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 Supine Leg Check 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

Congenital Hip Dysplasia 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? Old enough to sit still... 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.

Just because it sticks out doesn‘t mean it‘s subluxated! 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 Be creative! 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 together Cleft 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 Gluteal fold observation 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)

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

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 Function: begin to develop between 6-9 years of age (are complete at age 18) Function: guide the coupled motion of rotation and lateral flexion, limiting side bending

Chiropractic Care for the Pediatric Patient, Fysh 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.