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Chiropractic Management of Common Conditions

Chiropractic Management of Common Conditions. Asthma. Asthma?. Patient Presentation. Parents report: Episodic or persistent coughing Wheezing Shortness of breath Rapid breathing or chest tightness Worse in the evening or early morning hours Associated with triggers

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Chiropractic Management of Common Conditions

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  1. Chiropractic Management of Common Conditions

  2. Asthma

  3. Asthma? Patient Presentation Parents report: • Episodic or persistent coughing • Wheezing • Shortness of breath • Rapid breathing or chest tightness • Worse in the evening or early morning hours • Associated with triggers • exercise, allergen exposure • 50-80% of children develop symptoms before 5 Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7): 1341-8.

  4. Differential Diagnosis Wheezing is not present in all patients with asthma! • Wheezing is not a sign exclusive to asthma • Respiratory infections • Rhinitis • Sinusitis • Vocal cord dysfunction • Consider differentials that may cause similar symptoms • Foreign body aspiration • Cystic fibrosis • Heart disease Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7): 1341-8.

  5. Diagnosis “In most children, the primary diagnostic tool is clinical assessment.” • Pulmonary function tests (spirometry) should be performed as soon as possible • Unreliable in infants and many preschoolers • Poor technique, adult-sized equipment • More reliable after 3-4 years of age • Allergy testing • Atopy is the strongest predictor for wheezing progressing to asthma Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7): 1341-8.

  6. “Allergic March” Infancy Food Allergy-Associated GI Disorders and Dermatitis Early Childhood Allergic Rhinoconjunctivitis Asthma Courtney AU, McCarter DF, Pollart SM. Childhood Asthma: Treatment Update. Am Fam Physician 2005;71:1059-68.

  7. Medical Treatment • Patient education • Trigger avoidance • Drug therapy Compliance is a major problem • Route of administration • Frequency of dosing • Medication effects • Risk or concern of side-effects Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7): 1341-8.

  8. Chiropractic Care & Asthma Evidence is adequate to support the “total package” of chiropractic care as providing benefit to patients with asthma • Symptoms were reported to improve • Medication use decreased • One study (Guiney) showed improved peak expiratory volume • No adverse effects were reported Hawk C, et al. Chiropractic Care for Nonmusculoskeletal Conditions: A systematic Review with Implications for Whole Systems Research. J Altern Complement Med 2007;13 491-512.

  9. What is the goal of treatment? • Reduce symptoms (wheeze and cough) • Improve lung function • Reduce the risk and number of acute exacerbations • Minimize adverse effects of treatments • Minimize sleep disturbances • Minimize absences from school Courtney AU, McCarter DF, Pollart SM. Childhood Asthma: Treatment Update. Am Fam Physician 2005;71:1059-68.

  10. What is the “Total Package”? What does the average chiropractor do when a patient presents with asthma as a primary complaint?

  11. Represented 10 different chiropractic schools • Average of 8 years in practice Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1):113-5.

  12. Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1):113-5.

  13. Summary Chiropractic Management Included: • Spinal adjusting (most common modality used) • thoracic spine and C1/C2 • A significant number of non-spinal adjustment modalities Limitations: • Small sample size • Does not address the efficacy of the modalities reported Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common Pediatric Conditions: Otitis Media and Asthma. J Clin Chiro Ped 1997; 2 (1):113-5.

  14. Chiropractic Management • Chiropractic adjustments • Full spine, ribs, upper cervical • Trigger avoidance & environmental control measures • “Evaluation of stress/environment” • “Evaluation of environmental pollutants” • “Removal of dairy/wheat from diet” • “Review of medication/side effects”

  15. Trigger Avoidance • Allergens from dust mites or mold spores • Animal dander • Cockroaches • Pollen • Indoor and outdoor pollutants • Irritants (smoke, perfumes, cleaning agents) • Pharmacologic triggers (NSAIDS, sulfites) • Physical triggers (exercise, cold air) • Physiologic factors (stress, GER, URTI, rhinitis) Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7): 1341-8.

