Pursuing a Pain-based Model to
Chiropractic Clinical Practice

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    DrDiGiorgi@aol.com

By Dennis DiGiorgi, DC, CHCQM, CCIC

drdigiorgi@aol.com

Author information

Launch the References

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Abstract

After decades of effort to secure and maintain a position in mainstream health care delivery the chiropractic profession has reached a critical juncture in its history. If the profession is to advance in a modern health care world then it must move beyond some of its age-old care-governing principles. More than a century has passed since the profession was founded. Yet there remains insufficient experimental data to support the validity and merit of certain tenets which have historically influenced patient care. Adherence to and guardianship of these tenets continues today within the profession, with one or more of them oftentimes serving as an integral component to the report-of-findings patient encounter or as a means to justify various aspects of treatment, whether therapeutic or elective in nature. In an effort to stimulate professional dialogue and action during an opportune time in the history of chiropractic in the United States, this paper will address politically sensitive points regarding the vertebral subluxation hypothesis.

As the central element to the “separate and distinct” ideology, to one extent or another, this founding care governing tenet continues to be relied upon in nearly a profession-wide manner. Disproportionate dependence upon it and continued distraction by it in the individual clinical practice could have implications beyond deterred professional maturation. An unwanted collective departure of the profession from mainstream health care may be an eventual outcome, while skilled, evidence-minded and well-integrated doctorate level physiotherapists attentively maneuver themselves to the forefront as they seize, investigate and advance the cause of spinal manipulation. If chiropractors can expect their profession to remain part of an evidence driven system of health care delivery, they must advocate the change being called for by the findings of emerging science. While this is no small challenge, the compelling evidence for therapeutic joint manipulation (TJM) for nociceptive pain supports the adoption of a new operational model for the clinical practice.

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Background:   Founding Chiropractic Philosophy vs Contemporary Science

“The chiropractic subluxation stands pretty much today as it did at the dawn of the 20th century:
an interesting notion without validation.”

— Keating, et al   [1]

Evidence based patient care has been qualified as an integrative decision-making process [2] which is applied for the purpose of yielding the best possible outcomes [3]. As such, evidence based health care is intended to elevate quality standards of clinical practice. Where high quality evidence is lacking, irrespective of specialty, health care providers tend to rely upon more traditional care approaches and/or draw from empirical evidence in rendering treatment decisions for individual patients. This is particularly true for the chiropractic profession [3–4], considering that longstanding philosophical tenets, which have historically governed or directly influenced practitioner choice of treatment, continue to contribute to contemporary clinical decision-making. Surveys have shown that some of these tenets are accepted and/or relied upon by a significant percentage of field practitioners [5–6], from which it is easily inferred that they remain as trusted elements of the chiropractic patient management equation.

The hallmark of the “separate and distinct” ideology that has shaped the chiropractic profession from its inception is the treatment of vertebral subluxations. Direct descendants of this ideology are the relatively common practice of full-spine care applications and the tendency for providing maintenance/preventive/wellness care. As a mantra, “separate and distinct” [7–9] had once served as a useful impetus by which the profession claimed and maintained itself as an alternative to allopathic medicine. In contrast to this position today, chiropractic manipulation can serve as a component to either the multimodal integrative approach to chronic pain [10] or standard medical treatment of musculoskeletal conditions. As such, it is in the context of an ever evolving health care delivery system that continued devotion to the dogma of ‘separate and distinct’, or any of its scientifically invalid or yet-to-be proven components, will serve to impede professional growth. Namely, with a rigid philosophic or isolationist stance regarding the purpose or role of chiropractic in a contemporary health care marketplace [11–13] the profession will project an unwillingness to participate in the evidence-based, collaborative approach to patient care. With most chiropractors lacking knowledge or interest in evidence-based approaches [3], one must now consider what the ultimate outcome of that will be. This unfavorable inclination could negatively influence public perception and/or the actions of other disciplines in health care. As such, it may eventually render insignificant or erode chiropractic’s established position, long since recognized by policymakers, accrediting agencies, state workers’ compensation boards and private/public health care finance systems.

A number of chiropractic clinical papers openly address the need for the profession to put to rest the controversial subject of the vertebral subluxation [1, 7, 13–16]. Other efforts directly speak to or look beyond this issue in proposing seminal ideas for professional reform [17–18], renewal [19], integration [12, 17] and scope of practice expansion [11]. It is easily inferred that the intent of each of these proposed concepts is not to be divisive but rather to prompt the profession, through reason and practicality, to adopt and promote an evidence-driven approach to chiropractic clinical practice in overcoming longstanding constraints that have inhibited professional growth opportunity. It would appear that these efforts have yet to elicit willful and decisive collaborative action aimed at securing a more integrative future through a new identity. In fact, recent efforts at initiating reformative change by the Council on Chiropractic Education (CCE) were upended by a dissenting faction of the profession, resulting in a petition to the U.S. Department of Education that aimed to have the CCE’s accreditation authority revoked [20]. Nevertheless, the work of Murphy, et al [21] and Russell [22] demonstrate that novel opportunities exist in a changing health care landscape [23], with a proposed model and role for chiropractors as primary spine care practitioners. Moreover, perhaps the CCE wellness standards that were recently incorporated into DC educational programs [24], and since expounded on in a best-practice document [25], could be adopted as clinical practice initiatives for novice and veteran practitioners alike. Considering the health promotion demands of the contemporary health care delivery system [24], developing a broader wellness model to chiropractic clinical practice can serve to meet that need.

Across the population of spine pain patients a significant percentage has conditions that are nociceptive in nature [26–28]. The widening pool of research evidence supports the use of manipulation in the treatment of various types of neck and low back pain conditions [29–30]. The physical therapy profession is aware of the benefits of spinal manipulation for musculoskeletal pain. Many recently published clinical papers, of non-chiropractic authorship, investigate or aim to uncover the clinical role or therapeutic effects of spinal manipulation without giving credence to the vertebral subluxation concept [31–66].

Table 1 highlights some of the more recently published high quality studies in this area (randomized controlled trials and systematic reviews), as undertaken by physiotherapists.

