pediatrics for the chiropractor -...

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Pediatrics for the Chiropractor: Full Spine Adjusting Techniques, Patient Evaluation & Management, and Sports Injuries in Children

Presented by: Elise G. Hewitt, DC, CST, DICCP, FICC

Portland Chiropractic Group 2031 E. Burnside Street Portland, Oregon 97214 503.224.2100 www.DrEliseHewitt.com [email protected]

© 2013 Elise G. Hewitt, DC

Disclaimer: The views and opinions expressed in this presentation are solely those of the author. NCMIC does not set practice standards. We offer this only to educate and inform.

Disclaimer


Earn NCMIC Premium Discounts  Full-time D.C.s attending an eight-hour

qualifying seminar will receive a 5% discount for three consecutive years on the renewal of their malpractice insurance premium (2.5% discount for part-time D.C.s).

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Tools of the Chiropractic Trade

 Depending on state, scope of practice includes:  Manual therapies (manipulation, massage, CST, etc.)  Physiotherapies  Exercise and postural advice  Herbal and nutritional supplements  Lifestyle and dietary advice

… all to enhance health of child  Chiropractors are much more than just spinal

adjusters… Chiropractic physicians are doctors who use a natural, integrative, conservative-first approach to healthcare.


Clinical Rationale for Manual Therapy Aspects of Chiropractic  Chiropractors seek to restore normal biomechanics

to the articulations of the body with the aim of normalizing neurological and physiological function to local and systemic structures related to the affected joints.

 Joint dysfunction can have adverse affects on neurological and physiological function, both locally and systemically.


Local Effects of a Joint Dysfunction

 Joint dysfunction can lead to:  Altered biomechanics

 Neurological irritation (facilitation or inhibition)

 Muscle spasm

 Altered hemodynamics

 Cellular inflammation

 Pain


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KINESIOPATHOPHYSIOLOGY NEUROPATHOPHYSIOLOGY

HISTOPATHOPHYSIOLOGY

ANGIOPATHOPHYSIOLOGY

MYOPATHOPHYSIOLOGY

Local Effects of Joint Dysfunction

INFLAMMATION

IMPAIRED NUTRIENT DELIVERY & WASTE REMOVAL

MUSCLE SPASM

NERVE FACILITATION OR INHIBITION

RESTRICTED JOINT MOTION

PAIN

JOINT DYSFUNCTION


Systemic Effects of Joint Dysfunction  Body has inherent self-regulatory mechanisms

Homeostasis = balance

 Joint dysfunction can interfere with these mechanisms by altering function in neurological and vascular systems, creating dis-ease

Dis-ease = imbalance = asymptomatic malfunction

 Long-term consequence of dis-ease is disease Disease = symptomatic malfunction

 Aim of chiropractic is to strengthen host and restore normal regulatory mechanisms by removing cause of pathophysiology (joint dysfunction)

Preferably before dis-ease progresses into disease


Systemic Effects of Joint Dysfunction: Research   Leboeuf-Yde, Pedersen et al performed a survey of 5,600

chiropractic patients in 7 countries to determine the nature and frequency of non-musculoskeletal health benefits associated with their chiropractic treatment.   25% of all patients reported at least one positive non-

musculoskeletal response (non-MSR).

  Most common improvements were for complaints related to the respiratory, digestive and circulatory systems.

Leboeuf-Yde C, Pedersen EV, Bryner P et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: a multination survey. J Manipulative Physiol Ther 2005;28:294-302.


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Systemic Effects of Joint Dysfunction: Research   Rosner in a 2003 analysis of the state of pediatric chiropractic

research found compelling outcomes for otitis media, colic and asthma. More recent studies include promising results for nursing dysfunction, constipation, headaches, neurological disorders (incl. autism, ADD/ADHD)

Rosner A. Infant and child chiropractic care: an assessment of the research. Foundation for Chiropractic Education and Research. Norwalk, IA. 2003.


Systemic Effects of Joint Dysfunction: Research  Miller et al studied 104 colicky infants who were randomized

into three groups – 1) treatment with and 2) without parent blinding and 3) no treatment with parent blinding. By day 10, daily crying time had decreased by an avg. 48% in both treatment groups vs. 18% in no-treatment group, with no difference between blinded and non-blinded treatment groups.