  16. Environmental Control Measures • Remove carpets • Wash bedding and clothing in hot water (weekly) • Hypoallergenic mattress and pillow covers • Remove stuffed animals • Keep pets outdoors • Hypoallergenic furnace filters • Dehumidifier (household humidity <50%)? For more ideas: http://www.aaaai.org Kenp JP, Kemp JA. Management of Asthma in Children. Am Fam Physician 2001; 63(7): 1341-8.

  17. Family life, TV, school, daycare, siblings, etc. More research is needed but… • Avoid dairy/wheat • Highly allergenic… remember the “allergic march”? • Dairy in a mucous-producing agent • Limit processed sugars • Avoid food additives & preservatives (MSG) • May trigger attacks • Relaxation techniques, stress control and reduction • May benefit lung function Schetchikova NV. Asthma: An Enigma Epidemic , Part II-Asthma Treatment. J Am Chiropr Assoc: JUL 2003 (40:7) 30-37.

  18. More research is needed but… • Probiotics • May reduce inflammation, reduce allergic symptoms • Omega-3 fatty acids • May decrease inflammation • Calcium and magnesium • May cause bronchial smooth muscle relaxation and reduces histamine response • Antioxidants (vitamins C and E, selenium, zinc) • May reduce allergic reactions and wheezing Schetchikova NV. Asthma: An Enigma Epidemic , Part II-Asthma Treatment. J Am Chiropr Assoc: JUL 2003 (40:7) 30-37.

  19. Index to Chiropractic Literature • Gibbs AL. Chiropractic co-management of medically treated asthma. Clin Chiropr: SEP 2005(8:3) 140-144. • Ressel O, Rudy R. Vertebral subluxation correlated with somatic, visceral and immune complaints: an analysis of 650 children under chiropractic care. J Vert Sublux Res: 2004 (OCT:18) Online access only 23p. • Schetchikova NV. Asthma: An Enigma Epidemic (Part 1). J Am Chiropr Assoc: June 2003 (40:6) 22-29. • Schetchikova NV. Asthma: An Enigma Epidemic , Part II-Asthma Treatment. J Am Chiropr Assoc: JUL 2003 (40:7) 30-37. • Blum CL. Role of chiropractic and sacro- occipital technique in asthma treatment. J Chiropr Med: MAR 2002(1:1) 16-22. • Clinical Trial: Asthmatics and Chiropractic. J Am Chiropr Assoc: FEB 2001 (38:2)46-47. • Wellness Alert: Hold Your Breath. J Am Chiropr Assoc: MAR 2001(38:3) 30-38.

  20. Colic

  21. “Rule of Three” • Crying for more than 3 hours per day • for more than 3 days per week • for longer than 3 weeks …in an infant who is well fed and otherwise healthy • Typically begins at 2 weeks of age and usually resolves by 4 months Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4): 735-40.

  22. Parents Report • Attacks of screaming in late afternoon and evening • Flushed face, furrowed brow, clenched fists • Legs pulled up to abdomen • Piercing, high-pitched screams • Prolonged bouts • Unpredictable, spontaneous • unrelated to environmental events • Cannot be soothed, even by feeding Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4): 735-40.

  23. Etiology? • Gastrointestinal? • “Gas” does not seem to be the cause of colic • Excessive crying may lead to aerophagia • Psychosocial? • Not a sign of a “difficult temperament” • Not related to maternal personality or anxiety • Neurodevelopmental? • Upper end of the “normal distribution” • same temporal pattern, just more severe • Most infants “outgrow it” Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4): 735-40.

  24. CNS CNS abnormality (Chiari type I malformation) Infantile migraine Subdural hematoma Gastrointestinal Constipation Cow’s milk protein intolerance GER Lactose intolerance Rectal fissure Infection Meningitis Otitis media UTI Viral illness Trauma Abuse Corneal abrasions Foreign body in the eye Fractured bone Hair tourniquet syndrome Organic Causes?<5% of infants presenting with excessive crying Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4): 735-40.

