Hewitt Handouts 2009 April 6 Per

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Pediatrics for the Chiropractor: SpinalAdjusting and Treatment Protocols for

Common Pediatric Conditions

Presented by:

Elise G. Hewitt, DC, CST, DICCP, FICC

Portland Chiropractic Group

2031 E. Burnside Street

Portland, Oregon 97214

503.224.2100

[email protected]

Tools of the Chiropractic Trade

Depending on state, scope of practice includes: Manual therapies (manipulation, massage, CST, etc.) Physiotherapies Exercise and postural advice Herbal and nutritional supplements Lifestyle and dietary advice

… all to enhance health of child Chiropractors are much more than just spinal

adjusters Chiropractors are doctors

Clinical Rationale for ManualTherapy Aspects of Chiropractic

Care

Chiropractors seek to restore normal biomechanicsto the articulations of the body with the aim ofnormalizing neurological and physiologicalfunction to local and systemic structures related tothe affected joints.

SUBLUXATION

KINESIOPATHOPHYSIOLOGY NEUROPATHOPHYSIOLOGY

HISTOPATHOPHYSIOLOGY

ANGIOPATHOPHYSIOLOGY

MYOPATHOPHYSIOLOGY

Local Effects of a Subluxation

INFLAMMATION

IMPAIRED NUTRIENT DELIVERY& WASTE REMOVAL

MUSCLE SPASM

NERVE FACILITATIONOR INHIBITION

RESTRICTED JOINT MOTION

PAIN

Systemic Effects of a Subluxation

Body has inherent self-regulatory mechanismsHomeostasis = balance

Subluxation can interfere with these mechanisms byaltering function in neurological and vascular systems,creating dis-ease

Dis-ease = imbalance = asymptomatic malfunction

Long-term consequence of dis-ease is diseaseDisease = symptomatic malfunction

Aim of chiropractic is to strengthen host and restorenormal regulatory mechanisms by removing cause ofpathophysiology (subluxation)

Preferably before dis-ease progresses into disease

Systemic Effects of a Subluxation -Research

Leboeuf-Yde, Pedersen et al performed a survey of 5,600 chiropracticpatients in 7 countries to determine the nature and frequency of non-musculoskeletal health benefits associated with their chiropractictreatment. 25% of all 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 tochiropractic intervention: a multination survey. J Manipulative Physiol Ther 2005;28:294-302.

Rosner in a 2003 analysis of the state of pediatric chiropracticresearch found compelling outcomes for otitis media, colic andasthma. More recent studies include promising results for nursingdysfunction, constipation, headaches, neurological disorders (incl.autism, ADD/ADHD)Rosner A. Infant and child chiropractic care: an assessment of the research. Foundation forChiropractic Education and Research. Norwalk, IA. 2003.

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Klougart in cohort study of 316 infants with colic treated in 50 differentchiropractic clinics found significantly reduced symptoms in 92%following three treatments over a 2-week period.Klougart N, Nillson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases.J Manipulative Physiol Ther 1989;12(4):281-88.

Mills et al in RCT involving 57 children with recurrent otitis media (OM)found those receiving manipulative therapy (OMT), as compared to thosereceiving routine pediatric care, had fewer episodes of OM, fewer surgicalprocedures and higher rates of normal tympanograms.Mills MV, Henley CE, Barnes LLB et al. The use of osteopathic manipulative therapy as adjuvant therapyin children with recurrent acute otitis media. Arch Ped Adolesc Med 2003;157(9):861-66.


Bakris et al Journal of Human Hypertension 2007: found thatchiropractic adjustments to the cervical spine created marked andsustained reductions in blood pressure equivalent to the use of atwo-drug combination therapy.Bakris G, Dickholtz M, et al. Atlas vertebra realignment and the achievement of arterial pressuregoal in hypertensive patients: a pilot study. Journal of Human Hypertension 2007;21:347-352.

Haavik-Taylor and Murphy in Clinical Neurophysiology 2006:measured changes in somato-evoked potentials in frontal andparietal lobes of brain following cervical adjustments. Found thatcervical adjustments reduced excessive afferent signals in the brainand altered cortical somatosensory processing and sensorimotorintegration. No changes were noted in the passive range of motioncontrol group.Haavik-Taylor H, Murphy B. Cervical spine manipulation alters sensorimotor integration: asomatosensory evoked potential study. Clinical Neurophysiology 2006;118(2):391-402.

Why Children Need ChiropracticCare

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

Causes of Subluxation

Trauma In utero constraint - including multiples Prolonged or precipitous birth Malposition, malpresentation Assisted delivery - forceps, vacuum extraction, Caesarean section Falls, car accidents, bike crashes, mishandling, etc.

