Do NOT manipulate these people!


If you have any interest in manipulation (i.e. high-velocity low amplitude thrust), you’ve likely learned a variety of techniques and which patients may benefit from this technique.  Most quality courses will also at least give some mention to contraindications or precautions to performing manipulation on patients.  Having posted a few videos on this blog about different manipulation techniques, I’ve realized that this is a topic that should also be discussed and not left as an assumption that those viewing our videos are aware of these things.  So, the following are some information I’ve learned from others over the years… most recently from my training with the North American Institute of Orthopaedic Manual Therapy (NAIOMT).


Generic contraindications:

  1.  Hypermobility syndromes/collagen deficits (i.e. Marfan’s, Ehler’s-Danlos, Hypermobility spectrum disorder, etc.).  The concern with these patients are how mobile their articular structures are and the possible strain that could be place on neural/vascular structures that pass from one segment to another.  With such extreme amounts of movement possible, these tissues risk being injured.
  2.  Induced collagen problems (i.e. long-term steroid use).  The concern here is the collagen tissues are severely weakened by issues such as long-term steroid use.  In such a case, articular structures could be weakened enough where a manipulation could cause injury (i.e. capsular injury, ligament sprain, fracture, etc.)
  3.  Osteoporosis (for any reason, but some may include:  immobilization for long periods, young females with known eating disorder, heavy drinkers/smokers, long-term aspirin users).  One of the biggest concerns here is a possible fracture.  Forget about causing a fracture with your manipulation, you don’t want to miss a patient that is presenting with a fracture.  It’s one thing to cause a fracture, but quite another to displace a fracture and cause neural or vascular injury.
  4.  Bleeding/clotting disorders and/or patients on anti-coagulants.  The concern here is obviously causing a bleed in a vascular structure that is around the area you are manipulating.
  5.  Patient does not consent to it.  This may seem obvious, but in reality there are many many clinicians out there that do not obtain proper consent for an intervention like manipulation.  Explaining to the patient what you would like to do, the reasons why, giving a “mini-thrust” to let them know what you are talking about, asking permission to do that, and still giving them an out as you are setting up are all necessary BEFORE performing a manipulation.  Even if the patient gives their consent, if their body language or facial expression is saying otherwise, beware!
  6.  The ‘unlucky’ patient that has had everything go wrong with them.  Maybe I’m alone on this one, but has anyone else had the occasional patient that has seen umpteen medical providers and find their way to you somehow?  They’ve been dealing with multiple aches/pains/symptoms since they got injured years before.  Everything seems to flare them up and most treatments that may help are ususally just temporary.  They probably mention how previous clinicians made them feel worse… but, they’re totally fine with whatever you want to do.  Beware of these patients because you don’t want your head to be the next one mounted on their wall.
  7.  Gut feelings.  Maybe everything is a green light for this patient in front of you, that manipulation is indicated and there is nothing contraindicating that intervention.  However, something deep inside you is saying “I’m not so sure this is a good idea!”  It could be that you aren’t having the best day yourself, so don’t chance it.  It could be something else that your sub-conscious noted when observing or conversing with the patient.  Either way, if the hairs on the back of your neck are standing up and you don’t know why… better to wait for another day.


Specific contraindications:

  1.  Suspicion of fracture within kinetic chain you may manipulate.  Obviously if you knew there was a fracture in or around where you want to manipulate… you wouldn’t do it!  BUT, maybe they haven’t been properly imaged or diagnosed with a fracture.  Now your clinical skills must come in to play to recognize signs/symptoms that could indicate a fracture.  Better to play it safe and not displace something already fractured and cause even more problems.
  2.  Instability that can be effected by your manipulation.  Clinical instabilities are abnormal translatory movements that occur in a motion segment beyond it’s “normal” boundries.  Being able to identify these problems can be vital, and your one chance to not only avoid further injury to a problematic spinal segment… but, be the one person that can identify the actual issue and provide appropriate interventions.  As my palpation skills have grown over the years, I’ve noticed how problematic these problems can be.  Consequently, my interventions have changed to accomodate these findings.



Well, there you have it.  This list is certainly not all-encompassing.  That being said, I’d love to hear what you think are certain things we should all keep in mind that would indicate NOT manipulating certain patients.  While manipulation can be a marvelous intervention that requires a lot of skill to perform well, perhaps more skill is required to understand who NOT to manipulate.








2 Comments on “Do NOT manipulate these people!

  1. Hello Matt! Have you found any evidence or contraindications for performing manual therapy for patients with EDS in general? How would you treat musculoskeletal complaints and muscle tightness/discomfort in this population (especially if they are not sedentary) ?

    Liked by 2 people

    • Hi Aaron, I certainly do not believe all manual therapy is contraindicated for patients with EDS. Careful mobilization, functional mobilization, muscle-energy techniques are effective. In terms of specific evidence contraindicating it, I know of none. However, I have not done extensive research on that topic.

      Liked by 1 person

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