  25. A diagnosis of exclusion… Apnea, cyanosis, struggling to breathe… • Undiagnosed pulmonary or cardiac condition? Frequent, excessive spitting up… • GER, pyloric stenosis? Lethargy, poor skin perfusion, tachypnea, fever, poor weight gain… • Infection, gastrointestinal disorder, nervous system disorder? Bruising, fracture… • Abuse? Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70(4): 735-40.

  26. Management? There is limited or no evidence to support… • Simethicone (Mylicon) • no more effective than placebo • Lactase • Fiber-Enriched Formulas • Carrying the infant more • Car ride simulators • Intensive parent training • Sucrose Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70: 735-40. Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics 2000; 106:184-90.

  27. Recommended Management • Low allergen diet (breastfeeding mothers) • Eliminate milk, eggs, wheat, & nuts • Hypoallergenic formulas • Soy formulas? • May develop allergy to soy • Herbal tea • Chamomile, vervain, licorice, fennel, and balm-mint • Reduce infant stimulation Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004; 70: 735-40. Garrison MM, Christakis DA. A Systematic Review of Treatments for Infant Colic. Pediatrics 2000; 106:184-90.

  28. New Research • Probiotics (Lactobacillus reuteri) • Improved colicky symptoms within 1 week • No adverese effects were reported Many parents try remedies recommended by family & friends, or found online… • “White noise”, car ride, walk in the stroller • “Gripe water” • Relief from flatulence and indigestion? • Avoid versions made with sugar or alcohol • Look for products made in the USA Savino F, et al. Lactobacillus reuteri Versus Simethicone in the Treatment of Infantile Colic: A Prospectice Randomized Study. Pediatrics 2007;119:e124-30. Roberts DM, Ostapchuk M, O’Brien JG. Infantile Colic. Am Fam Physician 2004;70:735-40.

  29. Chiropractic Care & Colic Evidence is adequate to support the “total package” of chiropractic care as providing benefit to patients with colic • Improvement with SMT • Improved parent-reported outcomes with chiropractic care • No adverse effects were reported Hawk C, et al. Chiropractic Care for Nonmusculoskeletal Conditions: A systematic Review with Implications for Whole Systems Research. J Altern Complement Med 2007;13 491-512.

  30. Index to Chiropractic Literature • Miller J, Croci SC. Cry baby, why baby? Beyond colic: Is it time to widen our views? J Clin Chiropr Pediatr: 2005(6:3) 419-423. • Hipperson AJ. Chiropractic management of infantile colic. Clin Chiropr: DEC 2004 (7:4) 180-186. • Hewitt EG. Chiropractic care and the irritable infant. J Clin Chiropr Pediatr: SUM 2004(6:2) 394-397. • Leach RA. Differential compliance instrument in the treatment of infantile colic: a report of two cases. J Manipulative Physiol Ther:JAN 2002(25:1) 58-62. • Nilsson N, Wiberg JMM. Infants with colic may have had a faster delivery: a short preliminary report. J Manipulative Physiol Ther:MAR/APR 2000(23:3) 208-210. • Working with young patients. J Am Chiropr Assoc:FEB 1999 (36:2) 12-15.

