![PRISMA flow diagram [31]](https://www.researchgate.net/profile/Annalie-Basson/publication/366410500/figure/fig2/AS:11431281108436324@1671505657790/PRISMA-flow-diagram-31_Q320.jpg)
Access to this full-text is provided by Springer Nature.
Content available from BMC Pediatrics
This content is subject to copyright. Terms and conditions apply.
Milneetal. BMC Pediatrics (2022) 22:721
https://doi.org/10.1186/s12887-022-03781-6
RESEARCH
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco
mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Open Access
Spinal manipulation andmobilisation
inthetreatment ofinfants, children,
andadolescents: asystematic scoping review
Nikki Milne1,2*, Lauren Longeri1, Anokhi Patel1, Jan Pool3, Kenneth Olson4, Annalie Basson5 and Anita R. Gross6
Abstract
Purpose: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and
mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies,
regulations, position statements and practice guidelines informing their clinical use.
Design: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and
grey literature from root to 4th February 2021.
Participants: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition.
Intervention: Spinal manipulation and mobilisation
Outcome measures: Outcomes relating to common childhood conditions were explored.
Method: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed
methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and
Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods
Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis
of reported findings was undertaken using a levels of evidence approach.
Results: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobi-
lisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adoles-
cent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD),
back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches,
infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and pla-
giocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipula-
tion or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described
in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic
reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for
‘no significant effect’ of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enu-
resis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw
conclusions regarding spinal mobilisation to treat paediatric populations with any condition.
*Correspondence: nmilne@bond.edu.au
1 Department of Physiotherapy, Faculty of Health Sciences and Medicine,
Bond University, Queensland, Australia
Full list of author information is available at the end of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 2 of 24
Milneetal. BMC Pediatrics (2022) 22:721
Conclusion: Whilst some individual high-quality studies demonstrate positive results for some conditions, our
descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in
paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks.
Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric popula-
tions are warranted.
Keywords: Spine, Manipulation, Mobilisation, Infant, Child, Adolescent
Background
Various healthcare professionals utilise manual ther-
apy including spinal manipulation and or mobilisation
as a treatment modality for musculoskeletal and non-
musculoskeletal conditions. ese treatment modalities
are being utilised to treat paediatric clients, including
infants, young children and adolescents with a variety
of acute and chronic conditions [1, 2]. Manual therapy
is an umbrella term that encompasses any hand move-
ment that produces a physiological or mechanical
change in soft tissue and joints [3]. Spinal mobilisation
is one form of manual therapy which may be used after
a thorough and extensive clinical reasoning process. It
comprises a continuum of skilled passive movements
appliedto the spine at varying speeds and amplitudes,
impacting joints, muscles or nerves with the intent to
restore optimal motion and function, and to reduce
pain [3].Spinal manipulation is another form of manual
therapy and is defined in Australian Health Practitioner
Regulation National Law as “any technique delivered
by any healthprofessional that involves a high velocity,
low amplitude (HVLA) thrust beyond the usual physi-
ological range of motion, impacting the spine, within
the limits of anatomical integrity” [4]. e International
Chiropractic Association (ICA) utilises two terms that fit
within this definition; i) ‘Spinal Adjustment’—a specific
directional thrust that is believed to set the vertebra into
motion with the intent to improve or correct vertebral
subluxation or malposition, reducing or correcting neu-
roforaminal / neural canal encroachment and; ii) ‘Spi-
nal Manipulation’ – a specific thrust to a spinal joint to
mobilise the joint or put it through its range of motion
[5]. Whereas, the International Federation of Orthopae-
dic Manipulative Physical erapists (IFOMPT), refer to
spinal manipulation as a passive, HVLA thrust applied to
a spinal joint complex within its anatomical limit, with
the intent to restore optimal motion, function, and/or to
reduce pain [6].
According to the World Health Organisation (WHO),
regulations guiding the utilisation of spinal manual
therapy and manipulation are consistent between coun-
tries [7]. For example, in Australia, under the Health
Practitioner Regulation Law (ACT) Sect. 123, a per-
son must not perform spinal manipulation unless they
are registered practitioners in one of the following
healthprofessions: Chiropractic, Osteopathy, Medical or
Physiotherapy [4]. is is consistent acrossseveralother
countries including but not limited to the United States of
America [8] and Canada [9]. Whilst not common in the
physiotherapy profession [10] or used by some evidence-
based chiropractors or osteopaths [11–13], the treatment
of non-musculoskeletal conditions with spinal manipula-
tive therapy is a long-standing tradition in chiropractic
and osteopathic professions [14, 15] and this is based on
the underpinning theory that spinal dysfunction, or sub-
luxations can negatively impact the autonomic nervous
system and the bodies self-healing ability [16–18], and
spinal manipulation can remedy this by impacting the
autonomic nervous system and improving physiological
functions [19, 20].
ere is great controversy regarding the safety and
efficacy ofspinal manipulationin paediatricpopulations
[2]. An independent expert review was commissioned
by Safer Care Victoria in October 2019 and
aimedtoidentify evidence to support position statements
for both safety and efficacy of spinal manipulation
in children under 12 years of age and resulted in
recommendations to the Council of Australian
Governments [2, 21]. An announcement by health
ministers in Australia regarding spinal manipulation
ensued and prompted the Chiropractic Board of
Australia to enforce an interim policy prohibiting the
use of chiropractic spinal manipulation in children
under the age of two years [22]. When exploring the
appropriateness of utilising clinical interventions, it is
important to explore both effectiveness and adverse
events. An adverse event is any unfavourable sign,
symptom or disease associated with treatment, despite
whether it was caused by the treatment [23]. Patient
harm creates both a burden to patients and their families,
and strains health system finances significantly. is leads
to increased levels of care and resource utilisation [24].
Whilst several reviews of varying methodological qual-
ity have explored the effects and adverse events from spi-
nal manipulation in paediatric populations [1, 21, 25–27],
there have been conflicting findings published addressing
a broad spectrum of conditions and there has been little
exploration of the policies, guidelines, regulations or laws,
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 3 of 24
Milneetal. BMC Pediatrics (2022) 22:721
supporting or prohibiting the use of spinal manipula-
tion or mobilisation in the management of infants, chil-
dren and adolescents. Some reviews on this topic have
limited their inclusions toexplorethe effects or harms in
infants, and there has been less exploration of the effects
or harms of spinal manipulation and mobilisation of chil-
dren aged 12years or older. e conflicting information in
publishedreviews conducted to date,appears to be due,
at least partially, to the inclusion of low-quality research
or lack of critical appraisal for included studies [28–30].
ere has been limited publication of policies, guide-
lines and position statements regarding the use of spinal
manipulation and mobilisation of paediatric clients, with
only one review exploring this in paediatric populations
from birth – 12 years [21]. Both the inconsistency of
empirical research findings and the apparent lack of guid-
ance documents to support or restrain practice in this
clinical area, leaves both healthcare professionals and pae-
diatric clients vulnerable to inappropriate, ineffective, or
potentially harmful interventions and a broader synthesis
of the collective literature to guide clinicians in this clini-
cal area is warranted.
e purpose of this systematic scoping review was to
identify and map the available evidence related to the use
of spinal manipulation and mobilisation techniques in
the treatment of infants, children and adolescents with a
variety of common paediatric conditions. is systematic
scoping review was planned as a joint investigation by the
International Federation of Orthopaedic Manipulative
Physical erapists [IFOMPT] and International Organi-
sation of Physical erapists in Paediatrics [IOPTP] to
inform future position statements on this clinical practice
topic and guide more focused research investigations if
warranted. In this systematic scoping review, we identi-
fied and mapped the results of empirical research, reviews
of empirical research, published guidelines for practice,
policies and position statements. In relation to infants,
children and adolescents, we addressed the following
questions:
1. What conditions are being managed with spinal
manipulation and mobilisation?
2. Is spinal manipulation and mobilisation effective?
3. Is spinal manipulation and mobilisation harmful?
4. Are there policies, regulations, position statements
and practice guidelines informing the clinical use of
spinal manipulation and mobilisation?
Methods
e PRISMA statement extension for scoping reviews
(PRISMA-ScR) was used to guide the reporting of this
systematic scoping review [31]. e review protocol
was registered with Open Science Framework on June
14, 2020 (Retrieved from https:// osf. io/ zm8e6) prior to
conducting the search.
Identication andselection ofstudies
After consulting with the Health Sciences and Medicine
Faculty librarian at the host university, the appropriate
Medical Subject Headings (MeSH terms) and Boolean
operations were incorporated before the empirical lit-
erature was systematically searched, combining syno-
nyms for “infant”, “child” and “adolescent”,and key words
related to “spinal manipulation” and “spinal mobilisa-
tion”, followed by outcomes associated with common
childhood conditions. e following databases were
searched: PubMed, Embase, CINAHL and Cochrane.
Grey literature was searched using Google utilising key
terms including “paediatric” (and associated synonyms)
AND “spinal manipulation” OR “spinal mobilisation”
(and associated synonyms) AND “policies” OR “guide-
lines” OR “statements”, hand-searching reference lists
from all included research articles and reviewing arti-
cles via expert referral of relevant literature. e search
strategy was wide in scope to support the nature of the
review and details on the search strategy are presented
in Supplementary File 1.
e four databases were searched from root up to
18 June 2020 with an updated search up to 4th Febru-
ary 2021. To identify relevant grey literature, agoogle
search for files ending with [file: PDF] and [file: doc] was
conducted. e initial and follow-up search was per-
formed independently by two authors (A.P. and L.L.).
Studies were gathered, and duplicates were removed
using EndNote (Endnote Version X9.1.1, Clarivate Ana-
lytics; 2019).Once duplicate articles were removed, two
authors (A.P.and L.L.) independently conducted title and
abstract screening to identify potentially relevant articles
for full-text review. After undertaking an initial process
of consensus, outstanding disagreements between two
authors (A.P. and L.L.) were resolved by a third author
(N.M.).Studies that appeared to meet the inclusion cri-
teria at title and abstract screening stage were retrieved
in full text. Eligibility criteria were applied.Table1pro-
vides a comprehensive list of the inclusion criteria for
both research articles and grey literature. Studies were
excluded if individuals were aged over 18years, if man-
ual therapy techniques were applied to areas of the body
other than the spine, if paediatric data was unable to be
extracted from mixed populations or if it was an ani-
mal study. Grey literature was searched to gain a deeper
understanding of current professional services regard-
ing the use of spinal manipulation and or mobilisation.
We excluded documents that did not have an attributed
author or publisher and protocols with no full published
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 4 of 24
Milneetal. BMC Pediatrics (2022) 22:721
study were excluded. To achieve a final consensus on
included full text articles, all discrepancieswereresolved
by a third reviewer (N.M.). Reference lists of included
articles were hand-searched for other possible arti-
clesthat may have been missed during the initial search.
e results of the searchare presented in flowchart for-
mat according to the PRISMA extension for scoping
reviews (PRISMA-ScR) [31].
Assessment ofcharacteristics ofreviews
andstudies
Quality appraisal
e quality assessment process was independently
conducted by two authors (A.P. and L.L.) (see
Supplementary File 2) and a summary of the critical
appraisal scores has been summarised. Cohen’s kappa
statisticwasappliedto determine the level of agreement
in scoring between the tworeviewersand disagreements
were settled by a third reviewer (N.M.).e following
critical appraisal tools were used to assess qualitydue to
diversity ofincludedstudy designs, while grey literature
which did not fulfil the critical appraisal tools below were
not critically appraised.
1. e Joanna Briggs Institute (JBI) Checklist for Sys-
tematic Reviewsand Research Synthesiswas usedto
assess quality of included Systematic Reviews [32]
(Supplementary File 2).is tool includes 11 domains
and criteria were assessed using the following scoring:
‘yes’ scoring ‘1’ and ‘no’ or ‘unclear’ scoring ‘0’.
2. e Mixed Methods Appraisal Tool (MMAT) was
used to assess the quality of the quantitative and
qualitative studies [33] (Supplementary File 2).
MMAT appraises quality of five categories including
qualitative research, randomised control trials (RCT),
non-randomised studies, quantitative descriptive
studies and mixed methods studies. Criteria were
assessedby scoring ‘yes’ as ‘1’ and ‘no’ or ‘can’t tell’
as ‘0’.
3. e International Centre for Allied Health Evi-
dence Guideline Quality Checklist (ICAHE) was
used to assessthe quality of guidelines included in
grey literature[34] (Supplementary File 2). is tool
includes six domains: availability, dates, underlying
evidence, guideline developers, guideline purpose
and users, and ease of use.Criteria were assessed by
scoring ‘yes’ as ‘1’ and ‘no’ as ‘0’.
4. e Joanna Briggs Institute (JBI) Critical Appraisal
Checklist for Text and Opinion Papers was used
to assess quality of the text and opinion papers
[35] (Supplementary File 2). is tool includes six
domains: source, expertise, relevant population,
logic, reference to the literature and incongruence
with the literature.Criteriawere assessed by scoring
‘yes’ as ‘1’ and ‘no’ or ‘unclear’ as ‘0’.
