Manual Therapy In Children, evidence for occipitocervical injuries from the Medical Profession: A book review

Manual Therapy in Children” Ed Heiner Biedermann MD (2004, Elsevier) is a comprehensive review of the effects of injury of the joint between the skull and the first cervical vertebra, the atlas (also known as the occipito-cervical junction) on newborns, and an exploration of the common clinical syndromes it causes in infants and in school age children. In particular it comments extensively on the relationship between this problem and the clinical syndrome of attention deficit disorder (ADD). Heiner Biedermann is an MD who is a practitioner in Conservative Orthopedics in Cologne, Germany.

Injuries at the occipito- cervical junction have been the source of ongoing dispute between the chiropractic profession and the medical profession for many years. They have been known by many names, such as atlas subluxations, atlas malalignments and, by this group of authors, subocciptal strain.

This book is unusual in that it is a comprehensive review involving orthopedic surgeons, an obstetrician, professors in anatomy and cell biology, paediatricians, neuropaediatricains, psychologists, orthodontists, experts in rehabilitation medicine, a physiotherapist, a radiologist and a general practitioner.

The book is based on extensive clinical experience in the editor’s clinic (over 30,000 patients over 40 years), supported by research and case studies and linked in with current research on neurological development and infant-caregiver attachment.

 Biedermann outlines the causes of this injury:

It has been identified in 1/3 of all births in series he has studied.

It is especially associated with difficult births or birthing interventions.

It runs in families and appears to be associated with subtle heritable variations in the anatomy of the upper two cervical vertebrae.

 He then goes on to outline profound effects that a small malalignment at the occipitocervical joint can have and the developmental sequence that follows if the injury is uncorrected.

In infants he describes KISS syndrome- Kinematic Instability due to Suboccipital Strain -a simple problem of obstructed movement in the upper neck causing blockage of head movements, then abnormal persistence of primitive reflexes (especially the asymmetrical atonic neck reflexes) leading to a baby either with a crooked neck progressing to a scoliosis along the whole spine or a baby whose neck is often stuck in hyperextension.

These infants are irritable, often colicky, physically sensitive and often dislike touch, they sleep poorly and are very difficult to settle.

They generally attach poorly to one breast, and their stereotyped sleeping positions often result in a flattened head. This issue, and the biomechanics of abnormal loading then often play out as orthodontic, and temporomandibular joint problems in adolescence and adulthood.


Symptoms usually subside about age 1 only to become more obvious at school.

As the patterns of reflex adjustment to the original injury progress, normal perceptuo-motor development and head control are delayed, often leading to infants who have normal intellectual development, but are highly frustrated by their sensorimotor delay.

The spinal problems worse, developing into hypertonicity down the whole of one side and a more severe S shaped scoliosis, with disturbed function of the sacroiliac joint, and a distorted chest wall leading to problems with the mechanics of breathing, or to a failure of the extensor reflexes in the back of the chest, leading to a permanently stooped posture.

The perceptual problems are significant, and Biedermann calls this syndrome “KIDD syndrome”

(KISS induced dysgnosia and dyspraxia)

The full list of symptoms are:

First School Years:

Difficulty at drawing and writing, and these are often refused

Global motor skills poor – often bad at sport- so socially unpopular

Often cover by playing the “clown”

Headaches mentioned more frequently


Difficulty with social interaction in the foreground

Often described as being unable/unwilling to fulfil the requirements of school Headache: almost always mentioned: and is often a lead symptom

Broad Symptoms:-poor impression of themselves

-quickly frustrated and attempt to avoid new symptoms

-frequently late, and forget easily

-easily distracted, unable to concentrate on one topic.

-fear of heights

Physical Examination:

-Imbalanced muscular coordination- asymmetrical tonus of postural muscles

-shortened hamstrings

-kyphotic posture, hyperextension of the neck, hypotonus of the dorsal muscles of the thoracic area, often accompanied by orofacial hypotonia (blank- non reactive facial expression)

-Scoliotic posture on sitting and/or standing

-shoulders at different height

-sacroiliac joint mobility asymmetrical often with asymmetry of leg rotation

-balance tests insufficient and mostly asymmetrical

-insufficient co-ordination of vestibular input (eg standing with raised arms and closed eyes difficult)

-acoustic orientation difficult

-combination of arm and leg movements difficult

-fidgeting and restlessness, sometimes tics

-using eye control to compensate for lack of proprioception, refusing to lie down supine, clinging with one hand to the examination table

-decompensation when personal space is invaded by the examiner, wild resistance against palpation

Depending on the character of the child, some become hyperactive aggressive and uninhibited, and others withdraw.


As can be seen the full range of symptoms look very similar to ADHD, and Biedermann reports that

the majority of referrals to his clinic for school age children are for ADD like symptoms.

While avoiding getting caught in controversies about a formal diagnosis, Biedermann reports that roughly 2/3 of such patients improve substantially after manual therapy, and usually make much more significant and sustained gains in academic performance than such children usually do with stimulant therapy.

KIDD- Milder manifestations:

Biedermann emphasises that milder cases exist, where the problems for the child are more of social difficulties caused by un-coordination, and that even some of these cases can master their coordination problems and even become elite athletes.


Unfortunately what this book cannot cover is the multitude of other problems that can be associated with the postural distortions caused by the KISS/KIDD progression.