Miller JE, Newell D, et al. Efficacy of chiropractic manual therapy in infant colic: a pragmatic single-blind, randomized controlled trial. J Manipulative Physiol Ther 2012;35:600-607.


Systemic Effects of Joint Dysfunction: Research  Mills et al in RCT involving 57 children with recurrent

otitis media (OM) found those receiving manipulative therapy (OMT), as compared to those receiving routine pediatric care, had fewer episodes of OM, fewer surgical procedures and higher rates of normal tympanograms.

Mills MV, Henley CE, Barnes LLB et al. The use of osteopathic manipulative therapy as adjuvant therapy in children with recurrent acute otitis media. Arch Ped Adolesc Med 2003;157(9):861-66.


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Systemic Effects of Joint Dysfunction: Research  Miller et al performed a clinical case series of

chiropractic care for 114 infants with hospital- or lactation consultant-diagnosed nursing dysfunction. Average age at first visit: 3 weeks (most common age 1 week). All children showed some improvement, with 78% able to exclusively breastfeed after 2-5 treatments within a 2-week period.

Miller JE, Miller L, et al. Contribution of Chiropractic Therapy to Resolving Suboptimal Breastfeeding: A Case Series of 114 Infants J Manipulative Physiol Ther 2009;32(8):670-674.


Systemic Effects of Joint Dysfunction: Research  Survey of parents of toddlers who were colicky as

infants: 117 who had received chiropractic care as infants and 111 who had not received chiropractic care. Toddlers who received chiropractic care as infants were twice as likely not to experience long-term sequelae of infantile colic, such as temper tantrums and frequent nocturnal waking.

Miller JE, Phillips HL. Long-term effects of infant colic: a survey comparison of chiropractic treatment and non-treatment groups. J Manipulative Physiol Ther 2009;32(8):635-638.


Systemic Effects of Joint Dysfunction: Research  Bakris et al Journal of Human Hypertension 2007:

found that chiropractic adjustments to the cervical spine created marked and sustained reductions in blood pressure equivalent to the use of a two-drug combination therapy.

Bakris G, Dickholtz M, et al. Atlas vertebra realignment and the achievement of arterial pressure goal in hypertensive patients: a pilot study. Journal of Human Hypertension 2007;21:347-352.


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Systemic Effects of Joint Dysfunction: Research  Haavik-Taylor and Murphy in Clinical Neurophysiology

2006: measured changes in somato-evoked potentials in frontal and parietal lobes of brain following cervical adjustments. Found that cervical adjustments reduced excessive afferent signals in the brain and altered cortical somatosensory processing and sensorimotor integration. No changes were noted in the passive range of motion control group.

Haavik-Taylor H, Murphy B. Cervical spine manipulation alters sensorimotor integration: a somatosensory evoked potential study. Clinical Neurophysiology 2006;118(2):391-402.


JOINT DYSFUNCTION

MYOSPASM IN TENSOR VELI PALATINI MUSCLE

OCCLUSION OF EUSTACHIAN TUBE

POOLING OF FLUID IN MIDDLE EAR

BACTERIAL/VIRAL GROWTH AND INFECTION

ANTIBIOTICS TO KILL BACTERIA

PATHOGEN REGROWTH

REPEATED USE OF ANTIBIOTICS

How a Joint Dysfunction Can Lead to Otitis Media


Is Chiropractic Care for Children Safe?   Cassidy et al looked at incidence rates of VBA stroke following

visits to a chiropractor compared to visits to a primary care physician (PCP). Looked at all VBA strokes from 1993-2002 (818 strokes over 100 million person-years). Concluded:“We found no evidence of excess risk of VBA stroke associated with chiropractic care as compared to primary care.” Patient is just as likely to suffer a stroke after visiting the PCP as after visiting a chiropractor.

Cassidy D, Boyle E et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008;33(4S)Neck Pain Task Force:S176-183.


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  Hayes and Bezilla did a retrospective review of AE in 346 pediatric patients who had received at least two treatments of OMT. None had serious AE; 31 (9%) had mild, self-limiting, transient AE. Authors concluded “…OMT appears to be safe in the pediatric population when administered by physicians with expertise in OMT.”

Hayes NM, Bezilla TA. Incidence of iatrogenesis associated with osteopathic manipulative treatment of pediatric patients. J Am Osteopath Assoc 2006;106:606-608.

