8.1 Indications and Contraindications for Chiropractic Care
Key Takeaways
- Absolute contraindications (fracture, infection, malignancy, severe osteoporosis, VBI signs, cauda equina, spinal instability) forbid manipulation at that segment regardless of technique.
- The 5 D's, 3 N's, and A screen (dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, numbness, nystagmus, ataxia) is the standard pre-manipulative VBI screen; a positive finding stops cervical HVLA.
- Relative contraindications (mild osteoporosis, disc herniation with radiculopathy, spondylolisthesis, pregnancy, anticoagulation) change the technique, not the decision to treat.
- A modification ladder -- soft tissue work, mobilization, instrument-assisted adjusting, flexion-distraction, then HVLA -- guides technique escalation when a relative contraindication is present.
- Cauda equina syndrome (saddle anesthesia, bladder/bowel dysfunction, bilateral leg weakness) is a surgical emergency requiring immediate referral, not manipulation.
Chiropractic technique selection begins with a careful screening decision: is manual thrust (HVLA) manipulation safe at this segment, in this patient, on this day? Part III of the NBCE examination tests not just how to deliver a spinal or extremity adjustment, but whether a given clinical presentation permits an adjustment at all, and if not, what safer alternative applies. Contraindications are traditionally divided into absolute (manipulation must not be performed at the involved region, regardless of technique modification) and relative (manipulation may proceed with modification, alternative technique, or after further workup).
Absolute Contraindications
Absolute contraindications describe conditions in which the structural integrity of bone, disc, cord, or vasculature is compromised enough that even a low-force adjustive thrust carries an unacceptable risk of catastrophic injury -- fracture displacement, cord compromise, vascular dissection, pathologic fracture, or spread of infection.
| Condition | Why It Is Absolute | Clinical Clue |
|---|---|---|
| Acute fracture or fracture-dislocation at the level | Thrust force can displace fragments, damage the cord/nerve roots, or convert a stable fracture into an unstable one | Trauma history, point tenderness, positive Ottawa/Canadian C-spine criteria |
| Bone or spinal cord malignancy (primary or metastatic) at the level | Pathologic bone is weakened and prone to fracture under normal adjustive loads; metastatic disease near the cord risks acute compression | Unrelenting night pain, unexplained weight loss, prior cancer history |
| Active infection of bone or disc (osteomyelitis, septic discitis, tuberculous spondylitis/Pott disease) | Thrust can seed infection into adjacent tissue and destabilize already-weakened bone | Fever, elevated ESR/CRP, focal severe pain, recent infection or IV drug use |
| Cauda equina syndrome | Surgical emergency; any delay from manipulative treatment can worsen permanent neurologic loss | Saddle anesthesia, bladder/bowel retention or incontinence, bilateral leg weakness |
| Severe/advanced osteoporosis | Adjustive forces a normal vertebra tolerates can produce a compression fracture in severely demineralized bone | Elderly patient, long-term corticosteroid use, DEXA T-score in the severe range, height loss |
| Signs of vertebrobasilar insufficiency (VBI) or vertebral artery dissection | End-range cervical rotation/extension positioning is the mechanism implicated in rare vertebrobasilar injury; a positive screen is an absolute stop | Positive 5 D's/3 N's screen (see below), recent neck trauma, new severe headache with neck pain |
| Unstable os odontoideum or ligamentous instability (e.g., atlantoaxial instability from Down syndrome, RA, or trauma) | Loss of the normal C1-C2 restraint allows excessive translation that a thrust can convert into cord injury | Known diagnosis, positive instability imaging, hypermobility on exam |
| Acute myelopathy or progressive neurologic deficit | Ongoing cord or nerve compromise requires urgent medical evaluation, not manipulation | Progressive weakness, hyperreflexia, clonus, gait disturbance |
| Aortic aneurysm at or near the level | Thrust or positioning can theoretically increase risk in a friable vascular wall | Known diagnosis, pulsatile abdominal mass, family history |
Vertebrobasilar Screening: 5 D's, 3 N's, and A
Because cervical adjusting carries the most scrutinized (though statistically rare) vascular risk, every Part III candidate must know the classic pre-manipulative screening symptoms, often taught as "5 D's, 3 N's, and an A":
- Dizziness/vertigo
- Diplopia
- Dysarthria
- Dysphagia
- Drop attacks
- Nausea
- Numbness (facial)
- Nystagmus
- Ataxia
A positive finding on history, or one that appears during end-range cervical rotation/extension testing, is an absolute contraindication to cervical HVLA at that time and warrants referral rather than a modified adjustment at that segment.