Dataextractionand analysis
Data was extracted independently by two authors (A.P.
and L.L.) using a standardisedpre-piloteddata extrac-
tion form (see Supplementary File 3) to collect rel-
evant information including study design, participant
characteristics, intervention and outcome measures.
A third author (N.M.) ensured accuracy and validity of
extracted data. Information relating to adverse events
and harms were extractedfrom systematicreviews and
individual studies when reported.Adverse events were
then classified using a modified version of the common
Table 1 Inclusion Criteria
Design
• Full-text articles published in English language only
• Research articles: systematic reviews, randomised controlled trials (RCTs), intervention studies, observational studies, cross sectional studies
• Grey literature: policies, procedures, guidelines, recommendations, position statements or perspectives (including commentaries, opinions and
editorials)
Participants
• Study participants must be male or female infants (0 to < 2), children (2 to 12) or adolescents (13 to < 18) (WHO, 2006)
Intervention
• Study participants must have had spinal manipulation and/or spinal mobilisation carried out by health professionals with an international body
guiding their practice
Outcome
• Patient/caregiver reported outcome (PRO), observation-based outcomes, other structure impairment, reports, policy statement or recommendation
statement related to body function or structure impairment, activity limitation or participation restriction
• Adverse events and harms
Comparison (for intervention studies)
• Any comparison group in a randomised or non-randomised study: placebo, waitlist, no treatment, adjunct treatment, or comparison intervention
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 5 of 24
Milneetal. BMC Pediatrics (2022) 22:721
terminology criteria for adverse events (CTCAE) pub-
lished in the Adverse Event Reporting Requirements by
the National Cancer Institute [36] and were considered
‘mild’ – if individuals were experiencing mild symp-
toms requiring self-care only; ‘moderate’—if symptoms
were limiting age-appropriate activities of daily living or
requiring care from a physician and; ‘severe’ – if expe-
riencing medically significant symptoms leading to a
life-threatening outcome resulting in urgent interven-
tion, hospitalisation or death [36]. Authors of papers
were contacted to request missing or additional data if
required.
All included articles were reviewed to identify the pre-
senting paediatric conditions being treated with spinal
manipulation and/or mobilisation. e form of interven-
tion used in the studies was identified and classified as
“spinal manipulation”, “spinal mobilisation” or a combina-
tion of both alongside other treatmentmodalities (e.g.,
“soft tissue massage” or “exercise”). For transparency of
overlap between studies and reviews, a matrix (Supple-
mentary File 4) was developed to identify the percentage
of overlap for included studies which were already repre-
sented in the included review articles. Only studies that
achieved 5/7 or more on critical appraisal (i.e., higher
quality studies), would also be included in the descrip-
tive synthesis using a levels of evidence approach. Infor-
mation from each systematic review was extracted and
represented according to the focus of the paediatric con-
ditions and impairments.
After data extraction, a descriptive synthesis was com-
pleted to explore the effectiveness of spinal manipula-
tion and mobilisation with paediatric populations. e
descriptive synthesis involved two stages. Initially, the
results from investigations (reviews and studies) were
coded based on whether the effect was significantly posi-
tive (i.e., favourable) ( +), negative (i.e., unfavourable) ( −),
had no significant effect (0) or was inconclusive (Inc – for
reviews only). For individual studies with control groups
when there was no difference in effect between control
(standard care) and intervention groups (standard care,
plus spinal manipulation or mobilisation), a code of zero
(0) was applied, or a statistically significant difference
(p < 0.05) favouring the intervention group or control
group was coded (+ or -) respectively [37]. Results from
systematic reviews were only included in the descriptive
synthesis when more than one study was synthesised in
the review and was relevant to the outcome explored in
that review. If only one study was included in a review,
that study was identified in the individual studies, inclu-
sion and exclusion criteria were applied, as were critical
appraisal methods. To be included in the descriptive syn-
thesis, studies had to be of good methodological qual-
ity scoring at least five out of seven on the MMAT tool.
Reviews that did not synthesise data were excluded from
the descriptive synthesis stage of analysis.
Finally, to ensure that findings reported were from
the highest available level of evidence, a levels of evi-
dence approach adapted from previously published lit-
erature [37–40] was utilised to assess both the quality
and quantity of evidence (reviews and studies) relating
to the outcomes for defined impairments for each con-
dition (Fig.1). After following the decision tree in Fig.1
which is based on the quality of evidence and quantity
of such evidence, the levels of evidence statements avail-
able for each outcome were: Very strong, strong, moder-
ate or limited evidence for a positive (favourable) effect,
negative (unfavourable) effect or no significant effect.
Consistent positive results (≥ 66.6% of relevant investi-
gations at the identified level reporting significant posi-
tive results) or consistent negative (66.6% of relevant
investigations at the identified level reporting significant
negative results) were needed to achieve very strong,
strong, moderate or limited levels of evidence state-
ments. Consistently no significant effect (≥ 66.6% of rel-
evant investigations at the identified level reporting no
significant effect) was required to determine that the
intervention has ‘no significant effect’ on the condition/
outcome. If the above percentages were not reached and
the results of the decision tree were mixed, the evidence
for that intervention was deemed to be ‘inconclusive’
and if there were insufficient studies / reviews exploring
the intervention for the identified condition / outcome,
then ‘insufficient’ evidence was documented for the lev-
els of evidence statement. If evidence from the system-
atic reviews resulted in statements of ‘insufficient’ or
‘inconclusive’, collective results from individual studies
(if available) were utilised for the final level of evidence
statement. All levels of evidence are based on previ-
ously published National Health and Medical Research
Council (NHMRC) levels of evidence hierarchy for stud-
ies [40] and JBI levels of evidence for systematic reviews
[39]. e level of evidence utilised are summarised in
Table2 below.
Results
Flow ofstudies throughthescoping review
e initial literature search yielded 3866 papers (Fig.2)
with 95 additional studies included from scanning refer-
ence lists or other sources, and after applying the inclu-
sion and exclusion criteria in the screening process, 348
full text articles were assessed for eligibility and 87 arti-
cles met the eligibility criteria (Table1).
Of the 87 included articles, 35 were systematic reviews
with seven being level 1a reviews according to the JBI
Levels of Evidence for Systematic Reviews [1, 41–46], 16
RCT’s, 11 other studies (n = 2 surveys , n = 1 naturalistic
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 6 of 24
Milneetal. BMC Pediatrics (2022) 22:721
study, n = 5 cohort studies, n = 1 prospective outcome
study, n = 1 retrospective study, n = 1 feasibility study),
two guidelines, 14 text and opinion papers and nine pol-
icy and policy developments (Fig.2).
e matrix presented in Supplementary File 4
revealed that only 1 systematic review [21] captured a
large proportion of the studies from the present scop-
ing review. e descriptive synthesis in the present
Fig. 1 Flow chart of decision-making process for levels of evidence approach, based on study design, quality and quantity
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 7 of 24
Milneetal. BMC Pediatrics (2022) 22:721
scoping review was undertaken for reviews, and studies
(scoring ≥ 5/7 on the MMAT) independently and any
differences are discussed below.
Characteristics oftheincluded studies
Quality
A summary of critical appraisal consensus scores for all
studies and grey literature is reported in Table3 with
a detailed breakdown of individual critical appraisal
scores in Supplementary File 2. ere was moderate
inter-rater agreement on the critical appraisal score
between the two independent reviewers (κ = 0.61,
p = < 0.001). After a process of consensus, 100%
agreement was achieved for all papers during the
consensus process. Critical appraisal revealed that
review articles generally scored poorly in questions
regarding methods to minimise errors in data
extraction, and in their assessment of the likelihood
of publication bias. Regarding grey literature (see
Supplementary File 2), one guideline lacked underlying
quality of evidence [47]. Critical appraisal revealed the
methodological quality of text and opinion papers was
mostly reduced due to poor reporting of the source
of opinion, not using an analytical process to form an
opinion, or logically defending incongruences in the
literature (see Supplementary File 2).
Participants
Participants represented in both the systematic
reviews and studies ranged from birth to ≤ 18 ye ars
(Supplementary File 3). The included articles assessed
the effects of spinal manipulation or mobilisation to
manage a variety of impairments related to many dif-
ferent conditions, including: adolescent idiopathic sco-
liosis (AIS), asthma and breathing difficulties, autism
spectrum disorder (ASD), attention deficit-hyperac-
tivity disorder (ADHD), back/neck pain, breastfeeding
difficulties, cerebral palsy (CP), dysfunctional voiding,
headache, infantile colic (excessive crying and sleep
disturbances), kinetic imbalance due to suboccipital
strain (KISS) disorder, nocturnal enuresis, otitis media,
torticollis and plagiocephaly. Supplementary File 3
presents a detailed description of all included articles
with relevant data extracted. Table4 outlines the num-
ber of included articles exploring spinal manipulation
and mobilisation according to study design and age
groups explored.
Intervention
Interventions explored in the present systematic scoping
review included spinal manipulation and mobilisation.
ese interventions were conducted by health profes-
sionals with guiding international professional bod-
ies [65, 111–113] including chiropractors (18 reviews,
Table 2 Levels of Evidence Definitions used for Descriptive Synthesis
RCT Randomised Controlled Trials, NHMRC National Health and Medical Research Council, JBI Johanna Briggs Institute
Source: [39, 40]
Level of Evidence Study Types
Reviews (JBI, 2013)
Level 1 Level 1.a – Systematic review of Randomised Controlled Trials (RCTs)
Level 1.b – Systematic review of RCTs and other study designs
Level 2 Level 2.a – Systematic review of quasi-experimental studies
Level 2.b – Systematic review of quasi-experimental and other lower study designs
Level 3 Level 3.a – Systematic review of comparable cohort studies
Level 3.b – Systematic review of comparable cohort and other lower study designs
Level 4 Level 4.a – Systematic review of descriptive studies
Studies (NHMRC, 2009)
II A randomised controlled trial
III-1 A pseudorandomised controlled trial (i.e., alternate allocation or some
other method)
III-2 A comparative study with concurrent controls:
▪ Non-randomised, experimental trial
▪ Cohort study
▪ Case–control study
▪ Interrupted time series with a control group
III-3 A comparative study without concurrent controls:
▪ Historical control study
▪ Two or more single arm study
▪ Interrupted time series without a parallel control group
IV Case series with either post-test or pre-test/post-test outcomes
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 24
Milneetal. BMC Pediatrics (2022) 22:721
8 RCTs, 10 other studies), physiotherapists (4 RCTs) a
combination of chiropractors, osteopaths, physiothera-
pists and/or manual therapists (17 reviews and 2 RCTs),
medical doctors specialising in manual therapy (2 RCTs)
and a manual therapist (not otherwise defined) (1 RCT
and 1 other study).
Below is a summary of findings from the included
reviews and studies, including the results from the
descriptive synthesis in Supplementary File 5 regarding
the effectiveness of spinal manipulation and mobilisation.
e effects of spinal manipulation and mobilisation have
been reported separately according to the conditions being
managed in paediatric populations (see Supplementary
File 5).
Eects ofspinal manipulation ininfants, children
andadolescents
Of the 35 included reviews, 24 investigated the effective-
ness of spinal manipulation in paediatric clients and pro-
duced quantifiable results which could be utilised in the
descriptive synthesis (Supplementary File 5). ree were
focused on treatment for AIS [104, 106, 107], seven on
asthma [1, 21, 45, 91, 96, 98, 104], two for ASD [51, 102],
two on spinal pain [104, 109], four on breastfeeding dif-
ficulties for infants [28, 30, 99, 104], two on CP [25, 104],
15 on infantile colic—excessive crying / behaviours [1,
21, 25, 26, 42, 43, 66, 91, 96, 98, 103, 104], four on infan-
tile colic – sleep issues [42, 66, 91, 104], five on noctur-
nal enuresis [26, 44, 46, 96, 98], three on otitis media [98,
104, 105] and one on torticollis [62] (see Supplementary
File 5). Additionally, there were four systematic reviews
on adverse events from spinal manipulation [73, 100, 108,
110] and nine reported on multiple conditions including
those mentioned above as well as neck and back pain,
and upper cervical dysfunction [1, 21, 25, 26, 91, 96, 98,
104, 109].
