Chiropractic Care In Pediatrics

Series On Chiropractic Care

JASSIN M. JOURIA Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e- module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

ABSTRACT

Although modern medicine offers a wide array of pharmaceutical and surgical treatments for pain, chiropractic care offers a natural, drug-free treatment modality that can alleviate pain in many patients. Chiropractic care has been shown to be successful in children, adults, and older adults, and for a range of ailments. Although chiropractic care focuses on the spine, correcting maladjustments can improve a patient’s overall health and wellbeing and reduce or eliminate many seemingly unrelated conditions.

1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Health clinicians will find that patients often tend to seek complementary and alternative remedies or treatments along with or in lieu of conventional medical care for prevention and healing. 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 are 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

2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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 and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 1. True or False: Parents of children who receive chiropractic care have reported several improvements in their children’s health and

3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com behavior as a result of chiropractic treatments, including a better overall behavior and attitude.

a. True b. False

2. Congenital spinal abnormalities are birth defects that affect the spine

a. and the spinal cord. b. and that develop before a baby is born. c. and that can eventually affect other areas of the body. 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. The ______eventually harden through ossification as it/they become bones and the notochord ultimately forms the intervertebral discs.

a. cartilage b. neural tube c. annulus fibrosus d. somites

5. ______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. Spina bifida c. Anencephaly d. Paresthesia

Introduction

4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Children can certainly be candidates for chiropractic care and they often respond well to many of the techniques used in chiropractic medicine. Children often heal at a faster pace when compared to adults, and the methods used in chiropractic care of some children have been shown to be valuable in promoting health by supporting children’s bodies’ 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 improved sleep habits, improved immune system functioning, and better overall behavior and attitude.45 These results are commonly reported by parents in addition to the positive support that chiropractic care clinicians, including for pain relief and symptom control when illness is present.

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, the person can eventually have problems in other areas of the body, 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.

5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Small segments called somites start to form on either side of the neural tube, and these segments will eventually develop into the vertebrae of the spine. The somites eventually harden through ossification as they become bones and the notochord ultimately forms the intervertebral discs.

There are various reasons why the spine does not form normally during development. Neural tube defects are some of the more commonly understood congenital anomalies involving the spine and they include such conditions as 1) spina bifida, in which a portion of the spinal cord protrudes through the vertebrae when the neural tube does not close properly during development, 2) anencephaly, which happens when a significant portion of the brain and the skull do not form, and 3) 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. 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.

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. However, there are many children who are born with spina bifida who survive and who thrive with proper care. Severe cases of spina bifida can cause back deformities and difficulties with mobility; if the condition is untreated and is serious, the child could suffer from poor mobility and/or paralysis, and will often have difficulty with bladder control. Milder cases of spina bifida can be managed through nonsurgical interventions that focus on

6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com stretching the muscles of the back, improving range of motion, and supporting daily routines.

Spina bifida occulta is a type of spina bifida in which the neural tube closure is not obvious; in many cases, the patient may be unaware that the condition exists. Spina bifida occulta occurs most commonly in the lumbar region of the spine and it could cause difficulties with walking or moving, as well as back pain, vertebral disc herniation, and nerve dysfunction.44 This particular type of spina bifida is often much more common than what is diagnosed because physical examination does not always reveal the condition. Some patients may have a hairy nevus on the back at the location of the defect; however, a large percentage of cases display no signs of the defect at all. The affected patient can still develop symptoms associated with spina bifida whether the condition is readily recognized or not.

Although spina bifida occulta is the mildest form of the condition, it can still cause muscular weakness and bladder dysfunction for some people. 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. A case report published in the Journal of Chiropractic Medicine reviewed a case of a 10- year-old boy who was taken to a chiropractor for care of low back pain after falling. When the chiropractor performed radiological testing, it was noted that the child had spina bifida occulta in the lumbar spine, as well as mild scoliosis. Of note, the authors stated that approximately 20 percent of the population has spina bifida occulta and most people are actually unaware of it. Because the condition is so common, many chiropractors are likely to come across it when treating patients. The child in the case report underwent chiropractic treatment with instrument-assisted joint mobilization in the lumbar spine, as well as high-velocity, low amplitude thrust

7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com manipulation in the same region near the deformity and for treatment of low back pain. After six treatment sessions, the child’s pain was under control and there were no unwanted effects on the spina bifida condition.44

To review, chiropractic care will not resolve spina bifida conditions, but when a patient does seek help for circumstances that cause pain or deformity, chiropractic care can be administered to control symptoms and to improve functional abilities so that the patient is able to continue with less pain.

In addition to neural tube defects, other spinal deformities can include 1) abnormal curvature of the spine, such as through congenital scoliosis, 2) misshapen vertebrae, which includes the conditions of butterfly, wedge, or hemi-shaped vertebrae, and 3) torticollis, or congenital lordosis or kyphosis. 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.

Congenital scoliosis is described as the spine having a curvature to the side instead of its usual vertical structure. It develops in utero when the bones of the vertebrae fail to form normally in a regular pattern. Children with congenital scoliosis may also have twisted vertebrae, or the spine may be turned and bent upon itself, however, the condition is not always apparent at birth and symptoms may not develop until childhood or adolescence. The nearby structures of the ribs and the shoulder blades can also be affected. The child can have problems with other organ systems as well, including with the heart or kidney problems, or issues with the nerves or the urinary system.

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With abnormal spinal growth, the child may not reach a full height and the child’s posture could be stooped. 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.

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. The Committee also recommended that clinicians working with children with congenital scoliosis should include radiology testing of the spine, including X-ray and CT scans during diagnosis, as well as further testing of the heart and kidneys.40 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 in the time surrounding these treatments to help the child. This may include spinal manipulations, stretching, and range-of-motion exercises to strengthen muscle groups as well as to diminish some of the effects of the 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.

9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Kyphosis is a condition that causes an abnormal rounding of the spine that produces a hump in the back; on appearance, the child may seem to have a hunched back. It most often occurs in older adults after years of wear on the spinal column that leads to compression of the intervertebral discs and compression fractures. However, kyphosis can also develop in utero to cause congenital kyphosis. During embryonic development when the spinal column is coming together, at least one of the intervertebral discs or the vertebrae themselves 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 a lump on the back and there may be other problems with different organ systems as well that are not as apparent.41

Lordosis is another spinal anomaly that can develop before birth. It describes an abnormal curve in the lumbar region of the back, in which the

10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com lumbar spine curves inward toward the abdomen. In comparison to kyphosis, which causes a hump on the back, lordosis causes the back to appear concave as it curves inward. Congenital lordosis 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.42 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. If it is not treated, the child can grow to develop abdominal pain from the pressure on the spine and can have difficulties walking and growing normally.

