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[Physio Discussed] Should spinal manipulation be used in paediatrics? With Anita Gross, Nikki Milne and Jenifer Dice

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In this episode, we discuss Physiotherapy within the Paediatric population. We explore: 

  • Cervical manual therapy in infants, children and adolescents: yes or no?
  • Evidence based treatment for paediatric conditions e.g. colic, torticollis
  • Appropriate manual therapy technique selection for paediatrics 
  • Shared decision making within the paediatric realm
  • The collaboration of the Paediatric Spinal Task Force

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Anita Gross is an Associate Clinical Professor at McMaster University, where she has directed their advanced orthopedic musculoskeletal program, and is also a respected educator with the Canadian Physiotherapy Association and Western University. With a sustained research trajectory, she has made substantial contributions to clinical research in neck and back pain, leading the Cervical Overview Group, a global research collaboration responsible for producing and maintaining Cochrane and other high-quality systematic reviews related to neck pain. 

Jenifer Dice brings over 25 years of clinical experience delivering pediatric physical therapy across a range of settings, serving patients from birth through adolescence. Currently based near Houston, Texas, Jen balances a full-time Assistant Professor role in the Doctor of Physical Therapy (DPT) program at Texas Woman’s University with continued outpatient pediatric practice. Her academic and clinical interests focus on integrating manual therapy approaches into pediatric physical therapy, and her research reflects a commitment to connecting hands-on care with evidence-based inquiry. 

Associate Professor Nikki Milne is an experienced paediatric physiotherapist, researcher, and educator with over two decades of expertise in child health, fitness, and health professional education. She is the Paediatric Lead for research and coursework in the Physiotherapy Department at Bond University (Gold Coast, Australia) and is also the Assistant Dean of Research for the Faculty of Health Sciences at Medicine at Bond University.  Her research focuses on paediatric motor development, safe and effective paediatric physiotherapy, physiotherapy education, injury prevention in sport, and student-led school health programs. 

You can find further information on the policies discussed in this podcast here: 
Position Statement - Open Access Article; Gross, A. R., Olson, K. A., Pool, J., Basson, A., Clewley, D., Dice, J. L., & Milne, N. (2024). Spinal manipulation and mobilisation in paediatrics – an international evidence-based position statement for physiotherapists. Journal of Manual & Manipulative Therapy, 32(3), 211–233.

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Our host is @sarah.yule from Physio Network

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SPEAKER_01:

Welcome to the Physiodiscussed podcast. Today we're joined by three world-leading experts in pediatric physiotherapy, where we'll be exploring the International Position Statement on Pediatric Spinal Manipulation. This is a topic that's been the centre of much discussion, and today we'll unpack the evidence, clarify any misinformation, and highlight what this means for clinicians working with children. Jennifer Dice is an assistant professor and practicing pediatric therapist based in Texas. With more than 25 years of clinical experience across hospital, community, and outpatient settings, she has built a career on integrating evidence-based manual therapy into pediatric physiotherapy. She's also a global contributor to the IFOMT IOPTP Task Force, helping shape the Global Position Statement on Pediatric Spinal Manipulation. Anita Gross is an associate clinical professor at McMaster University and a leading voice in musculoskeletal physiotherapy research. She has coordinated the IFOMT IOPTP Task Force on Pediatric Manipulation, where the team has developed eight foundational publications underpinning the forthcoming International Position Statement on Pediatric Spinal Manipulation. Anita is a multi-award-winning researcher and clinician who continues to bridge academic rigour with day-to-day clinical practice in Canada. Nikki Milne is a pediatric physiotherapist, researcher and educator with over two decades of expertise in child health. She currently leads pediatric research and coursework at Bond University, as well as serving as Assistant Dean of Research for the Faculty of Health Sciences and Medicine. Nikki's work spans motor development, physiotherapy education, injury prevention, and international leadership in pediatric curriculum design and safety standards. She too is contributing to the international efforts to guide safe and effective pediatric physical therapy practice alongside Anita and Jen. Today's episode is a must-listen for anyone treating infants, children or adolescents, whether in private practice, hospital or community care. We'll unpack the International Physician Statement on Pediatric Spinal Manipulation, clarify any misinformation, and explore what the future of safe, evidence-informed practice looks like. You're going to love today's episode. I'm Sarah Yule, and this is Physio Disgust. Well, welcome back to the Physio Network podcast. Today we're diving into a marvellous topic on pediatric physiotherapy, where our three marvellous guests have been at the forefront of leading international research and involved in shaping the forthcoming global position statement. So welcome to the three of you. Nikki, can you take us back to the beginning? Why was this task force formed and what was happening internationally that made guidance in this space so necessary?

