Chiropractic Management of Common Conditions

Transcription

Chiropractic Management of
Common Conditions
Asthma
Patient Presentation
Parents report:
 Episodic or persistent coughing
 Wheezing
Asthma?
 Shortness of breath
 Rapid breathing or chest tightness
 Worse in the evening or early morning hours
 Associated with triggers

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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.
Differential Diagnosis
Wheezing is not present in all patients with asthma!
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Wheezing is not a sign exclusive to asthma
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Respiratory infections
Rhinitis
Sinusitis
Vocal cord dysfunction
Consider differentials that may cause similar
symptoms
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Foreign body aspiration
Cystic fibrosis
Heart disease
1341-8.
Diagnosis
“In most children, the primary diagnostic
tool is clinical assessment.”

Pulmonary function tests (spirometry) should be
performed as soon as possible
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Unreliable in infants and many preschoolers
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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
1341-8.
“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 2005;71:1059-68.
Medical Treatment
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Patient education
Trigger avoidance
Drug therapy
Compliance is a major problem
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Route of administration
Frequency of dosing
Medication effects
Risk or concern of side-effects
1341-8.
Chiropractic Care & Asthma
Evidence is adequate to support the “total
package” of chiropractic care as providing
benefit to patients with asthma
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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 2007;13 491-512.
What is the goal of treatment?

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?

?
?
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 2005;71:1059-68.
What is the “Total Package”?
What does the average chiropractor do when
a patient presents with asthma as a primary
complaint?
Modalities Used for the Treatment of Asthma
N=33 Consensus=24 (75%)
# of DCs using modality
Chiropractic adjustment of the T spine
33
Chiropractic adjustment of C1/C2
32
Evaluation of stress/environment
32
Neurolymphatic drainage of chest wall
30
Evaluation of environmental pollutants
30
Family history evaluation
29
Removal of dairy/wheat from diet
28
Review of medication/side effects
26
 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.
Modalities Used for the Treatment of Asthma
Chiropractic adjusment of ribs
21
Adjustment of other spinal segments
20
Cranial adjustments
20
Supplementation with vitamin C
20
Increased exercise
16
Supplementation with garlic
9
Homeopathic medications
6
Breathing exercises
5
Use of “breatheasy” tea
5
Liver nutritional support
2
Supplementation with cranberries
1
Lotus root tea
1
Summary
Chiropractic Management Included:
 Spinal adjusting (most common modality used)

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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
Chiropractic Management

