Contraindications And Precautions

All systems of medical treatment have contraindications to their use, or the timing and dosage of their use. There is more than one way of looking at contra-indications to osteopathic technique and treatment. Although there are some deficiencies in the system, this book will continue using the notation of the description of absolute and relative contraindications. It provides some useful guidelines that are not too difficult to follow.

Some authorities feel that the manipulative prescription must be guided only by which type of manipulative technique is suitable and possible for the case. The idea is that no case is beyond the aid of osteopathic treatment. The choice of technique will be made with due consideration for all the factors presenting. Procedures will be used which cannot be expected to produce any damage, whatever the condition. In this way, treatment of even a terminally ill patient can be undertaken. If there is any small benefit gained, even for a very short time, this can be justified. I have some sympathy for this type of thinking, but feel that it is inappropriate for a student to be expected to work in this way. For this reason the considerations of absolute and relative contra-indications remain in use.

As in all skills it is possible to develop a sixth sense for warnings and precautions. If an experienced operator puts his hands on a patient, there will often be an immediate awareness of a disturbed tissue state when there is any reason for caution. This sixth sense is a combination of learning and experience. Many hidden cues are being used that cannot even be identified on a conscious level. It can become a very reliable method of deciding to stop and re-consider in a given case. This must be in addition to reasoning and normal caution, but must not become a substitute. It is far better to be too cautious and to be wrong, than to be not cautious enough, and be wrong! Hindsight gives 20/20 vision, but this is no comfort to a patient hurt or, worse, permanently or even fatally damaged. Until this sixth sense has been developed over a considerable passage of time, some rules are advisable.

Absolute contra-indications relate to situations where certain techniques should not be used. It would be rare, however, for no treatment at all to be possible. Relative contraindications relate to certain cases that require special caution for an identified reason as to the choice of technique. As experience grows, some techniques previously considered unwise may become possible with suitable precautions for the case.

Thrust techniques are virtually outside the active control of the patient and joints may be taken to their limit of anatomical movement where ligaments and capsules are put at risk of damage. This means that contra-indications to thrust technique will generally be more specific than for other types of technique. However, strong articulation, springing, or very firm soft tissue kneading are powerful in their own right and also require caution. Adhesions around joint structures are often stronger than the normal tissues and force applied may damage normal tissues before adhesions are broken. In the presence of adhesions, force is often increased in an attempt to break them down and the risk factor increases proportionately. Generally, the shortest amplitude possible consistent with the production of the desired result is to be encouraged. Even the highest velocity, if combined with ultrashort amplitude can be made relatively safe. Naturally, this is a skill-dependent factor that requires time to develop and not every practitioner is going to be able to acquire this skill.

The increasing use of the category of minimal leverage technique helps to reduce risk and many cases previously incapable of being thrust can be treated in this way. Caution is still necessary, however, as forces generated can still damage vulnerable tissues.

A decision must be made as to whether a given case is treatable at all and if it is, which techniques are most likely to help deal with the presenting problem. If a case is deemed to be untreatable using any category of technique, suitable consideration must be given to methods of referral and the patient must be informed why this decision is being made. If this is not done, there is a danger of them going to another manipulator who may not recognize the contra-indication, treat the patient and cause them damage.

A case which is not going to be helped by treatment is contra-indicated, not because harm will be done, but because no good can be done. In the presence of a seemingly 'hopeless' case where many other therapies have been used, there may be a case for some 'trial' treatment. It is a good idea to make a 'contract' with the patient to try a few treatments and if there is no good result, to review and reconsider. There is then less of a problem about treating apparently hopeless cases.

There is a school of thought that feels that the use of high levels of traction can render all manipulative procedures 'safe'. They feel that as joint surfaces are separated and foraminae opened, the chance of nerve or blood vessel damage and impingement is reduced. In my view it is dangerous to place absolute reliance on this. In some cases, particularly when using violent techniques, this may be true. Traction, in its many guises, is a valid and useful method of treatment, but to use it to render safe an otherwise unsafe procedure seems an inadvisable approach. Excessive reliance on any absolute rule such as this is responsible for a rigid approach with no possibility of variation for different circumstances. The osteopathic approach is to make constant subtle changes according to the needs of the tissues at the time they are being worked.

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