SPEAKER_03:

Yeah, sure. Happy to talk to that. That way back around 2018, I think it was, we had a little bit of controversy going on here in Australia where there was some media coverage, very strong media coverage at the time, and it went on for a little while about some chiropractic adjustments, which we, you know, our language is manipulation of the spine going on. And it was quite aggressive kind of techniques being used, and that made it into the media. And then there's a bit of a media storm that kicked off about that, and it went international, so it spread all over the world. And then our we had members from within the physiotherapy community all over the world starting to make contact with their leads in the member organizations and then eventually reaching out to World Physiotherapy's specialty groups, iFont. And so they're the manual, they've changed names now, but used to be manual and manipulative therapy group, but now they're manual musculoskeletal group. So they reached out to them to ask for advice. What's the physiotherapy position on this? Are we doing this? Is this something that physios should or shouldn't be doing? And there's some varied practice going on around the world by physios. So they were really looking for some guidance because we didn't have any guidance documents at all. And so soon after that, the Australian government actually commissioned a report from SaferCare Victoria. So I'm not sure if you've come across that report, but it looked at doing a systematic review, very rapid review, quickly to look at what the evidence was and to see whether in Australia those who were licensed to do manipulation of the spine should be doing it for all of these different conditions they explored. So in Australia, people who are licensed to manipulate spines are physiotherapists, osteopaths, medical practitioners, and chiropractors. Whilst not all of them manipulate the spines of children, there was quite a lot of that activity going on in chiropractic at the time. After that Safer Care Victoria report, the Australian government put an interim ban on manipulating the spines of children under two. So nobody was able to manipulate the spines of infants essentially at that time. And then you know it went quiet for a little while, but in the background, we had in 2020 established the Pediatric Spinal Task Force, which was a collaborative group of researchers and clinicians from iFumped to the more adult-oriented group, and then also the iOCT, which is the International Organization of Physiotherapists in pediatrics. And so that's how we all came together. And Anita chaired that group. So she's done an amazing job over the last five years leading us through a series of activities in order to try and prepare ourselves to offer a position statement. And initially we thought, oh, this won't be too hard. We'll do a review of the literature and have a look at what our position is. And quickly found out there just wasn't enough. And I'm sure we'll talk about that later. Information for us to be able to get an immediate grasp on it. Nobody had hadn't been enough reviews of the wider literature because the Safer Care Victoria report just looked at the very high-end literature, RCTs, etc. And so that set us off on a journey. So we really decided, okay, we'll bring this group of researchers together and we'll start. We started meeting weekly, lots of early mornings for myself and some very late nights for some of the other members from like our South African member. And then we just got busy going through a series of studies to try and eventually come together with a position statement, which we worked on for four years. And the position statement essentially used the combined efforts of all of the studies that we did in order to make a decision about what we would recommend as a physiotherapy profession, which we published just before we presented at the iFunk conference last year. So around June, I think May, June, it got published in 2024.

SPEAKER_01:

Fantastic context. Anita, from your perspective in research, what were the key questions that clinicians were asking at the time?

SPEAKER_00:

They wanted some clear evidence, guidance about the benefits, about the risks of spinal manipulation and mobilization, and kind of get a practice framework around clinical reasoning that helps clinicians kind of weigh out the potential harms against the expected benefits in order to select the appropriate outcomes, in order to choose which manipulation mobilization for what infant, what child, what adolescent. And they wanted really clear guidance on how to use that in spinal manipulation or mobilization of muscoskeletal and non-muscoskeletal conditions, again in infants, children, and adolescents. Our primary question was twofold at the time. The first was to systematically do that synthesis as was already described on benefits and harms. And the second was then to get that position statement that they could lean on and appropriately use. We went through a series of about uh three-stage processes in order to achieve that, to gain that knowledge. And as it was already identified, it was a systematic or literature search stage where there were one major scoping review that Nikki and her team of students, and our team as well, but she led that one basically. And the second was uh psychometric properties reviewing the clinical outcome measures. And that was one of the Nick Master students and the whole team as well, and led often by uh Jan Poole and myself and the students. And then there was a Delphi stage, a three round Delphi study of international physiotherapy experts led by Jen. And then the final stage was a refinement stage. This final stage was based on the evidence to decision framework. It's kind of a summative analysis, position statement development, and then evidence gap map analysis to so it took multi-layers to come up with the final position statement. So I I think, Jen, you if you want to discuss some of the findings related to that, that would be great. Yeah.