From the 18 studies included in the descriptive synthe-
sis that explored the effectiveness of spinal manipulation
in paediatric populations, one was focused on AIS [59],
two on asthma [49, 56], four on back/neck pain [57, 63,
Fig. 2 PRISMA flow diagram [31]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 24
Milneetal. BMC Pediatrics (2022) 22:721
Table 3 Summary of Critical Appraisal Scores (CAS)
JBI for Systematic Reviews MMAT- RCT’s MMAT- Other studies Grey Literature
Author (Year) CAS Author (Year) CAS Author (Year) CAS Author (Year) CAS
Alcantara, et al. (2011a) [48] 3/11 Balon (1998) [49] 7/7 Alcantara, et al. (2009) [50] 6/7 iCAHE – Clinical Guidelines
Alcantara, et al. (2011b) [51] 8/11 Borusiak (2009) [52] 5/7 Davies & Jamison (2007) [53] 6/7 Council of Chiropractic Prac-
tice (2008) [54]13/14
Alcantara, et al. (2015) [55] 4/11 Bronfort et al. (2001) [56] 5/7 Hayden, et al. (2003) [57] 6/7 NSW Government (2016) [47] 9/14
Brand, et al. (2005) [41] 7/11 Browning and Miller (2008)
[58]7/7 Lantz and Chen (2001) [59] 5/7
Bronfort, et al. (2010) [1] 7/11 Cabrera-Martos, et al. (2016)
[60]7/7 Lebouef (1991) [61] 3/7 JBI for Text and Opinion Papers
Brurberg, et al. (2019) [62] 6/11 Dissing, et al. (2018) [63] 6/7 Miller and Benfield (2008) [64] 7/7 World Federation of Chiroprac-
tic (WFC) (2019) [65]2/6
Carnes, et al. (2018) [66] 11/11 Evans, et al. (2018) [67] 6/7 Miller and Phillips (2009) [68] 5/7 Chiropractic Board of Australia
(CBA) (2017) [69]4/6
Clar, et al. (2014) [25] 10/11 Haugen, et al. (2011) [70] 5/7 Miller and Newell (2012) [71] 5/7 Chiropractors’ Association of
Australia (CAA) (2016) [72]4/6
Corso, et al. (2020) [73] 11/11 Kachmar, et al. (2018) [74] 7/7 Saedt, et al. (2018) [75] 5/7 International Chiropractic
Association (ICA) (2019) [76]6/6
Dobson, et al. (2012) [42] 10/11 Lynge, et al. (2021) [77] 6/7 Sawyer, et al. (1999) [78] 6/7 Barham-Floreani (2014) [79] 4/6
Driehuis, et al. (2019) [26] 10/11 Miller, Newell & Bolton. (2012)
[80]5/7 Zhang and Snyder (2004) [81] 5/7 Marron (2011) [82] 6/6
Edwards and Miller (2019) [28] 8/11 Nemett (2008) [83] 4/7 Chevrier (2016) [84] 6/6
Ellwood, et al. (2020) [27] 10/11 Olafsdottir, et al. (2001) [85] 7/7 Kirkey (May 2019) In College
of Chiropractors of Ontario
(2019) [86]
3/6
Ernst (2009) [43] 6/11 Reed (1994) [87] 2/7 Kirkey (July 2019) In College
of Chiropractors of Ontario
(2019) [88]
2/6
Fairest, et al. (2019) [29] 3/11 Selhorst and Selhorst (2015)
[89]7/7 Collie (2019) In College of
Chiropractors of Ontario (2019)
[90]
2/6
Ferrance and Miller (2010) [91] 3/11 Wiberg, et al. (1999) [92] 5/7 Lindsay (2019) In College of
Chiropractors of Ontario (2019)
[93]
3/6
Fry (2014) [30] 5/11 Rosner (2003) [94] 5/6
Glazener, et al. (2005) [44] 10/11 Australian Chiropractic Asso-
ciation (ACA) (2019) [95]4/6
Gleberzon, et al. (2012) [96] 10/11 Sellhorst (2015) [97] 5/6
Green, et al. (2019) [21] 10/11
Hawk, et al. (2007) [98] 8/11
Hawk, et al. (2019) [99] 11/11
Hondras, et al. (2005) [45] 10/11
Huang, et al. (2011) [46] 7/11
Humphreys (2010) [100] 5/11
Karpouzis, et al. (2010) [101] 7/11
Kronau, et al. (2016) [102] 11/11
Lucassen (2010) [103] 7/11
Parnell, et al. (2019) [104] 11/11
Pohlman & Holton-Brown
(2012) [105]8/11
Romano & Negrini (2008) [106] 6/11
Theroux, et al. (2017) [107] 10/11
Todd, et al. (2015) [108] 7/11
Vaughn, et al. (2012) [109] 11/11
Vohra et al. (2007) [110] 7/11
Key: JBI Joanna Briggs Institute for Systematic Reviews (0 to 11), MMAT Mixed Methods Appraisal Tool (0 to 7), iCAHE International Centre for Allied Health Evidence
Guideline Quality Checklist (0–14), JBI Joanna Briggs Institute for Text and Opinion Papers (0–6), CAS Critical Appraisal Scores
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 24
Milneetal. BMC Pediatrics (2022) 22:721
67, 89], one on CP [74], two on headache [52, 77], six on
infantile colic – excessive crying / behaviours [53, 58, 68,
71, 85, 92], one on infantile colic – sleeping disturbances
[58] and one on torticollis [70].
Only 14 of the 62 included research articles provided
supporting evidence (e.g., references to other papers) of
psychometric properties for the outcome measures being
utilised in the research evaluations and none of the arti-
cles provided actual psychometric values for reliability,
validity and responsiveness, to suggest the selected out-
come measure was a suitable tool to measure effective-
ness of treatment. e findings from the descriptive
synthesis using the levels of evidence approach are pro-
vided below for each condition which met our methodo-
logical thresholds for undertaking a descriptive synthesis.
Adolescent idiopathic scoliosis (AIS) From three reviews
[104, 106, 107] and one observational study [59] explor-
ing spinal manipulative therapy for treating scoliosis, our
descriptive synthesis revealed ‘inconclusive’ results for
using spinal manipulation to manage impairments and
symptoms of AIS (Table5).
Asthma From seven reviews [1, 21, 45, 91, 96, 98,
104] and two RCTs [49, 56], our >descriptive synthe-
sis revealed very strong evidence that spinal manipula-
tion on paediatric populations had ‘no significant effect’
on pulmonary function and findings were inconclusive for
peak expiratory flow, general asthma symptoms, severity
levels and quality of life (Table5).
Autism spectrum disorder (ASD) Of the two reviews
[102, 104], one concluded that there was a reduction
in Autism related symptoms after spinal manipulation
[102], however, results from this review must be inter-
preted with caution as many included studies were case
reports. ere were no individual studies of good meth-
odological quality exploring this topic included in the
present scoping review. Our descriptive synthesisrevealed
‘inconclusive’ findings for spinal manipulation to treat
autism related impairments in children (Table5).
Attention deficit hyperactivity disorder (ADHD) Whilst
our scoping review captured two systematic reviews that
explored the effectiveness of spinal manipulation in pae-
diatric populations with ADHD [21, 104], both reviews
included the same single study on the topic, which was
screened for inclusion in our review but excluded due to
not meeting our definition for spinal manipulation. No
additional studies were identified on this topic and sub-
sequently there was not sufficient evidence to complete a
descriptive synthesison the effects of spinal manipulation
for children with ADHD (Table5).
Spinal (Back / Neck) Pain (mixed acute and chronic pres-
entations) Two reviews [104, 109] explored the effec-
tiveness of spinal manipulation for managing low back
pain severity, with one review [104] (n = 1 RCT and 1
observational study exploring 239 participants) conclud-
ing favourable outcomes for reducing a mixture of acute
and chronic back pain severity in children and adoles-
cents, with the second review [109] finding inconclusive
results regarding the effectiveness of spinal manipula-
tion for managing a mixture of acute and chronic spinal
pain. Additionally, four studies [57, 63, 67, 89] explored
the effects of back and neck pain (with mixed acute and
chronic presentations) in children and adolescents. One
well powered RCT [67] showed spinal manipulation
(added to exercise) had significant favourable effects on
reducing chronic low back pain severity and one lower
quality study [57] showed spinal manipulation resulted
in significantly favourable reductions in severity of acute
back pain. However, two additional RCTs [63, 89] and
one other study [57] provided strong evidence that spi-
nal manipulation had ‘no significant effect’ on spinal
pain (mixed acute and chronic) severity in children and
adolescents despite strong evidence of improvements
in global perceived effects rated by caregivers [63, 67].
ere is ‘insufficient’ research to conclude the effective-
ness of spinal manipulation on recurrence of spinal (back
and neck) pain, episode length, pain medication use,
and quality of life in children and adolescents (Table5).
Table 4 Participant type in included articles
Key: I Infants, C Children, A Adolescents. NB: Duplication exists between reviews and studies
Study Design I C A I + C C + A I + C + A Unspecied
Paediatric
Reviews on spinal manipulation 10 1 1 3 5 10 -
Reviews on spinal mobilisation 1 - - - - - -
RCTS and other studies on spinal manipulation 8 3 1 - 9 - -
RCTS and other studies on spinal mobilisation 3 - - 1 - - -
Reviews on spinal manipulation and mobilisation - 1 - 1 - 1 1
RCTS and other studies on spinal manipulation and
mobilisation - - - 1 - 1 -
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 24
Milneetal. BMC Pediatrics (2022) 22:721
Table 5 Summary results of descriptive synthesis with levels of evidence statement for spinal MANIPULATION to manage paediatric populations with a variety of conditions
Conditions (Population) Levels of Evidence Statement Adverse Events Documented in reviews and studies included in the
descriptive synthesis
Reviews High-Quality Studies Summary Statement Original Report
(Author & Year) Adverse Event / (Practitioner
Type) Further cited by
Spinal MANIPULATION
Adolescent Idiopathic Scoliosis
^ (AIS)
(C&A)
Inconclusive Insufficient Inconclusive Rowe (2006) Two benign reactions (no
further detail documented)
(Chiropractic)
Theroux (2017) [107]
Todd (2015) [108]
Asthma
(C&A)
Inconclusive STRONG Evidence of
No Significant Effect STRONG Evidence of
No Significant Effect #
ASD ^
(C&A)
Inconclusive - Inconclusive
Spinal (Back / Neck) Pain ^
(C&A)
(Combined Chronic and Acute
Pain)
Inconclusive Inconclusive Inconclusive *Evans (2018) Unusual or increased soreness
(51%-54%) and different type of
pain (31%-34%) (Chiropractic)
L’Ecuyer (1959) Neck pain in 12-year-old girl with
a history of congenital torticollis,
progression to unsteady gait,
poor coordination, drowsiness,
and hospitalisation with
delayed diagnosis of congenital
occipitalisation. (Chiropractic)
Green (2020) [21]
Vohra (2007) [110]
Ziv (1983) Back pain in 12-year-old girl
with history of osteogenesis
imperfecta—progressive
neuromuscular deficits in legs,
clonus at rest, urinary urgency
and frequency, paraplegia.
(Chiropractic)
Vohra (2007) [110]
Breastfeeding Difficulties ^
(I)
Inconclusive - Inconclusive
CP ^
(I, C, A)
Inconclusive Insufficient Inconclusive
Headache
(C&A)
Insufficient STRONG Evidence of
No Significant Effect STRONG Evidence of No
Significant Effect Borusiak (2010) Hot skin and dizziness, transitory
increase in headache intensity
and frequency and loss of
consciousness in both treatment
sessions; quick recovery once
treatment stopped. (Manual
therapist)
Green (2020) [21]
Zimmerman (1978) Severe occipital and bifrontal
headache, vomiting, left facial
weakness, diplopia ataxia.
(Chiropractic)
Vohra (2007) [110]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 12 of 24
Milneetal. BMC Pediatrics (2022) 22:721
Table 5 (continued)
Conditions (Population) Levels of Evidence Statement Adverse Events Documented in reviews and studies included in the
descriptive synthesis
Reviews High-Quality Studies Summary Statement Original Report
(Author & Year) Adverse Event / (Practitioner
Type) Further cited by
Held (1966) Acute respiratory
decompensation, tracheotomy,
neurologic deficits at C6 and C7
vertebrae, neck pain. (Medical
practitioner)
Vohra (2007) [110]
Infantile Colic – crying
(I)
Inconclusive Inconclusive Inconclusive Miller (2012) One child in comparison
group reported an AE of
increased crying. Incidence of
increased crying in comparison
group:2.94% (0.52, 14.92)
(Chiropractic)
Corso (2020) [73]
Shafrir (1992) In three of these studies a small
number of mild harms was
reported; the other two studies
(n = 145) reported no harms. One
study (n = 956) reported side
effects or reactions in children
after chiropractic treatment
(n = 557), but both side effects
or reactions and treatment
techniques were not specified.
(Chiropractic)
Driehuis (2019) [26]
Ellwood (2020) [114]
Infantile Colic^ – Sleeping
(I)
Inconclusive Insufficient Inconclusive Koch (1998) Vegetative reactions, bradycardia,
tachycardia, and reflex apnoea
recorded in more than half of
patients. Although apnoea was
of short duration (< 10 s) and
reversible, it can be regarded
as a potentially life-threatening
adverse event. NB: Conditions
were mixed (colic, opistotonus,
hypertonus, wryneck,
plagiocephaly, scoliosis, limb
weakness and slobbering).
