Contraindications and Proper Applications of Spinal Manipulation

Introduction

If you’re going to correct subluxations by manual manipulation you should check the integrity of the structures involved and any other co-morbidities, medications, surgeries, etc. There is a standard of care that must be adhered to. There is a deductive process progressively linked in proper sequence starting with the initial patient phone call to the first and every office visit including all interactions from the office staff to the D.C. relationship. Everything counts! The proper medical protocols and correct proper standard of care must be followed for the well being of the patient. A violation of this can lead to a malpractice suit in causation of injuries by you.

In the course of human history spinal and joint manipulation has been delivered by parents, spouses, medical physicians, osteopath physiatrists, physical therapists, acupuncturists, chiropractors, sport trainers and just plain layman. They just innately felt that this was the correct treatment to render. This therapy has been actively practiced for thousands and thousands of years of lying on of the hands to the spine to relieve pain and restriction. Yes, throughout the years this was called many professional names and unprofessional ones, unfortunately!

The evolution of scientific knowledge regarding diagnostic and therapeutic information has advanced the medical delivery system to great heights. The educational requirements to be granted a license to perform spinal manipulation has increased drastically. This has refined the medical therapeutic services rendered, thus increasing the improved results of how the patients respond.

The achievement of eliminating the pain and discomfort of our patients and offering excellent health to our community is of paramount priority. As medical professionals we want to offer the best care to our patients. Sometimes the best medical care is no care at all. Not rendering a therapy of any type seems to be against everything we were taught. It is our human nature to render something substantial to help. The inner salesperson kicks into mode whether subconsciously or not and without avaricious intent to render a substantial service.

This physician’s most enlightening moment of their life will be to say NO this type of medical treatment is not for you and to refer out to another medical specialist. Not only will the patient and family embrace you, but the whole community will know and respect you for your decision.

We as clinical physicians are so wrapped up in schools and seminars, which teach us to treat and how to treat. This article intends to have the treating physician rendering spinal manipulative therapy to make a decision whether to treat, treat with a co-physician of another complimenting diagnostic or treatment procedure, or just refer out without any treatment for another medical specialty treatment or opinion.

In the many years of my clinical and consulting career, I have come across and reviewed multitudes of cases where the treating physician has deviated from the proper standard of medical care. Even in my clinical career I make a choice whether to accept a patient, co-treat, or refer out all together.

This, however, does not mean to underestimate or insult my colleagues of all medical specialties that render medical spinal manipulation, but only to truly draw attention to the contraindications of spinal manipulation. This has been a huge delinquency in the medical community, which has lead to too many malpractice cases that were reported and could have been most certainly avoided.

It is my opinion and the consensus of the medical community, that all people should not be “adjusted”, that is receiving spinal manipulation, despite what they may or may not have been taught in chiropractic schools and at seminars. It seems that so many chiropractors try so hard to fit each patient and/or their condition into some type of treatment plan. There are so many cases where spinal manipulation is contraindicated; the “absolutely don’t touch” policy should be enacted immediately. Let me make it clear, that you sometimes even should refrain from active ranges of motion. For example, it is sometimes necessary to abstain even from performing Jackson’s test or Foramina Compression test. There are times when I advise not even to harshly perform any orthopedic test and including a Lévesque Straight Leg maneuver. Let me be clear that after the consultation you might even refer out.

It is my intention in the following paragraphs that will be outlined in the numerous litigation malpractice cases I have been an expert witness in, to prove to you and the spinal manipulation community to exercise extremely intense caution .

Just today a pre-certification utilization review company refused to authorize an MRI of a patient involved in a very traumatic motor vehicle accident. Please remember not to compromise your diagnostic evaluations prior to any treatment. It is still your responsibility to have all your systematic diagnostic evaluations prior to any rendering of spinal manipulation. In all actuality, if this patient does not want to pay for your prescribed diagnostics due to the denial, it would be the proper standard of care to deny the treatment of spinal manipulation.

