15. Pediatrics




At a time when adult use of complementary and alternative medicine (CAM) continues to increase, 1,2 with chiropractic the most widely used nonallopathic professional service, 3 one would expect commensurate use in children. Moreover, with increasing concerns about the safety, effectiveness, and long-term outcomes of several types of pediatric medical interventions, 4 particularly those involving the use of psychotropic medications, many parents are seeking alternative approaches for the care of their children, 5 often without telling their medical pediatricians. 6 In one study on the use of CAM therapies for children, the most common types were self-care methods such as herbs, prayer healing, high-dose vitamin therapy and other nutritional supplements, and folk and home remedies, along with two professionally administered interventions: massage therapy and chiropractic. 7 In a cross-sectional survey study by Lee and colleagues8 on chiropractic care of pediatric patients, an estimated 420,000 pediatric visits took place in the Boston metropolitan area alone in 1998, representing a health care expenditure of approximately $14 million.

In this introductory chapter, the biomechanical features unique to the pediatric spine are reviewed, which provide the rationale and foundation for the discussion on pediatric adjusting, the hallmark of pediatric chiropractic care. 9,10 A series of case presentations follows, along with an examination of current research.


BIOMECHANICAL CONSIDERATIONS

The pediatric spine has unique biomechanical features that distinguish it from the adult spine, particularly with regard to its greater flexibility of both soft and hard tissues. These factors are incorporated into the process of detecting and correcting spinal subluxations in the pediatric patient. Inattention to these differences may lead to misdiagnosis and iatrogenesis (i.e., causation of an adverse condition as the result of a health intervention). For example, normal physiologic ligamentous laxity of the pediatric spine may result in a false impression of subluxation of C2 on C3. Attempt at correction through the application of a high-velocity, low-amplitude (HVLA) thrust would be inappropriate for this pseudosubluxation. On the other hand, true instability of C2 on C3 may be misdiagnosed if the chiropractor is not aware of the limits of physiologic ligamentous laxity in his or her patients. Both situations may have serious consequences.



Central to the uniqueness of pediatric spinal biomechanics11 is the capacity for active growth and remodeling. The development of the neuromusculoskeletal system is multifactorial, with ongoing dynamic interactions at the molecular and cellular levels, as well as increasingly complex processes of control over developing tissues, organs, and systems. Embryogenic development is characterized by morphogenesis (formation and growth of bodily structures) involving programmed development of the embryonic cells of the endoderm, mesoderm, and ectoderm. Abnormal progression of the previously listed processes (i.e., malformation, deformation, disruption) may lead to structural defects, particularly in the spine and spinal cord. 12 Understanding the spine’s growth process and potential alterations in this process is an essential aspect of pediatric chiropractic.


Malformation, Disruption, and Deformation

Malformation results from dysfunctional embryogenesis of a specific anatomic structure. Once a malformation is anatomically established, the asymmetry may continue, resulting in adverse spinal development throughout the fetal and postnatal periods. The malformation will affect three-dimensional development and growth of the individual, contributing to dysfunction.

Disruption results from the destruction of a normally formed structure. The cause may involve altered growth patterns resulting from trauma, infection, tumors, or metabolic alterations. This condition involves the limbs more frequently than the spine during the fetal stage.

Deformation results from altered structure (and hence function) of normally developed structures during the fetal period, the postnatal period, or both. The nature of the deformity is contingent on the extrinsic and intrinsic properties of the structure, as well as the forces involved. For example, deformations may develop whenever normal movements, whether prenatal or postnatal, are constrained.


CHIROPRACTIC APPLICATIONS

How do the biomechanical features of growth and the potential abnormalities involved (i.e., deformation, malformation, disruption) become important considerations for the doctor of chiropractic? An example is the common use of leg length measurements, sometimes used by chiropractors as an indicator of lumbosacral subluxation. Because children can have asymmetrical growth in the long bones of the legs, interpreting leg length inequalities should always be augmented by other procedures. Similarly, using orthotics in young children should also be approached with caution.

A fetus may undergo physical alteration if constrained for a sufficient period. For the developing fetus, several factors are associated with uterine constraint. These factors include intrauterine (i.e., multiple fetuses) and extrauterine (i.e., increased abdominal and pelvic muscle tone) factors, as well as aberrant fetal position (i.e., malposition, malpresentation). The range of deformities and their health consequences (short- and long-term) may not yet be fully appreciated, particularly for adverse fetal presentation. Larry Webster (1937–1997), a pioneer in chiropractic pediatrics, advanced a technique for altering adverse fetal presentation. 13 The Webster technique is described by Forrester and Anrig14 and taught in the postgraduate program of the International Chiropractic Pediatric Association (ICPA).


