Spinal Subluxation
Joel Alcantara
Joey D. Alcantara
Junjoe Alcantara
The chiropractic subluxation is at the core of chiropractic’s founding principles and tenets and uniquely defines chiropractic as “separate and distinct” from all other health care professions. Recent transformations in health care practice have led to the development of integrative medicine—the thoughtful incorporation of concepts, values, and practices from alternative, complementary, and orthodox medicine in the care of patients (1). Efforts on the part of the chiropractic profession toward integrative care of patients was reflected at the most recent 2010 Association of Chiropractic Colleges-Research Agenda Conference (ACC-RAC) in Las Vegas, NV. The conference theme was, “Chiropractic and Public Health in the 21st Century.” In keeping with the theme, the conference concluded with a panel discussion entitled “Subluxation Theory as a Component of Public Health.” In response, it is our belief that the chiropractic subluxation is congruent with the principles and practice of public health. Daniel David Palmer, the discoverer of chiropractic, commented more than a hundred years ago that, “The determining causes of disease are traumatism, poison, and autosuggestion” (2). Palmer’s proposed etiology finds many similarities in the epidemiologic triad of agent, host, and environmental factors as a cause of disease. In this age of chronic disease epidemiology, and prevention as the best intervention, the diseases of childhood such as asthma, diabetes, obesity, and developmental disabilities (3) find common pathophysiology in “traumas, thoughts, and toxins.” With the evolution and development of chiropractic as a profession worldwide, spinal subluxation continues as an a priori guiding principle for chiropractic care within an integrative setting (4).
It is beyond the scope of this chapter to address the many facets and complexities of spinal subluxation. Indeed, a textbook on the subject offers a more comprehensive approach to the subject (5). One model coined the term vertebral subluxation complex (VSC) to reflect the growing complexity of our understanding of “spinal subluxation.” The overriding theme from which we address this subject will follow Palmer’s disease etiology of “traumas, thoughts, and toxins.” This is not meant to imply our disagreement with current models; rather, it is our belief that this approach offers clinical utility through its simplicity and allowance for all aspects of the pediatric chiropractic clinical encounter. Furthermore, as a reflection of our current knowledge, this chapter will focus on the biomechanical aspects of pediatric trauma. “Thoughts and toxins” leading to the development of spinal subluxation are introduced here and addressed through various chapters in this book. The chapters on Neurodevelopmental Disabilities by Buerger (Chapter 25), the Challenged Child by Goble (Chapter 27), Wellness Care by McCoy (Chapter 2), Pediatric Nutrition by Parsons (Chapter 18), and Vaccinations by Alcantara (Chapter 19) all incorporate aspects of “thoughts and toxins” as a cause of disease from the pediatric chiropractic perspective. This chapter is written with the intent that those interested in the chiropractic care of children are evidence-informed. In the chiropractic care of children, strict adherence to the principles and methodology of evidence-based medicine (i.e., reliance and dependence on experimental research designs) would lead to the incorrect conclusion that there is insufficient evidence (i.e., not enough randomized controlled trials) to support this approach to pediatric care and that more research is necessary. The reality is that practice empiricism rather than research evidence dominates in pediatric care, orthodox, or alternative medicine. The guiding principle behind evidence-informed care is awareness of and the use of research evidence when available, individual recommendations made based on one’s clinical experience and expertise when research evidence is not available, and transparency about the process used in the clinical decision making (6). Regardless of evidenceinformed or evidence-based practice, the challenge for chiropractors in the care of children remains how
to integrate their individual clinical expertise with the best available external research evidence while at all times respecting the needs and wants of parents (7,8). From the parents’ perspective, health services research continues to demonstrate the popularity of chiropractic for themselves and their children (9,10). Davis et al. (11) estimated that chiropractic visits increased 57% from 2000 to 2003 with visits from 7.7 million to 12.1 million, respectively. The inflation-adjusted national expenditures on chiropractic care increased 56% from $3.8 billion in 1997 to $5.9 billion in 2006. Because the use of alternative therapies by parents is highly predictive of alternative therapy use by their children (12,13), it should come as no surprise that pediatric chiropractic is popular. In an analysis of the 2007 US National Health Information Survey, Barnes et al. (14) reported that of the practitioner-based alternative therapies, chiropractic was the most popular for children.
to integrate their individual clinical expertise with the best available external research evidence while at all times respecting the needs and wants of parents (7,8). From the parents’ perspective, health services research continues to demonstrate the popularity of chiropractic for themselves and their children (9,10). Davis et al. (11) estimated that chiropractic visits increased 57% from 2000 to 2003 with visits from 7.7 million to 12.1 million, respectively. The inflation-adjusted national expenditures on chiropractic care increased 56% from $3.8 billion in 1997 to $5.9 billion in 2006. Because the use of alternative therapies by parents is highly predictive of alternative therapy use by their children (12,13), it should come as no surprise that pediatric chiropractic is popular. In an analysis of the 2007 US National Health Information Survey, Barnes et al. (14) reported that of the practitioner-based alternative therapies, chiropractic was the most popular for children.