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, though, 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 with some treatments for kyphosis or lordosis.

Many studies have shown that helping patients with these conditions to work on their posture and to stand up straight have had no impact on the condition. Spinal adjustments made by chiropractors will not realign the spine to correct the curvature, but these adjustments could help to control some of the pain and inflammation of the condition. The chiropractor could also work with an osteopathic physician to provide techniques that could decrease some of the damage of the spinal curve as well as to help the patient to achieve as much functional ability as possible while continuing to

11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com grow. As another option, chiropractic care could also help with healing following surgical correction of the condition.

Congenital muscular torticollis is present at birth or can develop during infancy. The condition is sometimes called wryneck and refers to a tightening of the sternocleidomastoid muscle on the neck and side of the head. As this muscle constricts, 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 in utero when the infant is turned or positioned abnormally as he grows in the womb. 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.43

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. 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.

The main treatment for torticollis is a non-surgical approach through regular stretching and positioning exercises. However, if the condition is significant and the neck angle is severe, the torticollis may need to be treated with surgery.

12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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 if the baby continually sleeps on one side.

A case report published in the Journal of Chiropractic Medicine discussed a case of a 23-month old child who was born with congenital torticollis and who had developed abnormal fixation of one eye. 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 on the cervical vertebrae, as well as routine massage and stretching exercises for a period of four weeks. At the end of the sessions, the torticollis was almost completely resolved and the deviated eye gaze was corrected.39 The chiropractic care administered in this situation was able to provide enough stretching to improve range of motion of the head and 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 repaired.

The above case report is a useful example of a situation in which a child with a spinal problem can be safely and effectively helped through chiropractic care. When a health condition is present at birth because of abnormal development in utero, the child may struggle with the condition for the rest of his or her life. However, many treatments, including surgical and pharmacological methods are available to help. Chiropractic care can be used as part of standard treatment to significantly reduce the time of healing, and in some cases, it may delay or even replace more invasive methods of care.

13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Spinal Problems During Birth

A birth injury, or birth trauma, is an injury that harms the infant during the birthing process. There are various types of injuries and outcomes that occur as a result of damage to the infant’s body, and the extent of damage can range from very mild circumstances such as head molding or small abrasions on the scalp to significant damage that can cause lifelong disabilities, including intracranial hemorrhage and nerve paralysis. Birth trauma most often occurs when there is difficulty with the infant making the transition through the birth canal, such as when the baby is large for gestational age or if in the breech or side-lying positions in utero.46

The actual process of birth often involves a caregiver holding the baby’s head during delivery and assisting with rotation of the body to deliver the shoulders and the rest of the body. There may be times, though, that delivery requires extended pulling or twisting to actually deliver the infant’s body. Sometimes, physicians must use assistive devices through forceps or vacuum extraction that help with the infant’s delivery; however, these devices often cause tissue trauma, most often to the baby’s head and back.

A difficult delivery can also cause spinal damage to the infant, which could cause lifelong health problems. There are some children who are permanently disabled because of damage sustained during a particularly difficult delivery. Infants who are positioned abnormally in utero – that is, positioned in a manner other than the typical head-down position – are more

14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com likely to have a difficult delivery. Additionally, infants who are breech, face up, or in any other position besides the standard presentation for delivery are at highest risk of spinal damage during birth because the delivery process is much more complicated.

The spine can be damaged when there is too much traction placed on the baby’s body while emerging through the birth canal. For example, in the case of a footling breech birth where the legs are first to emerge through the birth canal, excess traction or pulling on the legs and the length of the body could cause damage to the baby’s spine. At times, the infant’s head may also be hyperextended during the birth transition; this position is sometimes called the stargazer fetus because of the position of the infant’s head facing up. Unfortunately, attempting to induce vaginal delivery with this form of fetal presentation places the infant at risk of birth trauma, including spinal cord injury.

One of the more significant injuries to occur due to birth trauma is spinal cord injury, in which there is partial or complete split in the spinal cord, often combined with bleeding. The condition most often occurs when the infant’s back is stretched or pulled in a longitudinal fashion so that the cord is stretched beyond its normal capacity. Trauma to the vertebrae which results in fractures can also damage the cord, although it is rare that the birth trauma is so extensive that the cord is completely severed.

As mentioned, hyperextension of the head during delivery can also cause spinal cord damage if the infant’s head is pulled or rotated; this presentation and subsequent extraction can cause the spinal cord to be damaged or severed in the neck. Spinal injury due to birth trauma often occurs in the cervical region of the neck, although it can happen anywhere along the

15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com spine.46 If the spinal cord is completely severed during delivery, the infant will suffer paralysis and may have difficulty breathing. An infant with a complete spinal cord separation can survive, but will live with paralysis and have a lifelong disability.

An infant may also suffer damage to the vertebrae of the spine during birth, which may not necessarily harm the spinal cord, but that could cause misalignment of the spinal column. Traumatic birth syndrome describes a condition in which an infant sustains damage to the head or spine, including misalignment of the spinal column, because of the events that happened during birth.47 Because of the sometimes traumatic nature of infant delivery, which can involve pulling on the infant’s head, turning the body, or using assistive devices when the birth is difficult, the infant is at risk of injuries to the back, including the bones of the spine, the surrounding muscles and intervertebral discs, and the associated nerves.

A baby may be born with spinal subluxation because of birth trauma, but the effects may not be immediately seen. Problems with muscle weakness, poor development, and difficulties with feeding and with sleeping can all develop as a result of vertebral subluxations that occur during birth. There are some chiropractors that specifically work with infants who are suffering from the effects of traumatic birth syndrome, while other clinicians who work with children may see older infants or children who have been struggling with the ongoing effects of spinal misalignment that occurred during the birth process.

