CHIROPRACTIC CARE: PEDIATRICS
MARILYN LAJOIE, MD, DC, CCSP
Dr. Lajoie is a medical doctor, specializing in Internal Medicine, and a Chiropractic Physician. She has 40 years of experience as a Chiropractor and over 20 years as a medical doctor. As a Diplomate of the Chiropractic Board of Examiners, she is also a Certified Chiropractic Sports Physician. She has worked extensively in the private sector, then for over five years with the Veterans Healthcare System. Integrating traditional with complementary forms of treatment, Dr. Lajoie has specialized in pain management and musculoskeletal disorders. She is licensed to practice in Florida, Massachusetts and Montana. Additionally, she has two doctorates in theology, a Doctorate in Biblical Studies and a Doctorate in Ministry. Dr. Lajoie is a Local Minister, and combines this in Integrative Holistic Medicine, caring for the body, the mind and the soul. She and her husband live in Helena, Montana, raising a herd of 20 llama.
ABSTRACT
Chiropractic care is considered a complementary or alternative treatment for pain management and other disorders. Although most people think of chiropractic care as a treatment for adults, chiropractic interventions can also benefit the pediatric population. Chiropractic treatment involves manipulation of the spinal and/or extremities for pain management and other disorders. It may incorporate other modalities such as physiotherapy, diet, and acupuncture. Chiropractic care offers a holistic approach to healthcare and can improve a patient’s overall health and wellbeing and reduce or eliminate many seemingly unrelated conditions.
Policy Statement
This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.
Continuing Education Credit Designation
This educational activity is credited for 2 hours at completion of the activity.
Statement of Learning Need
Chiropractic care is often sought as an option for the treatment of certain medical conditions, and clinicians need to be prepared to answer patients’
questions by understanding the general chiropractic philosophy and methods of holistic care and healing. As greater control over their healthcare needs is being sought, complementary and alternative medicine may be selected by patients over invasive procedures and prescription medications that may need to be incorporated into patient treatment planning.
Course Purpose
To provide clinicians with knowledge of chiropractic medicine as a complementary and alternative approach to treat a medical condition, to better understand patient preferences, and to educate patients on options for treatment.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members.
Disclosures
Marilyn Lajoie, MD, DC, CCSP, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, PMHNP-BC – all have no disclosures. There is no commercial support.
Self-Assessment of Knowledge Pre-Test:
1. True or False: Parents of children who receive chiropractic care have reported improvements in their children’s health and behavior as a result of chiropractic treatments.
a. True b. False
2. Congenital spinal abnormalities are birth defects that begin to develop
a. after birth.
b. before a baby is born.
c. during adolescence.
d. All of the above
3. During embryonic development, the spinal cord begins to form ____________________ after conception along with the initial growth of the neural tube.
a. within a couple of weeks b. during the second trimester c. a couple months
d. during the third trimester
4. ______________ is a condition in which a portion of the spinal cord protrudes through the vertebrae when the neural tube does not close properly during development.
a. Encephalocele b. Anencephaly c. Paresthesia d. Spina bifida
5. When the neural tube fails to close during fetal development, the child can develop encephalocele if
a. a significant portion of the brain and the skull do not form.
b. a sac containing part of the brain and the meninges protrudes through an opening at the base of the skull.
c. a portion of the spinal cord protrudes through the vertebrae.
d. vertebral disc herniation and nerve dysfunction are present.
Introduction
Chiropractic treatment has become more common as a complementary and alternative form of holistic care in the pediatric population. Children who sustain injuries or those born with hereditary spinal conditions can benefit from specific spinal treatments by a trained chiropractor. Infants have also been treated for conditions germane to the birthing process that can lead to subsequent discomfort and crying. More research is needed to evaluate the role of chiropractic care for musculoskeletal dysfunctions in children of all ages.
Prevalence of Chiropractic Use in Children
Chiropractic is one of the categories of complementary and alternative medical therapies (CAM) and is sought by patients with not only pain syndromes. Chiropractic care is being utilized for the pediatric population, as well as for adults. The U.S. Centers for Disease Control and Prevention (CDC) has reported that approximately 3% of children have undergone either chiropractic or osteopathic spinal manipulation.1 Shaw (2014) reported that for every 100 children in the United States, an estimated 3 children have received chiropractic care.1
Many children can be expected to heal from injuries at a faster rate when compared to adults, and the methods used in chiropractic care have been shown to be valuable in promoting health by supporting children’s abilities to heal. According to the International Chiropractic Pediatric Association (ICPA), parents of children who receive chiropractic care have reported several improvements in their children’s health and behavior as a result of chiropractic treatments, including improvements in sleep habits and improved immune system functioning, as well as better overall behavior and attitude.2,3 According to Alcantara, et al. (2020) these results are commonly reported by the young patients and their parents in response to improvements in pain and illness management.3 Also, as far as the overall behavior and attitude, Alcantara, et al., stated that a “majority of parents assess the change/improvements in their child’s quality of life similarly to their children.”3
Chiropractic treatments for children have been rising over the past decades. In 2009, that number of pediatric patients receiving chiropractic treatment had reached 68 million in the U.S., which was about double the rate reported in 2000.1 In 2010, an estimated 17% of chiropractic patients were younger than 18 years of age and 7.7% were ≤ 5 years of age and approximately 9.4% were between ages 6 and 17.1
The use of chiropractic care in pediatrics has been controversial in terms of the safety of spinal manipulative therapy. Shaw (2014) also reported:1
• In 2011, 0.53% to 1% of pediatric chiropractic patients experienced mild adverse events due to manipulative therapy.
