352-245-6169 mdthomasdc@gmail.com

 Note:  This paper was originally published in the The Upper Cervical Monograph, Volume 7, number 2, September 2009. 

 

A Brief Look at Biedermann et al., and the “KISS” Syndrome.

 

Michael D. Thomas, D.C.

 

There is a developing body of literature on treatment of the upper cervical area (primarily in infants) that comes to us from Biedermann and others (Gutman, etc.) in Europe.  This body of work virtually constitutes a parallel system of upper cervical ‘adjustment’ (manipulation) developed over several decades that seems to be essentially separate from either the articular or orthogonal approaches developed in a similar (although initially earlier) time frame in North America.  Important similarities and differences exist. 

 

Biedermann, in a summary of his work in 1992, noted that the craniovertebral junction in newborn and young babies can be the site of a syndrome of problems that he termed “kinematic imbalances due to suboccipital strain” or KISS.  He detailed a wide variety of clinical signs and symptoms which have responded well to manual therapy.  The main signs of KISS being torticollis, unilateral microsomy, C-scoliosis, motor asymmetries, unilaterally retarded maturation of hip joints, and slowed motor development.  Etiological factors include intrauterine misalignment, application of extraction aids, prolonged labor and multiple fetuses.(1)

 

Biedermann has brought a variety of functional disorders and symptoms into his KISS concept.  As he notes: “The definition of a functional disorder that is caused primarily vertebrogenetically enables pediatricians, physiotherapists, speech therapists, and others to widen their scope of available therapeutic options and to include the “functional approach” in their therapeutic considerations.” (2)

 

Functional Medicine is growing in influence and has the potential to become a potentially guiding force in medicine here in the United States. (3) Biedermann’s approach  is consistent with the functional model.  Functional indications that the KISS syndrome may be present include:

Tilt posture of the head, torticollis, opisthotonos, uniform sleeping posture (baby cries if mother tries to change the posture), asymmetric motor patterns, asymmetric posture of trunk and extremities, sometimes combined with a tilting head position reminiscent of a persisting asymmetric tonic neck reflex, sleeping disorders (baby awakens every hour crying), extreme sensitivity of the neck, cranial scoliosis (swelling of facial soft tissues on one side), blockages of the iliosacral points, asymmetries of the gluteal muscles, asymmetric development and range of motion of the hips, fever of unknown origin, loss of appetite and other symptoms of central nervous system disorders.  Other examination findings include:  C-scoliosis, mobility of the vertebral spine reduced by more than 30%, feet deformities, pathological reflexes.(4)

 

Biederman has further subdivided his syndrome into two basic types.  KISS I is defined as a fixed lateral flexion posture and KISS II is defined as primarily a fixed retroflexion posture.  These postures involve the entire body of the infant.  KISS I clinical markers include “torticollis, unilateral microsomia, asymmetry of the skull, C-scoliosis of neck and trunk, asymmetry of gluteal area, asymmetry of motion of the limbs, retardation of motor development of one side.”(5)  Clinical marker for KISS II include: “hyperextension (during sleep), (asymmetric) occipital flattening, shoulders pulled up, fixed supination of the arms, cannot lift trunk from ventral position, orofacial muscular hypotonia, breast-feeding difficult on one side”(6)

 

Primary indications of the presence of KISS include asymmetry of posture and movement.  Hypersensitivity and restricted range of movement in the suboccipital structures should, Biedermann argues, result in referral of the infant to a ‘specialist’.(7)

 

Biedermann also has defined a KIDD syndrome.  It was noted over time that infants often recovered when they began to verticalize, which is a term Biedermann uses for the various maturation processes in which infants begin to get upright in preparation for walking.  It was found that the differentiation between KISS I and KISS II “loses its meaning after verticalization, as the influence of the upright stance modifies the basic conditions to such an extent that the fixed posture is almost abandoned.” (8).  The second to fourth years are perceived as a ‘silent’ period when few problems are noted.  From the fourth year to preadolescence, a variety of problems can occur including:

“imbalance of the muscular coordination with asymmetrical tonus of the postural muscles, shortened hamstrings, kyphotic posture with hyperlordosis of the cervical spine and hypotonus of the dorsal muscles of the thoracic area, often accompanied by orofacial hypotonia; scoliotic posture in sitting/standing position; shoulders at different height; sacroiliac(SI) joint mobility asymmetrical often with asymmetry of leg rotation; balance tests insufficient and mostly asymmetrical; insufficient coordination of vestibular input, e.g. standing with raised arms and closed eyes difficult; acoustic orientation laborious; locating the source of an ‘interesting’ noise difficult; combination of arm and leg movements difficult, e.g. jumping-jack test; 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 the close range is invaded by the examiner; wild resistance against palpation.”  