A chiropractor who works with very young children and infants should specialize in the unique needs and treatment of patients in this particular population. Parents may take their infant to see a chiropractor for help with

16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com spinal adjustments to correct subluxations, which could potentially resolve other problems the child may be having as well. Problems due to vertebral subluxations in infants may manifest in a number of ways, such as through colic, in which the infant cries inconsolably, sometimes for hours at a time. Some parents have noted that their child suffers from reflux and excess spitting up of milk or formula as a result of vertebral subluxations, as well. A chiropractor who is trained to treat young children can perform spinal adjustments on babies who have subluxations that occurred during childbirth.48

A case series published in the Journal of Pediatric, Maternal & Family Health reported an instance of twin boys, born prematurely, who had suffered birth trauma that included plagiocephaly (a flattened part of the skull) and scaphocephaly (a narrowed skull). By the age of seven months, the infants were having difficulties with breastfeeding, and had long-term reflux and chronic irritability. The babies underwent 16 weeks of spinal adjustments, and at the end of the term, their mother reported a complete resolution of reflux, few problems breastfeeding, a marked reduction in irritability, and significant improvement in head shape following the plagiocephaly and scaphocephaly.49

Birth trauma may cause damage to the nerves due to compression or nerve stretching beyond its normal capacity. The damage can cause weakness and paralysis of nearby structures. Brachial plexus nerve injury may occur from excess stretching of the nerve in the upper arm and shoulder while the baby is being delivered, such as in cases of shoulder dystocia, where there is difficulty delivering the infant’s shoulders past the mother’s pubic bone after the head has already been delivered. The brachial plexus is found in the cervical regions of the neck and the upper portion of the thoracic spine;

17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com significant manipulation of the baby’s body during delivery can traumatize this network of nerves. The injury can lead to various forms of palsy, including Erb’s palsy, which can cause weakness or paralysis and paresthesia in one arm; or Klumpke palsy, which causes paralysis in the wrist and the hand.

Horner syndrome is a condition where there is such damage to the nerves that the child has weakness, paralysis, and facial changes on one side of the upper body, including small pupil size and ptosis on the affected side.46 The condition can cause a lifelong disability for the affected child and often has to be managed with ongoing therapy and rehabilitation to prevent complications.

In some cases, chiropractic care may be utilized to improve range of motion, function, and flexibility among infants with nerve damage due to birth trauma. Adjustments and stretching exercises can improve symptoms and may restore some strength in the affected areas. Chiropractic manipulation may also be able to completely restore health and function to normal capacity for some children. A case of Erb’s palsy that was resolved following chiropractic manipulation was published in the Journal of Pediatric, Maternal & Family Health, which referenced a case of a 5-month-old girl who suffered from Erb’s palsy as a result of obstetric care. The girl had poor range of motion and limited movement in the right arm. She underwent chiropractic care for two months, which involved gentle stretching, adjustment, and manipulation that was modified for her age. After two months, the infant experienced significantly improved range of motion and resolution of the palsy.50

18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Chiropractic care of infants is specialized to this particular population in that the chiropractor modifies his or her techniques when working with infants. An infant’s body is much more fragile when compared to an older child or an adult; the chiropractor must take into consideration the developmental stage of the infant as well as the muscle and bone growth present. When making an adjustment, the chiropractor is gentle and does not use much force at all when aligning the spine and manipulating the tissues. Instead, tissue manipulation or spinal adjustment is done by gently moving and stimulating the muscles and joints.

The infant can also undergo range-of-motion exercises as the chiropractor gently repositions and rotates the head, back, and extremities. Exercises to increase flexibility and to stretch the muscles are performed similarly, while considering the fragile state of the infant’s muscle and joint structures. Many infants tolerate chiropractic procedures quite well and the experience can be calming and soothing for them, sometimes promoting relaxation and sleep.

Related Disorders

In addition to the research performed on the benefits of chiropractic care in utero and on newborn infants, there is evidence that chiropractic medicine can be beneficial for care of some very common disorders that affect children. While children often have more rapid healing outcomes when compared to adults, they are also more likely to develop illnesses that can be temporarily debilitating, which can weaken their health and prevent them from going to school or daycare.

When illnesses occur in adults they are less likely to have as significant an effect as in children. For example, an adult who develops a viral respiratory infection that manifests as the common cold may feel under the weather and

19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com may suffer from a sore throat, cough, and nasal congestion. These symptoms may also occur in a child with a similar illness, but the child may also have a fever and such fatigue that a need may arise to stay home at bedrest. The adult with a cold will often continue working and performing routine activities. Whereas, the child who develops an illness or injury and receives chiropractic care may shorten the time of illness symptoms and return to normal activities faster.

Ear Infections

Ear infections are common illnesses seen in young children. They are often short lived because they can be treated quickly, but there are some children who have chronic ear infections. Parents of children who suffer from frequent ear infections may seek alternative forms of treatment or therapy if the condition is recurring and does not otherwise respond to conventional treatment through medication. Acute otitis media, typically referred to simply as an ear infection, occurs when there is an infection in the middle part of the ear, the pressurized space beyond the tympanic membrane. Children typically contract ear infections more often than adults; often, children cannot describe what is wrong or why they are experiencing pain in the ear. The infection is usually viral or bacterial in origin and may be treated with antibiotics, although many physicians are now backing away from frequent antibiotic use for otitis media treatment and are choosing a wait-and-see approach to allow the infection to resolve on its own.

Ear infections can be very uncomfortable for children. They typically cause pain in the ear, fever, and a feeling of pressure in the head. There may be fluid draining from the ear as well. Very young children who develop ear infections often have difficulties eating and sleeping and are frequently irritable. Normally, the Eustachian tubes link the nasopharynx to the middle

20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com ear and are responsible for regulating the pressure in the middle ear and ensuring that excess fluid does not build up in the space, which could contribute to ear infections. The Eustachian tubes are very small and can be easily blocked, particularly in children who suffer from frequent inflammation or upper respiratory infections that can cause swelling and that can obstruct the tubes. When the tubes do not drain fluid and air, increased pressure and fluid in the middle ear increases the risk of infection.

Some children develop chronic ear infections because of consistent fluid buildup behind the tympanic membrane, necessitating placement of drainage tubes in the eardrum, which regulate the pressure behind the membrane and drain fluid out of the middle ear, thereby decreasing the risk of ear infections. Based on the potential causes of ear infections and common reasons for their development, chiropractic care may not necessarily be the first choice of treatment for this condition. However, many parents take their children to see chiropractors for treatment of frequent ear infections, and there seems to be a connection between chiropractic medicine and the resolution of ear infections. As discussed, chiropractic medicine provides holistic care, so if a child has suffered from frequent ear infections, the chiropractor is more likely to try to find the root cause of the condition, rather than prescribing medication right away.

