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Advanced Spinal

Assessment for the

Infant & Child

ICPA Chiropractic Pediatric Certification Program

Ron Castellucci, BS, DC, ACP Professor, Chairman Technique Department

Sherman College of Chiropractic

CASTELLUCCI: ADVANCED SPINAL ASSESSMENT FOR THE INFANT AND CHILD 09/26/2019

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Advanced Spinal Assessment for the Infant and Child

Why do Children Need Chiropractic Care? Think about how delicate a baby is. Now imagine the stress of the birth process upon a tiny baby spine. The effect of birth on the spine is the most overlooked health problem in our society for two reasons; no obvious symptoms and no visible trauma. A child’s health and the health of their spine are intimately related. It is well documented that even a so called ‘normal’ birth places tremendous stress on the spine and is a primary cause of vertebral subluxation. As the child grows, subluxation progressively interferes with proper body function limiting their ability to express optimum health. Left uncorrected, subluxation will have a devastating effect on their life.

Points to ponder:

Children were designed to be healthy & vital all their life They deserve the best chance to express optimum health Their nervous system controls their amazing development Subluxations limit their expression of life A newborn spine is most adaptable to correction The question then must be asked…when does subluxation begin?

‘As the twig is bent, so grows the tree’

Before weight bearing the child’s spine is most adaptable to correction. It is not denied that the process of adaptation occurs prior to weight bearing however as weight bearing ensues the bones, muscles and ligaments will respond to the stress of upright posture.

In place of healthy spinal development, adaptation to the subluxation is the result.

Is your why big enough?

Here’s mine…

‘to connect with, encourage and inspire others to become exceptional’

write yours here:


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Advanced Muscle Palpation…the confidence of knowing

Advanced Muscle Palpation is a tonal approach to

subluxation analysis, evaluating paravertebral muscle response to proprioceptive input Physiology behind Working Muscles

Advanced Muscle Palpation is an applied muscle palpation technique, and a tonal approach to the analysis of vertebral subluxation offering a unique insight regarding vertebral positon and thus proper line of correction. The style of muscle palpation, as presented in this class was first used by Reggie Gold, DC. Advanced Muscle Palpation is based upon analysis of the tone of specific para-spinal muscles in response to proprioceptive input from the central nervous system.

increased tone of paravertebral muscles indicates a corrective response by the CNS to

correct subluxation Basic and Clinical Anatomy of the Spine, Spinal Cord and ANS, 2nd ed. Cramer & Darby, 2005

Advanced Muscle Palpation is the art of evaluating paravertebral muscle reflex response to a loss of proper vertebral joint alignment and subsequent joint restriction. The para-spinal muscles of the spine attach directly to the vertebral processes and are stretch sensitive due to their inherent muscle spindles. The stretch reflex causes contraction of the stretched muscle thus attempting to restore proper joint alignment.

This is a very local response versus the general response which occurs due to injury, muscle spasm, splinting or repetitive use

This is a very local response under the control of the CNS and differs from a spastic or injured muscle which presents as a more general response. Correct joint position is maintained by muscles, tendons, ligaments and joint capsules through the neurological phenomenon of proprioception. When vertebral subluxation occurs, proprioceptive receptors send sensory information to the brain, which then determines proper joint positioning and creates the appropriate muscular response to maintain proper joint position.

We will casually call them ‘tight’ muscles

The body innately attempts to correct vertebral subluxation by increasing the tone of specific para spinal muscles. The vertebral muscles are said to be in an active tonal state rather than in a resting tonal state. These muscles are referred to as ‘working’ which means working to restore and maintain proper joint alignment.


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Proprioception…joint position sense

The ability to sense stimuli arising within the body regarding position, motion, and equilibrium. This awareness of the alignment or position of a joint is also known as joint position sense. Mechanoreceptors provide constant information on vertebra position and muscle action for appropriate coordination of joint movements. Mechanoreceptors within the muscle spindles send information to the brain regarding proper joint position. Thus proper vertebra alignment is maintained intelligently via proprioception through these mechanoreceptors within the para-spinal muscles of the spine, the associated ligaments/tendons and joint capsules. Vertebral subluxation causes a loss of proper alignment thereby stretching muscles attached to the vertebral processes.

the ability to sense stimuli arising within the body regarding position, motion, and equilibrium, this is also known as joint position sense

mechanoreceptors within muscle spindles provide constant information on joint position and the surrounding muscle tone

this is necessary to achieve appropriate joint alignment for coordinated spinal movements.


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Mechanoreceptors role in maintaining proper vertebral position

Guytons Textbook of Medicine notes the most important proprioceptive information is derived from joint receptors in the neck & lower spine.

Para-spinal muscles have more mechanoreceptors per surface area than any region of the body especially the cervical & lumbo-sacral spine

Interesting that mechanoreceptors are most numerous in the upper cervical region suggesting proprioceptive control is most refined here

Robert McLain, MD

Department of Orthopedic Surgery Cleveland Clinic

McLain also found mechanoreceptors in spinal facet joints. He states “The presence of mechanoreceptors in facet capsules prove that even these tissues are monitored by the CNS which implies neural input from these facets are important to proprioception.

