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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

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abc s of pediatric adjusting

ABC’s Of Pediatric Adjusting

Modifications for the Pediatric Patient

Stephanie C. O’Neill, DC, DICCP

wellness care
“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
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
Joan Fallon

The Child Patient: A Matrix for Chiropractic Care

  • published as a supplement to JCCP

(Vol. 6, No. 3)

  • www.icapediatrics.com
overview
Overview
  • Assessing the pediatric patient
  • Unique features of the pediatric spine
  • Adapting your technique
  • Comfort and Safety
newborn evaluation7
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
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
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
WARNING!

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

Congenital Hip Dysplasia

reverse fencer part 111
Reverse Fencer- Part 1

Heel swing (cont‘d):

  • Compare motion from side to side
    • restricted? twitching?
what if
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
“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
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
Interpreting your findings...

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

interpreting your findings16
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
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...

instrumentation
Instrumentation
  • DP nervoscope & newborns?
    • can‘t sit up
    • lots of skin
    • accuracy?
      • size of probes
      • patient relaxation
  • Old enough to sit still...
atlas fossa reading
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 reading22
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 if23
What if…?
  • Atlas fossa: R 85 L86
  • No other findings in the cervical spine

_ _ _ _ _ _

what if24
What if…?
  • Atlas fossa: R 85 L86
  • No other findings in the cervical spine

S A C R U M

posture analysis
Posture analysis
  • Head tilt
  • Head rotation
  • High shoulder
  • Scoliosis
  • High ilium
  • Genu varus and valgum
  • Internal & extenal foot rotation
normal development
Normal Development

Normal evolution from bowlegs to knock-knees to normal valgus

2 years 3 years 5 years

static palpation
Static Palpation
  • Taut and tender fibers
  • Muscle spasm
    • common with congenital torticollis
  • Sudoriferous changes
    • stickiness/dryness
  • Temperature
pay attention to the child
Pay attention to the child!
  • They’ll let you know…
    • squirming
    • fussiness
    • clutching at your hand
    • etc.
clinical note
Clinical Note

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

for example
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
Motion palpation
  • Similar to adults but much more subtle
    • ligament laxity, cartilagenous vertebrae
  • Be creative!
gross range of motion
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
Sacrum and Pelvis
  • Gluteal Cleft Deviation
  • Sacral Dimples
  • Dangling legs
  • Gluteal Folds
gluteal cleft check
Gluteal Cleft Check
  • Pinch cheeks together
  • Cleft should be midline
gluteal cleft deviation
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
Sacral Dimples
  • Asymmetry (with fixation of SI joints) suggests pelvic misalignment
  • Palpate S2 to PSIS
other things to note
Other things to note...
  • Dangling legs
    • ilium rotation
  • Gluteal fold observation
    • sacral tilts
older babies and toddlers
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
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
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 features43
Unique Features…
  • Anatomy
  • Biomechanics

MacGregor, 2000

anatomy
Anatomy
  • Underdeveloped cervical lordosis
  • Low vertebral height
  • Horizontal facets (until age 10)
  • Undeveloped uncinates (until age 7)
slide45

lordosis? vertebral height? facets? uncinates?

11 months old 3 years old 5 years old

Taylor & Resnick

biomechanics
Biomechanics
  • Large head
  • Weak muscles
  • Spine is more flexible

MVA injuries

joint end play
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
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

Pediatric Technique

Chiropractic Care for the Pediatric Patient, Fysh

adjusting considerations
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
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
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
Occiput (AS)

Correction

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

Findings

  • Fixation at C1

We’ll add…

  • T&T
  • Instrumentation
  • Etc.
atlas56
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)

clinical note58
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
C2 – C7

Findings

  • Muscle spasm – usually side of spinous process deviation
  • Fixation – spinous does not move away with lateral bend
c2 c760
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
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
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
L1 – L3
  • Sagittal plane, facet joints

Correction

  • Contact mammillary process with a light thumb contact
  • P-A, I-S thrust
l4 l5
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
Sacro-iliac

Correction

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