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Chiropractic Journal of Australia : CJA March 2013
6 Chiropractic Journal of Australia Volume 43 Number 1 March 2013 Dorland’s medical defnition of a subluxation does not differentiate it from a sprain, although displacement is not mentioned in The defnition of the latter, suggesting the articular bones resume their normal juxtaposition after injury. The dictionary defnes luxation as simply a "dislocation." A ‘medical subluxation’ as thus defned would only be possible in a dry spine, consequently it begs a more detailed defnition. Not even ligamentous injury is mentioned in the defnition, which therefore portrays quite a different image.47 Medicine itself has adopted some alternative models of care, such as acupuncture, calling it medical acupuncture. It has become a recognised, if not an integrated part of medicine, yet it is still essentially a theoretical model as to how it works, or indeed what its key element of chi is. One would suggest that there is less 'medical evidence' (apart from anecdotal records) underlying acupuncture than there is for chiropractic. Even so, logic would suggest that the evidence-base for all the health professions must include anecdotal evidence (as in clinical trials) as one of the evidential elements. There is no clinical health profession with a 100% evidence base of RCTs. In addition, reservations have again been raised as to the appropriateness of aspects of current EBM criteria for the clinical health professions.48 Questioning evidence concerning the VSC is essentially no different to the state of evidence supporting a number of medical regimens. For example, Udvarhelvi stated in 2006 that -- “Clearly, there is a lot in medicine we don’t have defnitive answers to.”49 While Eddy claimed that “only 15% of what doctors did was backed by hard evidence.”49 That medical journals and doctors can use the term subluxation in the chiropractic sense, and it is still denied or rejected by some, is another distinct contradiction.36 The medical paediatrician Biedermann uses the euphemism kinematic imbalance to cover the same entity.50 Lewit calls the same fnding "functional pathology," but also refers to 'movement restrictions' and disturbed function (p33). Both describe a number of so-called visceral conditions associated with the 'vertebral subluxation.'51Murtagh has adopted the term spinal manipulation and published on the topic. He has explained "segmental dysfunction" as "The most common cause of back pain presenting to the doctor is dysfunction of the spinal intervertebral joints." 52 While Bourdillon and Day are not supporters of the chiropractic hypotheses, they appear to have borrowed heavily from chiropractic for their text. Their term for the chiropractic subluxation is spinal joint lesion.53 Again, there appears to be no disputation regarding this medical recognition of these so-called lesions -- only the variations on naming the vertebral subluxation. On the other hand, Atlas recommends considering spinal manipulation of the lumbar spine for low back pain, but does not specify exactly what is to be manipulated. He has avoided using any term at all as the object to be addressed by the procedure.54 These medical doctors are among a number of primarily European medical doctors who have published widely on spinal manipulation. This would appear contrary to those allopathic colleagues in the English speaking countries who oppose chiropractic concepts. While some physiotherapists (manipulative therapists) address these mechanical vertebral lesions as spin al dysfunction, there still seems to be a lack of a defnition identifying precisely what fnding they address by manipulating patients' spines. The term spinal dysfunction also implies purely a mechanical lesion without other involvement. Nor does there seem to have been any reservations for use of the term spinal lesion or segmental dysfunction that some osteopaths and manipulative physiotherapists adopted. Both terms again imply merely the mechanical aspects of the VSC. In confrmation, a Medscape web site explains that manipulation has a "primary goal of restoration of diminished ROM" with no mention of subtle or apparent neural disturbance.55 The osteopathic definition of somatic dysfunction in itself does not necessarily imply related systemic effects of the lesion, and can therefore be limited or restricted in its interpretation. Like chiropractic, this has not prevented osteopaths publishing papers on a number of associated disorders, including visceral conditions. Somatic dysfunction has been defned in osteopathy as A defect in structure and/or function, which can be diagnosed by identifying tenderness, asymmetry, restricted motion, and tissue texture changes.56 Somatic dysfunction has been associated with the term neuromuscular lesions in such a wide variety of conditions as dysphasia, bladder dysfunction, and tendon refexes, and in the feld of psychology, as well as with other conditions. Neuromuscular lesions have been described as: 1. in psychology, embodied neuroses. The physical manifestation of psycholo-gic defenses. 2. in neuromuscular therapy, an area of limited motion and physical tenderness.54 To add to the perplexity, two further defnitions exist for primary somatic dysfunction. Not only are they additional meanings, but they use the same term in the offered defnition. The claim that the term subluxation has other meanings is somewhat countered by the fact that the term somatic dysfunction also has other meanings and requires separate defnitions to differentiate them and obviating that as an optional term. 1. any somatic dysfunction whose existence maintains an entire dys-functional pattern. 2. the initial somatic dysfunction in a pattern of dysfunction.58 The traditional allopathic regimen in addressing the mechanical spinal symptoms of a VSC is with pharmaceuticals (e.g. NSAIDS, steroids or analgesics). This may seem a contradiction, by addressing a physical condition with a chemical approach. All such models and definitions incorporate limited elements of the more inclusive chiropractic subluxation. They do not outline the potential for wider complications incorporated in a total complex. Such a tendency would tend to overlook the clinical signifcance of the disturbed spinal segment, and could limit the possibility aetiology and diagnosis of some conditions. COMMENTARY ROME
CJA December 2012
CJA June 2013