It is now 120 years since D.D. Palmer first adjusted Harvey Lillard on the 4th floor of the Ryan building in Davenport, Iowa. He termed the basic malfunction to be “subluxation”. Definition of this ‘lesion’ has been problematic ever since. The various definitions of “subluxation” can and do take up whole books at this point. We all see things from our own perspective and each definition has come from this variable clinical experience. The word itself refers to a dis-relationship between contiguous vertebrae. Less than a luxation means it is not dislocated but there is still something askew about the relationship between the vertebrae altering kinesis and function.
The idea that there is one bone out of place (BOOP) was seen to be an oversimplification of the actual relationships in the spine and other tissues many decades ago. Clarence Gonstead defined the extended alteration of structure and function with his idea of major and minor subluxations. In upper cervical work, the atlas came to be seen as the “major” with all other fixations/dis-relationships as secondary. The atlas became the ‘canary in the mine’ so to speak, and alerted upper cervical doctors to the presence of disharmony in the structure and function. Adjustive correction of the atlas position as analyzed on properly aligned x-ray views correlated with clinical improvement and evening of apparent leg length inequality. Ralph Gregory realized that the whole cervical spine was misaligned and began to call it the “Atlas Subluxation Complex” recognizing that the cervical misalignments fell into patterns involving the whole cervical spine and head. He also realized the importance of the orientation of the pelvis and helped design (with Seemann) the Anatometer to measure pelvic excursion, although this information did not alter the biomechanics of the vectored adjustment.
Quantum Spinal Mechanics (QSM3) was formed because we wanted to first re-examine the basic procedure and make sure that physical principles were being applied appropriately. This re-evaluation was decades overdue. Concurrently, we were also looking at the concepts underlying the biomechanics and the adjustment itself. Lever systems require fulcrums and without defined fulcrums (bones do not touch each other and therefore cannot transmit the operative forces) the vector based biomechanics was incomplete. Dr. Cockwill revealed the atlas to act as a coupling between the head and axis (C2) in a 1996 paper published in the Upper Cervical Monograph.(1) While this paper was rejected by the leadership in NUCCA, the point had been made. As is often noted in science, correlation does not necessarily mean causation.
Historically, the clinical evidence had revealed that a 3/4degree misalignment of the atlas with the head (on a properly aligned nasium) was always consistent with a short leg on supine leg check. Correction of the measured misalignment correlated with evening of the leg length on supine leg check. The biggest problem facing upper cervical work is that this measurement is difficult to achieve in an accurate fashion and requires several critical steps to be performed impeccably. Very few people have been able to achieve this level of precision day in and day out. The ability to measure these structures and the error inherent is quite close to the measured values themselves. This has made using the atlas measurement as a ‘biomarker’ problematic. Sometimes it seems quite sensitive to the presence of subluxation and other times the atlas misalignment is miniscule. Full spine films had long shown that the misalignment of the individual extended far beyond the cervical spine and included the thoracic, lumbar and pelvic structures too. Considering that the biomechanical analysis was only analyzing the cervical spine, many of the cogent variables remained unmeasurable. The pelvis is the prime mover of the spine considering its considerable mass (especially considering the small mass of the atlas!) and its central position in terms of balance. These factors do not however, alter the vectored approach at all (in the previous systems). For any particular atlas misalignment identified by orthogonal analysis there are six major pelvic misalignment patterns that could be present. Restoration of the pelvis to proper orientation and alignment with the gravity line is imperative for long term stability.
NUCCA’s landmark study regarding results with previously untreatable hypertension in 2007 caused even the National Institute of Health (NIH) to take a look at the work. They soon found however, that this finding was an isolated one and that the definitional work underpinning the results had not been appropriately published. They asked for three things. They wanted to know how prevalent this ‘ASC’ was in the population. They wanted a biomarker that was defined in the peer reviewed literature and they wanted a defined mechanism. None of these issues has been accomplished yet although Woodfield has had some success with inter-examiner reliability in basic x-ray analysis. Further work by Woodfield and others on blood and cerebral spinal fluid flow in the presence of misalignment is also tentative but promising.