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Table 1 : Recent Investigative Efforts by Physiotherapists on the Efficacy of Joint Manipulation

Author(s)	Publication year	Region(s) investigated	Study design
González-Iglesias, et al [31]	2009	Thoracic spine, for neck pain	RCT
Gonzalez-Iglesias, et al [32]	2009	Thoracic spine, for mechanical neck pain	RCT
Walser, et al [33]	2009	Thoracic spine, for musculoskeletal conditions	Systematic review and meta-analysis of RCTs
Cleland, et al [34]	2010	Thoracic spine, for neck pain	RCT
Cross, et al [35]	2011	Thoracic spine, for mechanical neck pain, ROM and function	Systematic review
Lau, et al [36]	2011	Thoracic spine, for chronic mechanical neck pain	RCT
Puentedura, et al [37]	2011	Thoracic vs cervical spine, for acute neck pain	RCT
Martínez-Segura, et al [38]	2012	Cervical or thoracic spine, for neck pain and ROM	RCT
Dunning, et al [39]	2012	Cervical and thoracic spine vs mobilization, for mechanical neck pain	RCT
Saavedra-Hernández, et al [40]	2013	Cervical and thoracic spine, for chronic neck pain	RCT
Masaracchio [41]	2013	Thoracic and cervical spine, for mechanical neck pain	RCT
Molins-Cubero, et al [42]	2014	Pelvic, for low back/pelvis pain with dysmenorrhea	RCT
Vieira-Pellenz, et al [43]	2014	Lumbosacral spine, for low back pain and mobility	RCT
Gemma and Antonia [44]	2014	Cervical spine, for pain and neck mobility in subjects with tension headache	RCT
Haik, et al [63]	2014	Thoracic spine, for scapular kinematics	RCT
Kardouni, et al [64]	2015	Thoracic spine, for subacromial impingement syndrome	RCT
Calixtre, et al [65]	2015	Cervical spine or thoracic spine, for temporomandibular disorder	Systematic review of RCTs
Riley, et al [66]	2015	Thoracic spine, for shoulder symptoms	RCT

In a contemporary time, the chiropractic profession faces distinct internal challenges [19], identity conflict issues [67], competition [23] as well as external demands imposed by evidence-based medicine [68]. If it can expect to survive in an evolving health care environment, then as a collective body it must embrace the advancements of modern science which favor the use of joint manipulation for nociceptive pain but not unsubstantiated theory for subluxation-based care [11]. Likewise, it must recognize that its future could be imperiled should physical therapists, as natural manual therapy partners of allopathic medicine [69], take greater competitive interest in and prioritize making the manipulative arts their own [11].

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The Chiropractic Vertebral Subluxation

“Since our very beginnings, our rigidness and uncontrolled egos have provided a rich medium
for our dysfunctional future. We embarrassed ourselves because of our blind discipleship,
we isolated ourselves by choosing to speak a different language and we failed to grow
because of our refusal to be accountable in our clinical reporting.”

— Carter   [13]

A majority of chiropractors practicing in North America adhere to the premise of correcting spinal subluxation in addressing musculoskeletal and/or visceral conditions [5]. Nonetheless, more than a century after the founding of the chiropractic profession, the term “subluxation”, in its chiropractic sense, is essentially recognized only by the chiropractic professional. Initially a simplistic concept put forth by D.D. Palmer, with displaced vertebrae impinging upon exiting spinal nerve roots, the vertebral subluxation was believed to cause 95% of disease [70]. That particular model has since been rebutted from the standpoints of physical plausibility [71] and neurophysiologic application [15]. In fact, with general regard to the manner in which the chiropractic vertebral subluxation may be associated with any particular disease, the work of Mirtz, et al demonstrates a lack of supportive epidemiologic evidence to meet even the most basic criteria of causation [16].

Various entities have put forth operational definitions for the chiropractic subluxation. Most commonly characterized by language that places established physiologic terminology atop a foundation of philosophical belief, the subluxation remains a presumptive concept. Despite this, it remains present in the curricula of chiropractic academic institutions [72], with its preservation desired by a majority of chiropractic students recently surveyed [73].

D.D. Palmer’s vertebral subluxation model of singular causation is no longer taught within any of the accredited chiropractic colleges in North America [5]. In spite of this, some within the chiropractic profession remain receptive to this outdated concept– albeit likely a small percentage. For this faction, the modern day operational definition of vertebral subluxation may be analogous to that which was published as recent as 1993, within the Practice Guidelines for Straight Chiropractic [74].

“A misalignment of one or more articulations of the spinal column or its immediate weight-bearing articulations, to a degree less than a luxation, which by inference causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum potential.” [74]

It is posited here that for those who acknowledge definitional statements such as this, there is an inclination to subscribe to the paradigm of asymptomatic care [75], open-ended care durations [75], and the rendition of chiropractic treatment in the absence of a designated or definable clinical endpoint [76]. This particular approach to patient care, driven by belief systems, may reach the level of religiosity [15]. But paradoxically, it represents a modern day application of founding vertebral subluxation theory which is inconsistent with both D.D. Palmer’s intention to treat the sick [13] and what B.J. Palmer had reportedly professed in terms of appropriate care durations [77]. Furthermore, some of the present-day chiropractic marketing/business practices that accompany the focused-scope or subluxation-based approach to patient care, which are often touted as serving the public interest, may in fact be identified as something else- the substance of avarice and/or compromised practitioner ethics [78–79]. By this point in the evolution of chiropractic it should be plainly apparent to all of its members that the convenience of subluxation theory has resulted in a complex intertwining of philosophical, religious and pecuniary based motivations that has failed to meet the demands of a patient-centered, evidence-based approach to treatment.

Alternatively, the paradigm statement put forth by the Association of Chiropractic Colleges likely provides the more contemporary and widely accepted working description of chiropractic subluxation in the United States and Canada [16]. The Association website describes the subluxation as “… a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health” [80]. Nevertheless, that description does not represent a known or scientifically validated nexus between articular pathomechanics/pathoanatomy (of the subluxation) and some precise effect on neural integrity, organ system function or general health. In other words, for any subluxated spinal articulation, there is no proven connection between its dysfunction, structural variance or pathologic state and the manifestation of a clinical condition that can be measured, predicted and reproduced (through a loss of neural integrity, visceral malfunction or some other indicator of compromised human health).

In light of the findings of numerous research papers [50, 81–100], it would appear that the currently known neurophysiologic effects of spinal manipulation are integral to a primitive system of reflex pathways that are activated with direct mechanical input or sudden positional change (stretch) to adjacent joint elements. As opposed to subluxation correction, the therapeutic benefits commonly experienced by those who receive chiropractic manipulative treatment for musculoskeletal symptoms are consistent with neurologic response phenomena- evoked when high-velocity afferent mechanical input bombards the peripheral and central nervous systems. Similar to the deep tendon reflex, the sudden input of a thrust manipulation or mechanical impulse to the spine can be said to disrupt the resting state of underlying tissues and elicit a rapid neurophysiologic response. In clinical practice, the desired effects of this response are reductions in pain and muscular spasm. It is the nature and breadth of the neurophysiologic responses reported throughout the spinal manipulation literature [50, 81–100] that likely accounts for the therapeutic benefits anecdotally observed across the chiropractic profession throughout its history, irrespective of the patient presentation, the practitioner’s preference to technique and the given magnitude/direction of force of the manipulative maneuver. This concept holds greater clinical applicability and professional usefulness than the notion that spinal manipulation serves to “correct” some unidentifiable and potentially deleterious articular lesion.

