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Chiropractic Management of Common Conditions. Asthma.

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Presentation on theme: "Chiropractic Management of Common Conditions. Asthma."— Presentation transcript:

1 Chiropractic Management of Common Conditions

2 Asthma

3 Patient Presentation Parents report: Episodic or persistent coughing Wheezing Shortness of breath Rapid breathing or chest tightness Worse in the evening or early morning hours Associated with triggers  exercise, allergen exposure 50-80% of children develop symptoms before 5 Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7): Asthma?

4 Differential Diagnosis Wheezing is not present in all patients with asthma! Wheezing is not a sign exclusive to asthma  Respiratory infections  Rhinitis  Sinusitis  Vocal cord dysfunction Consider differentials that may cause similar symptoms  Foreign body aspiration  Cystic fibrosis  Heart disease Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7):

5 Diagnosis “In most children, the primary diagnostic tool is clinical assessment.” Pulmonary function tests (spirometry) should be performed as soon as possible  Unreliable in infants and many preschoolers Poor technique, adult-sized equipment  More reliable after 3-4 years of age Allergy testing  Atopy is the strongest predictor for wheezing progressing to asthma Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7):

6 “Allergic March” Infancy Food Allergy-Associated GI Disorders and Dermatitis Early Childhood Allergic Rhinoconjunctivitis Asthma Courtney AU, McCarter DF, Pollart SM. Childhood Asthma: Treatment Update. Am Fam Physician 2005;71:

7 Medical Treatment Patient education Trigger avoidance Drug therapy Compliance is a major problem  Route of administration  Frequency of dosing  Medication effects  Risk or concern of side-effects Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7):

8 Chiropractic Care & Asthma Evidence is adequate to support the “total package” of chiropractic care as providing benefit to patients with asthma  Symptoms were reported to improve  Medication use decreased  One study (Guiney) showed improved peak expiratory volume  No adverse effects were reported Hawk C, et al. Chiropractic Care for Nonmusculoskeletal Conditions: A systematic Review with Implications for Whole Systems Research. J Altern Complement Med 2007;

9 What is the goal of treatment?  Reduce symptoms (wheeze and cough)  Improve lung function ? Reduce the risk and number of acute exacerbations  Minimize adverse effects of treatments ? Minimize sleep disturbances ? Minimize absences from school Courtney AU, McCarter DF, Pollart SM. Childhood Asthma: Treatment Update. Am Fam Physician 2005;71:

10 What is the “Total Package”? What does the average chiropractor do when a patient presents with asthma as a primary complaint?

11 Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1): Modalities Used for the Treatment of Asthma N=33 Consensus=24 (75%) # of DCs using modality Chiropractic adjustment of the T spine33 Chiropractic adjustment of C1/C232 Evaluation of stress/environment32 Neurolymphatic drainage of chest wall30 Evaluation of environmental pollutants30 Family history evaluation29 Removal of dairy/wheat from diet28 Review of medication/side effects26  Represented 10 different chiropractic schools  Average of 8 years in practice

12 Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1): Modalities Used for the Treatment of Asthma N=33 Consensus=24 (75%) # of DCs using modality Chiropractic adjusment of ribs21 Adjustment of other spinal segments20 Cranial adjustments20 Supplementation with vitamin C20 Increased exercise16 Supplementation with garlic9 Homeopathic medications6 Breathing exercises5 Use of “breatheasy” tea5 Liver nutritional support2 Supplementation with cranberries1 Lotus root tea1

13 Summary Chiropractic Management Included: Spinal adjusting (most common modality used)  thoracic spine and C1/C2 A significant number of non-spinal adjustment modalities Limitations: Small sample size Does not address the efficacy of the modalities reported Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1):113-5.

14 Chiropractic Management Chiropractic adjustments  Full spine, ribs, upper cervical Trigger avoidance & environmental control measures  “Evaluation of stress/environment”  “Evaluation of environmental pollutants”  “Removal of dairy/wheat from diet”  “Review of medication/side effects”

15 Trigger Avoidance Allergens from dust mites or mold spores Animal dander Cockroaches Pollen Indoor and outdoor pollutants Irritants (smoke, perfumes, cleaning agents) Pharmacologic triggers (NSAIDS, sulfites) Physical triggers (exercise, cold air) Physiologic factors (stress, GER, URTI, rhinitis) Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7):

16 Environmental Control Measures Remove carpets Wash bedding and clothing in hot water (weekly) Hypoallergenic mattress and pillow covers Remove stuffed animals Keep pets outdoors Hypoallergenic furnace filters Dehumidifier (household humidity <50%)? For more ideas:http://www.aaaai.orghttp://www.aaaai.org Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7):

17 More research is needed but… Avoid dairy/wheat  Highly allergenic… remember the “allergic march”?  Dairy in a mucous-producing agent Limit processed sugars Avoid food additives & preservatives (MSG)  May trigger attacks Relaxation techniques, stress control and reduction  May benefit lung function Family life, TV, school, daycare, siblings, etc. Schetchikova NV. Asthma: An Enigma Epidemic, Part II-Asthma Treatment. J Am Chiropr Assoc: JUL 2003 (40:7)

18 More research is needed but… Probiotics  May reduce inflammation, reduce allergic symptoms Omega-3 fatty acids  May decrease inflammation Calcium and magnesium  May cause bronchial smooth muscle relaxation and reduces histamine response Antioxidants (vitamins C and E, selenium, zinc)  May reduce allergic reactions and wheezing Schetchikova NV. Asthma: An Enigma Epidemic, Part II-Asthma Treatment. J Am Chiropr Assoc: JUL 2003 (40:7)

