Head Neck pain

What's needed is a classification system to determine just how bad our head neck pain is.

It still astonishes me how often I have a new patient with a cervical spine problem of several decades duration who has never consulted a chiropractor. Fifty years ago I can understand; there weren't too many DCs around in those days.

But to have been suffering all those years, gulping down prodigious quantities of pills that are known to poison the kidneys, or just suffering in misery, makes absolutely no sense when science proves so conclusively what causes migraine, for example.

Here's a quote from the Kidney Foundation website.

Generally, when used as directed, over the counter analgesics are reasonably safe. On the other hand, long term or heavy use of drugs, especially those that contain a mixture of different painkilling medications in one capsule, have been associated with chronic kidney disease. Read the labels and beware should you see aspirin, acetaminophen and caffeine, for example, all in one pill.

Almost everyone will have head neck pain periodically. 
Why? For many reasons, but not least that there are few of us who have not had a car accident, fallen down the stairs or taken a tumble from a horse or bicycle. Getting out of bed in the morning is dangerous but there's only one thing more dangerous; not arising from your slumbers.

Most people die in their beds.

Head Neck pain

 But seriously, just when is the right time to go to your doctor or chiropractor, (sorry, got that wrong: your chiropractor, or your doctor) with neck pain and headaches? Yes, we really do know what causes headache.

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Neck pain treatment

"How bad is my head neck pain?" is a question you may have been asking yourself. "Am I being a baby with a low pain threshold, or do I actually have a problem?"

A few thoughts. Just because you have a pain in the neck, or elsewhere, does not mean you must rush off to the chiropractor or your doctor. But then when should you go?

These are my golden tips. If you have

• Really severe pain,
• Neck pain which radiates down the arm
• Stiff neck and headache
• Neck pain and a fever
• Headache and a fever
• Pain which you know is not getting better

Now it's time to get help. After, mm, how many days? That's difficult to say; it's best to use your own intuition. But recognise that if you arrive at the chiropractor with a pain you have had for three months or more, the definition of chronic, then you will certainly need more than a few treatments.

What's more, research shows that if you've had neck pain for over six months then, no matter what treatment you have, it's with you for life. It can be managed, helped, reduced, relieved, but it won't ever go away completely.

For an acute problem that has only begun in the last few days or weeks, as a rule, after a short course of chiropractic neck pain treatment, one may expect the problem to go away completely. Better still, if you go through a short course of rehabilitation, there's a good chance that it won't return for a long time.

But if you've had head neck pain for months or years, it is more difficult for your chiropractor to give you an assurance that your symptoms will recede completely. Don't wait too long. But don't go too soon either unless it's really severe, or you have a pinched nerve that radiates down your arm.

Then you really shouldn't wait; arm pain probably won't go away on its own.

If you're handy you can make a home traction unit that is very effective against head neck pain particularly if it radiates to the arm; make it yourself for a fraction of the cost of a commercial unit.

One of the great things about the chiropractic adjustment is that it's rarely painful. Artfully done, even with severe neck pain, and you're terrifiied that he or she is going to hurt you, or make it worse, it's rare that the cervical adjustment is painful.

Just this week, a lady with very severe neck pain; just one adjustment, no pain from the treatment, and she's eighty percent better; it's not always like that, especially if there's also arm pain.

Make sure you tell as accurately as possible any old injuries and illnesses that you may have had. I certainly, and I presume others have too, missed that a patient has had breast cancer, for example. It's not common but every chiropractor will have had patients who have metastases from an old, and presumed quiescent, cancer. That's why a complete lifestyle change is so important after cancer. Never accept the we got it all statement; don't live in terror of cancer but do change what you eat, and don't eat. Changing to a healthy lifestyle is important for us but particularly for the cancer patient. Otherwise it just comes back, often years later. 

Or a car accident that happened thirty years ago, and was presumed irrelevant. It's those old injuries that cause the chronically fixated joints that become arthritic. 

• arm pain 
• home traction unit 
• neck pain treatment

In the interim, a good massage from your spouse may relieve your head neck pain, particularly for back of head headaches, use some alternating ice and heat, do a few simple exercises, and don't go playing silly twits! This is not the time for a game of rugby, or lifting pianos. Avoid carrying heavy groceries on the affected side.

