter which of the definitions is used, physical therapists can and do perform manual manipulation of the spine to correct a subluxation. This is true even though, in most cases, a physical therapist would not use the term to describe the condition they were treating."
The principles and practice of chiropractic have made great progress, especially with the resolution of the boycott, fighting back other providers who were intent on replacing us in Medicare, and the successful gains of chiropractic access in the Department of Defense and the Veterans Administration health care systems. Our profession has earned footholds that benefit our senior citizens, the disabled, and the active-duty men and women of our military, along with veterans. These milestone achievements have not gone unnoticed by our adversaries and competitors. They appreciate that if the profession remains largely apathetic to what is required to maintain and continue our progress, and whose leaders do not take advantage of clarifying a lexicon that is not understood by anyone but chiropractors, then they will take full advantage to replace the chiropractic service with other providers who complement and talk the universal language of the health care marketplace.
Chiropractic is truly an international profession. Associations in 90 countries are now members of the World Federation of Chiropractic, which is in official relations with the World Health Organization (WHO). In 2005, the WHO published Guidelines on Basic Training and Safety in Chiropractic, which recommends to governments worldwide that chiropractic is a valuable addition to their health care systems. The guidelines have been translated and published in 12 languages. There are now more chiropractic schools outside than inside North America, and most are in publicly funded universities. Numerous ministers of health in countries throughout the world are seriously considering how best to implement chiropractic into their health care systems.
According to the WHO guidelines, chiropractic is: "A health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system, and the effects of these disorders on general health. There is emphasis on manual techniques, including joint adjustments and/or manipulation with a particular focus on subluxations."
The guidelines go on to say, "It is hypothesized that significant neurophysiological consequences may occur as a result of mechanical functional disturbances, described by chiropractors as subluxation and vertebral subluxation complex."
Noted chiropractic historian Joe Keating, PhD, said, "Chiropractic differs from other health disciplines in that we have not reached consensus about scientific method, which makes it difficult for us to integrate with the wider health science community. When will chiropractors scientifically explore the clinical meaningfulness of subluxation, as well as the possible non-subluxation explanations for the benefits of manipulation and related conservative measures?"
In an address to Palmer College in Florida in 2004, he stated: "Chiropractors have yet to experimentally determine whether or not subluxation-correction has any benefit for any clinical condition. Among the consequences of this neglect are conflict with the wider scientific community and a lack of cultural authority for the profession."
Charles Henderson, DC, PhD, associate professor with the Palmer Center for Chiropractic Research, wrote, "The chiropractic subluxation remains an invalidated theoretical construct because there is no widely accepted physical model of the subluxation. It remains an abstract concept, free to drift with the shifting winds of political/legal necessity and philosophical/entrepreneurial influence."
Anthony Rosner, PhD, has written: "Despite its history of usage ... it has sometimes been held up for derision by detractors of chiropractic as an opaque, inaccessible, or - even worse - unscientific or cultist term. Even more problematic is the fact that the term subluxation has been chastened at chiropractic research conferences. ...We need to maintain an open mind and sustain a vigorous dialogue rather than slink away in silence when faced with the 's' word."
And in the words of 1925 Palmer graduate C.O. Watkins, DC: "We could decide to commit to an evidence-based approach to subluxations and its theoretical effects on various conditions. Will you accept the challenge to make of chiropractic the health care science that the profession has always aspired to be?
The health care debate in the United States, and indeed the world, deserves to have a chiropractic influence. For that to happen, we have to raise the level of professional support to gather the resources necessary to make a difference in the health care playing field. We have to back our science and art with evidence-based outcome studies. We should be demanding our national and state associations convince state and federal law- and policy-makers to appropriate adequate funding for chiropractic research. If every voice in our profession were raised, along with those of our patients, we could see chiropractic research grants increase.
Our participation in the DoD and VA is deserving of serious study on chiropractic methods to include the subluxation to prove our efficacy, our safety and our cost savings. Chiropractic is health care reform and is an antidote to a failing and increasingly expensive system that places too little attention on prevention and too little emphasis on conservative health care measures that integrate chiropractic principles - principles that are so valuable to "man the biped."
Today, Dr. Gatterman would tell you there are not 100 synonyms for the word subluxation; there are more than 300. In the second edition of her book (2005), she writes: "Failure to resolve the issues surrounding the use of the term subluxation continues to be a barrier to communication and fans the flames of disunity that continue to engulf the chiropractic profession. If we are to move ahead as a unique profession, we must cease the song sung by the chorus that keeps adding to the synonyms for subluxation that has grown from the original 100 identified in 1995 to more than 300."
The subluxation in our profession, in 2008 and beyond, demands clarity - a 21st-century meaning that the profession can rally behind with the confidence of appropriateness. It is not a holy word or an albatross to be discarded. Let us not forget that every profession makes use of both standard scientific terminology and its own unique technical language. Our profession's best minds need to take a new look and determine just where subluxation fits and where it may not fit into our lexicon. Is it biologically plausible, and can it withstand scientific scrutiny? Is it not also an important part of our history that deserves to stay with us, and if so, redefined in modern terms? These answers will match our certainty with clarity.
Dr. J. Michael Flynn former state-association president, two-time president of the Louisiana Board of Examiners, and ACA chairman of the board, has served as a member of the Foundation for Chiropractic Progress board since its inception. He is the current president of the WFC.