Is it possible to have subluxations and working muscles without pain? Guytons Textbook of Medicine notes It is well known that localized palpable muscle bands are found in individuals who have no subjective pain complaints. Nociceptors have much higher thresholds than mechanoreceptors which explains why a subluxation triggering a muscle response occurs without pain.

Do subluxations occur without pain? Working para-spinal muscles indicating subluxation are often found in individuals who

have no pain Nociceptors have a higher firing threshold than mechanoreceptors, thus subluxation can

trigger a muscle response without pain -Guyton’s Textbook of Medicine

Our Concept is simple

The body is aware of where the vertebra is and where it is supposed to be The increased muscle tone is a corrective response from the CNS The increased muscle tone is felt when compared to the opposite side.

This is a pure innate response, literally a window into the innate workings of the body. This is a subtle sensation and practice is essential to refine these tactile skills

The Procedure:

the child should be as relaxed as possible palpate gently across the muscle fibers note the tone the muscle, comparing it to the opposite side


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In Summary: Muscle Response to Misalignment

The intrinsic muscles of the spine attach to the vertebral processes and are stretch sensitive due to muscle spindles fibers

The mechanism which causes the muscle to respond is called the stretch reflex The muscles are attempting to restore proper juxtaposition to the joint

Working Muscles

A working muscle is more "active" and maintains a subtle increase in tone Are found by comparing them to the tone of same muscle on the opposite side When found, a subtle asymmetry in tone and tension will be noted

Muscle response to Subluxation

Sensory receptors in joint capsules send joint-position information to the brain enabling one or more para-spinal muscles to respond by increasing tone

The body thereby attempts to correct the subluxation by the action of specific vertebral muscles where the tone of these muscles will be increased above the "normal" tone of the surrounding musculature

Correction of a misalignment may occur, either by natural forces of movement during daily activity or as the result of a force introduced by a chiropractor

While muscles, tendons, ligaments, joint capsules and vertebra’s bony structure dictate position due to anatomical construction, it is the innate wisdom of the body through muscle action that ultimately determines vertebral position

Over Time

Imbalance of muscle length contributes to chronic fixation and permanency of subluxation

Chronic misalignment and associated hypo mobility leads to damaged muscles and connective tissues

Decreased mechanoreceptor stimulation and dulled nociception diminishes proper neuromuscular responses

Permanent structural adaptation occurs which is a good reason to begin chiropractic care early in life

Muscle Palpation Procedure:

Palpate gently and across the belly of each muscle Make a note of the tone of each muscle, comparing it to its counterpart on the

opposite side and decide which one has greater tone.

Isolation Tests: isolation tests are used to learn where the muscle is and how it might feel when it

is working or tight Isolation tests are NEVER used during an exam of an actual patient


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The Cervical Muscles SternoCleidoMastoid … anterior atlas Location: between mastoid & sternoclavicular joint Indicates: tight on side of anterior atlas or lateral occiput or posterior occiput

Levator Scapula … lateral atlas Location: intertransverse space C1-C2 Finding: tight on the side of lateral atlas

Intertransversarii … lateral atlas Location: lateral to the levator scapula in the intertransverse space C1-C2 Finding: tight on the side of lateral atlas

Splenius Cervicis … anterior atlas Location: medial to the levator scapula between C1 TP & C2 TP Finding: tight on the side of anterior atlas

Rectus Capitis Posterior Minor … lateral Atlas Location: midline between atlas posterior arch and occiput Finding: tight on the side opposite atlas laterality

Superior Oblique … anterior atlas Location: behind mastoid between atlas TP and occiput Finding: tight on side of anterior atlas


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Inferior Oblique … anterior atlas Location: midway between C1 TP & C2 SP Finding: tight on side of anterior atlas or opposite C2 SP rotation

Splenius Capitis & Semispinalis Capitis … postreior atlas Location: palpate along base of occiput Finding: tight on side of posterior atlas

RCP Major … C2 rotation Location: midway between occiput and Axis SP Finding: tight opposite C2 SP rotation

Multifidus … C2-C7 rotation Location: between SP & TP below C2-C7 Finding: tight opposite SP rotation C2-C7

the TouchPoints Muscle Palpation Scan … 9 Touch Points

Midline RCP minor

Base of Occiput Semispinalis & Splenius Capitis

Post mastoid Superior oblique

Atlas TP SCM

Lateral IT space Intertransverse & Levator scapulae

Medial IT space Splenius cervicis

Lateral C2 SP Inferior oblique

Above C2 SP RCP major

Lamina gutter Multifidus


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Visual analysis Visual analysis is performed when the child is too young for a standing postural analysis and looks for positional/postural imbalances which is evidence of vertebral subluxation. Because many children cannot adapt to your needs in chiropractic analysis, visualization may become one of your primary analysis tools. Visual analysis focuses primarily on the non-ambulatory infant, app. 0-12 mos and is observed with the patient supine. The visual/postural position of the infant most closely reflects the position of the spine since postural muscles are not yet fully developed.

Head tilt The side of head tilt can indicate either occiput or atlas laterality on that side. The

infant will have difficulty with lateral flexion toward the fixation. The child will be fussy nursing or sleeping on one side. Ask the parent about the preferred side of breastfeeding.

Holding the infant under the axillae very slowly and gradually tip the infant laterally. Guide the head with your thumbs as

you perform this maneuver. Then laterally tip the infant in the other direction. The side that has less lateral flexion of the head is the side of a possible open wedge.

