When is spinal manipulation unsafe?

When is spinal manipulation unsafe?
 
A question we sometimes get asked here at Hawtin Chiro is “Is it safe for you to crack my spine?” For the most part, cracking techniques known as High-Velocity Low-Amplitude Thrust techniques, aka ‘HVLAT’ are very safe and effective techniques used to improve spinal range of motion, normalise muscle tone and reduce pain. Most of the research into the safety of spinal manipulation focuses on the neck region of the spine due to possible complications relating to the blood vessels that run through the neck up to the brain. Research is varied on the incidence of blood vessel related injury direct from a neck manipulation. It is considered extremely low with rates to be estimated at approximately 1 in 5 million manipulations.There are definite cases where it is considered unsafe for a manipulation to be carried out (we call these ‘contraindications’). Clinicians are well-trained to know when it is and isn’t safe to perform these types of techniques. These decisions are based on a thorough case history which includes details of your problem, your medical history and a detailed physical examination. This may also include details of reports from images that may have been taken of your spine before.

Contraindications for HVLAT techniques are broadly broken down into the following categories:

Bone-related disease: This includes any condition which may have affected the strength of the bone itself, including:
• Fracture from a trauma
• Cancers/tumours affecting the bone
• Genetic diseases including dysplasia of bone
• Severe inflammatory disease including rheumatoid arthritis (RA)
• Long-term steroid medication use which can lead to osteoporosis
• Severe degenerative disease including advanced osteoarthritis of the spine

Blood vessel-related disease: Including any of the following diagnosed conditions:
• Carotid artery or vertebral artery dissection or dysfunction (important neck artery diseases)
• Abdominal aortic aneurysm (AAA)
• Excessive bleeding diseases including haemophilia

Nerve-related disease: Including any of the following spinal cord or nerve related conditions:
• Cervical myelopathy (i.e. compression of the spinal cord in the neck)
• Spinal cord compression elsewhere in the spine including that which occurs in Cauda Equina Syndrome (a low back nerve compression problem) or nerve root compression with progressive neurological symptoms including severe weakness.

There are also other instances where we would not manipulate you. These would include:

• No diagnosis: If we do not know what we are treating, then we do not manipulate.
• No consent: If you as a patient does not wish to be manipulated, then we do not perform that technique. We ensure patients are informed about the reasons any technique is used, and any associated risks. You will always be offered time to think over this decision and you won’t be expected to consent to the technique there and then if you are not comfortable with it.

We constantly strive to build trust with our patients, and ensure patients are always comfortable with our chosen techniques. We hope this helps you to feel secure when it comes to our approach to using spinal manipulation. We take every patient through a thorough screening before making the decision on our treatment plan. And we will always ensure you are well-informed of that treatment plan and agree to it before we carry it out. If you would like more information on this topic, speak to us next time you are in the clinic.

References
1. Gibbons, P. and Tehan, P. 2010. Manipulation of the spine, thorax and pelvis. 3rd ed. Churchill Livingstone Elsevier. Edinburgh, UK
2. Chadwick, L. et al. 2015. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. Journal of Manipulative and Physiological Therapeutics. 38 (9). 672-676. Available from: https://www.sciencedirect.com/science/article/abs/pii/S016147541300273X