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 subluxation formation exacerbated by prolonged poor posture; ex> “screen time”

Why Children Are Often Unaware ofSubluxations

Ligament laxity

Immaturity of joint structures

Lack of structural/degenerative changes

No repetitive spinal loading

Increased whole body movement

Unique Aspects of the Pediatric Spine

Bone Cartilage vs. osseous tissue Primary vs. Secondary ossification

Soft Tissue Ligament structure

Conclusions Children have the equivalent of an unstable,

hypermobile spine

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Is Chiropractic Care Safe? Boyle et al compared incidence rates of vertebrobasilar artery (VBA)

stroke and chiropractic utilization rates in 2 Canadian provinces from 1993-2004. Found that VBA stroke rates increased without a correspondingincrease in chiropractic utilization. Concluded: “At the ecological level,the increase in VBA stroke does not seem to be associated with an increasein the rate of chiropractic utilization.”Boyle E, Cote P et al. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine.2008;33(4S)Neck Pain Task Force:S170-175.

Cassidy et al looked at incidence rates of VBA stroke following visits to achiropractor compared to visits to a primary care physician (PCP). Lookedat all VBA strokes from 1993-2002 (818 strokes over 100 million person-years). Concluded: “We found no evidence of excess risk of VBA strokeassociated with chiropractic care as compared to primary care.” Just aslikely to suffer a stroke after visiting the PCP as after visiting achiropractor.Cassidy D, Boyle E et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-basedcase-control and case-crossover study. Spine. 2008;33(4S)Neck Pain Task Force:S176-183.

Is Chiropractic Care Safe?

Herzog et al 2002 studied actual forces within vertebral artery (VA) during:1) normal range of motion, 2) diagnostic testing and 3) cervicalmanipulation. Found that maximum forces on VA from manipulation areless than the strain during normal daily neck movements and thatmanipulation is very unlikely to mechanically disrupt the VA.Symons B, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinalmanipulation. J Manipulative Physiol Ther 2002;25(8):504-10.

Thiel et al evaluated incidence of adverse events (AE) following spinalmanipulation 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 nationalstudy. Spine 2007;32(21):2375-2378.


Vohra et al performed a systematic review of the incidence of adverseevents (AE) following spinal manipulation in children. Review covered allliterature for past 110 years. Found 9 cases of serious AE, with estimated30 million annual pediatric visits to the chiropractor.Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinalmanipulation: a systematic review. Pediatrics. 2007;119:275-283.

Miller et al examined 781 pediatric patients under 3 years of age (73.5% ofwhom were under 13 weeks) who received a total of 5242 chiropractictreatments at a chiropractic teaching clinic in England from 2002-2004.85% of parents reported improvement; 7 reported a minor adverse effects;there were no serious adverse effects (reaction lasting >24 hours or needinghospital care).Miller JE, Benfield K. Adverse effects of spinal manipulation therapy in children younger than 3 years: aretrospective study in a chiropractic teaching clinic. Jour Manip Physiol Ther 2008;31(6):419-422.


Modifications are made in adjustive procedure toadapt to the pediatric spine:

Modified contact

Modified patient positioning

Decreased force

Decreased amplitude of thrust

Adjusting Technique Modificationsfor the Pediatric Spine

Speed of thrust Increase compared to adult patient Why? - increased flexibility of tissues

Force of thrust Decrease compared to adult patient Why? - smaller point of contact

Contact Points Audible release Be flexible and make it fun!

Pediatric Adjusting Techniques byRegion

Age ranges: newborn/infant, toddler/pre-schooler and school age

Regions: sacroiliac, lumbar, thoracic andcervical

Pediatric adjusting: spinal examination andadjustive techniques

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Pediatric Adjusting Techniques byRegion - Sacroiliac Joints

NEWBORN-INFANT EVALUATION

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

ADJUSTMENT Leg as lever Prone assisted Prone drop


TODDLER-PRESCHOOLER EVALUATION

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

segments

ADJUSTMENT Leg as lever Prone assisted or drop Side posture, when big enough


SCHOOL AGE EVALUATION (same as toddler)

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

segments

ADJUSTMENT Side posture Prone drop

Pediatric Adjusting Techniques byRegion - Lumbars


Palpate P -> A translation prone across lap Non-palpating hand supporting chest and distal shoulder

ADJUSTMENT Prone “thumb-index finger” with child in same position 3 parts: impulse with palpating hand, slight spread of

legs, slight lift with non-palpating hand



Palpate lumbar spine while sitting on parent’s lap orwhile prone (on parent’s lap, on doctor’s lap, on table)

ADJUSTMENT (same as SI region) Leg as lever Prone drop Side posture, when big enough


SCHOOL AGE EVALUATION

Motion or prone palpation of lumbar spine Watch for “dip” at L4-L5-S1 sp’s - possible

spondylolisthesis; x-ray to confirm

ADJUSTMENT (same as SI region) Side posture Prone drop If find spondy, adjust segment above and have child do

pelvic tilt exercises for life

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Pediatric Adjusting Techniques byRegion - Thoracics


Evaluate P->A translation with baby prone, over edge oftable on doctor’s lap, against doctor’s chest, or againstparent’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 translatory adjustment accomplished in several

ways: hanging distraction, against doctor’s chest, parent’schest or on table.