A strong recommendation ... 

Research indicates that if you have neck pain for six months, then YOU WILL PROBABLY HAVE IT FOR THE REST OF YOUR LIFE. Once you know it's not going to get better of its own accord, then do something -- or spend the rest of your life suffering from head neck pain.

Why is that? Frankly, we're not totally certain but what we do know is that the hyaline cartilage in the little bones in your neck is very sensitive to subluxations - it's now proven that the cartilage begins to degenerate within 13 hours (in white mice anyway).

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A simple classification system for head neck pain

• Grade I head neck pain:

No signs or symptoms suggestive of major structural pathology (ie no severe pain, no radiation, no recent trauma) and no interference with activities of daily living. This will likely respond to those simple things suggested above; it does not usually require intensive investigations or ongoing treatment.

• Grade II cervical neck pain:
No severe pain or radiation, but now begins to interference with activities of daily living. You wake in the night with pain. You can't turn your head, and driving the car is thus dangerous. After a week or ten days, you have to acknowledge that it's not really improving. Then we suggest it's time to make an appointment with your chiropractor (or even your doctor first, if that is your first choice). A good examination is in order, and perhaps some early intervention aimed at preventing long-term disability.

• Grade III cervical neck pain:
with the onset of neurological symptoms. Headache, radiation pain or tingling down the arm, or into the midback. Now it's definitely time to get help, particularly if it has lasted for more than a few days.

• Grade IV cervical neck pain:
Still no signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness, and/or sensory deficits. In my opinion it is now definitely time for x-rays, perhaps even a scan. The pain of a pinched nerve in neck is often severe, the ache in your arm something you cannot escape, no matter how you change your position. It's often worst at night. This head neck pain should no longer be ignored.

• Grade V neck pain: Signs or symptoms of major structural pathology, such as fracture, myelopathy, neoplasm, or systemic disease; requires prompt investigation and treatment, and probably a consultation with a specialist. Certainly if the condition is not responding within a few weeks to conservative treatment.

Stiff Neck Exercises for Neck Pain

Exercises for stiff neck

STIFF NECK EXERCISES FOR NECK PAIN is a simple routine to do on a daily basis whether you have head neck pain or arm pain or not. Since 70% of the general population will have neck pain in any one year, and for 12% it will be disabling, a bit of prevention makes sense.

We recommend you take these exercises one at a time, do it for a few days, and when you're happy, go on to the next one.

There is no exercise program that fits with everyone. Listen to your body, take it slowly. If it doesn't feel good, leave it out, and move on to the next one. If you're not sure if you are doing it right, get someone to watch you do them.

Obviously first prize is to get a professional check that you are doing them correctly.

1. Neanderthal Man

Fix the eyes on a point on the wall directly in front of the eyes, and move the head forwards and backwards (retraction), slowly and rhythmically, careful to keep the chin on the same plane. Avoid flexion / extension - looking up and down.

A slight chin tuck on retraction is important.

Not to be done in public! Do this exercise in the car, and in the loo.

In general it's good practice to stretch tired and sore muscles. However, my experience, with the neck muscles, stretching them often increases the pain.

If there's any concomitant injury to the disc or facet joint complex, stretching the neck muscles may subluxate the weak joints. 

So I have no neck muscle stretches on this page. There is a place for them, but I'd rather you were taught them by your health professional, who must also decide: do you have a purely muscle condition in the neck, or is there is also an underlying joint condition. In which case, in my book, stretches are contraindicated. Others have a different opinion.

2. Neck Muscle Exercises

Cat and Camel

The Cat and Camel exercises for a stiff neck are more difficult, and probably should not be taught on a website. If you're not getting it, get help. It's an old yoga exercise.

In essence, it's the Neanderthal Man, with the head RETRACTRED against gravity. Once again, don't extend the head. Keep looking straight between your hands.

One of the reasons is that it requires two movement simulaneously:

1. humping and arching the lumbar spine.
2. moving the head and neck STRAIGHT UP AND DOWN.

Begin them separately and, when you can do each part confidently, then try combining them.

