Week 4 Contraindications PDF

Principles of Adjustive Technique CONTRAINDICATIONS Susan D. Miller, D.C., B.S.B.  Contraindications to & Complications of Adjustive Therapy “ Clinical corroboration of subluxation/dysfunction syndromes is NOT, in and of itself, an indication for adjustive therapy.” – Yo...

Principles of Adjustive Technique CONTRAINDICATIONS Susan D. Miller, D.C., B.S.B.  Contraindications to & Complications of Adjustive Therapy “ Clinical corroboration of subluxation/dysfunction syndromes is NOT, in and of itself, an indication for adjustive therapy.” – You, the doctor, must determine: Is it SAFE to adjust? – Just because a patient has subluxation/dysfunction, does not mean that adjustive therapy is appropriate for that patient – Spinal dysfunction may be concomitant with contraindications to some forms of manual therapy  CONTRAINDICATIONS Contraindication= problem identified b4 the procedure is performed – Potential to cause harm/injury → procedure not advised (serious injuries very uncommon) – May worsen associated disorder (instability) – If procedure may delay life-saving treatment (cancer) Adjustive therapy (if not contraindicated) can give significant pain relief & improve quality of life for cancer patients – **PALLIATIVE CARE MUST BE CONCOMITANT CARE W/ DR. TREATING MALIGNANCY** – Some conditions may contraindicate thrusting forms of manipulative therapy May be able to use other forms of manual therapy (mobilization) May be able to adjust other areas (improve quality of life) – May be Absolute or Relative contraindications  CONTRAINDICATIONS Absolute Contraindications= disorders that contraindicate ANY form of thrust manipulation Relative Contraindications= potential contraindications depending on severity/stage of disorder & it’s pathological process – Many contraindications to adjust are relative – May require modifications to treatment – Use CAUTION in applying adjustive therapy, consider: Pts. Age/state of health Nature of potentially complicating pathologic condition Stage of disorder, stage of development State of remission or exacerbation  CONTRAINDICATIONS Please see table 4-1 – Conditions requiring management modification – Potential complication(s) from manipulation – Method of detection – Specific management modifications – *There WILL be questions on the exam from this chart  ABSOLUTE CONTRAINDICATIONS WHO Guidelines list of ABSOLUTE CONTRAINDICATIONS for HVLA adjusting2: – Some anomalies (dens hypoplasia, unstable or os odontoideum, etc) – Acute fracture – Acute infection – Spinal malignancies, meningeal & spinal cord tumors, soft tissue/muscle neoplasia – Hematomas (cord or canal) – “Frank disc herniation with accompanying signs of progressive neurological deficit”2 – Basilar invagination or Arnold Chiari malformation (upper cervical) – Vertebral dislocation  ABSOLUTE CONTRAINDICATIONS WHO Guidelines list of ABSOLUTE CONTRAINDICATIONS for HVLA adjusting (continued)2: – Aggressive benign tumors – Internal stabilization/fixation devices – Positive Kernig’s (meningitis) or Lhermitte’s sign (MS) – Congenital, generalized hypermobility – Signs or patterns of instability – Syringomyelia – Hydrocephalus (unknown etiology) – Diastematomyelia – CES cauda equina syndrome  COMPLICATIONS Complication= problem that occurs after a procedure is performed – Serious injuries from adjustive therapy are very uncommon – May be associated with new tissue damage – May require a change in therapeutic approach (Table 4-1) – Most are resultant from misdiagnosis or improper technique Awareness of Complications/Contraindications & Sound Diagnostic Assessment help prevent injuries – Ranges from mild increase in local discomfort to serious permanent neurological complications/death – “The best available evidence indicates that chiropractic care is an effective option for patients with mechanical spine pain and is associated with a very low risk of associated serious adverse events”  COMPLICATIONS VS REACTIONS Reactions= transient episodes of increased symptoms that resolve spontaneously (Dvorak’s def) – No worsening of underlying condition or new iatrogenic injury – Normal vs adverse reactions Normal reactions= minor increase in discomfort – commonly occurs in patients who have been successfully treated Adverse reactions= more significant discomfort & temporary or permanent impairment (less common/complication)  COMPLICATIONS VS REACTIONS Reactions continued: Box 4-7 – ADEQUATE (acceptable) Reactions= transient episodes (probably a normal product of manual therapy& mobilization or stimulation of periarticular soft tissues) Onset 6-12 hrs Mild subjective symptoms Local soreness Tiredness Headache No decrease in work capacity duration< 2 days with spontaneous remission  COMPLICATIONS VS REACTIONS Reactions continued: Box 4-7 – EXCEEDING reactions= characterized by more pronounced discomfort Onset 6-12 hours Objective worsening of signs and symptoms Interferes with work, ADL’s Duration> 2 days with spontaneous remission  COMPLICATIONS VS REACTIONS Most Common Reactions – Study by Senstad, Leboueuf-Yde, & Borchgrevink Inc. local discomfort 55% Headache 12% Tiredness 11% Radiating discomfort 10% 85% of all reactions were mild-moderate 64% appeared within 4 hours 74% disappeared within 24 hours – *another study on cervical adjusting revealed a mild-mod transitory inc in pain (75%) without ANY serious