Musculoskeletal Function & Children

In 2003, Donald E Ingber, MD, PhD, published an article in the journal Annals of Medicine (1) titled:

Mechanobiology and Diseases of Mechanotransduction

Dr. Ingber is from the Vascular Biology Program, Departments of Surgery and Pathology, Children’s Hospital and Harvard Medical School. In this article, Dr. Ingber emphasizes the importance of mechanics and physical forces in influencing cellular physiology, health and disease. Dr. Ingber defines mechanotransduction as “the molecular mechanism by which cells sense and respond to mechanical stress.” Dr. Ingber notes:

“The current focus of medicine on molecular genetics ignores the physical basis of disease even though many of the problems that lead to pain and morbidity, and bring patients to the doctor’s office, result from changes in tissue structure or mechanics.”

“A wide range of diseases included within virtually all fields of medicine and surgery share a common feature: their etiology or clinical presentation results from abnormal mechanotransduction.”

“Mechanical forces are critical regulators of cellular biochemistry and gene expression as well as tissue development.”

“There is a huge disconnect between ‘genome-age’ technologies and the reality of how diseases manifest themselves. From the time the first human looked, listened and felt for what is wrong with a sick friend, caregivers have recognized the undeniable physical basis of disease.”

There is a “strong mechanical basis for many generalized medical disabilities, such as lower back pain and irritable bowel syndrome, which are responsible for a major share of healthcare costs world-wide.”

“Altered cell or tissue mechanics may contribute to disease development.”

Because our bodies are complex hierarchical structures, “mechanical deformation of whole tissues results in coordinated structural rearrangements on many different size scales.”

“All cells also contain ‘stress-sensitive’ (mechanically-gated) ion channels that either increase or decrease ion influx when their membranes are mechanically stressed.”

“Many ostensibly unrelated diseases may share a common dependence on abnormal mechanotransduction for their development or clinical presentation.”

“The therapeutic value of physical therapy, massage, and muscle stimulation is also well known.”

“The current focus in medicine is on the genetic basis of disease. However, it is not necessary to correct the underlying genetic defect in order to treat clinically relevant symptoms or relieve the pain and morbidity of disease. Moreover, most of the clinical problems that bring a patient to the doctor’s office result from changes in tissue structure and mechanics. Although these physical alterations have been commonly viewed as the end-result of the disease process, recent advances in mechanobiology suggest that abnormal cell and tissue responses to mechanical stress may actively contribute to the development of many diseases and ailments. Thus, it might be wise to search for a physical cause when chemical or molecular forms of investigation do not suffice.”

A summary of Dr. Ingber’s work indicates that the entire body is mechanically integrated through an extracellular matrix which attaches to cell membranes; cell membranes are attached to cell organelles through a filamentous cytoskeleton, including attachments to the nuclear membrane; the nuclear membrane is attached to the chromosomes through a nucleoskeleton. This is known as tensegrity or the tensegrenous matrix.

Altered alignment in gravity or altered movement patterns adversely affect this tensegrenous matrix, altering the function of cell membranes, cellular organelles, and genetic expression. Fortunately, applied mechanical forces improve altered alignment and abnormal movement patterns, and also improves the influence of the tensengrous matrix on a variety of cellular processes that in turn influence health and disease.

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The two largest professional organizations for chiropractors are the American Chiropractic Association (2) and the International Chiropractors Association (3). The two organizations are politically distinct, but they share a single post-graduate education certification program known as PEDIATRICS. The program is a three-year educational and hands-on learning certification program pertaining to the diagnosis, analysis and management of primary mechanical-based musculoskeletal problems in infants and children.

History indicates that manual therapy in children is not new. In the introduction of his 2004 text titled Manual Therapy in Children (4), German physician Heiner Biedermann states:

“In 1727 Nicolas Andry de Boisregard, who coined the word ‘orthopedics’, had mentioned the treatment of torticollis as one important field of this new discipline. In going back to the roots we understand that good posture in children was at the forefront of orthopedics diagnostics and treatment: Ortho-Pedics – ‘righting the young’ was so important for Andry that he used this concept as the definition of the medical procedures he published in his book.”