First, the Cat portion of the exercise.

The Cat stands proud during these stiff neck exercises for neck pain. Head up, neck retracted and back arched.

• On hands and knees, in a comfortable position, elbows straight.
• Place your watch between your hands. At all times down at your watch. This helps prevent the temptation or arch your head and neck into extension. Now retract your head and neck, keeping your eyes formly focused on your watch. 
• Now drop the belly and arch the back.

Do not arch the head and neck. 

This is a surprisingly vigorous exercise if you're suffering from neck pain. Take is slowly, not going to the extremes initially. 

The Camel

The Camel neck muscle exercise, done properly, is just as tricky. She's thirsty, and wanting to drink.

• Drop your head STRAIGHT DOWN (not chin on chest), keeping your eyes firmly fixed on your watch.
• Now hump your back.
• Eventually try doing them together, when you are confident that you can do each of these exercises for a stiff neck separately.

And now of course these two stiff neck exercises for neck pain (the Cat and the Camel) should be done simulaneously. First, just the head bobbing up and down, then the back arched and humped, and finally (if you can, some people can never coordinate it) head and back together.

Cervical Facet Syndrome 

A common complaint after whiplash

Keyword; cervical facet syndrome, chiropractic help, atlanto occipital joint.

This neck pain condition faces the chiropractic physician on a daily basis. Neck pain, headache and, less commonly, pain or tingling radiating down the arm, but more frequently to the region between the shoulders.

The cause? Quite simply, trauma, and sometimes poor posture. For example sleeping on your stomach. For years medicine has been in denial that whiplash, and other related trauma, can and frequently does cause injury to the various tissues in the neck. In a 10 year follow up study after whiplash, only 12 percent of the victims reported that they had absolutely no symptoms and had healed completely.

In another study reported in Spine, a prominent medical journal, fully 60 percent of whiplash patients were found to be suffering from a Cervical Facet Syndrome.

There is oodles of research now on whiplash, done by a whole range of specialists, chiropractic, orthopedic, neurological and radiological confirming the importance of the Cervical Facet Syndrome.

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Cervical Facet Syndrome 

The vertebrae, the ligaments, the muscles, the nerves, the discs and the facets (aka Z-joints) are all vulnerable to whiplash. Other more nebulous tissues too, like the fascia, of course the cord itself, and the blood vessels. Now there is overwhelming evidence that whiplash does cause permanent injury, and the cervical facet syndrome is one of the most traumatised tissues.

 SYMPTOMS

The facet joints in the neck have quite different shapes and orientations depending on their location, so the presentation varies quite dramatically according to which facet is involved. Very broadly, and frankly this is an over-simplification, we can divide the cervical facet syndrome into four different types:

The Atlanto Occipital joint (C0-C1)

• Read more about the ATLANTO OCCIPITAL JOINT …
• VERTIGO DIZZINESS

These two joints, right and left, lie between the base of the skull known as the occiput; and the first bone in the neck, called the atlas. Hence the name atlanto occipital joint. It is at this joint that nodding movements of the skull on the neck occurs; small up and down movements, adjusting the head position in relation to the monitor in front of you, for example.

Subluxation of these joints causes a deep ache at the very top of the neck, often causing severe headaches. A large artery supplying the base of the brain winds it's way around this joint.

Chiropractic help uses a variety of techniques including manipulation; the Chiropractic adjustment.  Sometimes the atlanto occipital joint is the problem; or that at the atlanto axial level. 

Subluxations of this joint can cause widely differing symptoms such asvertigo and loss of balance. Medically this is often causes a condition called benign positional paroxysmal vertigo, and sometimes Meniere's disease, if it there is associated deafness and ringing in the ear. However, in my experience, Meniere's is often wrongly diagnosed, the cause being either at this joint, or that condition in the inner ear, called BPPV that is very treatable with new techniques called the Epley Maneuver; this is a short course for chiropractors wanting to learn the Epleys.

Atlanto Axial joint anatomy (C1-C2)

These joints are quite different to C0-C1. It is here that most of the rotation of the neck occurs. Subluxations of the atlas are one of the causes of a severe stiff neck, often associated with headache too.

