This article is an excerpt of a much larger one about spinal manipulative therapy (SMT). Chiropractic “subluxation” is such a popular concept that it deserves its own page.
Joint mechanics and neurology are just insanely complex, and when that complex system fails in any way, we could (and should) call it a “joint dysfunction.” It’s a safely generic label. We can cram almost any kind of theory into that label — almost anything that might go wrong with spinal joints — without going too far out on a limb. There is little doubt that neck pain and back pain often involve some kind of “joint dysfunction.”
Or maybe there is doubt: maybe the joint just feels wonky. Pain distorts body image — our mental image of our own anatomy. An odd little 2008 paper demonstrated that people with back pain think their vertebrae are deviated to the painful side.1 Simple as it is, this phenomenon may be potent and persuasive. It could be a major reason for the belief in out-of-place vertebrae.
But if it’s not just warped sensation, if there actually is some kind of dysfunction, what kind?
The chiropractic explanation
Chiropractors believe that they know, and they’ve built a profession around it: “subluxation.” A misalignment. A “spine out of line.”2 Many doctors and scientists disagree!
Chiropractors often propose subluxation as both the main cause of back and neck pain and of disease and poor health in general.3 The chiropractic idea of subluxation has been defined in many different ways over the years, and more broadly all the time, to the point of absurdity, expanding beyond the spine to include any harmful “imbalance or distortion” anywhere in the body.4 This ominous definition of subluxation is both the most popular and the least defensible. Although there are other definitions — for instance, definitions that might be less controversial — they probably should not be used, because they are too easily confused with the dominant chiropractic definition.
In standard medical terminology, a subluxation simply refers to a partial traumatic dislocation of a joint. Ligaments around the joint may be painfully sprained, and cause severe pain closely coupled to movement, slowly fading over many weeks, like any other sprain. Slightly subluxed spinal joints often return to a more or less normal position immediately, like a dislocated shoulder popping back in.
Although that’s not the kind of “subluxation” that this article is about, such cases do provide important perspective, in that a true dislocation can be amazingly asymptomatic. There are many case reports of true spinal joint derangement and injury that cause little or no trouble, or certainly much less than most people expect. In the low back pain tutorial, I describe one of my own former patients with a very serious lumbar dislocation — and no low back pain (she came to see me for a foot problem). Another patient with extreme scoliosis, although often uncomfortable, was generally surprisingly fine and even fit. The patient pictured here, as reported in New England Journal of Medicine, had no “pain, weakness, or parasthesia”!5
For perspective, here’s an example of a spine that is genuinely “out of line.” Although this is a serious dislocation, the patient was quite healthy. See Akhaddar.
Another case report in the journal Spine describes a man who was born with part of a neck vertebra entirely missing — he also had no serious symptoms until he fell one day, and his unstable spine was dislocated “.6 After that he certainly was symptomatic: he had severe pain, but only pain.
Another fun example of congential deformity or anatomical variation is The Amazing Owl Man! You don’t see this every day. Enjoy this campy, cringe-inducing bit news reel about a dude who can “owl” his neck — rotate 180˚ degrees! — if we can believe our eyes:
What are we to make of this? Is this anything more than an eye-popping novelty? I have no idea how he can do that, but can I extract some clinical relevance from it anyway? Natürlich! (As my high school German language teacher used to say.) Many of these examples of dramatic joint injury and dysfunction actually cause less trouble than chiropractic subluxations, never mind the more dire neurological problems that most people would assume to be the case, or the diseases and organ failures that much milder chiropractic subluxations can supposedly cause.
If a painful or stuck-feeling neck or low back involves a “subluxation” in any sense other than partial dislocation, then, it must be something more subtle — something nowhere near so obvious as a traumatic injury — which puts it firmly in the category of the classic chiropractic subluxation.
But is there even any such thing? There is a decades-old argument between doctors and chiropractors about the existence or nature of chiropractic-style subluxations. Many chiropractors still believe in them, in one form or another, and some do not.7 Sam Homola writes:
What I read in books written by orthopedic and physical medicine specialists made more sense to me than what I was being taught in chiropractic college. I rejected the vertebral subluxation theory as a basis for use of spinal manipulation.
Sam Homola, Doctor of Chiropractic, in “Can Chiropractors and Evidence-Based Manual Therapists Work Together?”
As far as most doctors and scientists are concerned, and even for many chiropractors, the argument is long over. They believe that either subluxations do not exist at all, or they only exist in some clinically insignificant form. They argue that chiropractors still can’t prove they can even find alleged subluxations reliably, let alone treat them. They doubt that a spinal joint can be literally “out” in a clinically significant way, and think that belief “keeps chiropractic marginalized and subject to ridicule by the scientific community”.8 Edzard Ernst writes, “The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.”9
In all the years that they have been talking about them, chiropractors have never been able to furnish proof of these mysterious subluxations which they alone are able to see. They may convince their clients, but never have they provided proof of their pretensions to men of science.
About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
What’s new in this article?
2016 — Added reference to body perception, Moseley 2008.
- Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov;140(1):239–43. PubMed #18786763 ❐
In this small, unusual study, six patients with low back pain were asked to draw their perceptions of their back and spine. For comparison, a group of ten patients with no recent back pain were asked to do the same exercises. They were encouraged to “draw what it feels like” rather than how it actually looked.
“All the patients, and none of the controls, showed disrupted body image of the back” on the same side and level as the pain. For instance, they did not have a clear sense of the outline of their trunk.
