The application of manual techniques to pediatric athletic injuries has been considered alternative medicine. There are many injuries that are associated with loss of normal motion. Altered biomechanics can be readily identified and treated using manual methods. These include articular or thrust techniques, muscle energy, strain-counterstrain, and myofascial treatments, among others. Although there are few high-quality studies available, most available literature reports effectiveness of manual techniques in combination with therapeutic exercise for common pediatric motion restrictions.
There is little published evidence to support the use of osteopathic techniques in the treatment of pediatric athletes. Despite this, sports medicine practitioners commonly relate stories where a doctor with training in manual techniques “popped” something and an athlete was “cured.” Considered alternative medicine by most allopathic physicians, there are a few instances where manipulation is an accepted treatment; for example, most pediatricians readily accept manipulation of the radial head for the treatment of nursemaids’ elbow. Far from being an anecdotal trick, the nursemaids’ elbow diagnosis and its treatment by manipulation represent an underlying biomechanical principle, that motion restrictions are often the symptom of a biomechanical deficit. When the deficit is corrected, function is restored. In an age of evidence-based medicine, the lack of solid literature-based evidence gives even the most open-minded pause, especially when application is made to a pediatric population. Those with additional training in manual techniques look for asymmetry and restriction of motion; once identified, a variety of osteopathic techniques can used to address the deficit and affect change.
Practitioners who look at patients through a biomechanical or osteopathic lens may identify motion restrictions that are amenable to osteopathic treatment. Manipulation should not be thought of as a solitary treatment; it is best used to correct motion restriction and then followed by appropriate muscle retraining via physical therapy to facilitate long-term resolution. In those cases where motion asymmetry persists or recurs, a structural cause for the repeated dysfunction should be sought. In this article, a general discussion of osteopathic diagnosis and treatment rationale is followed by application to specific conditions associated with sports participation in the pediatric population where manual treatments may be of use.
Use and complications with manual medicine
A 2008 survey investigated the use of complementary and alternative medicine (CAM) in patients 18 years or younger. The Department of Health and Human Services found that more than 2 million youths (2.8%) had used chiropractic or osteopathic manipulation in the previous year. It was the second most common CAM behind the use of vitamins or other natural remedy. The most common reason cited for seeking care was back or neck pain. Children whose parents used CAM were twice as likely to be treated with CAM. Most who used CAM did so as an adjuvant to conventional medical care.
Manual medicine, spinal manipulation in particular, is not without risk; the risk of adverse events varies by technique and is likely small. Generally, many patients can be expected to experience some discomfort after manipulation. Aggravation of symptoms is usually short lived (1–2 days) and is attributed to changes in soft tissue and ligaments associated with the regions that are mobilized. In a literature review of complications associated with thrust manipulations performed by a therapist or physician and including adult and pediatric patients, catastrophic complications of manipulation were rare and were most commonly vertebral-basilar compromise (cervical manipulation) and cauda equina syndrome (lumbar manipulation). The investigators associated rotatory manipulation of the cervical spine with vascular compromise. Similar results are reported in osteopathic literature, showing that most complications appear as anecdotal case reports, making efforts to attribute risk or prevalence problematic.
In an effort to assess risk of manipulation in pediatric patients, Hayes and Bezilla performed a retrospective chart review of 502 pediatric patients treated with osteopathic interventions (all treatments, including thrust techniques). The investigators defined aggravations as patient complaints or worsening of symptoms after manipulation. Complications were defined as cerebrovascular accident, dislocation, fracture, pneumothorax, sprains and strains, or death as an outcome of treatment. In their review, there were no manipulation-related complications; aggravations occurred and were documented in approximately 12% of manipulations. The average duration of aggravation symptoms was less than 48 hours (evidence level B). In summary, most pediatric patients seem to have mild, short-lived, aggravation-type symptoms after osteopathic treatments. Complications, which seem rare, are likely underrepresented in the literature and usually associated with thrust-type manipulations.
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