• Alcantara, et al. (2011)4 reported an estimated 3 adverse events per 5,438 office visits involving 577 children who were treated. Parents reported 2 adverse outcomes from 1,735 office visits involving 239 children. This study reportedly had some methodological weakness.1
• Vohra, et al. (2007)5 published two randomized trials and 11 observational reports that reported 9 serious adverse events, 5 mild to moderate adverse events, 20 delayed diagnosis following chiropractic care that involved another condition. This study considered both chiropractic and other practitioners who performed spinal manipulation.
The American Chiropractic Council on Chiropractic Pediatrics reviewed this study and provided the opinion that the adverse events in pediatric patients receiving manipulative therapy have been very small
“considering how many millions of pediatric chiropractic visits there were over that same time period.”1
A strong indicator of the safety of pediatric chiropractic care is that the malpractice rates for chiropractors are the lowest of all existing primary care providers. Pediatric chiropractors have maintained the same malpractice insurance rates as their colleagues who only treat adults.1 Bourgeois, et al.
(2009) reported an estimated >585,000 pediatric adverse drug events every year that required medical attention and 27.5% were due to antimicrobial drugs.1,6
When practiced by a trained provider, pediatric chiropractic therapy is considered safe and effective. Because children’s joints are more flexible there are options of chiropractic care involving joint mobilization versus manipulation.1 Compared to adults, children voice other types of pain symptoms. The older the child the higher the chance of experiencing pain related to athletic events and of pain quality that is similar to a young adult.1
The bodies of babies typically involve conditions of colic, sleep problems, breastfeeding difficulty and not uncommonly initially stem from problems encountered during birth.1 Often, plagiocephaly and torticollis are diagnosed in newborns and in utero, babies can develop issues of pain following being stuck in one position for months or other “intrauterine constraint.”1 Babies can demonstrate “directional preferences, possibly due to shortened tissues during growth.”1 Chiropractic therapy for babies tends to aim at restoring biomechanical balance and motion to the tissues, lessening tension related to growth during this early phase of physical development and changes.1
Babies who have trouble latching to the mother’s breast to instinctively suck to feed tend to have high rates of breastfeeding failure. Challenges with latching on typically involve the suck-swallow reflex. Some chiropractors focus on treating the joints of babies with an effect upon the central nervous system (CNS) aimed at supporting brain communication with the throat and tongue.
Miller, et al. (2009) reported on 114 patients with less than optimal infant breast-feeding at ages ≤12 weeks after the babies were seen by multiple other medical providers and lactation specialists. Of the study population, 89 (78) were able to breast-feed after four chiropractic treatments.7 The authors noted certain limitations to this study, stating, “It is not known whether this is a result of chiropractic manual treatment, the co-treatment provided along with other health care providers or the natural course of this condition.”7
Parents can be encouraged to keep up a 24-hour “crying diary” to determine whether treatment corresponds with reduced crying episodes.7 There is a limited number of chiropractic specialists who solely treat children.
An estimated 225 pediatric chiropractors are in practice worldwide. An
estimated 175 are in practice within the U.S., although the numbers of these clinicians are increasing.7
Spinal Problems In Utero
Congenital spinal abnormalities are types of birth defects that affect the spine and that develop before a baby is born. These anomalies can impact how the spine forms during gestation, which can influence the size and shape of the vertebrae, their alignment, and the general function of the spinal cord.
Additionally, when spinal problems develop in utero, it may cause problems with other bodily systems, including the kidneys or urinary tract, as well as difficulties performing routine activities of daily living.
During embryonic development, the spinal cord begins to form within a couple of weeks after conception with the initial growth of the neural tube.
This tube forms around the central structure called the notochord, which is made up of cartilage and forms a shaft to support the growing embryo. The neural tube is eventually what will become the central nervous system.
Sclerotomes on either side of the neural tube migrate medially and fuse between the surface ectoderm and neural tube to form vertebral arches and around the notochord to form vertebral bodies.8 The notochord ultimately forms the intervertebral discs.8
Spinal deformities may result from neural tube defects, e.g., spina bifida, or abnormal curvature of the spine, such as through congenital scoliosis, misshapen vertebrae, which includes the conditions of butterfly, wedge, or hemi-shaped vertebrae, and torticollis, or congenital lordosis or kyphosis.9-12 All of these conditions can have significant impacts on an infant’s ability to live a healthy life after birth, as the spinal abnormalities not only affect the growth patterns of the infant’s body, but they can also affect other organ systems and may be related to anomalies associated with organs such as in the heart, lungs, kidneys, or brain. The intimate temporospatial relationships between caudal spinal cord and anorectal and urogenital development during early embryogenesis may result in associated malformations involving all 3 organ systems.13
Spina Bifida
Spina bifida is a birth defect characterized by an open vertebral column that usually affects the spinal cord. According to the Spina Bifida Association, there are three main types of spina bifida.14 Types of spina bifida include occulta, meningocele, and myelomeningocele. There are also variations on these three types: e.g., Occult Spinal Dysraphism (OSD), Lipomyelomeningocele, Fatty Filum Terminale, Split Cord Malformation, Terminal Myelocystocele.14
Spina Bifida Occulta
Spina bifida occulta refers to a form of the condition that often goes undiagnosed, or is “hidden,” as the word occult implies. With this condition there is a small opening in the spine but not significant enough to expose a vertebra or allow a cerebrospinal fluid-filled to form on the back. The spinal cord and the nerves usually are normal.14
Since spina bifida occulta is a milder subtype with no herniation of neural tissue, a patient may be unaware that the condition exists in many cases. It is usually seen at lower vertebral levels and is associated with a tuft of hair or dimpling of the skin at the level of the bony defect. It affects approximately 10% of the population.16 Since it may not exhibit physical symptoms, it may be undetected on examination. The affected patient can still develop symptoms associated with spina bifida whether the condition is readily recognized or not.