Is Chiropractic Care for Children Safe?


  Vohra et al performed a systematic review of the incidence of adverse events (AE) following spinal manipulation in children. Review covered all literature for past 110 years. Found 9 cases of serious AE, with estimated 30 million annual pediatric visits to the chiropractor.

Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 2007;119:275-283.



  Miller et al examined 781 pediatric patients under 3 years of age (73.5% under 13 weeks) who received a total of 5242 chiropractic treatments at a chiropractic teaching clinic in England from 2002-2004. There were no serious adverse effects (reaction lasting >24 hours or needing hospital care), 7 reported minor adverse effects. 85% of parents reported improvement in their children’s symptoms.

Miller JE, Benfield K. Adverse effects of spinal manipulation therapy in children younger than 3 years: a retrospective study in a chiropractic teaching clinic. Jour Manip Physiol Ther 2008;31(6):419-422.



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  Doyle did a literature review on the safety of chiropractic manipulative therapy for children; estimated rate of mild AE at 1 in 1310 -1812 patient visits. Found no serious AE reported in the literature since 1992 and no death even potentially related to pediatric chiropractic manual therapy for over 40 years.

Doyle, M.F. Is chiropractic paediatric care safe? A best evidence topic. Clinical Chiropractic 2011;volume 14, issue 3, pp. 97 – 105.



  Carnes et al did a systematic review of AE and manual therapy (MT) in all age groups (8 prospective cohort studies, 31 RCTs). Found no reports of serious or catastrophic AE. Authors concluded “The risk of major AE with MT is low… the relative risk of AE appears greater with drug therapy…”

Carnes D, Mars TS, et al: Adverse events and manual therapy: A systematic review. Manual Therapy 2010;15(4):355-363.



In health care, safety is a relative term - risks of a given treatment must be compared to the risks of alternative interventions for the same condition.

  Bourgeois et al examined data from children seeking medical care for an adverse drug event (ADE) during an 11-year period in the U.S. (1995-2005). They found the mean annual number of ADE-related visits was 585,922, of which 131,142 were ER visits. Children 0-4 years accounted for highest - 43% of all visits. Most frequently implicated drug - antibiotics.

Bourgeois FT, Mandl KD et al. Pediatric Adverse Drug Events in the Outpatient Setting: An 11-Year National Analysis Pediatrics 2009;124;e744-e750. www.pediatrics.org/cgi/content/full/124/4/e744



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Breaking news…


Breaking news…


 Modifications are made in adjustive procedure to adapt to the pediatric spine:

 Modify contact  Adapt patient positioning to size of child  Alter velocity of adjustment   Change force of the thrust  Modify amplitude of thrust



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If you want more Pediatrics… about ACA Pediatrics Council

 www.acapedscouncil.org

 Membership is $85/year ACA doctors, FREE for SACA students

 Includes quarterly newsletter, discount on Annual Symposium registration fees, listing in locator directory, access to list serve

 2014 Annual Pediatrics Symposium  October 10-12 in Portland, OR in collaboration with UWS

Annual Homecoming event  Details at www.acapedscouncil.org/events/



Partnership with Pediatricians  Pediatric medical care and pediatric chiropractic

care complement each other  “crisis care” vs. “quality of life care”

 Example: child with chronic ear infections  MD offers antibiotics if “crisis” (only 5% of cases)  DC offers:  Adjustment and craniosacral therapy  Lymphatic drainage to promote lymph flow  Endonasals  Ear drops, natural immune enhancing supplements  Probiotics to repair gut from repeated antibiotics  Dietary advice to aid healing, prevent recurrences


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Why Children Need Chiropractic Care

 Recent trauma for neonates (birth)

 Time of greatest spinal elongation

 Time of spinal curvature development

 Heuter-Volkmann law

 To optimize function of nervous system  Time of proprioceptive development

 Time of greatest brain growth


Causes of Joint Dysfunction in Children  Trauma

  In utero constraint - including multiples  Malposition, malpresentation  Prolonged or precipitous birth  Assisted delivery - forceps, vacuum extraction, Caesarean section  Falls, car accidents, mishandling, etc.