Most intriguingly, patients with back pain on just one side illustrated vertebrae deviated towards the painful side (without any obvious actual deviation).
- This is a very well-used bit of chiropractic marketing language. The rhyme and the simplicity have been used to sell chiropractic services for a century.
- In “Finding a Good Chiropractor”, Sam Homola writes, “With the development of osteopathy in 1874 and the appearance of chiropractic in 1895, spinal manipulation gave birth to a new theory. D. D. Palmer, the founder of chiropractic, a grocer, and a magnetic healer who healed by touch, announced his discovery that ‘ … 95 percent of diseases are caused by displaced vertebrae; the remainder by luxations of other joints.’”
- Chiro.org [Internet]. Rosner A. The Role of Subluxation in Chiropractic; 1997 November 6 [cited 19 Nov 6].
By the late 90s “through consensus of the chiropractic college presidents under the auspices of the Association of Chiropractic Colleges in July of 1996,” subluxation was defined as:
a complex of functional and/or structural and/or pathological changes that compromise neural integrity and may influence organ systems function and general health
So, anything that can go wrong with a joint, causing any kind of health problem. Gotcha. And yet, as broad as it is, note that pain isn’t even mentioned — it went straight to organs and general health. And then, much more recently (in 2014), the official definition is broader still! In fact, this definition widens the scope so far that we’re no longer even just talking about the spinal joints, but any harmful “imbalance or distortion” anywhere in the body:
Subluxation is a neurological imbalance or distortion in the body associated with adverse physiological responses and/or structural changes, which may become persistent or progressive. The most frequent site for the chiropractic correction of the subluxation is via the vertebral column.
- Akhaddar A, Boucetta M. Dislocation of the Cervical Spine. N Engl J Med. 2010 May 20;362(1920). PainSci #55145 ❐
A case report (and disturbing X-ray) of a traumatic cervical spine dislocation, notable for being mostly asymptomatic: just torticollis and limited motion, but no pain, weakness or altered sensation. That such a serious injury can have so little impact on a person is quite interesting!
A 22-year-old man presented with a 10-day history of torticollis. Two months before presentation, he had fallen from standing height but did not report subsequent cervical pain, weakness, or paresthesia. On examination, there was a reduced range of movement of the cervical spine without other neurologic deficits. Radiography of the cervical spine showed a marked reversal of the cervical lordosis, anterior displacement of 60% of C4 on C5, anterior callus formation, bilateral facet dislocation, and increased posterior interspinous distance (double arrow) (Panel A). Magnetic resonance imaging was performed. Sagittal T2-weighted imaging revealed a spinal cord angulation with mild compression but without intramedullary edema or hemorrhage (Panel B). The patient was admitted for surgery. With the use of an anterior approach, diskectomy, tricortical bone grafting, and insertion of a cervical plate were carried out, with a good outcome.
- Moon SJ, Lee JK, Seo BR, Kim SH. Traumatic subluxation associated with absent cervical pedicle: case report and review of the literature. Spine. 2008 Aug;33(18):E663–6. PubMed #18708921 ❐
This paper describes the case of a man who developed severe neck and shoulder pain after a fall. It turned out that a part of one of his neck vertebrae was entirely missing, since birth (“a relatively uncommon developmental anomaly”). The fall subluxed the joint substantially. Although painful, the lack of neurological symptoms is surprising — and more evidence that nerve roots are not easily pinched.
STUDY DESIGN: Case description.
OBJECTIVES: To describe a case of traumatic subluxation in association with a congenitally absent cervical pedicle, and review the pertinent medical literature.
SUMMARY OF BACKGROUND DATA: The congenital absence of a cervical pedicle is a relatively uncommon developmental anomaly that is frequently mistaken for a unilateral facet fracture-dislocation in the context of acute trauma. Because there is little evidence of recovery after surgery, and the symptoms are usually not disabling, surgery is not recommended for most cases.
METHODS: A 62-year-old man presented with severe neck and right shoulder pain after falling. Plain radiographs and computed tomography of the cervical spine showed the typical features of a congenitally absent pedicle at C6 with anterolisthesis of C6 on C7. We performed anterior interbody fusion at C6-C7 because of persistent neck pain and progressive instability.
RESULTS: Complete restoration of the C6-C7 subluxation was achieved with resolution of the presenting symptoms. At 18 months follow-up, flexion and extension dynamic radiographs demonstrated good alignment with solid fusion at C6-C7.
CONCLUSION: Although conservative treatment is the primary treatment for this clinical entity, surgery is an alternative option for those patients who fail to achieve recovery after conservative treatment or exhibit instability.
- Good examples of those who do not include chiropractor Dr. Sam Homola, author of Inside Chiropractic; Dr. Edzard Ernst, author of Trick or Treatment: The Undeniable Facts About Alternative Medicine (and who is not quite a chiropractor, but close enough); and Dr. Murphy , one of five research-oriented chiropractors who have bared their profession’s shortcomings in a 2008 article that calls for “dramatic changes” and states that chiropractic “finds itself in a situation in which it is rated dead last amongst healthcare professions with regard to ethics and honesty.”
- ScienceBasedMedicine.org [Internet]. Homola S. Chiropractic Vertebral Subluxations: Science vs. Pseudoscience; 2010 Sep [cited 16 Feb 13].
- Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage. 2008 May;35(5):544–62. PubMed #18280103 ❐
- Yes, this an old source! However, “men of science” (and women) remain unconvinced. The spirit of this statement is just as valid as it was more than forty years ago.