19 Index to Chiropractic Literature Gibbs AL. Chiropractic co-management of medically treated asthma. Clin Chiropr: SEP 2005(8:3) Ressel O, Rudy R. Vertebral subluxation correlated with somatic, visceral and immune complaints: an analysis of 650 children under chiropractic care. J Vert Sublux Res: 2004 (OCT:18) Online access only 23p. Schetchikova NV. Asthma: An Enigma Epidemic (Part 1). J Am Chiropr Assoc: June 2003 (40:6) Schetchikova NV. Asthma: An Enigma Epidemic, Part II-Asthma Treatment. J Am Chiropr Assoc: JUL 2003 (40:7) Blum CL. Role of chiropractic and sacro- occipital technique in asthma treatment. J Chiropr Med: MAR 2002(1:1) Clinical Trial: Asthmatics and Chiropractic. J Am Chiropr Assoc: FEB 2001 (38:2) Wellness Alert: Hold Your Breath. J Am Chiropr Assoc: MAR 2001(38:3)

20 Colic

21 “Rule of Three”  Crying for more than 3 hours per day  for more than 3 days per week  for longer than 3 weeks …in an infant who is well fed and otherwise healthy Typically begins at 2 weeks of age and usually resolves by 4 months Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4):

22 Parents Report Attacks of screaming in late afternoon and evening Flushed face, furrowed brow, clenched fists Legs pulled up to abdomen Piercing, high-pitched screams Prolonged bouts Unpredictable, spontaneous  unrelated to environmental events Cannot be soothed, even by feeding Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4):

23 Etiology? Gastrointestinal?  “Gas” does not seem to be the cause of colic Excessive crying may lead to aerophagia Psychosocial?  Not a sign of a “difficult temperament”  Not related to maternal personality or anxiety Neurodevelopmental?  Upper end of the “normal distribution” same temporal pattern, just more severe  Most infants “outgrow it” Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4):

24 Organic Causes? <5% of infants presenting with excessive crying CNS  CNS abnormality (Chiari type I malformation)  Infantile migraine  Subdural hematoma Gastrointestinal  Constipation  Cow’s milk protein intolerance  GER  Lactose intolerance  Rectal fissure Infection  Meningitis  Otitis media  UTI  Viral illness Trauma  Abuse  Corneal abrasions  Foreign body in the eye  Fractured bone  Hair tourniquet syndrome Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4):

25 A diagnosis of exclusion… Apnea, cyanosis, struggling to breathe…  Undiagnosed pulmonary or cardiac condition? Frequent, excessive spitting up…  GER, pyloric stenosis? Lethargy, poor skin perfusion, tachypnea, fever, poor weight gain…  Infection, gastrointestinal disorder, nervous system disorder? Bruising, fracture…  Abuse? Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4):

26 Management? There is limited or no evidence to support…  Simethicone (Mylicon) no more effective than placebo  Lactase  Fiber-Enriched Formulas  Carrying the infant more  Car ride simulators  Intensive parent training  Sucrose Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70: Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics 2000; 106:

27 Recommended Management Low allergen diet (breastfeeding mothers)  Eliminate milk, eggs, wheat, & nuts Hypoallergenic formulas Soy formulas?  May develop allergy to soy Herbal tea  Chamomile, vervain, licorice, fennel, and balm- mint Reduce infant stimulation Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70: Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics 2000; 106:

28 New Research  Probiotics (Lactobacillus reuteri) Improved colicky symptoms within 1 week No adverese effects were reported Many parents try remedies recommended by family & friends, or found online…  “White noise”, car ride, walk in the stroller  “Gripe water” Relief from flatulence and indigestion? Avoid versions made with sugar or alcohol Look for products made in the USA Savino F, et al. Lactobacillus reuteri Versus Simethicone in the Treatment of Infantile Colic: A Prospectice Randomized Study. Pediatrics 2007;119:e Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004;70:

29 Chiropractic Care & Colic Evidence is adequate to support the “total package” of chiropractic care as providing benefit to patients with colic  Improvement with SMT  Improved parent-reported outcomes with chiropractic care  No adverse effects were reported Hawk C, et al. Chiropractic Care for Nonmusculoskeletal Conditions: A systematic Review with Implications for Whole Systems Research. J Altern Complement Med 2007;

30 Index to Chiropractic Literature Miller J, Croci SC. Cry baby, why baby? Beyond colic: Is it time to widen our views? J Clin Chiropr Pediatr: 2005(6:3) Hipperson AJ. Chiropractic management of infantile colic. Clin Chiropr: DEC 2004 (7:4) Hewitt EG. Chiropractic care and the irritable infant. J Clin Chiropr Pediatr: SUM 2004(6:2) Leach RA. Differential compliance instrument in the treatment of infantile colic: a report of two cases. J Manipulative Physiol Ther:JAN 2002(25:1) Nilsson N, Wiberg JMM. Infants with colic may have had a faster delivery: a short preliminary report. J Manipulative Physiol Ther:MAR/APR 2000(23:3) Working with young patients. J Am Chiropr Assoc:FEB 1999 (36:2)

31 Enuresis

32 Classification Schemes According to time of day Nocturnal enuresis: passing of urine while asleep Diurnal enuresis or incontinence: leakage of urine during the day According to presence of other symptoms Monosymptomatic or uncomplicated nocturnal enuresis: normal voiding occurring at night in bed in the absence of other symptoms referable to the urogenital or gastrointestinal tract Polysymptomatic or complicated nocturnal enuresis: bed-wetting associated with daytime symptoms such as urgency, frequency, chronic constipation, or encopresis According to previous periods of dryness Primary enuresis: bed-wetting in a child who has never been dry Secondary enuresis: bed-wetting in a child who has had at least six months of nighttime dryness Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: ,

33 Etiology Genetic Predisposition  Most frequently supported Bladder Problems  Bladder function is normal however, functional bladder capacity may be less Arginine Vasopressin  Delayed development of a circadian rhythm may result in nocturnal polyuria Sleep Disorders  Controversial… sleep EEGs demonstrate no differences but parents report that their children are “deep sleepers”  More likely to have “confused awakenings”; night terrors, sleepwalking Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: ,

34 Other factors that have been implicated… Familial factors?  Social background, stressful life events, number of changes in family constellation or residences seem to have no relationship Psychologic factors?  No increased incidence of emotional problems  Not an act of rebellion  Psychologic factors are the result of, not the cause Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: ,

