J Manipulative Physiol Ther. 2016 (Jul); 39 (6): 401410 ~ FULL TEXT
Angela J. Todd, BAppSc(Chiro), Grad Dip, Matthew T. Carroll, PhD,
Eleanor K.L. Mitchell, PhD
Angela J. Todd, BAppSc(Chiro)
PO Box 1500,
Sale, VIC 3850, Australia
Objective The purpose of this study is to review the available literature that describes forces of the most commonly used chiropractic techniques for children.
Methods Review of the English-language literature using search terms Chiropract* and technique, protocol, or approach in databases PubMed, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, and Index to Chiropractic Literature and direct contact with authors of articles and book chapters.
Results Eleven articles that discussed the 7 most commonly used pediatric chiropractic techniques and the forces applied were identified. Chiropractic techniques reviewed described forces that were modified based on the age of the patient. Force data for mechanically assisted devices were varied, with the minimum force settings for some devices outside the age-specific safe range recommended in the literature when not modified in some way.
Conclusion This review found that technique selection and application by chiropractors treating infants and young children are typically modified in force and speed to suit the age and development of the child.
Key Indexing Terms: Chiropractic Manipulation, Children, Review of Literature
From the Full-Text Article:
More than 30 million child visits to doctors of chiropractic occur in the United States every year.  It is estimated that more than 19.1 million chiropractic visits occur in Australia annually  and other studies estimate that 8.6% of all visits are from children.  By combining these two studies findings, we can estimate that in excess of 1.6 million child visits occur in Australia every year. Given this estimate, the published cases of serious adverse events in infants and children receiving chiropractic or other types of manual therapy are exceedingly rare,  and there have been no cases of death associated with chiropractic care of children reported in the academic literature to date.  Nonetheless, studies of the amount of force used on children for safety purposes should still be considered.
In Australia and the United States, chiropractic students undertake extensive theoretical and practical training at the university level, including study of and experience with the pediatric population.  Chiropractors are trained to perform a thorough history and examination to determine whether chiropractic care is appropriate and identify a suitable technique, given the age and neurologic presentation of the child. Chiropractors have a range of techniques available to them and can modify these to suit the age and condition of the patient. The process of selecting one type of chiropractic technique over another is based on many factors, including the techniques the practitioner is clinically experienced in applying and the perceived effectiveness of each, as well as the practitioner's understanding of the biological plausibility of using a particular therapy and the associated research evidence base.  It should be noted that health professionals of all types face the same considerations when determining appropriate treatment approaches. 
Data from the National Board of Chiropractic Examiners identified that three-quarters of chiropractors use traditional styles of chiropractic spinal manipulation (diversified or Gonstead technique) and more than half use an Activator instrument or the sacro-occcipital technique (SOT).  Although these data are not age specific, a 2010 cross-sectional survey of 135 chiropractors with pediatric diplomate qualifications in the United States  revealed that reduced-force diversified technique (spinal manipulative technique that has been modified to be lower force and amplitude) was used by 59% of pediatric chiropractors; 63% reported using an Activator instrument, 59% a drop-section table, and 77% cranial therapy. In addition, this study found that cranial and Activator techniques were used mainly for children 5 years and younger, and that modified diversified, Activator, and drop-section table adjustments were used on older children. The Activator instrument, SOT, toggle, touch and hold, and modified spinal manipulative therapy (SMT) were typically used by chiropractors for restoring joint and neurologic function,  and particularly in children to reduce neck pain, back pain, and joint stiffness. 
Given the diversity of styles of chiropractic manipulation, there are currently no peer-reviewed articles that review the amount of force used in commonly used pediatric manipulation techniques. Therefore, the purpose of this study is to review the available literature that describes forces of the most commonly used chiropractic techniques for children.
Excluding mechanically assisted techniques and modified SMT, many of the methods used by chiropractors are similar to those of other manual therapists, [45, 46] including osteopaths using craniosacral therapy with a force of 1 N20 and physical therapists using spinal manipulation/mobilization with a force of 22 N measured in adults.  In his recent article, Rome [45, 46] notes that much of the concern about chiropractors using SMT on children is found in English-language medical practitioner journals, which seem to ignore the fact that their medical colleagues practicing manual medicine in Europe have been using SMT on children since the 1960s. Although it is known that medical manual therapists apply pediatric manual therapy with forces ranging from 50 N to 70 N,  specific force data on chiropractic modified SMT in children have yet to be measured. The information on forces applied and reported adverse events, if any, should assist therapists in selecting the most appropriate technique.