SPEAKER_02:

So our big findings, we had seven key findings out of the position statement. The first basically being to help guide our physiotherapists across the world is spinal manipulation and mobilization is not recommended and should not be performed on any infants. So not just manipulation, but also mobilization. Cervical lumbar spine manipulation should not be performed on children. Spinal manipulation and mobilizations, they're not appropriate to treat non-musculoskeletal conditions. So they are not appropriate to treat asthma, autism spectrum disorder, breastfeeding difficulties, cerebral palsy. Now, that's not to say that if a child with cerebral palsy might fall into a category that has a musculoskeletal issue, they may or may not, based on our guidelines, be eligible for some treatment. But let me finish the other one. So spinal mobilization, it could be appropriate to treat children with musculoskeletal conditions. So, in other words, some spinal mobility impairments, pain, neck pain, back pain with headache, those types of things. So kind of going back to my previous statement, if we have a child with cerebral palsy that maybe has some musculoskeletal neck pain, we might be able to treat the neck pain, but we're not going to change or treat the cerebral palsy with the spinal mobilization or manipulation, right? Again, another potential appropriate use is thoracic spine manipulation might be appropriate to treat children, again, with musculoskeletal conditions or mobility impairments that have neck or back pain. And ultimately, spinal manipulation and mobilization might be appropriate to treat adolescents with musculoskeletal contritions, including the neck and back pain and pain with headache. So, in other words, when we are saying it might be appropriate, the therapist should really have sound clinical reasoning behind why they're using those techniques in those patients. And the last major statement is there was no place where we could really 100% recommend that any spinal mobilization or manipulation is appropriate. It's really cautioned that it should be used. It should be used appropriately when there's a greater benefit than there is a risk to harming the children.

SPEAKER_01:

That's a great summary. Just for the listeners' clarity, can you define the difference between infant, children, and adolescent? Sure.

SPEAKER_02:

We considered an infant under the age of two. A child was three to, I believe, 12 years old, and above 12, we considered adolescent.

SPEAKER_03:

When we first started this, we were like, oh, where's our thresholds going to be when we're talking about these populations? Because there's a few different definitions around the world for classifying these groups of pediatric clients. But that was the thresholds that we decided on, just so we could have clarity for the entire process. So we didn't chop and change the groupings as we move through different studies.

SPEAKER_02:

There was a lot of discussion that we had in terms of even within the groupings, there's a difference between a five-year-old versus a 10-year-old. So it again, it has to really speak to there's got to be that sound clinical reasoning behind what they're doing and why they're doing it.

SPEAKER_01:

So it's sounding like the product of the Delphi studies, the systematic reviews, this consensus building, there's been a nice balancing of evidence safety and the clinical realities. Nikki, how do all of these findings translate into education and competency expectations?

SPEAKER_03:

Yeah, so that's interesting and that's a process that's very much still going on. I'm sure you can imagine that once research is published, it takes quite a while to make it into practice and probably even longer to make it into education pathways. But things that we have done is I teach pediatric, so I one of the conditions where this topic comes up quite a bit is around Tortocolis. And so historically, the way we taught our curriculum for Tortocolus was to teach them about the international guidelines, make sure that students understood what assessments to do and then what treatment techniques had evidence behind them. Fortunately for us, those guidelines got updated and they included some of our work. So they were able to then say, use our work to show that spinal manipulation was not effective because this was one of the conditions that we explored in the scoping review that we did. So we have now integrated that into our curriculum. So we have a situation where, which is really common, this, I'm sure Jen's experienced this too as a PEEDES therapist, where you have a family member come in and say to you, Well, my friend's child had this same condition and they went to the chiropractor and that worked. So should I do that? And so, how do you deal with that as a physiotherapist? What kind of conversation do you have right there? And if you're talking about doing your job well as a physiotherapist, you should be going through shared decision-making processes where you can explain all the options that they have available and you can present what the evidence is for those options. So we teach our students now about this research. So even though we're not saying to do it, we're teaching them what the evidence is around it right now and how to manage those kind of conversations. So we do that for colic. We do that because colic is a common referral when babies are all stiff and arching back, they'll often get referred to physio. So we are teaching our students about colic, about tortocolis, and then in the musculoskeletal parts of our curriculum, which are often delivered more in adult contexts, then we're making sure the students are aware of these, the position statement and the research that underpin the position statement, so that when they're translating their skills, they're learning in those subjects in musculoskeletal, that they also know how that applies to the pediatric populations. Anita is obviously leading the curriculum development in the manual therapy space as well and contributing really strongly in that area. So, Anita, do you want to add to that?

