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Objective: The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists., Methods: Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale., Results: Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:Manipulation is not recommended : (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels.Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic).Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels., Conclusion: Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

Objective: To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents., Methods: Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using Qualtrics Ⓡ . In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study., Results: Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist's knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning., Conclusion: This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population.

Introduction: An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions., Method: A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes)., Results: Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined., Conclusion: Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Introduction: Reliable, valid, and responsive outcomes is foundational to address concerns about the risks and benefits of performing spinal manipulation and mobilization in pediatric populations. The aim of this systematic review was to synthesize evidence on measurement properties from cohort/case-control/cross-sectional/randomized studies on patient-reported (SQLI - Scoliosis Quality of Life Index; VAS-Visual Analog Scale; PAQLQ - Pediatric Asthma Quality of Life Questionnaire), observer-reported (Crying Diaries; ATEC - Autism Treatment Evaluation Checklist) and mixed (PedsQL - Pediatric Quality of Life Inventory) outcome measurements identified through a scoping review on manipulation and mobilization for pediatric populations with diverse medical conditions., Method and Analysis: Electronic databases, clinicaltrial.gov and Ebsco Open Dissertations were searched up to 21 October 202221 October 2022. Two independent reviewers selected studies, extracted data, and assessed risk of bias. Qualitative synthesis was performed using COSMIN and Cochrane GRADE methodology to establish the certainty of evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), indeterminate (?)., Results: Eighteen studies (2 SQLI for scoliosis; 1 VAS - perceived influence of exertion or movement/position on low back problems; 1 PAQLQ for asthma; 1 Crying Diaries for infantile colic; 8 ATEC for autism; 5 PedsQL for cerebral palsy/scoliosis/healthy) with 9653 participants were selected. ATEC and PedsQL had overall sufficient (+) measurement properties with moderate certainty evidence. PAQLQ had indeterminate measurement properties with moderate certainty evidence. Very low certainty of evidence identified measurement properties to be indeterminate (?) for SQLI, Crying Diaries, and VAS- perceived influence of exertion or movement/position on low back problems., Conclusion: ATEC for autism and PedsQL for asthma may be a suitable clinical outcome assessment (COA); additional validation studies on responsiveness and the minimal important difference are needed. Other COA require further validation.

Introduction: Risks and benefits of spinal manipulations and mobilization in pediatric populations are a concern to the public, policymakers, and international physiotherapy governing organizations. Clinical Outcome Assessments (COA) used in the literature on these topics are contentious. The aim of this systematic review was to establish the quality of clinician-reported and performance-based COAs identified by a scoping review on spinal manipulation and mobilization for pediatric populations across diverse medical conditions., Method and Analysis: Electronic databases, clinicaltrials.gov and Ebsco Open Dissertations were searched up to 21 October 2022. Qualitative synthesis was performed using Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to select studies, perform data extraction, and assess risk of bias. Data synthesis used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) to determine the certainty of the evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), or indeterminate (?)., Results: Four of 17 identified COAs (77 studies, 9653 participants) with supporting psychometric research were classified as:Performance-based outcome measures: AIMS - Alberta Infant Motor Scale ( n  = 51); or:Clinician-reported outcome measures: LATCH - Latch, Audible swallowing, Type of nipple, Comfort, Hold ( n  = 10),Cobb Angle ( n  = 15),Postural Assessment ( n  = 1).AIMS had an overall sufficient (+) rating with high certainty evidence, and LATCH had an overall sufficient (+) rating with moderate certainty of evidence. For the Cobb Angle and Postural Assessment, the overall rating was indeterminate (?) with low or very low certainty of evidence, respectively., Conclusion: The AIMS and LATCH had sufficient evidence to evaluate the efficacy of spinal manipulation and mobilization for certain pediatric medical conditions. Further validation studies are needed for other COAs.

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 4 th 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 mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent 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 plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation 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 enuresis, 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., 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 populations are warranted., (© 2022. The Author(s).)

