Manual Therapy in infants and young children - a polarized debate requires nuance and clinical expertise

Introduction

There has been debate within manual therapy for decades about the application of mobilization techniques in infants and young children. Recently, this debate flared up again following publication of the IFOMPT & IOPTP Paediatric Manipulation & Mobilization Statement (2024). This recommended that manipulations and mobilizations of the spine in young children be largely avoided  based in part on risk assessment and limited evidence(Borusiak et al 2010). These guidelines were subsequently adopted by the Dutch Society of Manual Therapy (NVMT) and the Dutch Society for Pediatric Physiotherapy(NVFK). Nevertheless, this course of action raises many questions. Not only because of the limited substantiation of this policy line, but also because recent clinical experience, safe treatment practices and European data on positive treatment outcomes are largely ignored (Wuttke et al 2025). In this blog, we take a broader look at the discussion.

Summary of the IFOMPT/ IOPTP -Statement and implications.

The IFOMPT and IOPTP international position statement (2024) states:

• Manipulations and mobilizations of the spine are not recommended in infants.
• They may possibly be appropriate in children with musculoskeletal complaints such as neck pain and mobility limitations, if properly justified and performed by experts.Manipulation is a contraindication 
• There is caution against application in non-musculoskeletal complaints (such as reflux, ADHD, crying babies).

While these recommendations are understandable from a "safety first" perspective, critical comments can be made about the lack of transparency about the literature selection used and the exclusion of recent positive evidence.In a formal letter to the KNGF, Dutch experts express concerns about the scientific foundation of the statement (Saedt et al., 2025). They emphasize that:

•          Recent literature showing positive effects of mobilization in infants has not been included in the IFOMPT statement.
•          The risks presented are largely based on case histories from chiropractic, and thus not representative of Dutch practice within the specialized physiotherapist in musculoskeletal therapy. 
•          In a descriptive study  of the European Workgroup of Manual Medicine( EWMM ) there are >420.000 monitored treatments without serious adverse events thus not more than in babies and children who are generally treated by other forms of therapy (Sacher et al 2025).

This criticism is shared in international professional literature citing the debate on bias and biased policy making (Kusgen & Ammermann 2025)

 Infants and young children can also exhibit neck dysfunctions and related symptoms.

A planned article on HWS syndrome in children (von Piekartz, 2025) shows that neck pain in young children is often associated with craniofacial and cervical asymmetries, pain, movement anxiety and related developmental delays. Among other things, this article advocates the use of gentle mobilization techniques, such as within the Maitland concept (grades I-III, without provocation), with the goal of:

•         reducing (cranio)cervical dysfunctions and attenuating persistent nociceptive stimuli,
•         reducing movement anxiety,
•         promoting proprioception and postural control,
•         early normalization of asymmetries and functional retardation in the maxillofacial-cervical area through targeted stimulation.

Essential here is careful screening for red flags and use of specialized therapists with knowledge of pediatric (cervical) anatomy and developmental physiology. Parents are actively involved in the treatment process and instructed to continue lifestyle modifications and simple exercises at home (Jonslin et al., 2024).

My Personal Perspective from More Than 25 Years of Experience with Manual Therapy in Infants and Young Children

As a manual therapist, I have been working with infants and young children for over 25 years, with a focus on functional neuromusculoskeletal diagnosis and the application of gentle, non-provocative techniques. In particular, accessory mobilizations of Grades II, III, and IV—applied without discomfort and combined with craniofacial manual techniques—have proven clinically effective in reducing functional dysfunctions and suppressing persistent nociceptive stimuli (von Piekartz, 2015).Throughout all these years, I have not observed any serious side effects, provided that:

·       Careful screening for indications and contraindications is performed.

·       Mobilizations are applied correctly, individually tailored, and symptom-free.

·       Parental communication, education, and follow-up for several months after the end of treatment are an integral part of the treatment process.