As for the belief that organic disease may be caused by subluxation and that spinal manipulation serves as the method for ‘curing’ the like, a groundbreaking clinical paper published in 1995 [101] makes a compelling case against this supposition. Therein, it is cited that mimicry syndromes or the simulation of visceral organ disease by way of somatic dysfunction is a well-established phenomenon. More recently, preliminary evidence has been put forth for an association between the misalignment of Atlas and hypertension [102]. Nonetheless, it has yet to be determined whether the results of that pilot study are reproducible and whether those outcomes can be explained by a neurologic phenomenon, vascular compromise or something else. As it relates to traditional reliance upon chiropractic spinal adjustments to address non-musculoskeletal conditions such as infantile colic, childhood asthma, enuresis, otitis media and dysmenorrhea, the 2010 UK evidence report [29] deemed the evidence of efficacy for manipulation as either inconclusive or lacking (although absent specific consideration for subluxation). In 2014, an expanded analysis of that report led to no change in the evidence ratings for each of those conditions [30]. Thus, the notion that subluxation may influence organ system function, as described in the paradigm statement put forth by the Association of Chiropractic Colleges, is unsupported by current evidence.

Over the past decade or so, chiropractic authors have lent constructive criticism to the profession’s continued and steadfast use of a term that is foreign to the rest of the modern health care world [14, 103], and have addressed the need to confront issues that persist relative to the lack of evidence for the existence and/or clinical significance of the chiropractic subluxation [7, 16, 104–105]. While alternative terms for “subluxation” have been surveyed for consensus [103] and proposed for adoption (i.e., joint complex dysfunction [14]), none have gained universal acceptance as a possible permanent replacement term. Considering that clinical research papers in chiropractic peer-reviewed journals seldom contain studies that address or mention the existence of subluxation relative to the efficacy of spinal manipulation [104], it would appear that the profession’s most prominent researchers reject the simplistic concept that has long since been associated with this word.

A 2007 chiropractic opinion column prompts the reader to question the importance of subluxation, suggesting that the profession redirect itself through the “development of clinical prediction rules for spinal manipulation and the appropriate application of patient management strategies” [106]. That proposal would appear to be in accord with the mission of the now defunct National Association For Chiropractic Medicine (NACM), a small professional association which had defined itself as, “a consumer advocacy association of chiropractors who confine their scope of practice to scientific parameters and seek to make legitimate the utilization of professional manipulative procedures in mainstream health care delivery” [107]. In accordance with the current lack of evidence for the subluxation and the willingness of a growing number of chiropractors to openly address the matter in professional papers, perhaps the time has come for NACM’s practice definition (or something similar) to be considered for adoption by the chiropractic profession.

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Subluxation Theory and Full-spine Chiropractic Treatment Applications

“The principle of fidelity and the state of scientific knowledge regarding certain historical
chiropractic beliefs should not allow the expression of these beliefs to the patient as clinical truths.”

— Nelson, et al   [17]

Another tenet integral to chiropractic clinical practice is that which relates to treatment of the entire spine for the supposed attainment of structural and functional balance of the musculoskeletal system. This approach is common to chiropractic education and practice in the treatment of a sole regional condition, for example when there are objective findings of secondary but asymptomatic spinal regions [108]. Its theoretical basis rests in the notion that the spine is dynamic, with a series of anatomically and neurologically overlapping structures between which there is structural and functional interdependence.

The provision of full-spine care applications is common to chiropractic, irrespective of the treatment technique utilized. Favoring the concept of regional interdependence, there is good evidence to support the notion that manipulating the dorsal spine, for example, has clinical value in treating conditions involving the neck [31, 33–36, 38, 40, 45]. Warranting further investigation is the preliminary supportive evidence that exists for thoracic spine manipulation to treat shoulder conditions [33, 46–49]. How the efficacy of this practice may generally apply to other body regions or to numerous and varied clinical presentations has yet to be adequately explored. As such, the presumed therapeutic and functional benefits afforded with multiregional manipulation, as accepted in general by chiropractors, may not prove to be true for all clinical scenarios. In fact, a recent study involving targeted versus full kinematic chain mobilization/manipulation to treat osteoarthritis related hip joint symptoms resulted in similar outcomes between the comparison and experimental groups [109]. Therefore, the care governing principle which suggests that full-spine chiropractic manipulation is necessary for optimal patient outcomes, regardless of the suspected diagnosis or number of symptomatic spinal regions with which an individual presents, is not necessarily a clinical truth and remains untested.

Let’s consider for example the doctor who decides to treat a sole lumbar spine pain complaint by way of full spine manipulation. Would not the underlying premise the subluxation theory then make it requisite for the chiropractor to simultaneously address that same condition by way of evaluating and potentially manipulating the joints of the hips, knees, ankles and feet? After all, in a gravity environment, the closed kinematic chain has its origin at the feet. There are known functional relationships between the joint articulations of the lower extremity and the pelvis/low back [110–112]. Also, there is evidence of an association between lower extremity function and lower back pain [110, 112–118]. However, the clinical effectiveness of such a broad patient management approach is currently unsupported, absent experimental research. In fact, such practices would place no limits on the overall breadth of chiropractic treatment- which could otherwise be directed at every subtle incidental finding discovered throughout the entirety of the musculoskeletal system, in addressing a sole regional complaint. Ironically then, the historical practice of full-spine basis chiropractic manipulation, which by its nature is typically limited by an application of care solely to the axial spine, is operationally inconsistent with a philosophy that should seemingly call for evaluation and treatment of all components of the complete kinetic chain.

Manipulative treatment that is rendered to a spinal region immediately adjacent to a symptomatic region may sometimes be in order; that is, when the evidence supports or suggests that additional therapeutic benefit may be realized. However, there is a lack of clinical research in the area of chiropractic manipulative treatment of multiple body regions so as to reveal its significance in addressing asymptomatic subluxation. As such, one may reasonably deduce that a rationale for applying a multi-region manipulation approach to “treat” an asymptomatic person would need to extend beyond the default reasoning of vertebral subluxation. The following analogy takes the chiropractic philosophical principle of full spine manipulation, while addressing a sole regional complaint, and applies it to a hypothetical patient presentation scenario with an orthopedic surgeon.

