Orthopedic Manual

Therapy for the

Pediatric Patient

Mitchell Selhorst, DPT, OCS

Nationwide Children’s Hospital Sports and Orthopedic PT
Columbus, Ohio
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 Learning Objectives
The attendee will:
• Understand the specific precautions and the
relative risk of performing orthopedic manual
therapy on pediatric patients.
• Identify pediatric patients who are appropriate
for orthopedic manual therapy.
• Use orthopedic manual physical therapy to
minimize pain and maximize function in pediatric
orthopedic patients.
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 Pediatric Physical Therapy

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This is the Pediatric I Mean
Kids Need PT Too!
 Pediatric Pain is Not Benign
• Injury in childhood may lead to increased
risk of pain in adulthood.23

• Pain does not go away on its own

– 2/3 of adolescents with low back pain will
have chronic or recurrent symptoms 6 months
later.38
Clinical Practice Guidelines Recommend
use of Manual Therapy
Alright, Let’s Do Manual Therapy!
Wait…

Growing Children

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 Contraindications and Precautions
• Contraindication: A circumstance which
absolutely rules out the use of a
therapeutic method which would otherwise
be indicated.
• Precaution: The risks of a treatment have
to be carefully assessed before treatment
is initiated, and it can only be administered
if its benefits to the patient are greater
than its risks
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 Why are Children a Precaution
for Manual Therapy?
Controversial: Not all authors agree that a
growing child is a precaution.
• Growth plates and cartilage endplates
• Ability to give informed consent
• Lack of research

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 Growth and
Cartilage End Plates
Growth Plates Age of Ossification
Wrist 17‐19 years
Elbow 15‐18 years
Shoulder 19‐25 years
Hip 18‐25 years
Knee  19‐25years
Foot and Ankle 18‐20 years

End Plates Age of Ossification

Cervical 16‐18 years
Thoracic 16‐18 years
Lumbar 16‐18 years
Sacrum 18‐25 years
Females 1-2 years sooner than males
Forces of Manual Therapy
vs Normal Activity

<
 What is the Risk MT will
damage a growth plate?
• Unknown: No documented case of growth
plate injury has occurred due to manual
therapy.
– 10,000,000 manual therapy interventions
performed on children every year.
– 2.3 million performed in the US alone.31

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 Gaining Informed Consent
from a Child
• A minor cannot provide informed consent
• Discussion of the risks and benefits of
manual therapy becomes a family
discussion
 Risks from Lack of Research
• Children are not tiny adults, many
research results are not generalizable.

• We don’t know what we don’t know

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Children are Not Tiny Adults
I wish I had hair

Skeletally Mature I have hair

Avoids Activity Growth Plates

Remains Active
90% Non-
Specific LBP
< 50% Non-
Specific LBP
????

????????
Ruling out Cancer for Back Pain
• Negative on all 4 of these=100% sensitive
– Age >50 years of age
– Previous history of cancer
– Unexplained weight loss
– Failure to improve with conservative
management

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 Rely on your Red Flags
• Persistent pain
• Increases at rest
• Progressive neurological deficits
• Associated fever
• Night pain
• Bowel or bladder incontinence

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 Ruling out Fractures
• Ottawa Ankle Rules28 OK!

• Ottawa Knee Rules37 OK!

• Canadian C-Spine Rules STOP!

-Patients >10 years12 OK!

-Patient < 10 years12 Not Sensitive Enough

 Can we use CPR’s to guide
manual treatment?
• Manipulation for low back pain14
– Pain for <16 days
– No pain distal to the knee
– 1 Lumbar segment hypomobile ???
10-30% more hip IR
– Hip IR >35 degrees motion in children
– FABQ-work subscale score <19
 Can we use a Modified CPR
for Lumbar Manipulation
Patient meets 3 out of the 4
– Pain for <16 days
– No pain distal to the knee
– 1 Lumbar segment hypomobile
– Hip IR >35 degrees
OR
In a RCT assessing lumbar
manipulation in adolescents,
only 5% met either of these
modified rules. Unable to
assess the effectiveness of
these CPR’s.38

Patient have both of the following

-Pain for <16 days
-No pain distal to the knee
How to Identify Appropriate
Patients for Manual Therapy
Does the clinician think the patient
would benefit from MT?

