How ChiroMatch screens every patient.

Why we screen

Every year, millions of patients walk into chiropractic clinics without understanding their own risk profile. A 72-year-old on an anticoagulant and a bisphosphonate has a fundamentally different risk picture than a healthy 30-year-old with acute low back pain — but almost nothing in the patient's journey to the clinic surfaces that distinction before treatment begins.

ChiroMatch exists to close that gap. Our screening tool applies the clinical reasoning a careful Doctor of Chiropractic uses to assess a patient's suitability for manual therapy — before the provider ever meets them. This document records exactly what we screen for and the reasoning behind each rule.

The protocol is built on four safety pillars, plus two layers that shape the downstream provider match:

• Absolute contraindications — conditions where HVLA manipulation is not appropriate.
• Relative contraindications — conditions requiring technique modification or additional evaluation.
• Red flags — emergency or medical-first signs that route the patient away from chiropractic care toward urgent evaluation.
• Vertebrobasilar risk screening — specific posterior-circulation signs that contraindicate cervical thrust.
• Medication interactions — drug classes that change manipulation safety or modality selection.
• Modality-specific matching — mapping the 15 treatments we track to the patient's cleared profile.

Absolute contraindications to HVLA

High-velocity, low-amplitude (HVLA) manipulation is the thrust technique most associated with chiropractic care. The following conditions are treated as absolute contraindications to HVLA in the ChiroMatch screening. When any are present, the patient is routed toward lower-force alternatives — or, for the hardest absolutes, away from chiropractic entirely and toward medical evaluation.

• Osteoporosis / osteopenia. Reduced bone density substantially elevates fracture risk from thrust manipulation. Activator (instrument-assisted) adjusting, mobilization, and flexion-distraction are documented safer alternatives.
• Active or metastatic spinal cancer. Tumor-weakened vertebrae and seeding risk preclude manipulation; patients are routed to oncology and medical evaluation.
• Recent spinal fracture or surgery (within 6 months). Healing tissue should not be loaded with thrust forces; lower-force and non-spinal modalities only.
• Spinal infection / osteomyelitis. Active infection and structural compromise are absolute bars; medical evaluation required.
• Cauda equina syndrome. Surgical emergency. Any patient reporting bowel/bladder dysfunction with back pain is routed immediately to emergency care.
• Aortic aneurysm, abdominal or thoracic. Manipulation of adjacent segments risks precipitating rupture; no manipulation.
• Active bleeding disorder or untreated hemophilia. Hemorrhage risk with both thrust and aggressive soft-tissue work.
• Spinal cord myelopathy. Cord compression signs warrant surgical, not manual, evaluation.
• Ehlers-Danlos syndrome / significant hypermobility. Ligamentous laxity dramatically increases dislocation and vascular injury risk with thrust technique.
• Prior cervical artery dissection. Any documented history of vertebral or carotid artery dissection is a permanent contraindication to cervical HVLA.
• Atlantoaxial instability. Congenital (Down syndrome), post-traumatic, or inflammatory (RA) instability of the C1–C2 segment is an absolute bar to upper cervical thrust.

Relative contraindications

The following conditions don't automatically preclude chiropractic care, but require technique selection, additional imaging, or modified dosing. ChiroMatch downgrades HVLA to possible (rather than recommended) when these are present, and surfaces provider matches whose credentialed modalities fit the condition.

• Ankylosing spondylitis. Inflammatory fusion produces stress risers; thrust through fused segments risks fracture. Low-force and soft-tissue-first approaches preferred.
• Confirmed herniated disc with radiculopathy. Flexion-distraction and motorized spinal decompression are indicated; rotational HVLA is removed from the recommended set.
• Spinal stenosis. Extension loading must be avoided; flexion-based approaches and decompression take priority.
• Spondylolisthesis. Grade and stability of the slip determine suitable techniques; flexion-distraction is frequently preferred over rotational thrust.
• Rheumatoid arthritis, particularly cervical. Atlantoaxial instability must be ruled out before any cervical care, ideally with imaging.
• Uncontrolled hypertension. Blood pressure control should precede positional changes and cervical rotation; referral to medical management where needed.
• Pregnancy. Positioning modifications and technique adjustments (Webster technique familiarity, avoiding supine-prone loading) are indicated.
• Spinal hardware or joint replacement. Levels above and below fusion require careful assessment; manipulation of fused segments is avoided.
• Fibromyalgia / widespread pain sensitization. Treatment approach and dosing are modified; low-force and graduated exposure techniques preferred.

Red flags

Certain signs indicate a condition that falls outside the chiropractic scope of practice and warrants immediate medical evaluation. ChiroMatch does not surface provider matches to patients with active red flags; the screening result directs them to emergency or primary care.

• Loss of bowel or bladder control. Cauda equina syndrome — surgical emergency.
• Bilateral leg numbness or weakness. Suggests central neurological compromise; urgent evaluation.
• Saddle anesthesia. Classic cauda equina presentation.
• Rapidly progressive neurological loss. Worsening weakness or numbness over hours or days suggests cord compression, vascular event, or expanding lesion.
• Fever with back or neck pain. Raises suspicion for spinal infection or meningitis.
• Unexplained weight loss with back pain. Malignancy workup until proven otherwise.
• Significant recent trauma preceding pain. Fracture screening (often imaging) required before any spinal loading.
• Severe, constant night pain unrelieved by position change. Inflammatory, infectious, or neoplastic pathology until ruled out.

These categories align with standard red-flag screening for serious spinal pathology documented in systematic reviews of low back pain triage [1]. The intent of the screen is not to diagnose the underlying cause, but to route the patient out of the chiropractic pathway and into medical evaluation.