The chiropractor can evaluate what factors in the child’s life may be contributing to a tendency to develop ear infections, such as whether the child has frequent upper respiratory infections or allergies, or if a structural condition exists that would contribute to air or fluid buildup behind the eardrum.

21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Chiropractic medicine affirms that there is a link between subluxations, particularly those in the cervical region of the neck, and frequent ear infections in children. These subluxations may have developed very early in life, even during birth. By managing the subluxations and aligning the spine, the chiropractor may be able to treat an ear infection. The theory is that when the cervical vertebrae are aligned properly, it takes pressure off of some of the nerves in the neck that could be disrupting the work of the Eustachian tube. By restoring normal nerve function, the Eustachian tube may drain the fluid from the ear more efficiently and decrease the risk of infection from fluid buildup.57

Often, when parents bring a child with an ear infection to a pediatrician, they will receive a prescription for antibiotics for treatment. Unfortunately, antibiotics are not always effective in treating ear infections; some bacteria can become resistant to antibiotics over time and when the ear infection is caused by a virus, antibiotics are not useful anyway. There are also many children who suffer from chronic ear infections and who go through several rounds of antibiotic treatments but who still continue to develop them. If these infections are not well managed, they could lead to significant complications for the affected child, including hearing loss, speech difficulties, and the spread of the infection to other structures in the head and face.

A review by Marom, et al., published in the journal Medicine (Baltimore) considered the use of several different kinds of complementary and alternative treatments specifically for otitis media in children. The review stated that while many parents do seek conventional care for treatment of ear infections in their children, there is also a growing number of parents who consider additional treatments, often in conjunction with evidence-

22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com based medicine. The review looked at the use of spinal manipulation therapy through chiropractic care on children as treatment for otitis media and explained the hypothesis of why chiropractic care is often considered as a treatment for this condition. The theory is that spinal manipulation therapy produces certain biomechanical changes in the spine that ultimately affect the sympathetic and parasympathetic nervous systems.

The use of spinal manipulation can have an effect on muscle tension to decrease muscle rigidity and to promote excess fluid and lymphatic drainage, thereby reducing fluid buildup in the inner ear. The review found that chiropractic care could be helpful for some children with recurrent otitis media and that this type of treatment generally causes few adverse effects on children. Ultimately, more research about this specific form of treatment is needed for clarity.58

Despite a lack of scientific research proving the benefits of chiropractic care on the treatment of ear infections, there are many parents who count on this method for their children. Just as chiropractic care can improve symptoms of various conditions related to the musculoskeletal system, it could also be beneficial in promoting fluid drainage through manipulation of the spine and the muscles, making it an effective treatment option for some children.

Sore Throats/Colds

Upper respiratory infections, often referred to as colds, are caused by viruses that infect the upper airways, leading to cough, sore throat, sneezing, and congestion. Millions of people suffer from colds each year and because the infection can be caused by a number of different viruses, there has yet to be a cure discovered for this very common condition. Most upper respiratory infections are self-limiting, even in children, and they usually

23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com resolve with rest and routine care. The majority of children who develop colds have healthy enough immune systems that they are able to fight off the viral infection and the symptoms tend to resolve in a short time.

There may be some people who are more likely to develop colds and upper respiratory infections when compared to the general population. Additionally, some symptoms that appear to be just a cold or minor illness can actually be a sign of a much more serious situation. For example, a child with a sore throat, fever, and swollen glands in the neck may have strep throat instead of a viral respiratory infection. When a child’s sore throat or respiratory symptoms are related to a bacterial infection or something more serious than a virus, it typically needs to be managed with medication in addition to home remedies.

There are many situations where a child with a sore throat or with cold symptoms can be treated through chiropractic medicine. Chiropractic care may also help to prevent the onset of some symptoms and related viral infection. The goal of chiropractic care administered for the treatment of colds or sore throat is to strengthen the patient’s immune system to better fight off the viral infection. Chiropractic medicine asserts that this type of care specifically improves the flow of lymph fluid through its channels, which ultimately supports the immune system to allow a child to fight off a cold or infection.

The lymphatic system plays a key role in immune system function. It contains a system of channels that are somewhat similar to blood vessels in the circulatory system; these channels transport lymph, which contains a large number of white blood cells that are designed to fight infection. Lymph is actually formed when interstitial fluids and blood plasma are emptied into

24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com the lymph circulation. The fluid is circulated throughout the body and is filtered when it passes through lymph nodes, which also contain large numbers of immune system cells. Eventually, lymph enters blood circulation when it flows into the subclavian vein. Lymph channels have an internal structure that contains small valves that prevent the lymph fluid from moving backward. The fluid is propelled through the lymph channels through the force of smooth muscles as well as skeletal muscles.

The skeletal muscles apply pressure to the lymph channels when they contract, which plays a key role in the transport of lymph fluid. Because a significant amount of chiropractic care is focused on elements of the musculoskeletal system, the adjustment of tissues that affect the skeletal muscles could then further stimulate the flow of lymph through lymphatic channels. By utilizing chiropractic care to stimulate muscle contractions, an individual could potentially increase the flow of fluid through the lymphatic system, increasing the rate at which the white blood cells within the lymph fluid are able to respond to an infection or antigen.

It is through the stimulation of muscle contractions that chiropractic care is thought to work as a technique that can manage cold symptoms or sore throats in children. The body protects itself against infections by immune system defenses, so if chiropractic care is able to stimulate the lymphatic system to increase immune system response, it could potentially treat or prevent viral infections.

Spinal adjustments made to the neck in children with cold symptoms and sore throat could also decrease excess pressure on lymph channels and swollen lymph nodes. By aligning the vertebrae in the neck, the lymph channels may be unrestricted and free to allow proper lymph flow and an

25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com appropriate response to support the immune system. A chiropractor may also perform lymphatic massage, which may restore normal flow of lymph fluid. Lymphatic massage may also be referred to as lymphatic drainage and it is often employed in cases where a person has developed lymphedema, such as following surgery when lymph channels are disrupted and there is excess fluid accumulation.