(Chiropractic)
Brand (2005) [41]
Wilson (2012) Severe: Rib fractures (7th and 8th
posterior) (Chiropractic)
NB: referral reason not confirmed
Todd (2015) [108]
Nocturnal Enuresis
(C&A)
VERY STRONG Evidence
of No Significant Effect - VERY STRONG Evidence of No
Significant Effect Leboeuf (1991) 4 – 15-year-old children and
adolescents: Severe headache,
stiff neck and acute lumbar
spine pain. (5th year Chiropractic
students)
Green (2020) [21]
Vohra (2007) [110]
Hawk (2007) [98]
Glazener (2005) [44]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 13 of 24
Milneetal. BMC Pediatrics (2022) 22:721
Table 5 (continued)
Conditions (Population) Levels of Evidence Statement Adverse Events Documented in reviews and studies included in the
descriptive synthesis
Reviews High-Quality Studies Summary Statement Original Report
(Author & Year) Adverse Event / (Practitioner
Type) Further cited by
Otitis Media ^
(I & C)
Inconclusive Insufficient Inconclusive Sawyer (1999) 6-months to 6 years—Mid-back
soreness and increased irritability
(Academic Chiropractors)
Green (2020) [21]
Corso (2020) [73]
Vohra (2007) [110]
Hawk (2007) [98]
Pohlman (2012) [105]
Glazener (2005) [44]
Torticollis ^
(I & C)
Insufficient Insufficient Insufficient Jacobi (2001) Subarachnoid haemorrhage
and death of 3-month-old girl
(presenting condition unclear)
(Physiotherapist)
Green (2020) [21]
Vohra (2007) [110]
Ellwood (2020) [27]
Driehuis (2019) [26]
Brand (2005) [41]
Shafrir (1992) Quadriplegia in 4-month-
old boy, secondary to spinal
cord astrocytoma; regressed
to paraplegia (18 months
postoperatively). (Chiropractic)
Todd (2015) [108]
Driehuis (2019) [26]
Ellwood (2020) [27]
All ndings presented in this table are a result of the descriptive synthesis presented in Supplementary File 5
High quality evidence was not available to explore the eectiveness of spinal manipulation on individuals with the following conditions: Attention Decit Hyperactivity Disorder (ADHD), dysfunctional voiding, KISS
syndrome, upper cervical dysfunction
Populations: I – Infants, C – Children, A – Adolescents
# Asthma—spinal manipulation on paediatric populations had ‘no signicant eect’ on pulmonary function and ndings were inconclusive for peakexpiratory ow, general asthma symptoms, severity levels and quality
of life
^ Additional high-quality research (e.g., RCTs) may be warranted
All adverse events extracted from included systematic reviews, except those studies marked with * which have been extracted from individual studies
Insucient: Insucient high-quality evidence available on the topic and further research may be warranted
Inconclusive: Available evidence is inconclusive, and further research may be warranted
No Signicant Eect: High-quality evidence suggests the intervention is not eective and should not be used in clinical practice
Signicant Positive Eect: High-quality evidence suggests the intervention is eective and could be used when clinical reasoning supports its application
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 14 of 24
Milneetal. BMC Pediatrics (2022) 22:721
ere is also ‘insufficient’ research to conclude if spinal
manipulation is effective for managing paediatric popula-
tions presenting with chronic (only) spinal pain or acute
(only) spinal pain. Consequently, ourdescriptive synthesis
of the collective evidence suggests the effectiveness of spinal
manipulation for managing spinal (back and neck) pain
in paediatric populations remains ‘inconclusive’.
Breastfeeding difficulties Of the four reviews [28, 30, 99,
104], two suggested there was favourable findings for the
use of spinal manipulative therapy of infants with breast-
feeding difficulties, however, one of these was a low level
(Level 3b) review [99] and the other reviews [28, 104] did
not support these findings. No additional studies were
included on this topic. Our descriptive synthesis sug-
gests that the evidence for using spinal manipulation in
infants to improve breastfeeding outcomes is ‘inconclusive’
(Table5).
Cerebral palsy (CP) Two reviews [25, 104] explored
the use of spinal manipulation in children for manag-
ing a variety of impairments associated with CP and
both determined there was inconclusive evidence for its
effectiveness. Whilst a single RCT with 78 participants
[74] provides evidence of significant desirable effects
for spinal manipulation in children and adolescents for
reducing spasticity in wrist muscles, our descriptive syn-
thesissuggests ‘inconclusive’ findings regarding the effec-
tiveness of spinal manipulation to manage impairments of
CP in children (Table5).
Dysfunctional voiding Whilst two reviews [25, 104]
which investigated osteopathic manipulative therapy
for improving symptoms related to dysfunctional void-
ing in children, were captured in the present scoping
review, neither met the requirements for inclusion in
the descriptive synthesis as each review only included
one study on the topic. Additionally, no individual stud-
ies were captured, therefore adescriptive synthesison this
topic could not be undertaken (Table5).
Headache A single systematic review exploring the
effectiveness of spinal manipulation for improving
impairments related to headache in children and ado-
lescents [104], was included and indicated inconclu-
sive results. Two included RCTs [52, 77] have explored
the effects of spinal manipulation across six different
outcomes related to headache in children and adoles-
cents. Whilst one large (n = 194) RCT [77] found spinal
manipulation significantly reduced the number of days
with headache and significantly enhanced the global
perceived effect from parents, the collective included
evidence exploring the effects of spinal manipulation
demonstrated no significant changes to the duration of
headache, days of school missed due to headache, con-
sumption of analgesics or intensity of headache (see
Supplementary File 5). Subsequently our descriptive syn-
thesisof the collective research revealed there is strong evi-
dence that spinal manipulation has ‘no significant effec-
tive’ on headache (Table5).
Infantile colic From the twelve reviews [1, 21, 25, 26,
42, 43, 66, 91, 96, 98, 103, 104] that explored the effects
of spinal manipulation for managing crying / behaviour
related impairments of infantile colic, four [42, 66, 96, 98]
demonstrated significant positive results in infants for
reducing crying time and improved symptoms. However,
all other reviews demonstrated no significant effect, neg-
ative effects, or inconclusive findings (see Supplementary
File 5). Two additional RCT’s [58, 92] and two other stud-
ies [68, 71] showed significant positive effects for reduc-
ing crying time and later symptoms as a toddler, with
other RCTs [85, 92] and studies [53, 71] demonstrating
no significant effects from spinal manipulation in infants
(see Supplementary File 5). Four reviews [42, 66, 91, 104]
explored the effects of spinal manipulation for improving
sleep time for infants with colic and all found inconclu-
sive results, except Dobson [42] who found significant
improvements. One additional RCT captured in our
review [58] showed significant improvements in sleep
time from spinal manipulation in infants with colic. Con-
sequently, our descriptive synthesis revealed ‘inconclusive’
findings for the effectiveness of spinal manipulation to
manage infantile colic for both crying time and sleep dis-
turbances (Table5).
Nocturnal enuresis Five reviews [26, 44, 46, 96, 98]
explored the use of spinal manipulation in children and
adolescents to improve symptoms associated with noc-
turnal enuresis. Most found that there was no significant
effect, with one review [26] finding inconclusive results.
No additional studies were captured in our descriptive
synthesis. Our descriptive synthesissuggests that there is
very strong evidence of ‘no significant effect’ from spinal
manipulation for managing symptoms of nocturnal enu-
resis in children and adolescents (Table5).
Otitis media ree reviews [98, 104, 105] that met our
requirements for inclusion in the descriptive synthesis
investigated the effects of spinal manipulation in infants
to improve symptoms associated with otitis media. One
[98] found no significant effects and two reviews [104,
105] found inconclusive results. A small cohort study
[81] showed a significant reduction in otitis media symp-
toms (temperature and redness and bulging appear-
ance of tympanic membrane) in children post spinal
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 15 of 24
Milneetal. BMC Pediatrics (2022) 22:721
manipulation with a hand held pressure applicator but
their findings have not been replicated. One further study
[78] explored the use of spinal manipulation for improv-
ing otitis media-related symptoms in infants, however as
it was a feasibility study for a larger RCT, the analysis of
between group results was not reported. Ourdescriptive
synthesisreveals ‘inconclusive’ findings with no strong evi-
dence to support the use of spinal manipulation to man-
age otitis media (Table5).
Torticollis One review [62] exploring the use of spinal
manipulation in infants and children met our criteria for
descriptive synthesis. is review explored the effects of
spinal manipulation on eight different outcomes related
to torticollis, revealing inconclusive findings for each
outcome. A single study [70] was also included in our
descriptive synthesis and showed that lateral flexion and
head righting reactions were not significantly improved
after treatment involving spinal manipulation. Subse-
quently, our descriptive synthesis suggests ‘insufficient’
findings with no clear evidence to support the use of spinal
manipulation in infants to manage impairments related
to torticollis (Table5).
High quality evidence was not available to explore the
effectiveness of spinal manipulation for KISS syndrome
or upper cervical dysfunction.
Eects ofspinal mobilisation ininfants, children
andadolescents
Four systematic reviews [25–27, 104] explored the
effects of spinal mobilisation on paediatric populations
to manage impairments related to asthma [26], ADHD
[25], torticollis [27] and upper cervical dysfunction [104].
ree of the four reviews were included in the descriptive
synthesis as only one study was reviewed on the topic of
interest (upper cervical dysfunction) for Parnell, 2019,
which meant that it was precluded from our descriptive
synthesis. Four additional studies [60, 75, 80, 81] were
also captured in the present scoping review, exploring
the effects of spinal mobilisation on infants and children
with infantile colic, otitis media, plagiocephaly (without
torticollis) and upper cervical dysfunction respectively
(Supplementary File 5).
Asthma With only one review [26] included and show-
ing inconclusive results for the use of spinal mobilisation
to improve peak expiratory flow in children and adoles-
cents with asthma, ourdescriptive synthesis suggests that
there is ‘insufficient’ evidence to make conclusions regard-
ing the effectiveness of spinal mobilisation for managing
asthma symptoms. (Table6).
ADHD A single systematic review [25] met our criteria
for descriptive synthesis which explored the use of spi-
nal mobilisation to improve outcomes for children with
ADHD using the Connors Scale. No significant effects
were found, and as there were no additional studies
exploring the effects of spinal mobilisation on children
with ADHD, our descriptive synthesisreveals ‘insufficient’
evidence to draw conclusions regarding the use of spinal
mobilisation for managing ADHD. (Table6).
Infantile colic A single RCT [80] explored the effects of
spinal mobilisation on crying time in infants with colic,
showing positive effects in the medium term (8–10days)
but no significant effectives in the short term (0–6days).
Our descriptive synthesis revealed ‘insufficient’ evidence
to draw conclusions regarding the use of spinal mobilisa-
tion to improve infantile colic. (Table6).
Torticollis A single systematic review [27] met our
criteria for descriptive synthesis which explored the
effectiveness of spinal mobilisation for improving cer-
vical mobility and cranial symmetry using the Argenta
scale with infants. Both outcomes were reported to be
improved by spinal mobilisations in infants with torticol-
lis. However, as there are no additional reviews or studies
on the topic, ourdescriptive synthesis reveals ‘insufficient’
evidence to draw conclusions regarding the use of spinal
mobilisation to improve impairments associated with tor-
ticollis in infants. (Table6).
Plagiocephaly (without torticollis) andupper cervical dys-
function A single RCT [60] revealed that spinal mobili-
sation of the neck may reduce treatment days for infants
with plagiocephaly but had no significant effects on motor
development. Further, a single low level (Level III-2) study
[75], suggested that spinal mobilisation of the neck may
improve active and spontaneous movement of the neck
in infants with upper cervical dysfunction. Ourdescrip-
tive synthesissuggests that there is ‘insufficient’ evidence to
draw conclusions regarding the use of spinal mobilisation
with infants and children to improve outcomes related to
plagiocephaly (without torticollis) or upper cervical dys-
function. (Table6).
Adverse events associated withspinal manipulation
andmobilisation
For both reviews and studies included in the present
scoping review, there was limited reporting of adverse
events which means the true incidence is unknown.
Of the reviews and studies that did report on adverse
events related to spinal manipulation and mobilisation of
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 16 of 24
Milneetal. BMC Pediatrics (2022) 22:721
infants, children and adolescents, they varied from mild
to severe in nature (Table7). Table7 provides a summary
of the reporting behaviours from included articles and
demonstrates that six systematic reviews, eight RCTs and
five other studies did not report the adverse events asso-
ciated with using spinal manipulation to manage paedi-
atric populations for a variety of conditions. Six reviews
and three RCTs reported that there were no adverse
events from using spinal manipulation with paediatric
populations. When adverse events were documented, the
trend demonstrated in the RCT’s were mild, transitory
pain or soreness. All adverse events have been extracted
from the original articles and documented in Tables5
and 6 beside the conditions being treated at the time of
the adverse events. Most adverse events were associated
with spinal manipulation, rather than mobilisation and
most occurred in infants or children, with few noted in
adolescent populations.
Policies, regulations, position statements, practice
guidelines andopinion papers
Ten policy and policy development statements [2, 22, 95,
115–121] were included in this systematic scoping review.