No Yes

Yes Contraindications?
No

Yes Do risks outweigh

the benefits?
No

No improvement Trial MT

Manual Therapy Positive Outcome.

Not Appropriate Continue as Indicated
 Case of Low Back Pain
13-year-old female
– 2-month hx of LBP
– Insidious onset
– Has not improved over
past 4 weeks
– No report of pain, NT, or
weakness in LE’s
– No red flags noted during
evaluation
 Case of Low Back Pain
13-year-old female with 2-month hx of LBP
-Recreational dancer (Hip Hop and Ballet) 4
hours of class a week.
-Pain is worse with activity(2/10 at rest 6/10
pain during dance)
-Pain increases by 2/10 with lumbar extension
-Scored a 14/30 on Patient Specific Functional Scale
Dance 4/10
Bending backwards 5/10
Walking for >20 minutes 5/10
Should We Utilize Manual
Therapy with this Patient?
 Treatment Consideration for
the pediatric lumbar spine
• Much of pediatric back pain has an
anatomical cause, some can be
precautions or contraindications to manual
therapy

• Up to 50% of adolescent athletes with low

back pain have a spondylolysis or
spondylolisthesis.43
 Spondylolysis
Type  Name Pathogenisis
Type I Dysplastic Congenital abnormalities

Type II Isthmic Stress fracture in the pars 

interarticularis

Type III Degenerative Degeneration of the intervertebral

discs

Type IV Traumatic Acute fracture in areas other than 

pars

Type V Pathological Bone disease, tumor, or infection

Grades of Spondylolisthesis
Grade of ‐listhesis % Slippage of the 
vertebral body
Grade I 1‐25%

Grade II 26‐50%

Grade III 51‐75%

Grade IV 76‐100%
 Pediatric Spondylolytic Injury

Acute Lesion Chronic Lesion Lesion with anterolisthesis

Increased uptake (SPECT)  Lesion diagnosed but no  Grade I‐IV 

or edema (MRI) noted in  signs of active healing  Can be determined by     
the symptomatic region noted on imaging X‐ray, CT, MRI

Fibrous lesion, unlikely to  Precaution or 
Active fracture
achieve bony union.   Contraindication 
Manual Therapy is 
Manual Therapy is a  Depending on Grade and 
contraindicated in region
precaution stability of ‐listhesis
Are there contraindication for
manual therapy?
13-year-old female with 2-month hx of LBP

– Imaging
X-ray - Negative
MRI - Negative
 Risk and Benefits of Manual
Therapy with this Patient?
• Physical therapy, including manual
treatment, results in significantly better
outcomes in children with back pain.1

• Lumbar manipulation does not increase

risk of an adverse event in adolescents
with non-specific low back pain.38
Trial Manual Therapy!
 A Case of Neck Pain
9-year-old male injured his
neck 3 days ago while
tackling in youth football.
– Current patient (left shoulder)
– Reports 7/10 right mid-
cervical pain
– No report of numbness or
tingling
– Significant TTP of R C3-4
 A Case of Neck Pain
9-year-old male injured during
youth football
– Patient maintained consciousness
– Not a helmet-to-helmet collision
– Active cervical ROM
Flexion 65 deg. Ext 20 deg.*
Rotation L 75 deg. R 50 deg*.
– Difficulty sleeping at night due to pain
– No signs or symptoms of concussion
Should We Utilize Manual
Therapy with this Patient?
 Are there contraindications
for manual therapy?
• Unable to rule out cervical fracture.
– No imaging to rule out fracture.

– Canadian C-spine Rules not sensitive enough.