“Audry’s seminal book on orthopedics (published in 1741) contains entire chapters about the treatment of newborn babies with postural asymmetries.” (5)

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Dr. Biedermann is extensively published on the topic of pediatrics, but the majority of his work is only written in his native German. Dr. Biedermann is from the Surgical Department of the University of Witten-Herdecke, Germany. Fortunately, in 1992, Dr. Biedermann published important research in the Journal of Manual Medicine (6), which at the time was printed in both its original German language and it was also translated into English. The title of the article is:

Kinematic Imbalances Due To Suboccipital Strain In Newborns

In this article, Dr. Biedermann discusses the immense pathogenic potential for mechanical problems of the craniovertebral junction in newborn and young children. He refers to the symptom complex “kinematic imbalances due to suboccipital strain” (KISS syndrome), and notes that it is responsible for a “wide range of clinical signs and can in many cases be dealt with effectively with manual therapy.”

Dr. Biedermann’s paper is based upon the evaluation of more than 600 children, all less than 2 years of age. He notes that the main signs of the KISS syndrome are:

• • Torticollis
  • Unilateral face asymmetry
  • C-shaped spinal scoliosis
  • Motor asymmetries, often accompanied by unilateral retarded maturation of the hip joints
  • Slowed motor development

The main risk factors for the development of the KISS syndrome include:

• • Intrauterine misalignment
  • Application of extraction aids
  • Prolonged labor
  • Multiple fetuses

Most of the babies in his study had asymmetric posture, and the postural deformity did not correct during sleep. The babies also displayed the following:

1) Tilt posture of the head / torticollis.

2) The head is held in extension to the point where the baby was unable to lie on the back.

3) “Uniform sleeping posture, the child cries if the mother tries to change its position.”

4) Asymmetries of movement patterns.

5) Asymmetric posture of trunk or extremities.

6) “Sleeping disorders, the baby wakes up crying every hour.”

7) “Extreme sensitivity of the neck.” [Roy Sweat scanning test]

8) Asymmetry or swelling of the face / head.

9) Asymmetries of the gluteal muscles.

10) “Asymmetric development and range of movement of the hips.” “Retarded development of the hip joints.”

11) Fever of unknown origin.

12) Loss of appetite.

13) Feet deformities.

14) Pathological reflexes.

15) Reduced mobility of the cervical spine or other spinal regions by more than 30%.

16) The parent reporting that the baby does not eat or drink well.

Dr. Biedermann indicates that studies show that postural correction therapies developed for children with mild cerebral damage “greatly improved the changes of rehabilitation in these little patients.” “In many cases the duration of the treatment can be shortened by combining and/or replacing it with manual therapy of the suboccipital segments of the upper cervical spine.”

The suboccipital joints are most likely to be involved when the baby has a combination of asymmetry of motion, facial asymmetry, and sleeping disorders. The history of the affected babies reveals a high incidence of birth stress/trauma, including multiple fetuses, prolonged labor, and use of extraction aids.

Dr. Biedermann routinely exposed spinal radiographs on the babies that were referred to his clinic. The authors determine the direction of the manipulation with an “exact evaluation of the lateral displacement of atlas and/or axis against the occiput.” Additionally, Dr. Biedermann states:

• • “An A-P radiograph of the upper cervical spine is imperative.”
  • “The radiological evaluation helps to find malformations and aids in determining the direction of the manipulation.”
  • “In most cases the direction of the manipulation is determined by radiological findings (85%).”
  • “Selection of the direction of the treatment without x-ray seems the most plausible cause of the less encouraging results of some colleagues.”

Dr. Biedermann describes the treatment of these babies as “basically an impulse manipulation.” He further states:

“The manipulation itself consists of a short thrust of the proximal phalanx of the medial edge of the second finger.”

“The [manipulation] technique itself needs subtlety and long years of experience in the manual treatment of the upper cervical spine.”

“In the hands of the experienced the risk is minimal; we have not yet encountered any serious complications. Most children cry for a moment, but stop as soon as they are in their mother’s arms. In two cases (of ± 600) these children vomited after treatment; this had no negative effect on the outcome in either case.”

Pertaining to the KISS syndrome, Dr. Biedermann makes the following comments:

“The ‘typical’ KISS baby is first seen at the age of 6 to 12 months. Such babies are suffering from birth problems in the widest sense.”

