Talk:Vertebral subluxation/Draft

Hi Matt, well done. I've done a first run copy edit, culled out some bits that seemed to me to be rather introspective argument, and tried to put in a couple of bits based in part on the comments in the Talk page on WP. I'll come back to this, but I've bust my specs so ...Gareth Leng 07:23, 12 January 2007 (CST)

No problem! You probably needed a break:) It is really neat to watch things transform and "mature" as you make your changes. Like always, you've kept the concept and said it better. I am curious about the science section (more as a student:), did I misinterpret it, or did you think it wasn't necessary? --Matt Innis (Talk) 07:35, 12 January 2007 (CST)

No, no misinterpretations. I guess I saw the general case as mainstream established science, not new or controversial, and I thought that presenting it there made it seem new or controversial, especially by picking a few primary studies rather than quoting reviews. I'll come back to this though, and think again.Gareth Leng 09:58, 12 January 2007 (CST)

Okay, as long as I didn't read it wrong. After listening to critiques for so long, I begin to doubt myself sometimes;) Just wanted to make sure I was interpreting the information the way it was presented. If you don't think it is necessary from an editorial POV, I'm okay with that. I could go on for hours, but surely don't want to bore the audience:) --Matt Innis (Talk) 12:18, 12 January 2007 (CST)

I added some in the intro as well. Feel free to work with it. --Matt Innis (Talk) 15:59, 12 January 2007 (CST)

Matt, here's the problem I have with this article, its the same problem I have with vertebral subluxations- I can't grasp it because it always seems to be presented with circular reasoning. Here's what I mean: as far as I can tell a vertebral subluxation is something that must exist because fixing it cures a problem. But- there does not seem to be anything concrete presented about how to objectively tell a vertebral subluxation is there, The "scientific proof" does not address identifying a vertebral subluxation, in other words- granted that a misalignment of a vertebral joint can lead to arthritis, but vertebral subluxations are treated by chiropractors all the time when there is no measureable misalignment of the joint. I'm not saying that your working on the back is not effective, I'm saying that the theoretical basis may be imaginary. I was bringing this up in the Chiropracter article, believe me in medicine many physicians avoid having their examining skills tested, but some don't. In those who don't, if there is a diagnosis that is made on clinical examination the exams of many physicians can be compared. This is a lot of work, but not expensive and so, I don't buy that chiropracters don't have the support of major grant makers and that explains the lack of these kinds of studies. Maybe they do exist and you and I are not aware of them. Bottom line- what's the evidence that one chiropractor finds the same problems in a back that the next one does? It doesn't make sense to me that we say vertebral subluxations exist because of history and Palmer. Nancy Sculerati MD 18:45, 12 January 2007 (CST)

Okay, so what you are saying is that you would like to see some sort of solid information on how a subluxation is found and maybe some proof that there is some degree of certainty that several blinded doctors would find the same thing. I think there were some tests done in the 80's on this very thing. I'll see what I can find. --Matt Innis (Talk) 23:28, 12 January 2007 (CST)

Dumping ground as I find some. Feel free to view and let me know if you see something you like in particular.

• Manual Examination of the Spine: A Systematic Critical Literature Review of Reproducibility
• Intraexaminer Reliability of Identifying a Dysfunctional Segment in the Thoracic and Lumbar Spine
• Pubmed reliability articles

I'm going to have to stop there for now until I have a chance to go through some of them.

--Matt Innis (Talk) 00:54, 13 January 2007 (CST)

Are physicians leery of the claims made by chiropractors? What about Osteopathic Docs and Physical Therapists? I know that in terms of osteopathic manipulation, I trust the DOs coming out of the number 4 school in the nation for primary care - MSU COM, and one really good physical therapist who works in Okemos, MI. However, I definitely benefit from having T3-T5 joints "loosened up" about once a week - but I can do this sitting in a chair and pushing inferiorly and stretching my spine that way - pop, pop, pop. I'm interesting in reading more, even though I'm biased. I'm also really interesting to read some of the really new and interesting physical therapy research that is starting to get published. -Tom Kelly (Talk) 20:16, 12 January 2007 (CST)