Lymphatic massage is done to drain excess fluid and to restore normal lymphatic flow. It can also be performed on occasion to support the normal flow of lymph fluid through the lymphatic system, which ensures that the body is receiving normal amounts of fluid and that the immune system is functioning properly.

The holistic focus of chiropractic care means that a chiropractor who consults with a patient suffering from a cold or sore throat may also have other advice about what measures will treat or prevent future infections. For example, dietary supplements and the intake of certain vitamins and minerals is thought to impact the length of symptoms experienced from a cold and taking herbal supplements may support immune system function to prevent viral infections. Vitamin C supplementation, while it does not necessarily prevent cold symptoms, may decrease the duration of cold symptoms overall.59 A chiropractor may provide information to parents about diet and lifestyle factors that they can implement with their child that would help in the treatment or prevention of colds, in addition to performing spinal adjustments on the child to support physical health.

Colic/Reflux

Some infants suffer from colic, which can be aggravating and upsetting to parents who cannot otherwise understand how to calm their child. Colic is

26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com described as a condition in which an infant will cry inconsolably, despite being well fed and otherwise healthy. Technically, a baby is considered to have colic when crying for longer than three hours a day, three or more days a week, for a period of at least three weeks.60 Despite parents’ attempts to soothe, feed or change the baby, or otherwise meet all of the baby’s needs, the baby with colic will continue to cry for an unknown reason.

No one really knows what causes colic or why some infants develop the condition. It is not related to illness or any type of physiological anomaly that would cause pain or discomfort for the infant to trigger crying. Often, the infant with colic cries in a way that is loud and distressing, almost as if in pain, yet there is no source of discomfort. The infant with colic may draw the legs up toward the body, but the colic is not necessarily associated with gastrointestinal changes or excess gas buildup in the intestinal tract, except if the infant swallows a lot of air because of excessive crying. Colic is fortunately self-limiting and it resolves on its own, but often not before weary and exhausted parents have tried different treatments or methods to help their child stop crying.

Parents of infants with colic may be willing to try methods outside of conventional medicine if it means that the colic resolves sooner. Some complementary and alternative medicine techniques may play a role in soothing colic and reducing the length of crying episodes. An article published in the Italian Journal of Pediatrics considered possible new options for the treatment of colic, including chiropractic care, as well as dietary supplements, acupuncture, and behavioral interventions. The review showed that certain herbal supplements, including lemon balm, fennel, and chamomile could be reassuring and soothing for the infant and may aid in reducing abdominal distention from swallowed air. Acupuncture was also

27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com shown to be a safe and gentle method in reducing the duration of infant crying episodes, although studies have not specifically shown significant effects on infants who had acupuncture for crying due to colic. Chiropractic treatment through spinal manipulation has been shown to reduce duration of crying with colic, at least when administered on a short-term basis.61

A chiropractor may be able to help relieve some symptoms of colic by performing a gentle spinal adjustment on the baby’s back. In some cases, subluxations are present at different areas of the spine, and after adjustment, the intensity and duration of crying because of colic is reduced or even eliminated. Spinal disturbances can be present in infants for various reasons; most often because of birth trauma, even if it is not immediately apparent. An infant whose body has been pulled or manipulated during birth could have subluxations in one or more areas of the spine, which could potentially be related to colic that develops later.62 If a chiropractor performs a gentle adjustment on these areas to correct the subluxations, the colic symptoms can be helped.

Chiropractic care of colic is not an option for everyone; in fact, many parents do not wish to have their child seen by a chiropractor if they do not understand how the spinal manipulation can affect the baby’s health and behavior. Many chiropractors do not even know how spinal adjustment to correct subluxations can resolve colic symptoms, as it is difficult to establish the cause of the colic itself. However, there have been enough cases of spinal adjustments performed on babies with colic that clinicians have discovered often works over time. The problems with colic could be related to subluxations in the spine, and some children are more likely to have subluxations in the cervical regions, which, when adjusted, corrects the symptoms of colic. Subluxations related to colic symptoms are not only

28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com found in the cervical region, but have also been noted in all areas of the spine when performing these kinds of treatments.

An article published in Dynamic Chiropractic examined an early study that evaluated the treatment of colic in infants using chiropractic techniques. The study involved chiropractic treatment of over 300 infants with colic and found that 90 percent of the babies showed improvement in colic symptoms after only three chiropractic treatments.62 The exact mechanisms of why spinal adjustment can affect colic and can reduce its symptoms remains to be discovered, and more recent research is needed to support the results of this early study. Until there is more scientific evidence about the causes of colic and the connection between spinal adjustment and symptom resolution, chiropractic care can still be an option for many parents who are seeking to help their crying babies.

Reflux is another condition that may develop in infants and young children. It involves food, fluid, and acid back up in the esophagus from the stomach. In infants, reflux is often manifested as frequent spitting up. While it is normal for babies to spit up sometimes after eating, reflux causes frequent vomiting, as well as a cough, with an increased risk of aspiration of stomach contents into the lungs. Babies who cannot explain their discomfort with reflux often are irritable and may cry frequently; they may gag and spit when trying to eat or they might refuse to eat much at all. In older children, reflux causes pain after eating that is described as heartburn, as well as frequent burping or vomiting.

Esophageal reflux is typically treated with medication to reduce stomach acid secretions, although several lifestyle interventions may be included that can reduce the risk of some episodes, including feeding an infant in an upright

29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com position, avoiding lying down for a period of time after meals, and in older children, avoiding foods that are more likely to cause an upset stomach, such as citrus fruits, chocolate, tomatoes, and greasy or fried foods. Reflux often occurs because of an issue with the lower esophageal sphincter (LES), which separates the esophagus from the stomach. Normally, it is closed tightly, opening briefly to allow swallowed food to pass into the stomach and then closing again to prevent backflow of stomach acid. When the LES is weakened, it may not close tightly and acid is therefore more likely to reflux and cause heartburn and vomiting.

Gastroesophageal reflux disease (GERD) is a more severe form of chronic reflux, in which the child experiences frequent reflux, coughing, vomiting, wheezing, and problems with eating and sleeping. Children with GERD often need medication to control the problem and sometimes, surgery is warranted through fundoplication, which wraps part of the stomach around the base of the esophagus to prevent further reflux and damage to the esophageal tissue. Both acid reflux and GERD can lead to further problems in children because they can affect growth and development and can cause nutritional deficiencies.

