Presentation on theme: "ABC’s Of Pediatric Adjusting"— Presentation transcript:
1 ABC’s Of Pediatric Adjusting Modifications for the Pediatric PatientStephanie C. O’Neill, DC, DICCP
2 “Wellness Care” Fysh recommends spinal check-ups for school-aged children, at least every 3 monthsfor pre-school children, at least every 2 monthsfor infants in the first 2 years of life, at least every month
3 Determining Visit Frequency Several things should be taken into account:Historyphysical, chemical, and/or mental trauma will increase the likelihood s/he will require a higher frequencyExamination findingsLifestyle, activity and stress levels
4 Joan Fallon The Child Patient: A Matrix for Chiropractic Care published as a supplement to JCCP(Vol. 6, No. 3)
5 Overview Assessing the pediatric patient Unique features of the pediatric spineAdapting your techniqueComfort and Safety
8 McMullen Reverse Fencer <6 months oldless accurate once the child gains strength and control of the cervical spine musculatureMcMullen M. Assessing Upper Cervical Subluxations in Infants Under Six Months- Utilizing the Reverse Fencer Response. ICA International Review of Chiropractic. March/April;1990,39-41.
9 Reverse Fencer- Part 1 Heel swing: Hold infant upside down, making sure to have a solid grip on their anklesRelease one foot slowly, watch the child‘s head turn to that sideRepeat on other side
10 Congenital Hip Dysplasia WARNING!Before you suspend a child by their legs you must rule out hip instability.Congenital Hip Dysplasia
11 Reverse Fencer- Part 1 Heel swing (cont‘d): Compare motion from side to siderestricted? twitching?
12 What if...? Child arches backwards (opisthotonis) meningeal tension What do you do?Adjust them...upper C spine, occiput, sacrum
13 “He‘s so strong, he can hold his head up already...” Infant pulls away when you hold them against your shoulderOnly comfortable in the “football hold”Problems breastfeeding/sleepingEtc…
14 Reverse Fencer-Part 2 Acetabular pump: Infant supine, apply pressure along the shaft of the femur into the acetabular fossaCompare the resistance on each sideThe “spongy“ side is said to be the side of atlas laterality
15 Interpreting your findings... “a negative response (heel swing) indicates a subluxation complex between the atlas-axis or atlas-occ. on that side“
16 Interpreting your findings... Differentiating b/w atlas and occ.Dr. McMullen suggests that you look at the Acetabular Pump findingsspongy side=atlas lateralityeven=occiput
17 Supine Leg Check Lay the infant supine Gently straighten the legs make sure that the head is in a neutral positionCompare medial malleoli, fat folds at the knee, etc.Long leg side is “said to be“ theside of atlas laterality...
21 Atlas fossa reading DT-25 is used to measure atlas fossa temperatures hold 1/4“ away from the skinrepeat 3x each sideRemember to take into consideration the way the child was being held, sitting in the sun in the car seat, etc.
22 Atlas fossa readingThe cold side is “said to be“ the side of atlas laterality...More likely, it tells us there is an imbalance
23 What if…? Atlas fossa: R 85 L86 No other findings in the cervical spine_ _ _ _ _ _
24 What if…? Atlas fossa: R 85 L86 No other findings in the cervical spineS A C R U M
25 Posture analysis Head tilt Head rotation High shoulder Scoliosis High iliumGenu varus and valgumInternal & extenal foot rotation
26 Normal DevelopmentNormal evolution from bowlegs to knock-knees to normal valgus2 years 3 years years
27 TOE-IN TOE-OUT EX ilium IN ilium Inward tibial or femoral torsion Weak psoas or Glut. maxPsoas, piriformis or Glut. Max spasmCP (bilat)
28 Static Palpation Taut and tender fibers Muscle spasm common with congenital torticollisSudoriferous changesstickiness/drynessTemperature
29 Pay attention to the child! They’ll let you know…squirmingfussinessclutching at your handetc.
30 Just because it sticks out doesn‘t mean it‘s subluxated! Clinical NoteJust because it sticks out doesn‘t mean it‘s subluxated!
31 For ExampleL1 is often prominant in infants (similar to the adult‘s T4) but it is not always fixedYou must evaluate the motion, feel for springiness, T&T fibers, sudoriferous changes, instumentation findings, etc.
32 Motion palpation Similar to adults but much more subtle Be creative! ligament laxity, cartilagenous vertebraeBe creative!
33 Gross Range of Motion Can be evaluated by “playing“ with them Can they bend in half forward?Can they bend ear to foot equally on both sides?Can they cross shoulder to opposite foot comfortably?Remember, newborns should be flexible!
34 Sacrum and Pelvis Gluteal Cleft Deviation Sacral Dimples Dangling legs Gluteal Folds
35 Gluteal Cleft CheckPinch cheeks togetherCleft should be midline
36 Gluteal Cleft Deviation If it deviates...may either be to the side of posterior-inferior sacroiliac subluxation (P-R, PI-R, P-L, PI-L) or to the side of anterior-inferior sacral movement at the lumbosacral junction(Fysh, 2002)
37 Sacral DimplesAsymmetry (with fixation of SI joints) suggests pelvic misalignmentPalpate S2 to PSIS
38 Other things to note... Dangling legs Gluteal fold observation ilium rotationGluteal fold observationsacral tilts
39 Older Babies and Toddlers As they start to be mobile, you have to become more creative...Do they have to be on a table to get adjusted?Follow them as they crawl, play, etc.
