New International Guidelines for Pediatric Physiotherapy Ensuring Safety and Efficacy

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) and the International Organisation of Physiotherapists in Paediatrics (IOPTP) have published an evidence-based position statement on the use of spinal manipulation and mobilisation in pediatric care. Guidelines for Pediatric Physiotherapy, featured in the June 2024 issue of The Journal of Manual & Manipulative Therapy , aims to guide clinical practice and policy decisions, prioritizing the safety and efficacy of these interventions for infants, children, and adolescents.

The guidelines make several key recommendations. Firstly, spinal manipulation and mobilisation are not recommended for infants. Current evidence is insufficient to support their use, and the potential risks significantly outweigh any perceived benefits.

Secondly, the manipulation of the cervical (neck) and lumbar (lower back) spine should not be performed on children. The high vulnerability of these regions in children, coupled with a lack of supporting evidence for safety and effectiveness, makes such interventions inadvisable.

Thirdly, spinal manipulation and mobilisation should not be used to treat non-musculoskeletal conditions in pediatric patients. This includes conditions like asthma, ADHD (Attention Deficit Hyperactivity Disorder), autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis (bedwetting), and otitis media (middle ear infection). Evidence shows no benefit and potential harm from these practices for such conditions.

The IFOMPT Task Force on Pediatric Manipulation, active from 2020 to 2022, played a crucial role in developing this position statement. The task force brought together experts from several countries, each contributing their specialized knowledge and research. Important to mention all names - Ken Olson from the USA provided political insights and served as the primary liaison, while Anita Gross from Canada led systematic reviews on manipulation methods and adverse events. Jan Pool from the Netherlands focused on pediatric manipulation within OMPT (Orthopaedic Manipulative Physical Therapy). Annalie Basson from South Africa conducted systematic reviews and contributed to the methodology. Nikki Milne from Australia provided pediatric leadership and conducted scoping and umbrella reviews. Derek Clewley from the USA specialized in systematic reviews and knowledge translation.

The task force had several primary objectives. They aimed to summarize current practices of spinal manipulation and manual therapy for pediatric patients globally and to analyze research evidence on these techniques in pediatric care. Additionally, they sought to develop a comprehensive position statement to guide physical therapists in safely managing musculoskeletal disorders in pediatric patients. They also examined the political implications of the proposed position statement and planned for its effective dissemination to ensure widespread adoption.

The development of the position statement followed a rigorous three-stage process.

The first stage was the literature review. This involved a systematic scoping review of existing studies and literature on the benefits and harms of spinal manipulation and mobilisation in infants, children, and adolescents. The review also included two assessments of the psychometric properties of clinical outcome measures used in studies, ensuring that these measures accurately and consistently evaluate what they are intended to.

The second stage was the Delphi survey.

The term “Delphi” in modern contexts, such as the Delphi survey, evokes the idea of gathering wisdom or achieving a consensus through the input of knowledgeable individuals, much like how the ancient Greeks sought divine guidance from the Oracle. The Delphi method uses structured communication to harness collective intelligence and expert judgment, reflecting the ancient practice of seeking profound insights through consultation.

On this occasion conducted in three rounds, the survey gathered expert opinions on the clinical appropriateness of spinal manipulation and mobilisation for various pediatric conditions. Feedback was provided between rounds to refine and converge opinions towards consensus.

The final stage was the refinement phase. This involved consensus workshops where detailed discussions and synthesis of findings from the scoping review, psychometric properties reviews, and Delphi survey took place. The aim was to reach a consensus on the final position statements. This stage also included peer review and editorial review, where the draft position statements were scrutinized and validated by other experts in the field. A strategic plan for disseminating the position statement was developed, including online distribution, presentations at professional conferences, and the creation of infographics and notable quotes for effective knowledge translation.

The joint position statement by IFOMPT and IOPTP provides a robust framework for the safe and effective use of spinal manipulation and mobilisation in pediatric populations. By emphasizing evidence-based practice, the task force has highlighted the need for caution and the importance of prioritizing patient safety in pediatric physiotherapy.

What Next?

The recommendations not only aim to ensure safety but also to foster a positive approach to physical activities and holistic development in children. Physical therapists are encouraged to employ alternative tp the spinal mobilisations, evidence-based methods that support healthy growth and development, ensuring that all interventions are both safe and beneficial.

For further details, the full policy brief can be accessed through World Physiotherapy Specialty Groups – IFOMPT & IOPTP, 2024. This initiative underscores the commitment to promoting safe, effective, and positive physical activity and development among young patients.