For more about the anatomy of the atlas, and the cervical facet syndrome, 

C2-C3

This joint has no specific name (as C3 as no name). However, it is possibly the most commonly subluxated joint in the neck. (Chiros will argue vociferously about that!) It too can cause headaches and a very stiff neck called a Torticollis. Pain!

See those 'facet joints'? They are lined with glistening white hyaline cartilage. When healthy it's very hard but, because it has no blood supply, it's very dependent on certain physiological factors for health and restoration after injury. The alternative is arthritis, stiffness and pain. 

Chiropractic help for Lower neck and arm pain

(C4-T1)

Facets in the mid-to-low cervical spine again are rather different in orientation and also, by virtue of the fact that the nerves emerging from the region supply the shoulder and arm, the Cervical Facet Syndrome presents rather differently.

Thus headache is less of a feature in this region. Rather, the fixations cause stiffness of the neck, and associated tightness and pain in the shoulder muscles.

Just adjacent to the facets, small joints often injured in whiplash are found. 

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TMJ anatomy

Because the sensory Trigeminal nucleus of the nerve supplying the jaw joint is found in the upper neck, in the region C1-C3, sensory information from the cervical facets feeding into that same nucleus, neck pain andjaw joint pain (TMJ) often go hand in hand.

Between them, the cervical facets and the TMJs are the major cause of blinding Migraine headaches, though it must be recognised there are many causes of migraine. For more about headache in general, and the association between the TMJ and migraine, click here.

ARM PAIN

The whole arm becomes vulnerable.

The nerves emerging from this region supply the shoulder and arm. Should there be nerve involvement then the pain, tingling and numbness may spread into the arm, causing obscure arm pain and making you will be vulnerable to shoulder pain, conditions such as

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Take note of the first rib in the diagram above. A fixated rib is the most common cause of the so called Thoracic Outlet Syndrome which can affect the artery supplying the arm, and the nerves. Working with your hands above your head, as in hanging the washing, or using a drill above shoulder level, makes your arm tired very quickly.

To understand the low cervical facet syndrome properly you need to have some grasp of the low cervical facet anatomy.

The the basis of your arm pain be a pinched or irritated nerve in the neck? The basic test for a pinched nerve in the neck is known as the upper limb tension test

Vertebral Subluxation Complex

Medicine has its magic bullet theories to justify its treatment methods. Chiropractic has the subluxation. Both have their uses, but they also have their weaknesses.

Just as it is now being realised inflammation cannot simply tackled with drugs and it is now acknowledged that fifty years of war on cholesterol has failed dismally with one in four Americans taking statin drugs, yet death from heart disease continues to rise; foods to reduce inflammation. Likewise research continues to find gaps in chiropractors' theories about the subluxation.

Here, a fine article on chiropractic's striving with its roots in the Vertebral Subluxation Complex. 

The VSC concept has been one of the fundamental components of chiropractic theory since the founding of the profession. A history of the evolution of subluxation and joint dysfunction concepts is provided from DD Palmer's original anatomic and vitalistic model through through his son BJ Palmer's model of blocked neurological impulses.

Charles A. Lantz, DC. PhD. Director of Research, Life Chiropractic College West, 2005 Via Barrett, San Lorenzo, California 94580-1368

An account of chiropractic concepts of Vertebral Subluxation Complex from the beginning, even before DD Palmer founded the practice of chiropractic, to the present involves a review of a wealth of historical, scientific, and clinical information. There is a growing body of evidence, from both within and outside the discipline, that supports many of chiropractic's basic concepts.

Evidence regarding the contribution of spinal joint derangement to a number of significant health problems becomes more compelling as more is learned. The role of manual procedures, especially as performed by chiropractors, becomes more prominent each year. A new environment without the overt ostracism of political medicine and a burgeoning research enterprise within chiropractic academia and practice are helping to poise the profession for greater contributions to the health care of society.