In light of many of the cases I have been involved with, I feel it is so important to realize that rendering spinal and pelvic manipulation with an Activator instrument and or other types of instrumentation is not a substitute for manual osseous manipulation in a contraindicated patient. Remember, that whatever can due good will equally do harm if not performed correctly or performed on a contraindicated patient.

It is so important, and is the proper standard of chiropractic care, to gather past medical records and/or to conference with past treating physicians whether chiropractors or medical doctors. It is imperative not to depend only on what the patient tells you whatever the patient’s occupation.

Now armed with all this precautionary armor, the practitioner of the requested service of spinal manipulation care can either accept this case or not. Please, the comprehensive consultation and examination, the gathering of past medical records and information of past traumas along with conferencing with other past or present medical providers is essential before accepting a case for chiropractic care.

So, stop, think and listen... If your going to accept this patient have them sign an informed consent form. A chapter will follow of the proper informed consent form which is beyond the current standard of chiropractic care. We must protect ourselves but most importantly not harm anyone.

Discussion

The medical protocols of a thorough completion of comprehensive SOAP notes, initial evaluation and regular re-assessments consists in gathering medical records from other treating physicians, past and/or present medical records prior to treatment. This includes past and present x-rays, imaging studies, lab results, etc. Make sure you gather all this information prior to the first spinal manipulative treatment (SMT). You can have your staff do this during your initial assessment. Remember to include body temperature, familial history, blood pressure, gain or loss of weight. The most frequent malpractice cases besides strokes, are missing infections and even cauda equine syndrome. There are a lot of malpractice cases like hydrocollator and electric muscle stimulation burns as well.

Remember that you are only assessing the patient if they are a chiropractic case! That means that SMT is not contraindicated. This also means low aptitude activator, pellibone DNFT, etc. What can do good can also do harm. Don’t think you are getting around contraindications by using low aptitude mechanical on manual techniques. Remember “what is not written was not done” equate to “what is not legible is not done”. Never add after the fact and the facts should be done right after or during the treatments. Make sure you document everything even phone calls, and always have a third party observe and never close doors all the way. Please be very clear on this subject. All patients that present themselves to you for treatment are absolutely not cleared for chiropractic care until you have ruled out co-morbidity and/or contraindications’. The expressions thrown around our profession like; “everyone needs an adjustment” or “adjust everyone” is a malpractice case waiting to happen.

Over the many years in this profession we have been to haphazard just giving informal chiropractic adjustments. We should know better than to be like a sports trainer or fellow athlete performing a maneuver looking for cracks. We know that the joint will make an audible release whether it is moved back in place or not. Actually this separates the great busy practitioner from the on who doesn’t get good results. Just making noises does not correct subluxations. It could actually harm the patient. The reason we have that doctor title is to have the knowledge to differentiate between when to treat and when not to treat. It is imperative to conduct ourselves at all times as if this and any case will be presented in a professional malpractice case. A professional liability malpractice case could be brought against you for causation of injuries or as simple as a deviation of the proper standard of current chiropractic care or both.

We must perform at all times as if you are a defendant, medical board, chiropractic board, insurance fraud department and or your professors are actually present observing your actions. Of course, when it is mentioned “your actions” it also includes your staff. You are the responsible party. So there is no such thing as an informal adjustment. You should treat spinal and pelvic manipulation as if it was a surgical procedure and never anything less. You cannot have distractions, be tired, hungry, or angry. It must take 100% of your conscious thoughts. Without a perfect consultation and examination you cannot render the proper medical care and decide whether this patient is a candidate to be a chiropractic case.

It is my design of this text to scare you, thus protecting you and your patient from harm. It is not my design to educate you again to what the perfect consultation and or examination is. You should make it clear to your patient prior to the sit down consultation that today we will find out if they are a chiropractic case meaning you can proceed from consultation to examination, to a medical prescription plan then into their first treatment.

