Subluxation: Chiropractic's Elusive Buzzword

Stephen Barrett, M.D.

If you are examined by a chiropractor, you may be told that you have one or more subluxations of your spine. This article examines what this means and how you should react.
Chiropractic theory is rooted in the notions of Daniel David Palmer, a grocer and "magnetic healer" who postulated that the basic cause of disease was interference with the body's nerve supply. Approximately a hundred years ago, he concluded that "A subluxated vertebrae . . . is the cause of 95 percent of all diseases. . . . The other five percent is caused by displaced joints other than those of the vertebral column." [1] He proclaimed that subluxations interfered with the body's expression of "Innate Intelligence"—the "Soul, Spirit, or Spark of Life" that controlled the healing process. He proposed to remedy the gamut of disease by manipulating or "adjusting" the problem areas.
Over the years, chiropractors have gone beyond Palmer's theories, although some still cling to them for dear life. Some describe subluxations as "bones out of place" and/or "pinched nerves"; some think in terms of "fixations" and/or loss of joint mobility; some occupy a middle ground that includes any or all of these concepts; and a small percentage renounce Palmer's notions as biotheistic nonsense—which they were.

Are Subluxations Visible?

Chiropractors also disagree on whether their "subluxations" are visible on x-ray films. "Straight" chiropractors tend to believe that they cause nerve interference, are readily visible, and that virtually everyone gets them. Most other chiropractors (commonly referred to as "mixers") define subluxations loosely and see them when it suits their convenience. Chiropractors who reject subluxation theory consider them invisible but have been forced to acknowledge them to get paid by Medicare. When a respected chiropractic researcher was asked whether he had ever seen a subluxation on an x-ray film, he smiled and jokingly replied, "With my eyes closed." [2]
Old chiropractic textbooks show "before and after" x-rays that are supposed to demonstrate subluxations. In 1971, hoping to get a first-hand look at such x-rays, I challenged the local chiropractic society to demonstrate ten sets. They refused, suggesting instead that I ask the Palmer School to show me some from its "teaching files." When I did, however, a school official replied:

Chiropractors do not make the claim to be able to read a specific subluxation from an x-ray film. [They] can read spinal distortion, which indicates the possible presence of a subluxation and can confirm the actual presence of a subluxation by other physical findings [3].

In 1973, Congress authorized payment under Medicare for chiropractic treatment of "subluxations demonstrated by x-rays to exist." In 1972, to enable payment, chiropractors held a consensus conference that redefined "subluxations" to include common findings that others could see. The document, several pages long, described the supposed x-ray manifestations of 18 types of "subluxations," including "flexion malposition," "extension malposition," "lateral flexion malposition," "rotational malposition," "hypomobility" (also called "fixation subluxation"), "hypermobility," "aberrant motion," "altered interosseous spacing," "foraminal occlusion," scoliosis, and several conditions in which "gross displacements" are evident [4]. I have been unable to determine how many billions of dollars chiropractors have received from Medicare since the law took effect.
Some of these terms are fancy names for the minor degenerative changes that occur as people age. The conditions often have nothing to do with a patient's symptoms and are not changed by chiropractic treatment. Some, as acknowledged by the conferees, are not even visible on x-ray films. In 1997, Congress amended the law to permit payment for subluxations diagnosed by other means—a policy scheduled to take effect on January 1, 2000.
Chiropractors also differ about how to find "subluxations" and where they are located. In addition to seeing them on x-ray films, chiropractors say they can find them by: (a) feeling the spine with their hand, (b) measuring skin temperature near the spine with an instrument, (c) concluding that one of the patient's legs is "functionally" longer than the other, (d) studying the shadows produced by a device that projects a beam of light onto the patient's back, (e) weighing the patient on special scales, and/or (f) detecting "nerve irritation" with a device. Undercover investigations in which many chiropractors have examined the same patient have found that the diagnoses and proposed treatments differed greatly from one practitioner to another.
Subluxation is also a medical term. The medical definition is incomplete or partial dislocation—a condition, visible on x-ray films, in which the bony surfaces of a joint no longer face each other exactly but remain partially aligned. No such condition can be corrected by chiropractic treatment.

Elastic Definition

In 1996, in an attempt to "unify" chiropractic terminology, the Association of Chiropractic Colleges adopted the following definition:

A subluxation is a complex of functional and/or structural and or pathological articular changes that compromise neural integrity and may influence organ system and general health [5].

In 1997, the Foundation for Chiropractic Education and Research issued a pamphlet called "Subluxation: What It Means to You," which stated:

What the above means is that a subluxation is a joint problem (whether a problem with the way the joint is functioning, a physical problem with the joint, or a combination of any of these) that affects the function of nerves and therefore affect the body's organs and general health.