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Thumbs Down
A Case of Swimmers Shoulder
11-year-old female with R shoulder pain

• Clinical diagnosis of secondary GH

impingement and multi-directional instability.
• Generalized hypermobility noted
Beighton score of 6 out of 9
A Case of Swimmers Shoulder
11-year-old female with R shoulder pain

+ Hawkins-Kennedy
+ Painful Arc
+ ER weakness
+ Excessive anterior
GH joint laxity
+ Sulcus sign
- Apprehension
Should We Utilize Manual
Therapy with this Patient?
 Are there contraindications
for manual therapy?
Generalized Hypermobility is considered a
precaution by most, a few consider it a
contraindication.
– When treating a patient with hypermobility, the
therapist should examine opposite motions
and neighboring segments to find out if any
restrictions exist.
 Risks vs Benefits
• Risks: Manual therapy done incorrectly
could increase the patient’s hypermobility
and multi-directional instability.

• Benefits: Restoring motion to neighboring

segments could improve proper GH joint
mechanics- 2 case studies support this
theory.7, 27
 Trial Manual Therapy
Target restricted areas:
– Posterior Shoulder
– Pec Minor
– Thoracic Extension
– Scapular thoracic
 A Case Acute Ankle Sprain
15-year-old male with L inversion ankle sprain

– 5-days post injury

– Does not participate in sports

– Fell off obstacle course and

rolled his ankle

– No imaging performed

– Presents to clinic on crutches

and ACE wrap
 A Case of Acute Ankle Sprain
15-year-old male with L inversion ankle sprain
– Patient is able to walk in clinic
without use of crutches with
antalgic gait
– TTP at ATFL
– Talar Tilt, Anterior drawer + (pain)
– No tenderness at medial/lateral
malleoli, navicular or base 5th
metatarsal
– Mild swelling noted upon visual
examination
Should We Utilize Manual
Therapy with this Patient?
 Are there contraindications
for manual therapy?
• Rule out fracture with the Ottawa Ankle
Rules.

• No other precautions or contraindications

noted
 Risks vs Benefits
Risks: Minimal. No adverse reaction noted
in research for this population

Benefits: Short and long-term benefits

noted with use of manual therapy for acute
ankle sprain.44, 45
Trial Manual Therapy!
 Conclusion
• Manual therapy can be an effective way to
minimize pain and maximize function in
pediatric orthopedic patients.

