chiropractic management of common conditions. asthma

Chiropractic Management of Common Conditions

Asthma

Patient Presentation

Parents report: Episodic or persistent coughing Wheezing Shortness of breath Rapid breathing or chest tightness Worse in the evening or early morning hours Associated with triggers

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.

Asthma?

Differential DiagnosisWheezing is not present in all patients with asthma!

Wheezing is not a sign exclusive to asthma Respiratory infections Rhinitis Sinusitis Vocal cord dysfunction

Consider differentials that may cause similar symptoms Foreign body aspiration Cystic fibrosis Heart disease


Diagnosis“In most children, the primary diagnostic

tool is clinical assessment.”

Pulmonary function tests (spirometry) should be performed as soon as possible Unreliable in infants and many preschoolers

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


“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

Patient education Trigger avoidance Drug therapy

Compliance is a major problem Route of administration Frequency of dosing Medication effects Risk or concern of side-effects


Chiropractic Care & Asthma

Evidence is adequate to support the “total package” of chiropractic care as providing benefit to patients with asthma 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? 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?

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

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


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

SummaryChiropractic Management Included: Spinal adjusting (most common modality used)

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

Full spine, ribs, upper cervical

Trigger avoidance & environmental control measures “Evaluation of stress/environment” “Evaluation of environmental pollutants” “Removal of dairy/wheat from diet” “Review of medication/side effects”

Trigger Avoidance 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)


Environmental Control Measures 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


More research is needed but… Avoid dairy/wheat

Highly allergenic… remember the “allergic march”? Dairy in a mucous-producing agent

Limit processed sugars Avoid food additives & preservatives (MSG)

May trigger attacks Relaxation techniques, stress control and reduction

May benefit lung functionFamily 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… Probiotics

May reduce inflammation, reduce allergic symptoms Omega-3 fatty acids

May decrease inflammation Calcium and magnesium

May cause bronchial smooth muscle relaxation and reduces histamine response

Antioxidants (vitamins C and E, selenium, zinc) May reduce allergic reactions and wheezing


Index to Chiropractic Literature 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.


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.

“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

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 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

unrelated to environmental events Cannot be soothed, even by feeding


Etiology? Gastrointestinal?

“Gas” does not seem to be the cause of colic Excessive crying may lead to aerophagia

Psychosocial? Not a sign of a “difficult temperament” Not related to maternal personality or anxiety

Neurodevelopmental? Upper end of the “normal distribution”

same temporal pattern, just more severe Most infants “outgrow it”


Organic Causes?<5% of infants presenting with excessive cryingCNS

CNS abnormality (Chiari type I malformation)

Infantile migraine Subdural hematoma

Gastrointestinal Constipation Cow’s milk protein

intolerance GER Lactose intolerance Rectal fissure

Infection Meningitis Otitis media UTI Viral illness

Trauma Abuse Corneal abrasions Foreign body in the eye Fractured bone Hair tourniquet syndrome


A diagnosis of exclusion…Apnea, cyanosis, struggling to breathe…

Undiagnosed pulmonary or cardiac condition?

Frequent, excessive spitting up… GER, pyloric stenosis?

Lethargy, poor skin perfusion, tachypnea, fever, poor weight gain…

Infection, gastrointestinal disorder, nervous system disorder?

Bruising, fracture… Abuse?


Management?

There is limited or no evidence to support… Simethicone (Mylicon)

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 Low allergen diet (breastfeeding mothers)

Eliminate milk, eggs, wheat, & nuts Hypoallergenic formulas Soy formulas?

May develop allergy to soy Herbal tea

Chamomile, vervain, licorice, fennel, and balm-mint

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 Probiotics (Lactobacillus reuteri)

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”

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 Improvement with SMT Improved parent-reported outcomes with

chiropractic care

No adverse effects were reported


Index to Chiropractic Literature 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 SchemesAccording 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 Genetic Predisposition

Most frequently supported

Bladder Problems Bladder function is normal however, functional bladder

capacity may be less Arginine Vasopressin

Delayed development of a circadian rhythm may result in nocturnal polyuria

Sleep Disorders 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… Familial factors?