This "definition" is still poppycock because the vast majority of spinal problems do not affect the body's organs or general health. (In addition, it makes no sense to use the consensus process to try to define something that is not a valid concept [6]. If you'd like to have some fun, ask a chiropractor to list the diseases or general health problems that spinal manipulation can cure.

The Silent Killer?

In the late 1980s, the Vertebral Subluxation Research Institute (VSRI) was launched by Terry Rondberg, D.C., of Chandler, Arizona. Rondberg is president of the World Chiropractic Alliance (WCA), a group that promotes subluxation-based practice and is president of Chiropractic Benefit Services, a malpractice company that insures subluxation-based chiropractors. He also publishes TheChiropractic Journal (a newspaper for chiropractors), the Journal of Vertebral Subluxation Research and WCA News/ Health Watch (a weekly electronic newsletter that attacks what it considers to be "the dangers and abuses of medical and drug interests."). VSRI taught chiropractors how to recruit "research volunteers" and convert them into lifetime chiropractic patients. Its chiropractor clients were instructed to use telemarketing and other approaches to ask people to volunteer for a nationwide study on spinal conditions. During the first office visit they would be examined and given a brochure—"The Silent Killer"—which explains how subluxations can be caused by physical, chemical, and emotional trauma. (The brochure claimed, for example, that food additives, air pollutants, spoiled food, fear, worry, hate, greed, sadness, grief, emotional shock, and severe disappointment can cause muscle spasms that result in subluxations.) During the second visit, they would be advised to have their subluxations treated. TheVSRI program was concluded in 1991 [7]. A subsequent WCA survey found that 65% of members who responded said that their patient education material referred to the vertebral subluxation as the "silent killer."

The above ad from a telephone directory purports to show how misaligned spinal bones cause subluxations. A distributor of the poster to the right calls it "the most powerful single visual aid available." The poster to the far right, distributed during the mid-1980s, states that "chiropractic subluxations can be your health's worst enemy" and that "spinal adjustments wipe out this enemy."

A 1992 WCA training manual, written for chiropractic assistants by Rondberg's wife Cindy, describes how the subluxation concept can be explained to patients:

When—through physical, mental, or chemical stress—one of the 24 vertebrae in the spinal column becomes slightly misaligned, it's called a subluxation. When a subluxation occurrs, it puts pressure on delicate nerves, and the organ or body part at the other end of the nerve does not receive the proper messages it's so dependent on. This has been compared to someone stepping on a water hose, interfering with the flow of water. The vertebral subluxation does precisely the same thing, interfering with the messages from the brain to the body. When the communication from the brain to the organ is broken down, there is a malfunction and disease may eventually develop [8].

Patient Media, Inc., a company that markets patient education materials offers a subtler but still scary approach. Its "Subluxation" pamphlet states:

Subluxations are serious!
However, the most important aspect of a subluxation is its affect on your nervous system. Compromising the way your nervous system controls and regulates your body can have grave consequences. Distorted communications between your brain and your body can cause all kinds of health problems beyond just headaches and backaches. . . .
There are three basic causes of subluxations. Physical causes include slips and falls, accidents, repetitive motions and improper lifting. Stress, anger and fear are examples of emotional causes of subluxations. Alcohol, drugs, pollution and poor diet can be chemical causes of subluxations. . . .
You can have subluxations and not even know it. Like tooth decay or cancer, subluxations can be present before any warning signs appear. The results of a thorough examination can show the location and severity of any subluxations you may have [9].

FTC Action

Warnings about "subluxations" predate VSRI and still appear in many ads, brochures, and office posters. For example, a widely distributed pamphlet from Koren Publications warns:

A vertebral subluxation is a spinal abnormality that interferes with your nerves. It can create dis-ease, lowered resistance to disease, pain, imbalance, fatigue and can pave the way for ill health. It is sometimes called the "silent killer" because it can slowly eat away at your health and vitality without your having the slightest awareness of it. . . .
Subluxations are so very common they can be considered an epidemic—nearly everyone has them.
Subluxations can undermine your health just as termites can undermine the foundation of your home. . . . By the time symptoms appear a certain amount of the damage caused by longstanding subluxations may be irreversible.
For that reason periodic spinal examinations to locate and correct vertebral subluxations should be part of every family's health routine. Correcting silent subluxations today could save you and your family from diseases that, later in life, could not possibly be ignored [10].

