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

Figures & data

Figure 1. Stages of the guideline development process to formulate the position statements.

Box 1. Criteria for evidence to decision framework adapted from Table 1 in Alonso-Coello and colleagues [16].

Benefits and Harms	How substantial are the desirable anticipated effects? How substantial are the undesirable anticipated effects?
Level of evidence^¶	What is the overall level of evidence^¶ of effect from the scoping review? What is the expert Delphi panels perspectives when the evidence was inconclusive or indeterminate? What are additional considerations for each subgroup (i.e., by spinal region, by age, by spinal manipulation or mobilisation), implementation, monitoring, evaluation, and research priorities?
Clinical outcome assessments of importance	What is the overall certainty of evidence^§ for clinical outcome assessment used?
Balance	Does the balance between the desirable and undesirable effect favor the intervention?
Acceptability	Is the intervention acceptable to clients, carers, and healthcare providers? Is the intervention acceptable to key stakeholders?
Feasibility	Is the intervention feasible for clients, carers, and healthcare providers?

Key: ^¶Level of Evidence based on Joanna Briggs Institute-Checklist for Systematic Reviews and Research Synthesis [22]; ^§Certainty of Evidence using GRADE approach for systematic reviews as applied by COSMIN guidelines [23].

Table 1. Decision rules for final recommendations and directives are listed. They were based on summative analysis of one scoping review, two reviews of psychometric properties, and one 3-round expert Delphi panel survey.

Directive	Decision Rule
NO	When the scoping review summary statement was insufficient, inconclusive, no data, or evidence of no effect, and the Delphi study consensus was either not recommended or the condition was not identified by the Delphi expert panel as an appropriate condition to treat with the intervention, the taskforce recommendation is ‘No’ indicating the intervention is not recommended for clinical use. The taskforce may change an ‘Unclear’ to a recommendation of ‘No’, indicating the intervention is not recommended for clinical use, due to evidence of safety concerns or a lack of biomechanical and neurophysiological plausibility in application of spinal manipulation or mobilisation for a specific paediatric condition or impairment.
UNCLEAR	When the scoping review summary statement concluded insufficient, inconclusive, no data, or evidence of no effect, and the Delphi study consensus was positive or did not reach consensus for clinical use, the taskforce clinical recommendation is ‘Unclear’ indicating that the clinician must use appropriate biopsychosocial clinical reasoning to determine if the intervention is appropriate. When the scoping review summary statement was inconclusive for clinical use and the Delphi study did not reach consensus for or against clinical use, the taskforce recommendation is also ‘Unclear’ indicating that the clinician must use biopsychosocial clinical reasoning to determine when the intervention is appropriate.
YES	When the scoping review summary statement was a conclusive ‘Yes’ in support of the intervention, the psychometric properties were reliable, valid, and responsive to change a well as the Delphi consensus was positive for clinical use, the taskforce clinical use recommendation is ‘Yes’ for the intervention to be recommended.

Table 2. Summary of findings by musculoskeletal condition represent our recommendations and research direction across the 1) level of evidence from a scoping review, 2) psychometric properties from two psychometric property reviews, 3) expert Delphi survey data, 4) taskforce recommendation as appropriate for clinical use, and 5) future research priority. The Delphi table includes only the relevant ages Table 2.

KEY: Infant (birth to <2 years); Child (2 to 12 years); Adolescent (13 to < 18 years); 7 or 9-pt = 7 or 9-point scale; AE = Adverse Events; AIMS = Alberta Infant Motor Scale; passive F/R test = passive flexion/ rotation test; KISS = kinematic imbalance due to suboccipital strain; NRS = numeric rating scale; VAS = visual analogue scale; PedsQL = Pediatric Quality of Life Inventory; RMQ = Roland and Morris Questionnaire; C = Cervical; T = Thoracic; L = Lumbar. Levels of evidence rating (scoping review): very strong, strong, moderate, limited evidence; Summary Statement: ‘inconclusive’ = If ≥ 66.6% of relevant investigations were not reached and results of the decision tree were mixed, ‘insufficient’ = If there were insufficient studies/reviews exploring the intervention for the identified condition.