Double thumb, single thumb, covered thumb or fingertip



Prone on table (preferred) or parent, or sitting onparent’s or doctor’s lap

ADJUSTMENT Prone:

Bilateral or unilateral pisiform/knife-edge Upper thoracics: covered thumb, combo adjustment Lower thoracics: often easier side posture due to

extreme flexibility Supine: give stuffed animal to hug



Prone on table

ADJUSTMENT (same as toddler) Prone:

Bilateral or unilateral pisiform/knife-edge Upper thoracics: covered thumb, combo adjustment Lower thoracics: often easier side posture due to

extreme flexibility Supine: give stuffed animal to hug

Pediatric Adjusting Techniques byRegion - Cervicals


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 Lower Cervicals: supine rotation or lateral flexion correction Atlas: correct laterality with fingertip contact Occiput: unilateral or bilateral (see next slide)

Pediatric Adjusting Techniques byRegion - Occiput Adjustment

NEWBORN-INFANT Unilateral

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

Bilateral Patient supine, roll under neck

Contact forehead with thenars or knife-edge

Line of drive S->I and A->P

Can use toggle drop piece



Supine on table, supine across parent’s lap, or supine on supineparent, or sitting on parent’s lap

ADJUSTMENT Contact using thumb, or PIP or DIP of index finger Supine: rotation or lateral flexion correction Sitting: rotation or lateral flexion correction 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 move, adjust as soon asthey think about doing the move.

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ADJUSTMENT

Both are the same as with an adult, only adjustmentinvolves increased velocity, decreased force andmuch more fun!

About ACA Pediatrics Council

www.acapedscouncil.org Membership is $85/year Includes quarterly newsletter, discount on Annual

Symposium registration fees, listing in locatordirectory, access to list serve

This year’s Pediatrics Symposium: October 30- 31, 2009 in St. Louis Part of ACA Super Conference with several other councils Sessions on pediatric adjusting, nutrition, and more

Conditions that Respond Well toChiropractic Care

Colic/irritability

Plagiocephaly

Sutural ridging

Torticollis/Head tilt

Brachioplexis irritation

Poor sleep

Nursing dysfunction

Gastroesophageal refluxdisease (GERD)

Chronic constipation

Sleep apnea or snoring

Asymmetrical crawl orgait

Neonate-Infant


Toddler and Pre-School Age Child Chronic ear infections Chronic upper respiratory infections Asthma Growing pains/foot or leg cramping Primary or secondary diurnal or nocturnal enuresis Incontinence (bowel or bladder) Pervasive developmental disorder*

*including autism, sensory integration disorder, ADD, ADHD, learning disabilities


School-Age Child & Adolescent Back pain Neck pain Headaches Scoliosis Gait Abnormalities Extremity injuries (chronic ankle sprains, knee pain, shoulder

pain, etc.) Chronic constipation Chronic abdominal pain Chronic upper respiratory illness

Frequency of Care for Infants andChildren

Children respond much more quickly than adults, soinitial treatment plan usually relatively shortcompared 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

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Partnership with Pediatricians

Pediatric medical care and pediatric chiropracticcare complement each other “crisis care” vs. “quality of life care”

Example: child with chronic ear infections MD offers antibiotics if “crisis” (only 5% of cases) DC offers:

Adjustment and craniosacral therapy Lymphatic drainage to promote lymph flow Ear drops, natural immune enhancing supplements Probiotics to repair gut from repeated antibiotics Dietary advice to aid healing, prevent recurrences

Condition-Specific Treatment Toolsand Protocols

Otitis Media

Asthma

Congenital Torticollis

Clinical Rationale

State of Research

Treatment Tools

Treatment Protocols

Chronic Otitis Media

http://emedicine.medscape.com/article/803090-overview

Chronic Otitis Media -Clinical Rationale

Fluid in the middle ear cavity drains through theEustachian tube (ET)

Constriction of the ET may lead to OM

ET diameter is controlled by the surrounding tensor velipalatini muscle (TVP) innervated by the trigeminal nerve (CN V)

Secondary regulation by the levator veli palatini muscle(LVP) and the salpingopharyngeus muscle (SP) both innervated by the vagus nerve (CN X)

Superior cervical sympathetic ganglion has communicating fiberswith the vagus nerve


Irritation of CN V or CN X can lead to increased tone in TVP,LVP, SP muscles Irritation of the superior cervical sympathetic ganglion secondary to a

cervical subluxation can affect CN X Cranial subluxations can create irritation of CN V

Increased tone of these muscles can result in constriction orclosure of the ET

Closure of the ET creates pressure changes and fluid buildup inthe middle ear = otitis media w/effusion (OME) Both pressure & effusion can be painful, despite lack of infection

Eventually, fluid may become infected with pathogen (viral orbacterial) = acute otitis media (AOM)


Antibiotics often used at this point, but since the underlyingcause of effusion has not been addressed, fluid often remainsand recurrent infections occur. This typically leads to repeated courses of antibiotics

Spinal and cranial adjustments remove the subluxation, whichrelieves the neurological irritation (of the trigeminal, vagusnerves and/or superior cervical sympathetic ganglion), whichreleases the TVP/SP/LVP spasm, which allows fluid to onceagain drain through the ET, relieving the root cause of theOM.