Head Rotation The side of head rotation can indicate either atlas or axis rotation on that side. The

infant will have difficulty with rotation toward the fixation The child will be fussy nursing or sleeping on one side. Ask the parent about the preferred side of breastfeeding.

Superior head tile/gaze or chin forward or flexion This can indicate an AS occiput. This child may tend to choke regularly and may be a

head banger. Also as the child grows they may be a toe walker. This misalignment is often due to facial or brow birth. Head Banging may be a behavior that occurs with an AS or PS occiput

Head tilt with rotation and a superior or inferior gaze Can indicate an AS or PS occiput with laterality ex: AS-RS or PS RS

Torticollis: head Rotation, lateral flexion and extension Can indicate congenital torticollis especially if associated with SCM spasm and an

inability of the infant/child to laterally flex or rotate their head in the opposite direction

Head lateral flexion, thoracic and lumbar extension Can indicate KISS (kinematic imbalance due to sub occipital strain) which is a result

of birth trauma to the upper cervical spine causing subluxation. The child will not like being supine and will remain in extension when on tummy and inverted. This subluxation subsequent to birth trauma causes dural tension which is likely the cause of the child’s positioning.


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Prone Visual Observations of the Infant Posture can be analyzed prone on an infant below 3 months of age. Place the infant prone without a face piece. The child will automatically turn their face right or left

If the face is turned to the left, the thoracic spine should curve to the right.

If the face is turned to the right, the thoracic spine should curve to the left.

The arms and legs should be flexed symmetrically.

The legs and knees should be flexed symmetrically.

When you turn their head, the thoracic spine should adapt accordingly Pull to Sit Test: visual finding head lag The pull-to-sit test, done in infants as young as six months old, monitors whether or

not a child has head lag. While the test is not a diagnosis, children with head lag have a higher risk of autism

Some Milestone observations during different developmental times:

Newborns: all newborns check the upper cervical spine, if C-section birth also check the upper to mid-thoracics.

8-10 wks: a child should hold their head upright and maintain that position, if not check the lower cervicals.

5 mos: a child should be able to roll prone to supine to prone and lifts their torso up in prone position. If not check lower thoracics.

6-8 mos: a child should start to stand and sits without help. If not, check lumbar region.

10 mos: a child should pull themselves to a standing position but are unable to get down. If not, check the sacral region

11-15 mos: a child should be ross-crawling and beginning to walk or take steps. If not check sacroiliac region.

Static palpation helps evaluate the position of the spinal segments. Always be aware

of possible congenital spinal anomalies such as bent spinous processes in the thoracic region. There are no special procedures to discuss here except that your evaluation must not begin and end with static palpation. When combined with muscle and motion palpation, static palpation becomes a helpful analytical tool in evaluating the mal-position of a vertebral segment.

Use the proper digit to feel the structure Feel for bony misalignments, muscular rigidity, guarding, edema Helps evaluate the position of the spinal segments Can be unreliable due to congenital spinal anomalies A helpful analytical tool when combined with muscle & motion palpation


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Motion Palpation of the Pediatric Spine The objective of motion palpation is to identify motion restrictions of the vertebral segments of the spine and pelvis. Subluxation will always exhibit some degree aberrant motion. Our motion palpation evaluation includes general P-A glide restriction as well as specific segmental motion evaluations. The style of motion palpation, as presented in this class, is an adaptation of motion palpation described by Leonard Faye DC.

Joint motion is assessed in the child by feeling a soft gliding motion as the joint is gently moved through its range of motion. If there is joint restriction, a subtle resistance to movement will be felt. The most important point that must be noted when using motion palpation in the child’s spine is to never assess ‘end play’. The joints of the child’s spine are not fully developed thus end play is strongly discouraged and not recommended.

Motion palpation is always performed after muscle palpation. Line of correction is never determined by motion palpation findings alone and must incorporate muscle palpation. General P-A glide motion is used to identify joint restriction associated with subluxation in lower cervical segments.

Motion palpation of the cervical spine

Always begin with muscle palpation

A normal joint will have a soft gliding motion

Joint restriction, will have a subtle resistance to movement

When using motion palpation in a child’s spine never assess ‘end play’

The following are motion palpation procedures for specific levels of the spine and possible misalignments associated with the restricted motion:

Occiput: use a gentle gliding motion feeling for resistance to movement between the occiput and atlas. Be sure to isolate the occiput motions.

an AS occiput will resist A-P glide a PS occiput will resist P-A glide a lateral occiput will resist L-M glide

Atlas: use a gentle gliding motion feeling for resistance to movement between the atlas, occiput and C2. Be sure to isolate the atlas motions.

a lateral atlas will resist L-M glide an anterior atlas will resist A-P glide a posterior atlas will resist P-A glide

C2-C7: use a gentle P-A gliding motion by contacting the cervical articular processes. Be sure to isolate each vertebra motions, do not use extension or incorporate lateral flexion or rotation.

a posterior LPJ will resist P-A glide


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The Pediatric Leg Check; a pattern finding Leg Checks are not subluxation specific and are only used for pattern. Keep in mind that legs often grow asymmetrically and thus interpretation is very different than with adults. Infant leg checks are looking for a change pre and post adjustment Supine Leg Checks: on an infant can be performed well in the supine position.

