J Clinical Chiropractic Pediatrics 2012 (Jun); 13 (1): 958–967 ~ FULL TEXT
Josefa Langkau and Joyce Miller BS, DC , DABCO, FCC (UK), FEAC, FACO(US)
34 Morley Road,
BH5 2JL, Bournemouth,
Joyce Miller, BS, DC, DABCO, FCC (UK), FEAC, FACO(US)
Associate Professor, Anglo-European College of Chiropractic,
Bournemouth, United Kingdom
Objective: The purpose of this study was to describe etiology, presentation and treatment of musculoskeletal issues in early infancy by integrating a case series of infants diagnosed with kinematic imbalance due to suboccipital sprain (KISS) and treated in a teaching clinic in the United Kingdom with a critical review of the concept of KISS. The concept has been developed by Heiner Biedermann and medical doctors in Germany and contributed significantly to the development of manual therapy in
children in that country.
Methods: A literature review was conducted. The search was focused on German studies about KISS syndrome and English studies about musculoskeletal issues in infants. Search strategy: ZDB, ZB MED and PubMed and hand search in German libraries. The data were collected by survey via a data collection system and files in the Anglo European College of Chiropractic (AECC)
Results: The primary differences between the diagnosis and treatment recommended by Biedermann and that in the AECC clinic are 1) the recommended use of x-ray prior to treatment by Biedermann and 2) recommended force used in treatment (4 N at AECC versus 70 N with Biedermann).
Conclusion: Musculoskeletal issues caused by birth and intrauterine posture are commonly observable and early treatment is often recommended; however, the grounding in evidence is not yet known. What this study adds to the literature is that:
Radiologic evaluation of every child cannot be justified without any red flags due to known radiation hazards.
Different treatments involve very different forces. Future studies about effectiveness and safety should focus on specific treatment
style and force.
There is no genetic component to develop KISS syndrome and the predisposition of male sex is more likely related to a bigger than average size at birth.
From the Full-Text Article:
Musculoskeletal dysfunctions in the infant including torticollis, infantile scoliosis and facial asymmetry have been noted by various authors in the past two decades. [1–7] Facial asymmetries and head deformities in neonates are common and dysfunctional hip development has also been noted. 
The surgeon, Heiner Biederman, who contributed significantly
to the development of manual therapy in children
in Germany, also developed the concept of the kinematic
imbalance due to suboccipital strain or “KISS-syndrome”.
It suggests that functional abnormality in the atlantooccipital
and atlanto-axial joints (for example, caused by
birth trauma) might lead to a spectrum of symptoms and
complaints in newborns. 
Infant positional preferences are common with this being
present in 8%–12% of infants. [9, 10] About 2.4% retained
restricted range of motion and/or flattening of the skull at
the age of 2 to 3 years. Other long term effects have been
found. Sacher, for example, found that although dysfunction
of the suboccipital joints might be asymptomatic
during childhood, untreated functional abnormalities are
thought to become persistent during skeletal maturity,
leading to a fixed dysfunction causing symptoms in older
children and adults. 
It is controversial as how to best react to asymmetric
posture in infants. On the one hand it might be considered
as being self-limiting.  On the other hand more recent
studies imply the importance of treatment to avoid postural
fixed dysfunctions causing long term problems in later
childhood. [8, 11, 13–15]
Therefore it is important to investigate musculoskeletal
diagnosing in infants with the help of early markers
and examine whether the concept of early treatment
might be justified. This paper aims to give a deeper
understanding of musculoskeletal issues in children by
putting KISS and KISS-induced Dyspraxia and Dyslexia
(“KIDD”), Biedermanns’ diagnostic concepts, into context
within practice. Moreover, the presented case series on
23 symptomatic subjects adds to a critical evaluation of
current treatment procedures for musculoskeletal problems
The paper is a hybrid-type study, a narrative review
combined with a case series. The literature review focused
on German studies about KISS syndrome and English
studies about musculoskeletal issues in infants. ZDB,
ZB MED and PubMed were searched and the following
search strategy was used:
“KISS + syndrome”,
”Kopfgelenk + Asymmetrie”,
Finally, the reference lists of relevant reviews were
Additionally a wider search was done in libraries in
Germany (Deutsche Nationalbibliothek Leipzig, Medizinische
Bibliothek Chariete Berlin) to gather older
articles and journals which were not accessible in any internet
database. The library was searched for relevant text
For additional information and literature, telephone
and email correspondence with Dr. Heiner Biedermann,
specialist for KISS syndrome, have been used.