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SUBLUXATION

MYOSPASM IN TENSOR VELI PALATINI MUSCLE

OCCLUSION OF EUSTACHIAN TUBE

POOLING OF FLUID IN MIDDLE EAR

BACTERIAL/VIRAL GROWTH AND INFECTION

ANTIBIOTICS TO KILLBACTERIA

PATHOGENREGROWTH

REPEATED USEOF ANTIBIOTICS

How a Subluxation Can Lead to Otitis Media Otitis Media -State of Research

RCT, case series and case studies for over 450 patientssupport theory that manual care can help children with OM

Most cases resolve within 10 days, fewer than 5adjustments

Many require only 1-2 treatments

Remember, Sackett said “The practice of evidence basedmedicine means integrating individual clinical expertise with the bestavailable external clinical evidence from systematic research.”Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine:what it is and what it isn't. BMJ 1996;312:71-72 (13 January).

Otitis Media -State of Research

Mills MV, Henley CE, Barnes LLB, Carreiro JE, Degenhardt BF. Theuse of osteopathic manipulative treatment as adjuvant therapy inchildren with recurrent acute otitis media. Archives of Pediatrics andAdolescent Medicine 2003; 157(9): 861-866.

RCT of 57 patients (25 in intervention group, 32 in control) with hx ofchronic OM; intervention group received OMT with routine pediatric care,control group routine pediatric care only.

Intervention patients had fewer episodes of AOM (mean group differenceper month, -0.14 [95% confidence interval, -0.27 to 0.00]; P = .04), fewersurgical procedures (intervention patients, 1; control patients, 8; P = .03),and more mean surgery-free months (intervention patients, 6.00; controlpatients, 5.25; P = .01). Baseline and final tympanograms obtained by theaudiologist showed an increased frequency of more normaltympanogram types in the intervention group, with an adjusted meangroup difference of 0.55 (95% confidence interval, 0.08 to 1.02; P = .02).No adverse reactions were reported.


Degenhardt BF, Kuchera ML. Osteopathic evaluation andmanipulative treatment in reducing the morbidity of otitis media: apilot study. Journal American Osteopathic Assn 2006;106(6):327-334. Small sample, showed OMT may be effective for chronic OM

Fallon JM. The role of the chiropractic adjustment in the care andtreatment of 332 children with otitis media. Journal of ClinicalChiropractic Pediatrics 1997; 2(2): 167-183. 332 consecutive pnts with OM; found strong correlation between

CMT and resolution of OM

Froehle RM. Ear infection: A retrospective study examiningimprovement from chiropractic care and analyzing for influencingfactors. Journal of Manipulative and Physiological Therapeutics1996; 19(3): 169-177. 45 children with OM; 93% improved; 43% with 1-2 tx’s


Fysh PN. Chronic recurrent otitis media: Case series of fivepatients with recommendations for case management. Journal ofClinical Chiropractic Pediatrics 1996; 1: 66-78. All cases resolved following course of CMT; no complications, no

tympanostomy tubes needed

Sawyer CE, Evans RL, Boline PD, Branson R, Spicer A. Afeasibility study of chiropractic spinal manipulation versus shamspinal manipulation for chronic otitis media with effusion inchildren. Journal of Manipulative and Physiological Therapeutics1999; 22(5): 292-298. 22 pnts, aged 6 mo-6 yrs.; active SMT group had less parent-reorted

symptoms; no serious adverse events in either group.

Otitis Media -Treatment Tools and Protocols

Manual therapies

Supplements

Parent Education

Addressing underlying causes

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Treatment Tools for OM:Manual Therapies

Spinal adjustments Check entire spine (“Everything is connected to

everything else” - Gonstead) Occiput often involved

According to Fallon, alters pressure gradient in middle ear,inhibiting drainage.

To perform adjustment, rotate head 45˚ towards oppositeshoulder, contact mastoid with 2nd mp jt, superior tissue pull,line of drive towards opposite axilla.

Craniosacral therapy (or other form of cranial work) Again, check entire craniosacral system Temporal bones often involved

Treatment Tools for OM:Manual Therapies

Soft tissue modalities Lymphatic drainage

Helps lymph flow through system; flow often inhibited due tomuscle spasm 2˚ to subluxations; spasm often resolvesfollowing adjustments, allowing lymph to flow.

If significant lymphatic congestion remains, gently massagealong lymphatic channels in direction of heart.

Endonasal procedure Os located near nasopharynx and adenoids Post-nasal drainage can create mucus “plug” at os Endonasal is technique to remove mucus “plug” For a description of this procedure, see

http://www.healing.org/only-6.html

Treatment Tools for OM:Supplements

Herbal ear drops to treat acute infections

Immune Support: Echinacea for bacterial infections Sambucus (elderberry) for viral infections Homeopathic immune tincture for babies

GI Support: probiotics and prebiotics Critical for children who have been on antibiotics

Mucus drainage: N-Acetyl Cysteine Foundational Nutrition

Multivitamin, vitamin C, essential fatty acids daily


Herbal ear drops Purpose: mild analgesic, mild antibiotic

Source: Kid’s Ear Drops by Eclectic Institute www.eclecticherb.com, 503-668-4120

Dosage: 2-4 drops tid Note: drops should be warmed under tap water in dropper before

inserting into affected ear; have parent lightly traction pinna toencourage drops to reach TM; have child remain supine for a fewminutes with head rotated toward non-affected side; some ofproduct will drain from ear - this is normal.