Social background, stressful life events, number of changes in family constellation or residences seem to have no relationship

Psychologic factors? 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


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? Positive response: functional bladder disorder

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? Positive response: functional bladder disorder

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?


DiagnosisNot 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 Alarms

Negative reinforcement or avoidance Anxiety, disruptive to family?

May have to be used for up to 15 weeks Effective, low relapse rate

Pharmacological Treatment Not recommended for children under 6 Effective but high relapse rate Side effects

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 Positive Reinforcement Systems

earns “points” for every night he or she remains dry ~> prize

Responsibility training child is given age-appropriate responsibility, in a nonpunitive

way, for the consequences of bed-wetting (strip wet linens from the bed)

Elimination diet Hypnosis Retention control Biofeedback Acupuncture Scheduled awakenings Caffeine restriction


More research is needed but they have been shown to have positive effects…

Chiropractic Care & Enuresis

Evidence is insufficient at this time Promising

Adverse effects were mild and self-limiting


Index to Chiropractic Literature 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 middle-ear 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… Vague symptoms

neither specific nor sensitive for AOM Undue reliance on one feature: redness of the

tympanic membrane Failure to assess tympanic membrane mobility

must use pneumatic otoscopy Inadequate visualization of the typmpanic

membrane 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 “Watchful waiting”

symptomatic treatment for 24 to 48 hours before initiating antimicrobial treatment

Pain management 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)

AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis 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

Decreases the use of antibiotics Reduces cost and adverse effects (diarrhea)

No serious adverse events reported Interrupts the cycle of parental expectations

When are antibiotics most beneficial? <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

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

AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis 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 Due to poor eustachian tube function OR Inflammatory response following AOM

Concerns 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 cloudy tympanic membrane distinctly impaired mobility air-fluid level or bubble may be visible

Pneumatic otoscopy should be perfomed 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 Hearing testing Language testing

Re-examine at 3- to 6-month intervals until 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 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

Antihistamines Decongestants Antimicrobials Corticosteroids

Tympanostomy tube insertion – preferred initial procedure

Adenoidectomy – should not be performed unless a distinct indication exists nasal obstruction, chronic adenoiditis


Not recommended

*may be an option when the parent or caregiver has a strong aversion to impending surgery

Newer Research

Tubes marginally effective in Otitis Media with Effusion 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 meta-analysis. 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

Natural course of the illness? Fewer surgical procedures compared to usual

medial care Parent-reported positive side effects

relaxation, good nap

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.

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

SummaryChiropractic 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

Index to Chiropractic Literature 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

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.

C5 & C6

Differential DiagnosisKlumpke'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 reflexFractured 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


ManagementPrevent 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


Chiropractic Management

More research is needed

Chiropractic adjustments

vs. natural history?

Splinting Active and passive range-of-motion exercises

Recovery

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


Be cautious in predicting full recovery and closely follow affected infants!

Index to Chiropractic Literature 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 Breech or difficult forceps delivery

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.

MOST COMMON

Differentials to consider…LOCAL ETIOLOGY Congenital

Pseudotumor Hypertrophy or absence of

cervical musculature Spina bifida Hemivertebrae Arnold-Chiari syndrome

Otolaryngologic causes 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 PresentationINFANT 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


WorkupClinical 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



Chiropractic adjustments

Parental education Passive stretches Tummy time Positional changes

Car seat, sleeping,etc.

Secondary Effects of Untreated Torticollis Plagiocephaly

asymmetric skull deformity flattening of occiput ~> secondary

flattening of the contralateral forehead

Facial hypoplasia inhibition in the growth of the mandible

and maxilla due to muscle inactivity

Musculoskeletal effects compensatory ipsilateral elevation of the

shoulder cervical and thoracic scoliosis wasting of muscles in the neck


Improve as torticollis resolves

*May take years

Index to Chiropractic Literature 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 plagiocephalypositional head deformity (1/60)

external pressures on the rapidly developing skull from prolonged exposure to one position

2. 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.

