Spinal manipulation and mobilisation among infants, children, and adolescents

Key points

1. 01Spinal manipulation is not recommended for infants at any spinal level under any condition
2. 02Manipulation may be considered only for adolescents treating thoracic or lumbar joint hypomobility, and thoracic joint pain
3. 03Spinal mobilisation is recommended for children and adolescents with joint hypomobility, joint pain, and muscle or myofascial pain at all spinal levels
4. 04Severe adverse events including rib fractures, neurological deficits, and death have been documented from paediatric spinal manipulation in the literature
5. 05Consensus was not reached for several conditions (neurodevelopmental disorders, hypermobility, hypersensitivity, peripheral nerve disorders) across multiple age groups

How it was conducted

Design

3-round international Delphi consensus survey

Participants

26 expert physiotherapists invited from 8 countries; 11 completed all three rounds (from 7 countries across 5 continents)

Consensus threshold

>=75% agreement or disagreement on a 4-point Likert scale

Age groups

Infants (birth to <2 years), children (2-12 years), adolescents (13 to <18 years)

Spinal levels assessed

Cervical, thoracic, and lumbar

Round structure

Round 1 open-ended identification; Rounds 2 and 3 Likert-scale voting on conditions, impairments, spinal levels, and technique

What they found

• Consensus (>=75%) was achieved that spinal manipulation is not appropriate for infants at all spinal levels across all conditions and impairments
• Consensus was achieved that spinal manipulation is not appropriate for children across all conditions except neurodevelopmental disorders (thoracic) and peripheral nerve disorders (thoracic) where no consensus was reached
• Consensus was achieved that spinal manipulation may be recommended for adolescents for thoracic and lumbar joint hypomobility, and thoracic joint pain
• Consensus was achieved that spinal mobilisation is appropriate for children and adolescents for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels (cervical, thoracic, lumbar)
• Attrition from Round 1 to Round 2 was 40%; attrition from Round 2 to Round 3 was 8%; Round 2-3 retention was 92%
• Final Round 3 respondents: mean age 50.7 years (SD 10.8), mean 26 years of practice (SD 10.1), 64% female

Limitations

• Small final panel of 11 experts limits generalisability; not all countries were represented
• 40% attrition between Rounds 1 and 2 may have introduced selection bias
• Experts were required to have mastery of English, potentially excluding non-English-speaking specialists and limiting global reach
• Consensus reflects expert opinion, not empirical trial evidence; very little high-quality RCT data exists on mobilisation or manipulation effectiveness in paediatric populations

Why it matters

For patients

Parents and caregivers should be aware that spinal manipulation is considered inappropriate for infants and most children by leading expert physiotherapists, and even in adolescents it is recommended only for specific mechanical problems.

For clinicians

Physiotherapists treating paediatric patients should reserve spinal manipulation for adolescents with thoracic or lumbar joint hypomobility or pain, and can use mobilisation more broadly in children and adolescents for musculoskeletal impairments, while applying careful clinical reasoning given limited evidence.

For readers

This Delphi study fills a gap where RCT evidence is lacking by capturing structured expert consensus, offering actionable guidance for professional position statements while highlighting areas still lacking agreement.