Osteopathic practitioners have a responsibility to diagnose and refer patients as appropriate when the patient’s condition requires therapeutic intervention that falls outside the practitioner’s competence. It is also necessary to recognize when specific approaches and techniques may be contraindicated in specific conditions.

Osteopathic practitioners consider that a contraindication to OMT in one area of the body does not preclude osteopathic treatment in a different area. Likewise, a contraindication for any specific technique does not negate the appropriateness of a different type of technique in the same patient. Absolute and relative contraindications for OMT are often based upon the technique employed in each particular clinical situation.

The contraindications identified by the community of osteopathic practitioners are regrouped in function of the osteopathic techniques considered: these can be direct, indirect, combined, fluid and/or reflex-based (1). Direct techniques, such as muscle energy, thrust and articulatory manoeuvres, pose different risks from indirect, fluid and reflex-based techniques. There is only little published evidence on which techniques should be avoided in specific conditions. Osteopathic practitioners use their understanding of the pathophysiology of the patient’s condition and the mechanism of action of the technique to establish absolute and relative contraindications that are biologically plausible. On that basis the lists below have been established.

Contraindications to direct techniques

Direct techniques, may use thrust, impulse, muscle contraction, fascial loading or passive range of motion, to achieve tissue response. They can be applied specifically to a joint or nonspecifically to a larger area of the body. Often an area that should not be treated using a direct technique may safely and effectively be treated using an alternative technique, e.g. indirect, fluid or reflex-based. There are absolute and relative contraindications to direct techniques.

Systemic conditions that constitute absolute contraindications to direct techniques 

  • suspected bleeding disorder;
  • prolonged bleeding times;
  • anticoagulant pharmacotherapy without recent evaluation of therapeutic level;
  • clotting abnormalities;
  • congenital or acquired connective tissue diseases that result in compromised tissue integrity;
  • compromised bone, tendon, ligament or joint integrity, such as might occur in metabolic disorders, metastatic disease and/or rheumatoid diseases.

Systemic conditions that constitute relative contraindications to direct techniques 

  • osteoporosis;
  • osteopenia.

Absolute contraindications to direct techniques specifically applied at a local site 

  • aortic aneurysm;
  • open wounds, skin derangement, recent surgery;
  • acute hydrocephalus;
  • hydrocephalus without diagnostic workup;
  • acute intracerebral bleed;
  • acute cerebral ischemia, including transient;
  • suspected cerebral arterial-venous malformation;
  • cerebral aneurysm;
  • abdominal pain;
  • acute cholecystitis with suspected leakage or rupture;
  • acute appendicitis with suspected leakage or rupture;
  • acute or subacute closed head injury;
  • acute intervertebral disc herniation with progressive neurological signs;
  • suspicion or evidence of vascular compromise;
  • suspected vertebral artery compromise;
  • known congenital malformation;
  • acute cauda equine syndrome;
  • ocular lens implant (early post-operative period);
  • uncontrolled glaucoma;
  • neoplasm;
  • suspected bone compromise, such as osteomyelitis, bony tuberculosis, etc, or risk of same.

Absolute contraindications to direct techniques that specifically involve thrust or impulse applied at a local site 

  • specific technique at the site of surgical internal fixation of the joint;
  • compromised bone or joint stability, such as might occur focally in neoplasm, metastatic disease, suppurative arthritis, septic arthritis, rheumatoid diseases, osteomyelitis, bony tuberculosis etc;
  • acute fracture;
  • bony or intramuscular haematoma or abscess.

Relative contraindications to direct techniques that specifically involve thrust or impulse applied at a local site 

  • intervertebral disc herniation;
  • strained ligaments at the site;
  • acute acceleration-deceleration injury of the neck.

Contraindications to indirect, fluid, balancing and reflex-based techniques

Indirect, fluid, balancing or reflex-based techniques may be applied specifically to a joint or non-specifically to a larger area of the body. These techniques do not engage the restrictive barrier. They may include fascial and soft-tissue loading or unloading, hydraulic pressures, phases of respiration and cranial or postural adjustments, as part of the application of the technique. Relative contraindications to indirect techniques usually concern the clinical-temporal profile of the problem.

Absolute contraindications to indirect, fluid, balancing or reflex-based techniques applied at a local site 

  • acute hydrocephalus without diagnostic workup;
  • acute cerebral bleed;
  • acute intracerebral vascular accident;
  • suspected cerebral arterial-venous malformation;
  • cerebral aneurysm;
  • suspected acute peritonitis;
  • acute appendicitis or other visceral disease with suspected leakage or rupture;
  • recent closed head injury.

Relative contraindications to any indirect, fluid, balancing or reflex-based technique applied at the local site 

  • metastatic disease;
  • neoplasm;
  • closed head injury.
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