Kinematic Imbalances due to Suboccipital Strain
is probably not the most elegant acronym for all those cases we put into that
bucket , but I hope it helps its users to sum up the complex situation. It is
in fact the entire spine which is involved in the pathogenetic complex (like in
cases with a C-Scoliosis or fixed positioning of the lower limbs) but the trigger
is located in the SO-region.
"The etiology of congenital muscular torticollis
remains a mystery despite intensive investigation'' is a commonly held view; like
DAVIDS et al. . Most authors still put the blame on the traumatisation of the
sternocleidomastoid muscle [10, 11].
There is a controversial discussion about
how to react to a fixed and asymmetric posture in newborns. Some consider this
a 'physiological scoliosis' and think it passes by without treatment (see also
[12, 13]. More recent papers stress the importance of asymmetries in perception
and posture for the development of more severe consequences later on . BUCHMANN
remarked "The existence of an asymmetrical range of tilt in the SO-Region
of a child is no big deal. Only if additional signs accompany this an immediate
treatment might be necessary'' 
We do not agree completely and would propose
to draw the line for treatment very wide. KEESSEN et al. show that the accuracy
of the proprioception of the upper limb is reduced in cases with idiopathic scoliosis
and spinal asymmetry. As we know that the proprioception of the arms depends
heavily on a functioning SO-region, its that much more important to treat
Most of the babies were referred to us because of asymmetric posture.
The case histories included the following:
* Tilted posture of the head,
* Opisthotonos-like posture, head held in retroflexion. Unable
to lie on the back, as this forces the head into anteflexion
* Uniform sleeping
posture; the child cries if the mother tries to change its position
motor patterns, asymmetric posture of trunk and extremities, sometimes combined
with a tilted head position reminiscent of a persisting asymmetric tonic neck
* Sleeping disorders; the baby wakes up crying every hour
Extreme sensitivity of the neck
* Cranial scoliosis, swelling of one side
of the facial soft tissues
* Blockages of the iliosacral joints, asymmetries
of the gluteus muscles.
* Asymmetric development and range of movement of
Needless to say, these symptoms cover a wide range of pathological
conditions and cannot always be attributed to the SO-joints, but if we encounter
a combination of motor asymmetries, sleeping disorders and a facial scoliosis,
it is worthwhile to look at the SO-joints.
The case histories of these babies
reveal birth traumata in a higher proportion of cases than the general population.
Prolonged labor and the use of extraction aids are especially overrepresented
in the group of KISS-babies, as the following table shows:
Findings at first examination :
| ||n ||%|
|Mobility of cervical spine||<2/3
|Sonografic signs of retarded Hip Developement
|Mobility of the whole spine||< 2/3 12 ||10,5%|
Reflexes (average )|| ||3,2 of 7|
compared with the normal birth statistics
( 3,5%) ||1,3% ||1,2%|
|Premature Birth (<37th
week)||6 ( 5,3%)||6,8%||6,7%|
||53 ( 46 %)||40,0%||38,2%|
( 33 %)||12,0%||11,8%|
|Pelvic Presentation etc.||13
( 11,4 %)||38,2%||9,3%|
( 11,4 %)||15,1%||15,7%|
( 13,2%) ||6,1%||7,1%|
|Forceps||3 ( 2,6%)
Spontaneous complaints reported
by the parents
| ||n ||%|
|Tilt Posture ||57||50,0%|
|Retardation of Hip Developement||21||18,4%|
|Does not eat/drink
A Danish team (JENSEN et al.
) documented the long-ranging effects of bad motor performance in the first
year. Having followed these children for more than six years they showed that
the differences in performance persisted. Our experience, albeit not statistically
evaluated, points to similar conclusions: babies not treated for their strains
and imbalances in the SO-region have more difficulties finding their proprioceptive
pattern with all the wide-ranging consequences as e.g. senso-motoric diskybernesis
Diencephalic Disorders treatable by Manual Therapy
cases are much more difficult to classify. Already GUTMANN  had reported some
impressive cases. In the USA FRYMANN and others of the osteopathic school treat
related syndromes in children (see also ).
In quite a few cases we learned
only after the parents sent in their reports a month after treatment that the
spinal manipulation helped to make other symptoms disappear. These include:
sleeping problems: The babies wake up during sleep, wail and cry, and have to
be taken on the arm before they stop crying and continue to sleep.
of appetite: the children are `bad eaters', sometimes frequent vomiting or difficulties
keeping milk in the mouth are reported
* undiagnosed fever. No indications
of infection or an immunological problem can be found.