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Vertebral Subluxation Complex

The term subluxation is a medical term meaning "less than a true dislocation". For chiropractors the term Vertebral Subluxation Complex took on a life of its own. One feature of subluxation that emerged early in its development was the almost unspoken idea that the subluxation was often "medically" subclinical. Typically, medical physicians overlooked the subtle clinical manifestations of subluxations. Medicine's official perspective was that there was no legitimate evidence of what chiropractors called "subluxation", and it simply did not exist. It therefore became a matter of policy to discredit the very existence of chiropractic, from fundamental concepts to clinical practice.

This perspective extended into the 1970s. Research into chiropractic conducted by the medical community was so obviously biased that it had little credibility, although it did have tremendous political appeal. What little research chiropractors themselves engaged in was often proprietary and rarely disseminated and scrutinized. Thus, chiropractors built their practices in the shadow of medical dominance that depicted them as charlatans, quacks, and unscientific cultists. The lack of scientific credence was wielded by organized medicine against the chiropractic profession in an attempt to "contain and eliminate" chiropractic.

Probably one of the most important lawsuits directly affecting chiropractors, lasting eleven years, ruled that the American Medical Association was guilty of violating the Sherman antitrust laws in its attempt to destroy chiropractic ...

Vertebral Subluxation Complex: LA CAUSE CELEBRE

In the early formulations of the theory of vertebral subluxation complex and extending into contemporary times, the idea of subluxation has been linked with the idea of the chiropractic help 'adjustment', the uniquely chiropractic procedure directed at reducing subluxation. Because the vertebral subluxation complex concept emphasized a relationship between mechanical joint dysfunction and the establishment of nerve interference, chiropractic adjustment has often been equated to removal of "nerve interference." The subluxation is the "raison d' etre" of the adjustment.

In the simplistic, early twentieth century mindset in which the concept vertebral subluxation complex was developed, subluxation was seen as the "cause of all disease" or the "one cause" for which there was but "one cure." This concept gave rise to an extensive proliferation of chiropractic techniques and procedures for adjusting for the removal of subluxation. Attacking the concept of vertebral subluxation complex, one of chiropractic's central foundations, became an instrumental part of the strategy to discredit chiropractic.

With continuing assault from organized medicine, chiropractors became more entrenched in their defense of the concept, for if there is no Vertebral Subluxation Complex, there is no need for an adjustment; no adjustment, no need for chiropractors. Medical critics attacked the concept from an extremely narrow perspective, while chiropractic defenders interpreted the concept much more broadly. Since the idea of subluxation was first adapted by DD Palmer as a central conceptual focus of chiropractic, it has undergone continual refinement and development.

The origins of the Vertebral Subluxation Complex

The term Vertebral Subluxation Complex was not coined by chiropractic's founder, DD Palmer. Rather, it was a medical term adapted by Palmer to most closely describe the phenomenon that he experienced in his newly "discovered" clinical practice. Palmer stated, "I am not the first person to replace subluxated vertebrae, for this art has been practised for thousands of years."

Much of the controversy regarding the "Vertebral Subluxation Complex" may stem from the fact that the term already had a precise meaning in medical terminology. Arguments on both extremes ranged from claims that minor "subluxations" of vertebrae are not detectable or clinically significant, to claims that subluxations are measurable to absurd levels of precision and are the ultimate cause of all ills afflicting humanity.

Until recently, no amount of logic, reason, or evidence would sway the medical community and through it, the public regarding the validity or credibility of chiropractic clinical practice; it was pure and simple quackery, and until the mid 1970s, it was official medical policy to remove the cult's shield of legitimacy to combat and eliminate their brand of cultistic therapeutic nonsense. 

Early definitions

DD Palmer proposed that the "subluxation of a vertebrae is a slight deviation from its normal relation to adjacent vertebrae," [7] and this is said to cause "an alteration and narrowing of intervertebral foramina." With regard to adjustive procedures, "The Chiropractor places vertebrae in line by hand, thereby removing impingements and returning the nerves to their normal tonicity. Normal tension produces normal functions, harmony and health, "
Two distinctly chiropractic conceptions regarding subluxations are:

• They are correctable by adjustive (manipulative) proceedures, and
• Subluxated vertebrae interfere with proper neurologic functioning.

In 1828, the concept developed of compression of nerves "as they issue from the spinal marrow," resulting in "spinal irritation" as the "immediate cause" of pain, nervous complaints, and poor health. Throughout the mid- to late 19th century, medical authors referred explicitly to subluxation.