Immune Support: Echinacea for bacterial infections

Purpose: encourages immune response to bacterial agent

Source: Biostim Echinacea by Eclectic Institute

Dosage: 15 drops tid, in small amount of juice

Sambucus (elderberry) for viral infections Purpose: encourages immune response to viral agent

Source: Kid’s Elderberry by Eclectic Institute

Dosage: 15 drops tid for children over 1-yo


Immune Support: Homeopathic immune tincture for babies

Purpose: encourages immune response in infants

Source: Thymactiv by Integrative Therapeutics www.integrativeinc.com, 800-931-1709

Dosage: 15 drops tid Note: since product is a homeopathic, it must be kept as pure as

possible; therefore, attempt to deliver dosage without child touchingdropper.

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Gastrointestinal Support: Probiotics Purpose: re-colonization and support of normal

gastrointestinal flora Play an important role in digestion and immune function Often low in children with history of antibiotic usage

Source: Children’s Probiotic Powder by IntegrativeTherapeutics

Dosage: infant: 1/8 tsp qd-bid; older child: 1/4 tsp bid Use product that contains “prebiotics”:

Fructooligosaccharides (inulin, etc.) Enhance stabilization and optimize performance of probiotics


Mucus Drainage N-Actyl L-Cysteine (NAC)

Purpose: antioxidant; promotes mucus drainage

Source: NAC by Integrative Therapeutics

Dosage: 1/2 capsule bid, opened & mixed in food


Foundational Nutrition: Multivitamin

Purpose: provides basic nutrients not found in typical diet Source: Liquid Multivitamin from Integrative Therapeutics,

Multigenics Chewable from Metagenics www.metagenics.com

Dosage: 1-2 yo 1 tsp liquid qd; 3-4 yo 1 chewable qd; 5-10 yo1 chewable bid; over 10-yo 2 chewables bid

Vitamin C Purpose: antioxidant and immune support Source: Ultra-Potent C Chewable from Metagenics Dosage: 2-7 yo 1 qd, over 7-yo 1 bid


Foundational Nutrition: Essential Fatty Acids

Purpose: important for nerve cell growth, skin health, and lotsmore; not typically found in child’s diet.

Source: Metagenics for EPA-DHA, rest from Nordic Naturalswww.nordicnaturals.com

Dosage: product varies by age of child DHA Jr (chewable): 1-3 yo 2 bid; 3-5 yo 3 bid; ProOmega (chewable): 5-10 yo 1 bid; over 10-yo 2 bid EPA-DHA Extra Strength (not chewable): over 10 yo 1 bid Nursing infant: have mother take Metagenics EPA-DHA 1 tid Non-Nursing infant: DHA Jr. Liquid: 1/4 tsp qd

Treatment Tools for OM:Parent Education

Reassure parents that most children withOM will recover without antibiotics Spontaneous resolution rate 81%

Therefore, less than 20% will need antibiotics

Compare that to 93% resolution rate with antibiotics

(So antibiotics are only helping 12%!)

Most likely, chiropractic care can significantlyincrease rate of resolution without antibiotics


Educate parents about role of fever in illness Fever is body’s way of combating pathogen - heat

denatures cell walls of pathogen As result, want to let fever run, if safe for child

Use child’s demeanor, rather than number onthermometer as guide:

if child is relatively comfortable, drinks liquids, is interested inquiet play, let fever run its course.

If child is lethargic, very uncomfortable, not interested in anyactivities, then take measures to lower fever (cool compress,ibuprofin, etc.)

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Educate parents about ineffectiveness ofOTC cold and cough remedies for children


Educate parents about ineffectiveness of OTCcold and cough remedies for children FDA recommends OTC cold remedies not be use in children under

2-yo.

FDA advisory committee voted to ban all such products forchildren under 6-yo.

“There is no evidence that pediatric cold medicines provide anyrelief to children suffering from colds.”

“There are growing reports of deaths, convulsions, rapid heartrates, and some loss of consciousness associated with thesemedications.”

From “Renewed Warning on Cold Medicines” by Gardiner Harris, New YorkTimes, January 15, 2008, p. A15.


Home Remedies Humidifier in child’s room Warm compress affected over ear

Soothes aching ear Dampen wash cloth with warm water Cover affected ear with wash cloth

Temporarily eliminate dairy from child’s diet Dairy contains “adherens” - proteins which adhere to mucus

membranes and aggravate already inflamed tissues Parents must be careful to avoid all foods that contain dairy

(anything that comes from a cow) Watch for processed foods that contain “milk solids”, etc.


