Chiropractic Management of Common Conditions

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) 1341-8.
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) 1341-8.
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) 1341-8.
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
2005711059-68.
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) 1341-8.
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 200713
491-512.
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
2005711059-68.
10
What is the Total Package?

• What does the average chiropractor do when a
  patient presents with asthma as a primary
  complaint?

11

• Represented 10 different chiropractic schools
• Average of 8 years in practice

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.
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)113-5.
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) 1341-8.
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 lt50)?
• For more ideas http//www.aaaai.org

Kenp JP, Kemp JA. Management of Asthma in
Children. Am Fam Physician 2001 63(7) 1341-8.
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

Schetchikova NV. Asthma An Enigma Epidemic ,
Part II-Asthma Treatment. J Am Chiropr Assoc
JUL 2003 (407) 30-37.
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 (407) 30-37.
19
Index to Chiropractic Literature

• Gibbs AL. Chiropractic co-management of
  medically treated asthma. Clin Chiropr SEP
  2005(83) 140-144.
• 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
  (OCT18) Online access only 23p.
• Schetchikova NV. Asthma An Enigma Epidemic
  (Part 1). J Am Chiropr Assoc June 2003 (406)
  22-29.
• Schetchikova NV. Asthma An Enigma Epidemic ,
  Part II-Asthma Treatment. J Am Chiropr Assoc
  JUL 2003 (407) 30-37.
• Blum CL. Role of chiropractic and sacro-
  occipital technique in asthma treatment. J
  Chiropr Med MAR 2002(11) 16-22.
• Clinical Trial Asthmatics and Chiropractic. J
  Am Chiropr Assoc FEB 2001 (382)46-47.
• Wellness Alert Hold Your Breath. J Am Chiropr
  Assoc MAR 2001(383) 30-38.

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, OBrien JG. Infantile
Colic. Am Fam Physician 2004 70(4) 735-40.
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, OBrien JG. Infantile
Colic. Am Fam Physician 2004 70(4) 735-40.
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, OBrien JG. Infantile
Colic. Am Fam Physician 2004 70(4) 735-40.
24
Organic Causes?lt5 of infants presenting with
excessive crying

• CNS
• CNS abnormality (Chiari type I malformation)
• Infantile migraine
• Subdural hematoma
• Gastrointestinal
• Constipation
• Cows 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, OBrien JG. Infantile
Colic. Am Fam Physician 2004 70(4) 735-40.
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, OBrien JG. Infantile
Colic. Am Fam Physician 2004 70(4) 735-40.
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, OBrien JG. Infantile
Colic. Am Fam Physician 2004 70 735-40.
Garrison MM, Christakis DA. A Systematic Review
of Treatments for Infant Colic. Pediatrics 2000
106184-90.
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, OBrien JG. Infantile
Colic. Am Fam Physician 2004 70 735-40.
Garrison MM, Christakis DA. A Systematic Review
of Treatments for Infant Colic. Pediatrics 2000
106184-90.
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
2007119e124-30. Roberts DM, Ostapchuk M,
OBrien JG. Infantile Colic. Am Fam Physician
200470735-40.
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 200713
491-512.
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(63) 419-423.
• Hipperson AJ. Chiropractic management of
  infantile colic. Clin Chiropr DEC 2004 (74)
  180-186.
• Hewitt EG. Chiropractic care and the irritable
  infant. J Clin Chiropr Pediatr SUM 2004(62)
  394-397.
• Leach RA. Differential compliance instrument in
  the treatment of infantile colic a report of two
  cases. J Manipulative Physiol TherJAN
  2002(251) 58-62.
• Nilsson N, Wiberg JMM. Infants with colic may
  have had a faster delivery a short preliminary
  report. J Manipulative Physiol TherMAR/APR
  2000(233) 208-210.
• Working with young patients. J Am Chiropr
  AssocFEB 1999 (362) 12-15.