Standard of Care

The Dirty Dozen Contraindications of Spinal Manipulation

There is a standard of care to be followed that dictates the caution that must be exercised when administering medical spinal manipulation. The medical spinal manipulation can be chiropractic, osteopathic or rendered by other medical or non-medical persons all potentially ending in disastrous results. A definitive diagnosis and prognosis must be reached prior to treatment thru a comprehensive history and examination. There is a systematic medical protocol that must be adhered. This may even lead to radiological or imaging studies (MRI) prior to spinal manipulative treatment. Most important in this discovery procedure, is to determine if the patient is a candidate for SMT. Their symptoms may not be coming from spinal or pelvic misalignments. Their spinal and or pelvic structures may not be in good structural condition to accept a manipulation procedure. There can be so many co-morbidity factors such as congenital abnormalities, prior accidents, family histories and or cardiovascular susceptibilities that could end in death or stroke. These all must be ruled out prior to any treatment. Please understand that this is not meant to decrease the scope of what manipulation treats, but to minimize injuries caused by SMT. Of course, these are some of the deadly sins, but the Dirty Dozen Contraindications are as follows:

1) Rule out extruded disc myelopathy and refer out for MRI on any suspicion of a protruded disc that may have any degree of an annular tear.

2) Rule out cardiovascular predisposing factors, familial history. Perform at least four vertebral artery insufficiency test, especially for females, smokers, steroid or birth control and blood thinner medications.

3) check the structural integrity of the osseous structures prior to SMT, for example osteoporotic, degenerative osteoarthritic, degenerative disease, etc.

4) Check for congenital abnormalities or space occupying lesions, yes, this can take time, dig deep and be a good detective and easily refer for radiological and or diagnostic imaging studies.

5) Check vital signs especially temperature, there could be an infectious process developing.

6) Remember, that visceral symptoms mimicking musculoskeletal symptoms may not warrant SMT and may require an immediate medical or emergency room referral.

7) DO NOT PERFORM SMT INTO AN ACUTE SPASTIC MUSCLE REGION.

8) DO NOT PERFORM SMT WITHOUT MRI INTO A SPINAL REGION WITH BILATERAL RADICULAR EXTREMITY SYMPTOMS ESPECIALLY IF THERE OTHER ORTHOPDEIC AND NEUROLOGICAL TESTS THAT ARE POSITIVE.

9) SMT IS NOT GOING TO DECREASE THE PROGRESSIVE DESTRUCTIVE EFFECTS OF CONGENITAL JUVENILLE IDIOPATHIC SCOLIOSIS.

10) THE STANDARD OF CARE IS THAT IF SYMPTOMS DO NOT ABATE EVEN A LITTLE BIT WITHIN TWO WEEKS OF CARE IS TO REFER OUT AND CO-TREAT WITH ANOTHER MEDICAL PHYSICIAN FOR FURTHER DIAGNOSTICS AND/OR TREATMENT.

11) UNBELIEVABLE AS IT MAY SEEM AND QUITE OBVIOUS….DO NOT PERFORM SMT INTO SURGICAL FUSION HARDWARE, ESPECIALLY IF THE SURGERY WAS VERY RECENT.

12) REMEMBER, “WHAT CAN DO GOOD, CAN DO HARM!” ACTIVATOR AND/ OR OTHER MECHANICAL SMT TOOLS CAN DO HARM TO A CONTRAINDICATED PATIENT.

PLEASE NOTE THAT THIS IS NOT TO DECREASE THE SCOPE OF TREATMENT POSSIBILITIES THAT SMT CAN BE OF VALUE TO, BUT TO SINCERELY EXERCISE CAUTION WHEN CONSIDERING A PATIENT FOR SMT, WHICH IS CERTAINLY A MEDICAL PROCEDURE.

Chiropractic Spinal Manipulation & Stroke

Chiropractors are not the only physicians performing cervical spinal manipulative treatment. Actually, non-professionals, layman, and sports travelers are performing spinal manipulative treatment (SMT). Some people do it to themselves. So whoever is spreading the word that chiropractors may cause strokes when performing cervical manipulation is perturating an anti-chiropractic campaign.