Home Remedies Wet sock treatment - Chinese medicine technique

Draws “heat” and mucus out of head, stimulates immune system At bedtime, dampen pair of thin cotton socks with cold water and

put on child; ideally done after warm bath Cover with pair of thick socks (preferably wool or polypro.) and

have child go to sleep When child awakes in morning, cotton socks will be dry

Homeopathic remedies Several books written for parents that allow parent to choose

remedy based upon a description of child’s symptoms. Example: Everybody’s Guide to Homeopathic Medicines by

Stephen Cummings, Dana Ullman

Otitis Media -Treatment Protocols

Initial Phase 2-3x/week for 2 weeks

Treat with spinal adjusting, craniosacral therapy, herbalear drops (if acute), immune support (if acute),foundational nutrition, parent education;

If adequate progress, continue weekly until spinal andcranial findings are normal, typically 2-4 weeksdepending upon degree of chronicity.

Note: an incident of AOM may occur during thistreatment phase, but cases are usually less severe andresolve faster than pre-treatment.

Otitis Media -Treatment Protocols

At end of 2nd week, if biomechanical findings improve,but TM shows no improvement, use endonasal procedure1x/4 days for 2-4 treatments (until os is clear). Rationale: likely resolution of ET constriction, but drainage

prevented by mucus plug in os.

If continued recurrence, inflammation and/or middle eareffusion after manual care and endonasal, then beginsearching for underlying cause(s) of chronic inflammatorystate. Once this is discovered and corrected, chronic inflammation and

chronic OM will disappear

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Otitis Media -Addressing Underlying Causes

Gastrointestinal Dysbiosis Common sequela to antibiotic therapy Disruption of optimal growth of synergistic

microorganisms in the colon growth of pathogenicorganisms

Creates inflammation of gastrointestinal (GI) liningwhich prevents proper nutrient absorption and interfereswith function of immune cells in GI tract.

Common GI symptoms: constipation and/or diarrhea,abdominal gas, bloating, and/or discomfort

Can lead to leaky gut syndrome, food allergies, atopicdermatitis and chronic inflammation beyond GI tract(including soft tissues around os of Eustacian Tube).


Gastrointestinal Dysbiosis Diagnosis via stool testing

Source: Genova Diagnostics http://www.gdx.net/home/

Microbiology test Evaluates for presence of friendly bacteria, pathogenic or

potentially-pathogenic bacteria, yeast. If pathogen is detected, lab performs susceptibility testing

against common pharmaceuticals and herbs.

Parasitology test Evaluates for presence of all of above plus parasites


Gastrointestinal Dysbiosis Treatment

Treat according to findings of test If pathogen is detected, treat or refer for prescription

of herbs or pharmaceuticals, depending on degree ofsusceptibility to agent and scope of practice in yourstate

Once pathogen is eradicated, Use supplement to aid in healing of GI lining:

Source: Glutagenics by Metagenics Dosage: 1/2 tsp tid for 3 weeks

Supplement with probiotics/prebiotics as discussedpreviously for at least 3-6 weeks.

If no pathogens are detected, but friendly flora islow, supplement with probiotics/prebiotics as above.


Food Intolerances/Allergies Can lead to state of chronic inflammation

Can lead to OM by creating chronic adenoid inflammationwhich can prevent drainage through ET by occluding os

Often secondary to GI dysbiosis and resultant leaky gutsyndrome; once GI tract is healed, food allergies oftenresolve


Food Intolerances/Allergies Diagnose via:

Blood test: Often inaccurate in young children

Often have high level of false positives

Elimination diet: eliminate most common offendersfor several weeks; assuming symptoms have cleared,add foods back in one at a time while evaluating forre-appearance of symptoms

Can be difficult for family

Child may be allergic to combination of foods which isdifficult to detect by this method


Environmental allergies and biochemical stressors All can lead to chronic adenoid inflammation which can

block os of ET Examples include cigarette smoke, pets, household

cleaning agents, laundry products, etc. Removal of offender from child’s environment results in

decreased inflammation

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Nutritional Deficiencies Common due to Standard American Diet

(SAD) Dominated by simple carbohydrates, empty calories,

high sugar, unhealthy fats and little protein Most items highly processed which strips foods of

vital nutrients Added chemicals (including hormones, antibiotics)

and preservatives make foods less expensive, lookprettier or have a longer shelf life

Eventually leads to weakened immune system,obesity and diabetes

Chronic chemical ingestion often leads to state ofchronic inflammation


Nutritional Deficiencies To counteract SAD:

Increase unprocessed, fresh, organic foods Increase fruits, vegetables, whole grains Decrease simple carbohydrates, sodas, juices, Avoid chemical additives including food colorings,

preservatives, glutamates (“Natural Flavor”) Buy organic whenever possible Implement foundational nutrition protocol Elimination of chemicals from diet and addition of

essential nutrients will decrease systemic inflammationand strengthen immune response.