Company president Tedd Koren, D.C., is a 1977 graduate of Sherman College of Chiropractic, the "straightest" of the chiropractic colleges. The company publishes a large line of subluxation-based patient-education brochures which suggest that spinal manipulative care can help nearly the entire gamut of health problems. A 1998 flyer for Koren's 12-hour seminar on "The Natural Superiority of Chiropractic" stated that a total of 24 million of these brochures had been distributed worldwide. More recent patient education pamphlets claim that "A chiropractic adjustment can make the differnce between life and death" and "When your body is free from subluxations, your self-healing ability, your "inner healer," is better able to deal with all of your health problems."
Claims made in some of Koren's brochures were challenged by the Federal Trade Commission. In a 1998 catalog, Koren stated:

The FTC claims that chiropractors can only tell patients that chiropractic care can be beneficial for low back pain. Nothing else, not subluxations, wellness, headaches, sciatica, allergies, children's health, ear infections, whiplash, etc. Although Koren Publications' literature states that chiropractic is not the treatment of diseases but the correction of vertebral subluxations, the FTC doesn't like the "impression" we're giving the public and patients [11].

In October 1998, Rondberg filed a lawsuit intended to stop the FTC action against Koren and other likeminded providers. Asserting that Koren's publications (and therefore his own) should be protected by the Constitutional right to free speech, the suit papers stated:

In or about mid-1998, the FTC concluded that Dr. Koren's activities constitute false advertising and or deceptive trade practices. The FTC sent him a proposed consent order and a proposed administrative complaint. The FTC said sign the consent order or face a lengthy and costly administrative proceeding. The proposed consent agreement basically prohibits Dr. Koren from making any public claims about the benefits of chiropractic unless the claims are supported by scientific studies which the FTC believes to be authoritative or valid. . .
Although Dr. Koren's specific message is somewhat different from Dr. Rondberg's, their activities are quite similar. Both sell books and pamphlets which sometimes are distributed by chiropractors, and both are strong advocates of the benefits of chiropractic care. . . .
Dr. Rondberg does not believe that chiropractic is a direct cure or even a treatment for any disease or condition other than vertebral subluxation. However, all chiropractors believe that keeping the spine healthy and correcting spinal nerve interference can have a beneficial effect, and may sometimes lead to a resolution of some medical conditions. But Dr. Rondberg stresses that the purpose of chiropractic is to correct spinal nerve interference, not to treat any disease or medical condition [12].

On November 16, 1999, a federal judge granted the FTC's motion to dismiss their suit.
In 2001, the FTC abandoned its effort to limit Koren's claims. The FTC itself made no public statement, but articles in chiropractic publications describe a six-year investigation that ended in June 2001 [13].
Not all chiropractors regarded the FTC investigation as unwarranted. John Triano, D.C., Ph.D., one of chiropractic's most respected researchers, described certain of Koren's claims as "afflicted by absence of scientific merit." In a 1998 news report, he said, "Perhaps those who are calling for donations to Dr. Koren's legal defense would be better served to invest in donations to chiropractic research so that we may produce effective evidence for what we do." [14]
I agree with Dr. Triano. I also believe that a consent agreement as broad as the one described above would have had greater significance than any other health-related settlement in the FTC's history. I suspect that the FTC dropped the case because it concluded that the brochures were "patient-education" materials rather than advertising and thus were immune to federal regulation. Koren notified me that my "conjecture" is incorrect [15], but he refused three requests from me to state what he believes is correct.

The Bottom Line

My advice about "subluxations" is very simple. If a chiropractor purports to locate and fix them—"killer" or otherwise—seek treatment somewhere else.

References

1. Palmer DD. The Science, Art and Philosophy of Chiropractic. Portland, Oregon: Portland Printing House Company, 1910.
2. Weiss R. Bones of contention. Health 7(4):44-53, 1993.
3. Frogley R. Letter to Stephen Barrett, M.D., 1971.
4. Schafer RC (editor). Basic Chiropractic Procedural Manual, fourth edition. Arlington, Va.: American Chiropractic Association, 1984.
5. Chiropractic paradigm. Association of Chiropractic Colleges, 1996.
6. Nelson C. The subluxation question. Journal of Chiropractic Humanities 7:46-55, 1997.
7. Bodney DJ. Letter to Stephen Barrett, M.D. May 20, 1998.
8. Rondberg C. The CA Advisor Training Manual: Basic Training for Chiropractic Assistants. Chandler, AZ: World Chiropractic Alliance, 1992.
9. Esteb W. What patients want to know about subluxations. Denver CO: Patient Media Inc., 1999.
10. Koren T. What Is a Subluxation?, Philadelphia: Koren Publications, 1995.
11. Chiropractic Wellness: The Practice Building Journal from Koren Publications. Volume 1, 1998-1999, back cover. Distributed October 1998.
12. Rondberg vs. Federal Trade Commission, filed Oct 28, 1998.
13. Feds drop Dr. Koren's case: First amendment rights of health care professionals were at stake. Dynamic Chiropractic, Aug 2001.
14. FTC questions Koren's claims. Is Koren Publications Just the Beginning? Dynamic Chiropractic, Sept 21, 1998, pp 1,17,42,49.
15. Koren T. E-mail message to Dr Stephen Barrett, September 13, 2001.

