Manual Therapy in Children: Proposals for an Etiologic Model

The frontal angle of C0/C1_. In children it is not easy to measure this angle because the cartilaginous tissue is much thicker during the first years.

This 6-month-old infant boy has joint planes that are nearly horizontal, something common during the first year of life.

The saggittal angle C0/C1. The saggittal plane shows development similar to the frontal plane. Here the angle decreases from 36° to 28°, restricting the range of motion.

KISS I clinical markers. Fixed lateroflexion: torticollis, unilateral microsomia, asymmetry of the skull, C-scoliosis of neck and trunk, asymmetry of gluteal area, asymmetry of motion of the limbs, retardation of motor development of one side.

KISS II clinical markers. Fixed retroflexion: hyperextension (during sleep), (asymmetric) occipital flattening, shoulders pulled up, fixed supination of the arms, cannot lift trunk from ventral position, orofacial muscular hypotonia, breast-feeding difficult on one side.

A posture of fixed lateroflexion of KISS I. The left arm will be used more; therefore, the motor capabilities of this arm will be more advanced compared with the right arm. Often this asymmetry extends to the lower extremities and lead to an asymmetry of the gluteal furrows, which may be the first symptom observed by the pediatrician.

The overextended sleeping position of KISS II. These children may have an orofacial hypotonia, which leads to sucking and swallowing problems. If these symptoms are combined with a fixed lateroflexion, these difficulties may lead to unilateral breast-feeding problems.

A common situation with regular morphology and a shift of C1 to the right. In this case the radiograph helps verify the clinical tests, as we would expect a right-convex posture in this child.

The right C2 articular facet is dysplastic; thus, the asymmetry of the suboccipital region is not purely functional. Use of manual therapy should take into account that this anatomic situation may lead to recurrent episodes of fixed asymmetry.

Congenital posterior fusion of the C2/C3 vertebra. This finding is not necessarily connected to clinical problems; however, it helps to know about such a morphologic problem beforehand as one can advise, for example, not to do somersaults and to use an inclined work table to prevent unnecessary stress during anteflexion.

MTC of an infant. The infant lies supine in front of the therapist. In most cases the radiological examination preceded the examination and one is able to compare the radiological and the clinical picture. The treatment may ensue immediately after the examination, which has the additional advantage to avoid unnecessary stress for the nervous mothers. Most of parents do not realize the exact moment when we treated their child, as the protest of the young patient is almost as strong during the examination as during the manipulation.