Most were from the United States of America with three
of seven policies from Australia [2, 69, 95]. Two policies
recommended the use of spinal manipulation in infants,
Table 6 Summary results of descriptive synthesis with levels of evidence statement for spinal MOBILISATION to manage paediatric
populations with a variety of conditions
All ndings presented in this table are a result of the descriptive synthesis presented in Supplementary File 5
High quality evidence was not available to explore the eectiveness of spinal mobilisation on individuals with the following conditions: adolescent idiopathic scoliosis
(AIS), autism spectrum disorder (ASD), back/neck pain, breastfeeding diculties, cerebral palsy (CP), dysfunctional voiding, headache, infantile colic, KISS syndrome,
nocturnal enuresis
Populations: I – Infants, C – Children, A – Adolescents
All adverse events extracted from included systematic reviews, except those studies marked with * which have been extracted from individual studies. ^Additional
high-quality research (e.g., RCTs) may be warranted
Insucient: Insucient high-quality evidence available on the topic and further research may be warranted
Inconclusive: Available evidence is inconclusive, and further research may be warranted
No Signicant Eect: High-quality evidence suggests the intervention is not eective and should not be used in clinical practice
Signicant Positive Eect: High-quality evidence suggests the intervention is eective and could be used when clinical reasoning supports its application
Conditions
(Population) Levels of Evidence Statement Adverse Events Documented in reviews and studies
included in the descriptive synthesis
Reviews High-Quality Studies Summary Statement Original Report
(Author & Year) Adverse Event /
(Practitioner Type) Further cited by
Spinal MOBILISATION
Asthma ^ (C&A) Insufficient - Insufficient
ADHD ^ (C) Insufficient - Insufficient
Otitis Media ^ (I&C) - Insufficient Insufficient
Torticollis ^ (I) Insufficient - Insufficient
Plagiocephaly ^ (I)
(With no torticollis) - Insufficient Insufficient
Upper Cervical
Dysfunction ^ (I)
- Insufficient Insufficient Saedt (2018) Mild: back soreness,
irritability, poor feeding,
mild distress, increased
crying, increased
head tilt, temporary
vegetative responses
after mobilisation
including:
- Flushing: 17.8% (14.03,
22.59)
- Hyper-extension: 4.3%
(2.49, 7.11)
- Perspiration: 3.6% (2.01,
6.30)
- Gastro-esophageal
reflux: 0.3% (0.06, 1.82)
- Short breathing
pattern changes: 9.2%
(6.39, 12.87)
Corso (2020) [73]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 17 of 24
Milneetal. BMC Pediatrics (2022) 22:721
children and adolescents [117, 118]. e International
Chiropractors Association [118] recommend the earliest
possible evaluation, detection and correction (using spi-
nal manipulative therapy) in infants to maximise normal
growth and development. One policy [117] stated that
spinal manipulation must only be performed to manage
three conditions: (i) if there has been documented symp-
toms involving the spine, (ii) subluxations of the spine are
evidenced with corresponding symptoms and therapy has
a direct relationship with improving function and (iii) if
manipulation is appropriate to restore function that has
been compromised by illness or injury. Contrary to above
recommendations, seven policies do not recommend the
use of spinal manipulation in infants, children and ado-
lescents with arguments stating that it is experimental,
unproven and not medically necessary [2, 69, 115, 116,
119–121]. Two of these policies specifying age groups,
with one stating that spinal manipulation should not be
used on paediatric patients under the age of two years
[22] and the other not recommending it under the age
of 12years [119]. Of the policies that do not support this
form of treatment, most don’t specify the conditions it is
not recommended for. In those that do, there is a general
trend towards prohibiting use for non-musculoskeletal
conditions including ADHD, ASD, asthma, infantile colic,
nocturnal enuresis and otitis media.
ere were 14 text and opinion papers included in this
systematic scoping review. Six did not support the use
of spinal manipulation in infants, children and adoles-
cents with comments suggesting there is limited research
Table 7 Adverse event reporting practice of included reviews and studies
L1a – Systematic Review of RCTs; L1b – Systematic Review of RCTs and other studies; L2a – Systematic review of quasi-experimental studies, L2b – Systematic review
of quasi-experimental and other lower-level studies; L3a – Systematic Review of comparable cohort studies; L3b – Systematic review of comparable cohort and other
lower-level studies; L4a – Systematic review of descriptive studies; LII – RCT, LIII-1 – Pseudorandomised controlled trial, LIII-2 – Comparative study with concurrent
controls, LIII-3 – Comparative study without concurrent controls
Adverse events not reported Nil adverse events reported Adverse events reported
Mild Moderate Severe
Adverse events associated with spinal manipulation
Reviews
Alcantara (2015) L2b [55]
Ernst (2009) L1a [43]
Fairest (2019) L4 [29]
Fry (2014) L3 [30]
Karpouzis (2010) L3b [101]
Kronau (2016) L2b [102]
Edwards (2019) L3b [28]
Ferrance (2010) L1b [91]
Huang (2011) L1a [46]
Hondras (2005) L1a [45]
Romano (2008) L3b [106]
Vaughn (2012) L1b [109]
Alcantara (2011a) L1b [48]
Carnes (2018) L1b [66]
Corso (2020) L1b [73]
Gleberzon (2012) L1b [96]
Pohlman (2012) L1b [105]
Theroux (2017) L1b [107]
Vohra (2007) L1b [110]
Brand (2005) L1a [41]
Glazener (2005) L1a [44]
Green (2019) L1b [21]
Hawk (2007) L1b [98]
Vohra (2007) L1b [110]
Brand (2005) L1a [41]
Corso (2020) L1b [73]
Green (2019) L1b [21]
Todd (2015) L1b [108]
Vohra (2007) L1b [110]
RC T ’s
Bronfort (2001) LII [56]
Browning (2008) LII [58]
Dissing (2018) LII [63]
Kachmar (2018) SII [74]
Lynge (2021) LII [77]
Nemett (2008) LII [83]
Olafsdottir (2001) LII [85]
Reed LII (1994) [87]
Miller, Newell & Bolton (2012) LII
[80]
Selhorst LII (2015) [89]
Haugen LII (2011) [70]
Balon LII (1998) [49]
Borusiak LII (2009) [52]
Evans (2018) LII [67]
Other studies
Davies (2007) LIII-3 [53]
Hayden (2003) LIII-3 [57]
Lantz (2001) LIII-2 [59]
Miller & Newell (2012) LIII-2 [71]
Miller (2009) LIII-2 [68]
Alcantara (2009) LIII-3 [50]
Sawyer (1999) LIII-2 [78]Leboeuf (1991) LIII-3 [61]
Adverse events associated with spinal mobilisation
Reviews
Parnell (2019) L1b (104) Brurberg (2019) L1b [62] Ellwood (2020) L1b [27]
Driehuis (2019) L1b [26]
Corso (2020) L1b [73]
Corso (2020) L1b [73] Corso (2020) L1b [73]
RC T ’s
Cabrera-Martos (2016) LII [60]
Other studies
Zhang (2004) LSIII-2 [81] Saedt (2018) LIII-2 [75]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 18 of 24
Milneetal. BMC Pediatrics (2022) 22:721
within the area, with no satisfactory evidence, suggest-
ing the risks outweigh the potential benefits [65, 69, 84,
88, 90, 93]. Two text and opinion papers suggest there is
limited, however, growing evidence for the use of spinal
manipulation and report that care should be taken when
using this form of treatment for managing impairments
in paediatric populations [82, 88]. Conversely, six text
and opinion papers support the use of spinal manipula-
tion as a form of treatment for paediatric clients [72, 76,
79, 94, 95, 97] arguing that most chiropractors use best
practice evidence-based treatment techniques, and that
spinal manipulation may be effective in treating the pae-
diatric populations. One text and opinion paper stated
they are disappointed by the temporary restriction in
Australia and believe chiropractors should not be singled
out in performing such treatment, with limited evidence
of harm [95].
Two guidelines were included in this review, one from
Australia and one from the United States of America. e
Australian guideline [47] suggested clinicians should not
recommend spinal manipulation in infants as evidence
is inconclusive. Conversely, the Council of Chiroprac-
tic Practice [54] recommendation suggests chiropractic
care (inclusive of spinal manipulation) may be indicated
at any age group and care must be taken to select the
most appropriate treatment technique along with paren-
tal education. However, it is important to note that this
guideline was published prior to the interim legislation.
Discussion
e primary aim of this systematic scoping review was
to identify and map the available evidence regarding
the effectiveness and harms of spinal manipulation
and mobilisation of infants, children, and adolescents.
Additionally, we aimed to identify and synthesise policies,
regulations, position statements and practice guidelines
informing the clinical application of spinal manipulation
and mobilisation in paediatric populations. In relation to
our first aim, this systematic scoping review revealed that
spinal manipulation and mobilisation is being utilised
clinically by a variety of health professionals to manage
paediatric populations with nocturnal enuresis, otitis
media, infantile colic, excessive crying, breastfeeding
difficulties, headaches, CP, back/neck pain, AIS,
ADHD, ASD, torticollis, asthma, KISS syndrome, and
dysfunctional voiding. We utilised a levels-of-evidence
approach in our descriptive synthesis and whilst some
individual high-quality studies demonstrated positive
effects from spinal manipulation and mobilisation for
some conditions, there is no collective evidence using
objective measures to explicitly support the application
of spinal manipulation or mobilisation for any condition
in paediatric populations, however, adverse events
were reported. Our descriptive synthesis revealed
very strong evidence that spinal manipulation has no
significant effect on nocturnal enuresis. Whilst results
from previously published systematic reviews were
inconclusive, our descriptive synthesis of studies with
high methodological quality suggests there is strong
evidence that spinal manipulation has no significant
effect on impairments related to asthma (pulmonary
function) or headache. e evidence was inconclusive
regarding the effectiveness of spinal manipulation for
managing impairments related to AIS, ASD, back/
neck pain (acute and chronic) and CP in children and
adolescents. Additionally, the evidence was inconclusive
regarding the effectiveness of spinal manipulation
for managing impairments and symptoms related to
breastfeeding difficulties, infantile colic (excessive crying
and sleep disturbances), and otitis media in infants and
children. ere was insufficient evidence to report on
the effectiveness of spinal manipulation for infants and
children with torticollis and ADHD. Further, there is
insufficient evidence to determine the effectiveness
of spinal mobilisation on paediatric populations for
managing any condition.
To further address our first aim, we explored the
adverse events/harms associated with spinal manipula-
tion and/or mobilisation in paediatric populations. e
findings in the present systematic scoping review revealed
that there is limited reporting of adverse events in the
included systematic reviews and studies, with six reviews,
eight RCTs and five other studies making no mention
of adverse events or harms associated with their spinal
manipulation intervention of focus (Table7). Although
some of these articles were published before 2010, those
RCT’s published after 2010, have failed to comply with the
internationally accepted updated CONSORT guidelines
which urges authors to be completely transparent in their
reporting of harms [122]. Four systematic reviews focused
specifically on adverse events and harms associated with
treatment of infants, children and adolescents involving
spinal manipulation and mobilisations and revealed that
adverse events ranged from mild – requiring self or par-
ent care only, to severe – for example, death. All adverse
events that were extracted from our included articles are
documented in the data extraction table (Supplemen-
tary File 3) and these have been summarised according
to the conditions being managed in the studies/reviews
reporting adverse events (Tables5 and 6). With respect to
potential harms, our review identified under-reporting of
adverse events across both reviews and studies (Table7),
impacting our ability to draw firm conclusions regard-
ing the safety of spinal manipulation and mobilisation in
infants, children and adolescents and this finding aligns
with conclusions expressed in previous reviews [21, 26].
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 19 of 24
Milneetal. BMC Pediatrics (2022) 22:721
Due to the limited reporting of adverse events in many
studies, the true incidence remains unknown [104, 110].
However, we would like to highlight that although there
have been some reports (studies and reviews) demon-
strating improvement in mild transient adverse symp-
toms (e.g., muscle soreness and tightness [21, 44, 73, 105,
110], anxiety [44] and increased crying [73] after receiving
treatment with spinal manipulation), there has also been
reports of more serious adverse events such as severe
headache [21, 52, 108, 110], loss of consciousness [21, 52,
110], poor coordination and unsteady gait [110], clonus at
rest [110], reflex apnoea [41], facial weakness [108], diplo-
pia ataxia [108], acute respiratory decompensation [110]
and urinary urgency and frequency [110]. Whilst most
adverse events are mild and transient, the most severe
adverse events from spinal manipulation noted in the
literature are progressive neuromuscular deficits lead-
ing to quadriplegia (later improving to paraplegia post-
surgically), missed or delayed diagnoses (e.g., spinal cord
astrocytoma and congenital occipitalisation), subarach-
noid haemorrhage and death. (Table5). Related to this
issue, it is evident that there is an important difference
in the practice of clinical reasoning for spinal manipu-
lation across the professions, with some advocating for
using a directional ‘thrust’ to move a spinal segment
back into alignment (i.e., adjustment) [5] and some pro-
fessions using a HVLA passive thrust to the spinal joint
within its anatomical limit [6]. Whilst the research team
were able to confirm ‘spinal manipulation’ as the treat-
ment technique in this review during study selection,
very little detail was given to describe the way the spinal
segment or joint was being manipulated. Future publi-
cations regarding spinal manipulation should explicitly
describe the form of manipulation being undertaken,
as it is entirely possible that the effectiveness and safety
could vary between techniques. Whilst the prevalence
of documented adverse events from spinal manipulation
and mobilisation appears to be relatively low, the most
severe adverse events were reported in infants during
treatment of conditions where it is difficult to monitor
the structures being impacted due to the small anatomi-
cal size of infants and where there are other effective
evidence-based intervention options (e.g., torticollis [27]
infantile colic [114]). Notably, there were less adverse
events reported for spinal mobilisation in paediatric
populations, with one review article [73] identifying
severe adverse events such as rib fractures and missed
significant diagnoses (e.g., spinal cord astrocytoma),
however, our scoping review also identified far less stud-
ies or reviews exploring the use of spinal mobilisation (as
opposed to spinal manipulation) in paediatric popula-
tions from which to extract this data.