Asthma


Asthma -Clinical Rationale

Most frequent cause of school absenteeism <17 years of age Onset usually occurs in 1st 5 years Asthma occurs when bronchioles are hyper-reactive causing

reversible obstructive lung disease Can be triggered by dust, pollen, animal, stress, exposure to

cold Trigger smooth muscle contraction, increased mucus

secretion, inflammation of mucus membranes increasedairway resistance expiratory wheeze and prolongedexpiration

Smooth muscle contraction controlled by balance ofsympathetic and parasympathetic nervous systems

Asthma -Clinical Rationale

Subluxation can abnormal tone in smooth muscle aroundbronchiole, can decreased airway diameter Can predispose child to asthmatic attack following exposure to a trigger

Subluxation can abnormal biomechanics in chest wallcomponents decreased expansion of chest during inspiration Decreases oxygenation Forces overuse and spasm of secondary muscles of respiration,

including trapezius, anterior scalenes, sternocleidomastoid and pectoralmuscles

CMT widened bronchiole diameter, moving child furtheraway from threshold of asthmatic attack

CMT increased respiratory volume and decreasedrespiratory effort improved tissue oxygenation and reducedoveruse of secondary muscles of respiration

Asthma -State of Research

4 randomized clinical trials, 3 cohort studies, 1 crossoverinvestigation & 4 cases involving 550 patients

Results mixed No improvements in lung function detectable (Bronfort 2002, Balon

1998), but improved quality of life scores and decreased medicationuse seen (Bronfort 2002)

Case reports and case studies showed positive clinical effect of spinalmanipulation for asthmatic children (Nilsson 1988, Beyeler 1965)

The largest randomized clinical trial to date comparingdifferent manipulative techniques in the management ofasthma is currently underway by Ali et al in Australia.Preliminary results show manipulation decreases cortisol andincreases immunoglobulin A levels (Ali 2002).

(See references next slides)

14

Asthma -Research References

Ali S, Hayek R, Holland R, McKelvey S-E, Boyce K. Effect of chiropractictreatment on the endocrine and immune system in asthmatic patients. Proceedingsof the 2002 International Conference on Spinal Manipulation, Toronto, Ontario,CANADA, October 4-5, 2002, pp. 57-58.

Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaugnessy D, WalkerC, Goldsmith CH, Duku E, Sears MR. A comparison of active and simulatedchiropractic manipulation as adjunctive treatment for childhood asthma. NewEngland Journal of Medicine 1998; 339(15): 1013-1020.

Beyeler W. Experiences in the management of asthma. Annals of the SwissChiropractic Association 1965;3: 111-117.

Bockenhauer Se, Julliard KN, Lo KS, Huang KE, Sheth AM. Quantifiable effectsof osteopathic manipulative techniques on patients with chronic asthma. Journal ofthe American Osteopathic Association 2002;102(7): 371-375.

Bronfort G, Evans RL, Kubic P, Filkin P. Chronic pediatric asthma and chiropracticspinal maniulation: A prospective clinical series and randomized clinical pilotstudy. Journal of Manipulative and Physiological Therapeutics 2002; 24(6): 369-377.


Dhami MSI, DeBoer KF. Systemic effects of spinal lesions. In Haldeman S [ed],Principles and Practice of Chiropractic, 2nd Edition. Norwalk, CT: Appleton &Lange, 1992, pp. 115-135.

Garde R. Asthma and chiropractic. Chiropractic Pediatrics 1994; 1: 9-16.

Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of osteopathic manipulativetreatment on pediatric patients with asthma: A randomized controlled trial. Journalof the American Osteopathic Association 2005; 105: 7-12.

Hunt J. Upper cervical chiropractic care of a pediatric patient with asthma: A casestudy. Journal of Clinical Chiropractic Pediatrics 2000; 1: 3-9.

Jamison JR. Asthma in a chiropractic clinic: A pilot study. Journal of the AustralianChiropractic Association 1986; 16: 138-144.

Killinger LZ. Chiropractic care in the treatment of asthma. Palmer Journal ofResearch 1995; 2: 74-77.


Lines D. A wholistic approach to the treatment of bronchial asthma in achiropractic practice. Chiropractic Journal of Australia 1993; 23: 408.

Nilsson N, Christiansen B. Prognostic factors in bronchial asthma in chiropracticpractice. Journal of the Australian Chiropractic Association 1988; 18: 85-87.

Nilsson NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma andchiropractic spinal manipulation: A randomized clinical trial. Journal of Clinicaland Experimental Allergy 1995; 25(1): 80-88.

Nilsson N, Christiansen B. Prognostic factors in bronchial asthma in chiropracticpractice. Journal of the Australian Chiropractic Association 1998; 18: 85-87.

Peet JB, Marko SK, Piekarczyk W. Chiropractic response in the pediatric patientwith asthma: A pilot study. Chiropractic Pediatrics 1995; 1: 9-13.

Peet JB. Case study: Eight year old female with chronic asthma. ChiropracticPediatrics 1997; 3: 9-12.

Asthma -Treatment Tools

Full spine CMT (especially T & costal regions) Gonstead said:

“wet” lungs: vagus nerve - look at atlas “dry” lungs - sympathetics - look at T spine

CST (especially respiratory and thoracic inlet diaphragms)

Deep breathing exercises to increase lung capacity(ex> blow up a large balloon)

Strengthen nutritional status to strengthen immuneresponse - foundational nutrition, diet, etc.