To date, two studies have been published that characterize the chiropractic care of children (15,16). Lee et al. (15) surveyed Boston chiropractors with a focus on questions pediatricians might ask about chiropractors in their communities, characterizing their practice patterns, fees, and pediatric care (see Table 3.1). The authors noted the broadening field of pediatric chiropractic, with safety as the overriding concern by medical pediatricians. To address this issue, Lee et al. (15) inquired of their responders their clinical response to the neonate with a fever and recommendations on the use of vaccines. Only 30% of the responders reported actively recommending childhood vaccinations and 17% indicated they would for the 2-week-old neonate with a fever than immediately refer the patient to a medical physician, an osteopath, or an emergency facility. Lee et al. (15) concluded that the chiropractic care of children is often inconsistent with the practice of medicine. Alcantara et al. (16) utilized a more comprehensive approach with the International Chiropractic Pediatric Association practice-based research network (PBRN) (17) to characterize pediatric chiropractic. The chiropractor responders were mostly from the United States, Canada, Europe, and Australia. Similar to the findings of Lee et al. (15), the primary practice activity of the respondents was the detection and elimination of spinal subluxation augmented with adjunctive therapies such as the use of herbal remedies, exercises, and rehabilitation. Parents presented their children for chiropractic care with the common conditions of childhood (i.e., asthma, enuresis, attention deficit disorder (ADD)/attention deficit hyperactivity disorder (ADHD), autism, etc.) but “wellness care” was the most common reason for chiropractic care. According to Alcantara et al. (16), this may be a reflection of the paradigm shift in health and healthcare from a purely biomedical approach to a holistic and vitalistic approach incorporated within a biopsychosocial model.
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HISTORICAL PERSPECTIVE
According to the Oxford English Dictionary (18), the word subluxation dates as far back as 1688 with the
definition, “Subluxation [sic], a dislocation, or putting out of joint.” However, the clinical entity of “bone out of place” as a cause of disease dates as far back as antiquity, to the ancient Greeks, Egyptians, Hindus, and Chinese. The concept was familiar to the likes of Hippocrates and Galen (19). In his investigation of the medical literature of the use of the term “subluxation,” Terrett (20) found that the fundamental hypothesis of chiropractic had been in existence well before chiropractic’s inception. The use of the term subluxation was made in the context of spinal biomechanics, neurology, and manual therapy. D.D. Palmer even exclaimed, “…I am not the first person to replace subluxated vertebrae, for this art has been practiced for thousands of years…” (21). However, this admission on the part of Palmer should not minimize his unique contribution. Palmer’s remarkable insight of neuroanatomy and the concept of nerve impulse independently led to his concept that correction of spinal subluxation leads to restoration and maintenance of homeostasis and health. According to Palmer, “The relationships existing between bones and nerves are so nicely adjusted that any one of the 200 bones, more especially those of the vertebral column, cannot be displaced ever so little without impinging upon adjacent nerves. Pressure on nerves excites, agitates, creates an excess of molecular vibration…nerve tension determines the velocity of the impulses transmitted…. Subluxations are corrected for the purpose of permitting the re-creation of all normal cyclic currents through nerves that were formerly not permitted to be transmitted through impingement” (20,22). Palmer coined the term “tone” to describe this nerve tension when he wrote: “Life is an expression of tone. Tone is the normal degree of nerve tension. Tone is expressed in function by normal elasticity, strength, and excitability…the cause of disease is any variation in tone” (2,23).