Most studies within the included reviews came from
low levels of evidence such as case studies or case series,
which were not included as individual studies for our cur-
rent systematic scoping review as we felt they were too
low in the levels of evidence hierarchy to provide addi-
tional meaningful results regarding effectiveness. e
inclusion of adverse events extracted from lower levels
of research published in the included systematic reviews,
has provided important safety related information for
readers to consider. However, since most of the literature
is based on low-level studies such as case reports, it is not
safe to assume that their conclusions can be generalised
to larger or alternate populations. Health professionals
would benefit from further training, either as graduates
or in entry-level programs, to better understand levels
of evidence to assist with interpretation of research, to
inform their choice of treatment techniques and to guide
design of future research, should they choose to do it.
Consistent with the lower levels of evidence and meth-
odological quality of studies, it was noted that very few
studies reported on the clinometric properties of the
outcome measures utilised, and we recommend future
research on this topic to include references regarding the
reliability, validity, utility, and efficacy of outcome meas-
ures used to explore effectiveness and to improve cred-
ibility of study findings. Healthcare professionals and
researchers should be aware of the reliability, validity, and
responsiveness of assessment tools and outcome meas-
ures to assist in their clinical reasoning, instrument selec-
tion and interpretation of clinical or research results.
Further evaluation of these factors must be completed in
future research to assist with interpretation of the collec-
tive findings on this important topic.
Regarding our final aim, we have identified that most
policy and policy development statements included in
this systematic scoping review were developed in the
United States of America, many by third party payers,
and only three published in Australia. is highlights the
need for more policies globally across all professions who
are performing spinal manipulation and mobilisation
with paediatric populations. Evidence-based guidelines
and policy or position statements are needed to guide
health professionals on the appropriateness of spinal
manipulation and mobilisation to manage a variety of
conditions for which paediatric clients commonly present
for care. is is particularly important considering our
comprehensive review and descriptive synthesis did not
determine spinal manipulation or mobilisation to be
effective for treating any condition examined (Tables5
and 6), albeit with limited research to examine for spinal
mobilisation. Whilst not captured by our inclusion
criteria (due to being published in Dutch language), the
Netherlands have produced four factsheets [123–126]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 20 of 24
Milneetal. BMC Pediatrics (2022) 22:721
on diagnostics and therapeutics in infants (0–1year) and
children (1–18years) to guide physiotherapy practice for
using manual therapy in paediatric populations, and their
guidance is congruent with the findings of the present
scoping review.
e findings from the present systematic scoping
review align with the findings from the previous work
by Green [21] for the Safer Care Victoria report on
Chiropractic spinal manipulation of children under 12:
Independent review [2] and the recent findings from
Cote and colleagues [14]. Green (2019) [21] explored
the effectiveness and safety of spinal manipulation (but
not mobilisation) in children under 12 years for any
condition or impairment, irrespective of the profession
providing treatment. e outcome of Greens’ review
was that spinal manipulation should not (due to a lack of
evidence and potential risk of harm) be recommended
for management of paediatric clients with; headache,
asthma, otitis media, cerebral palsy, hyperactivity
disorders or torticollis, however, they suggested that
there may be some (although unlikely) benefits of spinal
manipulation in the management of infantile colic
and nocturnal enuresis. e findings from the present
systematic scoping review differ slightly as our descriptive
synthesis using a levels of evidence approach, extends
these conclusions as we also found very strong evidence
that spinal manipulation is not effective for managing
nocturnal enuresis. Further, we found the evidence to be
‘inconclusive’ for managing excessive crying and sleep
in infants with infantile colic. Our findings, much like
those of Cote [14] suggest that evidence is lacking to
support the use of spinal manipulative therapy to treat
non-musculoskeletal disorders, undermining the validity
of the theory that spinal manipulation has physiological
effects on the organs and their function. e findings
from the present systematic scoping review add to the
Safer Care Victoria review in the following ways: (i)
exploring both spinal manipulation and mobilisation; (ii)
inclusion of paediatric patients up to the age of 18years;
(iii) inclusion of various study designs except individual
case reports and case studies; (iv) investigated policies,
guidelines and laws supporting or prohibiting the use of
spinal manipulation or mobilisation. It should be noted
that many of the policies identified in this scoping review
from the USA were reimbursement policies and there
remains a need in the USA for professional associations
to establish position statements and treatment guidelines.
A challenge that we faced in screening, appraising,
data extracting and synthesising the included articles,
was the lack of detailed descriptions of therapeutic
techniques being applied (i.e., spinal manipulation
and mobilisation techniques) on infants, children and
adolescents; a concern raised in a previous review on
the topic [26]. Relevant and necessary information
regarding the treatment technique used were often not
clearly stated. Due to the underreporting of specific
techniques, we had to exclude numerous reviews on the
basis that we were uncertain of the treatment technique
being applied. Consequently, this has limited our ability
to draw conclusions regarding effectiveness of specific
treatment techniques, particularly spinal mobilisation.
ese findings align with the findings of other reviews
who also highlight the importance of increasing
the methodological quality to describe intervention
techniques completed by the practitioner [26, 104]. To
assist with capturing a wider sample of studies in future
reviews, it would be beneficial for researchers to include
details describing the exact treatment technique, the
number and duration of treatments patients received,
and the healthcare providers experience and training.
A strength of this systematic scoping review includes
the wide breadth of searches undertaken. Several major
databases were searched with a detailed search strategy
and with a broad, yet specific inclusion criteria to ensure
the scope of existing literature was included. Hand
searching of reference lists for all included studies and
reviews was undertaken to ensure all relevant literature
was captured for this systematic scoping review. e
study selection, data extraction process and critical
appraisal was completed independently by two reviewers
to reduce the risk of reviewer error or bias and a third
reviewer was utilised to validate data extraction and
provide consensus for critical appraisal. Our review sets
itself apart from previous research by focusing on both
spinal manipulation and mobilisation, as well as including
participants from birth to 18 years of age. Exclusion
of individual case studies and case reports allowed for
conclusions to be based on higher levels of evidence
and this was particularly important when the collective
evidence from systematic reviews were inconclusive.
Due to the inclusion of systematic reviews, there
were several primary studies included more than once,
potentially leading to overrepresentation of individual
studies, which may have biased the interpretation of
the results. Whilst we independently descriptively
synthesised the individual study outcomes (from high
quality studies); the synthesis findings may have been
influenced by one study population or methods if they
had completed multiple investigations, and therefore,
one population sample may have biased our analysis. On
the occasion that this was likely (n = 2 conditions), we
have highlighted this to the reader (see Supplementary
File 5). As there was limited overlap and because
many reviews included low levels of evidence, data
extraction, critical appraisal and descriptive synthesis
was completed for both the studies and the reviews
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 21 of 24
Milneetal. BMC Pediatrics (2022) 22:721
independently before applying the levels of evidence
approach to our descriptive synthesis. e overarching
limitation of our findings is the high representation of
non-RCT (e.g., observational studies, case studies) in the
included reviews, leaving in some cases our synthesis
and conclusions to be based on the collective findings
from lower levels of evidence. A further limitation of
this scoping review is the use of a descriptive synthesis
employing a levels of evidence approach based on
quality and quantity of studies without consideration of
sample size, rather than a meta-analysis which meant
we were unable to determine effect sizes.
Despite the current limitations, this systematic scoping
review provides information to build awareness regarding
the available evidence for safety and effectiveness of spinal
manipulation and mobilisation in paediatric populations
(birth up to 18years) and these findings can be used to
guide more impairment focused quantitative analysis in
future meta-analyses. e results of this systematic scop-
ing review will also help to inform the future development
of a shared position statement between the IFOMPT and
IOPTP to guide clinical practice.
Conclusions
e present systematic scoping review revealed spinal
manipulation and mobilisation are utilised clinically by a
variety of health professionals to manage many different
musculoskeletal and non-musculoskeletal impairments
for paediatric populations. A broad descriptive synthe-
sis of the collective evidence (using a levels-of-evidence
approach) did not demonstrate evidence to explicitly sup-
port spinal manipulation or mobilisation as an effective
intervention for any condition in paediatric populations
with mild to severe adverse events reported. Strong to very
strong evidence exists to suggest that spinal manipulation
is not effective for managing asthma, headache or noctur-
nal enuresis whereas, there was inconclusive or insufficient
evidence for all other conditions explored. ere is insuf-
ficient evidence to determine the effectiveness of spinal
mobilisation for treating paediatric populations with any
condition, with some mild adverse responses reported.
Despite spinal manipulation and mobilisation being used
to treat infants, children, and adolescents internationally,
there is a lack of conclusive high-level evidence providing
positive (i.e., favourable) results with paediatric popula-
tions. More high-level clinically reasoned RCT’s, express-
ing the magnitude of effect from spinal manipulation and
mobilisation are needed, to further allow exploration of
the safety and effectiveness of these interventions with
infants, children and adolescents, for further conclu-
sions to be drawn. Future research should include strict
monitoring and recording of adverse events to determine
true risks and could start with small long term RCTs. If
evidence was accumulating for a given condition, a large
multicentre RCT would be beneficial. In addition, future
research in this field, should provide detailed information
about the therapeutic technique, the clinical reasoning,
and theoretical underpinnings for its use, particularly in
non-musculoskeletal conditions. Currently most research
informing the results of this systematic scoping review are
based on chiropractic interventions. Research regarding
physiotherapy methods for mobilisation and manipulation
for some conditions (e.g., back and neck pain/stiffness) in
older children and adolescents is warranted as it remains a
gap in the literature.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12887- 022- 03781-6.
Additional le1:Supplementary File 1. Search Strategy
Additional le2:Supplementary File 2.Critical Appraisal Consensus
Scores
Additional le3:Supplementary File 3.Data Extraction
Additional le4:Supplementary File 4.Matrix with RCT’s and other
studies included across all systematicreviews
Additional le5:Supplementary File 5.Descriptive Synthesis
Acknowledgements
Not applicable
Authors’ contributions
NM: Stakeholder engagement, project conceptualisation, study design and
planning methodology including search terms, consensus for screening
and critical appraisal, synthesis / analysis of results, supervision and editing
of manuscript writing, submission to journal. LL: Planning methodology
including search terms, independent screening and critical appraisal, synthesis
/ analysis of results, writing and editing of manuscript writing. AP: Planning
methodology including search terms, independent screening and critical
appraisal, synthesis / analysis of results, writing and editing of manuscript
writing. JP: Stakeholder engagement, project conceptualisation, study design
and planning methodology including search terms, editing of manuscript
writing. KO: Stakeholder engagement, project conceptualisation, study design
and planning methodology including search terms, editing of manuscript
writing. AB: Stakeholder engagement, project conceptualisation, study design
and planning methodology including search terms, editing of manuscript
writing. AG: Stakeholder engagement, project conceptualisation, study design
and planning methodology including search terms, editing of manuscript
writing. The author(s) read and approved the final manuscript.
Funding
Funding was obtained after the completion of the scoping review to support
Open Access Publication. Article Processing Charges were jointly funded by the
International Federation of Orthopaedic Manipulative Physical Therapists [IFOMPT]
and International Organisation of Physical Therapists in Paediatrics [IOPTP].
Availability of data and materials
All data generated or analysed during this study are tabulated in this
published article [and its supplementary information files].
Declarations
Ethics approval and consent to participate
Not applicable.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 22 of 24
Milneetal. BMC Pediatrics (2022) 22:721
Consent for publication
Not applicable.
Competing interests
The authors declare they have no competing interests.
Author details
1 Department of Physiotherapy, Faculty of Health Sciences and Medicine,
Bond University, Queensland, Australia. 2 International Organisation
of Physiotherapists in Paediatrics, World Physiotherapy Subgroup, Queensland,
Australia. 3 Research Group Lifestyle and Health, Institute of Human
Movement Studies, University of Applied Sciences, Utrecht, The Netherlands.