• Weigh the risks and benefits before

proceeding

• Rely on patient history, your clinical

expertise, and the patient’s preference
until there is better research to guide EBP.
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 References
1. Ahlqwist A, Hagman M, Kjellby-Wendt G, Beckung E. Physical therapy treatment of back complaints on
children and adolescents. Spine. 2008;33(20):E721-7. Epub 2008/09/17.
2. Alqarni AM, Schneiders AG, Cook CE, Hendrick PA. Clinical tests to diagnose lumbar spondylolysis and
spondylolisthesis: A systematic review. Physical therapy in sport : official journal of the Association of
Chartered Physiotherapists in Sports Medicine. 2015. Epub 2015/03/24.
3. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in
the treatment of musculoskeletal pain: a comprehensive model. Manual therapy. 2009;14(5):531-8. Epub
2008/11/26.
4. Blanch P. Conservative management of shoulder pain in swimming. Physical Therapy in Sport.
2004;5(3):109-24.
5. Bruggeman G. Biomechanics in gymnastics. Med Sport Science. 1987;25:142 Y 76.
6. Calvo-Munoz I, Gomez-Conesa A, Sanchez-Meca J. Physical therapy treatments for low back pain in
children and adolescents: a meta-analysis. BMC musculoskeletal disorders. 2013;14:55. Epub 2013/02/05.
7. Carson PA. The rehabilitation of a competitive swimmer with an asymmetrical breaststroke movement
pattern. Manual therapy. 1999;4(2):100-6. Epub 1999/10/06.
8. Chen KC, Chiu EH. Adolescent idiopathic scoliosis treated by spinal manipulation: a case study.
Journal of alternative and complementary medicine (New York, NY). 2008;14(6):749-51. Epub 2008/08/05.
 References
9. Clifford SN, Fritz JM. Children and adolescents with low back pain: a descriptive study of physical
examination and outcome measurement. The Journal of orthopaedic and sports physical therapy.
2003;33(9):513-22. Epub 2003/10/04.
10. DeVocht JW, Pickar JG, Wilder DG. Spinal manipulation alters electromyographic activity of paraspinal
muscles: a descriptive study. Journal of manipulative and physiological therapeutics. 2005;28(7):465-71.
Epub 2005/09/27.
11. d'Hemecourt PA, Luke A. Sport-specific biomechanics of spinal injuries in aesthetic athletes (dancers,
gymnasts, and figure skaters). Clinics in sports medicine. 2012;31(3):397-408. Epub 2012/06/05.
12. Ehrlich PF, Wee C, Drongowski R, Rana AR. Canadian C-spine Rule and the National Emergency X-
Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients. Journal of
pediatric surgery. 2009;44(5):987-91. Epub 2009/05/13.
13. Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous
theories. Journal of manipulative and physiological therapeutics. 2002;25(4):251-62. Epub 2002/05/22.
14. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, et al. A clinical prediction rule for classifying
patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine.
2002;27(24):2835-43. Epub 2002/12/18.
15. Fritz JM, Koppenhaver SL, Kawchuk GN, Teyhen DS, Hebert JJ, Childs JD. Preliminary investigation of
the mechanisms underlying the effects of manipulation: exploration of a multivariate model including spinal
stiffness, multifidus recruitment, and clinical findings. Spine. 2011;36(21):1772-81. Epub 2011/03/02.
16. Frost DM, Beach T, Fenwick C, Callaghan J, McGill S. Is there a low-back cost to hip-centric exercise?
Quantifying the lumbar spine joint compression and shear forces during movements used to overload the
hips. Journal of sports sciences. 2012;30(9):859-70. Epub 2012/04/04.
 References
17. Gal. Biomechanical studies of spinal manipulative therapy (SMT) quantifying the movements of
vertebral bodies during SMT. Journal of CCA. 1994;38(1):15
18. Gatt CJ, Jr., Hosea TM, Palumbo RC, Zawadsky JP. Impact loading of the lumbar spine during
football blocking. Am J Sports Med. 1997;25(3):317-21.
19. Gatterbauer A. Contraindications in Osteopathy. Vienna: Danube University Krem; 2009.
20. Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Immediate effects of a
tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle
instability. Journal of electromyography and kinesiology : official journal of the International Society of
Electrophysiological Kinesiology. 2011;21(4):652-8. Epub 2011/05/07.
21. Haun DW, Kettner NW. Spondylolysis and spondylolisthesis: a narrative review of etiology, diagnosis,
and conservative management. Journal of chiropractic medicine. 2005;4(4):206-17. Epub 2005/01/01.
22. Hayden JA, Mior SA, Verhoef MJ. Evaluation of chiropractic management of pediatric patients with
low back pain: a prospective cohort study. Journal of manipulative and physiological therapeutics.
2003;26(1):1-8. Epub 2003/01/18.
23. Hestbaek L, Leboeuf-Yde C, Kyvik KO, Manniche C. The course of low back pain from adolescence
