As we begin to more fully understand the nature of the various factors which come together to create the vertebral subluxation,

old models used to describe it are being expanded upon and new ones are evolving.

The more we read contemporary literature the more evidence we find for what we, as chiropractors, do. This information is not only contained in chiropractic literature but is also found in the biomedical literature.

For example, the American Medical Association's "Guides to the Evaluation of Permanent Impairment" devote considerable space to discussing the evaluation and impairment characteristics of several of the components of one model termed the vertebral subluxation complex.

The "Guides" include discussions of global range of motion, motion segment integrity and muscle strength -- all of which come under the headings of kinesiopathology and myopathology, two of the components of the VSC model.

Since it is felt that kinesiopathology (abnormal motion) is the initiating factor in subluxation degeneration, it seems this must be something chiropractors should pay particular attention to.

This column focuses on motion segment integrity which is evaluated using lateral radiographs of the cervical, thoracic, or lumbar spine. These can be neutral films or flexion/extension studies. Or, better yet, both.

You can draw the lines by hand and take the measurements yourself or have the films digitized. Either way, you're going to end up with a more objective assessment of the patient -- backed up by the AMA "Guides." I realize the AHCPR guides say X-rays are a "no-no." But let's focus on what's best for the patient for a moment and not worry about the insurance companies and IME docs.

Loss of motion segment integrity, aka structural integrity, will appear as abnormal translation and/or abnormal angular motion of one vertebra with respect to another. Loss of structural integrity is present when there is a translation of greater than 3.5mm in the cervical spine or greater than 5mm in the thoracic or lumbar spine.

Loss of motion segment integrity is also present when there is a difference in the angular motion of two adjacent vertebral segments greater than 11 degrees on flexion and extension studies. This abnormality must be a 15 degree difference at L5/S1 compared to L4/L5 to meet this definition.

The presence of abnormal motion segment integrity places the patient in an impairment category of 20-25%. Apparently even non-chiropractors understand how serious kinesiopathology is even without the presence of neurological findings. Remember, surgeons like to fuse hypermobile segments. Perhaps by adjusting the hypomobile segments there would be no need for the hypermobility or maybe of a lesser degree. Future research may bear this out.

As chiropractors, however, we understand that, by definition, neurological compromise is inherent in vertebral subluxation.

A review of articular neurology, proprioception, etc., and its interplay with the central nervous system, autonomic nervous system will clarify the relationship this has to dis-ease and a person's inability to comprehend his or her environment. As we're learning, Palmer wasn't necessarily speaking only of synaptic neurological information when he was discussing mental impulse.

These biomechanical abnormalities (kinesiopathology) set in motion a series of events which, if not arrested, will lead to interference of the mental impulse -- subsequently leading to quality of life changes, symptoms, and impact upon a person's physical, mental and social well being.

Dr. Ralph Boone writes in the recent issue of the Journal of Vertebral Subluxation Research (JVSR): "An eclectic approach is essential in regard to subluxation based chiropractic. The reason is that it is a discipline with both holistic components, related through its governing philosophy, and mechanistic components, expressed through biomechanics, and noted physiological changes occurring before and during care." (1)

While the AHCPR guidelines continue to be adopted by one state after another and the push continues to position D.C.s as "back pain specialists" who only see patients until their symptoms improve, let's remember the old timer's admonition: "Symptoms are the last to show up, but the first to go away."

We now have at least one recent research study to support this anecdotal statement which was also published in the most recent issue of JVSR. (2)

Lo and behold we find that subjective improvement occurs long before functional stabilization of the subluxation. So the pain gets better and even activities of daily living improve, while muscle strength, range of motion and X-ray changes don't happen as quickly. This is something practicing chiropractors have known for some time but which has not been discussed in a peer-reviewed, indexed journal devoted to subluxation related research, until now.

So, regardless of which way the third party winds blow, continue to focus on correcting your patients' subluxations and monitoring structural and functional changes. After all, this IS in the best interest of the patient.

References

(1) Boone WR, Dobson GJ: "A Proposed Vertebral Subluxation Model Reflecting Traditional Concepts and Recent Advances in Health and Science: Part III." Journal of Vertebral Subluxation Research, Vol. 1, No. 3, 1997.

(2) McCoy HG, McCoy M: "A Multiple Parameter Assessment of Whiplash Injury Patients Undergoing Subluxation Based Chiropractic Care: A Retrospective Study." Journal of Vertebral Subluxation Research, Vol. 1, No. 3, 1997.