Portland Chiropractic Groupocanow.com/images/uploads/Elise Hewitt - Notes... · Is Pediatric Chiropractic Care Safe? Is Pediatric Chiropractic Care Safe? ! Todd et al performed a

1

History Taking, Physical Examination and Spinal

Adjusting Techniques for the Young Pediatric Patient

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

© 2013 Elise G. Hewitt, DC

Portland Chiropractic Group 2031 E. Burnside Street

Portland, Oregon 97214 503.224.2100

www.PortlandChiropracticGroup.com www.DrEliseHewitt.com

[email protected] © 2013 Elise G. Hewitt, DC

2

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


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).


3

Overview !  Is chiropractic care safe for children? !  Why children need chiropractic care !  Etiology of joint dysfunction in children !  History taking for the pediatric patient !  Examination techniques for young patients !  Red flags in the history and examination !  When to x-ray the child !  Full-spine adjusting techniques for the pediatric

patient !  Frequency of care for pediatric patients !  How to learn more about pediatrics



4

Is Pediatric Chiropractic Care 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.


Is Pediatric Chiropractic Care Safe? !  Kosloff et al looked at incidence rates of VBA stroke

following visits to a chiropractor compared to visits to a primary care physician (PCP). "  Analyzed all VBA strokes using administrative data from

commercially insured and Medicare patients in the U.S. from Jan 2011 - Dec 2013 (1,829 VBA strokes).

"  Concluded: “We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke.”

"  Found significant association between PCP visits and VBA stroke, attributed to patients seeking care for symptoms of arterial dissection (HA, neck pain).

"  Side note – chiropractic visits did not include manipulation in 33% commercial and 50% Medicare populations, so inaccurate to use chiropractic visit as a measure of exposure to manipulation.

Kosloff TM, Elton D, et al. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Ther. 2015;23:19.


5


!  Thiel et al evaluated incidence of adverse events (AE) following spinal manipulation in 19,722 patients (50,276 cervical manipulations) in U.K. "  Found no serious AE. "  Concluded: “…the risk of serious adverse events,

immediately or up to 7 days after treatment, was low to very low.”

Thiel HW, Bolton JE et al. Safety of chiropractic manipulation of the cervical spine: a prospective national study. Spine 2007;32(21):2375-2378.



!  Piper et al looked at mechanical stress and strain on vertebral artery (VA) during cervical ROM and manipulation. "  Found that manipulation was less stressful on the VA

than cervical passive end ranges of motion. "  Strain from both ROM and CMT was well below

published VA failure rates. Piper SL, Howarth SJ, Triano J, Herzog W. Quantifying strain in the vertebral artery with simultaneous motion analysis of the head and neck: A preliminary investigation. Clinical Biomechanics 2014;29:1099–1107.


6


!  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



!  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 "  Estimated 30 million annual pediatric visits to the

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


7


!  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.



!  Doyle did a literature review on the safety of chiropractic manipulative therapy for children. "  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.


8

!  Jevne et al examined compensation claims for chiropractic in Denmark & Norway 2004-2012. "  338 claims filed, with 15% approved for compensation. "  Found children <10y regularly visit DC in both countries

○  In Denmark, 35% of these are infants.

"  Authors stated: “Our data did not reveal a single claim in this age group.”

Jevne J, Hartvigsen J and Christensen HW. Compensation claims for chiropractic in Denmark and Norway 2004–2012. Chiropractic & Manual Therapies 2014 22:37.




!  Todd et al performed a literature review of all reported cases of AE due to “chiropractic and other manual therapies” in infants and children ever published. "  Found 15 serious AE (7 involved a DC), including 3 deaths

(none involved a DC). High-velocity, extensional and rotational SM reported in most cases. Underlying pre-existing pathology was present in the majority of cases.

"  Concluded: 1)“Published cases of serious AE… are exceedingly rare”. 2) Perform thorough history/exam and modify techniques to suit the age, anatomy & physiology of the young patient.

Todd AJ et al. Adverse events due to chiropractic and other manual therapies for infants and children: A review of the literature. Jour Manip Physio Ther 2014.09.008.


9

!  CDC survey showed chiropractic/osteopathic care continues to be the most common doctor-directed complementary and integrative form of health care used by children in the U.S. "  Use of DC/DO manipulation by all children has

increased from 2.8% in 2007 to 3.3% in 2012.