A 56 year old female presented for orthopedic surgical consult following her referral for the like by her PCP.   She had a 5 week history of progressive right-sided cervicobrachial pain and numbness, following a fall at home, with no response to use of prescription strength medications and physical therapy treatment.   No other complaints were reported.

An MRI study, performed one week before her orthopedic consult, revealed a significant posterolateral disc herniation at C4/5 (with impingement upon the right C5 nerve root), and a moderate degree of hypertrophic changes of the apophyseal joints at C4/5 and C5/6 bilaterally.   Prior diagnostic testing included x-rays of the spine following her involvement in a motor vehicle accident 4 years earlier.   Those studies revealed signs of mild to moderate degenerative changes of the C4/5, C5/6, T7/8 and L5/S1 vertebrae (including mild disc thinning and osteophytosis at each of these levels).

The findings of the patient’s orthopedic physical examination and electrodiagnostic testing of the upper extremities revealed moderate to severe radiculopathy at C5 with significant muscle weakness upon resisted shoulder abduction on the right.   The patient was diagnosed with cervical disc herniation and degenerative disease of thoracic and lumbar intervertebral discs.

As a result, at the advice of her orthopedist, she consented to undergoing surgery that involved discectomy at C4/5 (with fusion) and debridement at the T7/8 and L4/5 vertebral levels.

As even a layperson could deduce, the extension of surgery into this fictional patient’s thoracic and lumbar regions is not consistent with her reason for pursuing care, her history of present illness, her physical examination findings or the results of her most recent diagnostic studies. However, because the surgeon believed that performing surgical procedures to the thoracic and lumbar regions (in removing arthritic tissue) would best ensure proper biomechanical function of the cervical spine, he advised the patient that it was in her best interest to receive those additional services during the surgical encounter.

This hypothetical patient management scenario accentuates the manner in which outside parties (including CMS and other third party payers) may view chiropractic treatment of conjoining, asymptomatic spinal/body regions simply on account of the doctor’s reporting of subluxations thereto.

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Subluxation Theory and Chiropractic Maintenance/Preventive/Wellness Care

“For the most part, clinical studies on the effectiveness of spinal manipulation are conducted
and reported without reference to the presence or absence or even the existence of subluxations.”

— Nelson   [104]

A recent literature review on chiropractic maintenance care reported no established prevalence of use [119]. Nonetheless, a majority of chiropractors surveyed in North America in 2000 (93.6%) reported delivering periodic maintenance/wellness care to their patients [5]. An earlier survey of practicing chiropractors in the United States revealed that maintenance care was recommended to 78.7% of chiropractic patients, with an average frequency of 14.4 visits per year [6]. A similar US study directed at a population of senior patients in receipt of long-term maintenance care revealed an average of 16.95 encounters annually [120]. The medical review data of the 2005 OIG report showed that 40% of the chiropractic services (manipulation) provided under the Medicare system for 2001 were rendered as maintenance care [121]. The disparities in utilization percentage do not only apply to US-based figures, but also with survey/study data from chiropractors practicing outside of the US [122, 123]. Nevertheless, maintenance care is a well-known concept within chiropractic [124]. It is perceived as a preventive measure [6, 123, 125], directed for example at thwarting recurrent bouts of low back pain [123].

The use or recommendation of maintenance/wellness care is common amongst chiropractors [5–6, 119, 126–129] such that it is considered integral to chiropractic clinical practice [25]. The principal rationales for use relate to the prevention or reduction of episodes of musculoskeletal pain, dysfunction or injury [127, 129] and to maintain for the patient a state of optimal health [6]. It has been proposed that chiropractic wellness care differs from maintenance care in that the former term represents a patient management approach with greater breadth [25]. However, in the absence of an evidence-based definition for maintenance care [119] or a standardized protocol for use of wellness care [25], any real difference between the two may simply be a matter of semantics insofar as the individual practitioner’s preference, or lack thereof, to utilize services beyond spinal manipulation. A recent chiropractic review paper on maintenance care concluded that the subject is not well researched [119]. Since then, investigation has shown a preliminary basis of support for use of manipulation in maintenance fashion [130–131]. However, that evidence currently pertains solely to nonspecific low back pain- a category of unidentified conditions which itself requires more consistent terminology and assessment methods [26]. Specifically, in analyzing workers’ compensation claims data, Cifuentes et al found less recurrent disability and an implied better cost-effectiveness for chiropractic maintenance care in low back pain patients [130]. Similarly, in a prospective controlled randomized trial undertaken by Senna and Machaly, a reduction of pain and disability was seen only in the group of chronic nonspecific low back pain subjects in receipt of maintained spinal manipulation therapy [131].

Preliminary evidence exists to support the provision of preventive chiropractic care in affecting pain and disability for patients with conditions of the low back [126, 130–131]. However, aside from the fact that not all patients with low back pain may respond to manipulation [131–132], the clinical usefulness or benefits afforded with the maintenance care model has yet to be revealed [124, 127] or adequately investigated in determining its role in managing individual patients [125]. Accordingly, maintenance care has yet to be recognized by third party payers as having enough value such that it has earned itself a place as a covered service. Thus, the challenge that chiropractors have historically faced relative to the funding of the wellness paradigm of health by government and private insurers [133] remains present today.

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The Case for Therapeutic Joint Manipulation in Managing Nociceptive Pain

“No matter how one looks at it, or what one would like reality to be, chiropractic medicine is about
back pain, neck pain and headache. Instead of fighting that fact (or denying it), we should embrace
it fully and focus on becoming society’s go-to profession for disorders in this area.”

— Murphy, et al   [18]

Various published studies, research efforts, reviews of the literature and clinical guidelines supply evidence for and illustrate a history of growing acknowledgement of the efficacy of spinal manipulation in the treatment of certain types of neck pain, lower back pain and headache conditions [29–30, 40, 42–44, 134–158]. Some supportive evidence also exists for the clinical effectiveness of treatment regimens that include manipulation of the spine and/or extraspinal joints in managing pain conditions affecting the shoulder [46–49, 62, 64, 66, 159–160], elbow [62, 161–162], hip [109, 163–164], and ankle [163–166]. Within the contemporary integrative patient care environment, the value of the current medical literature in these areas needs to be recognized precisely for what it represents for the chiropractic profession. It offers a scientifically tested, clinically cogent and evidence-based therapeutic joint manipulation model for modulating mechanical nociception. Further research is warranted in revealing the precise mechanism/s by which manipulation serves to alleviate acute and chronic pain of nociceptive origin [167]. However, for what is presently known about the neurobiological mechanisms of musculoskeletal pain [27, 168–169], the mechanical effects of manipulation [170], and the immediate neurophysiologic or hypoalgesic effects of spinal manipulation [81–85, 94–95, 171–172], there shines a beacon of opportunity for the chiropractic profession.

