Chiropractic Subluxation
Diagnosis/Condition:
Somatic or SegmentalDysfunction
Other, multiple, and ill-defined
dislocations
ICD-9
Codes:
739.0-739.5
839.0-839.69
Origination
Date: 10/2007
Review/Revised
Date: 01/2008
Next Review
Date: 1/2010
Discipline: Chiropractic
The clinical concept of the chiropractic subluxation has been one of the fundamental components
of chiropractic theory since the founding of the profession. However, this concept has been
controversial, almost from its inception. Subluxation originally was a medical term that was
adopted by DD Palmer to most closely describe the phenomenon that he experienced in his
newly "discovered" clinical practice of chiropractic. While the medical term subluxation refers to
an incomplete dislocation, the chiropractic concept of it has come to be thought of as involving
disturbances of any of the features of articular anatomy and physiology including abnormality of
motion, neurology, muscle, ligament, circulation, inflammation and others. The Association of
Chiropractic Colleges definition of chiropractic subluxation states, A subluxation is 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.
From an administrative perspective, subluxation is the most common diagnosis offered by
chiropractors. The International Classification of Diseases (ICD) however does not include the
term chiropractic subluxation in any of its definitions. Chiropractors use of ICD-9 codes to
describe the chiropractic subluxation is inconsistent. ICD-9 codes for Nonallopathic lesions,
segmental or somatic dysfunction (739.x) and Other, multiple, and ill-defined dislocations
(839.x) are used variably to indicate a diagnosis of chiropractic subluxation. Certain insurance
carriers have made local determinations about the ICD-9 codes that properly describe
subluxation. In some states, chiropractic laws specify subluxation as the only acceptable
diagnosis from a chiropractor. The diagnostic characteristics of subluxation have become
enshrined in Medicare policy (See addendum to this pathway).
Subjective Findings and History:
Most patients present to chiropractic physicians with complaints of pain or tightness
Onset may be acute or insidious
Pain or tightness is in a location associated with the involved articulation
Pain or paresthesia may occur in the neurologic distribution or zone of referral of the
involved structure. For example:
o Cervical region headaches, neck pain, dizziness, upper extremity pain and/or
paresthesias
o Thoracic region back pain, rib cage pain, referred arm or neck pain
o Lumbar and/or pelvic region low back, pelvic or hip pain, lower extremity pain,
paresthesias
o Peripheral joints-local pain, weakness, loss of motion
Inflammation, swelling
Stiffness, reduced range of motion
Objective Findings:
Physical and chiropractic examination procedures are used to rule out the red flags of
pathologic processes that can provide relative or absolute contraindication to chiropractic
treatments
Examination findings to determine the presence of subluxation have not been thoroughly
evaluated for reliability, specificity, and sensititvity
Expert consensus has identified classes of findings that together indicate the presence of
a chiropractic subluxation including:
o Pain / tenderness identified through observation, percussion, palpation,
provocative orthopedic testing
o Asymmetric qualities on spinal segmental or sectional levels identified through
observation, static palpation, diagnostic imaging
o Range of motion abnormality identified through motion palpation and stress x-ray
examination
o Tissue tone, texture and temperature abnormality (of the skin, fascia, muscle,
ligament) are identified through observation, palpation, instrumentation and tests
for length and strength
Assessment:
The patient must have a significant health problem necessitating treatment
The clinical impression should indicate the specific anatomical structures involved and
clinically correlate with the complaints, mechanism of injury, the history and objective
findings
The patients condition must bear a direct relationship to the level of subluxation.
The assessment should identify any barriers to recovery
Plan:
The treatment plan should indicate
The frequency and duration of at least an initial trial of care
The modalities to be used
A time frame in which a re-evaluation is planned
Goals or outcomes of treatment and how they will be measured
Interventions that will address any obstacles to recovery identified in the evaluation
Passive Care
Chiropractic adjustment, mobilization
Soft tissue techniques
Physical therapy modalities
Patients at risk for becoming chronic should have care plans that avoid physician
dependence, limit passive care and encourage active care approaches
Active Care
Active exercises/stretches for mobility and strength
Advise about work and non-work physical activity
Use of heat/ice
Frequency and Duration of Treatment
Frequent treatment (up to 5 visits per week) may be necessary early in the course of care
Progressively declining frequency is expected as the patient improves and moves from
passive to active care
The evidence for the duration of chiropractic treatment is inconclusive
Duration and intensity of care should not extend beyond the time frame observed in the
natural history of the condition
The duration of treatment is driven by the patients response to treatment
Referral Criteria:
Referral to an appropriate provider should be considered when:
The presence of red flags of pathologic conditions are discovered
The patients presents with conditions that are outside the chiropractic scope of practice
Failure to improve after appropriate trials of treatment
Practitioner Resources:
J ournal of Manipulative and Physiological Therapeutics (J MPT) is dedicated to the advancement
of chiropractic health care. It provides the latest information on current developments in
therapeutics, as well as reviews of clinically oriented research and practical information for use in
clinical settings.
