ABC’s Of Pediatric Adjusting

1. ABC’s Of Pediatric Adjusting Modifications for the Pediatric Patient Stephanie C. O’Neill, DC, DICCP

2. “Wellness Care” • Fysh recommends spinal check-ups • for school-aged children, at least every 3 months • for pre-school children, at least every 2 months • for infants in the first 2 years of life, at least every month

3. Determining Visit Frequency • Several things should be taken into account: • History • physical, chemical, and/or mental trauma will increase the likelihood s/he will require a higher frequency • Examination findings • Lifestyle, activity and stress levels

4. Joan Fallon The Child Patient: A Matrix for Chiropractic Care • published as a supplement to JCCP (Vol. 6, No. 3) • www.icapediatrics.com

5. Overview • Assessing the pediatric patient • Unique features of the pediatric spine • Adapting your technique • Comfort and Safety

6. Where do you start? Newborn Evaluation

7. Newborn Evaluation • Reverse Fencer Maneuver • Heel swing • Acetabular pump • Supine Leg Check • Instrumentation - atlas fossa reading • Posture analysis • Static Palpation • Motion palpation

8. McMullen Reverse Fencer • <6 months old • less accurate once the child gains strength and control of the cervical spine musculature McMullen M. Assessing Upper Cervical Subluxations in Infants Under Six Months- Utilizing the Reverse Fencer Response. ICA International Review of Chiropractic. March/April;1990,39-41.

9. Reverse Fencer- Part 1 Heel swing: • Hold infant upside down, making sure to have a solid grip on their ankles • Release one foot slowly, watch the child‘s head turn to that side • Repeat on other side

10. WARNING! Before you suspend a child by their legs you must rule out hip instability. Congenital Hip Dysplasia

11. Reverse Fencer- Part 1 Heel swing (cont‘d): • Compare motion from side to side • restricted? twitching?

12. What if...? Child arches backwards (opisthotonis) • meningeal tension What do you do? • Adjust them... • upper C spine, occiput, sacrum

13. “He‘s so strong, he can hold his head up already...” • Infant pulls away when you hold them against your shoulder • Only comfortable in the “football hold” • Problems breastfeeding/sleeping • Etc…

14. Reverse Fencer-Part 2 Acetabular pump: • Infant supine, apply pressure along the shaft of the femur into the acetabular fossa • Compare the resistance on each side • The “spongy“ side is said to be the side of atlas laterality

15. Interpreting your findings... “a negative response (heel swing) indicates a subluxation complex between the atlas-axis or atlas-occ. on that side“

16. Interpreting your findings... • Differentiating b/w atlas and occ. • Dr. McMullen suggests that you look at the Acetabular Pump findings • spongy side=atlas laterality • even=occiput

17. Supine Leg Check • Lay the infant supine • Gently straighten the legs • make sure that the head is in a neutral position • Compare medial malleoli, fat folds at the knee, etc. • Long leg side is “said to be“ the side of atlas laterality...

18. Prone Leg Check – Older Child

19. Instrumentation • DP nervoscope & newborns? • can‘t sit up • lots of skin • accuracy? • size of probes • patient relaxation • Old enough to sit still...

20. Advances in Instrumentation www.titronics.com

21. Atlas fossa reading • DT-25 is used to measure atlas fossa temperatures • hold 1/4“ away from the skin • repeat 3x each side Remember to take into consideration the way the child was being held, sitting in the sun in the car seat, etc.

22. Atlas fossa reading • The cold side is “said to be“ the side of atlas laterality... More likely, it tells us there is an imbalance

23. What if…? • Atlas fossa: R 85 L86 • No other findings in the cervical spine _ _ _ _ _ _

24. What if…? • Atlas fossa: R 85 L86 • No other findings in the cervical spine S A C R U M

25. Posture analysis • Head tilt • Head rotation • High shoulder • Scoliosis • High ilium • Genu varus and valgum • Internal & extenal foot rotation

26. Normal Development Normal evolution from bowlegs to knock-knees to normal valgus 2 years 3 years 5 years

27. TOE-IN TOE-OUT

28. Static Palpation • Taut and tender fibers • Muscle spasm • common with congenital torticollis • Sudoriferous changes • stickiness/dryness • Temperature

29. Pay attention to the child! • They’ll let you know… • squirming • fussiness • clutching at your hand • etc.

30. Clinical Note Just because it sticks out doesn‘t mean it‘s subluxated!

31. For Example • L1 is often prominant in infants (similar to the adult‘s T4) but it is not always fixed • You must evaluate the motion, feel for springiness, T&T fibers, sudoriferous changes, instumentation findings, etc.

32. Motion palpation • Similar to adults but much more subtle • ligament laxity, cartilagenous vertebrae • Be creative!

33. Gross Range of Motion • Can be evaluated by “playing“ with them • Can they bend in half forward? • Can they bend ear to foot equally on both sides? • Can they cross shoulder to opposite foot comfortably? • Remember, newborns should be flexible!

34. Sacrum and Pelvis • Gluteal Cleft Deviation • Sacral Dimples • Dangling legs • Gluteal Folds

35. Gluteal Cleft Check • Pinch cheeks together • Cleft should be midline

36. Gluteal Cleft Deviation If it deviates... • may either be to the side of posterior-inferior sacroiliac subluxation (P-R, PI-R, P-L, PI-L) or to the side of anterior-inferior sacral movement at the lumbosacral junction (Fysh, 2002)

37. Sacral Dimples • Asymmetry (with fixation of SI joints) suggests pelvic misalignment • Palpate S2 to PSIS

38. Other things to note... • Dangling legs • ilium rotation • Gluteal fold observation • sacral tilts

39. Older Babies and Toddlers • As they start to be mobile, you have to become more creative... • Do they have to be on a table to get adjusted? • Follow them as they crawl, play, etc.

40. Toddlers & School Aged Kids • “Flying Airplane” • Child lays on their tummy (table, dad’s lap, your lap…) • Have them hold their arms out like wings • You lift both legs and go through motion palpation of lumbars ~> thoracics

41. Toddlers Want to be in control of their world • important to respect their need for autonomy but you also have to maintain control of the interaction Give them choices between 2 acceptible options “Do you want to lay on your front or on your back?“ NOT “Do you want to get adjusted?“

42. Unique Features…

43. Unique Features… • Anatomy • Biomechanics MacGregor, 2000

44. Anatomy • Underdeveloped cervical lordosis • Low vertebral height • Horizontal facets (until age 10) • Undeveloped uncinates (until age 7)

45. lordosis? vertebral height? facets? uncinates? 11 months old 3 years old 5 years old Taylor & Resnick

46. Biomechanics • Large head • Weak muscles • Spine is more flexible MVA injuries

47. How will this affect your adjustment?

48. Joint End Play • Determined by the degree of flexibility and elasticity of a joint • Increased in children Some say that… “Spinal adjusting in the pediatric spine should be performed at a point somewhat before the end of the passive range is reached.”

49. Motion Joints of Lushka/Uncovertebral Joints • begin to develop between 6-9 years of age (are complete at age 18) Function: • guide the coupled motion of rotation and lateral flexion, limiting side bending

50. Pediatric Technique Chiropractic Care for the Pediatric Patient, Fysh