What are the contraindications for chiropractic care?

Contraindications for Chiropractic Care

Chiropractic spinal manipulation is strongly contraindicated in patients with spinal fusion or advanced spinal osteoporosis due to significant risk of spine fractures, spinal cord injury, and paraplegia. 1

Absolute Contraindications

• Spinal conditions:

  • Spinal fusion (surgical or pathological)
  • Advanced spinal osteoporosis
  • Acute fractures or suspected fractures
  • Spinal cord compression
  • Spinal instability

• Vascular conditions:

  • Vertebrobasilar insufficiency
  • Carotid artery disease
  • Aneurysms
  • Anticoagulant therapy with unstable INR

• Inflammatory/Infectious conditions:

  • Active inflammatory arthropathies (during flares)
  • Spinal infections
  • Osteomyelitis
  • Discitis

Relative Contraindications

• Bone integrity issues:

  • Moderate osteoporosis
  • Bone-weakening diseases (multiple myeloma, metastatic cancer)
  • History of pathological fractures

• Neurological concerns:

  • Progressive neurological deficits
  • Myelopathy
  • Cauda equina syndrome

• Inflammatory conditions:

  • Rheumatoid arthritis (particularly with cervical involvement)
  • Ankylosing spondylitis 1

Evidence Supporting These Contraindications

The American College of Rheumatology strongly recommends against spinal manipulation with high-velocity thrusts in patients with ankylosing spondylitis who have spinal fusion or advanced spinal osteoporosis 1. This recommendation is based on case reports of spine fractures, spinal cord injury, and paraplegia following chiropractic spinal manipulation, particularly of the cervical spine 1.

Similarly, the 2022 American College of Rheumatology guideline conditionally recommends against the use of chiropractic therapy for rheumatoid arthritis management due to potential cervical spine complications 1. The panel perceived a lack of benefit specifically for RA and indicated concerns about burden and costs.

Case reports have documented compression fractures in elderly patients with osteoporosis following chiropractic adjustments 2. Failure to diagnose a compression fracture before treatment, combined with spinal manipulation in the area of fracture, can worsen symptoms and prolong disability.

Special Considerations

• Pre-treatment imaging: Patients with osteoporosis who have suffered a fall or injury should be x-rayed before treatment is given 2
• Elderly patients: Special care should be exercised in elderly patients with osteoporosis 2
• Recent trauma: Patients with recent trauma should be thoroughly evaluated before manipulation
• Anticoagulation: Patients on anticoagulant therapy require careful consideration due to potential bruising and bleeding risks

Alternative Approaches

For patients with contraindications to spinal manipulation, alternative approaches may include:

• Physical therapy with gentle mobilization techniques
• Exercise therapy
• Massage therapy (conditionally recommended for rheumatoid arthritis) 1
• Thermal modalities (heat, cold therapy) 1

Clinical Decision Making

When evaluating a patient for chiropractic care:

1. Thoroughly assess for absolute and relative contraindications
2. Obtain appropriate imaging when indicated (especially with history of trauma, osteoporosis, or suspected pathology)
3. Consider the risk-benefit ratio for each individual patient
4. Select alternative treatment approaches for patients with contraindications

The evidence clearly demonstrates that while chiropractic care may be beneficial for certain musculoskeletal conditions, the risks of spinal manipulation in patients with specific contraindications far outweigh any potential benefits.