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Table 2

Absolute and Relative Contraindications to Manual Therapy


Withdrawal of consent by the parent or childPotential for litigation

Hypermobility of the joints of the childIncreased flexibility of joint structures and less muscular resistance than the adult

Long-lever and high force manual proceduresAnatomically immature: no joint "lockup."

Occipito-atlantal &
Atlanto-axial instability
Common in children with Down Syndrome, Juvenile Rheumatoid Arthritis, Marquio's, Klippel-Feil Syndrome

Brain or spinal tumorsPotential of neurologic damage or vascular compromise by the introduction of specific or non-specific force due to the pathophysiology or anatomical position of the tumor;
immediate referral to appropriate healthcare provider

Active metaphyseal
growth tissue
Zone of provisional calcification- the transitional region between cartilage and newly formed metaphyseal bone is subject to separation and avascular necrosis when subject to force


Cervical Spine adjustmentsReduce the incidence of potential adverse event by refraining from over treating the sensitive structures of the cervical spine

Down Syndrome or other congenital anomaliesIf you see an anomaly in one region, be suspicious of anomalies elsewhere.

Recent upper respiratory tract virusPotential for inflammatory disruption to the atlanto-axial joint

Symptoms and signs incongruous with
palpatory findings.
Diagnosis requires corroboration of signs and symptoms with exam findings (including palpatory findings). When they are incongruous, further diagnostic studies should be ordered to rule out any potentially serious underlying pathology.

History of sleep-disorder in infants <12 weeks of ageWatchful waiting first 12 weeks (rule out Arnold Chiari Syndrome)

Inversion of neonate or young infantRelative contraindication secondary to neonatal circulation and clotting factors, respiratory distress, cranial and cervical birth trauma, undiagnosed perinatal or postnatal stroke, undiagnosed hip dysplasia.