Kiss syndrome – physical therapy approach to disorders of posture and movement

The term “Kopfgelenk” refers to the craniocervical junction, or the functional dynamic unit between the base of the skull, and the first and second cervical vertebrae. Although in medical literature the clinical picture was described earlier, for the first time in 1984 it was named as cervical-diencephalic kinesiological syndrome. Since 1991 its name has been abbreviated to KISS syndrome, and a detailed description of the clinical picture, a classification of variations of the syndrome and recommendations for therapy have been presented in numerous articles by Dr. Heiner Biedermann, the German surgeon, specialized in manual medical therapy, especially in children. (In our clinical practice, the following titles are occasionally used: spastic torticolis, spastic crooked neck, painful wrong head posture in a child that cries a great deal). In the practice of physiatrists the issues encompassed by KISS syndrome are encountered occasionally, but they give rise to certain dilemmas regarding diagnostics and therapy. In etiopathogenetic terms, KISS syndrome is assumed to be a functional blockage in the craniocervical junction, slightly more rarely on the level of the distal cervical intervertebral dynamic segments. The cause of the functional blockage in the craniocervical junction or in other segments of the cervical spine are most frequently dislocation of intervertebral joints or changes in the surrounding soft para-articular tissues. The risk factors for development of KISS syndrome are mainly in the mechanism of birth trauma as the head of the baby passes through the birth canal, and in the limiting conditions of intrauterine growth of the baby and the development of movement. A greater predisposition is also mentioned in babies from multiple pregnancies and those in whom poor intrauterine movement has been noticed, babies born with the use of mechanical means (vacuum, forceps) and genetic predisposition. In the clinical picture we find vertebral, vertebrogenic and numerous secondary symptoms. We differentiate KISS I and KISS II variations of the syndrome in terms of the dominant, fixed abnormal head posture in the newborn or infant. The dominant vertebral symptom is fixed asymmetric head and neck posture in lateral or retro flexing, accompanied by asymmetric hypertonus of the paravertebral muscles and local tactile hypersensitivity. Accompanying symptoms which are clearly expressed in the clinical picture are sucking and swallowing difficulties, insufficiencies in the orofacial area (drooling, incomplete mouth closure), occipital asymmetric configuration of the head and asymmetry of the trophic muscle structure. Children have difficulties establishing a sleeping-waking rhythm, behavior problems (unrest, over sensitivity, excessive crying), abdominal colic and febrile episodes without pathological changes in laboratory findings. The spontaneous movements of the newborn are meager in quantity and in terms of variety in the repertoire of movements, with dominant asymmetry of head posture, mostly accompanied by abundant crying when the child is being handled in everyday activities. In the early motor development of the craniocervical junction, or the position of the head in relation to the body, there is an exceptionally strong influence on the characteristics of primary reflex activities, the distribution and quality of muscle tone, and on the development of the postural reactions of straightening up, balance and defense. Since these are the foundations of normal sensor and motor development in a newborn and infant, it is clear that insufficiencies in attaining the vital symmetry by the third and at the latest by the 6th month of infancy, will be reflected in many ways in the sensor and motor development of the child. Fixed asymmetric head posture, accompanied by local muscle hypertonus and pain will hinder the normal development of head movements, and disturb the cranio-caudal direction of development of posture control, dynamic stability and mobility of the body and extremities. These discrepancies will be reflected in the development of sensor integrity, perception, balance and coordination. Local pain sensitivity and limited movement are early senso-motoric experiences which will also have a significant effect on the emotional and social development of the infant, and interaction between the child and parents, or care-taker, will be burdened by mutual difficulties. In the further course of psycho-motor development, apart from sensor-motor developmental difficulties, the infant will increasingly clearly demonstrate difficulties in organizing attention and concentration, which will be reflected in the quality of cognitive, speech and fine motor development. During motor development, first of all adaptation to the asymmetric posture will develop, and later the range of secondary symptoms during growth and development will be joined by the development of compensation, primarily in the area of the spine and body, which may lead to the development of poor posture and scoliosis. The diagnosis of KISS syndrome is founded on a detailed history (where it is good to rely on a questionnaire created to identify risk factors) and on a clinical examination and experience. Radiological diagnostic methods are also a great help – X-rays of the craniocervical junction, US and MRI. In view of the high cervical anatomic localization of the organic substrate of the disorder, it is clear that the therapeutic approach requires great caution, a good knowledge of functional anatomy, high quality training and experience in the therapist. A problem like this in posture and movement in a newborn or infant cannot be resolved by basic neurodevelopmental kinesiotherapeutic approaches (Bobath therapy or kinesiotherapy according to Vojta). Priority should be given to manual therapeutic intervention by a suitably trained and experienced therapist, by which he/she will try to attain good congruency of the joints and a more favorable biomechanical relationship between the soft para-articular tissues. In Europe various manual therapeutic techniques are used, such as Atlas therapy after Arlen, HIO therapy according to Gutmann, craniosacral therapy and osteopathy, and within the federation of manual therapists, a group of narrow specialists have defined themselves separately as KISS therapists. In our context this kind of training is still in the very early stages, apart from some oportunities for training in manual medicine. It is also not completely defined who may carry out manual manipulation in the area of the cervical vertebrae – a doctor and/or a physiotherapist. The approach to the diagnostics and therapy of KISS syndrome should certainly be interdisciplinary, as it requires cooperation between neuropediatricians, orthopedists, physiatrists and physiotherapists.

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