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Définition de l’ajustement chiropratique

Selon L’Organisation Mondiale de la Santé (L’OMS est l’autorité directrice dans le domaine de la santé des travaux ayant un caractère international au sein du système des Nations Unies), l’ajustement chiropratique se définie comme suit: « Tout acte chiropratique utilisant essentiellement force, pression, direction, amplitude et vélocité contrôlées, qui est appliqué à des articulations et aux tissus adjacents. Les chiropraticiens recourent à ces actes pour agir sur la fonction articulaire et neurophysiologique. »

Les ajustements chiropratiques administrés de manière efficiente et appropriée sont sûrs et indispensables pour enrayer et soigner un certain nombre de problèmes de santé. Les protocoles manuels employés en chiropratique présentent toutefois certains risques et contre‐indications connus.

Pourquoi l’ajustement chiropratique est perçu comme dangereux ?

Parce qu’en général, les gens ont de la difficulté à faire la nuance entre ce qui est dangereux de ce qui est risqué! Le danger se définit comme étant toute source potentielle de dommage, de préjudice ou d’effet nocif à l’égard d’une personne dans certaines situations, alors que le risque se définit comme la probabilité qu’une personne subisse un préjudice ou des effets nocifs pour sa santé en cas d’exposition à un danger. L’évaluation des risques est le processus qui consiste à déterminer les dangers, examiner ou à estimer les risques associés à un danger et identifier les moyens appropriés pour éliminer ou maîtriser ces risques.

Pour faire une analogie simple à comprendre, il existe un risque qu’un avion s’écrase sur votre maison mais il n’est pas dangereux d’y habiter puisque les chances que cela se produise, statistiquement, sont à peu près nulles.

Donc, il existe un risque ou une probabilité statistique connue, suite à un ajustement chiropratique,  qu’une personne subisse un préjudice ou des effets nocifs pour sa santé. Mais cette probabilité est si statistiquement minuscule, que l’ajustement chiropratique n’est pas dangereux quand il est prodigué par un docteur en chiropratique qui, par sa formation universitaire exhaustive dans le domaine du diagnostic musculosquelettique, lui permet de considérer l’existence ou non de contre-indications à l’ajustement et de l’utiliser ou non selon son jugement clinique.

Les contre‐indications de l’ajustement chiropratique vont de la non‐indication lorsque la manipulation ou la mobilisation n’ont aucun effet positif sans toutefois avoir d’effet négatif, à la contre‐indication absolue lorsqu’elles procurent un danger réel pour l’existence du patient. Dans grand nombre de cas, l’ajustement chiropratique peut être contre‐indiqué sur une partie de la colonne vertébrale et avoir des effets bénéfiques dans une autre région. Il ne faut pas perdre de vue qu’en plus d’utiliser l’ajustement chiropratique, le chiropraticien dispose d’un vaste répertoire de techniques manuelles à savoir, la traction manuelle, l’étirement passif, le massage, la compression ischémique des points gâchette et des techniques réflexes dédiées à simplifier la douleur et les spasmes musculaires.

Pour mettre en perspective les risques associés à différentes situations

  • David Ropeik, un instructeur de la communication des risques à l’Université Harvard, conclut en 2006 que les chances de mourir dans un accident d’avion sont de une sur 11 millions;
  • Selon Ropeik, les chances de mourir dans un accident de voiture sont de une sur 5 000;
  • Les chances de mourir dans une attaque de requin sont de une sur 3,1 millions;
  • Selon le Dr Scott Haldeman DC, MD, PhD, FRCP(C), FCCS(C), FAAN, professeur émérite à l’Université de Californie, suite à une étude menée sur une période de 10 ans, il y aurait une complication grave sur 5.85 millions d’ajustements chiropratiques;
  • Un voyageur pourrait voler, en moyenne, une fois par jour pour 4 millions d’années avant de succomber à un accident d’avion mortel.

Chaque intervention thérapeutique comporte un risque

Malheureusement, pour la manipulation vertébrale, certaines personnes mal informées ou, pire encore, mal intentionnées, laissent parfois courir des contre-vérités, pour faire peur aux patients.