35 History At what age was your child consistently dry at night?  "Never dry" suggests primary enuresis Does your child wet his or her pants during the day?  Positive answer suggests complicated nocturnal enuresis Does your child appear to have pain with urination?  Urinary tract infection How often does your child have bowel movements?  Infrequent stools: constipation Are bowel movements ever hard to pass?  Constipation Does your child ever soil his or her pants?  Encopresis Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: ,

36 How many times a day does your child void?  More than 7 times a day: functional bladder disorder Does your child have to run to the bathroom?  Positive response: functional bladder disorder Does your child hold urine until the last minute?  Positive response: functional bladder disorder How many nights a week does your child wet the bed?  Most nights: functional bladder disorder  One or two nights: nocturnal polyuria Does your child ever wet more than once a night?  Positive response: functional bladder disorder Does your child seem to wet large or small volumes?  Large volumes: nocturnal polyuria  Small volumes: functional bladder disorder How have you handled the nighttime accident?  Elicits information on interventions that have already been tried; punished or shamed ? Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: ,

37 Diagnosis Not considered enuretic until 5 years of age! Voiding diary 1 week or more Physical exam Gait – evidence of a subtle neurologic deficit Flanks and abdomen – masses? enlarged bladder? Lower back - cutaneous lesions? asymmetric gluteal cleft? Urinalysis Specific gravity and urinary glucose level Infection or blood in the urine? Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: ,

38 Medical Management Alarms  Negative reinforcement or avoidance Anxiety, disruptive to family?  May have to be used for up to 15 weeks  Effective, low relapse rate Pharmacological Treatment  Not recommended for children under 6  Effective but high relapse rate  Side effects Desmopressin – nasal irritation, nosebleeds, and headache; less common: emotional disturbances (aggressive behavior and nightmares) Imipramine – “side effects, including cardiotoxicity at high doses, occur frequently enough that it probably should not be considered a first-line treatment” Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: ,

39 Nonpharmacologic Management Positive Reinforcement Systems  earns “points” for every night he or she remains dry ~> prize Responsibility training  child is given age-appropriate responsibility, in a nonpunitive way, for the consequences of bed-wetting (strip wet linens from the bed) Elimination diet Hypnosis Retention control Biofeedback Acupuncture Scheduled awakenings Caffeine restriction Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67: , More research is needed but they have been shown to have positive effects…

40 Chiropractic Care & Enuresis Evidence is insufficient at this time  Promising  Adverse effects were mild and self-limiting Hawk C, et al. Chiropractic Care for Nonmusculoskeletal Conditions: A systematic Review with Implications for Whole Systems Research. J Altern Complement Med 2007;

41 Index to Chiropractic Literature McCormick J. Improvement in nocturnal enuresis with chiropractic care: A case study. J Clin Chiropr Pediatr:2006(7:1) Bachman TR, Lantz CA. Management of pediatric asthma and enuresis with probable traumatic etiology. ICA Rev: JAN/FEB 1995(51:1) Marko RB. Bed-Wetting: Two case studies. Chiropr Pediatr: APR 1994(1:1) Langely C. Epileptic seizures, nocturnal enuresis, ADD. Chiropr Pediatr: APR 1994 (1:1) 22. Bomerth PR. Functional nocturnal enuresis. J Manipulative Physiol Ther:NOV/DEC 1994(17:9) Aker PD, Kreitz BG. Nocturnal Enuresis: Treatment implications for the chiropractor. J Manipulative Physiol Ther: SEP 1994(17:7)

42 Otitis

43 Diagnosis of AOM 1.Recent, usually abrupt, onset of signs and symptoms of middle- ear inflammation and MEE. 2.The presence of MEE that is indicated by any of the following: a)Bulging of the tympanic membrane b)Limited or absent mobility of the tympanic membrane c)Air fluid level behind the tympanic membrane d)Otorrhea 3.Signs or symptoms of middle-ear inflammation as indicated by either: a)Distinct erythema of the tympanic membrane OR b)Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep) AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004;113(5):

44 Diagnostic accuracy is hindered by… Vague symptoms  neither specific nor sensitive for AOM Undue reliance on one feature: redness of the tympanic membrane Failure to assess tympanic membrane mobility  must use pneumatic otoscopy Inadequate visualization of the typmpanic membrane  low light output from old otoscope bulbs should be changed every 2 years  blockage of the ear canal by cerumen Pichichero, M. Acute Otitis Media: Part I. Improving diagnostic Accuracy. Am Fam Physician 2000; 61:

45 Recommended Medical Management “Watchful waiting”  symptomatic treatment for 24 to 48 hours before initiating antimicrobial treatment Pain management  acetaminophen, ibuprofen, or topical otic anesthetic drops for pain control Antibiotic therapy  reserve antibiotic therapy for specific cases < 6 months of age Severe illness (fever of >102.6, severe ear pain) AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics 2004;113: Garbutt J, et al. Diagnosis and Treatment of Acute Otitis Media: An Assessment. Pediatrics 2003;112,143-9.

46 Newer Research Wait-and-see  Decreases the use of antibiotics Reduces cost and adverse effects (diarrhea)  No serious adverse events reported  Interrupts the cycle of parental expectations When are antibiotics most beneficial?  <2years with bilateral disease*  Otorrhea (any age) *Not all children under 2 benefit from antibiotics as previously suggested Spiro DM, et al. Wait-and-see prescription for the treatment of actue otitis media: a randomized controlled trial. JAMA 2006;296: Rovers MM, et al. Antibiotics for acute otitis media: a eta-analysis with individual patient data. Lancet 2006;368:

47 Reducing Risk Factors Breastfeeding  Minimum of 6 months If bottle-fed, avoid supine bottle feeding Reduce or eliminate pacifier use (>6 months) Daycare – increased incidence of URTI Tobacco smoke AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004;113(5):

48 Otitis Media with Effusion The presence of fluid in the middle ear without signs or symptoms of acute ear infection  Due to poor eustachian tube function OR  Inflammatory response following AOM Concerns  Conductive hearing loss  Potential impact on language development  Potential impact on cognitive development AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:

49 Diagnosis Clinical presentation  cloudy tympanic membrane  distinctly impaired mobility  air-fluid level or bubble may be visible Pneumatic otoscopy should be perfomed  Tympanometry or acoustic reflectometry can be used in conjunction Document the laterality and duration of effusion, and the presence and severity of associated symptoms AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:

50 Management Watchful waiting for three months If OME persists greater than 3 months or if language delay, learning problems, or a significant hearing loss is suspected  Hearing testing  Language testing Re-examine at 3- to 6-month intervals until  Effusion is no longer present  Significant hearing loss is identified  Or structural abnormalities of the eardrum or middle ear are suspected AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:

51 Increased risk for speech, language, or learning problems? Evaluate hearing, speech, language, and need for intervention more promptly  speech and language therapy concurrent with managing OME  hearing aids or other amplification device for hearing loss independent of OME  insertion of tympanostomy tube  hearing testing after resolution of OME to document improvement AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:

52 Medical Management Antihistamines Decongestants Antimicrobials Corticosteroids Tympanostomy tube insertion – preferred initial procedure Adenoidectomy – should not be performed unless a distinct indication exists  nasal obstruction, chronic adenoiditis AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113: Not recommended *may be an option when the parent or caregiver has a strong aversion to impending surgery

53 Newer Research Tubes marginally effective in Otitis Media with Effusion  Improves hearing in children who have otitis media with effusion over the short term  Outcomes within 18 months, however, are the same  Tubes have no effect on language development  Watchful waiting is a reasonable option in most of these children Rovers MM, et al.Brommets in otitis media with effusion: an individual patient data meta- analysis. Arch Dis Child 2005;90:480-5.

54 Chiropractic Care & Otitis media Evidence is promising for the potential benefit of manual procedures for children with otitis media  Improvement with manual procedures Natural course of the illness?  Fewer surgical procedures compared to usual medial care  Parent-reported positive side effects relaxation, good nap  No adverse effects were reported Hawk C, et al. Chiropractic Care for Nonmusculoskeletal Conditions: A systematic Review with Implications for Whole Systems Research. J Altern Complement Med 2007;

55 When looking at the body of evidence, it is imperative that we distinguish between AOM and otitis media with effusion…

56 Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1): Modalities Used for the Treatment of Otitis Media N=33 Consensus=24 (75%) # of DCs using modality Chiropractic adjustment of C133 Chiropractic adjustment of Occ33 Removal of dairy/wheat from diet33 Manual lymphatic drainage33 Chiropractic adjustment of C232 Supplementation with acidophilus32 Cranial adjustment of temporal bone31 Cranial adjustment of occ30 Adjustment of TMJ29 Review of child’s eating habits28 Cranial adjustment of sphenoid26 Cranial adjustment of ethmoid25

57 Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1): Modalities Used for the Treatment of Otitis Media N=33 Consensus=24 (75%) # of DCs using modality Sacral adjusting23 Garlic/mullein oil23 Echinacea/golden seal supplementation21 Review of child’s daily activities20 Eustachian tube pull18 Homeopathis medications10 Vitamin A5 Vitamin D3 Cod liver oil2 Tea tree oil2 Foot reflexology2 Education about chiropractic retracing1

58 Summary Chiropractic Management Included: Spinal adjusting (most common modality used)  Primarily Occiput, C1, C2 and cranials A significant number of non-spinal adjustment modalities Limitations: Small sample size (representative?) Does not address the efficacy of the modalities reported Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1):113-5.

59 Chiropractic Theories…

60 Index to Chiropractic Literature Saunders L. Chiropractic treatment of otitis media with effusion: a case report and literature review of the epidemiological risk factors towards the condition and that influence the outcome of chiropractic treatment. Clin Chiropr: DEC 2004(7:4) Nelson-Hassel T. Pediatric Cephalgia. J Clin Chiropr Pediatr: SUM 2004(6:2) Chiropractic Approach to the Ear. J Am Chiropractic Assoc: AUG 2002 (39:8) Chiropractic for Infants and Children. J Am Chiropractic Assoc: FEB 1999(36:2) 7-8. Boline PD, Evans RL, Sawyer CE. A feasibility study of chiropractic spinal manipulation versus sham spinal manipulation for chronic otitis media with effusion in children. J Manipulative Physiol Ther: JUN 1999(22:5) Canty A. A Mother’s Perspective. J Clin Chiropr Pediatr: AUG 1998 (3:1) 201.

61 Erb’s Palsy

62 Birth Trauma Shoulder dystocia In-utero positioning of the fetus Precipitous second stage of labor Maternal forces  contractions & pushing Video Clip available at YouTube.com Baxley EG, Gobbo RW. Shoulder Dystocia. Am Fam Physician 2004;69: Sandmire HF, De Mott RK. Erb’s palsy: concepts of causation. Obstet Gynecol 2000;95:940-2.

63 Clinical Presentation Lack of shoulder motion Arm is adducted and internally rotated Elbow extended and the forearm pronated Moro, Biceps and radial reflexes absent Normal Palmar grasp No sensory loss Ipsilateral phrenic nerve paresis (5%) Fractured clavicle Hemady N, Noble C. Newborn with Abnormal Arm Posture. AAFP. Retrieved 7 August 2007 from Laroia N. Birth Trauma. eMedicine. Retrieved 7 December 2005 from C5 & C6

64 Differential Diagnosis Klumpke's paralysis  Hand paralysis with possible ptosis, miosis, anhidrosis (Horner syndrome) Fractured clavicle  Crepitus and bony irregularity felt; occasional bruising; possibly restricted active movements with absent Moro reflex on affected side; biceps reflex present Erb's palsy  Restricted active movements and absent Moro and biceps reflexes on affected side; "porter's tip" or "waiter's tip" appearance of upper extremity Cerebral palsy  Increased upper extremity tone; exaggerated biceps reflex; hyperactive grasp reflex Fractured humerus  Restricted active movements and absent Moro reflex on affected side, biceps reflex present; crepitus may be felt Hemady N, Noble C. Newborn with Abnormal Arm Posture. AAFP. Retrieved 7 August 2007 from Laroia N. Birth Trauma. eMedicine. Retrieved 7 December 2005 from