SPEAKER_00:

Um, sure. One of the things that we're doing at a kind of post-professional level for physiotherapists, that's where I teach in orthopaedic manual manipulative physiotherapy, is that the students have a clear understanding of the where the borders are of the age divisions of when one might start to consider mobilization and just have the exact same case study and just shift the age along from a four-year-old to an eight-year-old to a 12-year-old to a 17-year-old, and how all of a sudden this becomes absolutely don't do it to let's consider it. And perhaps mobilization or even manipulation might be a valued contribution to that. The adolescence, for example, neck pain or spinal pain of some form. So using case studies across the ages and including infant to adolescence really helps give them that diversity and of understanding in it. In our basic physio school, it's very much the same as you've done, it's an integrated so that they have an understanding of when not. When a parent comes to you and says colic or otitis medius or ear infection or asthma, that is not a place, that is not the place to do spinal mobilization or manipulation. That's one of the other pieces that we spent have spent so much time on, a mega time on, is that knowledge translation piece. Like first we published, you know, seven papers on this, then translated the main message into seven languages. This is all on the website. And you think, my goodness, we've done also all kinds of social media productions, all kinds of conferences, have attended lots of conferences, done editorials, are sending messages to professional organizations through editorials. And currently we're working on a decision needs analysis of parents themselves because we I don't think we can actually reach parents right now when they're in that process of making that decision. So on an everyday physiotherapy schedule, parents come in and will say, Oh, the child care service I'm in recommends my child is a little bit unrested or is unsettled in some way and should receive manipulation to help them settle. And maybe even the parents should receive manipulation to settle them down. And this is an example one of my students brought forward. And I'm going, we need to know as physiotherapists that there's many non-muskeletal conditions that this is just not appropriate for. And it's not not only not appropriate, it's not necessarily safe. So that knowledge translation piece has been, I think, a bit of a nix in our pathway. I don't know. We've spent four years working on it, we've spent now two years working on knowledge translation, and we still feel like I still feel like I'm still very much at the beginning because I haven't addressed the parent need. I think there's a need for the parent. I don't think the parent thinks there's a need. I think the parent thinks they're quite happy to take their unsettled child and have them settle down and for colitis or whatever it is, and they feel That the child or the baby settled, but I don't think they understood the risk that they put the child in.

SPEAKER_03:

It's really interesting because we get contacted all the time by people who see something or hear something or read something on social media and that it ignites a bit of concern for them. And then they're like, should this be happening? Are you able to address this? So things like I had somebody contact me who a childcare center was sending out advertisements from a local chiropractor saying, I am aware your child has autism. And we can offer adjustments of your child's spine. And also we can adjust your spine and that will help with bonding with your child. And so the parents are unarmed. They don't know what the evidence is around this. And of course, you're desperate, right? As a parent, when something's going on with your child, you absolutely want to do the best by your child. So if somebody says this is something you could do that works, of course, as a parent, you want to lean into that. So we get contacted. Should I do this? And I'm like, oh, what they should be telling you is what is the evidence behind that? So then I we share the evidence that we've got about this topic. We'll forward the position paper and highlight the parts that we think that the parent could digest or the person who's contacted us who has concerns. But it's just getting these messages to parents is really important. The other really common one is if a baby's had a difficult birth, for example, that they're getting referred off in some parts of the world, including here in Australia, by the midwives to have the spines adjusted of the babies. Now there is zero evidence that has any effectiveness, degree of effectiveness. And there is some evidence, not a lot, but some evidence that might be harmful for them. So we have to keep working on disseminating the evidence that we have and make sure as a research group that we keep updating the evidence so we're able to share the latest evidence with members of the public that contact us or other physios who want to get guidance about how to communicate with their families about it.