The major point here is that the search for a linear biomarker has been incredibly complex and difficult and has not yet been accomplished even after all these decades. This has led some in chiropractic (and certainly outside the profession) to decide that there is no such thing as subluxation. Anyone that works in this field becomes aware of the major improvements that occur with proper adjustment. Why it hasn’t been possible to find a biomarker that conclusively defines the subluxation has stymied and frustrated researchers for all these same decades.
Attempting to define the subluxation as a’ linear cause and effect’ entity misunderstands the nature of the complexity that life is. Any definition of a human being must understand that we are non-linear systems. The proportionality of linear systems is lost in the interconnectedness and complexity that define non-linear systems. A linear system can be defined by a measured output because the output is always proportional to the input. A non-linear system is dynamic, it is always changing. Stability exists, but it is not a static stability, it is a product of the vitality engendered by ALL of the aspects of the organism. The various systems within the body are not only balanced within themselves but an emergent balance also occurs at the level of the whole organism. This is not due to suppression or control of the individual aspects. In fact, it is the opposite. Each part (or holon) must have maximum freedom to optimally function if the whole system is to also function optimally. Loss of degrees of freedom diminishes the potential of not only the individual holon but also the entire organism. The ongoing relationship of the holons to each other and to the whole organism is an emergent and constantly unfolding process.
Medicine and science in general at this time in history is focused on mechanical reductionism. This has been a successful strategy in many ways but it has also caused us to lose much of the intrinsic meaning of our lives and frankly, threatens the future of all life on this planet. If the whole is the sum of the parts, then understanding each part means the whole is definable by the simple sum of the parts. Organisms however, cannot be described this way. The whole organism is easily seen to be greater than the sum of its parts. Non-linear systems, on the edge of chaos develop stability far from thermodynamic equilibrium that allows emergence of properties that cannot be predicted from examination of the individual parts.
Imagine a piece of sheet music. It is has a score with various notes and nomenclature on the paper. If you took this paper and cut out each note individually, put them into a box and shook the box, you could take one note out at a time and examine them. They would come out of the box in no defined order. You could understand a great deal about each individual note you have taken out but you have lost the emergent property of all the notes in proper relation to each other. It is not possible to understand what beauty and emotion is contained in the composition by looking randomly at one note at a time. This loss of context is profound if you want to understand music.
If you want to understand a human being you must look at the whole organism and measure the ever changing dynamics of all the holons with each other as the emergent metabolism and behavior is only discernable in the context of the whole. Medicine operates under the illusion that if it ‘fixes’ the discrete ‘pieces’ then the whole is healthy. Suppressive drugs can turn off a given symptomatic metabolic pathway causing concern, giving temporary relief but at a real long term cost to the whole organism.
Subluxation is not a bone or several bones out of place. It is a vital response of the entire organism to a given situation. The body always does the best it can with what it has to work with. It creates the optimal balance possible given the possibilities. Every technique in chiropractic sees a portion of this truth. This is exactly why each group has a slightly, or more than slightly, different definition and understanding of subluxation and the adjustment. Each clinician has a unique perspective based on their individual experience. Dr. Friedman has written about this several times in his look at other chiropractic techniques. He has woven many of the diverse findings into a wider perspective that includes the various individual findings but is not defined by any one of them. What we do as chiropractors to intervene in other’s lives is dependent upon our individual perspective regarding structure and function. We are as the blind men and the elephant, limited to what we individually know. Enlarging our perspective enlarges our understanding of the whole and enhances our ability to intervene meaningfully.
Subluxation represents a loss of degrees of freedom at multiple levels within the organism. The resultant change in apposition of the skeletal elements, the soft tissue structures, the organs, and perceptual shifts all contribute to a decrease in the potential of the organism to be free and healthy. Asymmetric constraints evolve into long term changes in tissues and organ function as well as altered perception of the outside world. Subluxation has long shown itself clinically to be quite real. Subluxation may or may not be able to be measured in the discrete holons, but it is a non-linear phenomenon and it is present there as well as in the whole organism and its behaviors. Changing how we understand subluxation will lead us to new definitions, new ways to measure, and improved ability to remove interference.
Michael Thomas, DC
(1). Cockwill, R. “Angular Measurement of the Upper Cervical Spine in the Neutral and Laterally Flexed Positions”, in The Upper Cervical Monograph 5(7):10-12, May 1996.