“The pathogenic importance of asymmetric posture and motion in small children is often played down if recognized at all.”

“In most children, the upper cervical spine remains a weak spot, which is why we re-examine them routinely before they start school at the age of 6.”

Upper cervical “delicate structures undergo considerable stress during delivery.” “The birth canal is one of the most dangerous obstacles we ever have to traverse.”

“Suboccipital strain is not confined to local complaints or even mechanical symptoms and is not taken into account when these children show signs of restlessness and concentration difficulties, etc.”

“The immense pathogenic potential of the proprioceptive afferents of the suboccipital region has until now been widely underestimated.”

During delivery, “A majority of newborns suffer from microtrauma of brain stem tissues in the periventricular areas.” Forgotten trauma of early childhood has a significant impact on “perceptuomotor development.”

“Head stabilization is a complex process involving the interaction of reflexes elicited by vestibular, visual and proprioceptive signals. Most of the afferent proprioceptive signals originate from the craniocervical junction. Any obstacle impeding these afferents will have much more extensive consequences for a nervous system in formation, which depends on appropriate stimuli to organize itself. Most of the cerebral development [occurs after birth]; this development begins at the head.”

“Traumatization of the suboccipital structures inhibits functioning of the proprioceptive feedback loops.” Consequently, the motor development cannot develop normally. “The price for this is a reduced capacity to absorb additional stress later on. These children may show only minor symptoms in the first months of their life” like fixation of the head in one position. “Later on, at the age of 5 or 6, they suffer from headaches, postural problems or diffuse symptoms like sleep disorders, being unable to concentrate, etc.”

Dr. Biedermann indicates that suboccipital strain does not always lead to clinical symptoms. This opens the prospect of having asymptomatic infants and children assessed for mechanical lesions of the upper cervical spine so that they can be appropriately treated. This would be done in an effort to avoid clinical problems later in life.

Dr. Biedermann cautions that babies with a contracted sternocleidomastoid muscle should not be subjected to operative measures to lengthen the muscle because they will nearly always respond perfectly to manipulation of the upper cervical spine. He also notes that in treating pediatric C-scoliosis and movement asymmetries, manipulation of the suboccipital region is superior to physical therapy because “suboccipital strain is the leading factor.” Also, manipulation of the occipital-cervical region leads to disappearance of problems that the parents had not reported because they did not see a connection with the spine. These parents would regularly note that their child would eat or sleep much better since the treatment.

The author presents 3 case histories successfully treated by specific upper cervical manipulation. In each instance, the problems were resolved shortly following the manipulation. The presented case studies include:

1) 4 month old with difficulty controlling head position, using her left arm, uniform sleeping position, and asymmetry of face and skull.

2) 5 month old with C-scoliosis, reduced use of left arm, poor muscle tone on left side of body, poor head control, and asymmetry of face and skull.

3) 6 month old, unable to turn head to left (since birth), pronounced facial asymmetry, cried when picked up, severely retarded movement development, recurrent fever of unknown origin.

In summary, babies tend to injure their upper cervical spine during the birth process. This is because the upper cervical spine is the “weak spot.” The potential for injury to the upper cervical spine is greater when there is intrauterine misalignment, multiple fetuses, prolonged labor, and the use of extraction aids. The upper cervical spine contains most of the proprioceptive afferent signals to the central nervous system. The brain requires appropriate afferent proprioceptive input from the upper cervical spine to organize itself during early development. Birth injury to the upper cervical spine robs the brain of the required proprioceptive afferent input it requires to organize itself, including visuomotor function. Typical early signs displayed by babies with upper cervical injury include asymmetric posture, tilted head, torticollis, using only one posture for sleeping, asymmetries of movement patterns, asymmetries or swelling of the face / head, asymmetries of the gluteal muscles, asymmetric development and range of movement of the hips, fever of unknown origin, and deformities of the feet. Typical early symptoms displayed by babies with upper cervical injury include fussiness when picked up, the baby wakes up crying every hour, extreme sensitivity of the neck to pressure, loss of appetite, the baby does not eat or drink well. Later symptoms displayed by these children at age 5 or 6 include restlessness, concentration difficulties, a reduced capacity to absorb stress, headaches, postural problems, and diffuse symptoms like sleep disorders. X-rays are important, “imperative.” They identify malformations and identify the direction of the manipulation, improving clinical outcomes. All children should be checked for restricted movement of the head and for increased pain sensitivity of the upper cervical spine. If positive findings are identified, the child should have a specific line-of-drive manipulation of the upper cervical spine.