* Retardation of
affective development, i.e. lack of interaction with the parents
than in the discussion of the KISS-symptoms we have to underline that only some
of these cases improve after manipulation. Improvement is to be expected if the
initial symptomatology is accompanied by signs of asymmetry. But even in cases
without specific KISS-symptoms it is sometimes useful to treat the SO-region.
We recommend our pediatric colleagues to examine the cervical spine for signs
of impaired function and refer the babies to a specialist if they find sensitivity
or restricted movement of the head.
How can we analyse the effect of manual
therapy in these cases? PERILLO  discussed this problem without being able
to give the optimal solution, a point he stressed himself. Future comparative
studies will need large numbers of cases to overcome the low signal-to-noise ratio
in this multi-factor setup. For the time beeing it seems preferable to treat one
too many, as the therapy is neither time-consuming nor risky. In any therapy involving
inter-personal communication there is no such thing as "immaculate perception".
In the evaluation of therapy of cerebral palsy (to use this well-known
but slightly misleading label) the influence of the more peripheral components
of the nervous system is often played down. The key role of afferential stimulation
in the development of the brain implies that any hindrance originating there will
further worsen the chances of babies with cerebral damage, any aid we can give
might improve it. All modern methods of physiotherapy use this principle.
development consumes 87% of the basic metabolic rate in newborn (as compared to
23% in adults, . It is therefore not exaggerated to consider a newborn as
a central nervous system plus support structures. What else could underline the
importance of the faultless functioning of these structures for the ultimate performance
of this developing organ!
GOULD considers the human infant to be born nine
months too early , and the implications of this for the brain development
in the first nine months cannot be over-estimated. This nine-months-limit coincides
with the beginning of the verticalisation. Typically around this time the infants
start to sit freely. Observations of the success rate in manual therapy of the
newborn suggest a significance of the nine months limit, too. Later on the treatment
is markedly less efficient and needs to be repeated more often . Any help
we can give during these most important first months will have a much larger impact
on the developing problems than afterwards. Other research confirmed that pre-
and perinatal damage can best be limited in the early phases, i.e. the frist two
years . Whatever we do or don't do during that time is many times more efficient
than later in life.
The term Cerebral palsy directs our attention too much
towards on (albeit the most important) part of the problem. Regrettably this part
is the least easy to influence, at least not in any direct way. If we keep thinking
about the intricate interaction between periphery and central nervous system 
our therapeutic perspective becomes more optimistic. Dynamic systems theory postulates
that new forms in behaviour emerge from the cooperative interactions of multiple
components. The transitions between different stages of preferred behaviour are
often nonlinear . This makes evaluation of a change in one of these environmental
variables so difficult.
When one dares to say that quite a few cases of
Cerebral Palsy or Minimal Cerebral Damage (MCD) are in fact KISS-kids the one
and only reason is the marked improvement after treatment. We saw dozens of children
referred to us with the diagnosis "imminent spastic diplegia/hemiplegia''
who improved so markedly that at least some of their problems had to be attributed
to suboccipital strain.
This complex field needs a lot of discussion and
compilation of the case histories observed. But I am confident that techniques
of manual therapy proper can increase the efficiency of the treatment.
"Head stabilization .... is a
complex process involving the interaction of reflexes elicited by vestibular,
visual and proprioceptive signals} '' . Most of the afferent proprioceptive
signals originate from the cranio-cervical junction. Any obstacle impeding these
afferential signals will have much more extensive consequences in a nervous system
in formation, which depends on appropriate stimuli to organize itself . "Most
of the cerebral development lies still in the future for the newborn'' ; this
development "begins at the head''.
These delicate structures undergo
considerable stress during delivery, as bipedal gait necessitated a radical restructuring
of the human pelvis. The initially straight birth canal had to be bent to fit
the new anatomical situation. Our ancestors in Central Africa had a pelvis construction
better adapted to upright gait . The increased cranial circumference of the
modern newborn worsens the situation further. The birth canal is one of the most
dangerous obstacles we ever have to traverse . WISCHNIK et al. showed
in experimental studies the biomechanics of delivery (see also . GOTTLIEB
 recently published a literature review with a lot of material.
delivery the head is rotated about 90º and pressed against the trunk by the
contractions of the uterine muscles. A majority of newborn suffer from microtraumata
of brain stem tissues in the periventricular areas . FRYMANN attracts our
attention to the often forgotten traumata of early and to their impact on sensorimotor
The traumatization of the suboccipital structures inhibits
the functioning of the proprioceptive feedback-loops. The motor development, though
pre-programmed, cannot develop normally.
These systems are fault-tolerant
and able to overcome considerable difficulties and restricted working conditions.
But the price for this is a reduced capacity to absorb additional stress later
on. These children may show only minor symptoms in the first months of their life,
e.g. a temporary fixation of the head in one position and `recover' spontaneously.