At times, a person may seek medical help for another reason, such as low back pain, and the spina bifida condition is identified on X-ray. Spina bifida occulta in the lumbar spine, as well as mild scoliosis are often not noticed by the patient.22 In the case report above, the patient underwent chiropractic treatment with instrument-assisted joint mobilization in the lumbar spine, as well as high-velocity, low amplitude thrust manipulation in the same region near the deformity to treat low back pain. Another option for milder cases of spina bifida includes nonsurgical interventions that focus on stretching the
muscles of the back, improving range of motion, and supporting daily routines.22
Chiropractic care will not resolve spina bifida occulta but when a patient does seek help for circumstances that cause pain or deformity, spinal treatment can be started to help control symptoms and to improve functional abilities. The goal in such cases is to enable the patient to continue in daily activities with less pain.
Meningocele
A more clinically significant case is described as meningocele spina bifida. Here the opening is more significant, and a fluid-filled sac protrudes from the back, but this does not include the spinal cord nerves.14
Neural tube defects are thought to be related to a combination of environmental and genetic factors, but women who are pregnant or are even thinking of becoming pregnant are advised to increase their intake of folic acid, as it has been shown to reduce the risk of these specific kinds of birth defects.15,16
Myelomeningocele
Myelomeningocele involves a failure of the lumbosacral spinal neural tube to close during embryonic development, and a fluid-filled sac protrudes through the opening in the baby’s back with nerves of the spinal cord.14,15 The exposed neural tissue degenerates in utero, resulting in neurological deficit that varies with the level of the lesion.14
Myelomeningocele is one of the more common congenital conditions, but the cause of this spinal malformation is largely unknown. An estimated 1,427 infants are born with spina bifida (1 in every 2,758 births). According to the Centers for Disease Control and Prevention (CDC), Hispanic children have the highest rate of spina bifida as compared with non-Hispanic white and non-Hispanic black children.19 The prevalence of spina bifida for each
racial/ethnic group included: Hispanic: 3.80 per 10,000 live births, non- Hispanic black or African-American: 2.73 per 10,000 live births, and non- Hispanic white: 3.09 per 10,000 live births.19
Myelomeningocele is a costly lifetime disease with many comorbidities, including sensory and motor lower limb disability, bladder/bowel dysfunction, scoliosis, club foot, and hydrocephalus. Treatment options have changed over time because routine use of fetal ultrasonography and magnetic resonance imaging (MRI) has provided prenatal diagnosis and the potential for fetal surgery.21 Typically, patients with this condition are not good candidates for chiropractic manipulation as part of their treatment plan.
Causes of Neural Tube Defects
According to Greene and Copp (2014) there are many factors and causes of neural tube defects.17 Neural tube defects have been studied extensively and are some of the more commonly understood congenital anomalies involving the spine.17,18 They include such conditions as spina bifida, in which a portion of the spinal cord protrudes through the vertebrae when the neural tube does not close properly during development, anencephaly, which happens when a significant portion of the brain and the skull do not form, and encephalocele, which occurs when the failed closure of the neural tube causes a sac that contains part of the brain and the meninges to protrude through an opening at the base of the skull.17
The genetic component is an approximate 60-70% but few causative genes are known.20 Non-genetic, maternal risk factors include reduced folate intake, anticonvulsant therapy, diabetes mellitus and obesity. Folic acid supplements in a woman’s diet prior to and during pregnancy are important to preventing neural tube defects, as demonstrated in clinical trials.14,20 Many countries fortify foods with folic acid for this reason.14,20
Some neural tube defects in infants, such as anencephaly, are severe and incompatible with life. Anencephaly leads to the infant’s death shortly after birth in almost all cases.18 However, there are many children who are
born with spina bifida of both subtypes who survive and who thrive with proper care, which may include chiropractic care. In one case (2014) a 10-year-old boy complained of lower back pain and muscle spasm and during the initial evaluation by his chiropractor the mother expressed concern about his spinal deformity.22 Pain at the lower lumbar spine region was described as moderate and became more prominent after a fall that occurred 3 days before the office visit. The patient’s history included one incident of a prior motor vehicle accident a year prior without known sequelae or positive findings on thoracic radiographs.22 A diagnosis of “lumbago, muscle spasm, and lower lumbar segmental dysfunction” were made.22 Spina bifida was also diagnosed based upon the patient history and prior radiographs.22
In this case, chiropractic treatment was started with the use of an instrument-assisted joint mobilization of the lower lumbar spine and soft tissue vibration therapy to treat the muscle spasm.22 To prevent positions that caused high stress on the lumbar spine during an episode of acute back pain, the patient and his mother were provided education on proper ergonomic safety and posture. A type of spinal manipulation started on the patient’s second visit involving high velocity/low amplitude (HVLA) side-posture manipulation. Vibration therapy continued with the use of HVLA.22 After 6 treatments with the use of HVLA, the patient denied having back pain.