 Gravitational forces and bipedal posture

 Spine designed like suspension bridge in quadrupeds  Upright posture changes the way forces are transmitted through spine  creates adaptive curvatures   increases likelihood of formation of joint restrictions  exacerbated by prolonged poor posture; ex> “screen time”


Examples of in utero constraint:


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Malposition and Malpresentation



Why Children Are Often Unaware of Joint Restrictions

 Ligament laxity

 Immaturity of joint structures

 Lack of structural/degenerative changes

 No repetitive spinal loading

 Increased whole body movement


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Pediatric History  Informed consent  Signed by parent or guardian



Portland Chiropractic Group 2031 E. Burnside, Portland, OR 97214!

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INFORMED CONSENT TO EXAMINE AND TREAT A MINOR The word “chiropractic” is derived from the Greek words “chiro”, meaning “hand” and “praxis”, meaning “practice”; so chiropractic is literally healthcare performed by hand. As a patient at Portland Chiropractic Group, you should expect your child to be touched, moved, assisted, and adjusted by our doctors, and to a more limited extent, by our chiropractic assistants and massage therapists. Occasionally, complications may arise from the care we render. The purpose of this consent form is to inform you of the possibility of complications or adverse effects. Please read, initial, and sign the following consents to examination and treatment, permitting us to continue.

CONSENT TO EXAMINATION Our chiropractic examination procedures include, but are not limited to, your child’s health history, posture and range of motion evaluation, orthopedic and neurological testing, palpation of various body structures, spinal and extremity mobilization, manual or mechanical muscle testing and palpation, and referral for specialized testing such as blood evaluations, diagnostic imaging, and other tests.

On very rare occasions, physical symptoms may manifest or complications may arise during this examination. By initially here, ______, I authorize the doctor to examine my child to assess his/her health concern(s). This authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor’s discretion.

******************

CONSENT TO TREATMENT

Chiropractic therapeutic procedures include, but are not limited to, spinal and extremity manipulation/mobilization, manual or mechanical muscle therapy, exercise demonstration and prescription, physiotherapy applications such as ice, heat, ultrasound, and electrotherapy, referrals to other practitioners, nutritional recommendations, and advice on posture and home-based self-care. The most common adverse effects of chiropractic treatment are short-term soreness and/or a temporary increase in pain. The likelihood of initial soreness or increased pain has been found to be similar to that of starting an exercise program1. In fact, a systematic review of the literature indicated that most adverse events that could be attributed to spinal manipulation were benign and transitory2. Fractures are rare and usually the result of an underlying bone pathology that we will try to assess during your history and examination. An event sometimes attributed to chiropractic manipulation is a stroke resulting from a cervical artery dissection3. This event is very rare, occurring at a frequency of between one per million and one per five million visits to a

1 Bronfort et al., 2001; Hurwitz, Moregenstern, Vassilaki, & Chiang, 2005 2 Gouvela, Castanho, & Ferreira, 2009 3 Rothwell, Bondy, & Williams, 2001; Smith et al., 2003

Portland Chiropractic Group 2031 E. Burnside, Portland, OR 97214!

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chiropractic office. To date, no study has shown a causal relationship between cervical spine manipulation and stroke. Research has demonstrated that a patient is as likely to have seen a primary care medical doctor as a doctor of chiropractic prior to experiencing a cervical arterial dissection4. In other words, the association of strokes and visits to either chiropractors or primary care physicians was equal, suggesting that the cause of the strokes could not be associated with any element unique to chiropractic care. Naturally, we will discuss our treatment plan with you. We will also inform you of other options for care, to the best of our knowledge. Please note that all forms of healthcare include some form of risk. In fact, there are even risks to not receiving care that may include a worsening of your current complaint or development of other untoward complications. Please read the above before signing this consent. If you have further questions or desire more information, simply ask and we will provide it.

Upon signing this form, I hereby request and authorize Dr. __________________________, and whomever he/she may designate as his/her assistant or authorized representative, to administer chiropractic care as he/she deems necessary to my dependent minor child. I also understand that there is no guarantee or warranty for a specific cure or result. I consent to examination and treatment of my child.

