Author Names
Brurberg KG, Dahm KT, Kirkehei I
Reviewer Name
Abby Davis, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctorate of Physical Therapy Division
Paper Abstract
Background: Professionals in fields including chiropractic, physiotherapy, manual therapy and osteopathy recommend manipulation techniques for the treatment of infant torticollis. This article summarises the research evaluating such treatment. Material and method: The article is based on a search in MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, AMED, PEDro, and the Index to Chiropractic Literature in August 2017. Controlled studies were included to assess efficacy, and observational studies to reveal the risk of harm. Results: We reviewed 3 418 unique hits from the literature search. We included three randomised controlled studies on the efficacy of manual therapy or osteopathy and three observational studies on possible adverse effects. Two studies on manual therapy suggested that manipulation techniques do not have any greater effect on symmetry and motor outcomes than parental guidance, physiotherapy and home exercises. One study suggested that osteopathy may contribute to increased symmetry compared to placebo, but the clinical significance of this change is uncertain. Neither the three randomised studies nor a large patient series involving 695 infants found manipulation techniques to be associated with a risk of serious adverse events, but three patient histories demonstrated that manipulation techniques may cause harm if the observed asymmetry has serious underlying causes. Interpretation: Manipulation techniques have not been shown to be efficacious in the treatment of infant torticollis, but the available evidence must be considered uncertain.
NIH Risk of Bias Tool
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Cannot Determine, Not Reported, Not Applicable
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
There is not enough evidence to recommend manipulative therapy for infants with torticollis at this time.
Key Finding #2
There is some anecdotal evidence that manipulations could cause adverse events if the patient has underlying medical conditions.
Key Finding #3
Conventional physical therapy, inlcuding gentle mobilizations, is the most proven and efficacious method of treating infants with torticollis.
Please provide your summary of the paper
This study sought to understand the evidence on manipulation techniques used for infantile torticollis or cervical asymmetries. There were six studies included in this review- three were randomized controlled trials and three were observational studies. The observational studies were to obtain information on possible adverse events that have occurred after manipulations. The result of this systematic review shows that manipulations are not more effective than traditional physical therapy with home exercises and caregiver education. There were no reported adverse effects in any of the randomized controlled trials, however the observational studies showed there could be adverse events as a result of manipulations in patients that have underlying medical conditions.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Based on the results of this systematic review, manipulations are not recommended to be performed on infants with torticollis. There is not enough evidence to show that it is beneficial for this patient population. Anecdotally, there are reports of discomfort from infants as a result of manipulations. There is some data that have shown apnea and bradycardia immediately post manipulation in infants. Overall, the evidence on manipulations for infant torticollis is not certain and therefore beliefs on this should not be firm until higher level evidence is published. However, manual therapy (mobilization) as a whole is recommended for these patients and should be utilized in clinic.
