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
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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Systemic Effects of a Subluxation -Research
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.
Systemic Effects of a Subluxation -Research
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.
Is Chiropractic Care Safe?
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.
Is Chiropractic Care Safe?
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
Pediatric Adjusting Techniques byRegion - Sacroiliac Joints
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
Pediatric Adjusting Techniques byRegion - Sacroiliac Joints
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
NEWBORN-INFANT EVALUATION
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
Pediatric Adjusting Techniques byRegion - Lumbars
TODDLER-PRESCHOOLER EVALUATION
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
Pediatric Adjusting Techniques byRegion - Lumbars
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
NEWBORN-INFANT EVALUATION
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
Pediatric Adjusting Techniques byRegion - Thoracics
TODDLER-PRESCHOOLER EVALUATION
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
Pediatric Adjusting Techniques byRegion - Thoracics
SCHOOL AGE EVALUATION
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
NEWBORN-INFANT EVALUATION
Palpate suboccipital region for spasm, heat, etc. Palpate atlas tp (located directly inferior to mastoid) Motion palpate occiput and remainder of C spine (if can
find it)
ADJUSTMENT 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
Pediatric Adjusting Techniques byRegion - Cervicals
TODDLER-PRESCHOOLER EVALUATION
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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Pediatric Adjusting Techniques byRegion - Cervicals
SCHOOL AGE EVALUATION
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
Conditions that Respond Well toChiropractic Care
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
Conditions that Respond Well toChiropractic Care
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
Chronic Otitis Media -Clinical Rationale
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)
Chronic Otitis Media -Clinical Rationale
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.
Otitis Media -State of Research
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
Otitis Media -State of Research
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
Treatment Tools for OM:Supplements
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.
Treatment Tools for OM:Supplements
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
Treatment Tools for OM:Supplements
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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Treatment Tools for OM:Supplements
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
Treatment Tools for OM:Supplements
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
Treatment Tools for OM:Supplements
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
Treatment Tools for OM:Supplements
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
Treatment Tools for OM:Parent Education
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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Treatment Tools for OM:Parent Education
Educate parents about ineffectiveness ofOTC cold and cough remedies for children
Treatment Tools for OM:Parent Education
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.
Treatment Tools for OM:Parent Education
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.
Treatment Tools for OM:Parent Education
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).
Otitis Media -Addressing Underlying Causes
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
Otitis Media -Addressing Underlying Causes
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.
Otitis Media -Addressing Underlying Causes
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
Otitis Media -Addressing Underlying Causes
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
Otitis Media -Addressing Underlying Causes
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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Otitis Media -Addressing Underlying Causes
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
Otitis Media -Addressing Underlying Causes
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
http://emedicine.medscape.com/article/1000997-overview
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)
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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.
Asthma -Research References
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.
Asthma -Research References
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)
http://emedicine.medscape.com/article/939858-overview
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
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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