Other medical physicians are osteopaths, orthopedists, physiatrists and physical therapists. The prudent physicians of all the above professions will rule out contraindications of SMT prior to any treatment.

It is unfair and belligerent to single out chiropractors like that, especially how advanced our education and excellence of performance of our physicians is in the new millennium.

Risk Factors for Stroke

No modifiable Risk Factors:

-Age: Stroke risk doubles in each successive decade after 55 years of age.

-Sex: Stroke is more prevalentin men than in women.

-Race/ethnicity: African Americans and some Hispanic have higher stroke death rates compared with European Americans.

-Family History: Family history of stroke associated with higher stroke risk.

 

Well-Documented Modifiable Risk Factors

-Hypertension: A major risk factor for stroke, with increased relative risk of 2-4 for people aged 50-70 years.

-Smoking: Increase relative risk of 1.8.

-Diabetes: Increased relative risk of 2-6 folds in diabetics.

-Carotid artery disease: Neck ceratoid arteries with atherosclerosis increases risk.

-Heat disease: People with heart problems (e.g. coronary heart disease) have high stroke risk.

-Sickle cell disease: Increases stroke risk.

-Hyperlipidemia: Abnormal blood lipids and lipoproteins increase stroke risk.

 

Less well documented or Potentially Modifiable Risk Factors

-Obesity: Increases stroke risk, especially abdominal obesity.

-Physical inactivity: There is increasing evidence that an inverse relation exists between level of physical activity and stroke.

-Poor diet/nutrition: Healthy diet of at least 5 servings of fruits and vegetables may reduce stroke risk.

-Alcohol abuse: This can raise blood pressure and increase stroke risk (especially hemorrhagic stroke).

-Hyperhomocystemia: Increasing evidence suggests this increasing stroke risk.

-Drug abuse: can cause cerebral emboli.

-Hypercoagulability: Several blood factors may increase risk of clot formation.

-Inflammatory processes: Several markers of inflammation (e.g. C-reactive protein, cytokines, activated T cells and macrophages) have been linked to elevated stroke risk.

Other obvious mistakes are slipping from a poor, normal or mechanical contact point, excessive force, not using pre-manipulation testing by bringing patients to a maximum range of motion before that gentle thrust, poor line of drive, especially going against the line of drive of the vertebral facets and of course greed.

Summary

All patients that present to you for chiropractic manipulative care must be screened through the proper standard of medico-chiropractic protocol. This is the deductive process of case history, familiar history, prescription and surgical history, etc. This is to be followed by the thorough comprehensive process of orthopedic, neurological, cardiovascular and chiropractic examinations. The process can be done with time efficiency and must be done and documented prior to accepting this patient in a formal presentation to them. Today MMA laws we have gathered all your past medical records and spoken to your treating and/or referring primary care physicians. We have our own assessments and feel your symptoms are not related to your subluxations and therefore you would not benefit from chiropractic care.

“Today, Mr. /Mrs. Jones we have completed your symptoms and/or condition and feel that your body would not be able to accept a chiropractic spinal manipulation because of some other co-morbidity factors. We will finally refer you back to your medical physicians or refer to our team of referring physicians.”

“Today Mr./Mrs. Jones, congratulations we are accepting you as a chiropractic patient.” This will be 95% of the accepted cases, but is the 5% that will drown you.

It only takes minutes to add a Valsalvas, heel walk, bilateral heel on leg raise, Lhermette sign, Haul pike maneuver, Dekleyn’s test, Hautant test, Underberg test and an Vertebral Basilar functional maneuver testing.

There is great software for SOAPS, evaluations, reassessments and they are very time efficient. It is a comprehensive history, complete diagnostic testing and medical records review that are collaborating factors to formulate the assessment for the prudent physicians to go forward with any medical therapy.

Be cost effective and time effective, friendly, loving and caring. Bring your patient to wellness care as quickly as possible!