Delphi:   = Consensus that the treatment (mobilisation or manipulation) is NOT appropriate (impairments) or NOT recommended (condition) for infant/child/adolescent; = No consensus; = Consensus that the treatment (mobilisation or manipulation) may be appropriate (impairment) or recommended (condition) for infants/children/adolescents.

¶Psychometric Property Criteria Rating: (+) = sufficient, (−) = insufficient, (±) = inconsistent, (?) = indeterminate, (NR) = searched for but not reported [14,23], (NS) = no search performed. Level of Certainty (for clinical outcome measure) using GRADE approach: H = high certainty evidence,  M = moderate certainty evidence, L = low certainty evidence, VL = very low certainty evidence.

§ Guidelines of the International Headache Society: Clinical outcome assessments tools should include improvements in severity/duration/frequency of headache and Quality of life [27,28]. Adverse Event (AE) documented in studies from the scoping review as Mild, Moderate, and Severe follow [17]: ¹Mild AE = Two benign reactions (no further detail documented, chiropractic) [29]; ²Mild AE = randomised controlled trial, unusual treatment soreness and different type of pain [30]; ³Severe AE = Unsteady gait, poor coordination, drowsiness, hospitalisation with delayed diagnosis of congenital occipitalisation in a 12-year-old girl with history of congenital torticollis [31], progressive deficits in legs, clonus at rest, urinary urgency, paraplegia in 12 year old girl with history of osteogenesis imperfecta [32]; ⁴Severe AE = subarachnoid hemorrhage and death; this case report was of a 3 month old girl [33]; quadra or paraplegia; this was a case report of a 4 month old boy astrocytoma [34]; ⁵Mild AE = Hot skin and dizziness, transitory increase in headache intensity & frequency; quick recovery once treatment stopped; this randomised controlled trial had 52 children age 7 to 15 years old; the trial was stopped early due to frequency of complaints [35]; ⁶Severe AE = Severe occipital and bifrontal headache, vomiting, left facial weakness, diplopia, ataxia; this case report was of a 7 year old boy gymnast [36]; ⁷Mild AE = Frequent (14%) mild AE (i.e. back soreness, irritability, poor feeding, mild distress, increased crying or head tilt, temporary vegetative responses); this prospective cohort study included 307 infants (<27 weeks) with upper cervical dysfunction [37]

Table 3. Summary of findings by non-musculoskeletal condition represent our recommendations and research direction across 1) level of evidence from a scoping review, 2) psychometric properties from two reviews, 3) expert Delphi survey data, 4) taskforce recommendation as appropriate for clinical use, and 5) future research priority.