SPEAKER_01:

I think you've all offered the fantastic observation that one of our biggest challenges as physios is, and probably for the pediatric world, you've got the challenge of the communication with the child and with the parent. In terms of the clinician that's that's working in this space, what advice do you have for them to better educate themselves, aside from listening to this podcast, but how do they equip themselves with improving the skill to actually translate this education and appropriately share it?

SPEAKER_03:

I think the concept of shared decision making is only just starting to hit more fully the clinical world. There's some parts of the world who don't, that that's a completely foreign concept to them still. And I'm probably lucky it's been talked about a lot around my university because some of the amazing researchers at our university were um, you know, front runners for pushing that concept forward. But essentially, shared decision making from a clinical point of view, if you're a clinician, means that when you are assessing a child and you say, okay, or an adult, depending whoever it is. But in our case, if you're assessing a child and you decide this is what's going on, this is the impairments that the child has that's causing the discomfort or the problems that you've come to us for, at that point, they need to explore what options are they, not just what I would do straight away as a therapist, because we all would come at that with different perspectives, different training backgrounds, but look at the evidence and then share that with the families and talk about, okay, this is what the research evidence says. This is what my clinical reasoning would say about how we could use this evidence to have a great outcome, or this other evidence to have a great outcome in the situation that they're dealing with at the time. And then let families make informed decisions about how they want to progress. And if you as a therapist are uncomfortable with or untrained in offering some of these techniques and a parent wants to progress with that, you may have to refer on to somebody else. Or you if they're dual tasking and they're sending their children to a physio and a chiropractor or a physio and an osteopath, and you're uncomfortable with what's going on, you like you don't feel like that's safe in the other context, the other professional group, then you can cease your treatment while they're exploring treatment in other areas and then they can come back to you. And that's certainly something I've done in practice, whereas that's your decision if you wish to explore that and go down that route. But the risk is that if there's an adverse event from a manipulation to the neck in an infant, for example, and you see them a couple of hours later or even the next day, then you could be caught up in the negative outcome. And so you have to be really careful, I think, when high-risk interventions are going on around your work as a physiotherapist. And so it's just about having really open, honest conversations with your families with the evidence in mind. So it means that our clinicians need to have read all of this evidence and they have an obligation to be able to share the correct information with their families.

SPEAKER_00:

I think the clinician can easily pick stuff up from that position paper. There's some sections that are green, yellow, red zones of where this is effective or not. We have little pictures as such that depict which conditions is it beneficial for, which conditions is it not beneficial for. And by going from red dots to green dots, you can see very quickly, just with those two, one table and one infographic, you can come to that knowledge very quickly. So I don't think it will take a lot of in-depth reading. It just takes at least some reading, though, in this field. Where can clinicians find that infographic?

SPEAKER_03:

So we've pushed it out a number of different ways. It's on our Instagram pages and Facebook pages, also on the IOPTP, the International Organization of Physiotherapists in Pediatrics, it's up on that website. And it's also up on the IFONT website. So all of the infographics, which are translation documents from the studies themselves, to try and make it really easy to digest the complex processes that we've gone through across the multiple research studies. So it's right there in their hands. And if they want more reading, they can go back and read the actual studies, which are also on those same websites, all the links to them. Or if they just look up pediatric manipulation of the spine, usually they'll find our paper if they're on Google Scholar, for example.

SPEAKER_02:

Our paper is available open access. So they should be able to get that without having to pay extra. I just wanted to add to what Nikki was saying in terms of the shared decision making. I think what a lot of it comes back to is being able to build that rapport with the family. Because when you can build that rapport with the family, let's say it's somebody that started PT, but then they heard from their cousin that chiropractic is good. If you have that rapport with the family, they'll feel safe to bring it up to you, not judged, but safe. And then you can have that conversation of this is the evidence that we've got. This is where I would not recommend that and give them the why. I think if you're giving them the why, not just, oh, no, don't do that, then that helps to put the parent at ease as to why it's not appropriate or why you're choosing to do this versus that.

