Absolute contraindications to spinal manipulative therapy (WHO) | Forum

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Admin Aug 11 '18
2. Contraindications to spinal manipulative
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
both may be performed safely in most situations where a relative contraindication is
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.

2.1 Absolute contraindications to spinal manipulative therapy
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


also attached here.

The Forum post is edited by Admin Aug 11 '18
  Chiro-Guidelines.pdf (500Kb)
Admin Aug 11 '18
Admin Aug 11 '18

This may not all be Gospel! -ed.

Chiropractic Contraindications When NOT To Get Chiropractic TreatmenChiropractic contraindications are extremely rare and chiropractic care is amazingly effective (and cost effective!) for the treatment of many types of spinal pain syndromes including back pain, neck pain, sciatica, headaches and whiplash. There are some instances however, when caution dictates that a different path should be taken.

Your chiropractor can and should take the proper steps to determine whether chiropractic care is appropriate for you. Their training dictates it!

Getting Proper Screening

My title perhaps should have been “when the #1 treatment of a chiropractor should be avoided.” There is a standard of care that should be followed to determine when and where a spinal manipulation (adjustment) is administered. A diagnosis and prognosis must be arrived at before any treatment. This can only occur when a comprehensive question-and-answer session occurs between you and your chiropractor, followed by examination and maybe even special testing such as an x-ray or MRI.

Most important in this “discovery” time is the determination of whether or not you are a candidate for spinal manipulative treatment (SMT). Understand these two things:

  1. Symptoms which seem to be coming from your back may not be coming from spinal or pelvic misalignments.
  2. Your spinal or pelvic structures may not be healthy enough to accept SMT.

There can be many other factors such as congenital (from birth) abnormalities of the spine or adjacent structures, prior accidents, family histories and/or cardiovascular weaknesses which could lead to danger from SMT. A good chiropractor will screen for all of thesebefore beginning treatment.

When Chiropractic Won’t Help: Chiropractic Contraindications

Here’s a list of the most common chiropractic contraindications for SMT:

  1. Ruptured disc. When evaluating for a disc injury, your chiropractor will want to rule out an extruded (or ruptured) disc and will refer you out for an MRI if he or she suspects that your disc is torn.  Ruptured discs CAN be successfully treated by chiropractors, but the methods of treatment will be unique to this condition.
  2. Cardiovascular problems. When considering the potential for cardiovascular issues, your chiropractor will look for predisposing factors based upon your family history. Your chiropractor will also ask about whether you are a smoker, are on steroids or blood thinning medications, and (if you are female) whether you are on birth control medications. Your chiropractor will perform special tests to evaluate your vertebral arteries (the small arteries in your neck which run alongside and within a portion of your vertebrae).
  3. Bone weakness. Your chiropractor will check for the structural integrity of your bones prior to SMT. If you have Osteoporosis, Rheumatoid or Osteoarthritic Degenerative Disease, special methods of SMT can be performed safely.  An instrument adjusting technique (Pro-Adjuster, Sigma Instruments, Pulstar Instruments) can be safely used.
  4. Abnormalities. Your chiropractor will check your spine for congenital abnormalities or space-occupying problems which could (very rarely) include tumors or disease.
  5. Infection. Your chiropractor will check your vital signs, especially temperature, to rule out the possibility of an infection.
  6. Problems with visceral organs. Symptoms from the viscera and internal organs can mimic musculoskeletal symptoms, and may require immediate medical or emergency room referral. (Gall bladder pain or an aortic aneurysm are examples of mimicked spinal pain.)
  7. Muscle spasms. If you have an acute spasm of a muscle, SMT in that immediate area will not be appropriate.
  8. Certain pain patterns. Your chiropractor will not perform SMT into a spinal region if you have symptoms into BOTH arms or BOTH legs without an MRI first. This is important if other orthopedic and neurological tests are positive.
  9. Congenital scoliosis. SMT is not going to decrease the progressive effects of congenital juvenile idiopathic scoliosis.
  10. Surgical hardware. Your chiropractor will not perform SMT into surgical fusion hardware, especially if the surgery was recent.

The standard of care is that if your symptoms do not reduce, even a little, within two weeks of the beginning treatment, then you may be referred to another type of doctor for further diagnostic testing and treatment or co-treatment.

As in all health care, remember that what can do good can also do harm. If you doubt this, pay attention to the next drug advertisement you see and hear. The litany of contraindications, side effects and adverse reactions which every medication creates is overpowering if you are not paying attention to the flowery images on your TV screen.

The chiropractor is trained to first do no harm, and to look for chiropractic contraindications. Every health care procedure has risk, but thankfully chiropractic is one of the least risky health care methods on our planet. The next time you experience musculoskeletal pain, consider chiropractic care first.  A chiropractor is uniquely qualified to find the reason for your pain, rule out chiropractic contraindications, and when appropriate, successfully and quickly help you improve!
photo credit: Pink Sherbet Photography via photopin cc

By |December 23rd, 2013|


cliff Aug 11 '18

World Health Organization

Guidelines on Safety of Chiropractic


2.1 Absolute contraindications to spinal manipulative therapy

It should be understood that the purpose of chiropractic

spinal manupulative 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



                8. frank disc herniation with accompanying signs of

                    progressive neurological deficit.

cliff Aug 12 '18

A question answered. “Why so much emphasis on avoiding SMT in true hernias (not disc bulge) cases” We look at the few CVA cases and see that the problems were caused by preexisting conditions: accidents waiting to happen. Therefore the same applies to lumbar root involvements-hernias, i.e. preexisting pathologies that can cause cauda equina situations if adjusted. (cites available on request).

The people who don’t like us want to make cervical adjusting disappear. Those same people have set their sights on lumbar adjusting, thinking it also too dangerous, and wanting it to disappear too. So, if we think it permissible to adjust pathological lumbar discs and causing cauda equine by so doing, we are playing into their hands (as well as creating a patient endangering situation).


Those among us who advocate treating hernias had better get modern.

cliff Aug 14 '18

Still treating hernias? Here are some comments from Wim:

I was an expert witness in a cauda equina case in the Netherlands. The patient, a young father, wears diapers now! The chiropractor involved ignored an absent achilles tendon reflex and adjusted the patient in side posture. Look for neurological findings:

  1. Strength loss
  2. Loss of reflexes
  3. Sensory loss
  4. Positive nerve tension tests

Admin Sep 6 '18
In as much as we get resistance, rather than cooperation, from general practitioners, regarding authorization of imaging studies, they are creating a potential public health hazard. This is an expression of frustration, meant as an appeal to cooperation, not intended to convey antagonism.
The Forum post is edited by Admin Sep 6 '18
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