"  A total of 1,854,000 children received DC/DO manipulation in 2012.

Black LI, Clarke TC, Barnes PM, et al. Use of complementary health approaches among children aged 4–17 years in the United States: National Health Interview Survey, 2007–2012. National Health Statistics Reports; no 78. Hyattsville, MD: National Center for Health Statistics 2015.



!  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.



10

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). "  Findings: 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 number of visits ○  43% of all ADE visits involved this age group. ○  13.2 ADEs per 1,000 children given rx in this age group. ○  Most frequently implicated drug in this age group -

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



antibiotics.

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

"  Modified contact "  Modified patient positioning "  Change in velocity "  Altered force "  Modified amplitude of thrust



11

If you want more Pediatrics… About ACA Pediatrics Council:

!  www.acapedscouncil.org

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

!  Includes "  Subscription to Journal of Chiropractic Medicine

(JCM) – both hard copy and digital versions "  Discount on Annual Symposium registration fees "  Listing in locator directory "  Access to list serve


If you want more Pediatrics…

!  9th Annual ACA Pediatrics Symposium "  Part of WFC-NCLC-ACC Super Conference

"  March 14-15, 2017 in Washington, DC

"  Details at www.acapedscouncil.org/events/ and www.dc2017.org

"  Limited space in pediatrics sessions, so if interested register early!


12

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


Tools of the Chiropractic Trade

!  Depending on state, scope of practice includes: "  Manual therapies (manipulation, massage, CST, etc.) "  Physical therapy modalities "  Exercise and postural advice "  Herbal and nutritional supplements "  Lifestyle and dietary advice "  …All to enhance the health of the patient

!  Chiropractors are much more than just spinal adjusters… Chiropractic physicians are doctors who use a natural, integrative, conservative-first approach to healthcare.


13

Clinical Rationale for Manual Therapy Aspects of Chiropractic

! What is chiropractic?

! How does the chiropractic adjustment affect change in the body?


Clinical Rationale for Manual Therapy Aspects of Chiropractic !  Doctors of chiropractic 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.


14

Local Effects of Joint Dysfunction

!  Joint dysfunction can lead to: " Altered biomechanics " Neurological irritation ○  Facilitation or inhibition

" Muscle spasm " Altered hemodynamics " Cellular inflammation "  Pain


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


15

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 manual therapy aspect 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. "  Up to 26% of 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.


16

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

"  There was 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.


17

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

recurrent otitis media (OM) "  Compared to those receiving routine pediatric care,

those receiving manipulative therapy (OMT) had:

○  Fewer episodes of OM ○  Fewer surgical procedures ○  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.


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 "  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.


18

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

infants: "  Compared 117 toddlers who had received

chiropractic care as infants to 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

evaluated changes in blood pressure following spinal manipulation in the upper cervical spine "  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.


19

Systemic Effects of Joint Dysfunction: Research !  Lelic, Haavik, et al in Neural Plasticity 2016 measured

changes in somatosensory evoked potentials in the brain following median nerve stimulation before and after spinal adjustments vs. sham procedures. "  HVLA adjustments to spine/pelvis improved sensorimotor

integration (SMI) in the brain. "  SMI alterations appear to occur in the prefrontal cortex. "  No changes were noted in the passive range of motion

control group.

Lelic D, et al. Manipulation of dysfunctional spinal joints affects sensorimotor integration in the prefrontal cortex: a brain source localization study. Neural Plasticity 2016;2016:3704964;pp1-9.


Causes of Joint Dysfunction in Children ! 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> texting, excess “screen time”


20


Examples of in utero constraint:


21

Malposition &

Malpresentation



22


Forceps Delivery


Vacuum Extraction

23


Caesarean Section

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 5-10% of cases) "  DC offers: ○  Manual therapies – CMT, CST, etc. ○  Lymphatic drainage to promote lymph flow ○  Endonasals ○  Herbal ear drops, natural immune enhancing

supplements ○  Probiotics to repair gut from repeated antibiotics ○  Dietary and lifestyle advice to aid healing, prevent

recurrences © 2013 Elise G. Hewitt, DC

24

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 © 2013 Elise G. Hewitt, DC


25

Pediatric History

!  Informed consent "  Signed by parent or guardian


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

Page 1 of 2

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!