Chiropractic adjustments
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Full spine, ribs, upper cervical
Trigger avoidance & environmental control
measures
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“Evaluation of stress/environment”
“Evaluation of environmental pollutants”
“Removal of dairy/wheat from diet”
“Review of medication/side effects”
Trigger Avoidance
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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)
1341-8.
Environmental Control Measures
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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 <50%)?
For more ideas: http://www.aaaai.org
1341-8.
More research is needed but…
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Avoid dairy/wheat
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Limit processed sugars
Avoid food additives & preservatives (MSG)
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Highly allergenic… remember the “allergic march”?
Dairy in a mucous-producing agent
May trigger attacks
Relaxation techniques, stress control and reduction
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May benefit lung function
Family life, TV, school,
daycare, siblings, etc.
Schetchikova NV. Asthma: An Enigma Epidemic , Part II-Asthma Treatment. J Am
Chiropr Assoc: JUL 2003 (40:7) 30-37.
More research is needed but…
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Probiotics
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Omega-3 fatty acids
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May decrease inflammation
Calcium and magnesium
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May reduce inflammation, reduce allergic symptoms
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 (40:7) 30-37.
Index to Chiropractic Literature
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Gibbs AL. Chiropractic co-management of medically treated asthma.
Clin Chiropr: SEP 2005(8:3) 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 (OCT:18) Online access
only 23p.
Schetchikova NV. Asthma: An Enigma Epidemic (Part 1). J Am Chiropr
Assoc: June 2003 (40:6) 22-29.
Schetchikova NV. Asthma: An Enigma Epidemic , Part II-Asthma
Treatment. J Am Chiropr Assoc: JUL 2003 (40:7) 30-37.
Blum CL. Role of chiropractic and sacro- occipital technique in asthma
treatment. J Chiropr Med: MAR 2002(1:1) 16-22.
Clinical Trial: Asthmatics and Chiropractic. J Am Chiropr Assoc: FEB
2001 (38:2)46-47.
Wellness Alert: Hold Your Breath. J Am Chiropr Assoc: MAR
2001(38:3) 30-38.
Colic
“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
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Typically begins at 2 weeks of age and
usually resolves by 4 months
Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4):
735-40.
Parents Report
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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
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unrelated to environmental events
Cannot be soothed, even by feeding
735-40.
Etiology?
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Gastrointestinal?
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“Gas” does not seem to be the cause of colic
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Psychosocial?
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Excessive crying may lead to aerophagia
Not a sign of a “difficult temperament”
Not related to maternal personality or anxiety
Neurodevelopmental?
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Upper end of the “normal distribution”
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same temporal pattern, just more severe
Most infants “outgrow it”
735-40.
Organic Causes?
<5% of infants presenting with excessive
crying
CNS
Infection
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CNS abnormality (Chiari
type I malformation)
Infantile migraine
Subdural hematoma
Gastrointestinal
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Constipation
Cow’s milk protein
intolerance
GER
Lactose intolerance
Rectal fissure
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Meningitis
Otitis media
UTI
Viral illness
Trauma
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Abuse
Corneal abrasions
Foreign body in the eye
Fractured bone
Hair tourniquet syndrome
735-40.
A diagnosis of exclusion…
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Apnea, cyanosis, struggling to breathe…
Undiagnosed pulmonary or cardiac condition?
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Frequent, excessive spitting up…
GER, pyloric stenosis?
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Lethargy, poor skin perfusion, tachypnea, fever, poor
weight gain…
Infection, gastrointestinal disorder, nervous system
disorder?
Bruising, fracture…
Abuse?
735-40.
Management?
There is limited or no evidence to support…
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Simethicone (Mylicon)
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no more effective than placebo
Lactase
Fiber-Enriched Formulas
Carrying the infant more
Car ride simulators
Intensive parent training
Sucrose
Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70: 735-40.
Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics
2000; 106:184-90.
Recommended Management
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Low allergen diet (breastfeeding mothers)
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Hypoallergenic formulas
Soy formulas?
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May develop allergy to soy
Herbal tea
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Eliminate milk, eggs, wheat, & nuts
Chamomile, vervain, licorice, fennel, and balmmint
Reduce infant stimulation
Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70: 735-40.
Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics
2000; 106:184-90.
New Research
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Probiotics (Lactobacillus reuteri)
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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”
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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 2007;119:e124-30. Roberts DM, Ostapchuk M,
O’Brien JG. Infantile Colic. Am Fam Physician 2004;70:735-40.
Chiropractic Care & Colic
Evidence is adequate to support the “total
package” of chiropractic care as providing
benefit to patients with colic
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Improvement with SMT
Improved parent-reported outcomes with
chiropractic care
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Miller J, Croci SC. Cry baby, why baby? Beyond colic: Is it time
to widen our views? J Clin Chiropr Pediatr: 2005(6:3) 419-423.
Hipperson AJ. Chiropractic management of infantile colic. Clin
Chiropr: DEC 2004 (7:4) 180-186.
Hewitt EG. Chiropractic care and the irritable infant. J Clin
Chiropr Pediatr: SUM 2004(6:2) 394-397.
Leach RA. Differential compliance instrument in the treatment of
infantile colic: a report of two cases. J Manipulative Physiol
Ther:JAN 2002(25:1) 58-62.
Nilsson N, Wiberg JMM. Infants with colic may have had a faster
delivery: a short preliminary report. J Manipulative Physiol
Ther:MAR/APR 2000(23:3) 208-210.
Working with young patients. J Am Chiropr Assoc:FEB 1999
(36:2) 12-15.
Enuresis
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; 67:1499-506,1509-10.
Etiology
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Genetic Predisposition
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Bladder Problems
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Bladder function is normal however, functional bladder
capacity may be less
Arginine Vasopressin
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Most frequently supported
Delayed development of a circadian rhythm may result in
nocturnal polyuria
Sleep Disorders
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Controversial… sleep EEGs demonstrate no differences
but parents report that their children are “deep sleepers”
More likely to have “confused awakenings”; night terrors,
sleepwalking
Other factors that have been implicated…
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Familial factors?
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Social background, stressful life events, number
of changes in family constellation or residences
seem to have no relationship
Psychologic factors?
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No increased incidence of emotional problems
Not an act of rebellion
Psychologic factors are the result of, not the
cause
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
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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?
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?
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?
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?
Medical Management
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Alarms
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Negative reinforcement or avoidance
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Anxiety, disruptive to family?
May have to be used for up to 15 weeks
Effective, low relapse rate
Pharmacological Treatment
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Not recommended for children under 6
Effective but high relapse rate
Side effects
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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”
Nonpharmacologic Management
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Positive Reinforcement Systems
 earns “points” for every night he or she remains dry ~> prize
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Responsibility training
 child is given age-appropriate responsibility, in a nonpunitive way,
for the consequences of bed-wetting (strip wet linens from the
bed)
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Elimination diet
Hypnosis
Retention control
Biofeedback
Acupuncture
Scheduled awakenings
Caffeine restriction
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More research is needed but
they have been shown to have
positive effects…
Chiropractic Care & Enuresis
Evidence is insufficient at this time

