ABCs Of Pediatric Adjusting

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ABCs Of Pediatric Adjusting

• Modifications for the Pediatric Patient

• Stephanie C. ONeill, DC, DICCP

2
Wellness Care

• Fysh recommends spinal check-ups
• for school-aged children, at least every 3 months
• for pre-school children, at least every 2 months
• for infants in the first 2 years of life, at
  least every month

3
Determining Visit Frequency

• Several things should be taken into account
• History
• physical, chemical, and/or mental trauma will
  increase the likelihood s/he will require a
  higher frequency
• Examination findings
• Lifestyle, 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)
• www.icapediatrics.com

5
Overview

• Assessing the pediatric patient
• Unique features of the pediatric spine
• Adapting your technique
• Comfort and Safety

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Newborn Evaluation

• Where do you start?

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Newborn Evaluation

• Reverse Fencer Maneuver
• Heel swing
• Acetabular pump
• Supine Leg Check
• Instrumentation - atlas fossa reading
• Posture analysis
• Static Palpation
• Motion palpation

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McMullen Reverse Fencer

• lt6 months old
• less accurate once the child gains strength and
  control of the cervical spine musculature
• McMullen M. Assessing Upper Cervical
  Subluxations in Infants Under Six Months-
  Utilizing the Reverse Fencer Response. ICA
  International Review of Chiropractic.
  March/April1990,39-41.

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Reverse Fencer- Part 1

• Heel swing
• Hold infant upside down, making sure to have a
  solid grip on their ankles
• Release one foot slowly, watch the childs head
  turn to that side
• Repeat on other side

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WARNING!

• Before you suspend a child by their legs you
  must rule out hip instability.
• Congenital Hip Dysplasia

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Reverse Fencer- Part 1

• Heel swing (contd)
• Compare motion from side to side
• restricted? twitching?

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What if...?

• Child arches backwards (opisthotonis)
• meningeal tension
• What do you do?
• Adjust them...
• upper C spine, occiput, sacrum

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Hes so strong, he can hold his head up
already...

• Infant pulls away when you hold them against your
  shoulder
• Only comfortable in the football hold
• Problems breastfeeding/sleeping
• Etc

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Reverse Fencer-Part 2

• Acetabular pump
• Infant supine, apply pressure along the shaft of
  the femur into the acetabular fossa
• Compare the resistance on each side
• The spongy side is said to be the side of atlas
  laterality

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Interpreting your findings...

• a negative response (heel swing) indicates a
  subluxation complex between the atlas-axis or
  atlas-occ. on that side

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Interpreting your findings...

• Differentiating b/w atlas and occ.
• Dr. McMullen suggests that you look at the
  Acetabular Pump findings
• spongy sideatlas laterality
• evenocciput

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Supine Leg Check

• Lay the infant supine
• Gently straighten the legs
• make sure that the head is in a neutral position
• Compare medial malleoli, fat folds at the knee,
  etc.
• Long leg side is said to be the
• side of atlas laterality...

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Prone Leg Check Older Child
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Instrumentation

• DP nervoscope newborns?
• cant sit up
• lots of skin
• accuracy?
• size of probes
• patient relaxation
• Old enough to sit still...

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Advances in Instrumentation
www.titronics.com
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Atlas fossa reading

• DT-25 is used to measure atlas fossa temperatures
• hold 1/4 away from the skin
• repeat 3x each side
• Remember to take into consideration the way the
  child was being held, sitting in the sun in the
  car seat, etc.

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Atlas fossa reading

• The cold side is said to be the side of atlas
  laterality...
• More likely, it tells us there is an imbalance

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What if?

• Atlas fossa R 85 L86
• No other findings in the cervical spine
• _ _ _ _ _ _

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What if?

• Atlas fossa R 85 L86
• No other findings in the cervical spine
• S A C R U M

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Posture analysis

• Head tilt
• Head rotation
• High shoulder
• Scoliosis
• High ilium
• Genu varus and valgum
• Internal extenal foot rotation

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Normal Development

• Normal evolution from bowlegs to knock-knees to
  normal valgus

2 years 3 years 5 years
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TOE-IN TOE-OUT
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Static Palpation

• Taut and tender fibers
• Muscle spasm
• common with congenital torticollis
• Sudoriferous changes
• stickiness/dryness
• Temperature

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Pay attention to the child!

• Theyll let you know
• squirming
• fussiness
• clutching at your hand
• etc.

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Clinical Note

• Just because it sticks out doesnt mean its
  subluxated!

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For Example

• L1 is often prominant in infants (similar to the
  adults T4) but it is not always fixed
• You must evaluate the motion, feel for
  springiness, TT fibers, sudoriferous changes,
  instumentation findings, etc.

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Motion palpation

• Similar to adults but much more subtle
• ligament laxity, cartilagenous vertebrae
• Be creative!