Page 2 of 2

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


26

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


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?


27

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)?

"  If so, what procedures and treatments were provided?


Nutritional and Digestive Health

!  Breast vs. bottle feeding !  If breastfeeding, how is latch?

"  Painful? Clicking? Bilaterally symmetrical? !  If bottle feeding, what’s in the bottle?

"  And why?

!  Frequency of feeding "  How many hours between feedings or how

many feedings per day

!  Length of time/amount per feeding !  Appetite?


28

Nutritional and Digestive Health

!  Issues with weight gain? !  Food sensitivities?

"  Did Mom have to change her diet while nursing?

!  Issues with gassiness or spitting up? !  Bowel Habits !  Medications/Vitamins/Fluoride

"  Baby and Mom


Growth and Development

!  Attitude !  Sleep habits !  Preference for head rotation or head tilt? !  Likes (or liked) tummy time? !  Sports, activities, hobbies


29

Growth and Development

!  Gross motor development !  Fine motor development !  Language development !  Cognitive development !  Social skills development


Normal Pediatric Developmental Milestones


30





31

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?



32

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


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


33



34

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 "  Observe symmetry of cranial vault (see next slide)


Pediatric Examination !  Symmetry of cranial vault/face

"  Look at shape of cranium - note flat spots, asymmetries

"  Evaluate axial, coronal and sagittal planes "  Look for symmetry in eyes, ears, cheekbones "  Look for alignment of bridge of nose, base of

nose, chin in sagittal plane


Axial Coronal Sagittal

35

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

abnormalities "  Evaluate quality of suck and gag reflex

!  Eyes "  Symmetrical light reflexes? "  PERRLA "  Red reflex present? "  Tracking normal?


36

Pediatric Examination !  Lymph node evaluation

"  Anterior cervical, posterior cervical, inguinal chains

!  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


37

Otoscopic Evaluation of Tympanic Membrane !  Overview article 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


Pediatric Examination !  Abdomen

"  Palpate for major organs "  Remember - most common cancer in infants is

Wilms tumor (nephroblastoma); make sure palpate region of kidneys.


38

Pediatric Examination !  Orthopedic highlights

"  Hips: Barlow’s, Ortolani’s tests (up to 3 months of age) ○  Allis sign (aka Galeazzi test) if older than 3

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


Newborn Neurological Examination Website !  From the University of Utah School of

Medicine !  Video clips of different aspects of

pediatric neurological examination "  Broken down by age group "  Includes primitive reflexes, cranial nerve

evaluation, motor, tone, DTRs, etc. http://library.med.utah.edu/pedineurologicexam/html/home_exam.html


39

Cranial Nerves

! Most evaluated by observation !  Example: suck reflex

"  Involves CN 5, 7, 9, 10, and 12

!  Example: eye movements (via tracking or Doll’s Eyes Reflex) "  Involves CN 3, 4, and 6 " Doll’s Eye Reflex: eyes will rotate in

opposite direction of head rotation


Cranial Nerves

! CN I – Olfactory " Generally not evaluated

! CN II – Optic " Observe response to light

! CN III – Oculomotor " Observe eye movements

! CN IV – Trochlear " Observe eye movements


40

Cranial Nerves

! CN V – Trigeminal " Observe facial and suck movements

! CN VI – Abducens " Observe eye movements

! CN VII – Facial " Observe facial and suck movements

! CN VIII – Auditory " Observe response to sound


Cranial Nerves

! CN IX – Glossopharyngeal "  Evaluate suck reflex and gag reflex

! CN X – Vagus "  Evaluate suck reflex and gag reflex

! CN XI – Spinal Accessory " Observe trapezius muscle tone

! CN XII – Hypoglossal "  Evaluate suck reflex and tongue position


41

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

42

Primitive Reflexes


reflex !  Rooting reflex !  Suck reflex !  Moro/Startle reflex !  Palmar/Plantar

reflexes !  Placement test

!  Stepping test !  Tonic neck reflex

(aka Fencer reflex)