40 Toddlers & School Aged Kids “Flying Airplane”Child lays on their tummy(table, dad’s lap, your lap…)Have them hold their arms out like wingsYou lift both legs and go through motion palpation of lumbars ~> thoracics
41 Toddlers Want to be in control of their world important to respect their need for autonomy but you also have to maintain control of the interactionGive them choices between 2 acceptible options“Do you want to lay on your front or on your back?“NOT“Do you want to get adjusted?“
48 Joint End PlayDetermined by the degree of flexibility and elasticity of a jointIncreased in childrenSome say that…“Spinal adjusting in the pediatric spine should be performed at a point somewhat before the end of the passive range is reached.”
49 Motion Joints of Lushka/Uncovertebral Joints Function: begin to develop between 6-9 years of age(are complete at age 18)Function:guide the coupled motion of rotation and lateral flexion, limiting side bending
50 Chiropractic Care for the Pediatric Patient, Fysh Pediatric TechniqueChiropractic Care for the Pediatric Patient, Fysh
51 Adjusting Considerations Minimize excessive range of motion/forcesReduce depth of thrustC-spine: lat bend and minimum rotation (30 degrees)Sometimes, pre-stress can effect a correction...Specificity
52 Contact Points Pediatric vertebrae are much smaller cervical spine of a newborn is <2 inches in lengthHigh degree of specificity is requiredPad of the finger-tip or thumb tip
53 Occiput Findings Fixation between Co/C1* Increased tension in suboccipital musclesunilateral/bilateral*If significantly fixed, infant may become irritable even with light palpation
54 Occiput (AS) Correction Light cephalad traction with the fingertips When released, infant becomes relaxed & may even fall asleep
55 AtlasFindingsFixation at C1We’ll add…T&TInstrumentationEtc.
56 AtlasCorrectionPlace lateral tip of the index finger against the prominent C1 transverseLaterally bend to the side of contact until end-rangeA quick, light, low-amplitude thrust is delivered to the tip of the C1 transverse toward the neutral position*Not uncommon for a young baby to cry seconds(stimulate Moro response)
58 Clinical NoteCompared with C1, rotation of C2-C7 is significantly reducedC1/C2 40 degreesC2/C3 3 degreesC7/T1 2 degreesTherefore, C2 and C7 are prone to subluxation with end-range rotation of the head
59 C2 – C7FindingsMuscle spasm – usually side of spinous process deviationFixation – spinous does not move away with lateral bend
60 C2 – C7 Correction Tip of index finger on articular pillar Rotate head degreesLaterally bend the neck over contact fingerIf no release is felt, apply a light thrust
61 Thoracic Spine – Infant & Child Prone thoracic adjustingIf the child will not lie quietly in the prone position (lifting head, extending trunk)…Move infant to edge of the table, supporting the legs over the edgeDoctor can flex the abdomen over the table’s edge to induce a normal thoracic curveInfant upright, chest to chest with doctor or parentInfant lying prone on top of parent
62 ThoracicsCorrectionDTH - thumbs on either side of the spinous processAnterior adjustingNot recommended for children under 3 years of ageFlexible rib cage
63 L1 – L3 Sagittal plane, facet joints Correction Contact mammillary process with a light thumb contactP-A, I-S thrust
64 L4 – L5CorrectionContact the spinous process (side of spinous rotation) with a light thumb contactApply light pressure over the contralateral mammilary process (stabilization)Thrust toward the spinous process*Side Posture: infants >12 months
65 Sacro-iliac Correction Prone or side posture Light adjustive thrust Direction appropriate to correct PI, AS, In or Ex
66 ReferencesAnrig & Plaugher. Pediatric Chiropractic. Baltimore, MD: Lippincott Williams & Wilkins, 1998.Anrig-Howe C. Scientific Ramifications for Providing Pre-natal and Neonate Chiropractic Care. The American Chiropractor, 1993; May/June:Fallon. Textbook on Chiropractic and Pregnancy. Arlington, VA: International Chiropractors Association, 1994.Forrester J. Chiropractic Management of Third Trimester In-utero Constraint. Canadian Chiropractor, 1997; 2(3): 8-13.Fysh. Chiropractic Care for the Pediatric Patient. Arlington VA: ICACCP, 2002.Kunau P. Application of the Webster In-utero Constraint Technique: A Case Series. Journal of Clinical Chiropractic Pediatrics, 1998; 3(1):McMullen M. Assessing upper Cervical Subluxations in Infants Under Six Months. ICA International Review of Chiropractic, 1990; March/April: 39-41Pistoles R. The Webster Technique: A Chiropractic Technique with Obstetric Implications. JMPT, 2002; 25(6).Webster L. Chiropractic Care During Pregnancy. Today’s Chiropractic, 1982; Sept/Oct: