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

“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

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

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

Overview
 Assessing the pediatric patient
 Unique features of the pediatric spine
 Adapting your technique
 Comfort and Safety

Newborn Evaluation
Where do you start?

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

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.

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

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

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

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

“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…

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

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

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

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...

Prone Leg Check – Older Child

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

Advances in Instrumentation www.titronics.com

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.

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

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

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

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

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

TOE-IN TOE-OUT
EX ilium
Inward tibial or femoral torsion
IN ilium
Weak psoas or Glut. max
Psoas, piriformis or
Glut. Max spasm
CP (bilat)

Static Palpation
 Taut and tender fibers
 Muscle spasm
– common with congenital torticollis
 Sudoriferous changes
– stickiness/dryness
 Temperature

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

Clinical Note

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.

Motion palpation
 Similar to adults but much more subtle
– ligament laxity, cartilagenous vertebrae
 Be creative!

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!

Sacrum and Pelvis
 Gluteal Cleft Deviation
 Sacral Dimples
 Dangling legs
 Gluteal Folds

 Pinch cheeks together
 Cleft should be midline

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)

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

Other things to note...
 Dangling legs
– ilium rotation
 Gluteal fold observation
– sacral tilts

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.

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

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?“

Unique Features…

Unique Features…


Anatomy
Biomechanics
MacGregor, 2000

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

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

Biomechanics
 Large head
 Weak muscles
 Spine is more flexible
MVA injuries

How will this affect your adjustment?

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.”

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

Pediatric Technique
Chiropractic Care for the
Pediatric Patient, Fysh

Adjusting Considerations
 Minimize excessive range of motion/forces
Reduce depth of thrust
C-spine: lat bend and minimum rotation (30 degrees)
Sometimes, pre-stress can effect a correction...
 Specificity

Contact Points
 Pediatric vertebrae are much smaller
– cervical spine of a newborn is <2 inches in length
 High degree of specificity is required
Pad of the finger-tip or thumb tip

Occiput
Findings


Fixation between Co/C1*
Increased tension in suboccipital muscles
– unilateral/bilateral
*If significantly fixed, infant may become irritable even with light palpation

Occiput (AS)
Correction


Light cephalad traction with the fingertips
When released, infant becomes relaxed & may even fall asleep

Atlas
Findings
 Fixation at C1
We’ll add…



T&T
Instrumentation
Etc.

Atlas
Correction



Place lateral tip of the index finger against the prominent C1 transverse
Laterally bend to the side of contact until end-range
A quick, light, low-amplitude thrust is delivered to the tip of the C1 transverse toward the neutral position
*Not uncommon for a young baby to cry 15-20 seconds
(stimulate Moro response)

Pediatric Drop Piece

Clinical Note
 Compared with C1, rotation of C2-C7 is significantly reduced
C1/C2 40 degrees
C2/C3 3 degrees
C7/T1 2 degrees
 Therefore, C2 and C7 are prone to subluxation with end-range rotation of the head

C2 – C7
Findings


Muscle spasm – usually side of spinous process deviation
Fixation – spinous does not move away with lateral bend

C2 – C7
Correction


Tip of index finger on articular pillar
Rotate head 25-30 degrees


Laterally bend the neck over contact finger
If no release is felt, apply a light thrust

Thoracic Spine – Infant & Child
 Prone thoracic adjusting


If the child will not lie quietly in the prone position (lifting head, extending trunk)…


Move infant to edge of the table, supporting the legs over the edge
Doctor can flex the abdomen over the table’s edge to induce a normal thoracic curve
Infant upright, chest to chest with doctor or parent
Infant lying prone on top of parent

Thoracics
Correction
 DTH - thumbs on either side of the spinous process
 Anterior adjusting
–
–
Not recommended for children under 3 years of age
Flexible rib cage

L1 – L3
 Sagittal plane, facet joints
Correction
 Contact mammillary process with a light thumb contact
 P-A, I-S thrust

L4 – L5
Correction
 Contact the spinous process (side of spinous rotation) with a light thumb contact
 Apply light pressure over the contralateral mammilary process (stabilization)
 Thrust toward the spinous process
*Side Posture: infants >12 months

Sacro-iliac
Correction
 Prone or side posture
– Light adjustive thrust
– Direction appropriate to correct PI, AS, In or Ex

References

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Anrig & Plaugher. Pediatric Chiropractic. Baltimore, MD: Lippincott Williams &
Wilkins, 1998.
Anrig-Howe C. Scientific Ramifications for Providing Pre-natal and Neonate
Chiropractic Care. The American Chiropractor, 1993; May/June: 20-26.
Fallon. Textbook on Chiropractic and Pregnancy. Arlington, VA: International
Chiropractors Association, 1994.
Forrester J. Chiropractic Management of Third Trimester In-utero Constraint.
Canadian Chiropractor, 1997; 2(3): 8-13.
Fysh. Chiropractic Care for the Pediatric Patient. Arlington VA: ICACCP, 2002.
Kunau P. Application of the Webster In-utero Constraint Technique: A Case
Series. Journal of Clinical Chiropractic Pediatrics, 1998; 3(1): 211-6.
McMullen M. Assessing upper Cervical Subluxations in Infants Under Six
Months. ICA International Review of Chiropractic, 1990; March/April: 39-41
Pistoles R. The Webster Technique: A Chiropractic Technique with Obstetric
Implications. JMPT, 2002; 25(6).
Webster L. Chiropractic Care During Pregnancy. Today’s Chiropractic, 1982;
Sept/Oct: 20-22.