Study Design: A secondary analysis of a systematic review., Background: Manipulations or mobilizations are commonly used interventions in patients with mechanical neck pain. The treatment effects have often been studied in randomized controlled trials (RCT) which are generally considered the gold standard in evaluating the treatment effects, mainly due to its high internal validity. External validity is defined as the extent to which the effects can be generalised to clinical practice. An important prerequisite for this is that interventions used in clinical trials can be replicated in clinical practice. It can be questioned if interventions utilized in randomized controlled trials can be translated into clinical practice., Objectives: The overall aim of this study is to examine whether the quality of the description of manipulation and mobilization interventions is sufficient for to replication of these interventions in clinical practice., Methods: A comprehensive literature search was performed. Two independent researchers used the Template for Intervention Description and Replication (TIDieR) which is a 12-item checklist for describing the completeness of the interventions., Results: Sixty-seven articles were included that used manipulation and/or mobilization interventions for patients with mechanical neck pain. None of the articles describe the intervention e.g. all the items on the TIDieR list. Considering item 8 (a-f) of the TIDieR checklist only one article described the used techniques completely., Conclusion: Manipulation or a mobilization interventions are poorly reported in RCTs, which jeopardize the external validity of RCTs, making it difficult for clinicians and researchers to replicate these interventions., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Study Design: A randomized clinical trial., Objective: To compare the effectiveness of a behavioral graded activity program with manual therapy in patients with subacute (4-12 weeks) nonspecific neck pain., Summary of Background Data: Neck pain is a common complaint, for which many conservative therapies are available in primary care. There is strong evidence for manual therapy in combination with exercises. Psychosocial factors are also believed to play a role in chronic pain. The evidence of the effectiveness of a program focused on these factors is still unknown., Methods: A randomized clinical trial was conducted, involving 146 patients with subacute nonspecific neck pain. The BGA program can be described as a time-contingent increase in activities from baseline toward predetermined goals. Manual therapy consists of specific spinal mobilization techniques and exercises. Primary outcomes were global perceived effect, the Numerical Rating Scale for pain and the Neck Disability Index. Secondary outcomes were the Tampa Scale for Kinesiophobia, the 4 Dimensional Symptom Questionnaire, and the Pain Coping and Cognition List. Measurements were carried out at baseline and 6, 13, 26, and 52 weeks after randomization. Data are analyzed according to the intention-to-treat principle, using multilevel analysis., Results: The success rates at 52 weeks, based on the GPE were 89.4% for the BGA program and 86.5% for MT. This difference was not statistically significant. For pain and disability, a difference was found in favor of the BGA program; mean difference for pain = 0.99 (95% CI 0.15-1.83) and mean difference for NDI = 2.42 (95% CI 0.52-4.32). All other differences between the interventions in the primary and secondary outcomes were not statistically significant., Conclusion: Based on this trial it can be concluded that there are only marginal, but not clinically relevant, differences between a BGA program and MT.

The objective of this study is to identify subgroups of patients with non-specific neck pain who are more likely to benefit from either physiotherapy, spinal manipulation therapy, or usual care, on the short- and long-term. Data of three recently finished randomised controlled trials, with similar design and setting, were combined. The combined study population consisted of 329 patients with non-specific neck pain in an adult (18-70years) primary care population in the Netherlands. The primary outcome measure was global perceived recovery and was measured at the end of the treatment period and after 52 weeks of follow-up. Fourteen candidate variables were selected for the analysis. Predictors were identified by multivariable logistic regression analysis and were tested for interaction with treatment. Based on the multivariable models with interaction terms a decision model for treatment choice was developed. The analysis revealed three predictors for recovery of which the effect is modified by treatment: pain intensity (0-10 scale) in the short-term model, age and (no) accompanying low back pain in the long-term model. With these predictors a clinically relevant improvement in recovery rate (up to 25% improvement) can be established in patients receiving a tailored instead of a non-advised treatment. In conclusion we identified three characteristics that facilitate a deliberate treatment choice, to optimise benefit of treatment in patients with non-specific neck pain: age, pain intensity, and (no) accompanying low back pain.

The objective is to present the design of a randomized clinical trial (RCT) on the effectiveness and cost effectiveness of a behavioural graded activity programme compared with manual therapy in patients with sub-acute neck pain. Sub-acute is defined as pain existing for 4-12 weeks. The behavioural graded activity programme is a time-contingent increase in activities from baseline towards pre-determined goals. Manual therapy consists mainly of specific spinal mobilization techniques and exercises. The primary outcomes are global perceived effect and functional status. Secondary outcomes are kinesiophobia, distress, coping, depression and somatization. The intensity and persistence of the pain and its interference with activities are also assessed. Direct and indirect costs are measured by means of cost diaries. Measurements take place at baseline and 6 and 12 weeks after randomization. To assess the long-term effect, measurements will also take place after 6 and 12 months. Finally some challenges are discussed concerning the use of a behavioural graded activity programme, manual therapy and outcomes.