"A vertebra is said to be displaced or luxated when the joint surfaces are entirely separated. Sub-luxation is a partial or incomplete separation: one in which the articulating surfaces remain in partial contact. This latter condition is so often referred to and known by chiropractors as sub-luxation.

The relationship existing between bones and nerves are so nicely adjusted that anyone of the 200 bones, more especially those of the vertebral column, cannot be displaced ever so little without impinging upon adjacent nerves. Pressure on nerves excites, agitates, creates an excess of molecular vibration, whose effects, when local, are known as inflammation, when general, as fever.

THE DEVELOPER OF CHIROPRACTIC

The concept of subluxation developed by DD Palmer's son, BJ Palmer, was distinct from that of his father. According to BJ Palmer, a subluxation represented a displaced bone that impinged on a nerve, thus  interfering with the transmission of vital nerve energy (or, more specifically, the transmission of mental impulses.

A clear delineation was made between a simple misalignment and a true subluxation, although no formal evidence was presented to justify such a distinction, BJ Palmer thus conceived that vital energy originating in the brain was transmitted from above, down, inside out. Thus an impingement near the origin of the transmission for example, the brainstem at the level of the atlas ring; would affect the whole system. The concept was appealing in its simplicity.

Perhaps the most widely quoted early definition of subluxation was that provided by RW Stephenson's 1948 chiropractic text Book; a subluxation is the condition of a vertebra that has lost its proper juxtaposition with the one above or the one below, or both; to the extent less than a luxation; which impinges nerves and interferes with the transmission of mental impulses.

SEEING IS BELIEVING

To more precisely determine the location and direction of subluxated vertebrae, radiographs were utilized to evaluate osseous misalignment. At the time that DD Palmer "discovered" chiropractic, there was no radiologic definition of Vertebral Subluxation Complex, since the first clinical radiographs had not yet been taken. However, the term was readily found in the medical literature and detined in medical lexicons. Radiographs continue to be a clinical tool used by many chiropractors for documenting the existence and location of subluxation pathologies.

It is perhaps serendipitous that chiropractic was "discovered" in the same year as X-radiation. Certainly the coincidence was not lost on either the founder or the developer of chiropractic, as one of the first clinical X-ray units was installed at the Palmer Clinic in Davenport, Iowa, near the turn of the century. Radiographs allowed the chiropractor to "see" and show others the misalignment.

The incorporation of radiographs into diagnostic procedures in chiropractic led to the development of systems of X-ray markings for "precise localization" of the subluxation and calculation of the extent of misalignment.

Essential support for the concept of radiographic subluxation was provided by a medical physician named Hadley who, between 1935 and 1955, described in detail radiologic accounts of osseous vertebral subluxation complex and discussed subsequent nerve impingement and alterations in neurologic function. Such evidence provided considerable ammunition for chiropractic practitioners and theoreticians.

Nerve interference 

One aspect of Vertebral Subluxation Complex that distinguishes it from classic medical subluxation is the existence of so-called "nerve interference." Although the DD Palmer's definition of subluxation stressed the "bone out of place", rather than joint disfunction, emphasis was also given to pressure on, or irritation of nerves, leading to increased nerve tension.

According to DD Palmer, the nervous system as well as other vital tissues existed in a state of vibration. Nerves were considered to be under a certain amount of "tension," similar to the strings of a piano or guitar. Metaphorically speaking, when the strings are tuned properly, the instrument plays harmoniously; when they are out of tune, there is dissonance or disharmony (dis-ease). Vitality, or health, represented a tone that was harmonious with a vital principle that Palmer referred to as "Innate Intelligence." This tone was transmitted to all tissues via the nervous system, and any interference with this transmission led to a disharmony and, subsequently, disease. 

Eminent chiropractor and researcher Dr J. Janse stated that "The Chiropractic adjustment helps to remove nerve impingement at the intervertebral foramen", even though he acknowledged that there was no tangible evidence of this phenomenon; he defended his position by stating that the assertion finds its "support in logic and anatomical reasoning." The concept of nerve interference remains central to many approaches to chiropractic practice and is primary in some of the more traditional and conservative perspectives.