For Additional Information
To what extent can chiropractors help people? Does it ever make sense to seek chiropractic care? If so, how can a reliable chiropractor be found? These questions—which are not simple to answer—are thoroughly discussed in Chiropractic: The Victim's Perspective (1995), written by George J. Magner, III, and Inside Chiropractic: A Patient's Guide (1999), by Samuel Homola, D.C. Both were edited by me and published by Prometheus Books. Together they provide the most detailed analysis of the chiropractic marketplace ever published.

Reader Comments The degree to which some chiropractic students are brainwashed with subluxation philosophy is demonstrated by email messages I get from time to time. The first message below came in February 1998 from a student at Parker Chiropractic College. The second came in March 1998 from a student at Life University. The third came in May 1998 from a recent graduate from Cleveland College. The fourth came in August 1998 from a Parker College intern who didn't specify which article(s) on Quackwatch had bothered him.

1. In order to bash something, you have to know what it is first. ALL chiropractors know that we can't heal anything, it is the body that does the healing. All we do is help the body maintain its normal function. In order to function normally, the nervous sytem must be able to flow freely, because it is the nervous system that basically controls everything else in the body. Whether it directly controls something such as muscles, or indirectly like enzyme release, it does effect every part of the body. In the course of the entire body, it is possible for the nerve to be compressed, either by bone directly, or by surrounding soft tissue. This works just like stepping on a water hose. If you step on a hose, the water coming out the end slows, and if you step hard enough, it stops. The same is basically true of nerves. If the nerve is compressed, then the nerve impulse is inhibited, if not completely stopped, thus affecting the area innervated by that nerve. Hopefully you will agree that if a specific muscle or other tissue loses its innervation, it will begin to atrophy, and can possibly die completely. All chiropractors do is move the surrounding bone and or soft tissue to relieve the compression on the nerve, thus allowing it to flow freely. The body can heal itself better than any drug can, and I think you know that.

2. As you well know, the body is an amazing example of communication and efficiency in that millions of cells are working together to achieve optimum function. Is the heart beating too fast? How much glucose is needed for the secretion of insulin? How much sodium in the blood stimulates the osmoreceptors in the HYPOTHALMUS to activate ADH? The answer is that communication between the BRAIN and the organs, glands, and cells of the body through the SPINAL CORD is needed for these functions to exist. How else would a structure in the brain (the hypothalmus) know that these processes are going on? Do subluxations cause an interference with this communication, that is the million dollar question. It is a theory, our theory, and it makes sense. I object to you calling us quacks and endorsing a closed minded approach to healing. In general, western medicine's philosophy of health in a pill is over-prescribed and harmful. . . . Millions are seeking alternatives, there is an innate healing power of the body, and chiropractors are well trained, intelligent health care providers. Much of the physiology of the body is still unknown, open your mind to new possibilities or you will be left behind.

3. I have never told my patients that I would be able to 'cure' them or their ailments. I have only tried to inform them that if their condition is being affected by pressure on a nerve (or group of nerves) that I may be able to help them by removing pressure (usually indirect pressure caused by the contents of the IVF when a vertebra is not moving properly) and allowing the nerve or nerves to function properly. [Editor's note: IVF stands for intervertebral foramen, the space between the spinal bones through which the spinal nerves emerge.]

4. If you believe that I am a "quack" for studying the amazingly wonderful entity of the anatomical human body and for learning the tremendous power that it possesses to both monitor and even heal itself (optimized by the removal of interference and toxins), then I must admit that I would never expect a doctor of your accomplishments and status to repeatedly express such a feeble, closed mind. My only goal as I enter practice will be to help everyone that I treat to obtain the maximum quantity and quality of life possible—the way the good Lord intended —without blindly accepting unnecessary poisonous drugs and surgery at the drop of a hat. Those things should be the final alternative, not the first and/or only choice. The Power that made the body heals the body. The problems should be addressed primarily, rather than the symptoms.

This article was revised on May 21, 2006.