Promising
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Adverse effects were mild and self-limiting
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McCormick J. Improvement in nocturnal enuresis with
chiropractic care: A case study. J Clin Chiropr Pediatr:2006(7:1)
464-465.
Bachman TR, Lantz CA. Management of pediatric asthma and
enuresis with probable traumatic etiology. ICA Rev: JAN/FEB
1995(51:1) 44-46.
Marko RB. Bed-Wetting: Two case studies. Chiropr Pediatr:
APR 1994(1:1) 21-22.
Langely C. Epileptic seizures, nocturnal enuresis, ADD. Chiropr
Pediatr: APR 1994 (1:1) 22.
Bomerth PR. Functional nocturnal enuresis. J Manipulative
Physiol Ther:NOV/DEC 1994(17:9) 596-600.
Aker PD, Kreitz BG. Nocturnal Enuresis: Treatment implications
for the chiropractor. J Manipulative Physiol Ther: SEP
1994(17:7) 465-473.
Otitis
Diagnosis of AOM
1. Recent, usually abrupt, onset of signs and symptoms of middleear inflammation and MEE.
2. The presence of MEE that is indicated by any of the following:
a) Bulging of the tympanic membrane
b) Limited or absent mobility of the tympanic membrane
c) Air fluid level behind the tympanic membrane
d) Otorrhea
3. Signs or symptoms of middle-ear inflammation as indicated by
either:
a) Distinct erythema of the tympanic membrane OR
b) Distinct otalgia (discomfort clearly referable to the ear[s] 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. 2004;113(5):1451-65.
Diagnostic accuracy is hindered by…
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Vague symptoms
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Undue reliance on one feature: redness of the
tympanic membrane
Failure to assess tympanic membrane mobility
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neither specific nor sensitive for AOM
must use pneumatic otoscopy
Inadequate visualization of the typmpanic
membrane
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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.
Recommended Medical Management
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“Watchful waiting”
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Pain management
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symptomatic treatment for 24 to 48 hours before
initiating antimicrobial treatment
acetaminophen, ibuprofen, or topical otic
anesthetic drops for pain control
Antibiotic therapy

reserve antibiotic therapy for specific cases


< 6 months of age
Severe illness (fever of >102.6, severe ear pain)
Media. Pediatrics 2004;113:1451-65. Garbutt J, et al. Diagnosis and Treatment of Acute
Otitis Media: An Assessment. Pediatrics 2003;112,143-9.
Newer Research

Wait-and-see
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Decreases the use of antibiotics
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Reduces cost and adverse effects (diarrhea)
No serious adverse events reported
Interrupts the cycle of parental expectations
When are antibiotics most beneficial?
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<2years 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 2006;296:1235-41. Rovers MM, et al. Antibiotics for acute
otitis media: a eta-analysis with individual patient data. Lancet 2006;368:1492-35.
Reducing Risk Factors
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Breastfeeding
 Minimum of 6 months
If bottle-fed, avoid supine bottle feeding
Reduce or eliminate pacifier use (>6 months)
Daycare – increased incidence of URTI
Tobacco smoke
Media. Pediatrics. 2004;113(5):1451-65.
Otitis Media with Effusion

The presence of fluid in the middle ear
without signs or symptoms of acute ear
infection
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Due to poor eustachian tube function OR
Inflammatory response following AOM
Concerns