As it relates to chiropractic treatment of spine-based neuromusculoskeletal conditions, a recent consensus process makes a series of recommendations toward managing chronic pain patients [173]. Another undertaking offers an algorithmic approach to the treatment of acute and chronic spine-related pain conditions while better defining patient care terminology integral to the chiropractic clinical practice [174]. Neither of these contemporary professional efforts, nor many others which aim to investigate or summarize the efficacy or effects of spinal manipulation [29–30, 126, 149, 153, 175–177], specifically mention the vertebral subluxation so as to associate it causatively to pain conditions of either the acute or chronic variety. From a practical application standpoint, the content of these clinical papers is consistent with a chiropractic treatment paradigm that utilizes therapeutic joint manipulation (TJM) to modulate known biological pain mechanisms. Manipulative therapy has a known and clinically relevant effect in pain reduction [178].

The time has come for the whole of chiropractic to complete the process of embracing a pain-based model to patient care, making the domain of neuromusculoskeletal pain management the primary professional endeavor aimed at serving societal needs. No longer can it rely upon concepts that are not biologically plausible, or unknown, to the larger scientific community [4, 16, 179]. Nor can it afford to sit idle with conviction that science will someday reinforce philosophy. By surrendering to the fact that decades’ worth of scientific inquiry, analysis and debate has failed to provide support for the traditional vertebral subluxation paradigm (with its related axioms and rationales for patient care applications), and by adopting a pain-based model for use in clinical practice, the chiropractic profession would be better suited to gain broader access to the population of neuromusculoskeletal pain patients with conditions of spinal/appendicular origin. Taking such a stance could serve as both the foundation and a springboard for practice initiatives in the areas of wellness and the attainment of PCP status for chiropractors. Perhaps more than any other health care discipline that offers conservative treatment for neuromusculoskeletal conditions, the profession of chiropractic is in a unique position to expand its reach as the specialty that treats and aims to prevent spine pain. To its advantage, it already has in place an accredited educational system, an established and growing base of academic and clinical knowledge, proven skill sets in the manipulative arts, general public recognition as the profession that provides spinal manipulation [1], a capable political network, and an untapped service access infrastructure through and upon which such a transition could be initiated and developed.

Professional maturation is the result of reflection upon the historical origins, founding operational principles and moral conflicts of that profession, followed by a common recognition of what has proven to be true through sufficient time, shared practical experience and scientific investigation. Together, the thoughts and impressions that are conceptualized and materialize can effectuate change in the defined mission and practices of that profession in meeting the needs of the public. As an honest and open-ended process, there must be latitude for refinement or potential revision in the deliverable scope and purpose of care, as dictated by emergent medical evidence, societal need and the related expectations of the broader medical community. Thus, professional maturation comes about in a transitional manner, the ideas for which do not suddenly emerge in trivial fashion or upon a call for change that is inconsistent with the revelations of an advancing science. Nevertheless, it cannot occur when there is stagnation of will or thought of its membership in this regard or when the influence of philosophic viewpoints prevents collaborative action toward advocating a patient care model with evidence at its center.

With professional maturation comes the demand of clinical and societal accountability. Specific to the proposed maturation needs of chiropractic, a critical first step would involve a conscious decision to graduate from the core theoretical tenet of the vertebral subluxation in aligning itself with the emerging science which favors TJM in the management of pain conditions of neuromusculoskeletal origin. Continued reliance upon age-old views and practices that are wholly or partly incompatible with the accumulated base of scientific knowledge will impede professional advancement and reduce the probability of a more integrative future. Above all, this is an ethical calling, one with a societal obligation component derived from an oath to stand ready in servitude. However, on account of the spectrum of individual field practitioners amongst whom there remains diversity in philosophical persuasion, variation in clinical practice preference, and fear of loss of professional credibility/viability with a changed practice model, it is recognized that an attempt at such an undertaking would not come without resistance. It is understood that there is no easy solution to have a majority of participants reach agreement toward professional (thought) reform in this regard.

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Matters of Public Interest

“Chiropractic’s problem is that subluxation based chiropractors are not only deluding themselves,
they are indoctrinating patients into believing in a purportedly dangerous mythical entity, and
that without regular adjustments, patients will not only fail to reach their full potential, they
will likely suffer serious health problems.”

— Simpson   [7]

Chiropractic still lingers between the mainstream and alternative forms of health care [180], despite its overall success penetrating into various third party payer/health care financing systems. As reported in the scientific literature, from a public opinion perspective, chiropractic has historically earned high patient satisfaction scores [181]. Perhaps this is because the principal service supplied by chiropractors, spinal adjustments/manipulation, is accepted by most patients as a feel-good, relatively innocuous and clinically effective therapeutic approach for musculoskeletal conditions. This view has likely contributed greatly to the overall success of the profession throughout its history. However, moving forward, what remains to be seen is whether the profession will be able to transcend the ambiguity imposed by the vertebral subluxation [1]. Dependence upon the spinal subluxation as an element of distinction to support chiropractic manipulation is no longer realistic or operationally practical considering that physical therapists are providing and investigating the clinical value of the very same manual therapy procedure without ascribing to the unproven vertebral subluxation concept.

Over the latter part of the last century, many millions of spinal adjustments have been rendered to chiropractic patients worldwide. Despite this, there is no evidence or suggestion that there has been an epidemiological shift in the prevalence of degenerative spinal conditions for that segment of society which has had regular exposure to the variable of chiropractic manipulation for vertebral subluxation. Moreover, to the author’s knowledge, not a single case report has ever been presented within the chiropractic literature proposing or demonstrating a permanently cured subluxation lesion, at any vertebral level. Somehow, it is only within the chiropractic sphere that this void of supportive evidence has had little impact on the perceived validity of the subluxation construct. To the contrary, through circular logic and self-serving/presumptive reasoning, many chiropractors have accepted that despite the evolutionary process of natural selection [71] the human spine is so delicate that vertebral subluxations will continually recur. Theoretically, this holds true for the entire human race and can potentially come about even by way of benign activities, postural imperfections, toxins, etc. By default, and under the magnifying glass of medical evidence, does this not render today’s vertebral subluxation a lesion of convenience which in essence places the doctor’s pecuniary interests above all else? After all, the subluxation is still espoused by some as requiring chiropractic intervention without end [76]. How does that ideal serve the best interest of the public, so as to render the mission and services of the chiropractic profession congruous with the ethical undertakings of, and self-imposed edicts adopted by, the remainder of the mainstream health care disciplines?