Hey Tom! Yes, I think it is safe to say that we are all leery of each other;) I don't blame you for being biased, DCs don't have the best reputation - mostly because we have some that keep shooting us in the foot:) Feel free to add whatever you like, and certainly at least check my spelling! I'm thinking "subluxation" in the upper thoracic region;)lol. --Matt Innis (Talk) 23:28, 12 January 2007 (CST)

I'd be wary of having this article become a representation over the debate about whether subluxations are real or not because its clear that as the term is used with such different intents even within chiropractic it is going to get confusing and will go nowhere. Nancy's difficulty seems to me to be that she's understood it exactly, yes, for some chiropractors, subluxation is simply whatever explains why chiropractic works - i.e. for them its an empirically evolved treatment with a rationale (subluxation) that seems to them to be a useful explanation of why it works, not least because patients can understand and be reassured by this. So I think the article should describe how the term is used 9in its various ways paerhaps) rather than try to make a consistent "scientific" definition of something that is not always used as such..???? Matt?????...Gareth Leng 05:53, 13 January 2007 (CST)

Good point. I think your consolidation on the science section does sum up the science pretty well, which is probably close to all we should try to do, because otherwise we open the door to a boatload of back and forth science that only adds volume but not content. Hopefully those that are interested can read the references - and we can add some there as we find them. We will end up with the same "feeling" that you have summarized already: that the "proof" is lacking - which doesn't bother most chiropractors because if they are science oriented, they are using subluxation in the somatic sense anyway and only use the visceral sense as a "lets watch and see" attitude. If they are "subluxation" based then they probably feel like BJ and think that if it is ever proven, medicine will steal it. Keep in mind that physical therapeutics was pioneered by chiropractors and a lot of the "really new and exciting stuff" has been around for awhile in chiropractors offices. A lot of what is now conventional thought has it's roots in chiropractic. Just as DOs have been drawn toward allopathy, PT has inevitably been drawn toward chiropractic. The fear was that if they prove it, scientific medicine will steal it and call it their own and chiropractors will have nothing to practice - after all they could not practice in hospitals or use any of the equipment until after 1991 - that was only 15 years ago. Along that same line, I think Nancy's POV is one that a lot of people have about chiropractic (including some chiropractors) that we need to handle - at least the subluxation part on this page. In the early 80's, chiropractors made an attempt to clarify what a subluxation was and went from subluxation to vertebral subluxation complex. I can at least put some of that in and then we can see if it makes more sense. I am glad for the discourse because this is where I get bogged down trying to decide what needs to go into the 32Kb article;) I need both your POVs. Thanks. --Matt Innis (Talk) 08:54, 13 January 2007 (CST)

Well, the PT research I was referring too mainly deals with peripheral nerves and the neuromuscular repair process, but I'm sure there are always great clinicians who have "theories" long before any research is ever done to prove it. And we all know that the world is driven by money. Just like there isn't as much money funding cranberry research as there is in other Drug related fields, there is less money in chiropractic research as in other fields. "Stealing?" How is that really possible if one person gets it published in a journal before "medicine steals it?" -Tom Kelly (Talk) 14:11, 13 January 2007 (CST)

Good comment, Tom. It is a really interesting story with lots of personalities and drama. If your interested, check out Chiropractic History, it will give you a better feel for how chiropractors think and why they think that way. "Steal" might not be the right word, but you'll see what I mean. --Matt Innis (Talk) 11:01, 15 January 2007 (CST)

Hi Matt, I looked at the JVSR site and saw that they dad some thumbnails of covers from Historic Print Editions _ wondered if one of these might be appropriate? On the science side, think it's important to stay quite light. There is no doubt that the spinal nerves do a lot more than just control muscles, so the idea that nerve dysfunction might have wide consequences is certainly credible, but on the other hand giving this too much weight may tend to make it appear that the subluxation theories are accepted, and that,s also not true - my reading is that they are credible explanations for things that we don't understand, but they might be wrong - we just don't know enough to be sure. As a wholly personal and unexpert bias I'd say that I think its very likely that spinal dysfunction in some cases does cause some of the "unexplained" symptoms in peripheral organs, but whether this is common or uncommon I'm not remotely qualified to judge. So I feel the right path is to acknowledge the credibility of the explanations without seeking to imply that they are necessarily true explanationsGareth Leng 10:25, 13 January 2007 (CST)

