Certain people should avoid chiropractic spinal manipulation entirely, while others need modified techniques or medical clearance first. The highest-risk groups include people with connective tissue disorders like Ehlers-Danlos syndrome or Marfan syndrome, those with advanced inflammatory spinal diseases, anyone with active spinal infections or tumors affecting bone, and people experiencing neurological emergency symptoms. Understanding which category you fall into can help you make a safer decision.
Connective Tissue Disorders
People with conditions like Marfan syndrome or Ehlers-Danlos syndrome face unique risks from traditional high-velocity spinal adjustments. These disorders weaken the connective tissue throughout the body, including the walls of blood vessels and the ligaments that stabilize the spine. The vertebral arteries, which run through the neck vertebrae and supply blood to the brain, are especially vulnerable. In people with connective tissue diseases, these arteries are more prone to tearing (dissection), which can cause a stroke. Vertebral artery dissections occur in both men and women at an average age of 40 and are more common in people with these conditions.
That said, the picture isn’t entirely black and white. Case reports in the chiropractic literature describe patients with Ehlers-Danlos syndrome who improved with low-force techniques, reducing both pain and their use of anti-inflammatory medications. The key distinction is between traditional high-velocity manipulation, which involves a quick thrust, and gentler approaches that avoid pushing hypermobile joints beyond their already excessive range. If you have a connective tissue disorder and want to explore chiropractic care, the conversation should center on whether a practitioner is experienced with low-force methods and understands the specific fragility of your tissues.
Spinal Tumors and Cancer That Has Spread to Bone
Manipulation of any spinal segment affected by a tumor is absolutely contraindicated. Cancer that has spread to the spine weakens bone quality, and the force of a manual adjustment can cause fractures or, worse, compress the spinal cord. If you have a history of cancer and develop new back or neck pain, metastasis needs to be ruled out before any hands-on spinal treatment.
Cancer itself is considered a relative contraindication, meaning it doesn’t automatically disqualify you from all chiropractic care. Patients whose bones aren’t compromised may still benefit from spinal manipulation, mobilization, soft tissue work, and rehabilitative exercises. Chiropractors can play a role in interdisciplinary cancer care, but the treatment plan has to be tailored around imaging results that confirm where the cancer is and isn’t affecting the skeleton.
Advanced Ankylosing Spondylitis
Ankylosing spondylitis is an inflammatory condition that gradually fuses the vertebrae together. In advanced stages, the spine becomes rigid and brittle, essentially turning into a single long bone that can fracture with relatively little force. The 2019 guidelines from the American College of Rheumatology and the Spondylitis Association of America specifically recommend against spinal manipulation for advanced ankylosing spondylitis, citing both a lack of evidence for benefit and evidence of potential severe harm, including acute fracture.
Earlier stages of the disease present a more nuanced situation, but the fused or fusing spine is the core concern. If you’ve been diagnosed with ankylosing spondylitis or a related condition in the spondyloarthritis family, your rheumatologist should be part of any decision about manual therapy.
Active Spinal Infections
Spinal infections like vertebral osteomyelitis (infection of the spinal bones) or discitis (infection of the discs between vertebrae) make the affected structures fragile and inflamed. Applying manual force to an infected segment risks spreading the infection or causing structural collapse. These infections typically cause persistent back pain that worsens over time, often accompanied by fever, and the pain tends not to improve with rest. Diagnosis requires imaging, usually an MRI, along with blood tests and sometimes a biopsy. Any chiropractic treatment should be postponed until the infection is fully treated and cleared.
Neurological Emergencies
Some symptoms that bring people to a chiropractor are actually signs of a neurological emergency requiring immediate medical care, not manual treatment.
Cauda equina syndrome is the most critical example. This occurs when the bundle of nerves at the base of the spinal cord becomes severely compressed, usually by a large disc herniation. The warning signs include numbness in the groin and inner thighs (sometimes called saddle numbness), loss of bladder or bowel control, difficulty starting urination or a sudden inability to hold it, and weakness in both legs. This is a surgical emergency. Delayed treatment, even by hours, can result in permanent nerve damage including lasting incontinence and sexual dysfunction. If you’re experiencing these symptoms, go to an emergency room, not a chiropractor’s office.
Similarly, certain neck symptoms signal possible damage to the blood vessels supplying the brain. These include sudden, severe neck or head pain unlike anything you’ve experienced before, numbness on one side of the face, visual disturbances like blind spots, difficulty with balance or coordination, and dizziness with slurred speech. These can indicate a vertebral artery problem or stroke in progress. High-velocity neck manipulation in this scenario could be catastrophic.
Severe Osteoporosis
Osteoporosis thins and weakens bones, making them more susceptible to fracture under mechanical stress. The spine is one of the most common fracture sites in people with osteoporosis, and the compressive and rotational forces of a traditional adjustment can be enough to crack a weakened vertebra. People with known osteoporosis, particularly postmenopausal women and older adults who haven’t had a bone density scan, should discuss their bone health with a doctor before pursuing spinal manipulation. As with connective tissue disorders, lower-force techniques may be an option for some patients, but that decision requires knowing your actual bone density status.
Unstable Fractures and Recent Spinal Surgery
Any existing spinal fracture that hasn’t healed, or a spine that’s been recently operated on, is off-limits for manipulation. The hardware, healing bone, and surrounding tissues need time to stabilize. Chiropractic care after spinal surgery isn’t permanently ruled out. The case literature includes patients who returned to chiropractic treatment months after procedures like decompression surgery for cauda equina syndrome. But the timing and approach need to account for what was done surgically and how recovery is progressing.
What About Blood Thinners?
You might assume that being on blood-thinning medications automatically rules out chiropractic care. The evidence is more reassuring than you’d expect. A study of 275 spinal procedures performed on patients continuing their blood thinners found zero cases of serious bleeding complications. That study looked at spinal injections rather than manual adjustments specifically, but the broader point holds: blood thinners alone don’t appear to be an absolute contraindication. They do warrant a conversation with both your prescribing doctor and your chiropractor, since the theoretical risk of bruising or bleeding in spinal tissues still exists.
Common Conditions That Don’t Increase Risk
It’s worth noting what doesn’t appear to raise your risk. Research indicates that people with atherosclerotic vascular disease, including those with high blood pressure or diabetes, do not have an increased risk of stroke after spinal manipulation compared to the general population. These conditions affect blood vessels throughout the body, but they don’t seem to make the vertebral arteries more vulnerable to the specific forces involved in neck adjustments. This distinction matters because many people with garden-variety cardiovascular risk factors assume they can’t see a chiropractor, when the actual concern is about connective tissue integrity rather than plaque buildup.