As of today’s date, I have the legal right to select and authorize health care service for the minor child named below. Child’s Name (printed):________________________________________________________ Your relationship to child:______________________________________________________ Legibly printed Parent/Guardian name:______________________________________________ Signature:_____________________________________________ Date: _______________

CUSTODY SITUATIONS If applicable, under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse, former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify this office. Parent/Guardian Signature:_____________________________________________________

4 Cassidy, et al., 2008

Pediatric History


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Pediatric History  Basic Information  Name, nickname, age, sex, birth date, parents’ names,

siblings names and ages

 Chief Complaint  Onset  Location  Quality  DIF, including recent changes  Exacerbating/Remitting factors  Treatment history


Pediatric History  Prenatal Health and Labor & Delivery  Pregnancy complications

 Full term?

 Spontaneous or induced labor?

 Was Mom + or – for strep B?

 Was baby in correct position (LOA)?

 How long was labor? Pushing phase?

 Was cord around baby’s neck?

 Were any special procedures needed?


Pediatric History  Neonatal health  Size at birth (weight, length, head circumference)

 APGAR scores (1 minute and 5 minute)  Appearance, pulse, grimace, activity, respiration

 Scored 0-2 points for each element

 Complications at birth?

 Nursery stay required (NICU)?


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Pediatric History  Nutritional and Digestive Health  Breast vs. bottle feeding  If breastfeeding, how is latch?  Frequency of feeding  Length of time/amount per feeding and between feedings  Appetite? Issues with weight gain?  Food sensitivities?  Issues with gassiness or spitting up?  Bowel Habits  Medications/Vitamins/Fluoride (baby and mother)


Pediatric History  Growth and Development  Attitude  Sleep habits  Gross motor development  Fine motor development  Language development  Cognitive development  Social skills development


Normal Pediatric Developmental Milestones

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Pediatric History  Growth and Development  Attitude  Sleep habits  Gross motor development  Fine motor development  Language development  Cognitive development  Social skills development  Sports, activities, hobbies


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Pediatric History  Medical Survey/Other  Immunization status

 Past Illnesses

 Past Traumas

 Exposure to smokers?

 Family history

 Does child have a cell phone?   If so, where is it kept at night?


Pediatric Examination


Pediatric Examination  Vitals  Height, weight, HR, RR, temperature, BP  In infants, also includes head circumference  Chart on growth charts to be sure following curves  http://www.cdc.gov/growthcharts/clinical_charts.htm


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Growth Charts  Separate charts for boys and girls

 Choice of 5th-95th or 3rd-97th percentiles

 Birth-to-36 months  length-for-age and weight-for-age

 head circumference-for-age and weight-for length

 Children 2-20 years  Stature-for-age and weight-for-age

 BMI-for-age




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Pediatric Examination  Vitals  Height, weight, HR, RR, temperature, BP  In infants, also includes head circumference  Chart on growth charts to be sure following curves  http://www.cdc.gov/growthcharts/clinical_charts.htm

 Appearance  Note general color, lesions, discolorations

 Symmetry of cranial vault/face  Look for symmetry in eyes, ears, cheekbones  Look for alignment of bridge of nose, base of nose, chin  Look at shape of cranium - note flat spots, asymmetries


Pediatric Examination  Neck/Pelvis torsion  Is there a preference for head rotation?  Is there torsion in trunk in supine position?

 Fontanel palpation  Anterior and posterior (if less than 3 months of age)  Note if bulging or depressed  MC causes of bulge - tumor, hemorrhage and hydrocephalus  MC cause of depression - dehydration

  Look for dry skin, poor skin turgor, oliguria


Pediatric Examination  Auscultation  Note any abnormalities in heart and lung sounds or rate

 Mouth  Look for thrush, enlarged tonsils, other lesions or abn’s  Evaluate quality of suck and gag reflex

 Eyes  Symmetrical light reflexes?  PERRLA  Red reflex present?

 Lymph node evaluation  Anterior cervical, posterior cervical, inguinal chains


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Pediatric Examination  Ears - Otoscopic examination if suspect otitis media  Erythema?

 Cone of light and malleus visible?

 Bulging or retracted TM?

 Fluid line/bubbles visible?

 Scarring on TM?

 Cerumen, blood, other fluid in canal?

 Is examination painful?


Normal Tympanic Membrane

Otoscopic Evaluation of Tympanic Membrane

 Overview site for Otitis Media: http://emedicine.medscape.com/article/994656-overview

 For a detailed description of the appearance of normal and abnormal tympanic membranes on otoscopic evaluation, see: http://www.aap.org/otitismedia/.