Examination of Occiput -C1  with accessory movements in an Infant

Photo : harry von Piekartz

Does this development fit into a broader paradigm shift within neuromusculoskeletal Physiotherapy (Manual Therapy)

Over the past five years, a clear trend is emerging within the physical therapy field: hands-on techniques are increasingly being replaced  by active forms of exercise, with some manual therapy techniques being explicitly rejected or given warnings. This trend manifests itself in education, in guideline development and even in the criteria of health insurance companies. Although the efficacy of active exercise therapy is well established and precisely the combination of manual therapy and targeted active rehabilitation tailored to the individual appears to be the most powerful, a polarizing opposition between passive and active interventions is undesirable especially in the context of pediatric manual therapy.

Therefore once again the statement of the IFOMPT Taskforce : Manipulations and MOBILISATIONS of the spine are not recommended in infants.

The specialized manual therapist, trained within the EWMM, CRAFTA or IMTA, among others, will never recommend:

•           manipulate infants and young children with a thrust technique - safe, properly performed mobilization in young children is not manipulation;
•          treat non-musculoskeletal complaints such as restlessness, crying babies or neurodermatitis etc.;
•          perform treatment when red flags are present.
•      in addition it is strongly advised to seek structural coordination with the referring physician or a specialized colleague, such as the pediatric physical therapist.

Conclusion

•          The recommendations from the IFOMPT statement require more nuance. Gentle mobilizations such as within the Maitland concept, if carefully indicated and performed by well-trained therapists, are safe and valuable for children with musculoskeletal complaints. 
•          Generalizing warnings or prohibitions without clinical rationale undermine evidence-based practice; it is time for a fair, balanced approach in which clinical experience, data and science reinforce each other. This debate is anything but closed.

References 

Borusiak, P., Biedermann, H., Boßerhoff, S., & Opp, J. (2010). Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: results of a prospective, randomized, placebo-controlled, and blinded trial. Headache: The Journal of Head and Face Pain, 50(2), 224-230.

Joslin, R., Allen, E., & Carter, B. (2024). Understanding the importance of therapeutic alliance during physiotherapy treatment for musculoskeletal pain in children: a scoping review. Frontiers in Pain 

Research, 5, 1452771. IFOMPT & IOPTP. (2024). Paediatric Manipulation and Mobilization Evidence-based Practice Position Statement - Policy Brief. https://doi.org/10.6084/m9.figshare.26038921

Sacher, R., Saedt, E., & Wuttke, M. (2025). Restricted use of spinal mobilization and manipulation in infants: How serious is the scientific debate? Manuelle Medizin, 1-4.

Küsgen, B., & Ammermann, M. (2025). There is no madness in spinal manual techniques in the pediatric setting. Journal of Manual & Manipulative Therapy, 33(1), 16-17.

Research, 5, 1452771. IFOMPT & IOPTP. (2024). Paediatric Manipulation and Mobilization Evidence-based Practice Position Statement - Policy Brief. https://doi.org/10.6084/m9.figshare.26038921

Saedt, E.van de Woude, B., Theunissen, P., & von Piekartz, H. (2025). Letter to Board KNGF, Reaction to IFOMPT statement. EWMM NL & CRAFTA.

von Piekartz, H. (2025). Das HWS-Syndrom bei Kindern im Alter von 2-7 Jahren in Physiopraxis, September. In press / In preparation.

Piekartz, H.,Budelmann K, (2015)Neuromuskuloskeletales Assessment und Management von kindlichen Kopfschmerzenp 574- 596 in . "Kiefer, Gesichts-und Zervikalregion. Neuromusculoskeletal Assessment und Behandlungsstrategien, H. von Piekartz." (2015).

 Wuttke, M., Knuedeler, M., & Wenning, K. (2025). Tendential and unscientific opinion regarding spinal manipulative therapy in the pediatric population: In Reference to: Olson KA, Clewley D, Milne, N et al.(2024): Spinal manipulation and mobilization for pediatric conditions: time to stop the madness. J Man Manip Ther. 32 (3), 207-210. Journal of Manual & Manipulative Therapy, 33(1), 10-12.

Comments

You are logged in as {{user.name}}

Name

Email

Your comment {{ comment.length }} / 2000

• {{ error[0] }}

Post Comment