EtiologyIf present at birth… In-utero or intrapartum

molding uterine constraint

multiple birth infants birth injury

forceps vacuum-assisted delivery

premature birth Craniosynostosis

If it develops later… Torticollis “Back to Sleep” campaign

Since 1992 there has been a significant increase in the diagnoisis of plagiocephaly one center reported a six-

fold increase (1992-1994)

Subluxation?

“result of static supine positioning”


Examination & Workup

Physical exam Palpate lambdoidal suture Check ear position Assess facial symmetry Observe unilateral bald spot Inspect by arial view

Skull Radiographs and CT? atypical skull pattern moderate-severe skull deformity suspecting craniosynostosis


PHD Synostosis

Differential Diagnosis

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


Management

Preventive counseling Mechanical adjustments Exercises Skull modling helmets Surgery


Early recognition is important

Preferred position ~> torticollis

Most improve within 2-3 months… If parents follow these guidelines

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


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


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)


Chiropractic Management 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.

Index to Chiropractic Literature 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 - EtiologyPrimary Headaches

Migraine majority of primary

childhood headaches see IHS criteria

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

Secondary HeadachesUnderlying CNS pathology

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

http://www.emedicine.com/neuro/topic528.htm

IHS Criteria for Migraine in ChildrenFive 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.Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from www.emedicine.com/neuro/topic528.htm

Classifying Headaches – Temporal Pattern Acute Headache

single episode of head pain without history of previous events Establish whether any neurologic symptoms accompany this HA

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 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…


http://www.emedicine.com/neuro/topic528.htm

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

Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):625-32.

Causes of Chronic-Progressive Headache (Differentials for the Chiropractor to Consider) 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

Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from www.emedicine.com/neuro/topic528.htm

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

Studies have shown that nearly “all children with serious underlying conditions had one or more objective findings on neurologic exam.”

Key features of intracranial disease


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 Rarely have primary headache syndrome Neurologic & fundoscopic exam can be difficult

Acute headache w/ focal neurologic symptoms/signs 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.

Index to Chiropractic Literature 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(Differentials for the Chiropractor to Consider)Pre-Pubertal Infectious

Diskitis Osteomyelitis

Tumors Spinal column Spinal cord

Trauma Falls MVA Some pars defects

Pubertal Tumors

Spinal column or cord Trauma

Spondylolysis/lysthesis Disc herniation Lumbar strain/sprain

Idiopathic 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

volleyball, climbing, golf, basketball, gymnastics Previous back injury Sitting at school Carrying back packs

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 Cutaneuos lesions (café-au-lait spots, dermal cysts, hairy

patches) may suggest spinal anomoly or tumor Postural examination

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. Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

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)

Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006. 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 Pain1. Child is <4 years old

Infection or neoplasm are common causes of back pain in this age group

2. Back pain causes a functional disabilityChildren like to play, if the pain causes them to ask to miss sports, gym or recess, the pain is serious

3. Duration >4 weeksMusculoligamentous injuries should resolve in that time

4. Fever is presentSuggests infection; osteomyelitis should be ruled out

5. Antalgic postureDisc herniation (not common in children); can be associated with bone tumor pain (osteoid osteoma)

6. Neurologic abnormality7. 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 painConstant pain

Night painRadicular pain

Abnormal neuro exam

Non-specific back pain

MRI

(+) X-rays

Specific diagnosis

Treat as medically diagnosed

Manage with chiropractic care

(-) MRI (+) MRI

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

Fatigue & pain in the upper back Exaggerated mid-thoracic kyphosis, cervical and lumbar

lordosis and anterior pelvic tilt Diagnosis

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

Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002. & Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

Facet Tropism Signs/Symptoms

Specific site of palpable tenderness in the lumbar region Diagnosis

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


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)


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


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

Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

Index to Chiropractic Literature 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. asthma

Documents

asthma slide

management of asthma

asthma symptoms

childhood asthma

asthma kenp jp

treatment of asthma

fam physician

kemp ja