In addressing asymptomatic vertebral subluxation [128], what determines how often chiropractic adjustments must be provided, what technique to use, or to what degree of force the manipulative procedure is to be delivered in perhaps ensuring the objective of achieving proper spinal alignment for general health? A clinically reproducible dose-response relationship [16] or a proposed model of optimal force thrust have yet to be established for the subluxation construct– taking into account the variables brought about by patient age [182], morphological differences in regional spinal anatomy [183–185], and other individual clinical/physiologic factors.

Bioengineering investigation has revealed that it takes about 20 minutes for cavitation to recur in previously cracked metacarpophalangeal joints [186]. Also, the refractory period of joint surface separation, which is probably affected by synovial fluid viscosity, has been shown to last for about 15 minutes following the attainment of an audible crack [186]. So, as it may theoretically apply to a sole “misaligned” vertebra, might any immediate and measurable biomechanical effect of a high velocity, low amplitude manipulative thrust be lost shortly after joint cavitation is achieved? An affirmative answer to this question would render the concept of repositioning misaligned vertebrae via chiropractic adjustments [187] simplistic and impractical, in part, on account of the fact that synovial joints will return to their pre-cracked resting internal state just minutes after undergoing manipulation. Absent significant force trauma [188] and barring underlying joint hypermobility or degeneration, it is seemingly self-evident that the orientation of osseous elements and varied spinal ligaments [189] offers passive stability in all directions. Moreover, likely through natural selection, in preventing nerve root impingement (via vertebral subluxation) from occurring, adjacent vertebrae undergo barest minimum displacement [71]. The latter two concepts would prevent an individual vertebra from being maneuvered beyond the transitory displacement associated with the dynamic manipulative thrust (the elastic deformation and subsequent rebounding of soft tissue holding elements).

On the whole, this oppositional idea to chiropractic “positional” theory [187] and subluxation correction is consistent with decades’ worth of anecdotal experiences of field practitioners. Namely, the observable phenomenon of changed segmental joint play between the pre- and post-manipulation assessments, followed by a recurrence of joint motion deficits (palpable dysfunction) at the same vertebral levels during successive patient encounters. Historically relied upon as evidence of vertebral subluxation, this phenomenon most likely exemplifies the temporary release of mechanically or reflexogenically restricted joint holding elements during the post-manipulation refractory period. Subluxation correction should then be an easily testable postulation from the standpoint that the subject who remains at rest after manipulation (i.e., while remaining still on the chiropractic table, in the very same position for which the adjustment was rendered) would expectedly no longer exhibit palpatory dysfunction or sign of “misalignment” upon expiration of the 15 minute post-cavitation refractory period. This kind of study has yet to be undertaken. In any event, the open-ended nature of subluxation based care [75] relies not only upon positional theory but likely the associated joint cavitation phenomenon as well. Some patients believe that the manipulative crack signifies the repositioning of misaligned vertebrae [187] and that the cracks encountered on subsequent chiropractic sessions exemplify a recurrence of these bony displacements. So, if not altering vertebral position to potentially bring about some health benefit, what then do chiropractic spinal adjustments directed at subluxation aim to accomplish clinically, when rendered at the doctor-preferred frequency and via techniques which vary in force application from provider to provider?

As part of a patient-oriented approach to care, it is likely that most chiropractors feel a professional obligation to deliver care by way of full-spine manipulative treatment and/or with “end-care” recommendation for periodic maintenance/wellness visits. However, neither of these models has been adequately tested by way of clinical trials to reveal the value and role of either in the patient management process or toward the prevention of episodic/recurrent spine pain or disability of varying etiology. Preliminary studies/analyses appear to favor the use of chiropractic maintenance care in reducing episodic recurrence of non-specific low back pain [130–131]. This has yet to be shown to be true for the neck [190]. Nevertheless, further research efforts are needed toward revealing the particular types of lower back conditions most amenable to ongoing chiropractic treatment, the specific individual or combined components of chiropractic care that may be responsible for the beneficial effects preliminarily realized, and whether spinal manipulation – as part of a well–rounded preventive treatment regimen – may yield long term benefit for pain conditions of other spinal/appendicular regions.

Chiropractic manipulation should be reserved for clinical circumstances that justify its use, and then delivered with care and mindful regard to the individual patient. Provider discretion concerning the type, breadth, magnitude, frequency and duration of spinal manipulative treatment is a necessity for each uniquely presenting patient. Those patients with chronic degenerative conditions may receive the benefit of palliative relief and improved functionality with periodic manipulative treatment. In select circumstances (i.e., ongoing care of a chronic condition [173]), the provision of more comprehensive treatment regimens, by way of multi-modal treatment approaches or with active care components that may be supervised by the chiropractor (when necessary) or self-directed by the patient at home or in a gym environment, may be clinically sensible in best ensuring maximum restoration and preservation of joint function/integrity. A recent Delphi methods consensus process offers professional parameters for the care of chronic spine pain conditions [173].

In view of all of this, can individual practitioners continue to propagate, in the public domain, age-old precepts that are without supportive evidence – thereby rendering chiropractic operationally inconsistent with how the remainder of the health care disciplines is evolving? The short-term financial gains realized by the individual practitioner who provides treatment based upon philosophical precepts may have long-term profession-wide implications across differing reimbursement systems, as has been suggested of the effects of overzealous use of maintenance care applications [119]. Moreover, in paradoxical fashion, the idea that the periodic provision of chiropractic spinal adjustments for silent or asymptomatic subluxation constitutes as “wellness” care is in direct contradistinction to both D.D. Palmer’s intention to treat the sick [13] and the “dis-ease” model of subluxation which has been forever pitched to the public.

Historically, public utilization of chiropractic services has ranged between 6% and 12% [191]. The latest figure for prevalence of chiropractic visits across twelve countries (7.5%) has reportedly changed little over the past 15–20 years [192]. Arguably, on account of these meager figures, and the prolonged historical dependency upon the philosophical tenets discussed herein, a culture of chiropractic patient education practices developed and remains active today toward retaining patients irrespective of the clinical condition with which they present. If the individual field practitioner continues to rely upon strategies which principally serve to maximize revenue generation in a low utilization market (through convincing patients to repeatedly attend after attaining maximum benefit, and by way of billing third parties for manipulation that extends into asymptomatic body regions), then a loss of clinical credibility will eventually be cast upon the entirety of the profession. After many decades of implementing these practices, and despite growing popularity of the complementary and alternative medicine movement [193], it has become plainly evident that adhering to chiropractic’s founding philosophical beliefs in the patient management process is not the path to meaningful professional growth or widespread public acceptance.