Okay, I think I'll just try and handle Nancy's concern without making judgements either way. I can't find the pictures your talking about. Can you point me in the right direction? --Matt Innis (Talk) 12:14, 15 January 2007 (CST)

The covers are on the website - unfortunately the downloadable ones have draft written all over them, but I was thinking that this cover might be good as a thumbnail, if it's possible to get a clean image? [1]Gareth Leng 04:47, 16 January 2007 (CST)

Were you thinking the whole cover (including the journal name) or just the picture of the spine? I assume you want me to try and get the "draft" off of it? What size do you want it to be - small like 1" or more like the gymnast picture of 4"? --Matt Innis (Talk) 10:19, 16 January 2007 (CST)

No I thought it might be possible to show a thumbnail of the cover, down at the bottom of the page. I have to admit when I went into the website page first the thumnnails were there but blocked and I assumed it was just my overprotective firewall, I later realised that I could access the covers but only with DRAFT all over them. Thought that a thumbnail of a journal cover would be fair use and easy to get - didn't mean to engage you in any hassle (dooh) Gareth Leng 11:50, 16 January 2007 (CST)

No problem! I can dooh that:) I'll put it here on the talk page and you can find the spot you want it. --Matt Innis (Talk) 13:25, 16 January 2007 (CST)

JSVR thumb

This is a small thumb size:

without frame

with frame

I can make it bigger without too much a dooh about nothin'.

I guess it has to be readable. What you think? This was just an idea, might have been a bad one. One of the problems is that red on black is not very readable at the best of times....Gareth Leng 04:17, 17 January 2007 (CST)

Flesnia....hmmmm...think I know what this stuff means, but there's a mish mash of jargon and hype here. It reads a bit like scare mongering in places and needs care and caution I think :)Gareth Leng 05:07, 17 January 2007 (CST)

OK. I'm not sure that I "get" this.

I think this is about the motor programmes that are learned in the spinal cord and in the cerebellum and brainstem. This motor learning occurs when networks of neurones are trained to behave in a new way. Actually we know quite a lot about this, but basically it involves strengthening connections between some neurons and weakening other connections, and this depends on "feedback". This type of learning is happening everuwhere in our nervous system all the time. In this case, if an injury forces some restriction of movement, initially the person may consciously move in a way that avoids pain, using a strange or unfamiliar sequence of muscle commands. Initially these movements will be planned and directed by higher centres of the brain, but with repetition, lower centres learn these sequences and take over, and the new set of movements then becomes instinctive.

Now this happens all the time and there's nothing irreversible or pathological about any of this. I think the suggestion here is that a subluxation means that the feedback information needed to train these networks is wrong, and so the new programmes that are formed are not optimal adaptations?? Gareth Leng 05:36, 17 January 2007 (CST)

Yes, it does happen all the time. And yes, I think you have the concept. Also note that even if the feedback information was correct initially, damage to the facet capsule results in fixations and that results in adaptations that result in changes in load bearing on the facet joints that are forced to adapt. The information coming from the facet capsules - which are loaded with mechanoreceptors and nociceptors - is either fascilitated or inhibited, either one having an altering effect on the rest of the system... One of the ways of detecting is because heat can be detected (Neurocalimeter, thermography, palpation) and it will be tender to the touch (palpation, patient feels it, sympathetic nervous system facilitated pain). Make sense? --Matt Innis (Talk) 10:29, 17 January 2007 (CST)

More -

• nothing irreversible - so long as the abnormal joint function/fixation is removed. If it remains, the process cannot reverse to "normal", right? It may adapt to something that is fine, but it is never optimal again.
• nothing pathological - not as far as being a normal response by the nervous system - but, the degenerative effects of fixating the joint develop into osteoarthritis - won't kill you but can make life less enjoyable by itself - add to that:
• facilitated and/or inhibited autonomic nervous system as a result of the overactive or underactive feedback from mechanoreceptors and nociceptors within the joint capsules of these osteoarthritic joints (and, yes, even in the beginning stages when there are no visible changes on xray). Does this affect the end organ (the organ that receives its innervation from the same spinal segment)? DCs think yes, perhaps via lamina I and IV where the "spillover" of neurotransmitters affects the facilitation of or inhibition of the sympathetic ns that have some effect on the "end organ" per a mechanism such as we describe in the next section. We don't know, yet.