  31. Enuresis

  32. Classification Schemes According to time of day Nocturnal enuresis: passing of urine while asleep Diurnal enuresis or incontinence: leakage of urine during the day According to presence of other symptoms Monosymptomatic or uncomplicated nocturnal enuresis: normal voiding occurring at night in bed in the absence of other symptoms referable to the urogenital or gastrointestinal tract Polysymptomatic or complicated nocturnal enuresis: bed-wetting associated with daytime symptoms such as urgency, frequency, chronic constipation, or encopresis According to previous periods of dryness Primary enuresis: bed-wetting in a child who has never been dry Secondary enuresis: bed-wetting in a child who has had at least six months of nighttime dryness Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  33. Etiology • Genetic Predisposition • Most frequently supported • Bladder Problems • Bladder function is normal however, functional bladder capacity may be less • Arginine Vasopressin • Delayed development of a circadian rhythm may result in nocturnal polyuria • Sleep Disorders • Controversial… sleep EEGs demonstrate no differences but parents report that their children are “deep sleepers” • More likely to have “confused awakenings”; night terrors, sleepwalking Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  34. Other factors that have been implicated… • Familial factors? • Social background, stressful life events, number of changes in family constellation or residences seem to have no relationship • Psychologic factors? • No increased incidence of emotional problems • Not an act of rebellion • Psychologic factors are the result of, not the cause Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  35. History • At what age was your child consistently dry at night? • "Never dry" suggests primary enuresis • Does your child wet his or her pants during the day? • Positive answer suggests complicated nocturnal enuresis •  Does your child appear to have pain with urination? • Urinary tract infection  • How often does your child have bowel movements? • Infrequent stools: constipation   • Are bowel movements ever hard to pass? • Constipation   • Does your child ever soil his or her pants? • Encopresis Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  36. How many times a day does your child void? • More than 7 times a day: functional bladder disorder • Does your child have to run to the bathroom? • Positive response: functional bladder disorder • Does your child hold urine until the last minute? • Positive response: functional bladder disorder • How many nights a week does your child wet the bed? • Most nights: functional bladder disorder • One or two nights: nocturnal polyuria • Does your child ever wet more than once a night? • Positive response: functional bladder disorder • Does your child seem to wet large or small volumes? • Large volumes: nocturnal polyuria • Small volumes: functional bladder disorder • How have you handled the nighttime accident? • Elicits information on interventions that have already been tried; punished or shamed? Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  37. Diagnosis Not considered enuretic until 5 years of age! Voiding diary • 1 week or more Physical exam • Gait – evidence of a subtle neurologic deficit • Flanks and abdomen – masses? enlarged bladder? • Lower back - cutaneous lesions? asymmetric gluteal cleft? Urinalysis • Specific gravity and urinary glucose level • Infection or blood in the urine? Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  38. Medical Management • Alarms • Negative reinforcement or avoidance • Anxiety, disruptive to family? • May have to be used for up to 15 weeks • Effective, low relapse rate • Pharmacological Treatment • Not recommended for children under 6 • Effective but high relapse rate • Side effects • Desmopressin – nasal irritation, nosebleeds, and headache; less common: emotional disturbances (aggressive behavior and nightmares) • Imipramine – “side effects, including cardiotoxicity at high doses, occur frequently enough that it probably should not be considered a first-line treatment” Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  39. Nonpharmacologic Management • Positive Reinforcement Systems • earns “points” for every night he or she remains dry ~> prize • Responsibility training • child is given age-appropriate responsibility, in a nonpunitive way, for the consequences of bed-wetting (strip wet linens from the bed) • Elimination diet • Hypnosis • Retention control • Biofeedback • Acupuncture • Scheduled awakenings • Caffeine restriction More research is needed but they have been shown to have positive effects… Thiedke CC. Nocturnal Enuresis. Am Fam Physician 2003; 67:1499-506,1509-10.

  40. Chiropractic Care & Enuresis Evidence is insufficient at this time • Promising • Adverse effects were mild and self-limiting Hawk C, et al. Chiropractic Care for Nonmusculoskeletal Conditions: A systematic Review with Implications for Whole Systems Research. J Altern Complement Med 2007;13 491-512.