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Conductive hearing loss
Potential impact on language development
Potential impact on cognitive development
AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:1412-29..
Diagnosis
Clinical presentation
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Pneumatic otoscopy should be perfomed
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cloudy tympanic membrane
distinctly impaired mobility
air-fluid level or bubble may be visible
Tympanometry or acoustic reflectometry can be used in
conjunction
Document the laterality and duration of effusion, and
the presence and severity of associated symptoms
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
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Hearing testing
Language testing
Re-examine at 3- to 6-month intervals until
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Effusion is no longer present
Significant hearing loss is identified
Or structural abnormalities of the eardrum or middle ear are
suspected
Increased risk for speech, language, or
learning problems?

Evaluate hearing, speech, language, and
need for intervention more promptly
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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
Medical Management
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Antihistamines
Decongestants
Antimicrobials
Corticosteroids
Not recommended
*may be an option when the parent or caregiver
has a strong aversion to impending surgery
Tympanostomy tube insertion – preferred initial
procedure
Adenoidectomy – should not be performed unless a
distinct indication exists

nasal obstruction, chronic adenoiditis
Newer Research

Tubes marginally effective in Otitis Media with
Effusion
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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 metaanalysis. Arch Dis Child 2005;90:480-5.
Chiropractic Care & Otitis media
Evidence is promising for the potential benefit of
manual procedures for children with otitis media

Improvement with manual procedures
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Fewer surgical procedures compared to usual
medial care
Parent-reported positive side effects


Natural course of the illness?
relaxation, good nap
When looking at the body of
evidence, it is imperative that we
distinguish between AOM and otitis
media with effusion…
Modalities Used for the Treatment of Otitis Media
Chiropractic adjustment of C1
33
Chiropractic adjustment of Occ
33
Removal of dairy/wheat from diet
33
Manual lymphatic drainage
33
Chiropractic adjustment of C2
32
Supplementation with acidophilus
32
Cranial adjustment of temporal bone
31
Cranial adjustment of occ
30
Adjustment of TMJ
29
Review of child’s eating habits
28
Cranial adjustment of sphenoid
26
Cranial adjustment of ethmoid
25
Modalities Used for the Treatment of Otitis Media
Sacral adjusting
23
Garlic/mullein oil
23
Echinacea/golden seal supplementation
21
Review of child’s daily activities
20
Eustachian tube pull
18
Homeopathis medications
10
Vitamin A
5
Vitamin D
3
Cod liver oil
2
Tea tree oil
2
Foot reflexology
2
Education about chiropractic retracing
1
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
Chiropractic Theories…
Subluxation
Neurological compromise
of the tensor veli palatini
Inadequate patency
of the eustachian tube
Otitis
Subluxation
Muscle spasm
Lymphatic blockage
Otitis






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(7:4)168-173.
Nelson-Hassel T. Pediatric Cephalgia. J Clin Chiropr Pediatr:
SUM 2004(6:2) 383-386.
Chiropractic Approach to the Ear. J Am Chiropractic Assoc: AUG
2002 (39:8) 12-14+.
Chiropractic for Infants and Children. J Am Chiropractic Assoc:
FEB 1999(36:2) 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(22:5) 292-298.
Canty A. A Mother’s Perspective. J Clin Chiropr Pediatr: AUG
1998 (3:1) 201.
Erb’s Palsy
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 2004;69:1707-14. Sandmire HF,
De Mott RK. Erb’s palsy: concepts of causation. Obstet Gynecol 2000;95:940-2.
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
C5 & C6
Ipsilateral phrenic nerve paresis (5%)
Fractured clavicle
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/topic2836.htm.
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
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
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
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
More research is needed

vs. natural history?


Splinting
Active and passive range-of-motion exercises
Recovery

Be cautious in predicting
full recovery and closely
follow affected infants!
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


Hyman C. Chiropractic adjustments and Erb’s Palsy: A case
study [case report]. J Clin Chiropr Pediatr 1997; 2: 157-160.
Harris SL, Wood KW. Resolution of infantile Erb’s palsy
utilizing Chiropractic treatment. J Manipulative Physiol Ther
1993; 16: 415-418.
Torticollis
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
MOST
Breech or difficult forceps delivery
COMMON
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.
Differentials to consider…
LOCAL ETIOLOGY
 Congenital