Stabilization exercises were recommended to help strengthen the lumbar spine musculature. The patient remained pain free with full range of motion during follow up visits.22
Congenital Scoliosis
According to the Scoliosis Research Society, congenital scoliosis refers to a spinal deformity caused by vertebrae that are not properly formed. This occurs very early in development; in the first six weeks of embryonic formation.23 Pediatric spine surgeons describe congenital spinal anomalies based on which part of the vertebra is malformed or connected. Depending on the structure of the anomaly, the child may exhibit scoliosis (a curve to the right or left), kyphosis (round back), or lordosis (spine curves inward as in a sway back). However, not all congenital anomalies fit neatly into these
categories.24 It develops in utero when the vertebrae fail to form normally in a segmental pattern of size and or shape. Symptoms may not develop until childhood or adolescence. The nearby structures of the ribs and the shoulder blades can also be affected. Organ system anomalies have been studied in patients with congenital scoliosis.25
Karimi and Rabczuk (2018) reported that the incidence of scoliosis varies between 2% and 13.6% worldwide.11 The main cause of scoliosis is not well understood. Although there have been multiple factors identified, much of the literature has focused primarily on genetics and environmental causes.
Peng, et al. (2020)12 raised prior a twin study of Simony, et al. (2016)13 that showed “a higher concordance rate in monozygotic pairs (0.13) than dizygotic pairs (0.00).”12 Justice, et al. (2003) discussed a region on the X chromosome that was possibly associated with inherited scoliosis;26 and Ward, et al. (2010) raised the polygenic origin of scoliosis, specifically suggesting a male to male transmission that was opposite to the X-linked heritance hypothesis.27 Karimi and Rabczuk also stated that while there are controversies related to the heritability of scoliosis, the development of inherited scoliosis has been linked to “chromosome abnormality, variations of gene loci.”11 These expressional alterations and epigenetic changes, amongst other environmental factors that further regulate gene expression, are believed to function all together to cause a dysfunction of cell activities seen in the development of scoliosis.11
A study by Furdock, et al. (2019) investigated the frequency of a number of organ system anomalies in patients with congenital scoliosis.25 The study found that 84% of patients had 1 or more organ defect. The number of defects were spread accordingly: “22% of patients had 1 organ defect, 19%
had 2, 18% had 3, and 18% had ≥4 organ defects. There was an average of 2.2 anomalies per patient.”25 Cardiac anomalies were the most common, arising in 54% of the patients who were evaluated. This percentage was more than twice the rate previously reported. Cardiac anomalies were followed in frequency by intraspinal anomalies, which were documented in 43% of patients. Syrinx was the most frequently found intraspinal anomaly.
Urogenital anomalies were reported in 39% of patients. The most prevalent anomaly documented was patients with only one kidney.25 In 12% of patients,
the triad of spinal, urogenital, and cardiac defects was observed.25 With abnormal spinal growth, the child may not reach a full height and the child’s posture could be stooped over. This also puts pressure on the lungs and respiratory system when the curvature of the spine prevents full lung expansion; often, breathing difficulties due to decreased lung volume can develop over time.25
A consensus statement regarding early onset scoliosis given by the Growing Spine Committee categorized congenital scoliosis as a type of early onset scoliosis, which is considered to be the presentation of the spinal deformity before the age of 10 years.28 All patients of congenital scoliosis need to be investigated in detail. Radiographs and MRI of the spine are usually ordered first, with additional studies for associated organ systems.29 Treatment recommendations include bracing, casting, or surgery on the spine, and while manual manipulation therapies and stretching exercises were not recommended to correct the condition, they could be used to control some other symptoms associated with the disability.
Chiropractors who care for patients with congenital scoliosis do not necessarily advise against braces or surgical treatment of the condition.