Adaptability

The ability of the pediatric spine to adapt to stresses is much greater than that of the adult spine. This adaptability can be attributed to the tissue plasticity and growth potential of the pediatric spine, which permit children to maintain a high level of functionality despite considerable structural dysfunction. Chiropractors experienced in detecting and correcting subluxation in the pediatric patient are sensitive to minor structural alterations in the developing child by virtue of their hands-on approach.



Malleability

In addition to the active process of adaptability, the pediatric musculoskeletal system has malleability; that is, it may be deformed with the application of external forces. In the past, some cultures have applied this principle in destructive ways that have caused aberrant structure in children, such as binding the feet of Chinese baby girls to limit growth and molding the skulls of young Chinook Indians with leather splints. In general, forces applied inappropriately will have detrimental effects.


Hypermobility

The physiologic range of motion of the pediatric spine is much greater than that of the adult as a result of differences in the ability of soft tissue structures to act as restraints, as well as differences in facet joint orientation. An appreciation of hypermobility in the pediatric spine will assist the pediatric chiropractor in his or her clinical assessment procedures and will lead to appropriate modifications in adjusting procedures. An example is the pseudosubluxation of C2 on C3 mentioned previously. Unlike hypermobility in adult spinal joints, this normal physiologic hypermobility in the child will not result in pathologic changes when subjected to normal or appropriately delivered forces.


Changing Spinal Contours

The sagittal spinal curvature of the pediatric spine begins as a C-shaped arc. The lordotic cervical and lumbar curvatures form gradually with spinal development. These secondary curves have considerable biomechanical relevance, because the transitional regions are sites where stress concentrates and are therefore more susceptible to developing vertebral subluxations. During periods of rapid growth, such as the typical adolescent growth spurt, the spine may be susceptible to both rotational and coronal plane deformities, potentially resulting in subluxations or scoliosis.


Changing Applied Forces


The infant’s head is relatively large compared with the body mass. As a result, the pediatric patient’s cervical spine experiences relatively larger forces during acceleration or deceleration compared with the adult patient. In situations involving vigorous shaking of a baby during play, or in cases of abuse, the pediatric patient is vulnerable to injury. The types of injuries sustained in patients undergoing whiplash are well documented. 16 Controversy exists as to the extent of injuries sustained from low-versus high-impact collisions. For the pediatric patient, forces involving even relatively low impact collisions can have significant consequences, due, in part, to the lack of stabilization of the cervical spine in the immature neuromusculoskeletal system. Although myelination of the central nervous system is completed during the first 2 years of a child’s life, development of balance and coordination continues well into adulthood. As a result, the child’s musculoskeletal system has an increased risk of injury and consequent predisposition to structural abnormalities.


SCOLIOSIS


When scoliosis develops in the adolescent spine, the resultant biomechanical stresses can cause permanent wedging of the vertebral bodies. Once significant deformation occurs, the curvature cannot be reversed by nonsurgical means. Aside from the pain and structural imbalances that patients with scoliosis can endure, it must also be understood that the most severe cases of scoliosis can involve mechanical pressure on the heart and lungs.


Nottingham Theory

Research has not determined the cause of AIS, but genetic predisposition may play a role in some cases (Figs. 15-1 and 15-2). One concept in the pathogenesis of AIS is the dinner plate-flagpole theory as proposed by the Nottingham group. 17 Briefly, the concept involves developmental disturbance in the central nervous system, which causes asymmetry of trunk muscle function as a result of asymmetrical central pattern generators in the spinal cord. During normal two-legged walking, rotation-inducing forces arise in the pelvis (the dinner plate) with counter-rotational forces in the upper trunk as a result of muscle action. The central pattern generators in the spinal cord control spinal rotators attached to ribs. Failure of control leads to failure of rotational control of the spine. A biomechanical breakdown ensues, resulting in the three-dimensional spinal deformity of scoliosis.








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Fig. 15-1

Sixteen-year-old adolescent with scoliosis.









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Fig. 15-2

Forty-seven-year-old mother of patient depicted in Fig. 15-1 with scoliosis. The degenerative changes at the apex of the curvature are noted.


Subsequently, the biomechanical features of the pediatric spine as previously discussed (e.g., growth, malleability, etc.), together with gravity, add to the neuromuscular asymmetry to exaggerate spinal curve progression. This concept suggests a rationale for care through motor control function by balancing the healthy trunk dynamically through activating nerve afferents of trunk muscles, tendons, and joints. This proprioceptive mechanism may involve rewiring during the process of learning. Other potential neurologic causes of central pattern asymmetry initiating AIS may arise in the spinal cord or higher centers. Pediatric chiropractic care is consistent with this theory. Recent research has demonstrated that spinal adjustments activate mechanoreceptors, 18 as well as affect brain function. 19


PALPATION AND ADJUSTMENT OF THE PEDIATRIC PATIENT

As with all patients, chiropractic pediatric care begins with a thorough history and examination. Discussing all the salient features of such an undertaking is beyond the scope of this chapter; the reader is therefore referred to the relevant chapters13,20 in Plaugher’s Textbook of Clinical Chiropractic: A Specific Biomechanical Approach and Anrig and Plaugher’s Pediatric Chiropractic for a more complete discussion. This introductory chapter will address the palpation and adjustment of the pediatric patient.