Later on - at the age of five or six - they suffer from headaches, postural problems
or diffuse symptoms like sleep disorders, being unable to concentrate etc. If
successful manipulation suggests the cervical spine as the main problem we look
for symptoms of KISS at an earlier age. Often there are indications of KISS-related
problems in the first two years.
The biomechanics of the SO-Region
far too complex to be dealt with in a few sentences. But it has to be said that
in the newborn and infants they do not follow the patterns we know from adults
. More often than in adults, where C 1 moves toward the ``lower'' side (i.e.,
to the right if the head is fixed in a right-bent position, C1 is found on the
higher side). The reason for this may be the less pronounced inclination of the
C1/C2 -joint in combination with the lack of gravitational pull before verticalisation.
This might be one reason why our results depend to a big extent on the stage of
neuromuscular development at the onset of therapy.
Limited rotation and/or
flexion to one side could not be directly correlated with the side of displacement
of C1/C2. The above mentioned trend depends on the stage of the motor developement
of the baby and the morphological features present. More insight into the finer
details should give us a better understanding how posture, biomechanics of the
cervical spine and neuromotor development interact.
Based on the analysis
of more than 2.500 cases a shift of C1 to the concave side of the cervical spine
has to be considered normal until verticalisation, i.e. about the 15th (boys)
- 20th (girls) month. After that time the pattern changes.
this is also the time most parents refer to when asked about the spontaneous cessation
of asymmetry symptoms in their children. MEYER stated that he saw a lack of thoracic
kyphosis in patients with birth trauma or accidents before verticalisation .
Using rasterstereometric equipment  we were able to document these postural
problems and their cessation after manual therapy.
This is also the time when
C-scoliosis as a reaction to vertebragenic strain is replaced by S-scoliosis.
The distinction between these 'postural' forms and the idiopathic scoliosis is
somewhat blurred. Nevertheless these two pathological entities should not be mixed
But birth trauma is not the only cause of KISS-problems. About a third
of our little patients had case histories pointing towards intra-uterine malpositioning
as another cause of suboccipital strain. PRECHTL  gave guidelines to analyse
fetal motor patterns as pathological. It would be exaggerating to attribute all
postnatal asymmetries to intrauterine oblique positioning, as most of the mothers
remember quite clearly that the baby moved until a few days before delivery, and
other factors - like extraction aids - are involved, too.
soft correlation between manual findings and clinical symptoms made it more difficult
to see the causal connection, even more so as these symptoms can be dealt with
using different methods. A C-scoliosis or motor asymmetries often improve under
physiotherapy; why leave this proven path and try something new?
Strain is the leading factor. Without its removal, the symptoms can be dealt with
by physiotherapy, but the re-appearance of symptoms caused by suboccipital strain
can later necessitate manipulation at or after entering school.
of suboccipital strain is the fastest and most effective way to treat the symptoms
of KISS; one session is sufficient in most cases.
* Manipulation of the
occipito-cervical region leads to the disappearance of problems not reported by
the parents, because they did not see any connection with the vertebral spine.
Later on, and especially when we made this retrospective enquiry, we heard time
and again 'that Lars (or Laura) sleeps (or eats) much better since the treatment',
is 'another child altogether' etc.
The procedure used is basically an
The babies lie on the examination table in front of
the therapist. After the kinesiological and neurological examination, the child
is put on it's back and we check the segments of the cervical spine. These findings
are compared with the X-ray findings. It is important to be patient; especially
agitated children are difficult to examine. Careful friction massage of the short
muscles of the neck helps manual palpation.
In most cases the direction of
the manipulation is determined by the radiological findings (85%) and in other
cases the direction of the torticollis, palpation or the local pain reaction.
The manipulation itself consists of a short thrust of the proximal phalanx of
the medial edge of the second finger. It is mostly lateral; in some cases the
rotational component can be taken into account.
Selection of the direction
of the treatment without the X-ray seems the most plausible cause for the less
encouraging results of some colleagues. The technique itself needs subtlety and
long years of experience in the manual treatment of the upper cervical spine.
In the hands of the experienced the risk is minimal; we have not yet encountered
any serious complications. Most children cry for a moment, but stop as soon as
they are in their mother's arms. In three cases (of more than 4.000 infants) the
children vomited after the treatment; this had no negative effect on the outcome.
Standard x-rays - during the first 18 months an a.p.-plate of the cervical spine
inc. the SO-region suffices - have to be of optimal quality and no manipulation
in the SO-region should be done without them. The detection of contraindications
is important . But we should not overestimate the potential of standard plates.
They are the base to find the best technique and to indicate those cases where
additional screening is necessary.
