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Manual Therapy in Newborn and Infants

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Manual Therapy in Newborn and Infants


Heiner Biedermann

A new Frontier

Manual therapy, having been gradually accepted by the medical community during the last decade, was until recently confined to the treatment of adults and adolescents. Reports of manipulations of infants were scarce and mostly casuistical [1, 2]. When we presented our results in 1983[3] I was astonished at how few reactions we got. In private discussions with colleagues I heard about many experiences those active in the field had, and their reluctance to publish them. Their success seems to hove been their worst enemy.
Too many different problems of infants were successfully approached and the results did not fit into the familiar patterns. One of them, Dr. NEUMANN in Milan, had treated many thousand during more than thirty years; regrettably he died before his knowledge had been extensively published [4, 5] beyond some papers on scoliosis.

Now manual therapy of children, infants and newborn has come of age. One reason for this -- and I can only refer to the situation in Germany - is the exact and subtle neuromuscular diagnosis of the schools of VOJTA, BOBATH, FLEHMIG and others [6, 7].
Pediatric neurologists and physiotherapists with this background were able to screen their small patients and send those they considered in need of manual therapy. They were also able to judge the results independently. This enabled us to see the number of cases (more than 4.000 Babies under 2 Y till the end of 1996) which gave us a database for the following presentation.


Is is intriguing to report individual cases which are astounding, but more convincing are groups of cases which can be classified and compared; three groups will be presented: KISS-Babies, cerebral palsy and co-ordination problems. The results of our therapy directed us towards the two poles of the spine, and notably the Sub-Occipital (SO-) region as a pivotal area for the pathogenetic potential and functionally oriented therapy (see also [8].
To a lesser extent the Sacro-Iliacal (SI-) Joints are involved, too. It seems that their importance increases only after attaining upright posture. Sitting up, and -- later on -- standing and walking necessitate a new postural programming and depend much more on the iliosacral joints as the statical base of posture and movement.

 

The KISS-Syndrome

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. [9]. 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 [14]. 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'' [15]
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[14]. As we know that the proprioception of the arms depends heavily on a functioning SO-region[16], its that much more important to treat it.

Most of the babies were referred to us because of asymmetric posture.
The case histories included the following:

* Tilted posture of the head, torticollis

* 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

* Asymmetric motor patterns, asymmetric posture of trunk and extremities, sometimes combined with a tilted head position reminiscent of a persisting asymmetric tonic neck reflex

* 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 the hips

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:

KISS-Babies: Findings at first examination [17]:

 n %
Mobility of cervical spine<2/3 8574,6%
Torticollis 4438,6%
C-Scoliosis 4035,1%
Unilateral Microsomy47 41,2%
Sonografic signs of retarded Hip Developement 5043,9%
Opisthotonos 119,7%
Mobility of the whole spine< 2/3 12 10,5%
Feet deformities1210,5%
Pathological Reflexes (average ) 3,2 of 7

KISS- children compared with the normal birth statistics

 KISSBaden-WüBayern
Twins4 ( 3,5%) 1,3% 1,2%
Premature Birth (<37th week)6 ( 5,3%)6,8%6,7%
Normal Birth 53 ( 46 %)40,0%38,2%
Prolonged Labor38 ( 33 %)12,0%11,8%
Pelvic Presentation etc.13 ( 11,4 %)38,2%9,3%
Caesarean (Singles)13 ( 11,4 %)15,1%15,7%
Vacuumextractor15 ( 13,2%) 6,1%7,1%
Forceps3 ( 2,6%) 1,7%1,5%

Spontaneous complaints reported by the parents

 n %
Tilt Posture 5750,0%
Torticollis2925,4%
Asymmetry of muscle tonus2320,2%
C-Scoliosis2118,4%
Retardation of Hip Developement2118,4%
Ophistotonos108,8%
Foot/Feet deformed87,0%
Restless Sleep65,3%
Does not eat/drink well43,5%

A Danish team (JENSEN et al. [19]) 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 and others.

Diencephalic Disorders treatable by Manual Therapy

These cases are much more difficult to classify. Already GUTMANN [20] had reported some impressive cases. In the USA FRYMANN and others of the osteopathic school treat related syndromes in children (see also [21]).
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.

* lack 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

Even more 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 [22] 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".

Cerebral Palsy

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.

Brain development consumes 87% of the basic metabolic rate in newborn (as compared to 23% in adults, [23]. 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 [24], 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 [25]. 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 [26]. 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 [27] 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 [28]. 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.

Pathogenetical Considerations

"Head stabilization .... is a complex process involving the interaction of reflexes elicited by vestibular, visual and proprioceptive signals} '' [29]. 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 [30]. "Most of the cerebral development lies still in the future for the newborn'' [31]; this development "begins at the head''[32].

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 [33]. 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 [34]. WISCHNIK et al.[35] showed in experimental studies the biomechanics of delivery (see also [36]. GOTTLIEB [37] recently published a literature review with a lot of material.

During 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 [38]. FRYMANN attracts our attention to the often forgotten traumata of early and to their impact on sensorimotor development.

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

are 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 [39]. 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[40] 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.
Interestingly enough 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 [41]. Using rasterstereometric equipment [42] 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 up.
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 [43] 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.

The Treatment

The 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?

* Suboccipital 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.

* Removal 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 impulse manipulation:
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 [44]. 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

The 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) and wait.
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 [45].
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 [46]. 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 [47] In doubtful cases a trial manipulation can help to diagnose KISS ex juvantibus [48].
The differential diagnosis should exclude 'simple' muscular asymmetries and cases of intramedullary tumor [49] 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.

The 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 [50]. The clinical picture sometimes even improves after the manual therapy [51]. 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') [52] " a well-documented but uncommon cause of childhood torticollis'' [53].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 [25]. So much to the problems of documenting birth trauma....

Today's knowledge

Medical 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.

Conclusion

Manual 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, swallowing).
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 cerebral palsy, children after a hydrocephalus shunt-operation, after meningitis or encephalitis etc.

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Dr.med.Heiner Biedermann nach oben
Chirurg / Chirotherapie
Huhnsgasse 34
Köln
email: hb@manmed.org
  
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