Contraindications and considerations for articulation techniques
In this chapter we will look at contraindications and considerations that the practitioner should weigh up before undertaking articulation techniques.
It is a professional practitioner’s duty to identify the treatment that will be most advantageous to the patient, and it should be borne in mind that not all cases can be helped by treatment with manual therapy. Indications offer reasons to choose a particular treatment in order to benefit the patient; contraindications are reasons why certain treatments may be risky or inappropriate.
All medical treatment methods have at least one contraindication associated with their use. Most skilled professionals develop the ability to detect warning signs that help them take necessary precautions when addressing a certain condition. Experienced manual therapists will immediately be aware that there is a problem when they put their hands on the patient, so allowing them to deal with the issue with caution. Experience is just as important as being educated about the problem being treated.
There are warning signs that may give you cause to stop for a moment and to rethink your decision to employ a particular technique. Is this the best possible treatment for this patient or should you consider a different modality? It is much better to be cautious and decide not to act when you could have done so than to act without caution and be wrong about your judgment – the latter leads to more harm than good (Hartman 1997).
Absolute and relative contraindications
By definition, a contraindication is a situation in which a procedure, drug, therapy or surgery should not be used because it may cause the patient harm. In medicine, contraindications are classified into two subsets: absolute contraindications and relative contraindications.
Certain conditions do not allow a particular treatment to be used because there is no reasonable justification for taking that route. For example, people with severe food allergies should not be given foods that they are allergic to as this may lead to an anaphylactic attack. This is a contraindication that is referred to as absolute.
Figure 3.1
Diagrammatic representation of a relative contraindication: the benefits of a treatment outweigh the risk(s)
Not all contraindications are absolute, however. Some contraindications are relative. This means that a patient may have a high risk of adverse effects or complications but these risks are outweighed or reduced by other treatment approaches (Figure 3.1). For example, X-rays are strictly inadvisable during pregnancy as they can negatively affect the developing fetus inside the mother’s womb. However, on occasions, X-ray may be necessary because the woman or fetus may be in danger – for instance, in the case of tuberculosis. In that situation X-rays are advised (Starke 1997). These are cautions that the practitioner needs to keep in mind when determining the best possible treatment for any individual patient.
Figure 3.2
Contraindications to manual therapy
Indications are reasons to choose a certain treatment in order to benefit the patient; they are the opposite of contraindications. A professional practitioner must find the treatment that will be most advantageous to the patient and which will cause minimal side effects, if any.
Treatment method | Indication | Contraindication |
Joint articulation | Restriction of joint movement Malalignment of joints Mechanical joint pain which worsens with movement Muscle tightness and imbalance Nerve root compression, disc lesions, spondylosis | Signs of vertebral artery disease Increased pain with manual therapy Signs and symptoms of spinal cord lesions Fracture or dislocation Instability of joint or ligament Pain from non-mechanical causes Active bone disease/malignancy |
Manual traction | Joint stiffness or compressive stress Nerve root compression or disk herniation that responds positively to manual traction | Same as above |
Table 3.1
Indications and contraindications to joint articulation and other modalities
Not all cases can be helped by treatment with manual therapy (Figure 3.2 and Table 3.1). The procedures that are chosen will be expected to cause no damage. However, if the seriousness of the patient’s current condition outweighs the risk of any possible long-term damage or side effect, the patient will be informed about risks and side effects relevant to the area that will be treated and/or their condition prior to the start of any treatment (Hartman 1997).
Joint articulation
Joint articulation is referred to as a manual therapy intervention – a passive movement of an articular surface or skeletal joint performed by a skilled manual therapist. Joint articulation focuses on providing a therapeutic effect to the patient. The techniques involved are used by a wide variety of manual therapists to improve joint alignment, increase flexibility and improve mobility. Their use is also aimed at reducing pain and discomfort and muscle spasms. This, in turn, helps to increase joint range of motion (ROM) (Mulligan 2010).
When joint articulation is applied to the spine, it is called spinal or vertebral articulation. The human spine has 24 articulating or movable vertebrae. When all 24 vertebrae articulate in a free manner, they are able to move load up and down the spine. There are a number of specific contraindications to undertaking spinal and joint articulations (see Table 3.2). It is important to be aware of these.
The flag system for musculoskeletal disorders
The origin of pain may sometimes be more psychological than physical. For example, a person may come to the therapist describing his pain as ‘excruciating’ but still be able to walk properly and to perform certain physical activities at a level which seems to be inconsistent for a person with that level of pain. In order to determine the physical intensity of pain in such a situation, the therapist can make use of the ‘flag system’, which employs ‘flags’ as markers of risk factors in musculoskeletal disorders.
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