therapy
Spinal manipulative therapy is the primary therapeutic procedure used by
chiropractors, and because spinal manipulation involves the forceful passive
movement of the joint beyond its active limit of motion, chiropractors must identify the
risk factors that contraindicate manipulation or mobilization (19, 20, 21).
Manipulations can be classified as either nonspecific, long‐lever techniques or specific,
short‐lever, high‐velocity, low‐amplitude techniques (the most common forms of
chiropractic adjustment) which move a joint through its active and passive ranges of
movement to the paraphysiological space (22).
Mobilization is where the joint remains within a passive range of movement and no
sudden thrust or force is applied.
Contraindications to spinal manipulative therapy range from a nonindication for such
an intervention, where manipulation or mobilization may do no good, but should
cause no harm, to an absolute contraindication, where manipulation or mobilization
could be life‐threatening. In many instances, manipulation or mobilization is
contraindicated in one area of the spine, yet beneficial in another region (23). For
example, hypermobility may be a relative contraindication to manipulation in one area
of the spine, although it may be compensating for movement restriction in another
where manipulation is the treatment of choice (24, 25). Of course, the chiropractor’s
scope in manual therapy extends beyond the use of manipulation or mobilization and
includes manual traction, passive stretching, massage, ischaemic compression of
trigger points and reflex techniques designed to reduce pain and muscle spasm.
Successful spinal mobilization and/or manipulation involves the application of a force
to the areas of the spine that are stiff or hypomobile, while avoiding areas of
hypermobility or instability (26).
There are a number of contraindications to joint mobilization and/or manipulation,
especially spinal joint manipulation, which have been reviewed in practice guidelines
developed by the chiropractic profession (27, 28) and in the general chiropractic
literature (29, 30, 31). These may be absolute, where any use of joint manipulation or
mobilization is inappropriate because it places the patient at undue risk (23, 32:290‐
291), or relative, where the treatment may place the patient at undue risk unless the
presence of the relative contraindication is understood and treatment is modified so
that the patient is not at undue risk. However, spinal manipulative therapy,
particularly low‐force and soft‐tissue techniques, may be performed on other areas of
the spine, depending upon the injury or disease present. Clearly, in relative
contraindications, low‐force and soft‐tissue techniques are the treatments of choice, as
Guidelines on safety of chiropractic
21
both may be performed safely in most situations where a relative contraindication is
present.
Conditions are listed first by absolute contraindications to spinal manipulative therapy.
Absolute and relative contraindications to spinal manipulative therapy generally are
then outlined as they relate to categories of disorders.
It should be understood that the purpose of chiropractic spinal manipulative therapy is
to correct a joint restriction or dysfunction, not necessarily to influence the disorders
identified, which may be coincidentally present in a patient undergoing treatment for a
different reason. Most patients with these conditions will require referral for medical
care and/or comanagement (33).
1. anomalies such as dens hypoplasia, unstable os odontoideum, etc.
2. acute fracture
3. spinal cord tumour
4. acute infection such as osteomyelitis, septic discitis, and tuberculosis of
the spine
5. meningeal tumour
6. haematomas, whether spinal cord or intracanalicular
7. malignancy of the spine
8. frank disc herniation with accompanying signs of progressive
neurological deficit
9. basilar invagination of the upper cervical spine
10. Arnold‐Chiari malformation of the upper cervical spine
11. dislocation of a vertebra
12. aggressive types of benign tumours, such as an aneurismal bone cyst,
giant cell tumour, osteoblastoma or osteoid osteoma
13. internal fixation/stabilization devices
14. neoplastic disease of muscle or other soft tissue
15. positive Kernig’s or Lhermitte’s signs
16. congenital, generalized hypermobility
17. signs or patterns of instability
18. syringomyelia
19. hydrocephalus of unknown aetiology
20. diastematomyelia
21. cauda equina syndrome
NOTE: In cases of internal fixation/stabilization devices, no osseous manipulation may be
performed, although soft-tissue manipulation can be safely used. Spinal manipulative
therapy may also only be absolutely contraindicated in the spinal region in which the
pathology, abnormality or device is located, or the immediate vicinity.
excerpted from:
WHO Chiropractic Guidelines
http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf
also attached here.