The decision to apply a specific grade of mobilization or manipulation should be based on the patient age, weight, height, sex, neurologic development, muscular control, patient preference, and the clinical confidence and experience of the practitioner.  In addition to these key factors, practitioners should also take into consideration the safe limits proposed by Marchand  to ensure that the forces associated with each technique are age appropriate. These safe limits suggest that low-force, low-speed therapies are more suitable for children younger than 2 years, increasing to moderate force with moderate speed in children aged 2 to 8 years, and then moderate force with high speed up to 18 years. Furthermore, Marchand recommends the newtons of force applied in the cervical spine be less than 20 N for infants and less than 85 N for 3 to 8year-olds. The results of this literature review demonstrate that these limits are achievable with the appropriate application of several of the modern mechanical instruments and with touch and hold, mobilization, modified SMT, modified Toggle, or sacro-occipital technique.
The values in Marchand's safe limits are based in part on the 2002 article by Koch et al  that reported that short-lasting apnea and bradycardia were associated with the use of around 50 N to 70 N of medically applied spinal manipulation in the cervical spine of a sample of 1year-old infants. Those younger than 3 months were twice as likely to have severe bradycardia than those between 4 and 12 months of age. [18, 27] It has been argued that for these measurements to accurately reflect the force likely to be experienced by the patient, allowances should be made for the compliance or flexibility of human tissue. This was noted by Liebschner et al  in their study of handheld adjusting devices, where the measurements were made using a soft tissue analog to better reflect a thrust into a spine on either an adult or a child (Fig 2).
The diversity of measurement approaches for mechanical instruments has led to confusion in the literature regarding the levels of force associated with different devices and settings, with initial levels of thrust of the NMI and Activators III and IV reported by Colloca et al  as being very high (>112 N) when on the lowest setting. However, the most recent research by Liebschner et al  indicates that the forces of Activator II, IV, and V are considerably lower when the measurements are conducted in a way that is analogous to the real-world application to the human spine.
Liebschner et al  indicate that individual patient characteristics may change the level of force received, with an infant/child with a hyperflexible spine receiving a lower peak thrust force than a more hypoflexible adult spine at the same power setting, and handheld instruments further reduced the peak thrust force as it increased tissue compliance. It is unknown how this affects the forces from these instruments. The depth of subcutaneous tissue is also larger in an adult and less in a child, and measurements for a flexible spine with a thinner polymorphous overlay may produce more accurate forces for children using an Activator instrument. The specificity of any of the instruments measured is also unknown because the applicator tip on most of them is larger than most cervical vertebrae in an infant. [16, 22] Considering all of this information, the application of the NMI, HAI, and each of the Activator II, IV, and V instruments to the cervical region of children younger than 3 months delivers a force less than the 50 N to 70 N  where medical spinal manipulation on children was recorded by Koch. In addition, the forces applied at the lowest settings of the Activator II and NMI were both at the 20 N range recommended by Marchand as a maximal safe limit for infants younger than 3 months ; however, the Activator IV and V minimum settings transmit forces above the 20 N level recommended by Marchand for children below 3 months of age when applied directly to the cervical spine.
This review did not include force data from other professions that share similar technique applications as chiropractic, and no data on joint displacement or laxity in children were collected or examined. All of the papers in this study where published in English, with the exception of one paper published in German that was translated into English. There is a need for research to be done on the forces applied with some mechanically assisted devices when used according to recommended protocols (such as through the thumb for a newborn child); therefore, some techniques were not included in this review because the research is not available. Finally, although adverse events from chiropractic and other manual therapies are rare,  this literature review found that the forces applied with manual modified SMT by chiropractors for children of any age have been estimated, not directly measured, and thus require further evaluation. Although there is a growing body of research on the forces associated with different techniques, there are numerous gaps relating to particular techniques. This information should be considered when applying this information in a clinical setting. 
This review found that technique selection and application by chiropractors treating infants and young children are typically modified in force and speed to suit the age and development of the child.
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