If needed have the parent hold an object above the child’s head Hold the child’s feet with your thumbs on the medial malleoli and gently bicycle

the child’s legs until you feel relaxation then pull down to complete the check. Place the thumbs above the knees to keep the legs in extension. With newborns, their legs will be flexed at the hips and knees. Gently pull their

legs down to an extended position and let go. Then pull down and perform the leg check as noted above.

Prone Leg Checks: leg checks on an infant can be performed in the prone position as well, simply pull their legs down to an extended position and let go. Then pull down and perform the leg check as noted above.

If one or both legs are rigid in extension before you do anything, there might be a hip dysplasia. Check Ortolani’s click or Barlow’s test If one leg stays rigid in extension there may be a posterior ilium on that side. If both legs stay extended there is a possibility of increased intracranial pressure. Increased intracranial pressure can be indicated by: an inability of the parent to diaper a baby because the legs stay rigid in extension

- Uneven eye level - the side of increased pressure on the lower eye. - Flat head syndrome. - Happy child suddenly crying when inverted. - Child fussing & moving hand toward ear (could be ear infection/teething)

A thought on thermography/Instrumentation Many forms of instrumentation can be used on children – Tytron, surface EMG, nervoscopes, neurocalometers as well as inexpensive infrared thermography devices used to measure in-ear temperature. Here are some generalities applicable to all instruments when dealing with children.

Show the child the instrument before using it. Have them touch the instrument and assure them that it won’t hurt

The Braun ThermoScan in-ear thermometer is an inexpensive, portable infrared thermometer that I use. Check each atlas transverse fossa and compare sides. Less than .20 difference indicates normal neurological function.

A thought on X-rays Many authorities have different viewpoints on when to x-ray a child. Some x-ray

from birth, some will x-ray when the child can stand, some choose a certain age. All have one thing in common, x-ray only when the need outweighs the risk


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The Art of Adjusting the Pediatric Spine

The adjustment techniques presented during this program are Gonstead, Diversified, Drop-piece and Logan Basic techniques adapted for use with infants and toddlers. Patient position, manual and segmental contacts, vectors of correction, types of thrust, necessary equipment and subtle variations in technique are important considerations. The following are a few basic considerations when adjusting children

Children are not just little people. They are unique and while the structures are the same but smaller, there are subtleties which must be considered

Do not expect cavitation of the joint commonly known as audible. When working with infants and toddlers especially, adjustments are often not heard; are very subtle and are felt by the chiropractor.

When working with infants, the forces must be very gentle with little or no rotation. When working with toddlers the same technique consideration is applied however with slightly more force.

A baby or child should never cry from an adjustment. Your adjustments must be gentle. Think less is more.

If your adjustment hurts, they may never get on your table again. Remember that their first experience with a doctor was not pleasant. You are a

doctor therefore take time to get to know them You are also a stranger so here is another reason to take the time to get to know

them. You must earn their trust. Once earned, never betray their trust by doing something you said you would never do.

Examples of adaptations to manual contact points made by the Chiropractor: newborns-infants:

tip of pinkie or index supported pinkie or index

toddlers-preschoolers: tip of index or thumb supported index or thumb

Examples of types of thrust (ordered light force to more force): newborns-infants:

sustained contact (10-12 sec or until segment moves) vibration impulse single sustained thrust

toddlers-preschoolers: impulse single sustained thrust


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Basic rules for adjusting children: use the amount of force appropriate for the weight of the child always err on the gentle side…less is more the smaller the bone, the smaller the contact the smaller the child, the smaller the force never, never, never adjust a child against their will have fun, if you are having fun, your patients will have fun

Contraindications for adjusting the pediatric patient hypermobility or instability is noted pathology of the involved bone is suspected or noted pathologic or non-pathologic fracture is present Infection of the bone to be contacted congenital or iatrogenic dislocations

Types of Thrusts used for the pediatric patient It is critical that the chiropractor consider the size, weight and development of the child when determining the type of thrust and the amount of force to use. Here are important rules to follow: (1) the smaller the child the smaller the manual contact; (2) the smaller the child the smaller the force; (3) always err on the gentle side; (4) limit lateral flexion and rotation; (5) do not expect audibles

Sustained Contact (best used for 0-12 mos) provides the least amount of force , essentially the amount of force you can stand on your eyeball comfortably, and can be used in any position.

Vibration (best used for 6-18 mos) provides slightly more force than sustained contact and can be used in any position

Impulse thrust (best used for 12-36 mos) provides slightly more force than vibration and can be used in any position

Single sustained thrust: (best used for 24mos and up) provides more force than impulse and can be used in any position and with the amount of force adapted to the size, weight and development of the child

Important Considerations: All cervical adjustments require minimal lateral flexion (no more than 100) & minimal rotation (no more than 100) below age 7. After age 7, the chiropractor must continue to appropriatly limit lateral flexion and rotation as well as moderate the force based upon the size, weight and development of the child. These same considerations must apply to all thoracic, lumbar, pelvic and sacral adjustments with appropriate adapations for each region of the spine.


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the Occiput

PS Occiput Supine - Have the child lying on the table Contact the mastoid groove behind the ear with the thenar Stabilize with the other hand by cradling the occiput. Keep head neutral with no rotation

o LOC: P-A; L-M; S-I (down and across the condyle) o Thrust: sustained contact or gentle single sustained thrust

AS Occiput Supine Sit at the head of the table, no block is necessary Hook pads of middle & ring fingers midline on base of occiput Place fleshy knife edge of other hand on forehead above the glabella.

o LOC: I-S with knife edge above glabella , I-S with fingers on occiput o Thrust: sustained contact or gentle single sustained thrust o note: this adjustment requires the use of both hands to thrust

Supine with cervical block, rolled wash cloth or replace block with infant drop piece Sit at the head of the table, must use a cervical block or rolled wash cloth Place the thenars of both hands on the lateral aspect of the skull, parietal region

while the your fingers around the occiput contacting the mastoid. o LOC: A-P & S-I in an arc moving the glabella inferior and occiput superior o Thrust: sustained contact or gentle single sustained thrust o note: this adjustment requires the use of both hands to thrust


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the Atlas Supine Diversified adaptation Doctor sits at head of table or at foot of table facing the child Contact the atlas TP with tip of middle, index or pinky Cradle the childs head with the opposite hand Limit lateral flexion (no more than 100) & rotation (no more than 100)

o Lateral atlas; contact lateral TP; LOC: L-M; S-I Thrust: sustained contact , vibration, impulse, single sustained thrust

o Lateral & Anterior atlas; contact antero-lateral TP; LOC: L-M; S-I; A-P Thrust: sustained contact, vibration, impulse, single sustained thrust

o Lateral & Posterior atlas: contact postero-lateral TP; LOC: L-M; S-I; P-A Thrust: sustained contact, vibration, impulse, single sustained thrust

Seated with drop piece With the patient seated, the doctor sits on the side opposite the side of contact with

drop piece around Dr’s neck & side of childs head on drop piece. option: Doctor holds headpiece, parent has headpiece around their neck

Contact the TP with the index of posterior hand, cover with index of anterior hand o Lateral atlas LOC: L-M; S-I (pull/scoop with both hands)

Thrust: single sustained thrust o Lateral & Anterior atlas LOC: L-M; S-I; A-P (pull/scoop with posterior hand)

Thrust: single sustained thrust o Lateral & Posterior atlas LOC: L-M; S-I; P-A (pull scoop with anterior hand)

Thrust: single sustained thrust


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The Lower Cervical spine (C2-C7) Supine Lamina contact Diversified adaptation Doctor sits at head of table or at foot of table facing the child Contact the lamina or articular process with tip of middle, index or pinky Cradle the childs head with the opposite hand Limit lateral flexion (no more than 100) & rotation (no more than 100)

o LOC: P-A; slight I-S Thrust: sustained contact (0-12 mos), vibration, impulse, single

sustained thrust Prone Lamina contact Diversified adaptation Doctor stands on side or head of table with child on table, on mom or in moms arms Contact the lamina or articular process with tip of middle, index or pinky Gently grasp the childs head with the opposite hand Limit lateral flexion (no more than 100) & rotation (no more than 100)

o LOC: P-A; slight I-S Thrust: sustained contact (0-12 mos), vibration, impulse, single

sustained thrust


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The Thoracic-Lumbar-Pelvic Region

Visual analysis

Visual analysis focuses primarily on the non-ambulatory infant, app. 0-12 mos and is noted with the patient supine or seated. The visual/postural position of the infant most closely reflects the position of the spine since para-spinal and other postural muscles are not yet fully developed.

Deviation of the natal cleft Squeeze the gluteal area and watch the top of the gluteal cleft. The upper part of it

will deviate toward the AI sacrum. Inferior pelvis in an infant if the pelvis/iliac crest is low with the head neutral, this may indicate an inferior

sacrum on that side. Watch a toddler crawl If the crawling child deviates to one side, suspect an anterior superior ilium on the

side he/she deviates toward. Difficulty diapering a baby because the legs stay rigid in extension can indicate increased intracranial pressure.

Toe in or toe out Can indicate an IN or EX ilium or possibly an anterior of posterior rotated sacrum. Prone Visual Observations of the Infant Posture can be analyzed prone on an infant below 3 months of age. Place the infant prone without a face piece. The child will automatically turn their face right or left

If the face is turned to the left, the thoracic spine should curve to the right.

If the face is turned to the right, the thoracic spine should curve to the left.

The arms and legs should be flexed symmetrically.

The legs and knees should be flexed symmetrically.

When you turn their head, the thoracic spine should adapt accordingly

To review, the Pediatric Leg Check is a pattern finding Leg Checks are not subluxation specific and are only used for pattern. Keep in mind that legs often grow asymmetrically and thus interpretation is very different than with adults. Infant leg checks are looking for a change pre and post adjustment


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The Thoracic-Lumbar-Sacral-Pelvis Muscles

Our Concept again… it’s simple The body is aware of where the vertebra is and where it is supposed to be The increased muscle tone is a corrective response from the CNS The increased muscle tone is felt when compared to the opposite side.

This is a pure innate response, literally a window into the innate workings of the body. This is a subtle sensation and practice is essential to refine these tactile skills

The Procedure: the child should be as relaxed as possible palpate gently across the muscle fibers note the tone the muscle, comparing it to the opposite side

The muscles: Longissimus … inferior sacrum (AI sacrum or PI sacrum) Location: para-spinal mid lumbar to sacral base Finding: tight on side of inferior sacrum

Iliocostalis … inferior ilium (PI ilium) Location: para-spinal mid lumbar to PSIS and iliac crest Finding: tight on side of inferior ilium

Sacro-Iliac Ligament … (PI ilium or AS ilium) Location: SI joint Findings: tight on side of posterior sacrum, anterior sacrum, PI ilium (upper), AS ilium (lower)

Gluteus medius … AS ilium Location: lateral to the PSIS Finding: tight on the side of AS ilium


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Gluteus Maximus … inferior sacrum Location: lateral border of sacrum Finding: tight on the side of inferior sacrum (PI or AI)

Piriformis … posterior sacrum Location: mid buttock lateral to the 3rd sacral tubercle Finding: tight on the side of the posterior sacrum

Sacro-tuberous ligament … inferior sacrum or PI ilium Location: between apex of sacrum & ischial tuberosity Findings: tight on side of inferior sacrum (AI or PI) or PI ilium

The Thoracic-Lumbar-Pelvic palpation scan … 7 Touch Points

Lamina gutter T/L spine Multifidus

Erectors L3-Sacral base Longissimus medial / Iliocostalis lateral

Sacro-iliac ligament above & below

Lateral to PSIS Gluteus medius

Lateral edge of sacrum Gluteus maximus

Lateral mid sacrum Piriformis

Between apex & ischial tubes Sacro-tuberous ligament


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Pediatric motion palpation of the thoracic-lumbar-sacral spine

Always begin with muscle palpation

A normal joint will have a soft gliding motion

Joint restriction will have a subtle resistance to movement

Never assess ‘end play’

The following are motion palpation procedures for specific levels of the spine and possible misalignments associated with the restricted motion:

Thoracic & Lumbar Spine:

o With the child prone, check for P-A glide by using your index finger and middle finger on the TPs. Adapt to the child’s position for their comfort

o With the child prone, palpate the TPs then lift the upper torso while checking for P-A glide on the TPs, then lift the legs by the ankles (no more than 100) and check for P-A glide on the MP’s

o If the child will allow you to place him/her across your lap prone, check for P-A glide at the TPs/MPs while simultaneously separating your knee

a posterior TP/MP will resist P-A glide Sacrum and Ilium:

o Ilium can be motioned by lying the child prone, palpating the PSIS and ASIS. Support the midline of the sacrum with the opposite thumb. Then rock the ilium into flexion/extension then glide the ilium medial then lateral. You may also contact the SI joint and lift the ipsilateral leg while feeling for SI restriction.

PI ilium / flexion malposition will resist extension AS ilium / extension malposition will resist flexion IN ilium will resist M-L glide, EX ilium will resist L-M glide

o Sacrum can be motioned by using the pad of the thumb and gently pushing P-A

the posterior sacrum will resist P-A glide

keep in mind, DO NOT assess end play, and feel for the subtle resistance to movement


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Adjusting the Thoracic Spine Prone Bi-Manual contact Diversified adaptation Contact the posterior TP with an index or thumb while supporting the opposite TP Hands must touch for stability Place your other fingers around the trunk of the child

o LOC: P-A; slight I-S or I-S lift then P-A Thrust: sustained contact (0-12 mos) or single sustained thrust

Prone single hand contact Gonstead adaptation Contact the posterior TP with an index Support the opposite hand by grasping the DIP joint and wrapping fingers around

contact hand OR support by placing index on top of nail of contact hand (again hands must touch for stability)


Prone vibration/impulse (0-12 mos)

With the child prone on the table, on the parent, or with the parent holding the child contact the posterior TP with tip of middle finger

Perform a vibration or impulse thrust P-A Supine vibration/impulse (0-12 mos)

With the child supine, reach around the back of the child and contact the posterior TP with tip of middle finger

Perform a vibration or impulse thrust P-A Parent Holding Child (0-12 mos)

With parent holdng the child contact the posterior TP with tip of middle finger Place your opposite hand on the parenst upper back for support Perform a vibration or impulse thrust P-A


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Adjusting the Lumbar and Sacral Spine Prone Bi-Manual contact lumbar Contact the posterior MP with an index or thumb while supporting the opposite TP Hands must touch for stability Place your other fingers around the trunk of the child


Prone single hand contact lumbar Contact the posterior MP with an index Support the opposite hand by grasping the DIP joint and wrapping fingers around

contact hand OR support by placing index on top of nail of contact hand (again hands must touch for stability)


Prone single hand contact with leg extension lumbar/sacrum Contact the posterior MP with an index or posterior sacrum w/broad thumb contact Wrap fingers of opposite hand around torso

o LOC: P-A; slight I-S (if inferior sacrum) with leg extension & slight traction Thrust: sustained contact (0-12 mos) or single sustained thrust

note: leg extension must be NO MORE than 100 and you MUST rule out hip problems

Prone vibration/impulse (0-12 mos)

With the child prone on the table, on the parent, or with the parent holding the child contact the posterior MP with tip of middle finger

Perform a vibration or impulse thrust P-A Supine vibration/impulse (0-12 mos)

With the child supine, reach around the back of the child and contact the posterior MP with tip of middle finger

Perform a vibration or impulse thrust P-A


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The Ilium PI Ilium prone (can be done supine) Doctor stands on same or opposite side of involvement. Thumb/thenar contact of superior hand on the inferior part of posterior superior

iliac spine/ fingers on ASIS o LOC: P-A, I-S in an arc rocking the ilium into extension

Thrust: sustained contact (0-12 mos) or single sustained thrust PI Ilium prone with leg extension Doctor stands on same or opposite side of involvement. Thumb/thenar contact of superior hand on the inferior part of posterior superior

iliac spine Opposite hand lifts the ipsilateral leg of the child just above the knee to take the

slack out of the SI joint o LOC: P-A, I-S in an arc w/leg extension no more than 100 o MUST rule out hip problems

Thrust: sustained contact (0-12 mos) or single sustained thrust only with the contact hand

AS Ilium prone (can be done supine) Doctor stands on same or opposite side of involvement. Thenar contact of superior hand on the superior part of posterior superior iliac spine

and the ischial tuberosity o LOC: S-I in an arc rocking the ilium into flexion

Thrust: sustained contact (0-12 mos) or single sustained thrust EX Ilium prone (can be done supine) Doctor stands on same or opposite side of involvement. Thenar contact of inferior hand on the PSIS fingers on the ASIS Opposite thenar supports the sacrum

o LOC: L-M in an arc Thrust: sustained contact (0-12 mos) or single sustained thrust as the

child is gently “rolled” toward from the contact. IN ilium prone (can be done supine) Doctor stands on same or opposite side of involvement. Thenar contact of inferior hand on the PSIS fingers on the ASIS Opposite thenar supports the sacrum

o LOC: M-L in an arc Thrust: sustained contact (0-12 mos) or single sustained thrust as the

child is gently “rolled” away from the contact.


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Logan Basic Technique for Infants Logan Basic Technique was developed by Hugh B. Logan in 1923 and focuses upon the foundation of the spine specifically the sacrum. The application of Logan Basic technique is for the correction of an anterior-inferior sacrum and will be applied in the infant-toddler age group. According to Logan, ‘the muscles radiating from the sacrum will be found in a tense, strained state, ready to return the sacrum to its proper location”. This concept is congruent with Sherman’s teaching of muscle palpation and the effect of tight muscles upon subluxated vertebra. It is important to understand that Logan Basic technique is an osseous correction of the anterior-inferior sacrum using the potential energy of tight/strained muscles and stretched ligaments. The correction is accomplished by assisting the innate intelligence of the child’s body with a light force contact on the apex of the sacrum. The anterior-inferior sacrum is a common finding in the infant population possibly due to the compressive forces of uterine contractions during labor as the infant’s pelvis passes through the birth canal. While the duration of labor is a factor, the biomechanics and angulation of the sacro-iliac joint lends to the theory that compressive forces upon the pelvis drive the sacrum anterior and ilia medial. This biomechanical phenomenon may explain the commonality of this subluxation pattern.

The Procedure

Be sure that you explain to Mom or Dad what you will be doing. This procedure and all infant adjusting is very unfamiliar to parents so it is best to explain where the contact will be made and to demonstrate on the palm of the hand the amount of pressure you will use. Place the infant on a blanket on the table or on Mom with Mom supine. Head rotation is fine during the adjustment however be sure to analyze the infant with their head neutral if possible. If their head is rotated, be sure to check the findings with the head in right and then left rotation. There should be no difference in findings with head rotation. There is no need to remove the diaper unless you are unable to palpate low enough. Try loosening the diaper first and pull it down before removing it. Also, be aware that the child will become chilled quickly so be ready with a light blanket is necessary.


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The Evaluation Visual Analysis

Deviation of natal cleft

to the AI side

Inferior pelvis on the AI

side

Toe out on the AI side

Static Palpation Findings (note these are the least reliable findings)

Anterior sacral base

Narrow distance

between 2nd sacral

tubercle & PSIS

Sacral base inferior on

the narrow side

Apex deviated opposite the inferior sacral base

Muscle/Ligament palpation findings (on the AI side) Longissimus tightness

G-max tightness

SI ligament tension

ST ligament tension

The Adjustment Patient position:

Prone on the adjusting table or on Mom.

Place the babies’ blanket on the table or on Mom.

While neutral is best, head rotation is fine during the adjustment.

Doctor position Doctor is to be seated on the opposite side of the AI sacrum and facing the table

The Apex Contact The contact is made with inside of the distal pinky of the inferior hand. With the doctor’s hand curved in a relaxed position and palm down, place the pinky contact on the sacro-tuberous ligament near its’ attachment with the apex of the sacrum. The pressure should be equivalent to the amount of pressure you can comfortably stand on your closed eye. The doctor then turns the palm up and angles the contact towards the AI shoulder. The doctor should now be contacting under the sacro-tuberous ligament exerting and A-P line of correction


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The LOC A-P & I-S it is important to NEVER cross the midline with your contact thus the contact MUST be directed towards the AI shoulder. Apply a gentle steady pressure as noted above for 1-3 minutes or until a softening of the sacro-tuberous ligament occurs. At the completion of the adjustment simply back your contact out.

The Auxiliary contacts:

Auxiliary contacts are light pressure contacts used with the free hand on subluxated segments found during your spinal exam. You will find that palpating for these subluxated segments will have a soothing effect on the child. Light pressure adjustments to the upper cervical spine while holding the apex contact will also stimulate the parasympathetic nervous system which will again contribute to this calming effect.

The Post Check Re-check your findings. If you still have positive findings but experienced a

softening of the ST ligament, don’t make another apex contact that day. On the

next visit you can adjust again if your findings indicate the necessity.

Please contact me with any questions

you may have

[email protected]

I am available to present a 12-hour CE seminar

Advanced Muscle Palpation

for your local or state association


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Muscle Palpation Guide:

OcciputMuscle Location Indication IsolationSternocleidomastoid midway between

mastoid process and

sternoclavicular joint

tight side of lateral

or posterior occiput

none

AtlasMuscle Location Indication IsolationRectus capitis

posterior minor

midline between atlas

and occiput

lateral atlas

(opposite side of

tight muscle)

resistance to slight head

extension

Levator Scapulae Inter-transverse

space C1-C2

lateral atlas shrug shoulders

Semi-spinalis capitis palpate along base of

occiput

posterior atlas none

Splenius-capitis palpate along base of

occiput

posterior atlas none

Superior Oblique behind mastoid

process

anterior atlas resistance to ipsilateral

head rotation

Inferior Oblique lateral to SP over C2

lamina

anterior atlas resistance to ipsilateral

head rotation

Sternocleidomastoid just below mastiod

process

anterior atlas none

Axis Rotation

Muscle Location Indication IsolationRectus capitis

posterior major

midway between

occiput and Axis SP

C2 rotation resistance to contralateral

head rotation

Inferior Oblique lateral to SP over C2

lamina

C2 rotation resistance to contralateral

head rotation

Lower Cervical RotationMuscle Location Indication IsolationMultifidi between SP & TP

below C3-C7

C2-C7 rotation none


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Muscle Palpation Guide:

Thoraco-Lumbar RotationMuscle Location Indication IsolationMultifidi between SP & TP

below T1-L5

T1-L5 rotation none

SacrumMuscle /

Ligament

Location Indication Isolation

longissimus along paraspinal

lumbar region to

sacral base

tight on side of

inferior sacrum

none

gluteus maximus inferior and lateral to

sacral apex

tight on side of

inferior sacrum

none

sacro-tuberous

ligament

midway between

sacral apex and ischial

tuberosity

tight on side of

inferior sacrum

none

piriformis lateral to the 3rd

sacral tubercle

tight on the side

ofposterior sacrum

none

sacro-Iliac ligament across the sacro-iliac

joint

tight on the side of

posterior sacrum

anterior sacrum

IN or EX ilium

none

IliumMuscle /

Ligament

Location Indication Isolation

iliocostalis lateral paraspinal

lumbar region to PSIS

and iliac crest

tight on side of

PI ilium

none

sacro-tuberous

ligament

midway between apex

of sacrum and ischial

tuberosity

tight on side of

PI ilium

none

sacro-iliac ligament across sacro-iliac joint tight above PSIS

PI Ilium

tight below PSIS

AS Ilium

none

gluteus medius lateral to the PSIS active on the side of

the anterior superior

ilium

none


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References

Basic and Clinical Anatomy of the Spine, Spinal Cord and ANS, 2nd ed. Cramer & Darby, Elsevier Mosby 2005

Spinal Palpation, 5th ed. Gates, D., Westwood, NJ, 1995

Correlative Spinal Anatomy, 4th ed. Gates, D., Westwood, NJ, 1995

The Physiology of the Joints, Volume 3, 2nd ed. Kapandji, IA, Churchill Livingston, 1998

Chiropractic Technique principles and procedures, 3rd ed Bergmann & Peterson, Elsevier Mosby 2005 Guyton and Hall

Textbook of Medical Physiology 12th Ed., Saunders 2011

Gray's Anatomy 40th Ed., Churchill Livingstone 2009

Gatterman, Foundations of Chiropractic: Subluxation 2nd Ed., Mosby 2005

Davies, Chiropractic Pediatrics: A Clinical Handbook 2nd Ed., Churchill Livingstone 2010

Biedermann, Manual Therapy in Children, Churchill Livingstone 2004

Anrig & Plaugher, Pediatric Chiropractic 2nd Ed., Lippincott Williams & Wilkins 2012

Bergmann & Peterson, Chiropractic Technique: Principles and Procedures, 3rd Ed., Mosby 2010

McLain RF, Pickar JG Mechanoreceptor endings in human thoracic and lumbar facet joints. Spine (Phila Pa 1976). 1998 Jan 15;23(2):168-73.

McLain RF Mechanoreceptor endings in human cervical facet joints. Iowa Orthop J. 1993; 13: 149–154.

Harold Portnoy and F. Morin, "Electromyographic Study of Postural Muscles in Various Positions and Movements," American Journal of Physisiology, 1956

Augustus A. White, III and Manohar M. Panjabi. Clinical Biomechanics the Spine. Lippincott Williams & Wilkins, 2nd Ed. 1990

Erick W. Donisch and John V. Basmajian, "Electromyography of Deep Back Muscles in Man," American Journal of Anatomy 133:1, 1972

Grieve, Common Vertebral Joint Problems, Churchill Livingstone, 2nd ed. 1988

Denslow J.S., Clough J.H. "Reflex Activity in the Spinal Extensors," Journal of Neurophysiology, 4, 1991


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