 Can also review case studies on site as well.

 $24 charge, includes continuing education credit

 Free otoscopic evaluation site: http://otitismedia.hawkelibrary.com/normal/1_G


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Pediatric Examination  Abdomen  Palpate for major organs  Remember - most common cancer in infants is Wilms tumor

(nephroblastoma); make sure palpate region of kidneys.

 Orthopedic highlights  Hips: Ortolani’s, Barlow’s tests (up to 3-6 months of age)  Allis sign (aka Galeazzi test) if older than 3-6 months  Also look for asymmetrical thigh folds

 Clavicle palpation in newborn  Posture evaluation and Adam’s test in older children  Cervical and thoracolumbar global ranges of motion  Spinal segmental range of motion


Pediatric Examination - Primitive Reflexes  Blinking reflex

 Acoustic Blinking reflex

 Rooting reflex

 Suck reflex

 Moro/Startle reflex


Moro/Startle Reflex


Elicit: sudden lowering of head relative to rest of body Response: 1. extension and abduction of arms followed by flexion of arms 2. “C” shape to fingers 3. crying

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 Rooting reflex

 Suck reflex


 Palmar/Plantar reflexes

 Tonic neck reflex (aka Fencer reflex)


Tonic Neck/Fencer Reflex


Elicit: rotation of head to one side Response: ipsilateral extension of arm/leg with flexion of contralateral arm/leg



 Rooting reflex

 Suck reflex




 Babinski reflex

 Galant test

 Perez test


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Galant Reflex


Perez Reflex (not pictured)

Elicit: stroke paraspinals S --> I Response: ipsilateral LF of spine

Elicit: stroke spinal I --> S Response: extension of spine



 Rooting reflex

 Suck reflex




 Babinski reflex

 Galant test

 Perez test

 Vertical suspension test


Unique Aspects of the Pediatric Spine

 Bone  Cartilage vs. osseous tissue  Primary vs. Secondary ossification

 Soft Tissue  Ligament structure  Muscle strength

 Conclusions  Children have the equivalent of an unstable, hypermobile

spine


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Adjusting Technique Modifications for the Pediatric Patient  Velocity of thrust  Increase or decrease?  Why?

 Force of thrust  Increase or decrease?  Why?

- increased flexibility of tissues

- smaller point of contact

- increase compared to adult patient

- decrease compared to adult patient


Force - How much do we use?  Force in a keystroke..................

 Force to fracture a rib................

 Crossed BL HVLA adult...........

 Double thumb HVLA infant .....

  13 N

 3300 N

  525 N*

  30 N

Informal measurements at a chiropractic institution's force computer simulation adjusting lab:

30/525 N = 5.7% of the force used on an adult

*Downie AS, et al. Quantifying the high-velocity, low-amplitude spinal manipulative thrust: a systematic review. J Manip and Physio Ther 2010; 33(7):542-553.


Adjusting Technique Modifications for the Pediatric Patient  Velocity of thrust  Increase or decrease?  Why?

 Force of thrust  Increase or decrease?  Why?

 Amplitude of thrust  Increase or decrease?  Why?

 Contact Points  Audible release  Be flexible and make it fun!

- increased flexibility of tissues

- smaller point of contact

- smaller joint space

- increase compared to adult patient




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Pediatric Adjusting Techniques by Region

 Age ranges:  Newborn/Infant  Toddler/Pre-schooler

 Regions:  Sacroiliac, lumbar, thoracic and cervical

 Pediatric adjusting:  Spinal examination  Adjustive techniques


Pediatric Adjusting Techniques by Region: Sacroiliac Joints

 NEWBORN-INFANT  EVALUATION  Observe gluteal crease  Observe gluteal folds

 Observe thigh folds

 Motion palpate SI joints and sacral segments

 ADJUSTMENT  Leg as lever (aka prone assisted)

 Prone drop


Pediatric Adjusting Techniques by Region: Sacroiliac Joints

 TODDLER-PRESCHOOLER  EVALUATION  Evaluate leg length (at extension, 90˚ flexion)  Evaluate maximal knee flexion

 Observe buttock height (pockets and pants seam)

 Motion or prone palpation of SI joints and sacral segments

 ADJUSTMENT  Leg as lever (aka prone assisted)