definition, “Subluxation [sic], a dislocation, or putting out of joint.” However, the clinical entity of “bone out of place” as a cause of disease dates as far back as antiquity, to the ancient Greeks, Egyptians, Hindus, and Chinese. The concept was familiar to the likes of Hippocrates and Galen (19). In his investigation of the medical literature of the use of the term “subluxation,” Terrett (20) found that the fundamental hypothesis of chiropractic had been in existence well before chiropractic’s inception. The use of the term subluxation was made in the context of spinal biomechanics, neurology, and manual therapy. D.D. Palmer even exclaimed, “…I am not the first person to replace subluxated vertebrae, for this art has been practiced for thousands of years…” (21). However, this admission on the part of Palmer should not minimize his unique contribution. Palmer’s remarkable insight of neuroanatomy and the concept of nerve impulse independently led to his concept that correction of spinal subluxation leads to restoration and maintenance of homeostasis and health. According to Palmer, “The relationships existing between bones and nerves are so nicely adjusted that any one of the 200 bones, more especially those of the vertebral column, cannot be displaced ever so little without impinging upon adjacent nerves. Pressure on nerves excites, agitates, creates an excess of molecular vibration…nerve tension determines the velocity of the impulses transmitted…. Subluxations are corrected for the purpose of permitting the re-creation of all normal cyclic currents through nerves that were formerly not permitted to be transmitted through impingement” (20,22). Palmer coined the term “tone” to describe this nerve tension when he wrote: “Life is an expression of tone. Tone is the normal degree of nerve tension. Tone is expressed in function by normal elasticity, strength, and excitability…the cause of disease is any variation in tone” (2,23).
THE MANIPULABLE LESION
A variety of healthcare professionals perform spinal manipulative therapy (SMT) for salutary purposes. Depending on the practitioner’s theoretical and clinical framework, the manipulable spinal lesion is categorized into meaningful clinical entities. For example, the same injury may have a primary neurological perspective (e.g., sciatica) by neurologists or bony abnormality (e.g., canal stenosis) by medical orthopedists; it may be considered as sprain/strain by a general practitioner, as somatic dysfunction by an osteopathic physician, and, uniquely chiropractic, a spinal subluxation. It should be acknowledged that these differing clinical points of view have clinical utility within their respective specialties but there is overlap between the specialties. Daniel David Palmer and Bartlet Joshua Palmer defined spinal subluxation in this way: “a (sub) luxation of a joint, to a chiropractor, means pressure on nerves, abnormal functions creating a lesion in some portion of the body, either in its action, or makeup” (24). Of course, chiropractic’s contemporary perspectives on spinal subluxation has evolved beyond the “bone out of place” concept but, as generalized by the Palmers, spinal subluxation represents a wide array of clinical signs and symptoms. From an epidemiological perspective, what is referred to by chiropractors as “spinal subluxation” represents only the “tip of the iceberg” and, as we hope to demonstrate, a complex causal web. According to Dishman (25,26), the original model of the VSC as developed by Faye consisted of five components: (a) kinesiopathology; (b) neuropathology; (c) myopathology; (d) histopathology; and (e) biochemical abnormalities. The model was refined by Lantz (27,28) to include a hierarchy with respect to the relative importance of each component to the development of the VSC. In order of descending hierarchy, the nine components of the VSC are (a) kinesiology; (b) neurology; (c) myology; (d) connective tissue physiology; (e) angiology; (f) inflammatory response; (g) anatomy; (h) physiology; and (i) biochemistry. Further refinements and expansions of the VSC model have since been proposed. For an update on the VSC model, we recommend to the reader the excellent review article by Kent (29).
Although our examination of spinal subluxation will incorporate a reductionistic/mechanistic approach, as alluded to earlier there is a vitalistic and holistic aspect to the identification and reduction of spinal subluxation. D.D. Palmer coined the term “innate intelligence” to refer to the inherent organizing intelligence of the universe and of life. According to Palmer, the seat of control for innate intelligence is the brain. From the brain, innate intelligence travels down the spinal cord, and from the spinal cord outward to the periphery—a pathway referred to as “above > down > inside > out” (A-D-I-O). The presence of spinal subluxation, therefore, would necessarily interfere with the flow of innate intelligence or, as Stephenson (30) put it, interference with the transmission of mental impulses. Lipton (31) provided an elegant dissertation on the vitalistic and holistic components of chiropractic philosophy and Palmer’s determinants of health in the context of cellular and molecular biology. According to Lipton, molecular biology has demonstrated that the binding and release of deoxyribonucleic acid (DNA) regulatory proteins are determined by the environment. In the simplest of organisms, such as bacteria, there exists “genetic engineering genes” that are capable of successful “adaptive” mutations to create new proteins. These novel proteins,
with altered structure/function, facilitate the survival of the organism and challenge the primacy of DNA, the building block of life; according to Lipton, these “adaptive” mutations are congruent with Palmer’s concept of innate intelligence (32). Palmer’s “auto-suggestion” as a cause of disease finds affirmation in the notion that biological expression (i.e., health to disease) is determined by one’s perception of life experiences (33). Therefore, congruent with the principles of public health, at the heart of the science, art, and philosophy of chiropractic care is a vitalistic and holistic approach to patient care that incorporates aspects of prevention and health promotion (34).