However, chiropractic care can be implemented concurrently with other treatments in coordination with the orthopedist or other specialist who is the child’s primary physician for this condition. This may include spinal manipulations, stretching, and range-of-motion exercises to strengthen muscle groups as well as to diminish pain and immobility secondary to this condition. The chiropractic care will not correct the spinal deformity, but it could provide enough support that it might decrease the time needed for braces or casting and it can help with recovery after surgery.30 According to Bettany-Saltikov (2016) there is no current evidence that one type of treatment over the other is more superior or effective, specifically in cases of severe scoliosis.31
Kyphosis
Kyphosis, more commonly referred to as hyperkyphosis, is an abnormal curvature of the spine that causes a roundedness of the thoracic spine, which appears as a hump in the back.32,33 Congenital kyphosis and kyphoscoliosis are much less common than congenital scoliosis; however, they are potentially more serious because compression of the spinal cord can sometimes lead to paraplegia.34 It most often occurs in older adults after years of degenerative changes of the spinal column that leads to compression of the intervertebral discs and compression fractures. However, excessive kyphosis can also develop in utero to cause congenital kyphosis. During embryonic development when the spinal column is forming, at least one of the intervertebral discs or the vertebrae form abnormally, causing an irregular curve to the spinal column, or a failure of the vertebrae to fully separate into distinct bones. The spine is bowed forward at an angle and as the infant continues to develop in utero, the angulation worsens with the growth of the spine. Eventually, the baby is born with an excessive roundness of the spine in the thoracic region and there may be other problems with organ systems, especially cardiac and pulmonary.35
Hyperlordosis
Congenital hyperlordosis is very uncommon, and usually develops in conjunction with kyphosis and scoliosis. Kyphoscoliosis is a disease of the thoracolumbar spine in which normal curvature is excessively deviated in multiple planes. Its complications are varied by multiple factors including the age of onset and the primary disease that contributes towards its presentation. These complications may range from mild to severe, so education on how these structural changes may result in physical limitations is strongly encouraged.36 Congenital hyperlordosis also develops during spinal growth of the embryo when an abnormality in vertebral segmentation causes the spinal column to grow forward in the lumbar region.37 The condition may not be readily apparent at birth, or the infant may present with an abnormal position of the back and hips and decreased movement. Rolfe, et al. (2017) stated that spinal abnormalities occurring during fetal development includes
underdevelopment of vertebral bodies and malformed cervical vertebrae with abnormal spinal curvature.38 The authors also stated that congenital spinal deformities (mild or undiagnosed) are associated with even small changes in curvature and progressive scoliosis “with vertebral body wedging due to asymmetric muscular loading during adolescent growth.”38 If it is not treated, the child can develop abdominal pain from the pressure on the spine and can have difficulties walking and growing normally.38
Treatments for Kyphosis and Hyperlordosis
The treatments for congenital kyphosis and lordosis can vary, depending on the severity of the angle of the defects. In some cases, the physician may closely observe the child as growth occurs to determine the most appropriate timing of intervention. When the spinal angle is significant, treatment through surgery is almost always necessary to prevent further complications and to prevent problems with mobility and pain as the child continues to develop. A chiropractor can also assist the orthopedist or other medical management of kyphosis or lordosis. Chronic low back pain and disability were studied in active-duty military personnel.39 Goertz, et al. (2018) conducted research focused on chiropractic care as an adjunct of multidisciplinary health care to manage low back pain.39 The authors stated that chiropractic care resulted in moderate short-term improvements when added to usual medical care.39
Vertebral segments do tend to rotate with the gravity assist of upright posture, and vertebral rotation within the scoliosis can cause nerve roots exiting the spinal cord to be encroached upon. Manipulation can reduce the rotational misalignment of the vertebrae. Paraspinal musculature is adversely affected by scoliosis.
The back muscles fall into three groups: the intrinsic or deep muscles;
the superficial muscles; and the intermediate muscles.40 “The intrinsic or deep muscles are those muscles that fuse with the vertebral column. The second group is the superficial muscles, which help with shoulder and neck movements. The final group is the intermediate muscles, which help with the movement of the thoracic cage.”40 Only the intrinsic muscles are considered
true back muscles, yet the chiropractor can assist with physiotherapy in the office to affect all three layers of musculature.40 A chiropractor could also work with an osteopathic physician to provide techniques that may decrease some of the future damage of the spinal curve and to help the patient achieve as much functional ability as possible while continuing to grow. As another option, chiropractic care could also help with healing following surgical correction of the condition.
Congenital Torticollis
Congenital torticollis is a physical deformity caused by “a contracture or fibrosis of the sternocleidomastoid muscle, on one side, leading to a homolateral inclination and contralateral rotation of the face and chin.”41 This condition most often appears in the neonatal period or after birth.41 The worldwide incidence rate of congenital torticollis varies between 0.3% and 1.9%, other studies indicate a ratio of 1 per 250 newborns being the third congenital orthopedic anomaly.41 The condition is sometimes called wryneck as the infant’s head is drawn to one side in a tilted position. The infant can also have difficulties with turning the head and there may be spinal involvement or developmental hip dysplasia. It is thought that congenital torticollis develops when the infant is turned or positioned abnormally during growth in utero.42 Prolonged anomalous positioning causes aberrant muscle development in the neck, and scar tissue eventually expands in the area, causing the muscle to be tight and shortened. The other theory is that there is fetal maldevelopment of the sternocleidomastoid muscle.42
A child with congenital torticollis could eventually develop other problems with poor range of motion in the head and neck. The child may be unable to turn the head from side to side and consistently lives with a tilt of the head in one direction.43 Eyesight can be affected, as the eyes would no longer be positioned within the horizontal field.44
Toopchizadeh et al. (2016) reported on a 5-year-old female with a diagnosis of congenital muscular torticollis who underwent left sternocleidomastoid muscle-release surgery.44 The child’s musculoskeletal
and neurologic evaluations and radiographic imaging revealed her cervical vertebrae were normal and there was no shortening of the neck muscles. She was evaluated by an ophthalmologist and other medical professionals and eventually right hypertropia and other orbital muscle reactivity. Her visual acuity was 10 out of 10. A diagnosis of congenital right superior oblique palsy was diagnosed. Corrective surgery was done and the hypertropia was resolved along with her head tilt.44
In another case report published in the Journal of Chiropractic Medicine (2015), a 23-month old child born with congenital torticollis and who developed abnormal fixation of one eye was reviewed.45 The child had an abnormal tilt of the head to one side, indicative of torticollis, as well as a slight curvature of the spine, and adduction of the right eye when he was looking straight ahead. The child underwent spinal manipulative therapy of the cervical vertebrae, as well as routine massage and stretching exercises for a period of four weeks.45 At the end of the chiropractic sessions, the torticollis was almost completely resolved and the deviated eye gaze was corrected.45 The chiropractic care administered in this case was able to provide enough stretching to improve range of motion of the cervical spine to resolve the torticollis. The abnormal eye gaze developed as a result of the tilt of the head over time, but with resolution of the torticollis, the eye gaze was also normalized.45
An earlier study by von Heideken, et al. (2006) re-evaluated the reported incidences of congenital torticollis and congenital hip dysplasia, which to that point were between 2 and 29%.46 This retrospective study reviewed patients referred for either of the two conditions, then screened for the other.