Voici la liste des contre-indications absolues:

  1. anomalies telles que hypoplasie de l’apophyse odontoïde, instabilité de l’os odontoïde, etc.
  2. fracture aiguë
  3. tumeur intra‐médullaire
  4. infections aiguës telles que ostéomyélite, spondylodiscite et tuberculose vertébrale
  5. tumeur méningée
  6. hématomes intramédulaires ou intracanaliculaires
  7. tumeur maligne de la colonne vertébrale
  8. hernie discale franche avec déficit neurologique progressif
  9. invagination basilaire de la colonne cervicale
  10. malformation d’Arnold Chiari au niveau des cervicales supérieures
  11. dislocation d’une vertèbre
  12. formes agressives de tumeurs bénignes telles que kyste anévrismal des os, tumeur à cellules géantes, ostéoblastome bénin ou ostéome ostéoïde
  13. appareil de fixation/réduction interne
  14. lésion néoplastique d’un muscle ou d’autres tissus mous
  15. signes de Kernig ou de Lhermitte positifs
  16. hypermobilité congénitale généralisée
  17. signes d’instabilité
  18. syringomyélie
  19. hydrocéphalie dont l’étiologie n’est pas connue
  20. diastématomyélie
  21. syndrome de la queue de cheval

Réduire le risque au minimum les risques associés à l’ajustement chiropratique ou la manipulation vertébrale

, L’ajustement chiropratique, Clinique TAG

Imagerie médicale

Comme vous pouvez le constater, il s’agit ici de conditions qu’on rencontre peu fréquemment chez nos patients mais qui nécessitent, en général, l’utilisation d’imagerie médicale comme la radiographie ou la résonance magnétique(IRM) afin de détecter ces contre-indications afin de réduire le risque statistique au minimum.

Conclusion

L’ajustement chiropratique ou la manipulation vertébrale n’est pas dangereux, quand il est effectué par un professionnel de la santé compétent, comme le docteur en chiropratique.

Voir une étude récemment publiée: « No Evidence Exists Between Chiropractic Care and Cervical Artery Dissection » 
Studin., Owens W., Edwards J. (2019) No Evidence Exists Between Chiropractic Care and Cervical Artery Dissection, The American Chiropractor 41(10) pgs. 28, 30-32 

 

 

Études publées récemment concernant l’ajustement chiropratique

Spinal Manipulation Therapy: Is It All About the Brain?
A Current Review of the Neurophysiological Effects of Manipulation

Journal of Integrative Medicine 2019 (May 9) [Epub] ~ FULL TEXT

In this article, we reviewed the relevance of various neurophysiological theories with respect to the findings of mechanistic studies that demonstrated neural responses following spinal manipulation. This article also discussed whether these neural responses are associated with the possible neurophysiological mechanisms of spinal manipulation. The body of literature reviewed herein suggested some clear neurophysiological changes following spinal manipulation, which include neural plastic changes, alteration in motor neuron excitability, increase in cortical drive and many more. However, the clinical relevance of these changes in relation to the mechanisms that underlie the effectiveness of spinal manipulation is still unclear. In addition, there were some major methodological flaws in many of the reviewed studies. Future mechanistic studies should have an appropriate study design and methodology and should plan for a long-term follow-up in order to determine the clinical significance of the neural responses evoked following spinal manipulation.

A Replication of the Ernst Study
“Adverse Effects of Spinal Manipulation: A Systematic Review”

Chiropractic & Manual Therapies 2012 (Sep 21) ~ FULL TEXT

The number of errors or omissions in the 2007 Ernest paper, reduce the validity of the study and the reported conclusions. The omissions of potential risk factors and the timeline between the adverse event and SMT could be significant confounding factors. Greater care is also needed to distinguish between chiropractors and other health practitioners when reviewing the application of SMT and related adverse effects.

The Biomechanics of Spinal Manipulation
J Bodyw Mov Ther. 2010 (Jul);   14 (3):   280–286 ~ FULL TEXT

Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the « para-physiological » zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.

Does Facet Joint Inflammation Induce Radiculopathy?
An Investigation Using a Rat Model of Lumbar Facet Joint Inflammation

Spine 2007 (Feb 15);   32 (4):   406–412

The association between lumbar facet joint inflammation and radiculopathy was investigated using behavioral, histologic, and immunohistochemical testing in rats. Both mechanical and chemical factors have been identified as important for inducing radiculopathy. In lumbar spondylosis, facet joint osteophytes may contribute to nerve root compression, which may induce radiculopathy. Furthermore, inflammation may occur in the facet joint, as in other synovial joints. Inflamed synovium may thus release inflammatory cytokines and induce nerve root injury with subsequent radiculopathy. (In this study) when inflammation was induced in a facet joint, inflammatory reactions spread to nerve roots, and leg symptoms were induced by chemical factors. These results support the possibility that facet joint inflammation induces radiculopathy.