Relative Contraindications and When to Modify
Relative contraindications do not forbid manual care outright; they change the decision about technique, not necessarily the decision to treat. The clinician weighs the likely benefit of care against a measurable, if lower, added risk, and frequently chooses a lower-force approach, a different region of contact, or referral for imaging/co-management first.
| Relative Finding | Typical Modification |
|---|---|
| Mild-to-moderate osteoporosis (not severe) | Favor low-force instrument-assisted adjusting or mobilization over HVLA; avoid recoil/high-amplitude thoracic techniques |
| Disc herniation with radiculopathy | Flexion-distraction (Cox technique) or mobilization directed away from the herniation; avoid extension-rotation loading toward the herniated side |
| Degenerative or isthmic spondylolisthesis | Avoid high-velocity shear-producing vectors at the listhesis level; favor flexion-based or distraction techniques and strengthening over aggressive mobilization at higher grades |
| Ligamentous laxity/hypermobility (e.g., Ehlers-Danlos, generalized joint hypermobility) | Reduce amplitude and frequency of HVLA; favor stabilization exercise over repeated cavitation |
| Pregnancy | Avoid prone positioning late in pregnancy; use side-posture with modified contact or a Webster-style sacral technique; avoid high-force direct abdominal-region contact |
| Anticoagulant therapy or bleeding disorder | Favor lower-force techniques; monitor for excessive bruising; coordinate with the prescribing physician for high-dose anticoagulation |
| Post-surgical spinal fusion | Do not thrust directly at fused segments; adjacent segments above/below the fusion may still be treated based on findings |
| Acute inflammatory arthritis flare (e.g., active RA flare, gout) | Treat once acute inflammation subsides; use gentle mobilization or soft-tissue work in the interim |
| Joint effusion | Address the effusion (RICE, referral if indicated) before applying a thrust technique at that joint |
The Modification Ladder
Part III scenario questions often ask which technique is most appropriate given a relative contraindication, not whether to treat at all. A practical hierarchy, from least to most aggressive, is:
- Soft tissue/myofascial work -- always available, essentially no biomechanical loading of bone or disc
- Mobilization (non-thrust, graded oscillation or sustained pressure) -- controlled movement within or at the edge of available range
- Instrument-assisted low-force adjusting -- precise, low-amplitude impulse, useful for osteoporosis, acute pain, and pediatric/geriatric patients
- Flexion-distraction/table-assisted technique -- decompressive, useful for disc lesions, stenosis, and some spondylolisthesis
- Manual HVLA -- reserved for cases without an absolute or unmanaged relative contraindication at that segment
Selecting too aggressive a technique for the contraindication present is the most common trap in Part III case-based items; choosing no care at all when only a relative, modifiable contraindication exists is the opposite -- and equally testable -- error.
A 68-year-old patient with a DEXA T-score consistent with severe osteoporosis presents with thoracic pain. Which approach is most appropriate?
Which finding on pre-manipulative cervical screening is an absolute contraindication to cervical HVLA at that time?
A pregnant patient in her third trimester needs lumbar adjusting for mechanical low back pain. What is the best positioning modification?
A patient presents with new saddle anesthesia, bladder retention, and bilateral leg weakness along with low back pain. What is the appropriate next step?