Beyond standard treatments through medication, some parents may consider chiropractic therapy as treatment of reflux and GERD. Chiropractic care may be implemented in combination with other types of treatment, but some parents turn to chiropractic medicine when other forms of treatment have not helped. Chiropractic medicine techniques may reduce some symptoms of reflux by decreasing backflow of stomach acid into the esophagus and it could help to prevent future reflux episodes.

30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Because GERD and reflux are thought to be caused in part by problems with the esophageal sphincter, chiropractic care often focuses on making spinal adjustments that can affect this issue and provide better control. Spinal manipulation therapy may reduce irritation on the nerves that affect the LES and the muscles that control how the stomach churns and agitates food during digestion. It is thought that when subluxations are present in the spine, they can irritate the nerves connected to the stomach and esophagus, which can decrease the transit of food through the stomach during digestion and can affect stomach acid production. Resolution of these subluxations, which are typically thought to occur in the thoracic area of the spinal column, may reduce pressure on the nerves connected to the stomach and esophagus and could therefore lead to partial or complete resolution of reflux.67

A literature review by Angus, et al., in the Journal of the Canadian Chiropractic Association found that chiropractic therapy through spinal manipulation, craniosacral therapy, and soft tissue modalities has controlled symptoms of GERD in pediatric patients as outlined in some clinical studies. The effects of the chiropractic therapies on the patients with GERD resulted in decreased severity and frequency of symptoms, as well as a decrease in overall irritability and sleep difficulties.64 A further study published in the International Journal of Medical Research & Health Sciences also showed a reduction in GERD symptoms among patients who underwent chiropractic care that involved kinesiology taping as well as certain exercises and the addition of medications to control reflux.65 Kinesiology taping involves the application of a type of tape to certain points on the body; the tape lifts the skin slightly to promote lymphatic drainage, to decrease inflammation, and to alleviate discomfort.66 The study evaluated the use of taping in a pediatric patient with reflux and indigestion in order to improve and correct stomach

31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com position and to stimulate a proprioceptive response in the skin of the abdomen above where the reflux was occurring.65

Parents of children who suffer from reflux may try conventional forms of treatment for this condition, but they have alternatives when they seek chiropractic care. The chiropractor can not only perform adjustments that can benefit the nerves in the stomach and esophagus that are contributing to the reflux, but can offer many other practical recommendations that will reduce symptoms as well. The chiropractic treatment of reflux is often successful when used in combination with conventional treatment and may reduce the amount of time that the child suffers from reflux symptoms.

Asthma

Asthma is a chronic disease that can develop in childhood or even infancy. It affects the bronchioles so that they become inflamed and constricted, often in response to environmental triggers. A child with asthma has airways that are sensitive to certain elements that can be irritating to the tissue. When coming into contact with these elements, the child’s airway becomes inflamed and can swell, causing constriction and ultimately decreasing air movement into and out of the lungs. There may be increased mucus production as well, which can cause further difficulties with breathing because of obstruction.

Asthma symptoms are typically not manifested on a continuous basis; rather they occur in episodes or asthma attacks following a trigger. An asthma attack causes significant coughing and difficulty breathing. The child may wheeze while trying to breathe and may use accessory muscles of the chest. Other symptoms include nasal flaring, activity intolerance, and fatigue. Asthma is a very serious chronic condition of childhood. Although there are

32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com adults with asthma, the condition seems to be prominent in children, with approximately 6 million kids in the U.S. having been diagnosed.63 Asthma can lead to further complications in which a child needs to be hospitalized periodically for treatment, and it can also increase the risk of the child developing pneumonia, pneumothorax from excessive coughing and wheezing, and even respiratory failure.

Asthma is closely associated with allergies in children, and the condition seems to run in families as well.63 Products in the environment that cause allergy symptoms may also act as triggers for asthma attacks, including pollen, hay, grass, dust mites, pet dander, or mold. Other stimulants, such as cigarette smoke and air pollution can also act as triggers for asthma attacks. Some children have exercise-induced asthma in which they develop bronchospasm during or after exercising. Often, the condition occurs because the individual must breathe harder and more rapidly when exercising, which can lead to bronchospasm and constriction.

Asthma must be managed carefully to prevent very severe complications that could develop during an asthma attack. Often, the most successful methods of controlling asthma are to learn what elements trigger symptoms and avoid those items. For some children, though, avoidance of all triggers is not possible, particularly when there are several items that can cause reactions. In some cases, daily treatment with long-term control medication can be used to prevent attacks from occurring in the first place, and a child may then also use an asthma inhaler during times of an attack. The daily control medication contains drugs that reduce the impact of environmental triggers and that prevent asthma attacks from occurring; these drugs often include theophylline or corticosteroids. The inhaler acts as an emergency relief medication for when bronchospasm occurs, and it typically contains

33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com medications that act on the beta receptors in the airways to prevent constriction and to increase airflow to restore normal breathing.

Chiropractic treatments may also be utilized to manage asthma in some children. A chiropractor may perform a spinal adjustment on a child with asthma, as the effects of spinal manipulation can benefit the lung tissue and the airways. If areas of the spine are compressing the nerves that innervate the airways and the lungs, the adjustment of the spine to reduce pressure on these nerves can then resolve some effects on the respiratory system. For instance, the diaphragm plays a significant role in the respiratory system and in support of breathing; when the diaphragm contracts, the lungs expand to take in air in response. The phrenic nerve, which controls the diaphragm, is located in the cervical region of the spine, at the levels of C3 to C5. If a child has subluxation in the cervical spine, it could put pressure on these nerves and cause irritation, which might affect the work of the diaphragm as well as how well the child is able to breathe. The nerves in and around the spine also affect many other muscles that contribute to normal breathing, including the intercostal muscles, as well as accessory muscles such as the sternocleidomastoid, trapezius, and pectoralis muscles.

When the spine is aligned after the work of a chiropractor, the person is more likely able to have fewer restrictions in the airway and a greater ability to take full, deep breaths. Spinal alignment can support proper positioning of the rest of the body so that even if the person develops breathing difficulties, such as with an asthma attack, the back muscles and chest may be stronger and may allow for full lung expansion and deeper breathing to allow for better air flow.