Helpful? --Matt Innis (Talk) 11:49, 17 January 2007 (CST)

OK, I'll have a go - I have some problems with the way it's written, so will edit out somephrases or words the meaning of which isn't clear to me or seems wrong, just scream if I take out something importamnt and we'll try to work it out. First problem is in knowing exactly what is meant by homeostasis here. Is this just a loose buzzword or is something very specific meant? But maybe you'd like to go at it first because I think you'll write it a lot better than Flesia did.Gareth Leng 11:46, 17 January 2007 (CST)

Organizational changes made- need more on DC research

Matt and Gareth (and others who may be out there!) I have made some organizational and language changes that I believe clarify the article. Please read through from the beginning. Matt, I think presenting the uncontested view of the spine etc, meaning that which DC and health science agree on, followed by the DC focus is a good and clear method of explanation. You had sent me refernces on actual DC research and this is what needs, in my mind, expansion. I'll wrtite you also on your talk page, regards, Nancy Sculerati MD 11:58, 17 January 2007 (CST)

Thank you, thank you, thank you.. I do apprectiate your help. As a side note to your sectioning of the article into health science and chiropractic, I think if you really examine the thoughts and theories you are going to find that 99% of chiropractic belongs in the health science section. Maybe 1% voodoo. That won't leave much for the VS. But then again, maybe it is time we acknowledged that we aren't that far apart. --Matt Innis (Talk) 12:14, 17 January 2007 (CST)

No objective evidence

Nancy, I notice that you concentrate on the "no objective evidence". I'm not sure if we have different concepts of "objective" evidence. IOWs, is palpation objective? When you palpate a lymph node, do you guys consider that objective evidence or is it only hard copy things such as blood tests, xrays, and MRIs? Really the only thing that we consider subjective are the things that patients tell us. We consider palpation and range of motion as objective evidence. Is that the way it is in medicine? IF it is, maybe we could clariy that some so it doesn't sound like DCs are just flying from the seat of their pants. --Matt Innis (Talk) 12:03, 17 January 2007 (CST)

I've palpated "a stiff back" before and after a PT has "loosened up" some joints. I'm not saying that was the right thing to do in all situations (and for many other reasons, cracking of backs is done too much, too often, and may have false claims in many situations), but i have seen it done in situations where there is immediate improvement. However, most people crack their back when all they really need to do is fire a few intervertebral muscles (and others) in a certain way (resistance, etc) to solve the underlying problem to their back pain without cracking the back at all. My bias against cp is often that they will align your spine but not deal with the muscles and underlying issue that caused the problem in the first place. I see where things can be argued both ways and where things are overused. However, it is possible to palpate stiff back joints, and I'm only a medical student. I don't actually time to read the article to even figure out what you are claiming to palpate, but i know in certain situations you can palpate joints that aren't moving like they should. And isn't it true that if you try to "crack" joints that are moving fine, they don't "crack" as often? -Tom Kelly (Talk) 16:11, 17 January 2007 (CST)

You certainly bring up some interesting "chicken or the egg" points;) Which came first, the muscle problem or the joint problem - and does it matter? Another good research project! However, as to the "'cracking' joints that are moving fine, they don't 'crack' as often", we pretty much know that it's just the opposite. IOWs, it's a combination of the tight muscles, shortened joint capsules and ligaments that won't let the joint seperate enough to create the vacuum necessary for cavitation(check out Chiropractic) to occur. The stuck one is one type of VSC. That is the one that needs manipulation type adjusting. There is no benefit in creating too much motion in a joint that is functioning normally already, which is what is happening when you are hearing those "cracks" on yourself. You're moving the ones that don't need moving. It feels good because you are firing the mechanoreceptors - like scratching an itch, you get some temporary relief, but you haven't really changed anything. As far as using muscle stretching, etc. consider this - if a facet joint is fixated from an injury and there are 10 other facet joints around it that move just fine, how are you going to create motion in the one stuck joint without creating more motion in the normal ones? Manipulation is used to move the "stuck" joint without creating more motion in the ones that aren't "stuck". It's purpose is to force that facet capsule and surrounding ligaments to lengthen, thus allowing more motion in the motor unit. So stop "cracking" those thoracic vertebrae:) --Matt Innis (Talk) 20:40, 17 January 2007 (CST)