Increased Multiaxial Lumbar Motion Responses During Multiple-Impulse
Mechanical Force Manually Assisted Spinal Manipulation

Chiropractic & Osteopathy 2006 (Apr 6);   14 (1):   6 ~ FULL TEXT

Knowledge of the vertebral motion responses produced by impulse-type, instrument-based adjusting instruments provide biomechanical benchmarks that support the clinical rationale for patient treatment. Our results indicate that impulse-type adjusting instruments that deliver multiple impulse SMTs significantly increase multi-axial spinal motion.

A Revised Definition of Manipulation
J Manipulative Physiol Ther 2005 (Jan);   28 (1): ~ FULL TEXT

We write this commentary to address a problem that we feel exists in the description of chiropractic theory regarding the definition of spinal manipulation. We will first outline the background of the problem and then state the problem as it exists currently. We will then propose a revised definition to more accurately describe spinal manipulation.

Cavitation Emptor:   Tracking the Holy Grail of Manipulation
Dynamic Chiropractic – September 13, 2004

From Roston and Haynes’ classic force-displacement curves of the third metacarpophalangeal joint in 1947, [1] through Sandoz’ application of this phenomenon to manipulation, [2] through the criteria established by Mierau, Cassidy, et al., in 1988 to operationally differentiate manipulations from mobilizations, [3] chiropractors have held the audible release to be a virtual hallmark (if not a holy grail) of a successful manipulation. Indeed, an elegant model proposed by Raymond Brodeur, one of FCER’s Peter Bommarito Residency Award-holders, has suggested [4] that the cavitation process provides a simple means for initiating reflex patterns associated with a manipulation. [5–7]

An Investigation into the Validity of Cervical Spine Motion Palpation
Using Subjects with Congenital Block Vertebrae as a ‘Gold Standard’

BMC Musculoskelet Disord 2004 (Jun 15);   5 (1):   19 ~ FULL TEXT

This study indicates that relatively inexperienced examiners are capable of correctly identifying inter-segmental fixations (CBV) in the cervical spine using 2 commonly employed motion palpation tests. The use of a ‘gold standard’ (CBV) in this study and the substantial agreement achieved lends support to the validity of motion palpation in detecting major spinal fixations in the cervical spine.

Degenerative Changes Following Spinal Fixation in a Small Animal Model
J Manipulative Physiol Ther 2004 (Mar);   27 (3):   141–154 ~ FULL TEXT

Fixed segments had more degenerative changes than nonfixed segments for all Z joint parameters (ANOVA, P <.0001). Osteophyte formation and ASD were directly dependent on duration of fixation. These findings indicate that fixation (hypomobility) results in time-dependent degenerative changes of the zygapophysial joints.

Neuromechanical Characterization of in vivo Lumbar Spinal Manipulation.
Part I. Vertebral Motion

J Manipulative Physiol Ther. 2003 (Nov);   26 (9):   567–578 ~ FULL TEXT

In vivo kinematic measurements of the lumbar spine during the application of SMTs over the FJs and SPs corroborate previous spinous process measurements in human subjects. Our findings demonstrate that PA, ML, and AX spinal motions are coupled and dependent on applied force and contact point.

The Effects of Mild Compression on Spinal Nerve Roots with Implications for Models of
Vertebral Subluxation and the Clinical Effects of Chiropractic Adjustment

Journal of Vertebral Subluxation Research 2001 (May);   4 (2):   1–13

There is evidence of nerve compression at the level of the intervertebral foramen (IVF) occurring anywhere from 15.4% to 78% of levels inspected. Most of the spines inspected were already prescreened to eliminate those that were definitely known to have nerve compression problems. Pressures as little as 10 mm Hg can alter the nerve root and dorsal root ganglion’s abilities to function normally. The concept that a vertebral subluxation can induce pressure increases at the level of the IVF is supported by the literature. This increase, though seemingly mild, is enough to alter nerve function. The garden hose theory or hard bone – soft nerve explanation of vertebral subluxation is considered by some to be archaic but appears to be a valid entity at least in the lower cervical spine. More research is needed to decipher the susceptibility to mild pressure increases throughout the spine.

Biomechanics of Spinal Manipulative Therapy
Spine J. 2001 (Mar);   1 (2):   121–130 ~ FULL TEXT

There currently are a number of named systems of manual procedures. No current triage system is available that predicts which patient has the greater likelihood of benefiting from manual treatment or the procedure type. The biomechanical parameters of SMT form a systematic characterization of manual procedures. Such a system may be used in future studies to test hypotheses of treatment effect from quantitatively defined procedures.