34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com A review by Lago, et al., in the Manual Therapy, Posturology, and Rehabilitation Journal evaluated the literature related to chiropractic care and osteopathic techniques in the treatment of asthma. The review stated that manual manipulation techniques act on the nerves that innervate the lung tissue and the diaphragm and that when spinal dysfunction is present, it can irritate these nerves, causing a multitude of problems, including decreased chest wall functioning, poor airway tone, and an increased risk of airway inflammation. The review showed that in the literature, there have been several published studies that have shown that spinal manipulation can be successful as adjunct therapy in the treatment of asthma. While the results have not shown that chiropractic spinal manipulation positively improves lung function as demonstrated through lung function testing, the use of chiropractic medicine is beneficial as a supplemental treatment and it may reduce the need for other standard forms of treatment, such as by decreased use of emergency inhalers or a reduced dose of daily control medications for asthma.68

Because asthma is so commonly associated with allergies seen in children, the two conditions may be treated simultaneously through chiropractic medicine. Some parents of children with allergies may bring their children to chiropractors for help in reducing allergic responses. Because of the impact that chiropractic adjustments can have on both the immune system and the muscles and nerves associated with the respiratory system, it is possible that spinal manipulation and correction of subluxations could help some children who also suffer from allergies. The adjustments made in the spine and the manipulation of skeletal muscles that occur with chiropractic treatments can improve lymph flow and subsequently support the immune system, which could then be more effective in protecting a child from allergic reactions.

35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Unfortunately, there is limited research about the established effects of chiropractic care in the management and prevention of allergies in children, but many parents believe in the success of chiropractic care as treatment for this condition, in addition to the treatment of asthma and other illnesses affecting the respiratory system.

Scoliosis

As previously discussed, scoliosis is a condition affecting the spine that causes abnormal twisting or curvature of the vertebrae in the spinal column. Scoliosis can be a congenital condition that is present at birth but the effects of the condition often do not appear until the child grows and becomes more mobile. Idiopathic scoliosis is more commonly seen during adolescence; it often develops as a child’s spine grows and changes shape during adolescent development. 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.

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. Consequently, a child with scoliosis may also be at greater risk of developing degenerative scoliosis later in life. As the bones of the spine degenerate, some areas may collapse onto themselves in a manner similar to compression fractures. 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

36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com scoliosis, which is more likely to occur in people who were born with genetic syndromes.

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 the condition 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 less-invasive measures to prevent further curvature of the spine, such as through chiropractic medicine. Chiropractic care uses non-invasive techniques through spinal alignment and suggestions for lifestyle modifications that may help to prevent the condition from worsening if it is caught early on.

Without appropriate treatment of scoliosis, it can worsen as the child grows, causing deformity and difficulties with normal functioning. It is important to correct the condition as soon as it is discovered in a child. Chiropractic adjustments on the spine could help to control the curvature of the spine and prevent it from worsening as the child grows. If a child is seen for chiropractic care who already has advanced scoliosis, spinal adjustments will not reset the vertebrae into normal alignment so that they grow correctly. Spinal adjustments can, however, reduce some of the effects of scoliosis, and can help the child to live well and function in spite of the deformity, and as an adjunct to other types of treatment, including back braces or surgery.

Most of the time, scoliosis does not cause pain in affected children, but for some, the curve in the spine can put pressure on nearby muscles and ligaments; the intervertebral discs may also bear excess pressure from the bones of the vertebrae. It may be possible that children who experience

37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com back pain because of scoliosis can benefit from chiropractic care because of the effects on the musculoskeletal system that this type of treatment offers. For instance, if a person is suffering from muscle pain due to spine curvature or deformity, manipulation of the spine will not reduce the curve but it could take some pressure off of the back muscles that are contributing to the pain. Spinal manipulation does not cure scoliosis and will not work in the same method as a back brace or surgery. It can, however, realign the vertebrae and correct subluxations that are otherwise irritating the nerves and contributing to discomfort. Through this technique, the child may have less pain from scoliosis and the process could reduce the amount of time the child must spend undergoing conventional scoliosis treatments, such as by decreasing time spent in a back brace or reducing the need for surgery.

A study by Morningstar, et al., in the journal Clinics and Practice looked at the effects of chiropractic rehabilitation on patients who had been diagnosed with adolescent idiopathic scoliosis. 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 percent 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. 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°.69 While more studies need to be conducted about the effects of chiropractic manipulation to achieve even greater angle correction, even some 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

38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com children and teens diagnosed with scoliosis when used in addition to conventional forms of treatment.

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.70

Headaches

Headaches are a common malady for most people, and they are no exception for children. There are some children who suffer from headaches, and in some cases, the pain may be common and recurring. Up to 51 percent of children under age 7 experience headaches, with the numbers rising to 57 - 82 percent by the age of fifteen.73 Children can develop tension headaches from stress and they may develop migraine headaches as well, which can be very painful. Most headaches that develop in children are self- limiting and are not related to a chronic condition; instead, they may develop when an acute illness is present, such as with an upper respiratory infection or influenza. They can also occur because of a variety of reasons related to environmental stimuli or simply life stressors, including due to lack of sleep, exposure to loud noises or strong scents, taking certain medications, or eating particular foods.

39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Children feel the pain of headaches in ways that are similar to adults. They may have pain in any area of the head, as well as in the face or neck. The pain may be worsened by exposure to bright lights or loud noises and some children feel better with rest and by limiting activity. The pain of a headache can also be severe enough that it causes nausea and vomiting, nasal congestion, and watery eyes; these symptoms are more closely associated with migraines. Kids who get headaches can often report to their parents many of their symptoms and explain how they are feeling, although very young children who are not able to explain themselves may be fussy and irritable because of the pain.

Chiropractic care of headaches involves an initial consultation to try to determine the cause of the problem and if there is another issue present that may be contributing. The chiropractor should speak with the parents about the child’s regular activities and what changes, if any, that have occurred that may be associated with the headaches. Other areas of discussion related to the patient’s medical history and physical examination might include talking about 1) the child’s diet, 2) how he or she relates to other family members and friends, 3) if there are any particular life stressors, 4) the level of sports or other activities that could cause head trauma, 5) whether medications or supplements are taken, and 6) if there is any family history of headaches. The chiropractor may also perform some imaging studies to be certain that the headaches are not caused by a more serious health issue.