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

Tonic Neck/Fencer Reflex


43

Primitive Reflexes





(aka Fencer reflex) !  Babinski reflex !  Galant test !  Perez test


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


44

Primitive Reflexes





(aka Fencer reflex) !  Babinski reflex !  Galant test !  Perez test !  Vertical suspension

test



45

Red Flags*: Infants – Immediate Referral Necessary! !  Inability to rouse the child !  Bulging or sunken fontanelle !  Fever >38˚C (100.4˚F) rectally in a child <90

days of age !  Signs of dehydration and/or decreased fluid

intake of 50% or greater over a period of 24 hours

(continued next slide)

*From Hawk C, Schneider MJ, Vallone S, Hewitt EG. Best practices for chiropractic care of children: a consensus update. Jour Manip Phys Ther 2016;39(3):158-68.


Red Flags: Infants – Immediate Referral Necessary! !  Acute weight loss exceeding 5% of body

weight !  Persistent inconsolable high-pitched crying

or a weak cry with drowsiness !  Asymmetrical thigh folds, positive Ortilani

and Barlow’s tests


46

Red Flags: Children of Any Age - Immediate Referral Necessary! !  Petechial or purpuric

rash !  Dyspnea, which may

be accompanied by nasal flaring or significant increase in respiratory rate

!  Sudden onset or persisting acute abdominal symptoms

!  Persistent vomiting

!  Bile-stained vomiting !  Convulsions,

particularly if no prior history or associated with head trauma

!  Cold, pale white distal lower extremities and or oral cyanosis

!  Pallor


Red Flags: Children of Any Age - Immediate Referral Necessary! !  Fever, chest pain,

altered mental status or other neurological findings in a child with Sickle Cell Disease

!  Fever of 40˚C (104˚F) or higher, particularly if spiking

!  Bone fracture or dislocation

!  Hot, swollen, tender joints, especially if the child refuses to bear weight

!  Other orthopedic emergencies such as slipped femoral epiphysis or Perthes' Disease

!  Fecal blood


47

Red Flags: Signs of Potentially Serious Illness - Refer &/or Co-Manage

!  Loss of developmental milestones

!  Persistent vomiting !  Persistent diarrhea !  Recurrent fevers

!  Unexplained bruising without trauma or suspicion of child abuse

!  New onset strabismus !  Slurred speech !  Personality change


Red Flags: Signs of Potentially Serious Illness - Refer &/or Co-Manage

!  Headache that wakes child at night

!  Scoliosis greater than 20 degrees

!  Positive neurological signs such a Babinski, Hoffman's, absent reflexes, motor weakness

!  Unexplained weight loss

!  Gait disturbance !  Parent suspects

chemical substance abuse

!  Suicidal ideation


48


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


49

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?


- increased flexibility of tissues

- smaller point of contact - decrease compared to adult

- increase compared to adult

- decrease compared to adult - smaller joint space

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 computerized 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.

50

Hot off the Presses…

!  Literature review of forces used in common chiropractic techniques for children: "  Specific force data on CMT in children have not yet

been measured "  Theoretical safe upper limits (proposed by Marchand): ○  <3m: ~11N 3-23m: ~22N ○  2-8y: ~55N 8-18y: ~90N

"  Concluded “…technique selection and application… are typically modified in force and speed to suit the age and development of the child.”

"  Also concluded we need more research in this area. Todd, AJ et al. Forces of commonly used chiropractic techniques for children: a review of the literature. Jour Manip Phys Ther 2016 39(6):402-410.


Adjusting Technique Modifications for the Pediatric Patient ! Contact points ! Audible release !  Be flexible ! Make it fun!


51

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 Technique by Region: Sacroiliac Joints ! Newborn-Infant

"  Evaluation ○  Observe gluteal crease ○  Observe gluteal folds ○  Observe thigh folds ○  Motion palpate SI joints and sacral segments

" Adjustment ○  Prone assisted (aka Leg as Lever) ○  Prone drop


52

Pediatric Adjusting Technique by Region: Sacroiliac Joints !  Toddler-Preschooler

"  Evaluation ○  Evaluate leg length (at extension and 90˚ flexion) ○  Evaluate maximal knee flexion ○  Observe buttock height (pockets and pants seam) ○  Motion or prone palpation SI joints and sacral

segments

" Adjustment ○  Prone assisted (aka Leg as Lever) ○  Side posture, when big enough