The evidence-based approach to patient care has begun to influence chiropractic education and practice [152]. However, most chiropractors lack interest in it [3]. As such, chiropractors may be their own worst enemies at a time when embracing the science and evidence which favors manipulation could open avenues for professional reform, greater collaborative practice opportunities, and expansion of reach in the areas of wellness, rehabilitation specialist or PCP status. It is not in the public interest to take the position of placing founding chiropractic philosophy ahead of the revelations of modern science. In some way this limits the manner in which that segment of the non-using public (88–94%) may be exposed to the option of chiropractic care for musculoskeletal pain, regardless of the manner in which this, or other barriers [194], may continue to impact upon direct or referral-based accessibility. These issues must be considered against the backdrop of the back-pain related public utilization statistics for physical therapy services [195], as well as a growing interest in spinal manipulation by physiotherapists.

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Conclusion

“As members of an established profession, chiropractors must rapidly wake up to the realisation that
there is a void in the field of non-surgical spinal healthcare which chiropractic can fill.”

— Brown   [12]

With growing interest in and the pursuit of articular manipulation by physiotherapists, this piece intends to reiterate and expound on the suggestion that continued adherence to the vertebral subluxation will eventually result in a displacement of chiropractors from the health care landscape [11]. Also, it posits that devotion to two directly related philosophical precepts (pertaining to full-spine treatment and maintenance care applications), each falling short of having had its clinical application parameters adequately defined through investigative research, will detract from more immediate chiropractic professional growth in the contemporary, competitive environment of evidence-based health care. A shift in the professed fundamental purpose of chiropractic care has become essential to the longevity of the profession. Public uncertainty over the dogma of subluxation [1] will be hastened through the relatively recent integration of spinal manipulation into physical therapy practice. In contrast to chiropractic, the physical therapy profession has historically operated under a medical paradigm, more recently showing a heightened interest in spinal manipulation research such that it is now using the procedure without regard for vertebral subluxation theory or a need to rely upon associated motivational tactics to attain/retain patients.

Absent scientific substantiation or well-defined parameters of clinical applicability, the management of chiropractic patients should no longer be based upon or governed by the once highly valued and profession-defining philosophical conviction of the vertebral subluxation. The time has come for the chiropractic profession to come to terms with letting go of this theoretical concept [7, 11, 106]. Unlike the past, the matter now reaches beyond the confines of internal debate elicited by those of differing philosophical persuasions. As opposing factions within the chiropractic profession remain at odds over the clinical significance and fate of the vertebral subluxation in a modern health care world, the collective body has balked at decisive action. There is no merit to the idea that relinquishing the subluxation principle connotes professional betrayal or that it will somehow render chiropractic unrecognizable to the public, thereby eliminating its distinctiveness. In fact, the opposite may prove to be true should the current state of affairs be permitted to play out to its logical end. Physiotherapists have recognized the evidence and implications of spinal manipulation for clinical practice [196] and have integrated thrust manipulation into educational curricula [197]. During the past several years the sheer volume of clinical papers emerging in this area reflects a cleverly organized step-wise progression to the research efforts of physiotherapists. That research not only pertains to thrust manipulation [31–45, 55–56, 60, 63, 198] but to flexion-distraction [199] as well. Perhaps this signifies that they are better positioning themselves to serve as the future go-to providers for this service.

There is a growing body of research evidence to support the clinical efficacy of multiregional manipulation in the treatment of specific conditions [31, 33–36, 38, 40, 45–49]. Also, preliminary evidence exists for chiropractic maintenance care for nonspecific low back pain [130–131]. However, that evidence cannot and should not be extrapolated to signify generalized validity to the philosophical precepts of full-spine manipulation and maintenance/preventive care so as to support their universal application to any/all clinical presentations. As a means of evidence-based treatment, full-spine manipulation should not be utilized unconditionally. Moreover, in accordance with current evidence, the provision of maintenance/preventive care should be reserved for selected lower back conditions in those individuals with identifiable risk factors for injury/episodic recurrence and who can be expected, through the clinical criteria of patient history and/or prior treatment response, to benefit from chiropractic care. Additional research must be conducted in numerous areas to evaluate the validity and the potential value/role of each of these practices for broader clinical application. That would include optimal procedure dose [200]. Until then, the tenets which have driven these practices should fall out of focus as general influencers for patient care and be replaced by a mindset that embraces an evidence-based therapeutic joint manipulation approach to chiropractic practice.

The compendium of research evidence for spinal manipulation [29–30] favors its utilization as a therapeutic procedure to manage nociceptive pain. In a contemporary time, that idea arguably serves the most clinically sound and politically viable operational model upon which chiropractic can advance itself in the public domain and in building new inter-professional relations so as to meet societal needs in the management of musculoskeletal pain. Such a model is both simple in concept and congruous with both the primary service that chiropractors have rendered for more than a century (spinal manipulation) and the principal reason that patients pursue or receive physician referral for chiropractic treatment (relief of musculoskeletal pain). There is an historical context to this, with regard to the profession’s successful penetration into the health care delivery system and its established role as the type of practitioner that treats the spine with conservative manual methods. Accordingly, it has become a necessity to shift professional interest, academic emphasis, research investigation efforts, patient education practices and clinician behavior in accordance with the widening supportive science component of the science-art-philosophy triad of chiropractic. In doing so, the profession may rise above the perception of illegitimacy that still lingers within some segments of the broader medical community. Moreover, it could earn itself a more favorable opinion across the general public, beyond the locus of its receptive patient base. As a result, it may find itself benefiting from the reform which is currently underway in the United States health care delivery system.

With resourcefulness and tactical preparation, the chiropractic profession can create new opportunities for itself in delivering well-reasoned care through a new evidence-based model that has a built-in transparency standard. With that, it may then find itself in a position to fulfill the moral obligation to reach and serve a larger percentage of society.