Uncover and reduce stressors - triggers, stress of life,food sensitivities

Asthma -Treatment Protocols

Tx 2-3x per week for 4 weeks Have parent keep diary of # daily episodes,

medications needed, severity of attacks If improvement in spine, but no improvement

in symptoms, look for other cause (allergens,toxicity, etc.)

Write up a case report with your results

Congenital Torticollis (CTC)


15

Congenital Torticollis -Clinical Rationale

Definition: lateral flexion combined withcontralateral rotation of head

2 most common causes of CTC: Birth trauma tearing of SCM “pseudotumor”

Appears about 2 weeks of age

Birth trauma upper cervical subluxation Present at birth; more common in breech presentations

Can lead to plagiocephaly if left untreated

Congenital Torticollis -Significant Points

DDX list: Pseudotumor 2˚ trauma in SCM muscle Upper cervical subluxation Spinal cord tumor: visible on plain film x-ray 50% of time Vertebral dislocation: secondary to birth trauma Vertebral anomaly: hemivertebra, klippel-feil syndrome

X-ray evaluation of cervical spine Perform if no pseudotumor is present Will r/o spinal cord tumor, vertebral dislocation, spinal anomaly

20% of neonates with CT also have congenital hipdysplasia Be sure to do thorough hip examination (incl. Ortilani & Barlow tests)

Congenital Torticollis -State of Research

Case studies only at this time

All report success using chiropractic care toaddress CT in the absence of pathology

(see references next slide)

Congenital Torticollis -State of Research

Aker PS, Cassidy D. Torticollis in infants and children: a report of threecases. J Can Chiro Assoc 1990;34(1):13-19.

Bolton PS. Torticollis: a review of etiology, pathology, diagnosis, andtreatment. J Manipulative Physiol Ther 1985;8(1):29-32.

Colin N. Congenital muscular torticollis: a review, case study, and proposedprotocol for chiropractic management. Top Clin Chiro 1998;5(3):27-33.

Fallon JM, Fysh PN. Chiropractic care of the newborn with congenitaltorticollis. J Clin Chiro Peds 1997;2(1):116-125.

McCoy Moore T, Pfiffner TJ. Pediatric traumatic torticollis: a case report.J Clin Chiro Ped. 1997;2(2):145-149.

Smith-Nguyen EJ. Two approaches to muscular torticollis. J Clin Chiro Ped.2004;6(2):387-393.

Congenital Torticollis -Treatment Tools

CMT As indicated by examination

CST As indicated by examination

STM Especially to SCM if pseudotumor present

Rehabilitation exercises (incl. home care) Stretching and strengthening exercises (usually positional) away from

tilt and rotation Beneficial to work with a PT for this

Parent education Parents should encourage movement in restricted directions and

perform daily stretching/strengthening exercises

Congenital Torticollis -Treatment Protocols

If 2˚ to SCM trauma: 2x per week for 2 weeks and re-evaluate.

If no pseudotumor is present: Further evaluation: x-rays of cervical spine

If negative for spinal cord tumor, spinal trauma and anomaly, treatas an upper cervical subluxation

2x per week for 2 weeks and re-evaluate

If no response after 2 weeks, MRI to r/o 50% ofspinal cord tumors not visible on x-ray

16

Making an Office Child-friendly

Don't focus on pain relief

Hire a receptionist who likeschildren

Have a little person's coatrack

Create a children's area inyour reception room

Keep a small toy bin in eachtreatment room

Have a stuffed animal ineach treatment room

Decorate treatment roomswith children’s décor

Take pictures of you andyour pediatric patients anddisplay photos in receptionarea

Get down to child's level EDUCATE, EDUCATE,

EDUCATE!!

How to See More Children inYour Practice

Ask patients who are parents to bring their child in for checkup Find pregnant patients - speak to birthing or prenatal exercise

classes Speak to “Moms” groups Speak to support organizations for pediatric conditions -

ex>allergy, asthma, etc. Sponsor an athletic team Network with pediatricians and other health care professionals Have a booth at a children's fair Volunteer at a children's service organization Have your own children

How to Learn More AboutPediatrics

ACA Council on Chiropractic Pediatrics (ACA CCP) www.acapedscouncil.org

ICA Council on Chiropractic Pediatrics (ICA CCP) www.icapediatrics.com

Annual ACA CCP Symposium on Chiropractic andPediatrics St. Louis in October 30-31, 2009

Super conference in combination with 3 other ACA Councils

Annual ICA CCP Conference on Chiropractic Pediatrics Colorado Springs, date unknown

How to Learn More AboutPediatrics

Subscribe to “Journal of Clinical Chiropractic Pediatrics” Available through ICA CCP Only peer-reviewed journal in chiropractic pediatrics

Upledger Institute for Craniosacral training 1-800-233-5880

Diplomate program: DICCP (Diplomate In ClinicalChiropractic Pediatrics) Overseen by independent board ICCP (Int’l College of

Chiropractic Pediatrics) Recognized by both ACA and ICA

Hewitt Handouts 2009 April 6 Per

Documents

Transcript of Hewitt Handouts 2009 April 6 Per