 

Biedermann’s protocol to define KIDD looks at four components:

“a case history with the relevant KISS symptoms during the first year; asymmetry of posture and movement during examination; a sufficient number of symptoms from the list above; the palpation of restricted movement to palpation in the suboccipital area.”(9)

 

Biedermann notes that the primary symptom causing parents to bring children in is headache.  There is advice to adjust these children in both the cervical area and also possibly in the sacral area. Biedermann notes a multitude of behavioral type therapies that can be helpful but notes they often have to be repeated with some frequency.  He finds that manual therapy usually doesn’t have to be repeated as often and he doesn’t usually follow up more than once a year.  (10)

 

Biedermann writes that Gutman, before him, looked at the upper cervical area as a cause of ‘pathogenetic significance”. (11)  He writes:

“As early as the 1950s and 1960s Gutmann published cases of what he called Atlas blockage syndrome.(12)  He drew attention to the pathogenetic significance of the cervico-occipital junction.  However C1 is not the only culprit and we cannot be certain to find a morphological substrate for a “blockage” in these immature soft joint tissues.  We prefer to use the term kinematic imbalances due to suboccipital strain (KISS syndrome).  It is well defined by well-defined clinical symptoms and anamnestic facts and its diagnosis gives the experienced effective access to a wide range of problems.” (13)

 

Biederman finds the birth process to be a greatly undervalued cause of trauma.  He points out previous studies revealing a high percentage of microtrauma in the periventricular areas of the brainstem.(14)  He also discusses the probability that the structures that lie exposed under the cranium suffer at least as much from traumas (such as the birth process) as the cranium.(15) In fact this has been shown in studies regarding the biomechanical forces involved in delivery.(16) Biederman writes that injury at birth may be the norm rather than the exception.  He further credits the incredible ability of the developing nervous system to overcome these traumas and repair much of the damage.”(17)

 

Biedermann utilizes what he terms, “functional and morphologic analysis of the “classic” radiographs of the cervical spine.” (18) He reports “If the desymmetrization of the occipito-cervical junction follows the established pattern…the direction of the impulse is confirmed.”  In his examples, a KISS I (A-P open mouth) radiograph showed what seems to be right laterality and a whole body lateral flexion to the right, including the right head tilt, somewhat similar perhaps, to our idea of a right type II.  Biederman apparently uses Gutmann’s protocol to x-ray the infants which is this A-P open mouth film.  There does not seem to be any attempt to radiographically measure rotation in the transverse plane.  Biedermann however does seem to reject the idea that it is possible to accurately and objectively measure misalignments the way we do in orthogonally based upper cervical work.  His analysis encompasses more than measurement of the osseous structures although he does state:

“Selection of the direction of the treatment without radiographs seems the most plausible cause for the less encouraging results of some colleagues.”(19)

 

Biedermann references Gutman (20) when discussing the films taken.    There are oblique references to ‘the classical techniques” and it appears that at least a lateral and AP open mouth film are taken.  He is also advocating taking full spine pictures too because that enters into his analysis.  There does not seem to be any visualization of the transverse or axial plane in the analysis of the cranio-vertebral junction.  He mentions MRI and other imaging techniques that might be used, but the application seems more to be ‘art’ and clinical experience in regard to the axial plane. 

 

If the x-rays and symptoms are in agreement, Biedermann uses the x-ray findings to direct the line of drive for manipulation.  He reports this occurs about 80% of the time.  “In those 20% of the cases where there is no match between radiological and clinical picture one has to be especially alert to find other discrete signs which might help to explain this discrepancy.  It is not always possible to come to a completely satisfactory explanation for this discrepancy but in most of these cases a central neurologic component is present.” (21)

 

Biedermann comments at some length on the emotional and scientific issues revolving around radiating patients.  He notes that fetuses and children are about twice as sensitive to radiation as adults but no more so.  He challenges the linear response curve that is usually regarded as the standard for damage from radiation which states that damage is proportional to dose, no matter how small the dose.  He adds that the dosages for cervical films on infants is one of the lowest dosages used in conventional radiology.   For him the risk-benefit analysis “clearly favors the standard procedure of taking radiographs before any treatment of the cervical spine regardless of the age of the patient.”(22) Even without the primacy of orthogonal analysis, Biedermann clearly sees the necessity of taking films before adjusting and sees no contest in terms of risk and benefit.

 

Apparently somewhat aware of the work done over the past century in chiropractic and osteopathy (or at least their origins) Biedermann finds little to help him there.  Although he invokes the names of Palmer and Still, he writes that although they had both remarked about the damage early traumas can create in development, there had not been given any specific signs that would illustrate this damage.  Therefore this early insight wasn’t, in Biedermann’s opinion, able to be practically applied at the time. (23)

 

Biedermann is convinced that the results of this work on infants far surpasses anything that is possible in the adult and cautions the reader not to assume that the reader’s experience of manipulation in the adult population  is comparative to MTC (Manual Therapy in Children).  An infant is in an extremely active phase of rapid growth and maturation.  The many osseous growth centers are very active and postural distortion from upper cervical misalignment creates structure that is asymmetrical and potentially less (or mal-) functional. This fundamentally changes the maturation of the structure of the body.  It is only at this early period that he believes real and permanent changes can be made that will affect the entire life of the individual.  He notes:

“Manual therapy in children bears only scant resemblance to the much less dramatic and well-known effects we see in adults.  We are aware that we often repair without being able to heal, thus condemning both therapist and patient to repeat this exercise sooner or later.”  (24)

 

As Dr. Scholten recently noted after speaking with Biederman, our concept of upper cervical work is that we are able to restore alignment to the osseous structures as they relate to each other.  The power of this procedure is well known to us.   Biedermann however, is more interested in working very early in life so that the discrete osseous structures themselves are formed properly (symmetrically).  Biederman sees functional (mal)function (KISS) affecting developing structure in the infant and young child.  Considering that most afferent proprioceptive signals come from the craniovertebral junction, any interference to normal signal flow will have extensive impact on the developing nervous system, much more than at any other time in life.  This has obvious importance throughout the entire lifespan of the individual.  As this developing structure is then laid down asymmetrically, it causes potentially permanent structural issues that can continue to cause problems through the whole lifespan.  Biedermann sees that in the early months of life, function therefore affects structure.  Once the structural development has been laid down, structure will affect function for the rest of the lifespan.  It is in these early months that Biedermann sees such outsized potential for phenomenal results.  (25)

 

In discussing the further maturational difficulties that can ensue due to upper cervical misalignment (our term): “Traumatization of the suboccipital structures inhibits functioning of the prioprioceptive feedback loops.  The motor development, though preprogrammed, cannot develop normally.  These systems are fault tolerant and able to overcome considerable difficulties and restricted working conditions.  But 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 e.g., temporary fixation of the head in one position, and “recover” spontaneously.  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.” (27)

 

Biedermann thinks that the suboccipital joints are most likely to be involved when several issues are seen concurrently: asymmetry of motion, facial asymmetry, and sleeping disorders. (28)

 

The procedure to adjust is described as an impulse mechanism.  After examination, the clinical findings are compared with the radiographic findings.  “In most cases the direction of the manipulation is determined by the radiographic findings. In the other cases the orientation of the torticollis, the palpation of segmental dysfunction, or the local pain reaction helps to find the best approach.  The manipulation itself consists of a short thrust of the proximal phalanx of the medial edge of the second finger.  It is mostly lateral; in some cases the rotational component can be added.” (29)

 

Biedermann has further elucidated the concepts of MTC in a 2004 text, Manual Therapy in Children. Edited by Heiner Biedermann Churchill Livingstone 2004.  The text is extensive and has so much to offer our perspective that a review such as this cannot do it justice.  The text has five sections, ‘The theoretical base, Clinical insights, The different levels: practical aspects of manual therapy in children, Radiology in manual therapy in children, and Making sense of it all’, twenty seven chapters in total.  The discussions of embryological development,  neurophysiology and clinical insights alone are more than worth the price of the text. 

 

I will include a couple of quotes to whet your appetite.

 

“…a clear statement of the relation between orthopedic and orthodontic disorders is still missing.  Most studies are based on clinical impressions and have anecdotal features.  Only a few controlled studies have shown that anatomical features of the craniocervical junction are associated with head posture, mandibular growth and angulation of the cranial base. 

In general, there seems to be an association between Angle class II-i.e. distal position of the mandible in the skull – and lordosis, as well as a high incidence of lateral crossbite in patients with scoliosis and torticollis.” (31)

 

”In about two-thirds of cases the effect of the treatment shows in the first 48 hours after the manipulation, but the other third of the successfully treated children need between 2 and 4 weeks to display a change for the better, sometimes only after an initial rebound….it is tempting to try to combine several other modes of treatment to alleviate this phase – for example by using pharmaceuticals.

     As far as experience seems to indicate, this approach is ineffective.  It seems better to allow enough time for the results of the manual therapy to take effect; they tend to be more profound and stable when the organism is given the chance to re-adjust its functions to the post-manipulation situation without further stimuli.”  (32)

 

Biedermann uses his examination of complexity theory to begin to describe two kinds of therapy.  He finds humans to be nonlinear systems and while ‘robust’ therapies “therapies designed to correct disease entities” (33) are important at times (such as adjusting to remove a ‘pinch’ in the shoulder, for example, he finds MTC to be a kind of ‘subtle’ therapy “involving therapeutic inputs into the extended network” (34) that can operate in a broader way throughout the entire network and over an extended time.  Examples (besides MTC) included lifestyle issues such as psychological state, diet and exercise.  Lack of an objective analysis for KISS and KIDD does however, leave the clinicians in a somewhat nebulous, philosophical zone where art and intuition must make up for the lack of objective rigor. 

 

Overall, we find much that is familiar to us and much that is viewed from a very different perspective.  Biedermann allows us in orthogonally based upper cervical work to look at the field from a different perspective.  Seeing through another’s eyes can be very revealing and productive.  Our work has found objective ways to measure the osseous misalignment that we have (completely –at least to our satisfaction)) correlated with postural distortion.  Dr. Biedermann and his colleagues do not discern the biomechanical symmetry that we have found (we are aware that there is not absolute symmetry, but symmetry that allows biomechanical stability as noted first by Dr. Gregory) using properly taken radiographs on aligned equipment, using proper patient positioning.   As we further develop our communications with Dr. Biedermann, both of our groups may find fertile ground to move forward. 

 

References

 

  1. Biedermann, H. “Kinematic imbalances due to suboccipital strain in newborns” Journal of Manual Medicine 1992.6:151-156.
  2. Biedermann, H. “Manual Therapy in Children: Proposals for an Etiologic Model”               J Manipulative Physiol Ther Mar/Apr 2005.  2005:28:211.e1-211.e15.
  3. Jones,DS.  Textbook of Functional Medicine. The Institute for Functional Medicine Gig Harbour, WA 2005.
  4. ibid, Biederman 1992 :151.
  5. ibid, Biedermann 2005: 211.e6.
  6. ibid, Biedermann 1992:151.
  7. ibid, Biedermann 2005: 211.e10
  8. Biedermann H. Manual Therapy in Children.  Churchill Livingstone 2004: 303.
  9. ibid, Biedermann 2004:306-7.
  10. ibid, Biedermann 2004:307
  11. ibid Biedermann 1992:153 (He ref: Gutman G (1953)Die obere HWS im Krankheitsgeschehen. Neuralmedizin 1:27-36., Gutman G (1968) HWS and HNO-Krankheiten. HNO Arzt 10:289-298., Gutmann G, Vele F (1970) Die Gelenke der oberen Halswirelsaule und ihre Einwirkung auf motorische Stereotypien. In Wolff HD (ed) Manuelle Medizin und ihre wissenschaftlichen Grundlagen. Verlag fur physikalische Medizin, Heidelberg.). 
  12. ibid, Biedermann 1992:153-4
  13. Valk J, van der Knaap MS, de Grauw T. The role of imaging modalities in the diagnosis of posthypoxic-ischaemic and haemorrhagic  conditions in infants. Klin Neuroradiol 1991; 2:83-140. 
  14. Lierse W. Das Becken. In: Wachsmuth VL, editor. Praktische anatomie. Berlin: Springer; 1984. p. 337.)  Wischnik et al (Wischnik A, Nalepa E, Lehmann KJ. Zur prevention des menschlichen geburtraumas I. Mitteilung: die computergestutzte simulation des geburtsvorganges mit hilfe der kernspintomographie und der finiten-element-analyse. Geburtshilfte Frauen heilkunde 1993;53:35-41.
  15. Govaert P, Vanhaesebrouck P, de-Praeter C. Traumatic neonatal intracranial bleeding and stroke. Arch Dis Child 1992;67:840-5.
  16. ibid Biedermann 2005:211.e3
  17. ibid Biedermann 2005:211.e10
  18. ibid Biedermann 2005:211.e12
  19. Gutman G 1969 Rontgendiagnostik der Occipito-Cervical-Gegen unter chirotherapeutischen Gesichtpunkten. Rontgenblatter 45-56.
  20. ibid, Biedermann 2005:211.e11
  21. ibid, Biedermann 2005:211.e11
  22. ibid, Biedermann 2005: 211.e12
  23. ibid, Biedermann 2005:211.e12
  24. UCRF Board meeting, telephone conversation 7-9-09
  25. ibid, Biedermann 1992:154
  26. ibid, Biedermann 1992:155
  27. ibid, Biedermann 1992:151
  28. ibid, Biedermann 1992:151
  29. ibid, Biedermann 2005:211.e12.

      30. ibid, Biedermann 2005:211.e11.  Within the quote, Biedermann references: Koch   LE, Koch H, Graumann-Brunt S, Stolle D, Ramirez JM, Saternus KS. Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants. Forensic Sci Int 2002;128:168-76.]

      31.  ibid, Biedermann 2004:146

32.   ibid, Biedermann 2004:207

33.  ibid, Biedermann 2004:277

34.   ibid, Biedermann 2004:277