with altered structure/function, facilitate the survival of the organism and challenge the primacy of DNA, the building block of life; according to Lipton, these “adaptive” mutations are congruent with Palmer’s concept of innate intelligence (32). Palmer’s “auto-suggestion” as a cause of disease finds affirmation in the notion that biological expression (i.e., health to disease) is determined by one’s perception of life experiences (33). Therefore, congruent with the principles of public health, at the heart of the science, art, and philosophy of chiropractic care is a vitalistic and holistic approach to patient care that incorporates aspects of prevention and health promotion (34).
PEDIATRIC TRAUMA AND NON-TRAUMA
For our purpose, the mechanisms involved in the development of spinal subluxation are dichotomized into those events resulting in trauma versus those events resulting from non-trauma. Trauma is defined from the biomechanical perspective as a failure of the neuromusculoskeletal (NMS) system to resist a load. Injuries resulting from trauma are further subdivided as those occurring from macrotrauma and microtrauma (35). In keeping with Palmer’s original concept of spinal subluxation, we will examine various aspects of altered spinal biomechanics among the pediatric population as a consequence of trauma and non-trauma. Altered spinal biomechanics are thought to result in altered sensory input to the central nervous system (CNS). This “dysafferentation model” (29) results in the modification of neural integration either by directly affecting reflex activity and/or by affecting central neural integration within motor, nociceptive, and possibly autonomic neuronal pools. Either of these changes in sensory input may elicit changes in efferent somatomotor and visceromotor activity, which, according to the “neurodystophic model,” results in altered function of specific and nonspecific responses of the immune and endocrine systems (29). Spinal adjustment is theorized to correct the altered spinal biomechanics (i.e., correction of spinal subluxation), leading to salutatory sensory input to the CNS and resulting in improved physiological function (36).
The major injuring vector (MIV) (37) leading to trauma and spinal subluxation is characterized as compressive, distractive, shearing, torsional, or combinations of these vectors. In macrotrauma, the forces involved are relatively large in magnitude, such as those involving motor vehicle collisions. For our purpose, we examine the MIV involved during the birthing process. Its been estimated that during the stage of labor, intrauterine forces on the fetal head are approximately 120 N during the volitional push. If a vacuum device is applied to the head for additional traction, an additional force of up to 113 N is applied per pull/distraction (typically up to 4 pulls) (38). In cases where obstetric forceps are used, an additional tractional force can reach up to 200 N (39). Not surprisingly, the child is at risk of developing spinal subluxation during the process of birth. Moczygemba et al. (40) estimated that 2.6% of births are complicated by some type of birth trauma. The resulting injuries involve the soft tissue (i.e., hematomas), nervous system (i.e., obstetric palsy), bones (i.e., clavicular fracture), and intra-abdominal areas (41,42). Documentation of the chiropractic care of infants with spinal subluxation concomitant with birth trauma in the peer-reviewed literature include torticollis (43,44), plagiocephaly (45,46), obstetrics palsy (47), cerebral palsy (48,49), failure to thrive (50), and general “birth trauma” (51,52).
