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Health Cost Management
Newsletter
September 2008 Volume 09, Number 09
Hot Topic… Subluxations and Somatic Dysfunction
Subluxations and Daniel Mangum, DO, FACP, Internal Medicine
Somatic Dysfunction
In the past newsletter, there was a reprinted JAMA editorial dating 100 years that adroitly discussed the
inappropriate and unscientific use of various and common diagnostic terms from that era. It was then suggested
Physicians that this problem still occurs today with fibromyalgia as one modern day example of an unsubstantiated condition.
I do believe that this phenomenon that a symptom must carry a diagnosis is still problematic in some areas of
New to HCM… medicine.
This seems particularly true in the area of back pain. How many patients, along with their treating medical
Frederick Wise, Ph.D. providers for example, believe that their chronic low back pain is due to “bulging” or degenerated discs? The data
Neuropsychology is overwhelming that these findings, without evidence of nerve impingement or secondary complications like
spinal stenosis, are not the source of pain.
Edgar E. Clark Jr, MD When I explain this to patients, they often respond by asking then what is the source or diagnosis for the pain.
Diagnostic Radiology Many chiropractors and some of my osteopathic colleagues believe they have the answer. The former often
might describe the diagnosis as one involving “subluxation(s)” while the later profession uses the term “somatic
Theodore Ford, MD dysfunction.” Some practitioners, at times, offer a related term of “segmental dysfunction.” This, they explain, is
Anesthesiology & Pain the source of the pain since something is out of place or misaligned.
Management Each description and explanation, to the lay public, sounds scientific, but many DC and DO providers avoid the
terms completely, and it is not even discussed within the MD community. Those that use the terms are often
Mark Endicott, MD adamant in their certainty and importance of the finding, not infrequently adding along the way that they have
Orthopedic Surgery superior diagnostic skills (and often, it seems, they are equally insistent that more care must then be provided
because of these findings).
Steven Novom, MD What do both terms mean exactly, and are these the kind of diagnostic claims that will eventually be tossed into
Neurologist the can of nonsense medical terminology? To understand this better, we need to travel back in time to their
origins in the late 19th century.
David Scharf, MD
Neurologist Spinal adjustments and massage may date back in antiquity, but the concept that problems or findings in the
spinal area may be related to, or a cause of, an internal illness (rather than just pain) was first proposed by John
Hilton in 1863. Dr. Hilton was known for his studies in anatomy and his work as a surgeon. A decade later,
Howard Shortley, MD another physician named A.T. Still took this idea further and became the founder of osteopathy in 1874 eventually
Orthopedic Surgery opening the first osteopathic college in 1892, while a grocer and magnetic healer named Daniel David Palmer
would start chiropractic care just a few years later in 1895.
Annette Swain, PhD, ABPP
Neuropsychology Dr. Still was convinced that structural troubles caused nearly every single medical problem. Like everyone at that
time, Dr. Still lacked any basic understanding of physiology, yet he concluded that impairment in the flow of
information from nerves to various organs was the source to all medical conditions from croup to liver disease. In
his memoir, he wrote,
Health Cost Management “It appears perfectly reasonable to any person born above the condition of an idiot (emphasis mine), who has
familiarized himself with anatomy and it’s working with the machinery of life, that all diseases are mere effects, the
1815 NW 169th Place cause being a partial or complete failure of the nerves to properly conduct the fluids of life.”
Suite 1040 His success at treating various medical problems was described in some of his writings. He wrote:
Beaverton, OR 97006 “I could twist a man one way and cure flux, fever, colds, and the diseases of the climate; shake a child and stop
scarlet fever, croup, diphtheria, and cure whooping-cough in three days by a wring of its neck, and so on…”
He claimed messianic-like (i.e.100%) cure rates for strep infections of the skin (a problem that today still causes
Phone: morbidity and mortality), and asthma (another problem that causes more deaths now than in the past) for which
(503) 439-1338 he claimed osteopathy was “king.”
(800) 755-4283 D.D. Palmer first reported success with spinal manipulation occurred after he adjusted a deaf man’s back and
allegedly restored his hearing. With the results of this single case, he also concluded that:
“A subluxated vertebra… is the cause of 95 percent of all diseases. …The other five percent is caused by
Fax: displaced joints other than those of the vertebral column.”
(503) 439-0488
Mr. Palmer also decided that when a bone was out of place, it pressed on a nerve and impaired the flow of some
(866) 444-4948 special force that he called the “Innate” (always capitalized), a force he believed was necessary to allow the body
HCM Clinic
to heal itself. 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. Without proper flow of Innate, people would
become ill or have less ability to recover. Mr. Palmer talked about chiropractic as a religion and it is not difficult to
September 9 (at HCM) see why given the near-miraculous claims made by him and by Dr. Still.
Chris Clark, DC The term subluxation then started at this time of late 19th century scientific ignorance, and initially meant exactly
Chiropractor what it means today, a partial dislocation of a bone, or “95%” of the time, a vertebra according to Mr. Palmer.