KEY: Infant (birth to <2 years 18); Child (2 to 12 years); Adolescent (13 to <18 years); 7 or 9-pt = 7 or 9-point scale; ADHD = Attention Deficit Hyperactivity Disorder (age 6 to 18); ARIOS = Autism research institute outcomes survey; ASD = Autism Spectrum Disorder; ATEC = Autism treatment evaluation checklist; CNS = central nervous system; sEMG = surface electromyography for autism spectrum disorder; LATCH = Latch, Audible swallowing, Type of nipple, Comfort, Hold; PAQLQ = Pediatric Asthma Quality of Life Questionnaire; C = Cervical; T = Thoracic; L = Lumbar; Levels of evidence rating (scoping review): very strong, strong, moderate, limited evidence. Summary Statement: ‘inconclusive’ = If ≥ 66.6% of relevant investigations were not reached and the results of the decision tree were mixed, ‘insufficient’ = if there were insufficient studies/reviews exploring the intervention for the identified condition/outcome.Delphi:   = Consensus that the treatment (mobilisation or manipulation) is NOT appropriate (impairments) or NOT recommended (condition) for infant/child/adolescent;  = No consensus;   = Consensus that the treatment (mobilisation or manipulation) may be appropriate (impairment) or recommended (condition) for infants/children/adolescents. ¶Psychometric Property criteria rating: (+) = sufficient, (−) = insufficient, (±) = inconsistent, (?) = indeterminate, (NR) = searched for but no report [14;23,] (NS) = no search performed; Level of Certainty (clinical outcome measure) using GRADE approach: H = high certainty evidence, M = moderate certainty evidence, L = low certainty evidence, VL = very low certainty evidence. Adverse Event (AE) based on scoping review [17]; ⁸Mild AE = Increased crying in a cohort study of 158 infants categorised into three subgroups, (A) infant colic, (B) irritable infant syndrome of musculoskeletal origin (IISMO) and (C) inefficient feeding crying infants with disordered sleep (IFCIDS) [38]; ⁹Moderate AE = 53% vegetative reaction - flushing, reflex apnoea, hyperextension, sweating, bradycardia, tachycardia; this cohort study was of 199 infants average age 5-months receiving gentle manipulation impulse (<5N) [39]; rib fracture; this case report of posterior rib fractures was in a young infant [40]; ¹⁰Moderate AE = This randomised controlled trial reported development of severe headache, stiff neck, acute lumbar spine pain [41]; ¹¹Mild AE = Increased irritability and mid-back soreness; this feasibility randomised controlled trial of 20 participants was conducted on infant (6-months) to children aged 6-years[42].

Table 4. Evidence-based practice position statement on spinal manipulation and mobilisations for paediatric populations predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.

Directive	Evidence-based practice position statement
NOT RECOMMENDED (do not perform)	Spinal manipulation and mobilisation should not be performed on infants. Cervical and lumbar spine manipulation should not be performed on children. Spinal manipulation and mobilisation are not appropriate and should not be performed to treat non-musculoskeletal conditions among infants, children and adolescents including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.
May be APPROPRIATE with sound clinical reasoning	Spinal mobilisation may be appropriate to treat children with musculoskeletal conditions including spinal mobility impairments associated with neck-back pain, and neck pain with headache. Thoracic spine manipulation may be appropriate to treat children with musculoskeletal conditions including spinal mobility impairments associated with neck-back pain. Spinal manipulation and mobilisation may be appropriate to treat adolescents with musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache.
RECOMMEND	No high certainty evidence is available to recommend spinal mobilisation or manipulation for paediatric populations.

Figure 2. Evidence gap map for INFANTS by musculoskeletal and non-musculoskeletal condition.

Figure 3. Evidence gap map for CHILDREN by musculoskeletal and non-musculoskeletal condition.

Figure 4. Evidence gap map for ADOLESCENTS by musculoskeletal and non-musculoskeletal condition.

Alonso-Coello P, Schünemann HJ, Moberg J, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: introduction. Br Med J. 2016;353. doi: 10.1136/bmj.i2016

 Google Scholar

Joanna Briggs Institute. JBI levels of evidence 2013. [cited 2023 Oct 27]. Available from: https://jbi.global/sites/default/fles/2019-05/JBI-Levels-of-evidence_2014_0.pdf

 Google Scholar

Prinsen CAC, Mokkink LB, Bouter LM, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res. 2018;27(5):1147–57. doi: 10.1007/s11136-018-1798-3

 PubMed Web of Science ®Google Scholar

Mokkink LB, Prinsen C, Patrick DL, et al. COSMIN methodology for systematic reviews of patient-reported outcome measures (PROMs). User manual. (version 1.0). Feb ed. Amsterdam, The Netherlands: VU University Medical Center, 2018.