“Among the patients with hip dysplasia, there was a 7.9% coexistence of congenital muscular torticollis, regardless of which was diagnosed first, and among the patients with torticollis, there was a 12.5% coexistence of hip dysplasia.46 Boys with hip dysplasia were 4.97 times more likely than girls to have both conditions regardless of which diagnosis preceded the other.”46 When examining a patient with either of these two conditions, the other must be evaluated for as well. Chiropractors are trained to seek these correlations between spinal congenital abnormalities.
Although surgery may be indicated, as in the example of the child reported by Toopchizadeh, et al. (2016),44 the main treatment for torticollis is a nonsurgical approach through regular stretching and positioning exercises.
Infants born with torticollis could receive treatment through chiropractic care to improve flexibility and range of motion of the head and neck. Chiropractic care of the condition can further prevent other mobility problems and plagiocephaly (flattened head syndrome) if the baby continually sleeps on one side.47 However, if the condition is significant and the cervical spine angulation is severe, the torticollis may require surgery. Lepetsos, et al. (2017) studied the outcomes on the surgical management of late presenting cases of congenital muscular torticollis in 31 cases involving surgery over a 20 year period (1990 to 2010).48 The authors reported that in children >7 years,
“surgical release combined with appropriate orthosis and a structured physiotherapy regime can lead to satisfactory results.”48
Infants with torticollis tend to sleep with their heads in the same position, which can cause the affected side of the head to become flattened and misshapen. If congenital hip dysplasia is also present, the child will have difficulty moving the lower part of the body as well and will have decreased mobility. A correlation has been known between congenital torticollis and congenital hip dysplasia.46
The case reports raised in this section help to elucidate how a child with a spinal condition can safely and effectively be helped through chiropractic care. When a health condition is present at birth because of abnormal development in utero, a child may experience a lifelong struggle. Many forms of treatments besides chiropractic care, including surgical and pharmacological methods are available to help manage painful symptoms.
Chiropractic care can be used as part of standard treatment to significantly reduce the time of healing, and in some cases, delay or even replace more invasive methods of medicine.
Idiopathic Scoliosis
In cases of congenital scoliosis, de Baat, et al. (2012) described the development of anatomical spine deformity during embryonic vertebral development.49 They reported an estimated 38-55% of these deformities appear as a syndrome with a variable prognosis and treatment on a case by case basis depending on the severity of the deformity.
Adolescent idiopathic scoliosis (AIS) is diagnosed at a young age, is typically rapidly progressive, and the magnitude of the curve can also progress even into adulthood.49 The neuromuscular condition underlying spinal deformity also influences treatment decisions and outcomes. The treatment, however, tends to be surgical correction as the child grows.49
As compared to adult scoliosis or degenerative scoliosis, idiopathic scoliosis in children tends to result in the same treatment as those for adults.49 There are neurologic impairments in cases of degenerative scoliosis where the focus of treatment is on the mechanical decompression of spinal cord or nerve roots.49
As the name implies, there is no particular reason why some children develop idiopathic scoliosis and why the spine curves and bends as it grows.
