ABC’s Of Pediatric Adjusting Modifications for the Pediatric Patient Stephanie C. O’Neill, DC, DICCP.

ABC’s Of Pediatric Adjusting

Modifications for the Pediatric Patient

Stephanie C. O’Neill, DC, DICCP

“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

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

Joan Fallon

The Child Patient: A Matrix for Chiropractic Care– published as a supplement to JCCP

(Vol. 6, No. 3)

– www.icapediatrics.com

Overview

Assessing the pediatric patient

Unique features of the pediatric spine

Adapting your technique

Comfort and Safety

Newborn Evaluation

Where do you start?

Newborn Evaluation

Reverse Fencer Maneuver– Heel swing– Acetabular pump

Supine Leg Check Instrumentation - atlas fossa reading Posture analysis Static Palpation Motion palpation

McMullen Reverse Fencer

<6 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/April;1990,39-41.

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 child‘s head

turn to that side Repeat on other side

WARNING!

Before you suspend a child by their legs you must rule out hip instability.

Congenital Hip Dysplasia

Reverse Fencer- Part 1

Heel swing (cont‘d):

Compare motion from side to side– restricted? twitching?

What if...?

Child arches backwards (opisthotonis) meningeal tension

What do you do? Adjust them...

– upper C spine, occiput, sacrum

“He‘s 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…

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

Interpreting your findings...

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

Interpreting your findings...

Differentiating b/w atlas and occ.

Dr. McMullen suggests that you look at the Acetabular Pump findings– spongy side=atlas laterality– even=occiput

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...

Prone Leg Check – Older Child

Instrumentation

DP nervoscope & newborns?– can‘t sit up– lots of skin

– accuracy? size of probes patient relaxation

Old enough to sit still...

Advances in Instrumentation

www.titronics.com

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.

Atlas fossa reading

The cold side is “said to be“ the side of atlas laterality...

More likely, it tells us there is an imbalance

What if…?

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

_ _ _ _ _ _

What if…?

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

S A C R U M

Posture analysis

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

Normal Development

Normal evolution from bowlegs to knock-knees to normal valgus

2 years 3 years 5 years

TOE-IN TOE-OUT

EX ilium IN ilium

Inward tibial or femoral torsion

Weak psoas or Glut. max

Psoas, piriformis or Glut. Max spasm

CP (bilat)

Static Palpation

Taut and tender fibers Muscle spasm

– common with congenital torticollis

Sudoriferous changes – stickiness/dryness

Temperature

Pay attention to the child!

They’ll let you know…– squirming– fussiness– clutching at your hand– etc.

Clinical Note

Just because it sticks out doesn‘t mean it‘s subluxated!

For Example

L1 is often prominant in infants (similar to the adult‘s T4) but it is not always fixed

You must evaluate the motion, feel for springiness, T&T fibers, sudoriferous changes, instumentation findings, etc.

Motion palpation

Similar to adults but much more subtle– ligament laxity, cartilagenous vertebrae

Be creative!

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!

Sacrum and Pelvis

Gluteal Cleft Deviation Sacral Dimples Dangling legs Gluteal Folds

Gluteal Cleft Check

Pinch cheeks togetherCleft should be midline

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)

Sacral Dimples

Asymmetry (with fixation of SI joints) suggests pelvic misalignment

Palpate S2 to PSIS

Other things to note...

Dangling legs– ilium rotation

Gluteal fold observation– sacral tilts

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.

Toddlers & School Aged Kids

“Flying Airplane”– Child lays on their tummy

(table, dad’s lap, your lap…)– Have them hold their arms out like wings

– You lift both legs and go through motion palpation of lumbars ~> thoracics

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?“

Unique Features…

Unique Features…

Anatomy Biomechanics

MacGregor, 2000

Anatomy

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

11 months old 3 years old 5 years old

Taylor & Resnick

lordosis? vertebral height? facets? uncinates?

Biomechanics

Large head Weak muscles Spine is more flexible

MVA injuries

How will this affect your adjustment?

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.”

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

Pediatric Technique

Chiropractic Care for the Pediatric Patient, Fysh

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

Contact Points

Pediatric vertebrae are much smaller– cervical spine of a newborn is <2 inches in length

High degree of specificity is required

Pad of the finger-tip or thumb tip

Occiput

Findings Fixation between Co/C1* Increased tension in suboccipital muscles

– unilateral/bilateral

*If significantly fixed, infant may become irritable even with light palpation

Occiput (AS)

Correction Light cephalad traction with the fingertips When released, infant becomes relaxed & may even

fall asleep

Atlas

Findings Fixation at C1

We’ll add… T&T Instrumentation Etc.

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)

Pediatric Drop Piece

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

C2 – C7

Findings Muscle spasm – usually side of spinous process

deviation Fixation – spinous does not move away with lateral

bend

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

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 table’s edge to induce a normal thoracic curve

Infant upright, chest to chest with doctor or parent Infant lying prone on top of parent

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

L1 – L3

Sagittal plane, facet joints

Correction Contact mammillary process with a light thumb

contact P-A, I-S thrust

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 >12 months

Sacro-iliac

Correction Prone or side posture

– Light adjustive thrust– Direction appropriate to correct PI, AS, In or Ex

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. Today’s Chiropractic, 1982;

Sept/Oct: 20-22.