SPEAKER_01:

Thank you, Jen. Anita, I'm curious, just going back to what you were speaking of earlier, you spoke about how you guide younger clinicians through that age-appropriate assessment and how technique selection changes. What does this actually look like practically for clinicians?

SPEAKER_00:

For sure. There's a series of uh screening tasks that would be done that are not different in pediatric necessarily than in adults. There's uh neuroscreens, there's a typical muscoskeletal range of movement assessments, and then there's uh full knowledge of red flags. So if there's co-symptoms that might come with infections and other uh red flag disorders, then having a knowledge of what those red flags would look like in an adult versus an infant being more unsettled, perhaps crying more than ever before, or maybe uh Nikki can jump in really quickly here because I'm not the biggest person on pediatric infants, but knowing that whole list of red flags is quite valuable, I think, in order to classify what the potential disorder type is and whether you need to move someone on to another clinician, while uh medicine, for example, their family doctor, um, because there's a lot of other co-conditions that are appearingly present.

SPEAKER_02:

Yeah, like a like a red flag condition might be changes in bowel and bladder. Well, that would be a red flag for adults or children. If you have a five-year-old that was previously potty trained and now they're having issues, that's a big red flag to me that they need to be referred out and not treat, definitely not treated with spinal manipulation or mobilization.

SPEAKER_03:

The red flags and the adverse events, this is work that we have highlighted that we want to do moving forward because what we found in a huge amount of the literature that we went through, went through a lot of studies across the professions, so not just physio, but chiropractic, osteopath, medical, and physio, and many of them never reported on adverse events. So it wasn't that they said there were no adverse events, it just wasn't mentioned at all. And then a couple did mention adverse events, and there were a series of there is a systematic review about the adverse events themselves, but there is across the studies there's some that are referred to as mild adverse events, some are a bit more severe, and then there was a really severe ones like death, for example, which was rare, but it was definitely in the adverse events that we looked at. So, but some of the ones that in some papers were referred to as mild, they referred to a term as vegetative reactions. And my heart like skips a beat when I read it every time because I'm like, that's not normal. That's not mild. And in my clinical training, that raises some big concerns. So what some people refer to as mild and they tolerate it and they say it's normal. We in the spinal task force believe that's a near-miss. You should not proceed when this happens. And there are things like where they've got reflex apnea that lasts for a period of time. So they stop breathing for a period of time. They might get noticeable sweating, which is not normal on a baby. We don't see that typically. They might get severe flushing after they've manipulated or mobilized the spine. They might get bradycardia. So those kind of things are documented in the literature. And I think if I was treating an infant for anything, if that happened, I'd pause and go, that probably wasn't something just happened with their autonomic nervous system or whatever it was. Something we don't understand what triggers some of these things, but I'd stop. I wouldn't proceed from that point on. But that in some of the literature is considered mild and move on, keep going with it kind of thing is happening. And so that's concerning for us. So we want to make sure that we understand the adverse events better than what the literature currently provides us. And as a task force, we've made a decision that we want to proceed with a new study which will monitor adverse events, which we know will probably be the worst of them, because it's quite hard to capture this information, except maybe in some high-quality RCTs, hopefully, people who are doing further research in this space, people who choose to do this kind of research, hopefully will start actually talking about their adverse events. But our task force is going to look at emergency department admissions. So we're planning a study, an international study where we work in some of the big emergency departments and we will do both retrospective and prospective auditing of the admissions of pediatric patients who have been admitted after some form of spinal treatment. So whether it's done by chiropractical physio or osteopath or medicine, if they've had that and then they're admitted with paralysis or severe headaches, or the parents are just saying they're not right. This baby's not the same as they were before they started this treatment. So those kind of things we want to monitor them and try and figure out whether we can actually quantify the adverse events a little better than what the literature currently tells us. And that'll give us more information to work with then.