Otolaryngologic causes








Pseudotumor
Hypertrophy or absence of
cervical musculature
Spina bifida
Hemivertebrae
Arnold-Chiari syndrome
Vestibular dysfunction
Otitis media
Cervical adenitis
Pharyngitis
Retropharyngeal abscess
Mastoiditis
Esophageal reflux
Syrinx with spinal cord tumor
LOCAL ETIOLOGY (cont’d)
 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
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
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
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

Parental education
 Passive stretches
 Tummy time
 Positional changes

Car seat, sleeping,etc.
Secondary Effects of Untreated Torticollis

Plagiocephaly



Facial hypoplasia


asymmetric skull deformity
flattening of occiput ~> secondary
flattening of the contralateral forehead
inhibition in the growth of the mandible
and maxilla due to muscle inactivity
Improve as
torticollis resolves
*May take years
Musculoskeletal effects



compensatory ipsilateral elevation of the
shoulder
cervical and thoracic scoliosis
wasting of muscles in the neck




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.
Plagiocephaly
Plagiocephaly - "oblique head” (Greek)
1.
Nonsynostotic plagiocephaly
positional head deformity (1/60)

2.
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
2003;67:1953-6.
Etiology
If present at birth…
 In-utero or intrapartum
molding

uterine constraint





multiple birth infants
birth injury


If it develops later…
 Torticollis
 “Back to Sleep” campaign
forceps
vacuum-assisted delivery
Since 1992 there has been
a significant increase in the
diagnoisis of plagiocephaly

one center reported a sixfold increase (1992-1994)
premature birth
Craniosynostosis

Subluxation?
“result of static supine positioning”
2003;67:1953-6.
Examination & Workup
Physical exam
 Palpate lambdoidal suture
 Check ear position
 Assess facial symmetry
 Observe unilateral bald spot
 Inspect by arial view

PHD
Synostosis
Skull Radiographs and CT?



atypical skull pattern
moderate-severe skull deformity
suspecting craniosynostosis
2003;67:1953-6.
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
2003;67:1953-6.
Management





Preventive counseling
Mechanical adjustments
Exercises
Skull modling helmets
Surgery
Most improve within 2-3 months…
If parents follow these guidelines
Early recognition is important
Preferred position ~> torticollis
2003;67:1953-6.
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
2003;67:1953-6.
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
2003;67:1953-6.
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)
2003;67:1953-6.

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.


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.
Headaches in Children
Classifying Pediatric Headaches - Etiology
Primary Headaches

Migraine



majority of primary
childhood headaches
see IHS criteria
Secondary Headaches
Underlying CNS pathology


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







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
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 2002;65(4):625-32.
Classifying Headaches – Temporal Pattern

Acute Headache
 single episode of head pain without history of previous events


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


Establish whether any neurologic symptoms accompany this HA
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…
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
Causes of Chronic-Progressive Headache





Brain tumor
Hydrocephalus
Pseudotumor cerebri
Brain abscess
Hematoma


Aneurysm and vascular
malformations
Medications


OCP, tetracycline, vitamin
A (high doses)
Intoxication (lead)
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
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 ~> intracranial tumors


Neurofibromatosis & tuberous sclerosis
Detailed neurological exam
A Detailed Neurological Exam is Essential!






Altered mental status
Abnormal eye movements
Optic disc distortion
Motor or sensory asymmetry
Coordination disturbances
Abnormal DTR’s
Key features of
intracranial disease
Studies have shown that nearly “all children with serious
underlying conditions had one or more objective findings on
neurologic exam.”
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
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
When is a neurological consult indicated?
May depend on the doctor’s experience and
confidence…

Children <3 years



Acute headache w/ focal neurologic symptoms/signs


Rarely have primary headache syndrome
Neurologic & fundoscopic exam can be difficult
Neuroimaging should be performed
Chronic-progressive headaches

Associated w/ increased ICP
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)
CHIROPRACTIC
“Cervicogenic headache”
“Headaches 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.