How do you create a motion that fixes the problem? have a D.O. who is really good at osteomanipulation fix the problem! (just a little bit of a friendly jab!) I wish they taught 4 years of osteomanipulation at MD school like at DO. Oh well. -Tom Kelly (Talk) 21:31, 17 January 2007 (CST)

Correction - a good DO school. like #4 (for primary care - which osteomanipulation falls under) Michigan State U DO - http://www.usnews.com/usnews/edu/grad/directory/dir-med/brief/glanc_04135_brief.php -Tom Kelly (Talk) 21:34, 17 January 2007 (CST)

http://www.usnews.com/usnews/edu/grad/rankings/med/brief/mdprank_brief.php for list of rankings for non subscribers -Tom Kelly (Talk) 21:35, 17 January 2007 (CST)

It's not too late to change your mind! Michigan State is looking pretty good compared to USC:) But your grades probably aren't good enough for chiro school, though with a good letter of rep, I might be able to get you in;) (two points:) --Matt Innis (Talk) 22:59, 17 January 2007 (CST)

A lymph node is objectively palpable, and yet can be missed by some examiners, absolutely if you operate, you find it. It is my understanding that a vertebral subluxation may exist even without externally verifiable objective evidence. Meaning: a DC feels its there but there is no "gold standard" in objective evidence to verify it. I look through the refernces, and I may not have interpreted them correctly, but I could not find any thing. Can you? If you object to the language changes I made, please alter them and we can go back and forth until we are both satisfied.Nancy Sculerati MD 12:48, 17 January 2007 (CST)

Sounds good. If you look at the references, they talk about palpation with provocative testing being intraexaminer and interexaminer reliable. Basically what they are saying to me is that when an examiner is able to palpate and put that together with range of motion and other tests that create pain, the results are reliable with other blind folks. They also state that when used by itself, palpation is not acceptable. I know in my office, I use palpation where I may find "lumps and bumps", but I'm not convinced that these are adjustable lesions until there is an element of pain elicited, whether with palpation or with range of motion or orthopedic testing (suggesting to me that the sympathetic ns is facilitated at that level). Do note - however - that a lot of the times no pain noted by the patient until it is palpated. In other words, it's like a carie on a tooth, you don't know it is there until the dentist pokes his little probe into it. As a disclaimer, that does not mean there aren't DCs out there doing some weird stuff, but I think most of us would find similar findings - and so would you if you were taught what to look for. The only thing we do that you don't is that we might add to our list of "positive" findings for a subluxation in the midthoracic region is that subjective complaint of indigestion that they have been suffering with for three years. We then treat the subluxation and "wait and see" what happens to the indigestion, because we are just as unsure as you are that it will help, but we also don't know that it won't, yet. Am I making sense? --Matt Innis (Talk) 13:27, 17 January 2007 (CST)

