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WHO Guidelines - Contraindications to SMT

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The following is taken from the World Health Organization (WHO) Guidelines for Chiropractic.

Contraindications to spinal manipulative 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 [1] [2] [3]

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 [4]

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 [5]

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 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.

Absolute contraindications

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.

Contraindications to joint manipulation by category of disorder

Articular derangement

Inflammatory conditions, such as rheumatoid arthritis, seronegative spondyloarthropies, demineralization or ligamentous laxity with anatomical subluxation or dislocation, represent an absolute contraindication to joint manipulation in anatomical regions of involvement.

Subacute and chronic ankylosing spondylitis and other chronic arthropathies in which there are no signs of ligamentous laxity, anatomic subluxation or ankylosis are not contraindications to joint manipulation applied at the area of pathology.

With degenerative joint disease, osteoarthritis, degenerative spondyloarthropathy and facet arthrosis, treatment modification may be warranted during active inflammatory phases.

In patients with spondylitis and spondylolisthesis, caution is warranted when joint manipulation is used. These conditions are not contraindications, but with progressive slippage, they may represent a relative contraindication.

Fractures and dislocations, or healed fractures with signs of ligamentous rupture or instability, represent an absolute contraindication to joint manipulation applied at the anatomical site or region.

Atlantoaxial instability represents an absolute contraindication to joint manipulation at the area of pathology.

Articular hypermobility and circumstances where the stability of a joint is uncertain represent a relative contraindication to joint manipulation at the area of pathology.

Postsurgical joints or segments with no evidence of instability are not a contraindication to joint manipulation but may represent a relative contraindication, depending on clinical signs (e.g. response, pre‐test tolerance or degree of healing).

Acute injuries of joint and soft‐tissues may require modification of treatment. In most cases, joint manipulation at the area of pathology is not contraindicated.

Although trauma is not an absolute contraindication to manipulation, patients who have suffered traumatic events require careful examination for areas of excessive motion, which may range from mild heightened mobility to segmental instability.

Bone‐weakening and destructive disorders

Active juvenile avascular necrosis, specifically of the weightbearing joints, represents an absolute contraindication to joint manipulation at the area of pathology.

Manipulation of bone weakened by metabolic disorders is a relative contraindication because of the risk of pathological fractures (34, 35). Demineralization of bone warrants caution. It represents a relative contraindication to joint manipulation at the area of pathology. The spine and ribs are particularly vulnerable to osteoporotic fracture, and those patients who have a history of long‐term steroid therapy, those with osteoporosis, and women who have passed menopause are most susceptible (19:229, 36). Benign bone tumours may result in pathological fractures and therefore represent a relative‐to‐absolute contraindication to joint manipulation at the area of pathology. Tumour‐like and dysphasic bone lesions may undergo malignant transformation or weaken bone to the point of pathological fracture, and therefore represent a relative‐to‐ absolute contraindication to joint manipulation at the area of pathology.

Malignancies, including malignant bone tumours, are conditions for which joint manipulation at the area of pathology is absolutely contraindicated.

Infection of bone and joint represents an absolute contraindication to joint manipulation at the area of pathology.

Severe or painful disc pathology, such as discitis or disc herniations, are relative contraindications and nonforceful, non‐high‐velocity and nonrecoil manipulative techniques must be employed.

Circulatory and haematological disorders

Clinical manifestations of vertebrobasilar insufficiency syndrome warrant particular caution and represent a relative‐to‐absolute contraindication to cervical joint manipulation at the area of pathology. This would include patients with a previous history of stroke (37).

When a diagnosis of an aneurysm involving a major blood vessel has been made, a relative‐to‐absolute contraindication may exist for joint manipulation within the area of pathology.

Bleeding is a potential complication of anticoagulant therapy or certain blood dyscrasias. These disorders represent a relative contraindication to joint manipulation.

Neurological disorders

Signs and symptoms of acute myelopathy, intracranial hypertension, signs and symptoms of meningitis or acute cauda equina syndrome represent absolute contraindications to joint manipulation.

Psychological factors

It is important to consider psychological factors in the overall treatment of patients who seek chiropractic care. Certain aberrant behaviour patterns represent relative contraindications to continued or persistent treatment. Failure to differentiate patients with psychogenic complaints from those with organic disorders can result in inappropriate treatment. Moreover, it can delay appropriate referral. Patients who may need referral include malingerers, hysterics, hypochondriacs and those with dependent personalities (25:162).

Contraindications to adjunctive and supportive therapies


Adjunctive therapies in chiropractic practice may include electrotherapies such as ultrasound, interferential current and transcutaneous electrical nerve stimulation (TENS). The equipment for these modes of treatment needs to be properly maintained and used in accordance with appropriate specifications and clinical indications, but in these circumstances such therapeutic methods pose only a very limited risk of causing harm (38, 39, 40).

Exercises and supplementary supportive measures

A wide range of rehabilitative exercises and supportive measures are used in chiropractic practice. These should be prescribed in accordance with each patient’s individual requirements, and the dosage or level of exercise should be specifically designed to address the individual’s limitations and needs, being generally conservative at first and then increasing over time. In these circumstances, there are no significant contraindications which could not be addressed by common sense and the practitioner’s professional knowledge (41).


  1. Gatterman, M (1992), "Standards for contraindications to spinal manipulative therapy.", Vear HJ, ed. Chiropractic standards of practice and quality of care (Gaithersberg, MD: Aspen Publishers, Inc) 20: 75–83 
  2. Vear, HJ (1985), "Standards of chiropractic practice.", Journal of Manipulative and Physiological Therapeutics (Gaithersberg, MD: Aspen Publishers, Inc) 8 (1): 33-43 
  3. Gatterman, MI (1982), "Indications for spinal manipulation in the treatment of back pain", Journal of the American Chiropractic Association (Gaithersberg, MD: Aspen Publishers, Inc) 19 (10): 51-66 
  4. Haldeman, DC, MD, PhD, Scott (1980), "Spinal manipulative therapy in the management of low back pain", Finneson GE, ed. Low back pain, 2nd ed. (Philadelphia, PA: JB Lippincott): 260-280 
  5. Gatterman, MI (1981), "Contraindications and complications of spinal manipulation therapy", Journal of the American Chiropractic Association (American Chiropractic Association) 15: 575=586