Absolute Contraindications

Situations where a particular technique is absolutely contra-indicated include those in which there is the possibility of tissue damage if the technique is performed. It is better to think of tissues rather than conditions, as there may be conditions that are unknown and that are, therefore, not diagnosed. If tissues are the main consideration, applied anatomy and physiology are the guiding factors.

As an example of this, consider a patient who complains of increasing back pain the longer he is upright. He gets some relief when lying down, but is much worse when carrying any weight. He has increased pain when descending in an elevator as it draws to a stop and finds that even lifting an arm out in front of him causes back pain. This pattern of symptoms is typical of a weight-bearing structure giving pain on increased loading. The two main weight-bearing structures in the lower lumbar spine are the discs and the vertebral bodies. Disc disease is not in itself a contra-indication to treatment, but will alter the choice of technique. Vertebral body damage is clearly a condition where treatment must be withheld until a clear diagnosis has been established. If there is bony weakness due to a secondary cancerous deposit, any technique putting forces through that segment would be unwise. Many other scenarios could be described to illustrate tissue analysis but applied anatomy and knowledge of tissue behaviour in health and disease is the key.

The most dangerous conditions are those that could weaken structures and so could possibly lead to a fatality or at best a severe injury. The greatest liability to this possibility is in the upper cervical region where inherent weakness in the vertebral ligamentous supporting structures may lead to nerve or vessel damage if unsuitable forces are applied. The vertebro-basilar system is particularly vulnerable to damage if excessive torsion is used. The results of this could be catastrophic and some tests exist to assess the possibility of potential trauma. No tests are an absolute safety screen, but may help to eliminate the most obvious cases from having ill-advised techniques and treatment. There is no excuse for insufficient diagnostic care and lack of precautions that could amount effectively to negligence. Every precaution that is necessary must be taken before undertaking any treatment to vulnerable areas.

The tests most often quoted as useful screening in the upper cervical spine follow:

1. EXTENSION TEST

Have the patient seated and slowly bring his head and neck into extension. Then sidebend and rotate it to one side and then the other. Any evidence of nystagmus, dizziness or dys-arthria should cause the operator to abandon all attempts at thrust techniques and should lead to an investigation of the reasons for the symptoms. These are classical symptoms of postural hypotension which is indicative of compromised vertebro-basilar circulation.

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