FINAL

1. FINAL • In addition to the last unit covered in class… ~10 questions related to: • Pregnancy adjusting & Webster’s • Pediatric chiro evaluation & adjusting • Pediatric radiology • Normal variants, anomolies… • Chiro Management of Common Conditions

2. Hawk’s review of the chiro literature • Adequate research supporting chiropractic: • Asthma • Colic • Promising • Otitis • Insufficient • Enuresis

3. Asthma - 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”

4. 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.

5. 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.

6. Colic • 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.

7. 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.

8. 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.

9. Enuresis • 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.

10. 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.

11. AOM - 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.

12. 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.

13. Newer Research • Tubes marginally effective in Otitis Media with Effusion • Improves hearing in children who have otitis media with effusion over the short term • Outcomes within 18 months, however, are the same • Tubes have no effect on language development • Watchful waiting is a reasonable option in most of these children Rovers MM, et al.Brommets in otitis media with effusion: an individual patient data meta-analysis. Arch Dis Child 2005;90:480-5.

14. Chiropractic Care & Otitis media Evidence is promising for the potential benefit of manual procedures for children with otitis media • Improvement with manual procedures • Natural course of the illness? • Fewer surgical procedures compared to usual medial care • Parent-reported positive side effects • relaxation, good nap • 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.

15. Erb’s Palsy - Chiropractic Management More research is needed • Chiropractic adjustments vs. natural history? • Splinting • Active and passive range-of-motion exercises

16. Torticollis - Chiropractic Management • Chiropractic adjustments Parental education • Passive stretches • Tummy time • Positional changes • Car seat, sleeping,etc.

17. Early recognition is important Preferred position ~> torticollis Plagiocephaly - Management • Preventive counseling • Mechanical adjustments • Exercises • Skull modling helmets • Surgery Most improve within 2-3 months… If parents follow these guidelines Biggs WS. Diagnosis and Management of Positional Head Deformity. Am Fam Physician 2003;67:1953-6.

18. Chiropractic Management • Retrospective; 25 cases, mean age: 3.74 months • Intervention • Chiropractic pediatric adjusting techniques • Spine & extremities • All 25 patients achieved complete resolution* • Mean time to full resolution - 3.64 months • Mean number of adjustments - 1.8 *Resolution • All criteria for establishing the diagnosis were no longer evident and a minimum period of 4 weeks in which the subluxation complex was no longer demonstrable Davies NJ. Chiropractic management of deformational plagiocephaly in infants: An alternative to device-dependent therapy. Chiropr J Aust 2002; 32: 52-55.

19. HeadacheWhen is a neurological consult indicated? May depend on the doctor’s experience and confidence… • Children <3 years • Rarely have primary headache syndrome • Neurologic & fundoscopic exam can be difficult • Acute headache w/ focal neurologic symptoms/signs • Neuroimaging should be performed • Chronic-progressive headaches • Associated w/ increased ICP Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):625-32.

20. CHIROPRACTIC Management of Primary Headache Once determined, reassure that the headache is not due to brain tumor or CNS pathology… • Quiet, dark room • Sleep • Manage stress • Encourage family to develop a “schedule” • Relaxation techniques • Biofeedback • Psychotherapy • Diet (avoid triggers) Lewis DW. Headaches in Children and Adolescents. J Am Fam Phys 2002;65(4):625-32.Lopez JI. Headache: Pediatric Perspectives. eMedicine. Retrieved 1 March 2007 from www.emedicine.com/neuro/topic528.htm

21. 7 Warning Signs for Pediatric Back Pain • Child is <4 years old Infection or neoplasm are common causes of back pain in this age group • Back pain causes a functional disability Children like to play, if the pain causes them to ask to miss sports, gym or recess, the pain is serious • Duration >4 weeks Musculoligamentous injuries should resolve in that time • Fever is present Suggests infection; osteomyelitis should be ruled out • Antalgic posture Disc herniation (not common in children); can be associated with bone tumor pain (osteoid osteoma) • Neurologic abnormality • Limitation of motion due to pain D'Alessandro MP. Back Pain in Children. Retreived 1 March 2007 from www.virtualpediatrichospital.org/providers/BackPainInChildren/Algorithm.shtml

22. Scheuermann’s • Signs/Symptoms • Fatigue & pain in the upper back • Exaggerated mid-thoracic kyphosis, cervical and lumbar lordosis and anterior pelvic tilt • Diagnosis • X-ray: anterior vertebral body wedging, loss of disc height and irregularity of the vertebral end-plates (3 or more adjacent vertebrae) • Management • Adjustments and soft tissue therapy • Stretch hamstrings & strengthen abdominal muscles • Strengthening exercises for the back Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002. & Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.

23. Facet Tropism • Signs/Symptoms • Specific site of palpable tenderness in the lumbar region • Diagnosis • X-ray: sagittally oriented facet which correlates w/ the side and level of pain (L4/5, L5/S1 normally coronal) • Essentially a lumbar lig. sprain; overuse; facet syndrome • Management • Adjustments • Avoid the sagittal facet - already hypermobile • Side posture may exacerbate symptoms; should be avoided • Strengthening exercises (abdominals) • Short-term limitation of activities • Avoid hyperextension and rotation of the lumbar spine Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002.

24. Spondylolysis • Signs/Symptoms • LBP aggravated by activity; asymptomatic in some cases • Increased lumbar lordosis, hamstring tightness, gait abnormalities • Diagnosis • X-ray: A-P, lat., & oblique • CT, MRI or bone scan may be necessary • Uni- or bilateral, acquired interruption of the pars; stress Fx • Management • If acute, bed-rest and restriction of activities • Allow Fx to heal before displacement occurs • Radiographic follow-up yearly to assess progression • Every 6 months in the adolescent (increased risk of slippage) Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002.

25. Spondylolisthesis • Signs/Symptoms • Often asymptomatic in children • During or after growth spurt: dull ache in the LB, buttocks and thighs during or after physical activity • Flattening of the post. sacrum and pelvis, shortening of the trunk, forward translation of the chest, lumbar hyperlordosis, changes in gait • Diagnosis • X-ray: anterior vertebral slippage • Myerding grading (1-5) • Management • Grades 1-2: carefully supervise activities • Grades 3+: refer for evaluation for possible surgery Fysh P. Chiropractic Care for the Pediatric Patient. Arlington, VA: ICA Council on Pediatrics, 2002.

26. Musculoligamentous Injury - Subluxation • Subluxation is the most common cause of back pain seen in the chiropractor’s office The chiropractor must, however, be careful to include all possible differentials in their clinical thinking… • Avoid prolonged, painful, frustrating, expensive programs of care d/t inaccurate diagnosis Fysh P. Low Back Pain in Children. Presented at that ICA Conference on Pediatrics. Nashville, TN: November 2006.