 Google Scholar

Abu-Arafeh I, Hershey AD, Diener H-C, et al. Guidelines update: guidelines of the international headache society for controlled trials of preventive treatment of migraine in children and adolescents, 1st edition – an experience-based update. Cephalalgia. 2023;43(5):03331024231178239. doi: 10.1177/03331024231178239

 Web of Science ®Google Scholar

(IHS) Olesen J. Headache classification committee of the International headache society (IHS) the international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211. doi: 10.1177/0333102417738202

 Web of Science ®Google Scholar

Milne N, Longeri L, Patel A, et al. Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review. BMC Pediatr. 2022;22(1):721. doi: 10.1186/s12887-022-03781-6. published Online First: 271

 PubMed Web of Science ®Google Scholar

Rowe DE, Feise RJ, Crowther ER, et al. Chiropractic manipulation in adolescent idiopathic scoliosis: a pilot study. Chiropr Man Therap. 2006;14(1):15.

 Google Scholar

Evans R, Haas M, Schulz C, et al. Spinal manipulation and exercise for low back pain in adolescents: a randomized trial. Pain. 2018;159(7):1297–307. doi: 10.1097/j.pain.0000000000001211

 PubMed Web of Science ®Google Scholar

L’Ecuyer JL. Congenital occipitalization of the atlas with chiropractic manipulations: a case report. Nebr State Med J. 1959;44:546–550.

 PubMedGoogle Scholar

Ziv I, Rang M, Hoffman HJ. Paraplegia in osteogenesis imperfecta. A case report. J Bone Joint Surg Br. 1983;65-B(2):184–185. doi: 10.1302/0301-620X.65B2.6826628

 Google Scholar

Jacobi G, Riepert T, Kieslich M, et al. Über einen Todesfall während der Physiotherapie nach Vojta bei einem 3 Monate alten Säugling - Fallbeschreibung und Bemerkungen zur Manualtherapie bei Kindern -. Klin Padiatr. 2001;213(2):76–85.

 PubMedGoogle Scholar

Shafrir Y, Kaufman BA. Quadriplegia after chiropractic manipulation in an infant with congenital torticollis caused by a spinal cord astrocytoma. J Paediatr. 1992;120(2):266–269. doi: 10.1016/s0022-3476(05)80440-8

 PubMed Web of Science ®Google Scholar

Borusiak P, Biedermann H, Bosserhoff S, et al. Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: results of a prospective, randomized, placebo-controlled, and blinded trial. Headache. 2010;50(2):224–30. doi: 10.1111/j.1526-4610.2009.01550.x

 PubMed Web of Science ®Google Scholar

Zimmerman AW, Kumar AJ, Gadoth N, et al. Traumatic vertebrobasilar occlusive disease in childhood. Neurology. 1978;28(2):185–8. doi: 10.1212/wnl.28.2.185

 PubMed Web of Science ®Google Scholar

Saedt E, Driehuis F, Hoogeboom TJ, et al. Common manual therapy practices in the Netherlands for infants with upper cervical dysfunction: a prospective cohort study. J Manipulative Physiol Ther. 2018;41(1):52–61.

 PubMed Web of Science ®Google Scholar

Miller J, Newell D. Prognostic significance of subgroup classification for infant patients with crying disorders: a prospective cohort study. J Can Chiropractic Assoc. 2012;56(1):40–48.

 PubMedGoogle Scholar

Koch LE, Biedermann H, Saternus KS. High cervical stress and apnoea. Forensic science international. Forensic Sci Int. 1998;97(1):1–9. doi: 10.1016/S0379-0738(98)00124-8

 PubMedGoogle Scholar

Wilson PM, Greiner MV, Duma EM. Posterior rib fractures in a young infant who received chiropractic care. Pediatrics. 2012;130(5):e1359–62. doi: 10.1542/peds.2012-0372

 PubMed Web of Science ®Google Scholar

Leboeuf C, Brown P, Herman A, et al. Chiropractic care of children with nocturnal enuresis: a prospective outcome study. J Manipulative Physiol Ther. 1991;14(2):110–115.

 PubMed Web of Science ®Google Scholar

Sawyer CE, Evans RL, Boline PD, et al. A feasibility study of chiropractic spinal manipulation versus sham spinal manipulation for chronic otitis media with effusion in children. J Manipulative Physiol Ther. 1999;22(5):292–298.

 PubMed Web of Science ®Google Scholar