ASIDE: Modern research has vindicated many of Dr Janse's opinions regarding the Vertebral subluxation complex.

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In 1971, neurologist and chiropractor Haldeman and Drum reviewed the relationship between compression lesions and the concept of subluxation and suggested that there was sufficient evidence to verify the existence and importance of the compression subluxation. Many of the theories supporting the effectiveness of chiropractic revolve around the "neurological connection."

Anatomically and physiologicaI1y, such a relationship can be readily characterized. Chiropractors adjust vertebrae, presumably restoring normal position or functional capacity. It is a simple extension of logic to postulate that the segmental nerves, coursing within the intervertebral canal (IVC) traversing between adjacent vertebrae could be compressed by a subluxated vertebra.

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The disc-wedge hypothesis

In 1934 medical researchers Mixter and Barr promulgated the concept of a herniated disc as a "cause" of low back pain; this concept became the pathophysiologic basis of orthopedic surgical intervention for low back pain. Many of the same undercurrents of information infuencing Mixter and Barr likely infuenced chiropractor Gonstead to develop the disc-wedge hypothesis of vertebral subluxation complex.

The intervertebral disc (IVD) consists of a gelatinous nucleus pulposus surrounded by tough sheets of annular fibers. According to Gonstead, the nucleus pulposus served as a pivot for the tilting of vertebrae, a sort of hydraulic ball bearing. It was the shifting of the nucleus that caused the vertebrae to become wedged and therefore subluxated: "subluxation is a disorder of the disc."

The wedging of the vertebrae leads to disc bulging on the side of the closed wedge, and it is the bulging disc that places pressure on the nerve roots in the IVF or neural canal. 

One consequence of this wedging is presumed to be a loss of segmental mobility. The vertebra is considered fixed, and the area of reduced mobility between the fixed vertebra and subjacent vertebra has been termed biomechanically as a fixation. For every fixation, there are apparent areas of compensatory hypermobility that manifest similar types of misalignment as the subluxated vertebrae. Consequently, it was an important distinction in the Gonstead system that subluxations themselves could not be seen on radiographs; there had to be independent evidence of nerve interference for an abnormality to qualify as a Vertebral Subluxation Complex.

Radiographs were merely confirmatory of the existence of the subluxation and provided information regarding the direction in which the adjustive force would have to be applied. To uncquivocally identify thc location of the subluxation, "emphasis is placed on finding the nerve involved."

Considerable emphasis in Gonstead theory was placed on the role of edema and inflammation, but only from a mechanical perpective. Edematous swelling was seen to lead to nerve root compression. "A subluxation occurs when two osseous structures become misaligned to the degree where interarticular protrusion from intra-articular swelling produces compression of nerve fibers."

Growing evidence 

In 1921 a medical doctor, Henry Winsor, published an article describing acorrelation between visceral disease and spinal segmental (sympathetic) lesions. Even in medicine, as late as the early 1950s, Hadley was promoting similar "spinal lesion" mechanisms to explain visceral degenerative processes.

After about 1955, the term subluxation largely disappeared from medical publications, and when it did appear, it was used only in a very narrowly defined radiological context. Although the focus and terminologies have changed today, scientists continue to search for evidence of "spinal lesions".

In response to the volume of new biomechanic, neurologic, endocrinologic, and wellness research findings that are becoming available, chiropractic theorists are incorporating new concepts and terminologies into subluxation and adjustive (manipulative) procedures models.

The "modern" era 

Currently, controversy over the term Vertebral Subluxation Complex continues, although its character has changed. Some of the controversy is fueled by the narrow medical definition of radiographic or anatomic subluxation as resulting from potential segmental instability, for which the application of "manipulative forces" is actually contraindicated.

Still, support for the concept of subluxation appears from both within and outside the profession. The work of De Boer, Verbon et al, Nansel et al, Sato and Swenson, and thers have pointed out new paths for chiropractic research in exploring neurologic relationships inherent in somato-visceral pathways.

