Manual Therapy in Children: Role of the Evidence-Based Clinician

Like many of you reading JMMT, I had always associated the use of manual therapy (MT) interventions with musculoskeletal complaints in adults. Although I have successfully treated orthopaedic problems in some adolescents with MT, until a recent visit to Europe it had never so much as crossed my mind to use this intervention in young children, let alone infants. However, in several Northern European countries, a significant number of our medical and physical therapy colleagues are treating infants, 0-12 months old, with MT interventions based on an etiologic model that links a great number of [non] musculoskeletal signs and symptoms to functional disorders of the upper cervical spine1.

Biedermann1 introduced a two-category diagnostic classification that proposes that birth trauma-induced upper cervical dysfunction has immediate and-–if left untreated--long-term consequences. Proposed signs and symptoms of the Kinetic Imbalance due to Suboccipital Strain (KISS) syndrome include but are not limited to torticollis, frequent vomiting, problems swallowing, scoliosis, plagiocephaly, facial asymmetry, and colic with excessive crying2. The second category of KISS-induced Dyspraxia and Dysgnosia (KIDD) syndrome has been associated with slow development of fine and gross motor skills, poor posture and equilibrium, delayed language development, restlessness, and insecurity in older children2. KISS-syndrome has even been implicated as a causative factor in attention deficit disorder (ADD)3. Biedermann1 proposed impulse manipulation of the upper cervical spine in the direction of sidebending and, at times, rotation as the treatment for both syndromes. He also noted that scientific methods normally used for verification of short-term effects of MT interventions in adults have only limited usefulness in determining the effects of the manipulative treatment of children with KISS- and KIDD-syndrome because these tests fail to capture the long-term interdependencies proposed in his etiologic model1.

We know that the newborn cervical spine is insufficiently able to protect the spinal cord, vessels, nerves, and brain from traction and rotation forces4. Koch5 reported facial and whole-body flushing, diaphoresis, crying, bradycardia, and temporary respiratory arrest in children treated for KISS-syndrome with impulse manipulation. Severe bradycardia was seen more frequently in the group of 1- to 3-month-old infants5. Perhaps relevant even despite the admitted difference in techniques applied, very similar symptoms have been reported in an infant who died after Vojta therapy to correct a congenital torticollis6. The lack of relevant outcome studies2,7, the assertion that the etiologic model does not lend itself to such studies1, and the suggested potential for adverse effects2 has understandably led to a heated debate in multiple countries on the topic of KISS and KIDD-syndrome2,7,8.

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