complications  COMPLICATIONS VS REACTIONS COMPLICATIONS: Reversible & Irreversible (Box 4-7) – REVERSIBLE complications= the pathological condition associated with the complication is reversible Onset within 2 days Requires diagnostic/therapeutic interventions Tissue damage **patient can return to pre-occurrence status – IRREVERSIBLE complications Onset within 2 days Requires diagnostic/therapeutic interventions Permanent tissue damage and impairment result  INFORMED CONSENT Patients have the right to know about any risks of significant harm (complications) & other treatment options before consenting to examination and care – The patient must understand the nature of the procedure(s) to be performed – They must give “ written, verbal, or implied consent.” Consent must be documented in the pts. Health record Malpractice/Assault & Battery: If Dr. treats/performs diagnostic evaluation without documented informed consent  INFORMED CONSENT Always inform patients of ANY risk of significant harm – Even though most risks are not significant CVA following cervical manipulation – Most studies actually show a higher incidence (1 in 100,000)of spontaneous VBA dissection than of post-manipulative VBA dissection (1-2 per 1,000,000) NCMIC reports a significant number of malpractice suits are filed due to a lack of informed consent – What is a material & significant risk is not clear up to the courts to decide in each case Contact an attorney specializing in health care law in the area you practice for advice on standards for obtaining informed consent  Complications of Lumbar Manipulation Risk of serious complications from Lumbar Manipulation is extremely low p. 103 – 3 degrees of axial rotation Full macroscopic failure of annular fibers @ 12 degrees Lumbar Facets & Left Facet synovial cyst LUMBAR PATHOLOGIES LUMBAR VERTEBRAE  LUMBAR IVD INJURY Does Lumbar rotation damage the IVD or do the lumbar facets limit rotation protecting the IVD’s from “undue torsional stress”? – Farfan postulated “ 90% of the torsional strength of a lumbar motion segment is provided by the disc & facet joints with the annulus providing the majority of the torsional resistance.” Stages of IVD injury: – 1. Circumferential separation of annular fibers – 2. Radial fissures develop – 3. Internal disruption of the disc – 4. Possible disc protrusions/herniations  LUMBAR IVD INJURY More recent studies show that the facet joints and posterior ligaments are the main structures resisting torsion in the lumbar spine – Adams & Hutton used a cadaver to show that the facets resist lumbar rotation before IVD Compressed facet was the first structure to give at the limit of rotation Articular cartilage and soft tissues showed significant injury b4 significant stress was transferred to the IVD Also showed that the disc is more vulnerable to flexion injuries – Flexion is NOT inhibited by the facets – Excessive flexion → disruption of the posterior annulus » Esp. when coupled with rotation, lateral bending, and axial loading (overweight) » Pts. Say “I just bent over to pick up a Kleenex”  LUMBAR IVD INJURY – Bogduk studied excessive rotation with flexion (fig 4-7) Flexion is presumed to tense the annular fibers In flexion, the inferior & superior articular processes don’t limit segmental rotation as much IAR shifts from the central posterior 1/3 of the disc (A) to the impacted/compression facet (B) Fig 4-7 A-B – New IAR @ compression facet allows excessive motion (superior vertebra pivoting about new IAR) → shear & torsion on contralateral facet » Fractures of the impacted facet- fig 4-7 (C) » Capsular tears or avulsion fractures of the contralateral facet (C) » annular circumferential discal tears- fig 4-7 (D) LUMBAR IVD INJURY (Fig 4-7)  LUMBAR IVD INJURY Broberg used a theoretical disc model to study how IVD’s respond to compression, shear, bending, and axial rotation – IVD stiffness increases sig. with axial load – Bending, shear & axial rotation only constitute a risk of annular fiber rupture in combination with very high axial loads (compression) Most studies were done on cadavers, some after removing the posterior elements (results vary study to study) **The IVD may respond VERY differently when there is associated disc herniation/motion segment instability  LUMBAR IVD INJURY SUMMARY 1. The posterior lumbar joints protect the IVD from rotational stress & injury 2. Marked rotational force would be required to injure the disc 3. Movement > normal ROM necessary to injure disc (most likely after significant injury to the posterior elements) 4. The disc is most vulnerable to FLEXION injuries (combining flexion and rotation most risky) 5. “The forces involved in skillfully delivered SP rotational manipulation are not sufficient to injure a healthy disc.” 6. Manipulative positions that incorporate excessive flexion and rotation should be avoided in patients with disc herniation. 7. Evaluation of lumbar movements should be conducted before applying adjustments in patients with disc herniations (or any pt.) 8. “Adjustments should not be delivered in positions & directions that implicate increased nerve root compromise – If set-up increases intensity or distal distribution of patient’s radicular pain  References Bergmann & Peterson. Chiropractic Technique. 3rd ed., Elsevier Health Sciences, 2010. WHO Guidelines on Basic Training and Safety in Chiropractic. 2005.