In osteopathy, the accepted term of somatic dysfunction was not coined so quickly. Perhaps best known to
September 9 (Medford) advance this concept was Louisa Burns who described osteopathic lesions in the early 1900's, and later wrote
five books, including Pathogenesis of visceral disease following vertebral lesions (1948). I have not yet
Robert Cook determined when the term somatic dysfunction was first used, but the current definition is listed near the end of
Orthopedic Surgeon this article. The use of somatic dysfunction however has not caused as much contentious debate or controversy
as subluxation. This is probably because osteopathic medicine included traditional medicine education and care,
September 10 (at HCM) while chiropractic training however maintained, pardon my pun, a devout fixation with spinal alignment.
Donald Ramsthel, MD Nonetheless, the actual chiropractic definition of subluxation has changed over the years particularly after
Internal Medicine Medicare in 1973 agreed to pay for treatment of subluxations, but with the caveat it would pay for only those that
could be shown by imaging studies.
September 17 (Eugene) In 1972, working towards Medicare payment and requirement to prove subluxations, chiropractors held a
consensus conference on the subject. The several paged document described 18 kinds including "flexion
Robert Cook, MD malposition," "extension malposition," "lateral flexion malposition," "rotational malposition," "hypomobility" (also
Orthopedic Surgeon called "fixation subluxation"), "hypermobility," "aberrant motion," "altered interosseous spacing," "foraminal
occlusion," and others.
September 17 (at HCM) Subluxation was no longer a dislocation, but a variety of alignment or movement findings. The problem with this
Donald Ramsthel, MD expanded definition was soon apparent by many that pointed out these terms and radiographic findings were
Internal Medicine found, to some extent, in nearly everyone and especially those of Medicare age. It was also clear that these
findings did not correlate in the least with symptoms, and did resolve following adjustments. They were, in other
words, a bunch of descriptive words for subluxation, allowing a “diagnosis” and the ability to get payment for
September 25 (at HCM) treatment.
William Duncan, MD Some chiropractors took this subject to a higher level. In the late 1980s, the Vertebral Subluxation Research
General Surgeon Institute (VSRI) was launched by Terry Rondberg, DC, of Chandler, Arizona and the World Chiropractic Alliance
Vascular Surgeon (WCA), a group that promoted subluxation-based practice and managed Chiropractic Benefit Services, a
malpractice company that insured subluxation-based chiropractors. This was a very organized and structured
business that included a brochure—"The Silent Killer"—which explained the horrors of subluxations. A typical
comment would include the following:
A vertebral subluxation is a spinal abnormality that interferes with your nerves. It can create disease, 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. . . .
It was stressed and noted to be critically important to treat and to correct this “silent killer,” even without any
Would you like to receive symptoms. The VSRI program ended in 1991, but comments on the evils of untreated subluxations are still
this newsletter via e-mail? widespread on the internet and there are many providers that still cling to this entire concept.
Just send your request to: Concerns and criticism on these theories of subluxation persisted and increased. In 1996, in an attempt to "unify"
HCM@healthcostmanagement.com chiropractic terminology, the Association of Chiropractic Colleges adopted the following and most current
definition of subluxation: A complex of functional and/or structural and/or pathological articular changes that
compromise neural integrity and may influence organ system and general health
This sounds nearly identical to the current osteopathic profession definition for somatic dysfunction: Impaired or
altered function of related components of the somatic (body framework) system: skeletal, arthrodial (joints), and
myofascial structures, and related vascular, lymphatic and neural elements.
Congress, in their wisdom and with their profound medical knowledge base, amended the Medicare law in 1997
to allow for payment to treat subluxations now using the above definition.
It is abundantly clear to many that there are numerous problems with these two descriptive terms. The fact that
the vast majority of spinal problems do not affect the body's organs or general health is one important point, yet it
is still claimed or suggested by these definitions. This has allowed promotion by some that adjustments are
Health Cost Management needed not just for pain, but for asymptomatic people to maintain good health without the slightest evidence this
1815 NW 169th Place is true.
Suite 1040 Adding to this mess includes the fact that the conditions themselves are essentially impossible to research. The
Beaverton, OR 97006 main reason is because of the inconsistency of the exam findings between providers. Many studies have shown
wide variation in inter-provider manual diagnostic skills. One provider may claim a certain dysfunction or
subluxation at one area of the spine, while the next discovers a different concern in the exact same person.
Phone: Still, the most obvious problem is that these terms are so vague and so extraordinarily non-specific that they allow
(503) 439-1338 the providers to use them without worry and often without criticism. Providers can then treat just about anything
(800) 755-4283 and anyone by claiming there is a subluxation, somatic dysfunction, segmental dysfunction or a combination of all
them sometimes with added terms from sprains to strains to myofascitis. Patients are given a specific “diagnosis”
which, as noted before, they find more satisfying. Insurance companies that cover these services have little
Fax: ability to contest the “diagnosis” and treatment.
(503) 439-0488 Where this is going is unclear to me. Perhaps one day these words will fall away into the waste basket of
(866) 444-4948 outdated medical-sounding jargon, but it seems unlikely as they remain entrenched and supported within the
professions.
