Comments on Guidelines for Manipulation and Mobilization for the Paediatric Patient Physiotherapist

The guidelines taken forth in 2024 by physiotherapists in regards to manipulation and mobilization of the paediatric patient fail to mention their safety record for this patient group [1-3]. There are several articles published simultaneously and besides their recommendations, Olsen, 2024 targets specifically and unjustifiably chiropractic treatment of the paediatric patient [4]. It is inappropriate for physiotherapists to judge the work of chiropractors when they obviously don’t know how we treat infants and children.

As chiropractors, we have recent guidelines in place recommending treatment forces to be reduced appropriately for the paediatric patient, there are also studies to support safety, cost effectiveness and satisfaction in regards to care of paediatrics [5]. 

Aurelie Marchand has researched and published information specific to treatment forces recommended for age groups. As clinicians we take into consideration as well the individual patients needs when treating infants and children [6]. 

There has been an editorial published in 2019 addressing specifically spinal manipulation in infants and children in response to Safer Care Victoria review for this topic. The editorial outlines the body of evidence and the evidence-based set of recommendations for “best practices” for chiropractic care of the paediatric population including infants. It includes the forces recommended for the age groups [7]. 

Studies by Miller show that treatment of infants according to this model are not only safe, but parents have been very satisfied with the results [8,9]. The research literature is clear that severe adverse reactions in chiropractic treatment of children are so rare as to be considered nonexistent [9,10]. 

Koch, the orthopedist, shows specifically that forces used typically on an adult applied to the infant cervical spine are associated with adverse events [11]. I would hope we all agree that using manipulation or mobilization forces commonly used in adults are inappropriate for the infant and child and some adolescents. I think we all also agree that practitioners, including medical professionals, orthopedists, physiotherapists, chiropractors, osteopaths should all have advanced education in paediatrics if they are working with and treating this patient group. 

The research base sorely lacks a clinical perspective where the infant or child with obvious biomechanical faults is dismissed from a medical examination as healthy and following their growth curve despite significant suffering for not just the child but the family. Practitioners with advanced education in paediatric manual therapy are versed in red flags to recognize the infant and child in need of emergent care, referring on to an appropriate practitioner if a short trial of treatment does not yield expected results. Most importantly we advocate and teach the appropriate forces for treatment which are modified for age and development [12]. Marchand outlines (based on her research) forces which are appropriate for use in the different age groups [6]. The model she presents suggests a clear modification of forces for the paediatric patient with a biomechanical disorder. The clinician of course takes into consideration that certain groups of patients would need modified forces due to their individual circumstances. For the infant, chiropractors are against using the forces applied to adults during spinal manipulation. The young infant with a biomechanical problem is treated with forces of 1-2 newtons as compared to the forces used by Koch, a medical practitioner (50 newtons) [13]. 

Serious adverse events reported are a result of Koch using inappropriate forces in treatment of infant cervical spine.¹² We no not advocate using adult forces which would be classic spinal manipulation, or forces used for adults in mobilisation in physiotherapy in the treatment of infants. The treatment of young children and children are also modified appropriately as they are growing and developing [14]. 

There is no evidence in the literature for any of the negative claims being made by physiotherapists, particularly Olson⁴ in regards to chiropractors treating children. I would call this Trumpian tactics to promote and protect their own territory.

1. Gross AR, Olson KA, Pool J, Basson A, Clewley D, et al. (2024) Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists. J Man Manip Ther 32: 211-233.
2. Dice JL, Brismée JM, Froment FP, Henricksen J, Sherwin R, et al. (2024) Spinal manipulation and mobilisation among infants, children, and adolescents: an international Delphi survey of expert physiotherapists. J Man Manip Ther 32: 284-294.
3. Dice JL, Brismee JM, Froment FP, Henricksen J, Sherwin R, et al. (2024) Perceived factors and barriers affecting physiotherapists' decision to use spinal manipulation and mobilisation among infants, children, and adolescents: an international survey. J Man Manip Ther 32: 295-303.
4. Olson KA, Clewley D, Milne N, Brismée JM, Pool J, et al. (2024) Spinal manipulation and mobilisation for paediatric conditions: time to stop the madness. J Man Manip Ther 32: 207-210.
5. Keating G, Hawk C, Amorin-Woods L, Amorin-Woods D, Vallone S, et al. (2014) Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature. J Manipulative Physiol Ther 38: 699-712.
6. Marchand AM (2015) A proposed model with possible implications for safety and technique adaptations for chiropractic spinal manipulative therapy for infants and children. J Manipulative Physiol Ther 38: 713-726.
7. Hawk C, Vallone S (2019) A summary of current studies related to chiropractic and manual therapies for pediatric patients. JCCP 18:
8. Miller JE, Hanson HA, Hiew M, Kwong DS LT, Mok Z, et al. (2019) Maternal Report of Outcomes of Chiropractic Care for Infants. J Manipulative Physiol Ther 42: 167-176.
9. Miller JE, Benfield K (2008) Adverse effects of spinal manipulative therapy in children younger than 3 years: a retrospective study in a chiropractic teaching clinic. J Manipulative Physiol Ther 31: 419-423.
10. Todd AJ, Carroll MT, Robinson A, Mitchell EKL (2015) Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature. J Manipulative Physiol Ther 38: 699-712.
11. Koch LE, Koch H, Graumann-Brunt S, Stolle D, Ramirez JM, et al. (2002) Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants. Forensic Sci Int 128: 168-176.
12. Todd AJ, Carroll MT, Mitchell EKL (2016) Forces of Commonly Used Chiropractic Techniques for Children: A Review of the Literature. J Manipulative Physiol Ther 39: 401-410.
13. Koch LE, Biedermann H, Saternus KS (1998) High cervical stress and apnoea. Forensic science international. Forensic Sci Int 97: 1-
14. Snodgrass SJ, Rivett DA, Robertson VJ, Stojanovski E (2009) Forces applied to the cervical spine during posteroanterior mobilization. J Manipulative Physiol Ther 32: 72-83.