Vertebral Subluxation Complex

In 1906 Smith et al were apparently the first to characterize subluxations other than bones out of place, but as a dysfunctional state of motion of adjacent vertebrae. A reasonable concept of joint dysfunction is that of afixation or restricted motion between adjacent vertebrae. Such a perspective, largely ignored for several decades, stimulated the development and refinement of motion palpation by a Belgian chiropractor, Henri Gillett.

This system was further refined by Faye and developed into a prominent chiropractic technique system in North America. Motion became a preeminent focus of Faye's model of vertebral subluxation complex and manipulation. Although this work was abstracted from earlier work by Janse, it was Faye who popularized the idea and organized the "motion" model, or rather lack of motion, into component parts.

The comprehensive contemporary model of the vertebral subluxation complex does not attempt to identify a single lesion or pathophysiologic entity to characterize as a subluxation. VSC incorporates multifactorial involvement from elements of each of the model's tissue-level components. Kinesiologic abnormalities are seen to be central in the concept of subluxation and are provided a position of prominence in the model; immobilization is seen as a primary but not exclusive element in specific subluxations.

Unique patterns of involvement are discernible in various types of vertebral subluxation complex; for instance, immobilization and inflammation are commonly seen as being involved in sacroiliac joint  "lesions" or subluxations and may give rise to radicular problems. Nerve impingement by IVDs causing lower back and leg pain is yet another discernible class of subluxation potentially amenable to manual chiropractic methods.

Frank trauma with edema, as occurs after a blow from a blunt instrument or from sprains and strains, is also recognized as a class of subluxation, as are whiplash-type injuries. ...

Degenerative disc disease and facet syndrome are additional medical diagnoses that represent classes of what chiropractors identify and treat as subluxations.

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Looking ahead 

It is the nature of theories and models to be dynamic, forever evolving as knowledge and understanding grow. As with all theoretical models, concepts of chiropractic clinical practice are also imperfect. The fact that chiropractic models continue to exhibit limitations and imperfections is not surprising. To suggest that chiropractic practice is without value in the absence of definitive "proof" is naive and perhaps even arrogant. Whenever people see things that they do not understand, theories will evolve to explain such things.

A tremendous amount of work remains to be done to refine the concepts that underpin the practice of chiropractic.

In the past, chiropractic has relied on research from other fields to substantiate its own theories. This is a result of the academic isolationism that grew out of organized medicine's policies to "contain and eliminate" the chiropractic profession, as well as chiropractic's long tradition of scientific neglect. Chiropractors, therefore, exerted no control over directions that medical research took (the specific questions asked, the design of research, etc).

Currently, however, the foundations of chiropractic research are growing, and chiropractors are increasingly recognizing the need to contribute to the scientific knowledge base, examining basic mechanisms of subluxation pathology, manifestations of the "subluxation syndrome", and the processes involved in correcting these lesions.

CONCLUSION

Chiropractic theory grew directly out of a working relationship between doctor and patient. One could say that the concept of subluxation was created to justify and explain the adjustive procedure utilized to correct it. The situation is similar for any clinical discipline, Science is a tool to be utilized and applied to the understanding of clinical experience. From a clinician's perspective, there is no greater need than to understand what he or she is doing and how to make it better.

If the concept of 'vertebral subluxation complex' cannot be placed in a physical perspective (ie, anatomy, physiology, epidemiology, biochemistry), then the profession may experience limitation in its true growth. Chiropractic is increasingly in the spotlight of public awareness.

With such "celebrity" status comes greater scrutiny and increasing demand for accountability from the public chiropractic serves. Although clearly not all questions have been answered, the tools and resources needed to obtain answers are more available to chiropractors than in earlier decades. The playing field has never been more favorable. However, with victory and recognition come responsibility.

The responsibility of the chiropractic profession is to provide answers for some very important questions. Chiropractic needs a solid foundation on which to build a sound clinical practice.

The current direction of the development of the vertebral subluxation complex may help to define and anchor that foundation. Although it is both incomplete and imperfect, 'subluxation' still offers a common conceptual model to describe the theory and practice of chiropractic. Attention and focus devoted to a comprehensive approach to VSC model building can serve as a common frame of reference for chiropractors everywhere well into the profession's second century.