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Dosage and timing is important in considering relative contra-indications. A severe reaction may settle in a day or so to a situation of a considerable improvement in signs and symptoms. If the same patient were to be seen during that phase of soreness from treatment, the practitioner might have wrongly assumed that he had approached the earlier

Relative contra-indications 27 treatment wrongly. For this reason, daily

treatment is generally to be discouraged. If the operator is prepared to perform only minimal treatment on each occasion and is ready to accept the possibility of an accumu- lating adverse reaction, then this may be acceptable. There may be reasons of urgency due to impending travel, sporting event or important life event that make daily treat- ment essential. From experience, I would say that absolute specificity is necessary in these cases. Short, purposeful treatment, aimed at one specific target tissue on each visit, seems to produce the best result without excessive reaction.

DISCS

The vexed question of whether to manipulate in the presence of evidence of disc herniation or prolapse will be the subject of discussion as long as manual therapy is in use. The use of magnetic resonance imaging (MRI) has shown that many cases with disc disease have been manipulated with great success. Had the MRI been performed earlier and a decision taken not to manipulate, the patient may not have had such a good result! Once again each case is individual and all factors must be considered in coming to a conclusion about the best approach. In the author's experi- ence, providing there are no signs of extreme nerve pressure, either before treatment, or when applying the technique positions slowly, then disc prolapse is a sign for caution, not abandonment. Powerful rotatory techniques in the presence of radiological evidence of large osteophytes are best avoided for fear of nerve impingement. Forced flexion tech- niques are unwise where there is evidence of disc prolapse in the lumbar spine as increase of prolapse can occur.

INFLAMMATION

A joint that is acutely inflamed is best left to rest for a while until treatment is com-

menced. Over-zealous attempts to force a joint to become fully functional in this situ- ation will often lead to extreme reactions. Inflammation due to ankylosing spondylitis or Reiter's disease is a situation where excess- ive active treatment is best avoided. Gentle settling techniques can be of use to reduce the irritability enough so more powerful procedures can be used later. The timing and selection of when to treat can only be gained by thought, consideration and experience.

ILLNESS

Although the original purpose of osteopathic treatment was for the treatment of systemic disease through the medium of the musculo- skeletal system, osteopathic medicine of this type is not as widely used as osteopathic treatment for mechanical dysfunction syn- dromes. This may not be the choice of work for many practitioners, but is governed by self-selection of patients. Cases where there is evidence of systemic disease can be treated either as a complement to conventional med- ical care, or as an alternative. If a patient is unwell systemically and is seeking treatment for the systemic disorder there will be a difference in approach from the same patient asking for treatment for a mechanical dis- order. A patient who has influenza, for example, may not get much help from treat- ment for their low back condition as their muscles and connective tissues may not be able to take the benefit of the treatment. The general illness will be making the system weak and normal mechanical treatment will often be wasted. It will tire the patient and the tissues will often be reactive and ultra- sensitive. This would then be a reasonable contra-indication to treatment at that time. Some diabetics may find their insulin balance disturbed by osteopathic treatment. Provid- ing they are warned to keep a close check on their glucose levels, this should not be a problem.

PREGNANCY

During pregnancy, any technique that might jeopardize the health of the mother or develop- ing infant must be avoided. The chief danger, of producing a spontaneous abortion, occurs in the first trimester. The possibility of pro- ducing a miscarriage with properly applied osteopathic care is so slight as to be almost discounted; nevertheless, in a patient with a history of spontaneous abortion care is essen- tial. Statistically, the highest incidence of miscarriage is in the 12th and 16th weeks of pregnancy. These are times when treatment is best withheld in such a case. This is not because it could cause a miscarriage, but more because there is the possibility of being accused of producing it. Treatment during the later stages of pregnancy will necessitate techniques modified somewhat from normal methods. Hormonal relaxation in tissues makes most osteopathic procedures easier to complete and light techniques can be most effective. With sufficient care a patient can be treated right through her pregnancy, and in certain cases osteopathic care has even been given during parturition itself with benefit. The B S O has an expectant mothers clinic that undertakes extensive work on pregnant women with excellent results.