to adulthood: eight-year follow-up of 9600 twins. Spine. 2006;31(4):468-72. Epub 2006/02/17.
24. Humphreys BK. Possible adverse events in children treated by manual therapy: a review. Chiropractic
& osteopathy. 2010;18:12. Epub 2010/06/08.
25. Koppenhaver SL, Fritz JM, Hebert JJ, Kawchuk GN, Childs JD, Parent EC, et al. Association between
changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal
manipulation. The Journal of orthopaedic and sports physical therapy. 2011;41(6):389-99. Epub 2011/04/08.
 References
26. Lanthois PE, Pollard H. Spondylolysis in a professional fast bowler. A case study. Australasian
chiropractic & osteopathy : journal of the Chiropractic & Osteopathic College of Australasia.
1997;6(1):1-9. Epub 1997/03/01.
27. Leao Almeida GP, De Souza VL, Barbosa G, Santos MB, Saccol MF, Cohen M. Swimmer's
shoulder in young athlete: rehabilitation with emphasis on manual therapy and stabilization of shoulder
complex. Manual therapy. 2011;16(5):510-5. Epub 2011/01/22.
28. Libetta C, Burke D, Brennan P, Yassa J. Validation of the Ottawa ankle rules in children. Journal
of accident & emergency medicine. 1999;16(5):342-4. Epub 1999/10/03.
29. Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilisation/manipulation in
treatment of lateral ankle sprains: a systematic review. British journal of sports medicine.
2014;48(5):365-70. Epub 2013/08/28.
30. McDevitt A, Young J, Mintken P, Cleland J. Regional interdependence and manual therapy
directed at the thoracic spine. Journal of Manual & Manipulative
Therapy.0(0):2042618615Y.0000000005.
31. Ndetan H, Evans MW, Jr., Hawk C, Walker C. Chiropractic or osteopathic manipulation for
children in the United States: an analysis of data from the 2007 National Health Interview Survey.
Journal of alternative and complementary medicine (New York, NY). 2012;18(4):347-53. Epub
2012/03/06.
32. O'Neal ML. The pediatric spine: anatomical and dynamic considerations preceding manipulation.
Comprehensive therapy. 2003;29(2-3):124-9. Epub 2003/11/11.
 References
33. Pellow JE, Brantingham JW. The efficacy of adjusting the ankle in the treatment of subacute and chronic
grade I and grade II ankle inversion sprains. Journal of manipulative and physiological therapeutics.
2001;24(1):17-24.
34. Pickar JG. Neurophysiological effects of spinal manipulation. The spine journal : official journal of the
North American Spine Society. 2002;2(5):357-71. Epub 2003/11/01.
35. Puentedura EJ, O'Grady WH. Safety of thrust joint manipulation in the thoracic spine: a systematic
review. Journal of Manual & Manipulative Therapy.0(0):2042618615Y.0000000012.
36. Redwood D. Advances in manual therapy for children. Journal of alternative and complementary
medicine (New York, NY). 2011;17(3):185-6. Epub 2011/03/23.
37. Robertson J. The Ottawa Knee Rules accurately identified fractures in children with knee injuries.
Evidence-based nursing. 2004;7(1):24. Epub 2004/03/05.
38. Selhorst M, Selhorst B. Lumbar manipulation and exercise for the treatment of acute low back pain in
adolescents: a randomized controlled trial. Journal of Manual & Manipulative Therapy.
2015;0(0):2042618614Y.0000000099.
39. Todd AJ, Carroll MT, Robinson A, Mitchell EK. Adverse Events Due to Chiropractic and Other Manual
Therapies for Infants and Children: A Review of the Literature. Journal of manipulative and physiological
therapeutics. 2014. Epub 2014/12/03.
 References
40. Vaughn DW, Kenyon LK, Sobeck CM, Smith RE. Spinal manual therapy interventions for
pediatric patients: a systematic review. The Journal of manual & manipulative therapy. 2012;20(3):153-
9. Epub 2013/08/02.
41. Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal
manipulation: a systematic review. Pediatrics. 2007;119(1):e275-83. Epub 2006/12/21.
42. Riddle G, Ross O, Spellane V. Orthopedic issues and treatment strategies for the pediatric
patient. Exercise Considerations for the pediatric patient. APTA. 2009
43. Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and
patterns. Archives of pediatrics & adolescent medicine. 1995;149(1):15-8. Epub 1995/01/01.
44. Cleland JA, Mintken PE, McDevitt A, Bieniek ML, Carpenter KJ, Kulp K, et al. Manual physical
therapy and exercise versus supervised home exercise in the management of patients with
inversion ankle sprain: a multicenter randomized clinical trial. The Journal of orthopaedic and
sports physical therapy. 2013;43(7):443-55. Epub 2013/05/01.
45. Whitman JM, Cleland JA, Mintken PE, Keirns M, Bieniek ML, Albin SR, et al. Predicting short-term
response to thrust and nonthrust manipulation and exercise in patients post inversion ankle
sprain. The Journal of orthopaedic and sports physical therapy. 2009;39(3):188-200. Epub
2009/03/03.