Pediatric Adjusting Technique by Region: Lumbars !  Newborn-Infant

"  Evaluation ○  Palpate P->A translation prone with baby across lap ○  Non-palpating hand supports chest and distal

shoulder

"  Adjustment ○  Prone “thumb-index finger” thrust with child in same

position ○  3 parts: impulse with palpating hand, slight

spreading of legs, slight lift with non-palpating hand


53

Pediatric Adjusting Technique by Region: Lumbars !  Toddler-Preschooler

"  Evaluation ○  Palpate lumbar spine with child sitting on

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

○  Motion or prone palpation in all ranges of motion

" Adjustment ○  Prone assisted (aka Leg as Lever) ○  Side posture, when big enough


Pediatric Adjusting Technique by Region: Thoracics !  Newborn-Infant

"  Evaluation ○  Palpate P->A translation with baby prone on

table, 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 translational adjustment accomplished in

several ways: hanging distraction, against doctor’s chest, parent’s chest or prone on table

○  Double thumb, single thumb, covered thumb or fingertip


54

Pediatric Adjusting Technique by Region: Thoracics !  Toddler-Preschooler

"  Evaluation ○  Prone on table or on parent, or sitting on parent’s or

doctor’s lap ○  Motion or prone palpation in all ranges of motion

"  Adjustment ○  Bilateral or unilateral pisiform/knife-edge ○  Upper thoracics: covered thumb or combination

adjustment ○  Lower thoracics: often easier side posture due to

extreme flexibility ○  Supine/anterior – give stuffed animal to hug


Pediatric Adjusting Technique 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 ○  Takes very little force; often releases prior to impulse ○  Lower Cervicals: supine rotation or lateral flexion

correction ○  Atlas: correct laterality with fingertip contact ○  Occiput: unilateral or bilateral (see next slide)


55

Pediatric Adjusting Technique by Region: Occiput !  Unilateral restriction

"  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 "  Evaluation: palpate joint play ○  Compare side-to-side

"  Adjustment: add impulse in same direction


Pediatric Adjusting Technique by Region: Occiput !  Bilateral restriction

"  Patient supine "  Place roll under neck to support cervical spine "  Contact forehead with bilateral thenars or

unilateral hypothenar "  Contact occiput with index & middle fingers if

using thenars or opposite hand if using hypothenar "  Evaluation: palpate joint play A->P and S->I ○  Remember C0-C1 motion is like a bowl

"  Adjustment: add impulse in same direction ○  Can use portable drop piece


56

Pediatric Adjusting Technique by Region: Cervicals !  Toddler-Preschooler

"  Evaluation ○  Supine on table, supine across parent’s lap, supine on

supine parent, or sitting on parent’s lap ○  Motion palpation in all ranges of motion

"  Adjustment ○  Contact with thumb, or PIP or DIP of index finger ○  Correct into direction of restriction ○  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 movement, 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 global range of motion

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

relax


57


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


58

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.


How to Learn More About Pediatrics

!  ACA Council on Chiropractic Pediatrics "  www.acapedscouncil.org

!  ICA Council on Chiropractic Pediatrics "  www.icapediatrics.com

!  9th Annual ACA Symposium on Chiropractic Pediatrics "  Part of WFC-NCLC-ACC Super Conference 2017 "  March 14-15, 2017 in Washington, DC "  Details at www.acapedscouncil.org/events and

www.dc2017.org © 2013 Elise G. Hewitt, DC

59


!  Texts on chiropractic pediatrics "  Neil Davies’ Chiropractic Pediatrics "  Claudia Anrig and Greg Plaugher’s Pediatric

Chiropractic "  Heiner Biedermann’s Manual Therapy in

Children



!  Journal of Clinical Chiropractic Pediatrics "  Published by the ICA’s Pediatrics Council "  Just become open access "  www.jccponline.com/index.html

!  Upledger Institute for Craniosacral training "  1-800-233-5880 "  www.upledger.com


Documents

Portland Chiropractic Groupocanow.com/images/uploads/Elise Hewitt - Notes... · Is Pediatric Chiropractic Care Safe? Is Pediatric Chiropractic Care Safe? ! Todd et al performed a