Luellen J. Chiropractic Care of Adolescent Migraine Headache
[Case Report]. J Clin Chiropr Pediatr: SUM 2004(6:2) 403-405.
Nelson Hassel T. Pediatric Cephalgia [Case Report]. J Clin Chiropr
Pediatr: SUM 2004(6:2) 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(26:6) Online Access only
3P.
Lisis AJ, Dabrowski Y. Chiropractic Spinal Manipulation for
Cervicogenic Headache in an 8-year-old. JNMS: FALL 2002(10:3)
98-103.
Anderson-Peacock ES. Chiropractic Care of Children with
Headaches: Five Case Reports. J Clin Chiropr Pediatr: JAN
1996(1:1) 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(38:3)
160-162.
Back Pain in Children
Causes of Back Pain in Children
Pre-Pubertal
 Infectious





Tumors



Diskitis
Osteomyelitis
Pubertal
 Tumors
Trauma



Falls
MVA
Some pars defects
Trauma

Spinal column
Spinal cord



Spondylolysis/lysthesis
Disc herniation
Lumbar strain/sprain
Idiopathic


Spinal column or cord
Scheuermann’s disease
Inherited disorders

Asynchromous spinal
development (facet tropism)
Adapted from: D'Alessandro MP. Back Pain in Children. Retreived 1 March 2007 from
www.virtualpediatrichospital.org/providers/BackPainInChildren/Diagnosis.shtml
Risk Factors for Back Pain in Children




Age (>12)
Females MC than males
Extended TV watching
Sports participation




Previous back injury
Sitting at school
Carrying back packs


volleyball, climbing, golf, basketball, gymnastics
worse if carried in hand or on one shoulder vs. on their
backs
Familial tendency

asynchronous vertebral bone growth?
Presented by Fysh P at that 2006 ICA Conference on Pediatrics: Troussier B, et al. Back
pain in school children: A study among 1178 pupils. Scan J Rehab Med, 1994 (26):143-146.
Evaluation

History



Mechanism of injury
Exacerbating factors
Frequency, duration & severity of the pain
Kids can be poor historians…



Establish a time-line using events (birthdays, holidays)
Inquire about specific tasks (climbing stairs, running) to
help identify neurological changes
Ask the parents, teachers, other caregivers…
Davies NJ. Chiropractic Pediatrics. London: Churchill Livingstone, 2000.
Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics.
Nashville, TN: November 2006.

Inspection


Postural examination




Cutaneuos lesions (café-au-lait spots, dermal cysts, hairy
patches) may suggest spinal anomoly or tumor
Scoliosis, kyphosis
Gait analysis
Trunk & hamstring flexibility
Neurological exam





Motor strength (squatting, heel- and toe-walking)
Sensory
DTR’s
Nerve root impingement
Upper motor neuron signs
Davies NJ. Chiropractic Pediatrics. London: Churchill Livingstone, 2000.
When are x-rays indicated? Lab studies?

Radiographic evaluation is essential


Rule out pathology
Diagnosis and choice of appropriate adjusting protocol
frequently depends on the radiographic findings


eg. spondylolisthesis vs. facet tropism
Lab studies may also be useful

Elevated white count or sedimentation rate (infection,
leukemia)
D'Alessandro MP. Back Pain in Children. Retreived 1 March 2007 from
www.virtualpediatrichospital.org/providers/BackPainInChildren/Summary.shtml
7 Warning Signs for Pediatric Back Pain
1.
Child is <4 years old
Infection or neoplasm are common causes of back pain in this age
group
2.
Back pain causes a functional disability
Children like to play, if the pain causes them to ask to miss sports,
gym or recess, the pain is serious
3.
Duration >4 weeks
Musculoligamentous injuries should resolve in that time
4.
Fever is present
Suggests infection; osteomyelitis should be ruled out
5.
Antalgic posture
Disc herniation (not common in children); can be associated with
bone tumor pain (osteoid osteoma)
6.
7.
Neurologic abnormality
Limitation of motion due to pain
D'Alessandro MP. Back Pain in Children. Retreived 1 March 2007 from
www.virtualpediatrichospital.org/providers/BackPainInChildren/Algorithm.shtml
Back pain was traditionally considered an
uncommon complaint among children and therefore
doctors have been inclined to use every available
test to reach a diagnosis.
It is now recognized that there are many cases of
back pain in children associated with less serious
conditions and the doctor of chiropractic must be
able to distinguish between the two.
Feldman DS, et al. Evaluation of an algorithmic aproach to pediatric back pain. J Pediatr
Orthop. 2006 May-Jun;26(3):353-7.
BACK PAIN
History & Physical Exam
(-) X-rays
Intermittent pain
(+) X-rays
Constant pain
Night pain
Radicular pain
Abnormal neuro exam
Specific diagnosis
Non-specific back pain
MRI
Manage with
chiropractic care
(-) MRI
(+) MRI
Treat as medically
diagnosed
Feldman DS, et al. Evaluation of an algorithmic aproach to pediatric back pain. J Pediatr
Orthop. 2006 May-Jun;26(3):353-7.
A look at chiropractic management…

