Table 2 Absolute and Relative Contraindications to Manual Therapy

Withdrawal of consent by the parent or child

Potential for litigation

Hypermobility of the joints of the child

Increased flexibility of joint structures and less muscular resistance than the adult

Long-lever and high force manual procedures

Anatomically 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 tumors

Potential 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

Reduce the incidence of potential adverse event by refraining from over treating the sensitive structures of the cervical spine

If you see an anomaly in one region, be suspicious of anomalies elsewhere.

Potential for inflammatory disruption to the atlanto-axial joint

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.

Watchful waiting first 12 weeks (rule out Arnold Chiari Syndrome)

Relative contraindication secondary to neonatal circulation and clotting factors, respiratory distress, cranial and cervical birth trauma, undiagnosed perinatal or postnatal stroke, undiagnosed hip dysplasia.