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Mechanical Irritation & Heart Rate Changes
In Infant Patient Populations

General practitioner physician LE Koch from Germany is the primary author of a study published in the journal Forensic Science International, August 28, 2002, titled (7):

Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants

In this study, Dr. Koch and colleagues are specifically assessing the hypothesis that there exists a relationship between mechanical dysfunction of the upper cervical spine and the incidence of sudden infant death syndrome. Their investigation is based on a survey of 695 infants between the ages of 1 and 12 months. These infants were strictly analyzed and manually treated using the KISS protocols of Dr. Biedermann, above.

Dr. Koch and colleagues indicate that in first world countries, sudden infant death (SID) is the most common cause of death during the first 12 months of postnatal life. A major risk for sudden infant death is the prone position of the sleeping baby, which enhances the death rate. Dr. Koch and colleagues indicate, referencing the work of Biedermann above, that manual therapy of the upper cervical spine causes alterations of visceral function, including heart and respiration rates. Consequently they hypothesize that there may be a relationship between upper cervical spine mechanical irritations and the risks of sudden infant death syndrome. These authors state:

“A pronounced sensitivity of the atlanto-occipital region was first noticed during routine chiropractic treatment of 6,000 infants that were diagnosed with ‘kinematic imbalance due to suboccipital strain’ (KISS).”

“This therapy included an impulse [adjustment] applied to the atlanto-occipital region which was often associated with vegetative responses.”

All of the infants involved in this study were diagnosed with orthopedic abnormalities, in particular asymmetries in the horizontal and sagittal plane of body posture and motion. The deficits included asymmetry such as wryneck and c-scoliosis of the spinal column. The asymmetry in the atlanto-occipital-C2 region was determined by X-ray analysis. The infants examined showed pathological neuromuscular development, yet none of the infants examined in this study had neurological disorders, idiopathic cerebral palsy, floppy babies, vitium cordis, basilar impression, assimilation of atlas, or other anomalies of the spinal column and spinal cord. All of the children in this study “were all taken for chiropractic treatment because of some sort of abnormality in their motor pattern (695/695).”

The manual therapy delivered was describes as follows:

“The therapeutic impulse used to treat KISS consisted of a short, gentle thrust administered onto the suboccipital region with the inner side of the interphalangeal portion of the second digit.”

“Although the force of the thrust was not measured in every case, representative impulses were measured and were ranged from 30 to 70 N, being in the order of 50 N and never exceeding these values.”

“For the chiropractic therapy the infants were positioned on their back while the chiropractor was sitting perpendicular to the child’s head. Great care was taken that the infant was comfortable before the impulse was administered. The child’s body was relaxed and any rotation of the spine was avoided. The impulse was applied to the side of the asymmetry.”

After observing the vegetative responses of these children to the manual therapy treatment of the upper cervical spine, these authors made the following conclusions:

“A mild irritation of the cervical region will more likely lead to a severe bradycardia in the first 3 months.”

“Thus, our findings are consistent with the possibility that a minor mechanical irritation of the cervical region may trigger the first step in the events that lead to sudden infant death.”

“A delayed maturity in motor activity should, therefore, be considered as a possible cofactor in the events that lead to SID.”

“Children with a disturbed symmetry of the atlanto-occipital region could be of higher risk for SID.”

As a reminder, the authors of this study are medical physicians, yet they are using chiropractic analysis and adjustments (manual therapy) to the joints of the upper cervical spine in infants between 1 – 12 months of age when they showed an asymmetry in spinal posture or motion. Consequently these authors included comments pertaining to the safety of chiropractic spinal adjusting on such a young patient population. Their commends are as follows:

“How safe is chiropractic treatment for young infants?”

“The chiropractic therapy has proven to be a successful technique which can be used to treat disorders, especially cerebral disturbances of motor patterns of various etiology (wryneck, c-scoliosis, irritation of the plexus brachialis), sensomotoric disturbances of integration ability (retardation of sensation and coordination), as well as pain related entities such as cry-babies with ‘3-month colic’ or hyperactivity with sleeplessness.”