65 Additional Workup Radiographic studies (shoulder and upper arm)  rule out bony injury Chest exam  rule out associated phrenic nerve injury Fast spin-echo MRI  minimizes need for general anesthesia  can define meningoceles; may distinguish between intact nerve roots and pseudomeningoceles (indicative of complete avulsion) CT myelography is more invasive and offers few advantages over MRI Electromyography (EMG) and nerve conduction studies are occasionally useful Hemady N, Noble C. Newborn with Abnormal Arm Posture. AAFP. Retrieved 7 August 2007 from Laroia N. Birth Trauma. eMedicine. Retrieved 7 December 2005 from

66 Management Prevent development of contractures… Partial immobilization and appropriate positioning of the upper extremity  arm is abducted to 90 degrees with external rotation at the shoulder, the forearm is supinated, and the wrist is extended slightly with the palm turned toward the face Supportive wrist splints Active and passive range-of-motion exercises should be started by the end of the first week Hemady N, Noble C. Newborn with Abnormal Arm Posture. AAFP. Retrieved 7 August 2007 from Laroia N. Birth Trauma. eMedicine. Retrieved 7 December 2005 from

67 When is a consult needed? Neurosurgical consultation should be obtained if the paralysis persists for more than 3-6 months*  Signs of nerve injury proximal to the brachial plexus may indicate more severe damage and warrant earlier consultation Electromyography and nerve conduction velocities are not reliable indicators of injury severity *Best surgical results in the 1 st year Hemady N, Noble C. Newborn with Abnormal Arm Posture. AAFP. Retrieved 7 August 2007 from Laroia N. Birth Trauma. eMedicine. Retrieved 7 December 2005 from

68 Chiropractic Management More research is needed Chiropractic adjustments vs. natural history?  Splinting  Active and passive range-of-motion exercises

69 Recovery Usually “spontaneuos”  may occur within 48 hours; can take up to 6 months Nerve laceration may result in a permanent palsy Possible long-term deficits  Progresive bony deformities  Muscle atrophy  Joint contractures  Possible impaired growth of limb  Weakness of shoulder girdle Hemady N, Noble C. Newborn with Abnormal Arm Posture. AAFP. Retrieved 7 August 2007 from Laroia N. Birth Trauma. eMedicine. Retrieved 7 December 2005 from Be cautious in predicting full recovery and closely follow affected infants!

70 Index to Chiropractic Literature Hyman C. Chiropractic adjustments and Erb’s Palsy: A case study [case report]. J Clin Chiropr Pediatr 1997; 2: Harris SL, Wood KW. Resolution of infantile Erb’s palsy utilizing Chiropractic treatment. J Manipulative Physiol Ther 1993; 16:

71 Torticollis

72 Congenital Muscular Torticollis Birth trauma with resultant hematoma formation followed by muscular contracture  Trauma to the soft tissues of the neck just before or during delivery  Breech or difficult forceps delivery Malposition in utero resulting in intrauterine or perinatal compartment syndrome  Up to 20% of children with congenital muscular torticollis have congenital dysplasia of the hip as well Saxena AK, Willital GH. Torticollis. eMedicine. Retrieved 7 August 2007 from Othee GS, Menckhoff CR. Torticollis. eMedicine. Retrieved 7 August 2007 from MOST COMMON

73 Differentials to consider… LOCAL ETIOLOGY Congenital  Pseudotumor  Hypertrophy or absence of cervical musculature  Spina bifida  Hemivertebrae  Arnold-Chiari syndrome Otolaryngologic causes  Vestibular dysfunction  Otitis media  Cervical adenitis  Pharyngitis  Retropharyngeal abscess  Mastoiditis Esophageal reflux Syrinx with spinal cord tumor LOCAL ETIOLOGY (cont’d) Traumatic causes  Birth trauma  Cervical fracture or dislocation  Clavicular fractures Juvenile rheumatoid arthritis COMPENSATORY ETIOLOGY Strabismus with fourth cranial nerve paresis Congenital nystagmus Posterior fossa tumor CENTRAL ETIOLOGY Dystonia Cerebral palsy Saxena AK, Willital GH. Torticollis. eMedicine. Retrieved 7 August 2007 from Othee GS, Menckhoff CR. Torticollis. eMedicine. Retrieved 7 August 2007 from

74 Clinical Presentation INFANT Sternomastoid tumor aka “pseudotumor”  visible, sometimes palpable swelling in the SCM  painless, hard mass (1-3 cm)  appears at 2-3 weeks  often persists until 1 year  rarely bilateral Head is tilted and flexed to the side of the fibrosis OLDER CHILDREN Tumor is less discrete  SCM appears thickened and foreshortened along its entire length Restricted rotation and lateral flexion of the neck Postural compensation:  elevate shoulder to maintain a horizontal plane of vision  twist the neck and back to maintain a straight line of sight Saxena AK, Willital GH. Torticollis. eMedicine. Retrieved 7 August 2007 from Othee GS, Menckhoff CR. Torticollis. eMedicine. Retrieved 7 August 2007 from

75 Workup Clinical examination  Palpate the entire length of the SCM Determine if fibrosis is present Generally stands out as a tight band *Alternative differential diagnoses must be considered if the muscle is neither short nor prominent Special studies  Plain film – Fracture, subluxation  CT or MRI (cervical spine) – Retropharyngeal abscess, neck masses  MRI or CT with contrast (brain) – Brain tumor  Ultrasonography  Electromyography – Define the degree of muscle or nerve involvement Saxena AK, Willital GH. Torticollis. eMedicine. Retrieved 7 August 2007 from Othee GS, Menckhoff CR. Torticollis. eMedicine. Retrieved 7 August 2007 from

76 Standard Management Parental physiotherapy  Passive stretching (90% respond within the 1 st year)  Changes in position; increase “tummy time” Surgical management is generally avoided until at least 1 year May be considered if:  Conservative methods are unsuccessful  Persistent SCM contracture limits head movement  Persistent SCM contracture accompanied by progressive facial hemihypoplasia  Other differential diagnoses have been excluded Saxena AK, Willital GH. Torticollis. eMedicine. Retrieved 7 August 2007 from Othee GS, Menckhoff CR. Torticollis. eMedicine. Retrieved 7 August 2007 from

77 Chiropractic Management Chiropractic adjustments Parental education Passive stretches Tummy time Positional changes  Car seat, sleeping,etc.

