Common Manual Therapy Practices in the Netherlands for Infants With Upper Cervical Dysfunction: A Prospective Cohort Study

Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists

INTRODUCTION

An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.

METHOD

A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).

RESULTS

Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined.

CONCLUSION

Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Parents' and healthcare professionals' perspectives on manual therapy in infants: A mixed-methods study

OBJECTIVES

Manual therapy in infants is embedded in Dutch healthcare despite inconsistent evidence and ongoing debate about its safety and merits. This study examines decision-making in manual therapy in infants and explores parents' and healthcare professionals' perspectives on this treatment approach.

METHODS

This mixed-methods study consisted of an online survey among manual physiotherapists and paediatric physiotherapists exploring decision-making on manual therapy in infants and interprofessional collaboration. These data prompted further exploration and were combined with data collected with semi-structured interviews exploring parents' and healthcare professionals' perspectives. Interviews were analysed using an inductive content analysis approach.

RESULTS

607 manual physiotherapists and 388 paediatric physiotherapists completed the online survey; 45% and 95% indicated they treat infants, respectively. Collaboration was reported by 46% of manual physiotherapists and 64% of paediatric physiotherapists for postural asymmetry, positional preference, upper cervical dysfunction, excessive crying, anxiety or restlessness. Reasons to not treat or collaborate were: limited professional competence, practice policy, not perceiving added value, lack of evidence and fear of complications. Analysis of interviews with 7 parents, 9 manual physiotherapists, 7 paediatric physiotherapists, 5 paediatricians and 2 maternity nurses revealed that knowledge and beliefs, professional norms, interpersonal relation, treatment experiences and emotions of parents influenced attitudes and decision-making towards choosing for manual therapy in infants.

CONCLUSION

Parents' and healthcare professionals' attitudes towards manual therapy in infants can be divided as 'in favour' or 'against'. Those who experienced a good interpersonal relation with a manual physiotherapist and positive treatment outcomes reported positive attitudes. Lack of evidence, treatment experience and related knowledge, safety issues due to publications on adverse events and professional norms led to negative attitudes. Despite lacking evidence, positive treatment experiences, good interpersonal relation and parents feeling frustrated and despaired can overrule negative attitudes and directly influence the decision-making process and choosing for manual therapy treatment.

Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review

PURPOSE

To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use.

DESIGN

Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4^th February 2021.

PARTICIPANTS

Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition.

INTERVENTION

Spinal manipulation and mobilisation OUTCOME MEASURES: Outcomes relating to common childhood conditions were explored.

METHOD

Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach.

RESULTS

Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for 'no significant effect' of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition.

CONCLUSION

Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.

Effects of Single Manual Medicine Treatment for Infants with Postural and Movement Asymmetries and Positional Preference: A Multicentre Randomised Controlled Trial – SMMT for IPMA

Objective The aim of the study was the evaluation of the effects of a single manual medicine treatment (SMMT) for infants with postural and motor asymmetries in upper cervical asymmetry disorder respectively kinematic imbalance due to suboccipital strain (KISS).

Methods Design: Multicentre double-blind randomised study Subjects/Setting: 202 infants at the age of 14–24 weeks with postural and movement findings were examined in four study centres using the standardized 4-item Symmetry-Score (points: 4=symmetric to 17=asymmetric). The inclusion criterion was a score of at least 10 points. The intervention group (IG) received a SMMT, whereas the control group (CG) did not receive any manual therapy. In addition, the infants of both groups were trained with a home exercise programme by their parents.

Statistical Methods The primary target parameter was the result of the Symmetry-Score, measured before the intervention and 4–6 weeks afterwards.

Results 171 children were randomised (IG=83/CG=88). All infants enrolled were measured to the second time-point (Intention-to-treat-analysis). The average improvement of IG compared to CG in Symmetry-Score was 2.3 points (p<.001). Following the score definition 80% of IG and 49% of CG fell below the treatment threshold of 10 points. No side effects were observed.

Conclusions The SMMT significantly improves postural and motor asymmetries in infants with KISS.

Manual therapy of infants with postural and movement asymmetries and positional preference

Background

There are different therapeutic approaches to persistent positional preference (kinematic imbalance due to suboccipital strain, KISS) in infants. There are no evidence-based or controlled studies investigating the effect of manual medicine treatment in children aged 3–6 months, particularly in combination with a home exercise programme. The presented monocentric study on one-time manual medicine treatment of infants aged 14–24 exhibiting these symptoms aims to close this gap.

Methods

This study comprises a controlled double-blind trial and per-protocol-analysis. Primary outcome was the 4-item symmetry score (4–17 points). The second measurement was performed after 4–6 weeks.

Results

A total of 62 infants were treated and evaluated (mean age 17 weeks). The intervention and control groups started with a symmetry score of 12.9 ± 2.1 and 12.5 ± 1.7 points, respectively. In the intervention group the score improved by 4.9 ± 2.4 to 8.0 ± 2.7 points, in the control group it improved by 2.9 ± 2.9 to 9.6 ± 3.0 points. The difference between the groups was statistically significant (p = 0.03). Both groups had significantly better values over time (p < 0.001). No adverse events or side effects were observed.

Conclusion

Manual medicine treatment of infants with postural and movement asymmetries as well as positional preference in combination with a home exercise programme is superior to a home exercise programme alone. Both treatment concepts achieved significant improvements. However, the manual medicine treatment played an important role in reducing the symmetry score value for the affected children, such they were no longer in need of treatment.