The MIVs involved in microtrauma are similar to those described for macrotrauma but involve forces of “sub-threshold” magnitudes, meaning that failure to resist a load on the part of the NMS system is not immediate. However, with multiple and prolonged exposures to these “sub-threshold forces” result in fatigue and eventual failure on the part of the NMS system. As an example, consider the effects of intrauterine constraint on the developing fetus. During pregnancy, a myriad of biomechanical and physiological changes occur for the expectant mother and developing fetus. For the mother, the production of the hormone relaxin increases 10-fold, leading to arthrodial laxity that allows the pelvis to accommodate the increasing size of the fetus. The muscles of the pelvis (e.g., pelvic floor muscles, coccygeus muscles, the levator ani muscles, and the abdominal muscles) must also accommodate the expanding pelvis by contracting to maintain force closure and stability in the joints (i.e., sacroiliac joint and pubic syphysis) of the pelvic bowl. However, over a period of time, sustained contraction of these muscles leads to fatigue. Fatigue leads to altered function (e.g., altered timing and motor control of contraction) and the ability of the lumbopelvis to withstand the forces from loads generated by body weight and gravity during walking, sitting, and standing is compromised (53,54). The inability of the lumbopelvis to maintain its integrity and function also leads to the development of inutero or intrauterine constraint. Intrauterine constraint is defined as the limitation of the inherent growth of the developing fetus because of both intrinsic and extrinsic factors. The effects of intrauterine constraint for the developing fetus are well established and deal with abnormal craniofacial and skeletal structures as well as malposition/malpresentation pregnancies (55). Fetal malposition and malpresentation may necessitate a cascade of medical interventions, which themselves carry risk for adverse outcomes for both the mother
and fetus. However, on a more fundamental level, intrauterine constraint for the fetus is equivalent to failure to thrive in-utero and after birth (56). Specific examples of structural defects of the craniofacial and peripheral skeleton as a consequence of intrauterine constraint include plagiocephaly, brachial plexus palsy, craniotabes, limb deficiency, polydactyly, and body wall defects (55,57,58,59). A chiropractic technique to address intrauterine constraint and its consequences is the Webster Technique. The Webster Technique is a site-specific chiropractic technique intended to correct sacral subluxation, reduce interference to the nervous system, and balance the functioning of the pelvic muscles and ligaments, which in turn facilitate the elimination of intrauterine constraint (60). Chapter 6 by Forrester, which addresses the Prenatal Period, provides a comprehensive review of the Webster Technique.
and fetus. However, on a more fundamental level, intrauterine constraint for the fetus is equivalent to failure to thrive in-utero and after birth (56). Specific examples of structural defects of the craniofacial and peripheral skeleton as a consequence of intrauterine constraint include plagiocephaly, brachial plexus palsy, craniotabes, limb deficiency, polydactyly, and body wall defects (55,57,58,59). A chiropractic technique to address intrauterine constraint and its consequences is the Webster Technique. The Webster Technique is a site-specific chiropractic technique intended to correct sacral subluxation, reduce interference to the nervous system, and balance the functioning of the pelvic muscles and ligaments, which in turn facilitate the elimination of intrauterine constraint (60). Chapter 6 by Forrester, which addresses the Prenatal Period, provides a comprehensive review of the Webster Technique.
Non-traumatic events associated with or capable of causing spinal subluxation (e.g., vertebral malposition, spinal misalignment) in the pediatric patient are numerous. These include infection resulting in acute tonsillitis, acute mastoiditis, and retropharyngeal abscess. A common complaint presented by patients with these aforementioned conditions include neck pain, fever, sore throat, a neck mass, and respiratory distress or stridor. During physical examination, the cervical spine is limited in flexion and extension and the child may initially present with torticollis (61). With spinal tuberculosis, the vertebral destruction is said to be more severe than in adults because of incomplete ossification and the presence of cartilage. The child can develop severe kyphosis leading to respiratory insufficiency, painful costopelvic impingement, and paraplegia. In children with hyperkyphosis of the lumbar spine, early degenerative lumbar canal stenosis may result in neurological deficits (62,63). In patients with osteomyelitis, vertebral destruction concomitant with vertebral malposition and dysfunction may ensue (64). Atlanto-axial dislocation is associated with rheumatic fever (65), whereas atlantoaxial subluxation results from Grissel’s Syndrome—a condition resulting from the infectious or inflammatory processes of the head and neck region (66). In children with rheumatoid arthritis, the occurrence of spondyloarthropathies and musculoskeletal pain is associated with destructive growths of supporting tissue structures (67,68) and the development of spinal subluxation.
As one can surmise from the above discussion, the pathomechanics of trauma and the development of spinal subluxation is present throughout a child’s development, from the onset of life in-utero, through the process of birth and the eventual exposure of the child to MIVs of potentially greater magnitude and variety as he or she develops from crawling to walking to running. A common source of exposure to MIVs in the developing child are various sport activities (69,70); these can result in acute injuries (i.e., macrotrauma) and overuse injuries (i.e., microtrauma). It should be noted, however, that today’s societal trends have altered the nature of play and the way children interact with each other and their environment. In general, these trends have resulted in a significant decrease in “physical” play by children and an increased dependence on electronic media such as video games and television (71). Consequently, the rates of childhood obesity and type 2 diabetes have reached epidemic proportions in the United States and other industrialized countries. Sedentary children are said to develop poor social skills, inferior problem-solving abilities, and a marked increase in psychological dysfunctions like depression. D.D. Palmer’s etiology of disease (i.e., traumas, thoughts, and toxins) seems to be enduring as it applies to the epidemiology of children’s health issues.
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