“In older children disturbances of this kind are known as retardation of development in motor patterns as well as in sensory abilities.”

“The epidemiological prevalence of such disturbances has been estimated to be as high as 16.8-17.8%.”

“In many cases, chiropractic treatment seems to be the most successful therapy which helps to treat such disorders.”

“Therefore, chiropractic treatment and manual therapy have become increasingly popular over the past decade.”

“We can report more that 20,000 children treated without serious complications.”

In summary, these experienced medical physicians provided an analysis

of the vegetative responses in appropriately selected infants to upper cervical spine adjustments (manual therapy). They document that chiropractic spinal adjusting of the upper cervical spine causes visceral responses. They concluded that minor mechanical irritations of the upper cervical spine may be related to the risk of sudden infant syndrome. They concluded that chiropractic spinal adjusting of infant upper cervical spines is successful in the management of “cerebral disturbances of motor patterns of various etiology (wryneck, c-scoliosis, irritation of the plexus brachialis), sensomotoric disturbances of integration ability (retardation of sensation and coordination), as well as pain related entities such as cry-babies with ‘3-month colic’ or hyperactivity with sleeplessness.” They concluded that chiropractic spinal adjusting of infant upper cervical spines is both safe and appropriate when a mechanical lesion is present.

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Manual Therapy in Children, edited by Heiner Biedermann, MD, is the most comprehensive book written on the subject. This 2004 text boasts 22 international experts from Germany, Russia, Japan, the United Kingdom, The Netherlands, Switzerland, and the United States. The book has 27 chapters that are broken into five sections that include anatomy/physiology, clinical insights, radiology, and practical insights of pediatric manual therapy.

The primary concept expressed in the book is that the developing infant has an amazing variety of potential developmental paths that can be followed. The primary influence on the development of the neuromotor system is the use or nonuse of a variety of orthopedics symmetries. Consequently, asymmetries of posture and/or movement will adversely influence the development of the neuromotor system. Proper function of the upper cervical spine influences the proprioceptive development of the central nervous system. Disturbances of proprioceptive input complicate the computation of spatial information, so that abnormal patterns acquired in early childhood can influence behaviour years or decades later. “This makes the understanding of neuromotor development at the beginning of our life so important.” The authors state:

“The basic trigger which makes pediatricians send the babies to a specialist in manual therapy is the hypersensitivity of the neck region in combination with a restricted range of movement of the head.”

Altered proprioception not only alters posture, it also alters locomotion. Spontaneous motor development in the first year of life includes tactile, vestibular, and proprioceptive information, all of which are directly connected with movement. Uncorrected alterations in proprioceptive input to the central neural axis can result in long-term changes in walking behaviors, which in turn further alters proprioceptive input. “The afferent impulses of the cervical receptor region are integrated into the motor system for control of body support.”

Mechanical problems in newborn babies, children, and adults can have their roots in pregnancy and birth. The birth process can be particularly mechanically difficult for the newborn infant, especially if the process involves rotational forces.

“Mechanical obstructions of the functioning of the vertebral joints termed ‘blockages’, occur in all age groups, with infants and the newborn being no exception.”

“Craniocervical blockages in infants and the newborn have special potency.”

“In newborns it is safe to declare the occipitocervical junction by far the most important part of the vertebral spine with a potential for functional disorder vastly greater than its size.”

Biedermann and colleagues also note that spinal mechanical lesions not only impair appropriate proprioception, neuromuscular integration and coordination, they also impair the ability of an infant to adequately use their developing auditory and visual systems. They note:

“The quality of the cervical system comes into play, as a proprioceptive organ and as an effector of head movements directing eyes and ears towards points of interest.”

Biedermann and colleagues cite several references that may account for the mechanical obstructions observed in infants and children, including forceps deliveries, vacuum extractions, multiple pregnancies, breech presentations, prolonged expulsion period, and transverse lie.