78 Secondary Effects of Untreated Torticollis Plagiocephaly  asymmetric skull deformity  flattening of occiput ~> secondary flattening of the contralateral forehead Facial hypoplasia  inhibition in the growth of the mandible and maxilla due to muscle inactivity Musculoskeletal effects  compensatory ipsilateral elevation of the shoulder  cervical and thoracic scoliosis  wasting of muscles in the neck Saxena AK, Willital GH. Torticollis. eMedicine. Retrieved 7 August 2007 from Othee GS, Menckhoff CR. Torticollis. eMedicine. Retrieved 7 August 2007 from Improve as torticollis resolves *May take years

79 Index to Chiropractic Literature Gloar CD, McWilliams JE. Chiropractic care of a six-year-old child with congenital torticollis. J Chiropr Med 2006; 5: Pederick FO. Treatment of an infant with wry neck associated with birth trauma: Case report. Chiropr J Aust 2004; 34: Smith-Nguyen EJ. Two Apporaches to Muscular Torticollis [CASE REPORT]. J Clin Chiropr Pediatr 2004; 6: Kukurin GW. Reduction of cervical dystonia after an extended course of chiropractic manipulation: a case report. J Manipulative Physiol Ther 2004; 27:

80 Plagiocephaly

81 Plagiocephaly - "oblique head” (Greek) 1. Nonsynostotic plagiocephaly positional head deformity (1/60) external pressures on the rapidly developing skull from prolonged exposure to one position 2. Synostotic plagiocephaly premature closure of the lambdoidal suture (1/100,000) Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67:

82 Etiology If present at birth… In-utero or intrapartum molding  uterine constraint multiple birth infants  birth injury forceps vacuum-assisted delivery  premature birth Craniosynostosis If it develops later… Torticollis “Back to Sleep” campaign  Since 1992 there has been a significant increase in the diagnoisis of plagiocephaly one center reported a six- fold increase ( ) Subluxation? “result of static supine positioning” Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67:

83 Examination & Workup Physical exam Palpate lambdoidal suture Check ear position Assess facial symmetry Observe unilateral bald spot Inspect by arial view Skull Radiographs and CT?  atypical skull pattern  moderate-severe skull deformity  suspecting craniosynostosis Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67: PHD Synostosis

84 Differential Diagnosis Positional Head Deformity Suture palpates WNL Ear on flat side appears more anterior Ipsilateral forehead protrudes Bald spot on side of flattening Craniosynostosis Palpable ridge Ear on flat side appears more posterior Forehead does not protrude No bald spot  no sign of external pressure Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67:

85 Management Preventive counseling Mechanical adjustments Exercises Skull modling helmets Surgery Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67: Early recognition is important Preferred position ~> torticollis Most improve within 2-3 months… If parents follow these guidelines

86 Preventive Counseling Parents should be counseled during the newborn period (2-4 weeks)  Alternate supine sleep positions (i.e. L & R occ.)  When awake and being observed, the infant should spend time in the prone position  Minimal time in car seats (when not a passenger in a vehicle) or other seating that maintains supine positioning Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67:

87 Mechanical Adjustments & Exercises Rounded side of the head is placed dependent against the mattress  Change the position of the crib in the room  Position toys, etc. to require the child to look away from the flattened side Supervised “tummy time” when the infant is awake and being observed If torticollis is present, parents should be taught specific exercises  Head rotation and lateral bend Done at each diaper change Hold 10 seconds; 3 repetitions Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67:

88 Skull-Molding Helmets Eliminates the tendency for the infant to continue to lie on the flattened area of the skull  Allows the rapidly growing skull to expand into areas unopposed by the helmet Research opinions are mixed Best results 4-12 months of age “…option for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustments and position changes.” AAP (2003) Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67:

89 Chiropractic Management Retrospective; 25 cases, mean age: 3.74 months Intervention  Chiropractic pediatric adjusting techniques Spine & extremities All 25 patients achieved complete resolution*  Mean time to full resolution months  Mean number of adjustments * Resolution All criteria for establishing the diagnosis were no longer evident and a minimum period of 4 weeks in which the subluxation complex was no longer demonstrable Davies NJ. Chiropractic management of deformational plagiocephaly in infants: An alternative to device-dependent therapy. Chiropr J Aust 2002; 32:

90 Index to Chiropractic Literature Quezada D. Chiropractic care of an infant with plagiocephaly [CASE REPORT]. J Clin Chiropr Pediatr 2004; 6: Davies NJ. Chiropractic management of deformational plagiocephaly in infants: An alternative to device-dependent therapy. Chiropr J Aust 2002; 32:

91 Headaches in Children

92 Classifying Pediatric Headaches - Etiology Primary Headaches  Migraine majority of primary childhood headaches see IHS criteria  Tension-type headaches “bandlike” sensation around the head associated with neck and/or shoulder pain can last for days may be associated with stressful events Secondary Headaches Underlying CNS pathology minority of headaches  Space-occupying lesions  Inflammation  Increased ICP  worse in the AM and improve as the day progresses  aggravated by sneezing, coughing, straining Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from

93 IHS Criteria for Migraine in Children Five or more headache attacks that: Last 1-48 hours Have at least 2 of the following features:  Bilateral or unilateral  Pulsating quality  Moderate to severe intensity  Aggravated by routine physical activities Accompanied by at least 1 of the following:  Nausea and/or vomiting  Photophobia and/or phonophobia Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4): Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from