The most common causes of LBP in children
include:





Schuermann’s disease
Facet tropism
Spondylolysis
Spondylolysthesis
Musculoligamentous injury (vertebral subluxation)
Presented by Fysh P at that 2006 ICA Conference on Pediatrics: Duggleby T, Kumar S.
Epidemiology of Juvenille Low Back Pain – a Review. Disability and Rehabilitation 1997.
19(12):505-512.
Scheuermann’s

Signs/Symptoms



Diagnosis


Fatigue & pain in the upper back
Exaggerated mid-thoracic kyphosis, cervical and lumbar
lordosis and anterior pelvic tilt
X-ray: anterior vertebral body wedging, loss of disc height
and irregularity of the vertebral end-plates (3 or more
adjacent vertebrae)
Management



Adjustments and soft tissue therapy
Stretch hamstrings & strengthen abdominal muscles
Strengthening exercises for the back
Pediatrics, 2002. & Fysh P. Low Back Pain in Children. Presented at that ICA
Conference on Pediatrics. Nashville, TN: November 2006.
Facet Tropism

Signs/Symptoms


Diagnosis



Specific site of palpable tenderness in the lumbar region
X-ray: sagittally oriented facet which correlates w/ the side
and level of pain (L4/5, L5/S1 normally coronal)
Essentially a lumbar lig. sprain; overuse; facet syndrome
Management

Adjustments




Avoid the sagittal facet - already hypermobile
Side posture may exacerbate symptoms; should be avoided
Strengthening exercises (abdominals)
Short-term limitation of activities

Avoid hyperextension and rotation of the lumbar spine
Pediatrics, 2002.
Spondylolysis

Signs/Symptoms



LBP aggravated by activity; asymptomatic in some cases
Increased lumbar lordosis, hamstring tightness, gait
abnormalities
Diagnosis

X-ray: A-P, lat., & oblique



CT, MRI or bone scan may be necessary
Uni- or bilateral, acquired interruption of the pars; stress Fx
Management

If acute, bed-rest and restriction of activities


Allow Fx to heal before displacement occurs
Radiographic follow-up yearly to assess progression

Every 6 months in the adolescent (increased risk of slippage)
Pediatrics, 2002.
Spondylolisthesis

Signs/Symptoms




Often asymptomatic in children
During or after growth spurt: dull ache in the LB, buttocks
and thighs during or after physical activity
Flattening of the post. sacrum and pelvis, shortening of the
trunk, forward translation of the chest, lumbar
hyperlordosis, changes in gait
Diagnosis

X-ray: anterior vertebral slippage


Myerding grading (1-5)
Management


Grades 1-2: carefully supervise activities
Grades 3+: refer for evaluation for possible surgery
Pediatrics, 2002.
Musculoligamentous Injury - Subluxation

Subluxation is the most common cause of
back pain seen in the chiropractor’s office
The chiropractor must, however, be careful to
include all possible differentials in their clinical
thinking…
 Avoid prolonged, painful, frustrating, expensive
programs of care d/t inaccurate diagnosis





The Chiropractic Century: Backpack Alert; Sandman Triathalon. J
Am Chiropr Assoc: JAN 2003(40:1): 48-49.
Hayden JA, Mior SA, Verhoef MJ. Evaluation of Chiropractic
Management of Pediatric Patients with Low Back Pain: A
Prospective Cohort Study. J Manipulative Physiol Ther: JAN
2003(26:1): 1-8.
Devonshire, Zielonka K, King L, Mior SA. Adolescent Lumbar
Disc Herniation: A Case Report. J Can Chiropr Assoc: MAR
1996(40:1): 15-18.
Kent C. Radiology in Pediatric Spine Pain. Chiropr Pediatr: APR
1994(1:1): 7-12
Kent C. Pediatric Back Pain: Imaging OCnsiderations. ICA Rev:
NOV/DEC 1991(47:6): 59-63.

Chiropractic Management of Common Conditions

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