Yes. I did read, I think in one of the Gale reviews, that pain was an inter-observer finding that was statistically significant. This is just what we need to go over in detail, and would be a real contribution to have - in my mind, anyway, as much on this as we can. But we have to go through those papers line by line, and not skim them, and discuss them line by line, and pull Gareth and others into the discussion in a no-holds barred, no bullsh*t effort to come to an understanding. When I use that rough and tough language, I do not mean it with animosity, I mean that we do respect each other and we are friends - but we are not going to lie to each other to "make nice", instead we are actually going to try to figure out the limits of what we think and believe about the subject, and what we can say here as truth. Frankly, there is grant support available from NIH for doing good studies on alternative medicine and the right design to test some of these points could even be come up with by us! Back to your original objection - my point about objective evidence is that is is not required for the diagnosis of a vertebral subluxation, and clearly- unless I have totally misunderstood (and yes, that does happen!) vertebral subluxation is not a concretely understood entity among DCs. If I am wrong about this point, please do not be too polite to openly correct me. So, my understanding is that its not like a lymph node in that sense, as you say- some even deny it exists whereas although MDs might disagree abouth whether they feel an enlarged node on a particluar exam, no one says they question the existence of lymph nodes. There are other equally real findings on a clinical exam, a heart murmur, a middle ear effussion, that are not obvious to all examiners- but again there is always some technical way to check the exam. It seems that there is no one specific agreed upon concrete finding for vertebral subluxation, but there is a common method among DCs for examining the back and there are shared methods among DCs for treating what they find, and that's where I think it makes sense to focus the rest of our efforts in this article. When it comes to "the science", it's kind of silly to try to review the zillions of bytes of knowledge about the anatomy and physiology of the spine from a general perspective, on the other hand, I (at least) have never come across an article written for the lay public that really tried to explain a chiropracter's thinking and really reviewed the techniques and the scientific evidence in a detailed way. I think that putting vertebral subluxation in that context is an exciting challenge. Nancy Sculerati MD 14:09, 17 January 2007 (CST) P.S. Tom, from what I have gathered through my reading and writing the Chiropractic article, there are identifiable changes in the exam that might correspond to subluxations, but these are very subjective to the examiner. Even babies get their spines adjusted, and it's not as if a DC vertebral subluxation corresponds to a well-defined anatomic abnormality, but that is not to say that the concept is fallacious, it's just to say that it is (in my mind, anyway) speculative. Matt, in medicine the difference between pain with palpation and pain even without being touched is that the first is called tenderness, and it is a distinction that does give information. Obviously, sometimes there is pain both ways as well, usually getting worse with palpation, but there are some pains that are somewhat relieved with pressure too, often depending on how the pressure is applied. Nancy Sculerati MD 19:58, 17 January 2007 (CST)

Nancy, you keep saying things like this: but these are very subjective to the examiner and it's not as if a DC vertebral subluxation corresponds to a well-defined anatomic abnormality. Exactly what is it that is not objective about what you have seen? I'm puzzled. --Matt Innis (Talk) 21:00, 17 January 2007 (CST)

Pain is similar for us, though we would use pain to describe all different types of sensations, including parasthesias. When we talk about provocative testing, we look for motions or positions or procedures that provoke the symptom. I'm sure that's the same for you. So palpation with provocative testing is reliable intra and interexaminer. --Matt Innis (Talk) 21:06, 17 January 2007 (CST) P.S. We also consider that as an objective finding - you would, too, I assume. --Matt Innis (Talk) 21:08, 17 January 2007 (CST)

Well, sorry to butt in here. Pain is classically a very difficult issue, and it's just not possible to quantify how much pain is felt by an individual, or to know whether the experiences of any two people are similar even when they describe it in similar terms. Accordingly we don't regard assessment of pain as objective - this does not mean it's not real or not important. The problem is that in coming to a diagnosis, pain may a) be reported differently by different people even if the cause is identical, b) be reported differently by the patient depending on who asks the questions or how or in what circumstances they are asked, and c) perception of pain may arise in many different ways and be blocked out in many different ways. So while minimising perception of pain is clearly a major objective of treatment, the subjective nature poses real difficulties for diagnosis. I think part of the difference in perspective may be related to the fact that in conventional medicine patients are typically seen by a succession of different specialists, whereas patients of chiropractors are under the continuous care of a single individual. So inter-observer differences in how symptoms are measured and recorded are much more problematic in a conventional setting, hence the emphasis on objectively documented findings. ???? Gareth Leng 04:15, 18 January 2007 (CST)

I agree with everything said with regard to the sensation of pain - it can be different from patient to patient, but provocation of pain is the key feature here. IOWs, if I find a "spot" that I think is suspicious, I then stand the patient up and put them through flexion, extension, laterally flex them, raise their leg to stretch it, etc. When the patient identifies that as painful(regardless of their perception of what pain is), the reliability from examiner to examiner and for me to find the same spot again is good. Also, in subsequent evaluations, a decrease in that sensation of that same pain by that particular patient when scored using scales such as 1 to 10 are found to be also objective. I think that is what the research is saying. You? --Matt Innis (Talk) 08:03, 18 January 2007 (CST)