The condition does seem to run in families and it tends to be more common in girls.50 “It usually presents as a rib hump visible at forward bending, together with unlevel shoulders and an asymmetrical waist. The diagnosis is confirmed by a standing spinal radiograph showing a lateral curvature of the spine exceeding 10 degrees.”50 Grauers, et al. (2016) stated that onset of idiopathic scoliosis at a young age tends to involve a large curvature of the spine, and a thoracic curvature corresponds with skeletal immaturity, which leads to progression of spinal deformity.50 The authors noted that thoracic curves in children carry the “highest risk of progression, 58–100%.”50 When growth stops, curves <30 degrees involve a very small risk of progression.50 Spinal curves at 50 degrees are likely to continue to progress at a rate of 1 degree every year in the adult.50
A major concern in idiopathic scoliosis is the lack of a reliable way to predict its progress. Patients are subjected to frequent follow-up visits, and testing, such as radiographs. Some patients may also receive unnecessary brace treatments because of this uncertainty. An estimated 10% of patients will have their condition progress to a moderate or severe spinal curve.50 The most common spinal curvature observed is a right thoracic convexity, with a compensatory left lumbar convexity. When the individual stops growing, the risk of progression diminishes.50
Another form of scoliosis that may affect older adults is degenerative scoliosis, which develops in adults who had scoliosis that was treated when they were younger, or in some people who have abnormal amounts of spinal deterioration with aging.51 Degenerative scoliosis patients typically present in the sixth decade of life, with back pain reported by 60–80% of patients with symptomatic degenerative scoliosis and most commonly on the convex side of the curve. This is due to degenerative changes within the spine as well muscle fatigue as a result of spinal imbalance.51 Consequently, a child with scoliosis may also be at greater risk of developing degenerative scoliosis later in life.51
As the vertebrae and intervertebral discs undergo degeneration, vertebral segments may have asymmetric endplate changes, causing compression fractures or wedge shaped changes to the vertebral body.52 The spine can become curved and bowed outward, further increasing pressure on the intervertebral discs and the bones of the spine. There are also other, rarer forms of scoliosis that are often associated with chronic illness, such as neurodegenerative scoliosis, which can occur with conditions such as cerebral palsy; and syndromic scoliosis which refers to scoliosis that is most commonly associated with systemic disease including Ehlers Danlos syndrome, Marfan syndrome, Down syndrome, Achondroplasia, and Prader-Willi syndrome.52
Scoliosis is often identified in children and teens when parents note a problem with their child’s mobility or the appearance of the spine. Scoliosis screenings are also often performed in schools and with routine well-child checks in physician’s offices. The severity of adolescent idiopathic scoliosis
(AIS) depends on the area of the back that is involved and the extent of the curvature; however, if it can be caught early, it may be treated through non- surgical measures to prevent further curvature of the spine, such as through chiropractic manipulative therapy and physiotherapy. Chiropractic care uses non-invasive techniques through spinal alignment and suggestions for lifestyle modifications that may help to prevent the condition from worsening if diagnosed early. “Determining the peak growth velocity of a patient with adolescent idiopathic scoliosis is important for timely treatment to prevent curve progression.”53
Predicting the rate that AIS will progress is important. The progression of the spinal curvature must be determined to the extent possible to maximize the benefits of any intervention for AIS. The distal radius and ulna classification may accurately predict skeletal growth; however, its ability to predict the progression of spinal curve in adolescents is unknown. A retrospective review was performed (2020)and found that “the maximal curve progression occurs after the peak growth spurt, suggesting that the curve should be monitored closely even after peak growth.”53 This progression continues for about one and one-half years after a person’s peak growth period and until skeletal maturity.53 This is important in determining the duration of treatment, goals for management, and the expectation for a scoliotic curvature to stop in its progression naturally.53
Chiropractic spinal manipulation could help to control the curvature of the spine and prevent it from worsening as the child grows. If a child is seen with advanced scoliosis, spinal adjustments would not be expected to stop the curve from progressing; however, the muscular imbalances due to the curvature could be managed. This would help the child to live well and function despite the spinal deformity, and as an adjunct to other types of treatment, including back braces or surgery.
Adolescent idiopathic scoliosis is the most common spine deformity in adolescent patients. Clinicians are aware that AIS leads to structural deformity and that these deformities may impact the health and function of the spine;
however, not much is known about back pain and chronic back pain, and the
factors associated with back pain, in AIS patients. A study by Wong, et al.
(2019) looked at the period prevalence rates of back pain among teenagers with AIS, and its association with curve severity.54 In this study, 1097 patients were treated non-surgically, which made up 98.3% of the study group. The prevalence of thoracic pain ranged from 6% to 14%, whereas that of low back pain ranged from 6% to 29%.54
Specifically, chronic thoracic pain or low back pain was least prevalent.
the lowest prevalence. Patients with back pain had more severe insomnia and daytime sleepiness compared with patients who reported no pain.54 Those with chronic back pain had the same problems along with moderate depression, insomnia and daytime sleepiness. Based on this study, biopsychosocial factors appear to be associated with the presence and severity of back pain in patients with AIS.54 “These results highlight the importance of considering back pain screening/management for patients with AIS with their psychosocial profile in addition to curve magnitude monitoring. In particular, sleep quality should be routinely assessed.”54
Chiropractic treatment can be utilized to manage the pain of AIS, while allowing for the holistic assessment of comorbid conditions of depression and insomnia.54 These conditions in the young can significantly affect their ability to function well in school and other activities, normal for a growing child or teen. Chiropractic treatment may also reduce the amount of time spent undergoing conventional scoliosis treatments, such as decreasing time spent in a back brace or reducing the need for surgery.54
A study by Morningstar, et al. (2017) looked at the effects of chiropractic rehabilitation on patients who had been diagnosed with adolescent idiopathic scoliosis.55 Because teens who have scoliosis are still in stages of development to where their spines have not finished growing, the authors of the study not only evaluated the subjects while they went through cardiac rehabilitation, but they also continued to follow the patients until they reached skeletal maturity.