4 International Federation of Orthopaedic Manipulative Physical Therapy
and Northern Rehab Physical Therapy Specialists, Anchorage, USA. 5 University
of Witwatersrand, Johannesburg, South Africa. 6 McMaster University, Hamilton,
Canada.
Received: 9 November 2021 Accepted: 28 November 2022
References
1. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness
of manual therapies: the UK evidence report. Chiropr Osteopat.
2010;18:3.
2. Safer Care Victoria. Chiropractic spinal manipulation of children under
12- Independent review Melbourne2019. [Available from: https:// www.
bette rsafe rcare. vic. gov. au/ sites/ defau lt/ files/ 2019- 10/ 20191 024- Final%
20Chi ropra ctic% 20Spi nal% 20Man ipula tion. pdf.
3. IFOMPT (International Federation of Orthopaedic Manipulative Physi-
cal Therapists). Educational standards in orthopaedic manipulative
therapy- Part A. 2016.
4. Australian Capital Territory. Health Practitioner Regulation National Law
(ACT). 2020.
5. International Chiropractors Association. ICA Policy Statement on
Spinal Adjustment and Spinal Manipulation 2017 [1]. Available
from: https:// www. chiro pract ic. org/ wp- conte nt/ uploa ds/ 2021/ 05/
The- ICA- Policy- State ment- on- Spinal- Adjus tment- and- Spinal- Manip
ulati on. pdf.
6. International Federation of Orthopaedic Manipulative Physical Thera-
pists (IFOMPT). Educational Standards in Orthopaedic Manipulative
Therapy Part A: Educational Standards. 2016 [Available from: https://
www. ifompt. org/ site/ ifompt/ IFOMPT% 20Sta ndards% 20Doc ument%
20defi niti ve% 202016. pdf.
7. World Health Organisation. WHO guidelines on basic training and
safety in chiropractic. 2005 Guideline.
8. National Center for Complementary and Integrative Health. Spinal
Manipulation: What you need to know 2019 [Available from: https://
www. nccih. nih. gov/ health/ spinal- manip ulati on- what- you- need- to- know.
9. Canadian Chiropractic Association (CCA). Education and the Countrolled Act
of Spinal Manipulation 2020 [Available from: https:// chiro pract ic. ca/ about-
cca/ code- of- ethics/ educa tion- contr olled- act- spinal- manip ulati on/.
10. No place for spinal manipulation in infant care [press release]. 2019.
11. Bussières AE, Al Zoubi F, Stuber K, French SD, Boruff J, Corrigan J, et al.
Evidence-based practice, research utilization, and knowledge transla-
tion in chiropractic: a scoping review. BMC Complement Altern Med.
2016;16(1):1–15.
12. Leboeuf-Yde C, Innes SI, Young KJ, Kawchuk GN, Hartvigsen J. Chiro-
practic, one big unhappy family: better together or apart? Chiropr Man
Ther. 2019;27(1):1–8.
13. Schneider MJ, Evans R, Haas M, Leach M, Hawk C, Long C, et al. US
chiropractors’ attitudes, skills and use of evidence-based practice: a
cross-sectional national survey. Chiropr Man Ther. 2015;23(1):1–12.
14. Côté P, Hartvigsen J, Axén I, Leboeuf-Yde C, Corso M, Shearer H, et al.
The global summit on the efficacy and effectiveness of spinal manipu-
lative therapy for the prevention and treatment of non-musculoskel-
etal disorders: a systematic review of the literature. Chiropr Man Ther.
2021;29(1):1–23.
15. Gatterman MI. Foundations of chiropractic: subluxation: Elsevier Health
Sciences; 2005.
16. Hannon S. Objective physiologic changes and associated health
benefits of chiropractic adjustments in asymptomatic subjects: a
review of the literature. Journal of Vertebral Subluxation Research.
2004:1–9.
17. McDonald WP, Durkin KF, Pfefer M, editors. How chiropractors think
and practice: the survey of North American chiropractors. Seminars in
Integrative Medicine; 2004: Elsevier.
18. Russell D. The assessment and correction of vertebral subluxation is
central to chiropractic practice: is there a gap in the clinical evidence?
J Contemp Chiropr. 2019;2:4–17.
19. Picchiottino M, Leboeuf-Yde C, Gagey O, Hallman DM. The acute effects
of joint manipulative techniques on markers of autonomic nervous
system activity: a systematic review and meta-analysis of randomized
sham-controlled trials. Chiropr Man Ther. 2019;27(1):1–21.
20. Rechberger V, Biberschick M, Porthun J. Effectiveness of an osteopathic
treatment on the autonomic nervous system: a systematic review of
the literature. Eur J Med Res. 2019;24(1):1–14.
21. Green S, McDonald S, Murano M, Miyoung C, Brennan S. Systematic
review of spinal manipulation in children: review prepared by Cochrane
Australia for Safer Care Victoria. Melbourne, Victoria: Victorian Govern-
ment 2019. p. 1–67.
22. Chiropractic Board of Australia. Interim policy on spinal manipulation
for infants & young children. Position Statament 2019 March 2019.
23. Pohlman KA, Carroll L, Tsuyuki RT, Hartling L, Vohra S. Active versus
passive adverse event reporting after pediatric chiropractic manual
therapy: study protocol for a cluster randomized controlled trial. Trials.
2017;18(1):575.
24. Slawomirski LA, A.;, Klazinga N. The Economics of Patient Safety OECD;
2017 March 2017.
25. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P. Clinical
effectiveness of manual therapy for the management of musculoskele-
tal and non-musculoskeletal conditions: systematic review and update
of UK evidence report. Chiropr Man Therap. 2014;22(1):12.
26. Driehuis F, Hoogeboom TJ, Nijhuis-van der Sanden MWG, de Bie RA,
Staal JB. Spinal manual therapy in infants, children and adolescents:
A systematic review and meta-analysis on treatment indication, tech-
nique and outcomes. PLOS One. 2019;14(6).
27. Ellwood J, Draper-Rodi J, Carnes D. The effectiveness and safety of
conservative interventions for positional plagiocephaly and congenital
muscular torticollis: a synthesis of systematic reviews and guidance.
Chiropr Man Ther. 2020;28(1):31.
28. Edwards CN, Miller J. What is the evidence that chiropractic care helps
sub-optimal breastfeeding? J Clin Chiropr Pediatr. 2019;18(1):1547–51.
29. Fairest C, Chiro B, Russell D. Improvement in behavior and attention in a
7-year-old girl with ADHD receiving chiropractic care: a case report and
review of the literature. J Clin Chiropr Pediatr. 2019;18(1):1525–33.
30. Fry LM. Chiropractic and breastfeeding dysfunction: a literature review.
J Clin Chiropr Pediatr. 2014;4(2):1151–5.
31. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P 2009 Preferred
reporting items for systematic reviews and meta-analyses: the PRISMA
statement BMJ 339 b2535
32. Joanna Briggs Institute. Checklist for Systematic Reviews and Research
Synthesis 2017 [Critical Appraisal Tool]. Available from: https:// jbi.
global/ sites/ defau lt/ files/ 2019- 05/ JBI_ Criti cal_ Appra isal- Check list_ for_
Syste matic_ Revie ws2017_ 0. pdf.
33. Hong QP, P.; Fabregues, S.; Bartlett, G.; Boardman, F.; Cargo, M.; Dagenais,
P.; Gagnon, M.; Griffith, F.; Nicolau, B.; O’Cathain, A.; Rousseau, M.; Vedel, I.
. Mixed Methods Appraisal Tool (MMAT) Version 2018 2018.
34. Grimmer K, Dizon JM, Milanese S, King E, Beaton K, Thorpe O, et al. Effi-
cient clinical evaluation of guideline quality: development and testing
of a new tool. BMC Med Res Methodol. 2014;14:63.
35. McArthur A, Klugarova J, Yan H, Florescu S. Innovations in the
systematic review of text and opinion. Int J Evid Based Healthc.
2015;13(3):188–95.
36. National Cancer Institute. NCI guidelines for investigators: adverse
event reporting requirements Guideline. 2013;2013:16.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 23 of 24
Milneetal. BMC Pediatrics (2022) 22:721
37. Farley JB, Barrett LM, Keogh JWL, Woods CT, Milne N. The relationship
between physical fitness attributes and sports injury in female, team ball
sport players: a systematic review. Sports Medicine- Open. 2020;6(1):45.
38. Abrahams S, Fie SM, Patricios J, Posthumus M, September AV. Risk fac-
tors for sports concussion: an evidence-based systematic review. Br J
Sports Med. 2013;48(2):91–7.
39. Joanna Briggs Institute. JBI Levels of Evidence 2013 [Available from:
https:// jbi. global/ sites/ defau lt/ files/ 2019- 05/ JBI- Levels- of- evide nce_
2014_0. pdf.
40. National Health and Medical Research Council. NHMRC additional
levels of evidence and grades for recommendations for developers of
guidelines- Stage 2 Consultation. 2009.
41. Brand PL, Engelber t RH, Helders PJ, Offringa M. Systematic review of the
effects of therapy in infants with kinetic imbalance due to suboccipital
strain (KISS) syndrome. J Man Manip Ther. 2005;149(13):703–7.
42. Dobson D, Lucassen PL, Miller JJ, Vlieger AM, Prescott P, Lewith G.
Manipulative therapies for infantile colic. Cochrane Database Syst Rev.
2012;12:CD004796.
43. Ernst E. Chiropractic spinal manipulation for infant colic: a systematic
review of randomised clinical trials. Int J Clin Pract. 2009;63(9):1351–3.
44. Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous
interventions for nocturnal enuresis in children. Cochrane Database of
Systematic Reviews. 2005(2).
45. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane
Database Syst Rev. 2005;2:Cd001002.
46. Huang T, Shu X, Huang YS, Cheuk DK. Complementary and miscellane-
ous interventions for nocturnal enuresis in children. Cochrane Database
Syst Rev. 2011;12:CD005230.
47. NSW Government. Infants and children: acute management of the
unsettled and crying Infant. In: Health, editor. 2016.
48. Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of infants with
colic: a systematic review of the literature. Explore (NY). 2011;7(3):168–74.
49. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O’Shaughnessy
D, et al. A comparison of active and simulated chiropractic manipula-
tion as adjunctive treatment for childhood asthma. N Engl J Med.
1998;339(15):1013–20.
50. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric
chiropractic: a survey of chiropractors and parents in a practice-based
research network. explore. J Sci Heal. 2009;5(5):290–5.
51. Alcantara J, Alcantara JD, Alcantara J. A systematic review of the litera-
ture on the chiropractic care of patients with autism spectrum disorder.
Explore (NY). 2011;7(6):384–90.
52. Borusiak P, Biedermann H, Bosserhoff S, Opp J. Lack of efficacy of man-
ual therapy in children and adolescents with suspected cervicogenic
headache: results of a prospective, randomized, placebo-controlled,
and blinded trial. Headache. 2009;50(2):224–30.
53. Davies NJ, Jamison JR. Chiropractic management of irritable baby
syndrome. Chiropr J Aust. 2007;37(1):25–9.
54. Council on Chiropractic Practice. Clinical Practice Guideline- Vertebral Sub-
luxation in Chripractic Practice. Council on Chiropractic Practice; 2008.
55. Alcantara J, Alcantara JD, Alcantara J. The chiropractic care of infants
with breastfeeding difficulties. Explore (NY). 2015;11(6):468–74.
56. Bronfort G, Evans RL, Kubic P, Filkin P. Chronic pediatric asthma
and chiropractic spinal manipulation: a prospective clinical series
and randomized clinical pilot study. J Manipulative Physiol Ther.
2001;24(6):369–77.
57. Hayden JA, Mior SA, Verhoef MJ. Evaluation of chiropractic manage-
ment of pediatric patients with low back pain: a prospective cohort
study. J Manipulative Physiol Ther. 2003;26(1):1–8.
58. Browning M, Miller J. Comparison of the short-term effects of chiro-
practic spinal manipulation and occipito-sacral decompression in the
treatment of infant colic: a single-blinded, randomised, comparison
trial. Clin Chiropr. 2008;11(3):122–9.
59. Lantz CA, Chen J. Effect of chiropractic intervention on small scoliotic
curves in younger subjects: a time-series cohort design. J Manipulative
Physiol Ther. 2001;24(6):385–93.
60. Cabrera-Martos I, Valenza MC, Valenza-Demet G, Benitez-Feliponi A,
Robles-Vizcaino C, Ruiz-Extremera A. Effects of manual therapy on
treatment duration and motor development in infants with severe non-
synostotic plagiocephaly: a randomised controlled pilot study. Child’s
Nervous System. 2016;32(11):2211–7.
61. Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC.
Chiropractic care of children with nocturnal enuresis: a prospective
outcome study. J Manipulative Physiol Ther. 1991;14(2):110–5.
62. Brurberg KG, Dahm KT, Kirkehei I. Manipulation techniques for infant
torticollis. Tidsskr Nor Laegeforen. 2019;138(1).