Manual Healing Diversity and Other Challenges to Chiropractic Integration
J Manipulative Physiol Ther 2000 (Mar);   23 (3):   202–207 ~ FULL TEXT

Chiropractic has made significant strides in establishing itself as a leading contender for integration in the emerging health care system.  However, recent articles in prominent medical journals illustrate key issues that must be resolved for chiropractic to fully establish itself within the new health care model.  Manual therapy diversity and the corollary question of whether chiropractic care should be defined solely in terms of the high velocity-low amplitude (HVLA) adjustment, are issues in need of urgent attention and analysis. Other problematic areas affecting chiropractic’s integration into the health care mainstream include research methodology issues, treatment of visceral disorders, and professional relationships.

Neurologic Effects of the Adjustment
J Manipulative Physiol Ther. 2000 (Feb);   23 (2):   112–114 ~ FULL TEXT

This paper discusses the several theories pertaining to the chiropractic adjustment, including the nerve compression theory, reflex theories, and pain relief theories. There is now sufficient scientific research to consider these theories reasonable working models to explain the effects of the adjustment but insufficient to consider them valid.

Reflex Effects of Subluxation: The Autonomic Nervous System
J Manipulative Physiol Ther 2000 (Feb);   23 (2):   104–106 ~ FULL TEXT

Recent neuroscience research supports a neurophysiologic rationale for the concept that aberrant stimulation of spinal or paraspinal structures may lead to segmentally organized reflex responses of the autonomic nervous system, which in turn may alter visceral function.

Spinal Pain Syndromes:
Nociceptive, Neuropathic, and Psychologic Mechanisms

J Manipulative Physiol Ther 1999 (Sep);   22 (7):   458–472 ~ FULL TEXT

Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.

Dysafferentation:   A Novel Term to Describe the Neuropathophysiological
Effects of Joint Complex Dysfunction. A Look at Likely Mechanisms
of Symptom Generation

J Manipulative Physiol Ther 1998 (May);   21 (4):   267–280 ~ FULL TEXT

Joint complex dysfunction should be included in the differential diagnosis of pain and visceral symptoms because joint complex dysfunction can often generate symptoms which are similar to those produced by true visceral disease.

Somatic Dysfunction and the Phenomenon of Visceral Disease Simulation:
A Probable Explanation for the Apparent Effectiveness of Somatic Therapy
in Patients Presumed to be Suffering from True Visceral Disease

J Manipulative Physiol Ther 1995 (Jul);   18 (6):   379–397 ~ FULL TEXT

The proper differential diagnosis of somatic vs. visceral dysfunction represents a challenge for both the medical and chiropractic physician. The afferent convergence mechanisms, which can create signs and symptoms that are virtually indistinguishable with respect to their somatic vs. visceral etiologies, need to be appreciated by all portal-of-entry health care providers, to insure timely referral of patients to the health specialist appropriate to their condition. Furthermore, it is not unreasonable that this somatic visceral-disease mimicry could very well account for the « cures » of presumed organ disease that have been observed over the years in response to various somatic therapies (e.g., spinal manipulation, acupuncture, Rolfing, Qi Gong, etc.) and may represent a common phenomenon that has led to « holistic » health care claims on the part of such clinical disciplines.

Biological Rationale for Possible Benefits of Spinal Manipulation
Chapter X;   AHCPR Publication No. 98–N002:   December 1997 ~ FULL TEXT

Manipulation is a form of treatment that dates to antiquity and has been practiced in some form in most cultures since that time (Lomax, 1997; Anderson, 1992). One of the first theories related to manipulation might be the statement attributed to Hippocrates: « Look to the spine as the cause of disease. » The theories of the early pioneers of chiropractic were firmly grounded in notions that had been widely held in the 1800s, particularly the idea of « spinal irritability » and its correlation with disease (Lomax, 1997; Terrett, 1987). Theories on the nature of the primary spinal disorder amenable to manipulation and on the mechanisms of action of spinal manipulation abound within chiropractic, osteopathy, physiotherapy, and manual medicine. The original chiropractic theory suggested that misaligned spinal vertebrae interfered with nerve function, ultimately resulting in altered physiology that could contribute to pain and disease. In recent decades, chiropractic theories about how mechanical spinal joint dysfunction might influence neurophysiology have undergone significant modification and reflect more contemporary views of physiology (Gatterman, 1995).

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