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 671499-506,1509-10.
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 671499-506,1509-10.
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 671499-506,1509-10.
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 671499-506,1509-10.
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 671499-506,1509-10.
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 671499-506,1509-10.
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 671499-506,1509-10.
39
Nonpharmacologic Management

• Positive Reinforcement Systems
• earns points for every night he or she remains
  dry gt 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

More research is needed but they have been shown
to have positive effects
Thiedke CC. Nocturnal Enuresis. Am Fam
Physician 2003 671499-506,1509-10.
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 200713
491-512.
41
Index to Chiropractic Literature

• McCormick J. Improvement in nocturnal enuresis
  with chiropractic care A case study. J Clin
  Chiropr Pediatr2006(71) 464-465.
• Bachman TR, Lantz CA. Management of pediatric
  asthma and enuresis with probable traumatic
  etiology. ICA Rev JAN/FEB 1995(511) 44-46.
• Marko RB. Bed-Wetting Two case studies.
  Chiropr Pediatr APR 1994(11) 21-22.
• Langely C. Epileptic seizures, nocturnal
  enuresis, ADD. Chiropr Pediatr APR 1994 (11)
  22.
• Bomerth PR. Functional nocturnal enuresis. J
  Manipulative Physiol TherNOV/DEC 1994(179)
  596-600.
• Aker PD, Kreitz BG. Nocturnal Enuresis
  Treatment implications for the chiropractor. J
  Manipulative Physiol Ther SEP 1994(177) 465-473.

42
Otitis
43
Diagnosis of AOM

• Recent, usually abrupt, onset of signs and
  symptoms of middle-ear inflammation and MEE.
• The presence of MEE that is indicated by any of
  the following
• Bulging of the tympanic membrane
• Limited or absent mobility of the tympanic
  membrane
• Air fluid level behind the tympanic membrane
• Otorrhea
• Signs or symptoms of middle-ear inflammation as
  indicated by either
• Distinct erythema of the tympanic membrane OR
• Distinct otalgia (discomfort clearly referable to
  the ears 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. 2004113(5)1451-65.
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 2052-6.
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
• lt 6 months of age
• Severe illness (fever of gt102.6, severe ear pain)

AAP and AAFP Clinical Practice Guideline
Diagnosis and Management of Acute Otitis Media.
Pediatrics 20041131451-65. Garbutt J, et al.
Diagnosis and Treatment of Acute Otitis Media An
Assessment. Pediatrics 2003112,143-9.
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?
• lt2years 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 20062961235-41. Rovers
MM, et al. Antibiotics for acute otitis media a
eta-analysis with individual patient data. Lancet
20063681492-35.
47
Reducing Risk Factors

• Breastfeeding
• Minimum of 6 months
• If bottle-fed, avoid supine bottle feeding
• Reduce or eliminate pacifier use (gt6 months)
• Daycare increased incidence of URTI
• Tobacco smoke

AAP and AAFP Clinical Practice Guideline
Diagnosis and Management of Acute Otitis Media.
Pediatrics. 2004113(5)1451-65.
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 20041131412-29..
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 20041131412-29..
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 20041131412-29..
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 20041131412-29..
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

• Not recommended
• may be an option when the parent or caregiver
  has a strong aversion to impending surgery

AAP Clinical Practice Guideline Otitis Media
with Effusion. Pediatrics 20041131412-29..
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 200590480-5.
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 200713
491-512.
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)113-5.
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)113-5.
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(74)168-173.
• Nelson-Hassel T. Pediatric Cephalgia. J Clin
  Chiropr Pediatr SUM 2004(62) 383-386.
• Chiropractic Approach to the Ear. J Am
  Chiropractic Assoc AUG 2002 (398) 12-14.
• Chiropractic for Infants and Children. J Am
  Chiropractic Assoc FEB 1999(362) 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(225) 292-298.
• Canty A. A Mothers Perspective. J Clin Chiropr
  Pediatr AUG 1998 (31) 201.