  41. Index to Chiropractic Literature • McCormick J. Improvement in nocturnal enuresis with chiropractic care: A case study. J Clin Chiropr Pediatr:2006(7:1) 464-465. • Bachman TR, Lantz CA. Management of pediatric asthma and enuresis with probable traumatic etiology. ICA Rev: JAN/FEB 1995(51:1) 44-46. • Marko RB. Bed-Wetting: Two case studies. Chiropr Pediatr: APR 1994(1:1) 21-22. • Langely C. Epileptic seizures, nocturnal enuresis, ADD. Chiropr Pediatr: APR 1994 (1:1) 22. • Bomerth PR. Functional nocturnal enuresis. J Manipulative Physiol Ther:NOV/DEC 1994(17:9) 596-600. • Aker PD, Kreitz BG. Nocturnal Enuresis: Treatment implications for the chiropractor. J Manipulative Physiol Ther: SEP 1994(17:7) 465-473.

  42. Otitis

  43. Diagnosis of AOM • Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE. • The presence of MEE that is indicated by any of the following: • Bulging of the tympanic membrane • Limited or absent mobility of the tympanic membrane • Air fluid level behind the tympanic membrane • Otorrhea • Signs or symptoms of middle-ear inflammation as indicated by either: • Distinct erythema of the tympanic membrane OR • Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep) AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004;113(5):1451-65.

  44. Diagnostic accuracy is hindered by… • Vague symptoms • neither specific nor sensitive for AOM • Undue reliance on one feature: redness of the tympanic membrane • Failure to assess tympanic membrane mobility • must use pneumatic otoscopy • Inadequate visualization of the typmpanic membrane • low light output from old otoscope bulbs • should be changed every 2 years • blockage of the ear canal by cerumen Pichichero, M. Acute Otitis Media: Part I. Improving diagnostic Accuracy. Am Fam Physician 2000; 61: 2052-6.

  45. Recommended Medical Management • “Watchful waiting” • symptomatic treatment for 24 to 48 hours before initiating antimicrobial treatment • Pain management • acetaminophen, ibuprofen, or topical otic anesthetic drops for pain control • Antibiotic therapy • reserve antibiotic therapy for specific cases • < 6 months of age • Severe illness (fever of >102.6, severe ear pain) AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics 2004;113:1451-65. Garbutt J, et al. Diagnosis and Treatment of Acute Otitis Media: An Assessment. Pediatrics 2003;112,143-9.

  46. Newer Research • Wait-and-see • Decreases the use of antibiotics • Reduces cost and adverse effects (diarrhea) • No serious adverse events reported • Interrupts the cycle of parental expectations • When are antibiotics most beneficial? • <2years with bilateral disease* • Otorrhea (any age) *Not all children under 2 benefit from antibiotics as previously suggested Spiro DM, et al. Wait-and-see prescription for the treatment of actue otitis media: a randomized controlled trial. JAMA 2006;296:1235-41. Rovers MM, et al. Antibiotics for acute otitis media: a eta-analysis with individual patient data. Lancet 2006;368:1492-35.

  47. Reducing Risk Factors • Breastfeeding • Minimum of 6 months • If bottle-fed, avoid supine bottle feeding • Reduce or eliminate pacifier use (>6 months) • Daycare – increased incidence of URTI • Tobacco smoke AAP and AAFP Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics. 2004;113(5):1451-65.

  48. Otitis Media with Effusion • The presence of fluid in the middle ear without signs or symptoms of acute ear infection • Due to poor eustachian tube function OR • Inflammatory response following AOM Concerns • Conductive hearing loss • Potential impact on language development • Potential impact on cognitive development AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:1412-29..

  49. Diagnosis Clinical presentation • cloudy tympanic membrane • distinctly impaired mobility • air-fluid level or bubble may be visible • Pneumatic otoscopy should be perfomed • Tympanometry or acoustic reflectometry can be used in conjunction • Document the laterality and duration of effusion, and the presence and severity of associated symptoms AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:1412-29..

  50. Management • Watchful waiting for three months • If OME persists greater than 3 months or if language delay, learning problems, or a significant hearing loss is suspected • Hearing testing • Language testing • Re-examine at 3- to 6-month intervals until • Effusion is no longer present • Significant hearing loss is identified • Or structural abnormalities of the eardrum or middle ear are suspected AAP Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics 2004;113:1412-29..

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