Transitioning the Clinical Practice In best fulfilling the civic duty component of what it means to be a health care professional in a modern era, and in opening avenues for greater inter-professional collaboration, it is proposed here that the philosophic chiropractic approach to patient care be replaced by one that is science-minded and evidence based. What can the interested chiropractor do in making a transition in this regard? The following points, concepts and practical application strategies should be given consideration: There is a growing outcome trend within recently published studies that favors therapeutic joint manipulation for nociceptive pain. Considering the scale of that trend, no longer can the efficacy of manual therapy methods in the treatment of certain musculoskeletal disorders be ignored by policymakers or downplayed by naysayers within the medical community. As such, the chiropractic profession potentially faces a wave of growth opportunity, but only if its members depart from the convenience, ease and refuge of subluxation theory and embrace this medical evidence trend as part of a paradigm shift. As a basic element to the pursuit of excellence in clinical practice, chiropractors must know the substance of the medical literature that pertains to their discipline and be effective communicators of that information to patients and other health care professionals. No longer is this optional for the individual practitioner. It is now obligational, considering the surge of manipulation research efforts by physiotherapists as well as the underlying and growing trend of incorporating manipulation into physical therapy educational curricula and clinical practice. Chiropractors should no longer be bound by the frustration of having to convince others of some unmeasurable value to the services they offer. The amount of evidence that now supports the principal chiropractic service of manipulation should be a source of excitement to the individual practitioner and the motivational force behind a desire to be a life-long subscriber to the medical literature. In the busy chiropractic practice, challenging oneself to read just one clinical paper per week would elevate the practitioner’s knowledge of the substance of the peer reviewed medical literature by 52 papers’ worth of information in a single year. That is not difficult to accomplish, and articles are readily accessible via the internet (from open access journals) or by way of submitting requests for specific papers to a chiropractic/medical college library. For starters, every chiropractor should become familiar with the findings of the 2010 UK evidence report [29] and the 2014 update paper that followed. [30] For those who may not be fully aware of the manner in which clinical papers can be located in the medical literature, keywords can be entered in searching for citations maintained within the US National Library of Medicine’s PubMed database [http://www.ncbi.nlm.nih.gov/pubmed]. As members of an evolving health care system that is beholden to rule of medical evidence, chiropractors who choose to embark on the path of science by regularly reviewing the medical literature may find themselves developing a previously untapped part of their professional being. By understanding the content of the scientific literature and the bearing that medical evidence can have upon the clinical practice, chiropractors may begin to critically review and reconsider previously accepted belief systems that were not grounded in or supported by basic science. How the profession can escape the political albatross of the Medicare-subluxation conundrum (undoubtedly, a delicate matter) is something to which many chiropractors have likely given thought. However, from a clinical practice perspective, the individual chiropractor who may be seeking to break free of the subluxation model need not find himself/herself troubled about that. It just so happens that the word “subluxation” need not appear anywhere in the chiropractic chart of a Medicare patient. [201] Also, subluxation treatment is already considered a pain-based approach, as identified in the Medicare Benefit Policy Manual. [201] At no point in the history of the chiropractic profession has the situation been more urgent, yet timely, for reform. With time, effort and renewed purpose, any chiropractor can begin to develop an understanding of what the medical literature reveals regarding therapeutic joint manipulation, while learning of the good that change can bring to the clinical practice. Transitioning to a pain-based operational model would offer the chiropractic profession far more than any short-lived inconveniences incurred.

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Author Dennis DiGiorgi is a 1996 Magna Cum Laude graduate of New York Chiropractic College and holds diplomate certification in health care quality and management with the American Board of Quality Assurance and Utilization Review Physicians.   Since 2003, he has held a seat on the editorial advisory board of the Official Disability Guidelines.

He is Adjunct Post Professional Faculty at National University Of Health Sciences.   Some of his other professional contributions, also aimed at elevating chiropractic through a transparency standard (in meeting needed qualitative improvements in an evidence driven health care environment), include a continuing education course on clinical documentation
http://nuhs.edu/academics/college-of-continuing-education/online-ce-courses/
and a published paper on manipulation under anesthesia
http://chiromt.biomedcentral.com/articles/10.1186/2045-709X-21-14.

He may be contacted at drdigiorgi@aol.com

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155. Negrini S, Giovannoni S, Minozzi S, Barneschi G, Bonaiuti D,
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156. van Tulder M, Becker A, Bekkering T, Breen A, del Real MT,
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157. Airaksinen O, Brox J, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al.
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158. Bryans R, Descarreaux M, Duranleau M, Marcoux H, Potter B,
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159. Brantingham JW, Cassa TK, Bonnefin D, Jensen M, Globe G, Hicks M, Korporaal C:
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160. Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL,
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161. Brantingham JW, Cassa TK, Bonnefin D, Pribicevic M, Robb A,
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162. Kearns G, Wang S:
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     J Man Manip Ther 2012, 20(2):90-5.

163. Courtney CA, Clark JD, Duncombe AM, O'Hearn MA:
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164. Brantingham JW, Bonnefin D, Perle SM, Cassa TK, Globe G,
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165. Loudon JK, Reiman MP, Sylvain J:
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166. Truyols-Domí Nguez S, Salom-Moreno J, Abian-Vicent J,
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167. Courtney CA, Fernández-de-Las-Peñas C:
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168. Arendt-Nielsen L, Fernández-de-Las-Peñas C, Graven-Nielsen T:
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169. Seaman DR, Winterstein JF:
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170. Branney J, Breen AC:
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171. Harvey MP, Descarreaux M:
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172. Millan M, Leboeuf-Yde C, Budgell B, Amorim MA.
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173. Farabaugh RJ, Dehen MD, Hawk C.
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174. Baker G, Farabaugh R, Augat TJ, Hawk C.
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175. Manison AM:
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176. Cashley MA, Cashley MA:
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     J Chiropr Med 2012, 11(4):260-6.

177. Gold PM, Albright B, Anani S, Toner H:
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178. Scholten-Peeters GGM, Thoomes E, Konings S, Beijer M,
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179. Bellamy JJ:
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180. Meeker, W., & Haldeman, S. (2002).
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181. Gaumer G:
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182. Marchand AM.
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183. Mercer S, Bogduk N:
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184. Sham ML, Zander T, Rohlmann A, Bergmann G:
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185. Lirk P, Kolbitsch C, Putz G, Colvin J, Colvin HP,
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186. Unsworth A, Dowson D, Wright V:
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187. Evans DW.
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188. Ivancic PC, Coe MP, Ndu AB, Tominaga Y, Carlson EJ,
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189. Sharma M, Langrana NA, Rodriguez J:
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190. Martel J, Dugas C, Dubois JD, Descarreaux M.
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191. Lawrence DJ, Meeker WC
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192. Cooper KL, Harris PE, Relton C, Thomas KJ:
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193. Frass M, Strassl RP, Friehs H, Müllner M, Kundi M, Kaye AD:
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194. Greene BR, Smith M, Allareddy V, Haas M:
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195. Childs JD, Fritz JM, Wu SS, Flynn TW, Wainner RS,
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196. Ladeira CE:
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197. Noteboom JT, Little C, Boissonnault W:
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198. Erhardt JW, Windsor BA, Kerry R, Hoekstra C, Powell DW,
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199. Choi J, Lee S, Jeon C:
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200. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB.
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201. Seaman D:
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     All DCs Are Required to Document the Same Way
     ACAnews Jan/Feb 2015, 16-21

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