61
Erbs 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 2004691707-14. Sandmire HF, De Mott
RK. Erbs palsy concepts of causation. Obstet
Gynecol 200095940-2.
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

C5 C6
Hemady N, Noble C. Newborn with Abnormal Arm
Posture. AAFP. Retrieved 7 August 2007 from
http//www.aafp.org/afp/20060601/photo.html.
Laroia N. Birth Trauma. eMedicine. Retrieved 7
December 2005 from http//www.emedicine.com/ped/to
pic2836.htm.
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
http//www.aafp.org/afp/20060601/photo.html.
Laroia N. Birth Trauma. eMedicine. Retrieved 7
December 2005 from http//www.emedicine.com/ped/to
pic2836.htm.
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
http//www.aafp.org/afp/20060601/photo.html.
Laroia N. Birth Trauma. eMedicine. Retrieved 7
December 2005 from http//www.emedicine.com/ped/to
pic2836.htm.
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
http//www.aafp.org/afp/20060601/photo.html.
Laroia N. Birth Trauma. eMedicine. Retrieved 7
December 2005 from http//www.emedicine.com/ped/to
pic2836.htm.
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 1st year

Hemady N, Noble C. Newborn with Abnormal Arm
Posture. AAFP. Retrieved 7 August 2007 from
http//www.aafp.org/afp/20060601/photo.html.
Laroia N. Birth Trauma. eMedicine. Retrieved 7
December 2005 from http//www.emedicine.com/ped/to
pic2836.htm.
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
http//www.aafp.org/afp/20060601/photo.html.
Laroia N. Birth Trauma. eMedicine. Retrieved 7
December 2005 from http//www.emedicine.com/ped/to
pic2836.htm.
70
Index to Chiropractic Literature

• Hyman C. Chiropractic adjustments and Erbs
  Palsy A case study case report. J Clin
  Chiropr Pediatr 1997 2 157-160.
• Harris SL, Wood KW. Resolution of infantile
  Erbs palsy utilizing Chiropractic treatment. J
  Manipulative Physiol Ther 1993 16 415-418.

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 http//emedicine.com/
ped/topic2998.htm. Othee GS, Menckhoff CR.
Torticollis. eMedicine. Retrieved 7 August 2007
from http//emedicine.com/orthoped/topic452.htm.
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 (contd)
• 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 http//emedicine.com/
ped/topic2998.htm. Othee GS, Menckhoff CR.
Torticollis. eMedicine. Retrieved 7 August 2007
from http//emedicine.com/orthoped/topic452.htm.
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 http//emedicine.com/
ped/topic2998.htm. Othee GS, Menckhoff CR.
Torticollis. eMedicine. Retrieved 7 August 2007
from http//emedicine.com/orthoped/topic452.htm.
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 http//emedicine.com/
ped/topic2998.htm. Othee GS, Menckhoff CR.
Torticollis. eMedicine. Retrieved 7 August 2007
from http//emedicine.com/orthoped/topic452.htm.
76
Standard Management

• Parental physiotherapy
• Passive stretching (90 respond within the 1st
  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 http//emedicine.com/
ped/topic2998.htm. Othee GS, Menckhoff CR.
Torticollis. eMedicine. Retrieved 7 August 2007
from http//emedicine.com/orthoped/topic452.htm.
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 gt 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

Improve as torticollis resolves May take years
Saxena AK, Willital GH. Torticollis. eMedicine.
Retrieved 7 August 2007 from http//emedicine.com/
ped/topic2998.htm. Othee GS, Menckhoff CR.
Torticollis. eMedicine. Retrieved 7 August 2007
from http//emedicine.com/orthoped/topic452.htm.
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 65-68.
• Pederick FO. Treatment of an infant with wry neck
  associated with birth trauma Case report.
  Chiropr J Aust 2004 34 123-128.
• Smith-Nguyen EJ . Two Apporaches to Muscular
  Torticollis CASE REPORT. J Clin Chiropr Pediatr
  2004 6 387-393.
• Kukurin GW. Reduction of cervical dystonia after
  an extended course of chiropractic manipulation
  a case report. J Manipulative Physiol Ther 2004
  27 421-426.