The data were collected by survey via a data collection
system and files in the clinic to determine, describe and
interpret the number of children presenting with KISS
and identify the history, cause of presentation, physical
findings and treatment given at the AECC teaching
clinic. All consent forms had been signed and no individual
child can be identified. All data are held completely confidential
and data collection was approved by the ethics
A review of recent records showed that, between 2003 and 2010, 23 infants presenting to the chiropractic teaching clinic in Bournemouth, United Kingdom had been diagnosed with KISS syndrome. The data collected included information suspected to be risk factors in Table 1 and treatment specific data shown in Table 2.
The mean presenting age was 7–8 weeks and with a
male:female ratio of 1.6:1.
13 of the 23 patients had a difficult and/or instrumental
assisted labor. The children were all full term and
the mean birth weight of 3,512 grams at the 50th centile
in the growth chart.
Most common presenting complaints were restriction
of rotation towards one side with or without difficulties
breastfeeding. General restrictions and tenderness in the
upper cervical segments and muscular tightness in the
suboccipital region, as well as pelvic and SI joint fixations
were noted. The most common differential diagnosis was
irritable infant syndrome of musculoskeletal origin (IISMO)
or biomechanical cervical dysfunction and treatment
consisted mainly of touch and hold and occipital-sacral
KISS syndrome is thought to be caused by irritation of
the cervical spine during birth,  which is a very demanding
procedure for the infant and its spine.  Other authors
found that asymmetry and restrictions are related to intrauterine
posture rather than birth trauma. [4, 7] Children with
a head preference to the right usually had an intrauterine
posture to the right.  Nevertheless there is a correlation
between craniofacial asymmetry and birth injuries.  It is
most likely that both the intrauterine environment and
birth injury contribute to the antalgic postures and asymmetries.
The relationship between etiology mechanism and
symptoms of KISS is shown in Figure 1.
The clinical picture of untreated KISS syndrome consists
of four stages: 
Up to 3 months: unspecific preliminary stage with
symptoms of autonomic irritation and dysphoria
(restlessness) e.g. crying babies and colic.
3–12 months: asymmetry during time scale of gaining
head control until verticalization. The typical clinical
presentation of KISS in this stage is summarized in
Verticalization until 4/5 years: symptom free, silent
KISS-induced dysgnosia and dyspraxia (“KIDD syndrome”): sensory-motor deficits leading to signs and
symptoms of dysgnosia — relating to a form of intellectual
impairment prohibiting learning; and dyspraxia
— a form of cognitive dysfunctions that impair the
ability to learn/use new motor-patterns. 
The data collection at the teaching clinic corroborates
previous findings that males more commonly present with
KISS syndrome.  Furthermore instrumental assisted delivery
was common which is thought to be another risk factor
contributing to the development of the KISS-syndrome. 
The cases collected at the teaching clinic further supported
the general literature  that manipulative therapy is very
effective after 4–6 treatments for musculoskeletal issues in
infants. When a fixation was detected, range of motion
could almost always be improved. Although there was not
always complete recovery, improvement was noted.
Comparing the common differential diagnosis to the
symptomatic picture of KISS, a lot of similarities can be
noted. A major difference is rather the perceived cause
and consequent treatment plan. Whereas for IISMO it
is suggested that the whole musculoskeletal system of
the infant might lead to symptoms,  the whole spine
will be in focus and specific imbalances will be treated.
KISS on the other hand is thought to develop due to an
imbalance in the cervico-occipital region; therefore the
treatment plan involves only manipulation to the upper
cervical spine.  Moreover, Biedermann suggests that
one treatment might be enough to resolve symptoms in
80% of patients and recommends not treating too often
with leaving a pause of 2–3 weeks. 
Most often touch and hold technique (TAH) is used as
pediatric manipulative therapy. Up to 3 months of age, only
light finger pressure should be used,  because the infantile
cervical spine is not ossified  and therefore susceptible to
compression forces. A gentle manipulation is not recommended
until the child is one year of age.  Pressure should
not exceed 85–141 grams  and the joint is not taken to its
end range of motion.
Another technique used quite commonly was occipitalsacral
decompression. With the infant supine a very gentle,
light distraction is applied for 30 seconds, by contacting
the occiput and sacral base, aimed to reduce tension and
This style of treating differs quite a lot from the treatment
described by Biedermann. At the teaching clinic a
very gentle approach to the whole spine is used to treat, and that the force applied in those pediatric manipulations not
exceed 4 Newton.  In contrast, Biedermann describes that
to manipulate the fixation, a short impulse is given with the
index finger towards the lateral mass of C1 or transverse
process of C2, aiming to affect the cervical receptors. As
the highest amount of proprioceptive muscle spindles is
found in the upper cervical spine, it is thought to have
the biggest effect on biomechanical motor function and
balance.  Koch and Girnus  measured the force of an
impulse for a pediatric manipulation done by Biedermann
and Koch to be 70 Newton.
This is one of the major differences between treatments
— the treatment at the teaching clinic involves
one twentieth of the force compared to the force applied
by Biedermann. Since the major issue of manipulative
therapy is safety, especially for pediatric patients who
have delicate anatomy, this difference might be important.
However, hardly any paper actually refers to a specific
style of treatment and there is no report of adverse events
associated with the Beidermann methods versus the low
force techniques performed in the chiropractic clinic
In future studies about adverse effects, focus should be
put on the force of treatment as well as the type of treatment
used to give a more detailed picture.
A genetic component has been suggested to the predisposition
to developing KISS,  since males were affected
more frequently than females. However, when comparing
the growth charts of male and females, a difference in
head circumference is noticeable. Whereas for girls a head
circumference of 37 cm at birth is in the 99.6th centile, in
boys the 99.6th centile is related to a head circumference
of 39 cm.  It is further known that male infants have a
more prominent occipital protuberance.  According to
the WHO growth charts, male neonates are usually bigger
as well. A bigger head circumference and size is a known
predisposing factor for injuries, [11, 29, 30] leading to the conclusion
that size is more likely to explain the ratio than an
unknown genetic component.
In contrast to the diagnostic procedure in the teaching
clinic where no child will be x-rayed, Biedermann states that
an x-ray of the cervico-occipital region needs to be made
before treating the patient to rule out any pathology and
important anomalies. This diagnostic process is criticized
by the German association for neuro-pediatrics because it
adds an additional risk of radiation hazards.  Infants may
be more susceptible to the effects of radiation.  Especially
in newborns the cells are still developing; therefore they
are rapidly dividing.  It is known that dividing cells are
easily affected by radiation,  which might lead to genetic
mutations. Even if the consequences of one-time radiation
are not fully researched, various studies show a correlation
between long-term radiation in childhood and
the incidence of acute and chronic side effects including
It is always important to consider potential risks and benefits when deciding to x-ray a patient.  The prevalence of KISS-syndrome is thought to be relatively high; therefore long-term effects of radiation should be considered. The manipulating therapist should have a very good education about contraindications of manipulation. A thorough history and examination for every patient might be enough to obtain suspicious findings or potential contraindications to treatment. Then an x-ray could be done to prove suspicion of a specific pathology instead of x-raying every infant presenting to the practice.
Therefore we suggest the following:
There is no genetic component to developing KISS syndrome as stated by Biedermann — predisposition of male sex is rather caused by bigger average size at birth.
Radiologic evaluation of every child cannot be justified without any red flags due to known radiation hazards.
Future studies about effectiveness and safety should focus on specific treatment style and force.
Suspected long term effects of untreated KISS syndrome
Musculoskeletal imbalances, such as KISS syndrome
are functional problems of the cervical spine which is still
plastic and changeable.  Therefore it can be resolved by
early treatment, whereas untreated it might become a
structural problem of the cervical spine. [38–40] Some authors
state, based on case studies, that the symptomatic cases will
resolve spontaneously [12, 41] questioning if early therapy is effective
and if it is needed.  However, children may become
asymptomatic but still have reduced head range of motion
with sensory-motor dysfunctions [8, 9, 15, 40, 42, 43] which may lead
to other functional problems.
Studies reveal that positional head deformities are still
persistent in one third of the affected children after 2–3
years,  and early treatment and education  for infants might
effectively reduce neck problems, and head preferences
otherwise leading to cosmetically significant  long-term
plagiocephaly. [3, 5, 45] The association can also be noted by
the trends in clinician referral with suspicion of KISS. In
1999 the prevalence of children referred to Biedermann
with suspicion of KISS was due to torticollis in 89.3%; in
2003 53% of children have been referred for torticollis but
67.6% for cranial asymmetry. 
It is suggested that in a dysfunctional upper cervical
spine, tonic neck reflex receptors cannot transmit the information
correctly, leading to impaired perception.  The
cervical spine musculature has many more muscle spindles
and proprioceptive receptors than the lower back musculature,  meaning that the upper cervical spine might be
important for smooth functioning of perception and motor
control.  This thesis is supported by a study by Owens et
al.  which evaluates the repositional accuracy of students
with contracted, shortened muscles, concluding that cervical
paraspinal musculature contraction influence the proprioceptive
accuracy of the neck. Therefore dysfunction in
the upper cervical spine may have an impact on the quality
of the kinesthetic system, leading to impairment in sensation
causing a dysfunction in development of fine motor
skills.  This theory finds anecdotal evidence in studies from
whiplash patients. The traumatic acceleration-deceleration
injury of the neck and surrounding structures  was found
to cause muscular imbalance and cervical spine dysfunction,
leading to poorer motor control, especially reduced
joint position sense. [52, 53] Even if the mechanism of injury
is different from birth, these studies provide evidence that
injuries to the cervical spine might lead to dysfunctions
that affect the sensory-motor system, especially proprioception.
Moreover, a recent meta-analysis found an association
between regulatory problems like crying, feeding problems
and sleeping problems (that contribute to the symptomatology
of KISS) and later behavioral problems. 
The symptoms of KISS are thought to progress and it
is suspected that, because “form follows function,” longterm
effects might develop from untreated KISS. Many
sources in the literature recommended early treatment and
case studies showed manipulative therapy to be effective in
reducing early dysfunctions and therefore signs and symptoms
of KISS and preventing long-time deformities.
However there is minimal evidence for observed
behavioral changes and attention deficits as described.
Even if sensation and proprioception might be altered by
dysfunctional joints, it is questionable if this accounts for
a variety of long term effects. More research is needed to
give a clearer picture.
Other studies about infant torticollis, asymmetry
and head deformities also conclude that early treatment
is favorable to prevent long-term deformities. [3, 7] Especially
sufficient education [4, 5] and adequate amount of “tummy
time” is suggested to be favorable, because it stretches the
tight musculature (especially SCM) and strengthens trunk
stability.  Further physical therapy is recommended in
infants with reduced neck range of motion. 
It might be concluded that, apart from the small
number of patients and the subjectivity of reporting, chiropractic
treatment for KISS syndrome at the teaching clinic appears to be effective and safe (although this type of study
cannot adequately determine either). The limitations of
case series do not allow for statements of efficacy, but can
merely show trends. Randomized controlled trials would
be best to address effectiveness of treatments. Moreover a
long-term follow up has not been made. Considering the
suspected long-term effects
In general, this paper was intended to give a better
understanding about musculoskeletal issues in infants. By
using many German research articles and combining it with
cases from the teaching clinic, it gives a deeper insight and
a better understanding of the concepts of KISS syndrome
and its long-term effects.
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