63. Dissing KB, Hartvigsen J, Wedderkopp N, Hestbæk L. Conservative care
with or without manipulative therapy in the management of back and/
or neck pain in Danish children aged 9–15: a randomised controlled
trial. BMJ Open. 2018;8(9):e021358.
64. Miller JE, Benfield K. Adverse effects of spinal manipulative therapy in
children younger than 3 years: a retrospective study in a chiropractic
teaching clinic. J Manipulative Physiol Ther. 2008;31(6):419–23.
65. World Federation of Chiropractic. Chiropractic Spinal Manipulation of
Children Under 12 2019 [Available from: https:// www. wfc. org/ websi te/
index. php? option= com_ conte nt& view= artic le& id= 535% 3Achi ropra
ctic- spinal- manip ulati on- of- child ren- under- 12- novem ber-1- 2019&
catid= 56% 3Anew s-- publi catio ns& Itemid= 27& lang= en.
66. Carnes D, Plunkett A, Ellwood J, Miles C. Manual therapy for unsettled,
distressed and excessively crying infants: a systematic review and meta-
analyses. BMJ Open. 2018;8(1).
67. Evans R, Haas M, Schulz C, Leininger B, Hanson L, Bronfort G. Spinal
manipulation and exercise for low back pain in adolescents: a rand-
omized trial. Pain. 2018;159(7):1297–307.
68. Miller JE, Phillips HL. Long-term effects of infant colic: a survey compari-
son of chiropractic treatment and nontreatment groups. J Manipulative
Physiol Ther. 2009;32(8):635–8.
69. Chiropractic Board of Australia. Statement on paediatric care.
2017;2017:20.
70. Haugen EB, Benth J, Nakstad B. Manual therapy in infantile torticollis: a
randomized, controlled pilot study. Acta Paediatr. 2011;100(5):687–90.
71. Miller J, Newell D. Prognostic significance of subgroup classification for
infant patients with crying disorders: a prospective cohort study. J Can
Chiropr Assoc. 2012;56(1):40–8.
72. Chiropractic care has an excellent safety record in Australia [press
release]. 11 May 2016 2016.
73. Corso M, Cancelliere C, Mior S, Taylor-Vaisey A, Côté P. The safety of
spinal manipulative therapy in children under 10 years: a rapid review.
Chiropr Man Therap. 2020;28(1):12.
74. K achmar O, Kozyavkin V, Kushnir A, Matiushenko O, Hasiuk M. Influence
of the spinal manipulation on muscle spasticity in cerebral palsy: a
randomized controlled trial. Dev Med Child Neurol. 2018;60:42–3.
75. Saedt E, Driehuis F, Hoogeboom TJ, van der Woude BH, de Bie RA,
Nijhuis-van der Sanden MWG. Common manual therapy practices in
the Netherlands for infants with upper cervical dysfunction: a prospec-
tive cohort study. Journal of Manipulative and Physiological Therapeu-
tics. 2018;41(1):52–61.
76. International Chiropractors Association. ICA Choice 2019.
77. Lynge S, Dissing KB, Vach W, Christensen HW, Hestbaek L. Effectiveness
of chiropractic manipulation versus sham manipulation for recurrent
headaches in children aged 7–14 years - a randomised clinical trial.
Chiropr Man Ther. 2021;29(1):1.
78. Sawyer CE, Evans RL, Boline PD, Branson R, Spicer A. A feasibility study
of chiropractic spinal manipulation versus sham spinal manipulation
for chronic otitis media with effusion in children. J Manipulative Physiol
Ther. 1999;22(5):292–8.
79. Barham-Floreani J. The legitimacy of chiropractic in family healthcare.
2014.
80. Miller JE, Newell D, Bolton JE. Efficacy of chiropractic manual therapy
on infant colic: a pragmatic single-blind, randomized controlled trial. J
Manipulative Physiol Ther. 2012;35(8):600–7.
81. Zhang JQ, Snyder BJ. Effect of the toftness chiropractic adjustments
for children with acute otitis media. Journal of Vertebral Subluxation
Research. 2004:4p-p.
82. Marron L. Request to shut down RMIT Chiropractic Paediatric Clinic for
teaching disproven treatments that target pregnant women, babies,
infants and children. In: Minister for Health and Aging, editor. Parliment
House: Australian Govenment; 2011.
83. Nemett DR, Fivush BA, Mathews R, Camirand N, Eldridge MA, Finney K,
et al. A randomized controlled trial of the effectiveness of osteopathy-
based manual physical therapy in treating pediatric dysfunctional
voiding. J Pediatr Urol. 2008;4(2):100–6.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 24 of 24
Milneetal. BMC Pediatrics (2022) 22:721
84. Chevrier P. Reser ved Act #15, Administering a high velocity, low
ampltide thrust to move a joint of the spine within its anatomical range
of motion- high neck manipulation. In: Duboff N, editor. 2016.
85. Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled
trial of infantile colic treated with chiropractic spinal manipulation. Arch
Dis Child. 2001;84(2):138–41.
86. College of Chiropractors of Ontario. Electronic Public Information Pack-
age Meeting. Item 5.1- National Post Newspaper Article “Pediatricians
alarmed by chiropractic treatments for babies that ’border on the
fraudulent’”. Minutes. 2019 14th of September 2019.
87. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic manage-
ment of primary nocturnal enuresis. J Manipulative Physiol Ther.
1994;17(9):596–600.
88. College of Chiropractors of Ontario. Electronic Public Information
Package Meeting. Item 5.2- National Post Newspaper Article “Research
is ’ongoing and growing: Chiropractic leaders defend manipulating
newborn spines”. Minutes. 2019 14th of September 2019.
89. Selhorst M, Selhorst B. Lumbar manipulation and exercise for the treat-
ment of acute low back pain in adolescents: a randomized controlled
trial. J Man Manip Ther. 2015;23(4):226–33.
90. College of Chiropractors of Ontario. Electronic Public Information Pack-
age Meeting. Item 5.4- National Post Newspaper Article “Should you
take your baby to the chiropractor? Experts weigh in”. Minutes. 2019
14th of September 2019.
91. Ferrance RJ, Miller J. Chiropractic diagnosis and management of
non-musculoskeletal conditions in children and adolescents. Chiropr
Osteopat. 2010;18:14.
92. Wiberg JM, Nordsteen J, Nilsson N. The short-term effect of spinal
manipulation in the treatment of infantile colic: a randomized con-
trolled clinical trial with a blinded observer. J Manipulative Physiol Ther.
1999;22(8):517–22.
93. College of Chiropractors of Ontario. Electronic Public Informa-
tion Package Meeting. Item 5.5- National Post Newspaper Article
“Exhaustive’review of chiropractic care for children ordered in B.C.”.
Minutes. 2019 14th of September 2019.
94. Rosner A. Infant and child chiropractic care: an assessment of the
research 2003 [Available from: https:// chiro. org/ pedia trics/ FULL/ Infant_
and_ Child_ Chiro pract ic_ Care. shtml.
95. Australian Chiropractors Association response to CBA interim policy on
spinal manipulation for infants [press release]. 14 March 2019 2019.
96. Gleberzon BJ, Arts J, Mei A, McManus EL. The use of spinal manipula-
tive therapy for pediatric health conditions: a systematic review of the
literature. J Can Chiropr Assoc. 2012;56(2):128–41.
97. Selhorst M. Orthopedic manual therapy for the pediatric patient. 2015.
98. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic
care for nonmusculoskeletal conditions: a systematic review with
implications for whole systems research. J Altern Complement Med.
2007;13(5):491–512.
99. Hawk C, Minkalis A, Webb C, Hogan O, Vallone S. Manual interventions
for musculoskeletal factors in infants with suboptimal breastfeeding: a
scoping review. J Evid-Based Integr Med. 2019;23(1–12):1600.
100. Humphreys BK. Possible adverse events in children treated by manual
therapy: a review. Chiropr Osteopat. 2010;18:12.
101. Karpouzis F, Bonello R, Pollard H. Chiropractic care for paediatric and
adolescent attention-deficit/hyperactivity disorder: a systematic review.
Chiropr Osteopat. 2010;18:13.
102. Kronau S, Thiel B, Jäkel A, Liem T. Clinical effects of spinal manipula-
tion in the management of children and young adults diagnosed with
autism spectrum disorder – a systematic review of the literature. J
Clin Chiropr Pediatr. 2016;15(3):1280–91.
103. Lucassen P. Colic in infants. BMJ Clinical Evidance. 2010;2010.
104. Parnell Prevost C, Gleberzon B, Carleo B, Anderson K, Cark M, Pohlman
KA. Manual therapy for the pediatric population: a systematic review.
BMC Complement Altern Med. 2019;19(1):60.
105. Pohlman KA, Holton-Brown MS. Otitis media and spinal manipulative
therapy: a literature review. J Chiropr Med. 2012;11(3):160–9.
106. Romano M, Negrini S. Manual therapy as a conservative treatment for
adolescent idiopathic scoliosis: a systematic review. Scoliosis. 2008;3:2.
107. Théroux J, Stomski N, Losco CD, Khadra C, Labelle H, Le May S. Spinal
manipulative therapy for adolescent idiopathic scoliosis: a systematic
review. J Manipulative Physiol Ther. 2017;40(6):452–8.
108. Todd AJ, Carroll MT, Robinson A, Mitchell EKL. Adverse events due to
chiropractic and other manual therapies for infants and children: a
review of the literature. J Manipulative Physiol Ther. 2015;38(9):699–712.
109. Vaughn DW, Kenyon LK, Sobeck CM, Smith RE. Spinal manual therapy
interventions for pédiatrie patients: a systematic review. Journal of
Manual & Manipulative Therapy. 2012;20(3):153–9.
110. Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associ-
ated with pediatric spinal manipulation: a systematic review. Pediatrics.
2007;119(1):e275–83.
111. Osteopathic International Alliance. Osteopathic International Alliance
2022 [Available from: https:// oiall iance. org/.
112. World Medical Association. World Medical Association 2022 [Available
from: https:// www. wma. net/ who- we- are/ membe rs/.
113. World Physiotherapy. World Physiotherapy 2022 [18th July 2022]. Avail-
able from: https:// world. physio/ our- membe rs.
114. Ellwood J, Draper-Rodi J, Carnes D. Comparison of common interven-
tions for the treatment of infantile colic: a systematic review of reviews
and guidelines. BMJ Open. 2020;10(2): e035405.
115. Aetna. Chiropractic Services - Medical Clinical Policy Bulletins 2020 [Available
from: http:// www. aetna. com/ cpb/ medic al/ data/ 100_ 199/ 0107. html.
116. Cigna. Cigna Medical Coverage Policy- Therapy Services Chiropractic
Care. 2020 15 Feburary 2020.
117. Indiana University. Chiropractic Services and Adjunctive Procedures
Policy (Children under 18 years of age). 2020 23 Janurary 2020.
118. International Chiropractors Association. ICA Policy Statement On The
Practice of Chiropractic. unknown year.
119. Healthcare M. Chiropractic spinal manipulation in children. Policy State-
ment. 2014;2014:25.
120. Premera Blue Cross. Medical Policy- Chiropractic Services 2020 [Avail-
able from: https:// www. preme ra. com/ medic alpol icies/8. 03. 501. pdf.
121. United Healthcare. United Healthcare Commerical Medical Policy:
United Healthcare Services; 2020 [Available from: https:// www. uhcpr
ovider. com/ conte nt/ dam/ provi der/ docs/ public/ polic ies/ comm- medic
al- drug/ manip ulati ve- thera py. pdf.
122. Schulz KF, Altman DG, Moher D, Group* C. CONSORT 2010 statement:
updated guidelines for reporting parallel group randomized trials.
Annals of internal medicine. 2010;152(11):726–32.
123. Driehuis F, Nijhuis-van der Sanden MWG, Saedt ER, van der Woude BH,
de Bie RA. Factsheet Manual therapy and therapeutic possibilities in
infants (0–1 years). Nederlandse Vereniging voor Manuele Therapie
(NVMT) 2018.
124. Driehuis F, Nijhuis-van der Sanden MWG, Saedt ER, van der Woude
BH, de Bie RA. Factsheet Manual therapy and diagnostic possibilities
in infants (0–1 years). Nederlandse Vereniging voor Manuele Therapie
(NVMT) 2018.
125. Driehuis F, Nijhuis-van der Sanden MWG, Saedt ER, van der Woude
BH, de Bie RA. Factsheet Manual therapy and therapeutic options for
children (1–18 years). Nederlandse Vereniging voor Manuele Therapie
(NVMT) 2018.
126. Driehuis F, Nijhuis-van der Sanden MWG, Saedt ER, van der Woude
BH, de Bie RA. Factsheet Manual therapy and diagnostic options for
children (1–18 years). Nederlandse Vereniging voor Manuele Therapie
(NVMT); 2018.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
Content uploaded by Annalie Basson
Author content
All content in this area was uploaded by Annalie Basson on Jan 09, 2023
Content may be subject to copyright.