80
Plagiocephaly
81
Plagiocephaly - "oblique head (Greek)

• Nonsynostotic plagiocephaly
• positional head deformity (1/60)
• external pressures on the rapidly developing
  skull from prolonged exposure to one position
• Synostotic plagiocephaly
• premature closure of the lambdoidal suture
  (1/100,000)

Biggs WS. Diagnosis and Management of Positional
Head Deformity. Am Fam Physician 2003671953-6.
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
  (1992-1994)
• Subluxation?
• result of static supine positioning

Biggs WS. Diagnosis and Management of Positional
Head Deformity. Am Fam Physician 2003671953-6.
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

PHD Synostosis
Biggs WS. Diagnosis and Management of Positional
Head Deformity. Am Fam Physician 2003671953-6.
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 2003671953-6.
85
Management

• Preventive counseling
• Mechanical adjustments
• Exercises
• Skull modling helmets
• Surgery

Most improve within 2-3 months If parents
follow these guidelines
Biggs WS. Diagnosis and Management of Positional
Head Deformity. Am Fam Physician 2003671953-6.
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 2003671953-6.
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 2003671953-6.
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 2003671953-6.
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 - 3.64 months
• Mean number of adjustments - 1.8
• 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 52-55.
90
Index to Chiropractic Literature

• Quezada D. Chiropractic care of an infant with
  plagiocephaly CASE REPORT . J Clin Chiropr
  Pediatr 2004 6 342-348.
• Davies NJ. Chiropractic management of
  deformational plagiocephaly in infants An
  alternative to device-dependent therapy. Chiropr
  J Aust 2002 32 52-55.

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
www.emedicine.com/neuro/topic528.htm
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 200265(4)625-32.Lopez JI.
Headache Pediatric Perspectives. eMedicine.
Retrieved 1 March 2007 from www.emedicine.com/neur
o/topic528.htm
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 200265(4)625-32.Lopez JI.
Headache Pediatric Perspectives. eMedicine.
Retrieved 1 March 2007 from www.emedicine.com/neur
o/topic528.htm
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 200265(4)625-32.
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 200265(4)625-32.
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
www.emedicine.com/neuro/topic528.htm
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 gt intracranial
  tumors
• Neurofibromatosis tuberous sclerosis
• Detailed neurological exam

Lewis DW. Headaches in Children and Adolescents.
J Am Fam Phys 200265(4)625-32.
99
A Detailed Neurological Exam is Essential!

• Altered mental status
• Abnormal eye movements
• Optic disc distortion
• Motor or sensory asymmetry
• Coordination disturbances
• Abnormal DTRs
• 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 200265(4)625-32.
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 200265(4)625-32.Lopez JI.
Headache Pediatric Perspectives. eMedicine.
Retrieved 1 March 2007 from www.emedicine.com/neur
o/topic528.htm
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 200265(4)625-32.
102
When is a neurological consult indicated?

• May depend on the doctors experience and
  confidence
• Children lt3 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 200265(4)625-32.
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 200265(4)625-32.Lopez JI.
Headache Pediatric Perspectives. eMedicine.
Retrieved 1 March 2007 from www.emedicine.com/neur
o/topic528.htm
104
Chiropractic ManagementCervicogenic
headacheHeadaches 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(62) 403-405.
• Nelson Hassel T. Pediatric Cephalgia Case
  Report. J Clin Chiropr Pediatr SUM 2004(62)
  383-386.
• 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(266) Online Access only 3P.
• Lisis AJ, Dabrowski Y. Chiropractic Spinal
  Manipulation for Cervicogenic Headache in an
  8-year-old. JNMS FALL 2002(103) 98-103.
• Anderson-Peacock ES. Chiropractic Care of
  Children with Headaches Five Case Reports. J
  Clin Chiropr Pediatr JAN 1996(11) 18-27.
• Hewitt EG. Chiropractic Care of a 13-year-old
  with Headache and Neck Pain A Case Report. J
  Can Chiropr Assoc SEP 1994(383) 160-162.

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
• Scheuermanns disease
• Inherited disorders
• Asynchromous spinal