94 Classifying Headaches – Temporal Pattern Acute Headache  single episode of head pain without history of previous events Establish whether any neurologic symptoms accompany this HA Acute-recurrent headache  pattern of head pain separated by symptom-free intervals Most commonly migraine Chronic-nonprogressive (or chronic-daily) headache  frequent or constant headache May have emotional or behavioral components; tension-type HA Mixed headache  Acute-recurrent headache (usually migraine) superimposed on a chronic-daily background pattern Chronic-progressive headache  gradual increase in frequency and severity Most ominous pattern… Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4): Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from

95 Causes of Acute Headache in Children (Differentials for the Chiropractor to Consider) URTI, w/ or w/out fever Sinusitis Pharyngitis Meningitis Migraine Hypertension Substance abuse Intoxicants (lead, CO) Medication (Ritalin, OCP, steroids) Ventriculoperitoneal shunt malfunction Brain tumor Hydrocephalus Subarachnoid hemorrhage Intracranial hemorrhage Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):

96 Causes of Chronic-Progressive Headache (Differentials for the Chiropractor to Consider) Brain tumor Hydrocephalus Pseudotumor cerebri Brain abscess Hematoma Aneurysm and vascular malformations Medications  OCP, tetracycline, vitamin A (high doses) Intoxication (lead) Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):

97 Must consider a possible underlying pathologic process if…  Worsening of headache severity and/or frequency (especially rapid progression)  Significant change in a previously diagnosed headache syndrome  Failure of an adequate trial of therapy Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from

98 Physical Exam Vitals (include BP and temperature) Head and neck exam  Sinus tenderness  Thyromegaly  Nuchal rigidity  Head circumference (increased ICP) Skin  Signs of neurocutaneous syndrome ~> intracranial tumors Neurofibromatosis & tuberous sclerosis Detailed neurological exam Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):

99 A Detailed Neurological Exam is Essential! Altered mental status Abnormal eye movements Optic disc distortion Motor or sensory asymmetry Coordination disturbances Abnormal DTR’s Studies have shown that nearly “all children with serious underlying conditions had one or more objective findings on neurologic exam.” Key features of intracranial disease Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):

100 Advanced Imaging, Other Studies? CT/MRI indicated in patients with:  Chronic progressive HA pattern OR  Abnormal findings in the neurological exam “Neuroimaging studies should not be performed routinely.” Lumbar puncture Blood cultures Sinus radiography Psychologic evaluation May also be considered Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4): Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from

101 When is CT/MRI indicated? HIGH PRIORITY Acute headache Worst headache of life Thunderclap headache Chronic progressive pattern Focal neurological symptoms Abnormal neurological exam Papilledema Abnormal eye movements Hemiparesis Ataxia Abnormal reflexes Presence of ventriculoperitoneal shunt Presence of neurocutaneous syndrome Age younger than 3 years MODERATE PRIORITY Headaches or vomiting on awakening Unvarying location of headache Meningeal signs Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):

102 When is a neurological consult indicated? May depend on the doctor’s experience and confidence… Children <3 years  Rarely have primary headache syndrome  Neurologic & fundoscopic exam can be difficult Acute headache w/ focal neurologic symptoms/signs  Neuroimaging should be performed Chronic-progressive headaches  Associated w/ increased ICP Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):

103 Management of Primary Headache Once determined, reassure that the headache is not due to brain tumor or CNS pathology… Quiet, dark room Sleep Manage stress  Encourage family to develop a “schedule”  Relaxation techniques  Biofeedback  Psychotherapy Diet (avoid triggers) Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4): Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from CHIROPRACTIC

104 Chiropractic Management “Cervicogenic headache” “Headaches of spinal etiology” Migraine and tension headache have been associated with musculoskeletal dysfunction of the neck Tension-type headache  Decreased lordosis of the C spine associated w/ excessive suboccipital muscle tension Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002.

105 Index to Chiropractic Literature Luellen J. Chiropractic Care of Adolescent Migraine Headache [Case Report]. J Clin Chiropr Pediatr: SUM 2004(6:2) Nelson Hassel T. Pediatric Cephalgia [Case Report]. J Clin Chiropr Pediatr: SUM 2004(6:2) Knutson GA. Vectored Upper Cervical Manipulation for Chronic Sleep Bruxism, Headache, and Cervical Spine Pain in a Child. J Manipulative Physiol Ther: JUL/AUG 2003(26:6) Online Access only 3P. Lisis AJ, Dabrowski Y. Chiropractic Spinal Manipulation for Cervicogenic Headache in an 8-year-old. JNMS: FALL 2002(10:3) Anderson-Peacock ES. Chiropractic Care of Children with Headaches: Five Case Reports. J Clin Chiropr Pediatr: JAN 1996(1:1) Hewitt EG. Chiropractic Care of a 13-year-old with Headache and Neck Pain: A Case Report. J Can Chiropr Assoc: SEP 1994(38:3)

106 Back Pain in Children

107 Causes of Back Pain in Children (Differentials for the Chiropractor to Consider) Pre-Pubertal Infectious  Diskitis  Osteomyelitis Tumors  Spinal column  Spinal cord Trauma  Falls  MVA  Some pars defects Pubertal Tumors  Spinal column or cord Trauma  Spondylolysis/lysthesis  Disc herniation  Lumbar strain/sprain Idiopathic  Scheuermann’s disease Inherited disorders  Asynchromous spinal development (facet tropism) Adapted from: D'Alessandro MP. Back Pain in Children. Retreived 1 March 2007 from

108 Risk Factors for Back Pain in Children Age (>12) Females MC than males Extended TV watching Sports participation  volleyball, climbing, golf, basketball, gymnastics Previous back injury Sitting at school Carrying back packs  worse if carried in hand or on one shoulder vs. on their backs Familial tendency  asynchronous vertebral bone growth? Presented by Fysh P at that 2006 ICA Conference on Pediatrics: Troussier B, et al. Back pain in school children: A study among 1178 pupils. Scan J Rehab Med, 1994 (26):