http://www.jmptonline.org/
Chiropractic & Osteopathy is the official journal of the Chiropractic & Osteopathic College of
Australasia (COCA). COCA has agreed to cover the cost of article-processing charges for all
papers submitted before March 2009. This will enable Chiropractic & Osteopathy to remain an
international open access journal without charge to authors during this time.
http://www.chiroandosteo.com/
Patient Resources:
The American Chiropractic Association (ACA) is the largest professional association in the world
representing doctors of chiropractic. As evidence supporting the effectiveness of chiropractic
continues to emerge, health care consumers are turning in record numbers to chiropractic care
a form of health care aimed primarily at enhancing a patient's overall health and well-being
without the use of drugs or surgery.
http://www.amerchiro.org/level1_css.cfm?T1ID=13
The National Center for Complementary and Alternative Medicine (NCCAM) is the Federal
Government's lead agency for scientific research on complementary and alternative medicine
(CAM). The mission of NCCAM is to explore complementary and alternative healing practices in
the context of rigorous science. To view NCCAMs Research Report About Chiropractic and Its
Use in Treating Low-Back Pain go to:
http://nccam.nih.gov/health/chiropractic/
The Evidence:
Henderson CN. Cramer GD. Zhang Q. DeVocht J W. Fournier J T. Introducing the external link
model for studying spine fixation and misalignment: part 1--need, rationale, and applications
J ournal of Manipulative & Physiological Therapeutics. 30(3):239-45, 2007 Mar-Apr.
Gemmell H, Miller P. Interexaminer reliability of multidimensional examination regimens used for
detecting spinal manipulable lesions: A systematic review. Clinical Chiropractic 2005
Dec;8(4):199-204.
Knutson GA, Owens EF. Active and passive characteristics of muscle tone and their relationship
models of subluxation/joint dysfunction - part I. J ournal - Canadian Chiropractic Association 2003
Sep;47(3):168-79.
Knutson GA, Owens EF. Active and passive characteristics of muscle tone and their relationship
to models of subluxation/joint dysfunction: Part II. J ournal - Canadian Chiropractic Association
2003 Dec;47(4):269-83.
Owens EF. Chiropractic subluxation assessment: what the research tells us. J ournal - Canadian
Chiropractic Association 2002 Dec;46(4):215-20.
Owens EF. Chiropractic subluxation assessment: what the research tells us. J ournal - American
Chiropractic Association 2002 Sep;39(9):20-4.
Osterbauer PJ , Hansen DT. Technology assessment of the chiropractic subluxation: reprise.
Topics in Clinical Chiropractic 2002 Sep;9(3):10-8.
Mootz RD. Professional identity: The role of chiropractic theory. Topics in Clinical Chiropractic
2001 Mar;8(1):1-8.
Ernst E. Is the chiropractic subluxation theory valid?. Focus on Alternative and Complementary
Therapies 2000 Dec;5(4):279.
Bergmann TF, Finer BA. J oint assessment - Parts. Topics in Clinical Chiropractic 2000
Sep;7(3):1-10.
Cramer G. Budgell B. Henderson C. Khalsa P. Pickar J . Basic science research related to
chiropractic spinal adjusting: the state of the art and recommendations revisited. J ournal of
Manipulative and Physiological Therapeutics. 2006 Nov-Dec; 29(9): 726-61.
Triano J J . The functional spinal lesion: an evidence-based model of subluxation. Topics in
Clinical Chiropractic. 2001 Mar; 8(1): 16-28, 74-6.
Gatterman MI. Foundations of chiropractic: subluxation. Mosby-Year Book, Inc. (St. Louis, MO)
1995; 487 p.
Peterson, David H. and Thomas F. Bergmann. Chiropractic Technique: Principles and
Procedures, 2nd edition. 2002, Mosby, Inc. St. Louis, MO.
Herren, Sheri. 1998 Chiropractic consensus panel: Guidelines for Medicare coverage: HCFA
makes a decidedly positive change in its policy on diagnosing subluxations. J ournal of the
American Chiropractic Association, Aug 1998.
The International Chiropractors Association. Recommended clinical protocols and guidelines for
the practice of chiropractic. J une 2000.
Clinical Pathway Feedback
CHP desires to keep our clinical pathways customarily updated. If you wish to provide
additional input, please click on the email address listed below and identify which clinical
pathway you are referencing. Thank you for taking the time to give us your comments.
Chuck Simpson, DC, CHP Medical Director: csimpson@chpgroup.com