 Side posture, when big enough


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Pediatric Adjusting Techniques by Region: Lumbars

 NEWBORN-INFANT  EVALUATION  Palpate P -> A translation prone across lap  Non-palpating hand supporting chest and distal shoulder

 ADJUSTMENT  Prone “thumb-index finger” with child in same position  3 parts: impulse with palpating hand, slight spread of legs, slight lift

with non-palpating hand


Pediatric Adjusting Techniques by Region: Lumbars

 TODDLER-PRESCHOOLER  EVALUATION  Palpate lumbar spine while sitting on doctor’s or parent’s lap or while

prone (on parent’s lap, on doctor’s lap, on table)

 ADJUSTMENT (same as SI region)  Leg as lever (aka prone assisted)  Side posture, when big enough


Pediatric Adjusting Techniques by Region: Thoracics

 NEWBORN-INFANT  EVALUATION  Evaluate P->A translation with baby prone, over edge of table on doctor’s

lap, against doctor’s chest, or against parent’s chest  Older infant can also sit on doctor’s or parent’s lap  As baby gets older, also evaluate rotation and lateral flexion

 ADJUSTMENT  P->A translatory adjustment accomplished in several ways: hanging

distraction, against doctor’s chest, parent’s chest or on table.  Double thumb, single thumb, covered thumb or fingertip


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Pediatric Adjusting Techniques by Region: Thoracics

 TODDLER-PRESCHOOLER  EVALUATION  Prone on table (preferred) or parent, or sitting on parent’s or doctor’s

lap

 ADJUSTMENT  Prone:

 Bilateral or unilateral pisiform/knife-edge  Upper thoracics: covered thumb, combo adjustment  Lower thoracics: often easier side posture due to extreme

flexibility

 Supine: give stuffed animal to hug


Pediatric Adjusting Techniques by Region: Cervicals

 NEWBORN-INFANT  EVALUATION  Palpate suboccipital region for spasm, heat, etc.  Palpate atlas tp (located directly inferior to mastoid)  Motion palpate occiput and remainder of C spine (if can find it)

 ADJUSTMENT  Lower Cervicals: supine rotation or lateral flexion correction  Atlas: correct laterality with fingertip contact  Occiput: unilateral or bilateral (see next slide)


Pediatric Adjusting Techniques by Region: Occiput Adjustment  NEWBORN-INFANT  Unilateral  Patient Supine  Rotate head 90˚ away from affected side   I -> S tissue pull onto mastoid process  Contact mastoid with 2nd mp joint  Rotate head back to 45˚ away from affected side  Line of drive toward opposite axilla

 Bilateral  Patient supine, roll under neck  Contact forehead with thenars or knife-edge  Line of drive S->I and A->P  Can use toggle drop piece


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Pediatric Adjusting Techniques by Region: Cervicals  TODDLER-PRESCHOOLER  EVALUATION  Supine on table, supine across parent’s lap, or supine on supine parent, or

sitting on parent’s lap

 ADJUSTMENT  Contact using thumb, or PIP or DIP of index finger  Supine: rotation or lateral flexion correction  Sitting: rotation or lateral flexion correction  Trick: Demo movement before actually do adjustment  Trick: Distract patient (heels together, wiggle toes, hands on belly button,

etc.) – don’t wait for them to do the move, adjust as soon as they think about doing the move.


Common Technical Mistakes When Adjusting Children

 Velocity too slow  Quicken impulse if having difficulties

 Joint not brought to tension  Make sure move through elastic tissues to point of

tension (don’t measure by range of motion)

 Not waiting for moment of relaxation  Use distraction to help child’s muscles relax


Frequency of Care for Infants and Children

  Children respond much more quickly than adults, so initial treatment plan usually relatively short compared to adults.

  Response proportional to age and degree of trauma   Older child or one with greater degree of trauma may

require more care

  Typical neonate with dysfunctional nursing:   2x/wk 1-2 weeks, 1x/wk 1-2 weeks


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Frequency of Care for Infants and Children

 Wellness care:  1st year of life: monthly wellness visits

 2nd year of life: bimonthly wellness visits

 After that: frequency ranges from 1x/month to 1x/year, depending on child’s specific health needs and stability of spinal joints.


pediatrics for the chiropractor -...

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