SPEAKER_00:

Mild symptoms really paralleled themselves to our early SID type of symptoms. And Nikki had been mentioning in some of our meetings that maybe it is SIDS that is, in fact, one of the symptoms. The other thing I wanted to mention as well is that there was a differential between manipulation and mobilization. While mobilization had this type of vegetative response, which is classified as mild, manipulation had a greater balance of severe side effects. Back and neck, they were like unsteady gait, poor coordination, drowsiness, hospitalization, for example, of a cervical tortocolis treatment in a 12-year-old. They were also things like subarachnoid hemorrhage and death in a case of a three-month-old, a quadriplesia, paraplegia in a case of a four-month-old. And this was for tortocolis treatment of tortois. And then for cervicogenic headaches, they were vomiting, they were facial weakness, diplopia, ataxia, and a seven-year-old. But the risk rates were undeterminable. They were in more found in the very low quality literature of case reports, for example, not in the high quality literature of, say, for example, systematic reviews. But a small systematic review will never be able to pick up a rare adverse event that's one in a hundred thousand or three hundred thousand if they're only studying 40 patients, for example. So the balance of mild adverse events was seemed to be heavier in mobilizations, and the balance of more severe occurrences were reported more often in the higher grade of the hands-on treatment of manipulation, which I found really interesting. So this concept of adverse events really needs to be addressed and dig into zones like SIDS that you think that child died of something else, but possibly in the background of that history of that child, there could have been a mobilization or a manipulation done in the past, and we're just not picking it up because they're not classifying them in a certain way in the emergency departments.

SPEAKER_01:

It's sounding like you've got some gaps or areas to focus on in your research moving forward. Just in terms of going back to the, I suppose, the age spectrum, how do you guide clinicians around when mobilization may be appropriate, if it is appropriate, in terms of that adolescent into adult for musculoskeletal conditions?

SPEAKER_02:

Well, one of the things I try to keep in mind, and it was another task force colleague that kind of coined this phrasing, but we can't necessarily think of adolescents or older children as adults, right? So we can't necessarily treat them the same way. I think for me, if we're guiding from the use of mobilization or manipulation and trying to figure out and do that critical clinical reasoning, right, where are they in terms of skeletal growth, right? And skeletal maturity. I think that's a big driving factor for me. And if we're on the younger side and there's no red flags, it would be something that could be beneficial. If the child younger, I would always err on the side of a mobilization because you're not going to be going beyond any physiological limit. But again, I would have to have my stars aligning before I would use that as an initial choice. I'd rather do some active movement that they're doing themselves, whether it's through play or whether it's through just general exercising and lifting, that sort of thing, functional activities as opposed to a mobilization or manipulation. That's only one tool that we have in our toolbox as physiotherapists, right? Manipulation and mobilization. There are so many other techniques that we can use.

SPEAKER_01:

Fantastic. No, exactly right. The biggest tool is the education piece, isn't it? 100%. Fantastic. So I suppose this work obviously represents years of international collaboration to hopefully bring some clarity and safety and evidence into a space that's perhaps been a bit clouded by uncertainty. So thank you to all three of you for not only leading this work, but in giving clinicians around the world a clearer path moving forward. A final round, Robin, in one line, what's one message that you want every clinician listening to walk away with today?

SPEAKER_03:

First one is do not manipulate the spines of infants. There's just too much, too many adverse events in that space and no evidence of effectiveness for any condition.

SPEAKER_00:

Ah, and the second one would be that the clinician can take actionable insights from this information and expand it and bring it to the patients they see, the parents that they see, the doctors they see, the midwives they see, the child care services and staff they see, or even the policymakers that they uh work with and inform them about this situation. That there have to be safe choices to that can be made with hands-on therapy in terms of manipulation mobilization for children. And they need to extend this research to that group of people. Help children meet major challenges in terms of their muscoskeletal or non-muscoskeletal situations.

SPEAKER_02:

And I'm gonna lean back to building that rapport with the patients of families that you're working with, whether it's the young adolescent that you're directly working with, or the parent of that adolescent child or infant. Because when you have that rapport, then you can have these conversations more easily. And you can also help that parent be an advocate for their own child as well. Because sometimes they might be getting pressure, whether it's from a friend or a cousin or grandma or whoever. But with that education, you can empower them to say, step back. This is my child, and this is what I feel is appropriate.

SPEAKER_01:

Great advice from all three of you. So thank you very much for joining today, and thank you for helping form this position statement, which hopefully paves the way forward for safer, smarter, and more united pediatric care worldwide. But thank you all very much. You're welcome.

SPEAKER_03:

Thank you for inviting us to be part of the DBO Network podcast.