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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!

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Sacrum and Pelvis

• Gluteal Cleft Deviation
• Sacral Dimples
• Dangling legs
• Gluteal Folds

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Gluteal Cleft Check

• Pinch cheeks together
• Cleft should be midline

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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)

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Sacral Dimples

• Asymmetry (with fixation of SI joints) suggests
  pelvic misalignment
• Palpate S2 to PSIS

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Other things to note...

• Dangling legs
• ilium rotation
• Gluteal fold observation
• sacral tilts

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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.

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Toddlers School Aged Kids

• Flying Airplane
• Child lays on their tummy
• (table, dads lap, your lap)
• Have them hold their arms out like wings
• You lift both legs and go through motion
  palpation of lumbars gt thoracics

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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
  interaction
• Give 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?

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Unique Features
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Unique Features

• Anatomy
• Biomechanics

MacGregor, 2000
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Anatomy

• Underdeveloped cervical lordosis
• Low vertebral height
• Horizontal facets (until age 10)
• Undeveloped uncinates (until age 7)

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lordosis? vertebral height? facets? uncinates?
11 months old 3 years old 5 years old
Taylor Resnick
46
Biomechanics

• Large head
• Weak muscles
• Spine is more flexible
• MVA injuries

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How will this affect your adjustment?
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Joint End Play

• Determined by the degree of flexibility and
  elasticity of a joint
• Increased in children
• Some say that
• Spinal adjusting in the pediatric spine should
  be performed at a point somewhat before the end
  of the passive range is reached.

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Motion

• Joints of Lushka/Uncovertebral Joints
• 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

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Pediatric Technique

• Chiropractic Care for the Pediatric Patient, Fysh

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Adjusting Considerations

• Minimize excessive range of motion/forces
• Reduce depth of thrust
• C-spine lat bend and minimum rotation (30
  degrees)
• Sometimes, pre-stress can effect a correction...
• Specificity

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Contact Points

• Pediatric vertebrae are much smaller
• cervical spine of a newborn is lt2 inches in
  length
• High degree of specificity is required
• Pad of the finger-tip or thumb tip

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Occiput

• Findings
• Fixation between Co/C1
• Increased tension in suboccipital muscles
• unilateral/bilateral
• If significantly fixed, infant may become
  irritable even with light palpation

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Occiput (AS)

• Correction
• Light cephalad traction with the fingertips
• When released, infant becomes relaxed may even
  fall asleep

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Atlas

• Findings
• Fixation at C1
• Well add
• TT
• Instrumentation
• Etc.

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Atlas

• Correction
• Place lateral tip of the index finger against the
  prominent C1 transverse
• Laterally bend to the side of contact until
  end-range
• A 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 15-20
  seconds
• (stimulate Moro response)

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Pediatric Drop Piece

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Clinical Note

• Compared with C1, rotation of C2-C7 is
  significantly reduced
• C1/C2 40 degrees
• C2/C3 3 degrees
• C7/T1 2 degrees
• Therefore, C2 and C7 are prone to subluxation
  with end-range rotation of the head

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C2 C7

• Findings
• Muscle spasm usually side of spinous process
  deviation
• Fixation spinous does not move away with
  lateral bend

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C2 C7

• Correction
• Tip of index finger on articular pillar
• Rotate head 25-30 degrees
• Laterally bend the neck over contact finger
• If no release is felt, apply a light thrust

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Thoracic Spine Infant Child

• Prone thoracic adjusting
• If 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 edge
• Doctor can flex the abdomen over the tables edge
  to induce a normal thoracic curve
• Infant upright, chest to chest with doctor or
  parent
• Infant lying prone on top of parent

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Thoracics

• Correction
• DTH - thumbs on either side of the spinous
  process
• Anterior adjusting
• Not recommended for children under 3 years of age
• Flexible rib cage

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L1 L3

• Sagittal plane, facet joints
• Correction
• Contact mammillary process with a light thumb
  contact
• P-A, I-S thrust

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L4 L5

• Correction
• Contact the spinous process (side of spinous
  rotation) with a light thumb contact
• Apply light pressure over the contralateral
  mammilary process (stabilization)
• Thrust toward the spinous process
• Side Posture infants gt12 months

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Sacro-iliac

• Correction
• Prone or side posture
• Light adjustive thrust
• Direction appropriate to correct PI, AS, In or Ex

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References

• Anrig 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
  20-26.
• 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)
  211-6.
• McMullen M. Assessing upper Cervical
  Subluxations in Infants Under Six Months. ICA
  International Review of Chiropractic, 1990
  March/April 39-41
• Pistoles R. The Webster Technique A Chiropractic
  Technique with Obstetric Implications. JMPT,
  2002 25(6).
• Webster L. Chiropractic Care During Pregnancy.
  Todays Chiropractic, 1982 Sept/Oct 20-22.