Even in adults who reach good emotional and attentional regulation, many will develop back pain, uneven loading of the legs will cause premature osteoarthritis of the hips and knees, the leg rotation caused by the pelvis imbalance will increase the risk of piriformis syndrome- the commonest cause of sciatica, the postural difficulties associated with Western Seated Posture (Upper Crossed Syndrome and Lower Crossed Syndrome) will be much more likely to develop in KISS individuals than individuals with better posture,and better integration of their movements. These syndromes can contribute to cardiovasular disease, hiatus hernia and a wide range of other conditions.

Biedermann emphasises that early intervention in infants is a minimal intervention, and only has to be done once, while for school age children several interventions at the occipitocervical junction may be required, along with further interventions at other levels of the spine.

My personal experience is that management of the problem in adults only gets more complex as we age and acquire more wear and tear due to our years of abnormal posture.

This book presents clear evidence of an association between attentional problems and suboccipital strain, and also presents a cogent case as to why this initially minor problem should cause such profound difficulties in later life.

There is clear evidence now that demonstrates the progression of untreated attention problems in children to a range of highly unsatisfactory outcomes in adults: anxiety, depression, bipolar illness, addiction problems, difficulty managing work and holding jobs, poor financial outcomes, increased risk of criminal convictions.

Given this association, and the association with more general medical conditions in adults, my personal opinion is that suboccipital strain/ atlas misalignments/subluxations, are probably the commonest easily treatable cause of preventable illness in Western society.

As a Medical Practitioner I am gravely concerned that

  • the rigidity of our academic hierarchy

  • current obsessions with molecular-genetic medicine that ignore the biopsychosocial model of holistic medicine

  • interprofessional rivalries and power games,

  • and our inability to follow up on good quality medical information that is not originally published in English

    has created a situation where we, as a profession are not keeping up with the whole evidence base that is available to us and cannot claim to be practicing evidence based medicine.

 I am also confident that Dr Biedermann’s research provides more than enough evidence to put this particular argument to rest once and for all, for anyone who cares to read it. Given the great controversy around this subject I list here all the contributing authors to this book. A few skeptical groups of doctors have sought to attack chiropractors presenting this information- so it is helpful to illustrate that these observations come from mainstream medicine:

Manual Therapy in Children(Biedermann et al)


Editor Heiner Biedermann MD



Lilia Babina MD

Professor Neuropsychiatric Dept Rehabilitation Clinic Pjatigorsk, Russia

Heiner Biedermann MD

Practitioner in Conservative Orhopedics, Cologne, member of the European Workgroup for Manual Medicine, formerly surgeon at Surgical Department ot the University of WittenHerdecke and Schwertze Hospital, Germany

Bodo E.A Christ MD

Professor Institute of Anatomy and Cell Biology University of Frieberg, Germany

Arnd Friedrichs

Friendly Sensors AG, Jena, Germany

Onur Gŭntŭrkŭn PhD (Psychol)

Professor of Psychology, Faculty of Psychology, Ruhr-University Bochum, Bochum Germany

Akira Hori MD

Professor, Research Institute for Neurology and Psychiatry. National Nishi-Tattori Hospital Japan

Ruijin Huang PhD Dr Med

Institute of Anatomy and Cell Biology, University of Frieberg, Frieberg, Germany

Susanne Huber Dipl Phys Dr rer nat

Research Fellow, Friedrich Michscher Laboratory of the Max Planck Society Tŭbingen, Germany

Freddy Hueginin MD

Former Consultant at the University Clinic of Physical Medicine and Rehabilitation of Geneva, Switzerland

Michael Hyland BscPhD BcPsychol

Department of Psychology, University of Plymouth, Plymouth UK

S.Iliaeva MD

Rehabilitative and Physical Medicine, Cologne, Germany

Bärbel Kahl–Nicke PhD Dr Med (Dental)

Chair of Department of Orthodontics, College of Dentistry, University of Hamburg, Hamburg, Germany

L.E.Koch Dr Med

General Practitioner and member for the European Workgroup for Manual Medicine Eckernförde,

The Netherlands

Heike Korbermacher Dr Med (Dent)

Associate Professor, Department of Orthodontics, College of Dentistry, iversity of Hamburg, Hamburg, Germany

Hanne Kŭhnen

Paediatrician Kevalaer, Germany

H. Mohr

Physiotherapist and Member of the European Workgroup for Manual Medicine, Manual Therapist and lecturer, Ede, The Netherlands

R. Rädel MD

Orthopedic Surgeon, Herne, Germany

Jan- Marino Ramirez PhD

Professor of Anatomy and Neurosciences, Department of Anatomy, The University of Chicago, Chicago, Illinois.

Dorin Ritzmann Dr Med FMHG (Gynaecology/Obstetrics) Cert Med Hypnosis Trauma Therapy (EMDR Francine Shapiro)

Zurich Switzerland

R Sacher MD

Private Practitionerand member for the European Workgroup for Manual Medicine

Dortmend, Germany

Reinhard W. Thieler Dr Med FMH

Paediatrician Neuro-rehabilitation and member for the European Workgroup for Manual Medicine

Trimbach, Switzerland

Peter Waibel MD

Chief of Section, Radiology Department, Ostschweizer Kinderspital, St Gallen Switzerland

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