Palpation

Static and motion palpation are core procedures in examining the chiropractic patient, pediatric or adult. Static palpation involves detecting edema or bogginess in musculature, as well as anatomic sites of tenderness. Tenderness is often present in regions of hypermobility as a result of a compensation for segments or regions of hypomobility. Motion palpation involves two types: end-play motion palpation and intersegmental range of motion. Both types warrant further investigation because the reliability of palpation has demonstrated mixed results. 21,22 (See Chapter 10 for a detailed discussion of palpation research.) Posteriority, as detected on flexion-extension motion palpation of the spine from C2 to S2, is the most common listing (specific description of abnormal joint position of movement) in the newborn and infant, although lateral flexion dysfunction is generally not a major finding. Spinous rotation is not as common in the young spine as it is in adults. However, this problem should be suspected in cases of rotational trauma to the spine or when long-term vertebral malposition exists as a result of compensation for a segmental dysfunction elsewhere in the spine.


Adjustment

Adjustment procedures are frequently modified for the adult patient based on factors that include clinical presentation, size, and patient comfort. This practice also holds true for the pediatric patient. The following discussion of pediatric adjusting considers the age and size of the patient, the importance of specificity of contact points, adjusting apparatus, positioning, and thrust characteristics for the pediatric patient. 23


AGE-RELATED FACTORS

In addition to clinical findings, adjusting procedures for the pediatric patient are guided by the age and size of the patient, particularly regarding the application of force. Older children are adjusted similarly to young adults. In much younger patients, force modification, table positioning, and clinician contact points must be reconsidered to provide effective chiropractic care. The amount of force needed to produce the desired movement or repositioning (or both) of a subluxated segment is generally less in smaller patients.

Young toddlers have special needs as they begin to demonstrate increased muscle control, as well as a will of their own. These factors create additional complexity for the chiropractor, thus rapport must be developed with the young patient so that he or she will follow guidance to relax and remain still before the adjustment. Clinicians should not attempt to overcome these challenges by treating the patient with suboptimal care or specificity or by forcing the patient to submit to procedures against his or her will. Communication and reassurance appear to be the only reasonable way of surmounting these difficulties. Communication may be facilitated in a number of ways. For example, children who have seen their parents being adjusted may be more receptive to participate in the process once their turn arrives. For infants, an explanation of the adjustment process is provided only to the parent.

Because of its smaller dimensions, the pediatric spine requires special care with respect to specificity of segmental contact points. This requirement is necessary to ensure that the appropriate segments are adjusted and to avoid introducing forces into adjacent normal or hypermobile functional spinal units. To achieve the desired level of specificity, clinicians may need to modify their adjusting methods by using smaller digits as contact points. For example, the lack of specificity seen in the double-thenar contacts or the anterior dorsal adjustment makes them unsuitable for the small child’s spine.


ADJUSTING OPTIONS FOR THE PEDIATRIC PATIENT

Adjusting the pediatric spine requires the utmost of a chiropractor’s psychomotor skills. Modification of adjustive technique is an essential aspect of pediatric care, with these modifications based on the size and age of the patient, as well as the functional segment to be adjusted. Adjustments may be performed prone, seated, or in a lateral recumbent or supine position.


Cervical Spine

The cervical spine, for example, can be adjusted in the prone position with the distal end of the fifth digit on a contact site, such as the C2 spinous process. This type of contact addresses the need for specificity on the small cervical spinous processes and the resulting short-lever adjustment. This type of adjustment will have a line of drive directed primarily from posterior to anterior and inferior to superior, with an arcing movement through the plane line of the intervertebral disk (IVD) and facet articulations. If the clinician’s hands are small enough and the patient is older, then the pisiform contact can be used on the same segments. If specificity cannot be achieved, then the procedure is contraindicated. Adjustments to the atlas in an infant can be achieved by using a thumb contact. The patient can be seated on the lap of a parent or assistant. The cervical chair can also be used if the child is large enough. The anterosuperior occiput can be adjusted in the supine position. An adjustment for an anterosuperior condyle subluxation (in hyperextension) may use a small-sized condyle block to support the posterior ring of the atlas and the inferior cervical segments. The thrust is made from anterior to posterior with the contact at the glabella of the frontal bone to achieve flexion of the C0-C1 functional spinal unit.

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Aug 22, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on 15. Pediatrics

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