Some Practical Details
results improve if we insist that there is no disturbance immediately before treatment,
i.e. no fall, strain ("roughed up by his brother'') or manipulation at least
14 days before. If this is the case one can use other methods (for example muscular-energy-techniques)
All children treated for cervicogenic problems during their frist
20 months have a tendency to re-develop symptoms after minor trauma, especially
in the first three months after treatment.
We recommend therefore to keep
these children under observation. The frequency of these visits depends on the
other professionals involved. In our case we can count on the physiotherapists
working with the children to alert the parents when they consider a re-evaluation
necessary, so we normally ask only for a yearly visit in those cases which can
be considered symptom-free. Children with a family history of scoliosis, fixed
morphological problems or other aggravating factors have to be seen more often.
Suboccipital strain does not always lead to the manifestation of clinical symptoms;
SEIFERT examined a random sample of over one thousand newborns and found 11% with
blockages in this region. In this group of 119 babies 78% showed asymmetries of
the vertebral spine, i.e. a scoliotic posture .
We can safely assume that
most of these children would not have been considered in need of a treatment had
they not been included in this study. 6% of British primary school children have
significant disorders of their visumotor system . How many of these could
profit from manual therapy of the suboccipital joints?
The indication for
manual therapy depends thus of the correllation of the clinical symptoms with
the manual and radiological findings  In doubtful cases a trial manipulation
can help to diagnose KISS ex juvantibus .
The differential diagnosis should
exclude 'simple' muscular asymmetries and cases of intramedullary tumor  or
a asymmetrically formed vertebra. The first category improves quickly under physiotherapy
and regains a symmetrical posture after a few treatments or even after waiting
for a few weeks. This is one reason why we propose to treat babies only after
the third month, i.e. the onset of voluntary head movements and control.
second category is more difficult to detect. The morphological asymmetries can
be seen on the x-rays, but signs of intramedullary tumors are too unspecific to
lead to a quick diagnosis. Torticollis can be one of the first symptoms .
The clinical picture sometimes even improves after the manual therapy . If
the effect of the treatment is only short-term or the problems even increase after
the first visit one should not hesitate to use e.g. a NMR to check for these --
admittedly rare -- cases.
Extreme cases, similar to the KISS-Syndrome of the
newborn are known as the Atlanto-axial rotary fixation ('AARF')  " a
well-documented but uncommon cause of childhood torticollis'' .These post-
traumatic cases are often associated with clavicular fractures. Interestingly
enough we saw quite a few healed clavicular fractures on our radiographies where
the parents had not reported a especially forceful delivery . So much to the
problems of documenting birth trauma....
Practice changed a lot through the ages. Those who bother to look back at the
procedures of our forefathers are often surprised by the success they obviously
had in spite of their doubtful remedies.
Having observed quite a few colleagues
in different European countries while they treated children I was astonished how
different their techniques were from those considered 'state of the art'. They
nevertheless succeeded, too, with their treatment. One common denominator was
their long interval between treatments. This fits into the results of an analysis
of fatal accidents after manual therapy: one of the most important findings for
us was the fact that more than half of the deaths attributed to manipulations
of the cervical spine happened at the second treatment which often was administered
shortly after the first.
It seems we have met the same effect looking around
us as looking back to old times: Different concepts, different methods result
in comparable success rates. If this is so, are there any 'hard facts' to take
into account when we discuss the guidelines for manual therapy in children? I
have tried to outline a few, based on my experience. Our goal -- as with all medical
work -- is to achieve the maximum effect with a minimum of therapy. All working
in the field of manual therapy have to define their role in the framework of a
- hopefully successful - therapeutically concept. This is true for all patients,
but especially important in children. We have to be very sure of the good it brings
to a child before we ask it to be hospitalized or even operated, as some doctors
active in the field increasingly advocate. After more than ten years of experience
we met very few cases where this seemed necessary.
Therapy in young children should only be used by the experienced. To avoid any
risk one should thoroughly examine the case history, where a rapid increase of
the symptoms often indicates a non-functional origin. Radiography of the cervical
spine is a conditio sine qua non.
The main indications are functional and/or
morphological asymmetries of the posture, motor patterns or development. Beyond
C-scoliosis, torticollis and unilateral hip hypoplasia a variety of less specific
indications attract the attention to the spine as a possible pathogenetic factor.
This includes the early symptomatology of cerebral palsy, hyperkinetic children
as well as unattributable problems of oro-facial co-ordination (i.e. sucking,
Examination of the neck for extreme sensitivity and (unilaterally)
reduced range of movement helps to narrow down the number of children to be treated
by manual therapy.
In other cases a test treatment can help to sort out those
cases where continuous manual therapy has to be applied. This includes cases of
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