Biedermann and colleagues indicate that they apply manual therapy to infants and children only if they have orthopedic indications, particularly asymmetries of posture and/or motion. Therefore, the main symptoms of KISS are:

• • Wry Neck
  • Fixed and Bent Trunk (asymmetry of posture)
  • Asymmetry of the Face
  • Flattened Back of the Head
  • Asymmetrical use of Arms or Legs

Other observations reported by parents include:

• • Fixed posture of the head to one side or to the back
  • Insufficient control of the head
  • Fixed retroflexion of the head with the arms pulled back
  • Fixed posture while sleeping with the head bent back
  • Difficulties getting the child to sleep
  • Frequent waking up at night crying
  • Uneven maturation of the hip joints
  • A bent and curved foot (pes adductus)
  • Highly irritable neck; the baby does not want neck to be touched
  • Head banging, especially against the sides of the bed
  • Asymmetric position of the ears
  • Colic
  • Incessant crying

Biedermann and colleagues also suggests to parents that there may be certain non-orthopedic observations that may indicate a need for a mechanical evaluation to see if manual therapy may be appropriate for their children. Their list includes:

• • Restlessness
  • Impulsiveness
  • Disturbs other children
  • Short attention span, does not finish the work
  • Constant fidgeting
  • Inattentive, easily divertible
  • Cannot wait, easily disappointed
  • Cries quickly
  • Mood changes quickly and drastically
  • Prone to fits of rage
  • Starts a lot and does not finish the work

Biedermann and colleagues suggest that if early life mechanical problems are not corrected, that the child will experience other difficulties as they age, including:

Problems learning to bicycle or walking on stilts. Lack of confidence in their own perception often leads to fear of heights and being afraid of unknown situations.

Hearing impairment, which makes it difficult for them to concentrate.

They become impatient, aggressive, and they ‘never listen’.

They become too slow, too timid, and too clumsy.

They have trouble dealing with stress.

They suffer from headaches.

These authors conclude:

“Manual therapy seems to be able to alter the course of an individual’s development profoundly at some well-defined moments of ontogenetical development.”

“Anything improving the symmetry of sensory input early on can only exert a positive influence on the further development of the child.”

In regards to the safety of manual therapy in children, in the July-August 2008 issue of the Journal of Manipulative and Physiological Therapeutics, Dr. Joyce Miller presented a three-year retrospective study of pediatric case files from the Anglo-European College of Chiropractic teaching clinic in Bournemouth, England. All files (781) of children younger than 3 years of age were reviewed. Most of these patients (73.5%) were infants 12 weeks of age or younger. 697 children received a total of 5,242 chiropractic treatments, with 85% of parents reporting improvement. Seven parents reported an adverse effect, or 1 reaction reported for every 749 treatments. Dr. Miller concluded:

“There were no serious complications resulting from chiropractic treatment (reactions lasting greater than 24 hours or severe enough to require hospital care).”

“This study shows that for the population studies, chiropractic manipulation produced very few adverse effects and was a safe form of therapy in the treatment of patients in this age group.”

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In conclusion, it appears that newborn infants may suffer from mechanical lesions, primarily to the upper cervical spine, as a consequence of various events surrounding the birth process. These mechanical lesions may impair both the proprioceptive/locomotion development and neurological integration for the child. These mechanical lesions may also impair aspects of auditory and visual development. These mechanical lesions can be easily and safely corrected by a well-trained chiropractor.

References:

1) Ingber DE; Mechanobiology and Diseases of Mechanotransduction; Annals of Medicine; 2003;35(8), pp.564-77.

2) American Chiropractic Association at www.amerchiro.org.

3) International Chiropractors Association at www.chiropractic.org

4) Biedermann H; Manual Therapy in Children; Churchill Livingstone; 2004.

5) Andry de Boisregard N; 1741; L’orthopedie ou l’art de prevenir et de corriger dans les enfants les difformites de corps; Vv Alix, Paris.

6) Biedermann H; Kinematic Imbalances Due To Suboccipital Strain In Newborns; Journal of Manual Medicine; June (No. 6) 1992, pp. 151-156.

7) Koch LE, Koch H, Graumann-Brunt S, Stolled, Ramireze JM, Saternus KS; Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants; Forensic Science International Volume 128, Issue 3, August 28, 2002, Pages 168-176.

8) Miller J, Adverse effects of spinal manipulative therapy in children younger than 3 years: a retrospective study in a chiropractic teaching clinic; Journal of Manipulative and Physiological Therapeutics; July-August, 2008; 31(6): pp. 419-423.

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