The study showed that 90% of the patients who had chiropractic care and idiopathic scoliosis achieved some amount of spinal angle correction when they were later evaluated at spinal maturity.55 The subjects in the study did
not use spinal braces to correct their scoliosis. The average amount of correction of spinal angle was 12.75 degrees.55
While more studies need to be conducted about the effects of chiropractic manipulation to achieve even greater angle correction, any amount of spinal angle correction can be helpful for affected patients and it prevents further progression of the spine into a scoliosis curve. With this in mind, chiropractic care can be very beneficial in helping children and teens diagnosed with scoliosis when used in addition to conventional forms of treatment.55
It should be noted that scoliosis treatment solely through chiropractic care is controversial and that some patients have described adverse effects of chiropractic care when they underwent treatment for their scoliosis, including muscle pain and generally feeling worse after receiving treatment.
Chiropractic care is not necessarily the right choice for everyone, and many people who utilize chiropractic medicine report only mild side effects. In general, people should continue to use chiropractic care when they do experience physical benefits from the techniques, particularly when it is in combination with other standard forms of treatment.56
Summary
Children and adolescents can certainly be candidates for chiropractic care and they often respond well to many of the techniques used in chiropractic manipulative therapy. Methods used in chiropractic care of some children have been shown to be valuable in promoting health by supporting the ability of children’s bodies to heal. According to the International Chiropractic Pediatric Association (ICPA), parents of children who receive chiropractic care have reported several improvements in their children’s health and behavior as a result of chiropractic treatments, including improved sleep habits, improved immune system functioning, and better overall behavior and attitude. These results are commonly reported by parents in addition to the positive support that chiropractic care clinicians provide, including pain relief and symptom control when illness is present.
A lack of research exists about the effectiveness of spinal manipulation on newborns and the effects of adjustments on controlling symptoms of colic, reflux, or sleeping difficulties in babies. Pediatric chiropractors who work with infants have suggested that these gentle adjustments to the spine to correct misalignment are safe and can help these and many other health problems in infants, in a manner similar to problems treated by chiropractic care in older children and adults. The long-term effects of chiropractic care of newborns will need more study and further clinical research to demonstrate that this type of therapy is safe and effective for infants.
Self-Assessment of Knowledge Post-Test:
1. True or False: Parents of children who receive chiropractic care have reported improvements in their children’s health and behavior as a result of chiropractic treatments.
a. True b. False
2. Congenital spinal abnormalities are birth defects that begin to develop
a. after birth.
b. before a baby is born.
c. during adolescence.
d. All of the above
3. During embryonic development, the spinal cord begins to form ____________________ after conception along with the initial growth of the neural tube.
a. within a couple of weeks b. during the second trimester c. a couple months
d. during the third trimester
4. ______________ is a condition in which a portion of the spinal cord protrudes through the vertebrae when the neural tube does not close properly during development.
a. Encephalocele b. Anencephaly c. Paresthesia d. Spina bifida
5. When the neural tube fails to close during fetal development, the child can develop encephalocele if
a. a significant portion of the brain and the skull do not form.
b. a sac containing part of the brain and the meninges protrudes through an opening at the base of the skull.
c. a portion of the spinal cord protrudes through the vertebrae.
d. vertebral disc herniation and nerve dysfunction are present.
6. Women who are pregnant or are even thinking of becoming
pregnant are advised to increase their intake of ________ to help reduce the risk of neural tube defects.
a. iron
b. Vitamin D c. folic acid d. zinc
7. True or False: Many neural tube defects are severe and in some cases, such as with anencephaly, are incompatible with life and the infant dies shortly after birth.
a. True b. False
8. Spina bifida occulta is a type of spina bifida that is a. severe, causing back deformities and poor mobility.
b. so severe it causes paralysis.
c. nonexistent and is a form of Munchausen syndrome.
d. not obvious and a patient may be unaware of the condition.
9. Congenital scoliosis is a curvature of the spine a. caused by a sac that protrudes from the back.
b. that forms a “hump” on the back of the spine.
c. to the side (right or left).
d. inward toward the abdomen.
10. _____________ is a condition that causes a roundedness of the thoracic spine, which appears as a hump in the back.
a. Lordosis
b. Congenital muscular torticollis c. Kyphosis
d. Scoliosis
11. True or False: The Growing Spine Committee recommends
manual manipulation therapies and stretching exercises to treat and correct congenital scoliosis.
a. True b. False
12. Lordosis is a spinal anomaly that is described as an abnormal curve in the lumbar region of the back, in which the lumbar spine
a. curves to the side instead of its usual vertical structure.
b. rounds in the shape of a hump.
c. curves inward (sway back).
d. is bowed forward at an angle.
13. Kyphosis is a spinal condition a. that most often develops in utero.
b. in which the spinal curve is normal but paralysis is present.
c. characterized by a “sway back.”
d. that most often occurs in older adults.
14. In children, chiropractic spinal manipulation could help
a. control spinal deformities and prevent their worsening as the child grows.
b. reverse advanced scoliosis.
c. cure spinal deformities if treatment is started early.
d. treat infections that may arise from a spinal deformity.
15. A chiropractor may work with an osteopathic physician to provide techniques that could
a. treat vertebrae that have fused.
b. restore bone density.
c. help a patient achieve as much functional ability as possible.
d. restore vertebrae that have been damaged.
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