109 Evaluation History  Mechanism of injury  Exacerbating factors  Frequency, duration & severity of the pain Kids can be poor historians… Establish a time-line using events (birthdays, holidays) Inquire about specific tasks (climbing stairs, running) to help identify neurological changes Ask the parents, teachers, other caregivers… Davies NJ. Chiropractic Pediatrics. London: Churchill Livingstone, Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

110 Inspection  Cutaneuos lesions (café-au-lait spots, dermal cysts, hairy patches) may suggest spinal anomoly or tumor Postural examination  Scoliosis, kyphosis Gait analysis Trunk & hamstring flexibility Neurological exam  Motor strength (squatting, heel- and toe-walking)  Sensory  DTR’s  Nerve root impingement  Upper motor neuron signs Davies NJ. Chiropractic Pediatrics. London: Churchill Livingstone, Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

111 When are x-rays indicated? Lab studies? Radiographic evaluation is essential Rule out pathology Diagnosis and choice of appropriate adjusting protocol frequently depends on the radiographic findings  eg. spondylolisthesis vs. facet tropism Lab studies may also be useful Elevated white count or sedimentation rate (infection, leukemia) Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November D'Alessandro MP. Back Pain in Children. Retreived 1 March 2007 from

112 7 Warning Signs for Pediatric Back Pain 1.Child is <4 years old Infection or neoplasm are common causes of back pain in this age group 2.Back pain causes a functional disability Children like to play, if the pain causes them to ask to miss sports, gym or recess, the pain is serious 3.Duration >4 weeks Musculoligamentous injuries should resolve in that time 4.Fever is present Suggests infection; osteomyelitis should be ruled out 5.Antalgic posture Disc herniation (not common in children); can be associated with bone tumor pain (osteoid osteoma) 6.Neurologic abnormality 7.Limitation of motion due to pain D'Alessandro MP. Back Pain in Children. Retreived 1 March 2007 from

113 Back pain was traditionally considered an uncommon complaint among children and therefore doctors have been inclined to use every available test to reach a diagnosis. It is now recognized that there are many cases of back pain in children associated with less serious conditions and the doctor of chiropractic must be able to distinguish between the two. Feldman DS, et al. Evaluation of an algorithmic aproach to pediatric back pain. J Pediatr Orthop May-Jun;26(3):353-7.

114

115 A look at chiropractic management…  The most common causes of LBP in children include: Schuermann’s disease Facet tropism Spondylolysis Spondylolysthesis Musculoligamentous injury (vertebral subluxation) Presented by Fysh P at that 2006 ICA Conference on Pediatrics: Duggleby T, Kumar S. Epidemiology of Juvenille Low Back Pain – a Review. Disability and Rehabilitation (12):

116 Scheuermann’s Signs/Symptoms  Fatigue & pain in the upper back  Exaggerated mid-thoracic kyphosis, cervical and lumbar lordosis and anterior pelvic tilt Diagnosis  X-ray: anterior vertebral body wedging, loss of disc height and irregularity of the vertebral end-plates (3 or more adjacent vertebrae) Management  Adjustments and soft tissue therapy  Stretch hamstrings & strengthen abdominal muscles  Strengthening exercises for the back Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, & Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

117 Facet Tropism Signs/Symptoms  Specific site of palpable tenderness in the lumbar region Diagnosis  X-ray: sagittally oriented facet which correlates w/ the side and level of pain (L4/5, L5/S1 normally coronal)  Essentially a lumbar lig. sprain; overuse; facet syndrome Management  Adjustments Avoid the sagittal facet - already hypermobile Side posture may exacerbate symptoms; should be avoided  Strengthening exercises (abdominals)  Short-term limitation of activities Avoid hyperextension and rotation of the lumbar spine Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002.

118 Spondylolysis Signs/Symptoms  LBP aggravated by activity; asymptomatic in some cases  Increased lumbar lordosis, hamstring tightness, gait abnormalities Diagnosis  X-ray: A-P, lat., & oblique CT, MRI or bone scan may be necessary  Uni- or bilateral, acquired interruption of the pars; stress Fx Management  If acute, bed-rest and restriction of activities Allow Fx to heal before displacement occurs  Radiographic follow-up yearly to assess progression Every 6 months in the adolescent (increased risk of slippage) Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002.

119 Spondylolisthesis Signs/Symptoms  Often asymptomatic in children  During or after growth spurt: dull ache in the LB, buttocks and thighs during or after physical activity  Flattening of the post. sacrum and pelvis, shortening of the trunk, forward translation of the chest, lumbar hyperlordosis, changes in gait Diagnosis  X-ray: anterior vertebral slippage Myerding grading (1-5) Management  Grades 1-2: carefully supervise activities  Grades 3+: refer for evaluation for possible surgery Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002.

120 Musculoligamentous Injury - Subluxation Subluxation is the most common cause of back pain seen in the chiropractor’s office The chiropractor must, however, be careful to include all possible differentials in their clinical thinking…  Avoid prolonged, painful, frustrating, expensive programs of care d/t inaccurate diagnosis Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

121 Index to Chiropractic Literature The Chiropractic Century: Backpack Alert; Sandman Triathalon. J Am Chiropr Assoc: JAN 2003(40:1): Hayden JA, Mior SA, Verhoef MJ. Evaluation of Chiropractic Management of Pediatric Patients with Low Back Pain: A Prospective Cohort Study. J Manipulative Physiol Ther: JAN 2003(26:1): 1-8. Devonshire, Zielonka K, King L, Mior SA. Adolescent Lumbar Disc Herniation: A Case Report. J Can Chiropr Assoc: MAR 1996(40:1): Kent C. Radiology in Pediatric Spine Pain. Chiropr Pediatr: APR 1994(1:1): 7-12 Kent C. Pediatric Back Pain: Imaging OCnsiderations. ICA Rev: NOV/DEC 1991(47:6):


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