Vertebrobasilar insufficiency screening

Cervical HVLA carries the most scrutinized risk in the chiropractic literature: vertebrobasilar artery dissection (VAD) and associated posterior circulation stroke. While the causal relationship between cervical manipulation and VAD has been examined in large population-based studies — most notably Cassidy et al. (Spine, 2008), which found no statistically significant increased risk of vertebrobasilar stroke following chiropractic care compared to matched primary care visits [2] — the profession's standard of care is to screen for posterior-circulation symptoms before any cervical thrust, regardless of population-level attributable risk.

ChiroMatch screens for the 5 Ds and 3 Ns, a widely-taught clinical mnemonic for posterior-circulation signs. When any are present, the screen downgrades cervical HVLA; when two or more are present, cervical thrust is contraindicated and the patient is routed to non-cervical-thrust modalities.

Medication interactions

Certain drug classes materially change manipulation safety or modality selection. ChiroMatch screens medications against the following flag categories:

Anticoagulants and antiplatelets

• Warfarin, apixaban, rivaroxaban, dabigatran — elevated bleeding and bruising risk. Cervical HVLA deprioritized; aggressive soft-tissue techniques (IASTM, ART, cupping with suction) avoided.
• Clopidogrel — antiplatelet use often signals prior cardiovascular event; combination risks of hemorrhage and pre-existing vascular disease drive the same downgrade.

Bone-affecting medications

• Long-term corticosteroids (prednisone, methylprednisolone, dexamethasone) — reduced bone density and tissue fragility affect technique selection.
• Bisphosphonates (alendronate, risedronate, zoledronic acid) — prescribed for osteoporosis, which is itself an HVLA contraindication.

Inflammatory-disease medications

• Methotrexate and biologic DMARDs (adalimumab, etanercept, infliximab) — imply active rheumatoid arthritis; cervical screening for atlantoaxial instability is required before any cervical care.

Other high-impact flags

• Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) — FDA black-box warning for tendinopathy and tendon rupture [3]. Aggressive IASTM, ART, shockwave, and heavy stretching contraindicated.
• Chronic opioids — altered pain perception; lower-force techniques and rehab emphasis preferred over high-force approaches.
• Active chemotherapy — immune compromise and bone-metastasis risk; manipulation contraindicated.
• Implanted electrical devices (pacemakers, ICDs, defibrillators) — electrical modalities (e-stim, some therapeutic ultrasound protocols) are contraindicated; cold laser and manual therapy remain safe.

Modality matching logic

Once contraindications, red flags, vertebrobasilar signs, and medications are screened, ChiroMatch matches the patient to the subset of chiropractic modalities that are clinically appropriate for their profile. Each modality is tagged with its own contraindication rules; a provider match is surfaced only when the provider offers at least one modality on the patient's recommended list.

The modality set includes: HVLA manipulation, Activator / instrument-assisted adjusting, joint mobilization, flexion-distraction, motorized spinal decompression, shockwave therapy, cold laser (LLLT), cupping, IASTM / Graston, Active Release Technique (ART), dry needling, corrective exercise and rehab, soft-tissue massage, therapeutic ultrasound, and kinesiotaping. A plain-language description of each is available in the modality library.

Representative matching rules:

• If osteoporosis is flagged, Activator and mobilization replace HVLA as the primary adjustment options.
• If a confirmed disc herniation with radiculopathy is present, flexion-distraction and motorized decompression are prioritized; rotational HVLA is removed.
• If the patient is on fluoroquinolones, IASTM, ART, and shockwave are removed from the recommended list.
• If a pacemaker or ICD is present, electrical modalities are removed; cold laser and manual therapy remain.
• If a prior cervical artery dissection is reported, cervical HVLA is permanently contraindicated; Activator, mobilization, and soft-tissue approaches remain.
• If the patient reports two or more VBI symptoms, cervical HVLA is contraindicated; non-cervical-thrust modalities are surfaced.

Scope and limits

ChiroMatch does not diagnose, treat, or replace professional medical evaluation. The screening is a pre-visit triage tool, not a substitute for a full clinical examination. Every patient matched through ChiroMatch still receives the provider's own clinical assessment at the first visit, including any functional tests (range of motion, orthopedic tests, neurological exam, cervical vascular testing) that cannot be reproduced through an intake survey.

The tool is also honest about directionality. If a patient's profile suggests that chiropractic is not the appropriate first stop — for example, in the presence of a red flag — we route them to medical evaluation. If the profile suggests a patient may be better served by a physical therapist, we say so. The goal is clinical appropriateness, not network volume.

Self-reported medical history carries inherent limitations. Patients may under- or over-report medications, may not know their imaging findings, and may miss contraindication-relevant conditions. The screen mitigates this with broad, plain-language question framing and by erring toward caution — downgrading rather than upgrading recommendations when uncertainty is present — but it cannot substitute for records the provider obtains at intake.

Authorship and review

The ChiroMatch screening logic was designed by a licensed Doctor of Chiropractic practicing in California. It draws on contraindication frameworks taught in accredited DC programs, clinical guidelines from the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), and peer-reviewed literature on manipulation safety, red-flag screening, and pharmacological interactions relevant to manual therapy.

This methodology is a living document. Versioning and revision dates are tracked at the top of the page. We actively welcome correction, critique, and citation suggestions from clinicians — chiropractors, physical therapists, primary care physicians, orthopedists, neurologists, and researchers. Feedback goes directly to the clinical author.

References

The following represent the most directly-cited literature informing the screening frameworks above. A broader working bibliography — covering modality-specific literature for flexion-distraction, Activator, motorized decompression, shockwave, cold laser, dry needling, and rehab — is maintained by the clinical author and available on request.