Measurement of range-of-motion in infants with indications of upper cervical dysfunction using the Flexion-Rotation-Test and Lateral-Flexion-Test: a blinded inter-rater reliability study in a clinical practice setting

Background: In infants with indications of upper cervical dysfunction, the Flexion-Rotation-Test and Lateral-Flexion-Test are used to indicate reduced upper cervical range-of-motion (ROM). In infants, the inter-rater reliability of these tests is unknown.

Objective: To assess the inter-rater reliability of subjectively and objectively measured ROM by using the Flexion-Rotation-Test and Lateral-Flexion-Test.

Methods: 36 infants (<6 months) and three manual therapists participated in this cross-sectional observational study. Pairs of two manual therapists independently assessed infants’ upper cervical ROM using the Flexion-Rotation-Test and Lateral-Flexion-Test, blinded for each other’s outcomes. Two inertial motion sensors objectively measured cervical ROM. Inter-rater reliability was determined between each pair of manual therapists. For subjective outcomes, Cohen’s kappa (ĸ) and the proportion of agreement (Pra) were calculated. For objectively measured ROM, Bland Altman plots were conducted and Limits of Agreement and Intraclass Correlation Coefficients (ICC) were calculated.

Results: The inter-rater reliability of the Flexion-Rotation-Test and Lateral-Flexion-Test for subjective (ĸ: 0.077–0.727; Pra: 0.46–0.86) and objective outcomes (ICC: 0.019–0.496) varied between pairs of manual therapists.

Conclusion: Assessed ROM largely depends on the performance of the assessment and its interpretation by manual therapists, leading to high variation in outcomes. Therefore, the Flexion-Rotation-Test and Lateral-Flexion-Test cannot be used solely as a reliable outcome measure in clinical practice and research context.

The safety of spinal manipulative therapy in children under 10 years: a rapid review

INTRODUCTION

The safety of spinal manipulative therapy (SMT) in children is controversial. We were mandated by the College of Chiropractors of British Columbia to review the evidence on this issue.

OBJECTIVES

We conducted a rapid review of the safety of SMT in children (< 10 years). We aimed to: 1) describe adverse events; 2) report the incidence of adverse events; and 3) determine whether SMT increases the risk of adverse events compared to other interventions.

EVIDENCE REVIEW

We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from January 1, 1990 to August 1, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (case reports/series, cohort studies and randomized controlled trials) were critically appraised. Studies of high and acceptable methodological quality were included. The lead author extracted data. Data extraction was independently validated by a second reviewer. We conducted a qualitative synthesis of the evidence.

FINDINGS

Most adverse events are mild (e.g., increased crying, soreness). One case report describes a severe adverse event (rib fracture in a 21-day-old) and another an indirect harm in a 4-month-old. The incidence of mild adverse events ranges from 0.3% (95% CI: 0.06, 1.82) to 22.22% (95% CI: 6.32, 54.74). Whether SMT increases the risk of adverse events in children is unknown.

CONCLUSION

The risk of moderate and severe adverse events is unknown in children treated with SMT. It is unclear whether SMT increases the risk of adverse events in children < 10 years.

Manual therapy for the pediatric population: a systematic review

Background

This systematic review evaluates the use of manual therapy for clinical conditions in the pediatric population, assesses the methodological quality of the studies found, and synthesizes findings based on health condition. We also assessed the reporting of adverse events within the included studies and compared our conclusions to those of the UK Update report.

Methods

Six databases were searched using the following inclusion criteria: children under the age of 18 years old; treatment using manual therapy; any type of healthcare profession; published between 2001 and March 31, 2018; and English. Case reports were excluded from our study. Reference tracking was performed on six published relevant systematic reviews to find any missed article. Each study that met the inclusion criteria was screened by two authors to: (i) determine its suitability for inclusion, (ii) extract data, and (iii) assess quality of study.

Results

Of the 3563 articles identified, 165 full articles were screened, and 50 studies met the inclusion criteria. Twenty-six articles were included in prior reviews with 24 new studies identified. Eighteen studies were judged to be of high quality. Conditions evaluated were: attention deficit hyperactivity disorder (ADHD), autism, asthma, cerebral palsy, clubfoot, constipation, cranial asymmetry, cuboid syndrome, headache, infantile colic, low back pain, obstructive apnea, otitis media, pediatric dysfunctional voiding, pediatric nocturnal enuresis, postural asymmetry, preterm infants, pulled elbow, suboptimal infant breastfeeding, scoliosis, suboptimal infant breastfeeding, temporomandibular dysfunction, torticollis, and upper cervical dysfunction. Musculoskeletal conditions, including low back pain and headache, were evaluated in seven studies. Twenty studies reported adverse events, which were transient and mild to moderate in severity.

Conclusions

Fifty studies investigated the clinical effects of manual therapies for a wide variety of pediatric conditions. Moderate-positive overall assessment was found for 3 conditions: low back pain, pulled elbow, and premature infants. Inconclusive unfavorable outcomes were found for 2 conditions: scoliosis (OMT) and torticollis (MT). All other condition’s overall assessments were either inconclusive favorable or unclear. Adverse events were uncommonly reported. More robust clinical trials in this area of healthcare are needed.

Trial registration

PROSPERA registration number: CRD42018091835