Parents often treat their child’s headaches with over-the-counter medications that are specified for pediatric use, such as acetaminophen or ibuprofen. Other measures, such as lying down in a quiet and dark room or putting a cool cloth on the forehead can also help to control some of the pain

40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com of a headache. A child who struggles with recurring headaches to the point that it affects activities and schoolwork should be seen by a physician. If a parent seeks chiropractic care for help with a child’s headaches, it may be as a sole treatment or it may be in conjunction with conventional treatment.

As with adults, chiropractors can manage headache pain in children through gentle spinal adjustments and by promoting lifestyle modifications that can prevent further headaches. Chiropractic care affirms that a significant number of headaches in children are related to vertebral subluxations that most commonly occur in the cervical spine. The subluxations could be present unknowingly for years and could have developed because of birth trauma or another injury for the child that did not immediately manifest itself. Chronic stress could also be a cause of vertebral subluxations and the child with significant life stressors may be more likely to develop subluxations and consequent headaches.71

Some children may suffer from cervicogenic headaches, which are headaches that occur as a result of pain or trauma to an area of the neck. These headaches are often confused with migraines, as the pain and symptoms can be similar. The cervical spine contains the cervical vertebrae as well as cervical nerve roots that are connected to the spinal cord and that extend away from it to control movement, sensation, and various other activities in the upper body. For instance, the cervical root nerves extending from C4 are important for controlling the diaphragm for breathing. The spinal roots located in the upper cervical vertebrae (C1, C2, and C3) affect the diaphragm to control breathing and they also control movement and sensation of the head.

41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com When the cervical nerve roots are irritated, it can send pain messages to the brain that are manifested as a headache.72 It is thought that chiropractic manipulation of the cervical vertebrae and treatment of subluxations in this area can relieve some pressure on the cervical nerve roots, decrease irritation, and relieve headache pain. A case report published in The Journal of Headache and Pain reported that there is supportive evidence for the use of spinal manipulation therapy in the treatment of cervicogenic headache pain in children. The report described a situation of a 6-year-old child who had suffered from chronic headaches for two years, but no physiological cause had ever been identified. The child was treated with high velocity, low- amplitude thrust spinal manipulation therapy for two months.73

The nerves in the neck and back are linked so intricately with the spinal column that changes in movement or improper positioning can negatively impact how they influence other body areas. The nerves are very sensitive and so when they become irritated, they can cause significant pain and other symptoms of muscle weakness or paresthesia. It is important to understand that some headaches are truly caused by irritation of the nerve roots in the spinal column and can be managed by aligning the vertebrae nearby.

Some children develop tension headaches, which often are manifested as muscle spasms in the neck and at the base of the skull. The rectus capitis posterior minor is a small muscle located at the base of the head, just under the occipital region of the skull. It is attached to the C1 and C2 vertebrae at the very top of the spinal column. This muscle plays a role in proprioception, which is the awareness of the body’s position within a space; it also helps to support the head and supports the movement of the neck. Although it is small, when this muscle is injured or has spasms, it can cause pain and disability in the affected person. If subluxations develop high in the spinal

42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com column, in the C1 or C2 region of the cervical vertebrae, it not only irritates the nerve roots found there, but the muscles in the region may also spasm, including the rectus capitis posterior minor muscle. The muscle is also connected to the dura mater, which acts as a covering to the brain and is very sensitive to pain. Consequently, with the spasm of this muscle, the affected person can feel headache pain.74 Correction of subluxations in the cervical vertebrae may reduce muscle spasms that can contribute to this type of headache pain.

Chiropractic care may also involve trigger point therapy for the reduction and relief of headache pain. Trigger points are areas that, when stimulated, can trigger pain in nearby regions in the body. For example, with a cervicogenic headache, the neck contains areas that are trigger points in that if they are irritated or aggravated in some manner, they can cause pain in other areas, often the head. Trigger point therapy is a type of massage that locates the areas that are irritated and that are causing pain and then massages them to release them and loosen any constricted areas. A chiropractor may identify trigger point areas when examining a child even prior to starting actual therapeutic massage.

Studies have shown that people who suffer from tension headaches have increased incidences of tenderness in trigger points in the muscles around the head and neck. A study by Moraska, et al., in the Clinical Journal of Pain found that patients with tension-type headache pain who underwent trigger point therapy reported greater improvement in pain. The study explained that trigger point therapy is an important component of treatment for tension headache pain.75 It is a non-invasive method of identifying those areas that are significantly contributing to a patient’s pain and then releasing the tension to improve the patient’s headache pain.

43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com A chiropractor may perform trigger point therapy on a child with headaches by addressing trigger points located in the neck and shoulders that could be contributing to headache pain. Some major muscle groups in these areas, including the sternocleidomastoid muscle and the trapezius muscles can become tight and constricted, particularly with increased stress and tension. The chiropractor may identify these or other muscles in the neck, shoulders, and at the base of the head where the muscles are very tight and constricted. This is done through gentle probing to avoid further irritation of the muscle tissue. Once identified, the chiropractor may then lightly massage the muscles and underlying connective tissue to reduce or eliminate the referred pain. This trigger point therapy, when combined with spinal adjustment or used independently as part of patient care, can make a big difference in helping a child who struggles with frequent headaches.

Bedwetting And Constipation

Most children are able to control their urination through toilet training by the time they are five years old, though some kids continue to have difficulty with bedwetting at night while asleep. Nocturnal enuresis is the technical term for bedwetting, which describes an involuntary release of urine at night while asleep. The term is defined for those children who are otherwise able to control urination while awake and who have been toilet trained. Normally, while awake, a child can sense the feeling of a full bladder and then use the bathroom to urinate. Nocturnal enuresis is present in up to 20 percent of 5- year-old children, 5 percent of 10-year-old children, and approximately 1 percent of 15-year-old teens.78

For a child with nocturnal enuresis, there is an inability to control the release of urine, either because the child is sleeping so deeply that he does not perceive a full bladder, or due to other factors, such as decreased

44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com vasopressin hormone, which normally decreases urine production, or chronic illness, including diabetes or spinal cord injury.76 Bedwetting can be embarrassing and problematic for affected children. Kids who struggle with chronic bedwetting often need to manage their diet and fluid intake in the evening before going to bed to reduce the chance of enuresis. Prescription desmopressin increases anti-diuretic hormone levels, which then decrease the amount of urine produced at night to reduce the chance of unmanageable urine release. Some children benefit from using bedwetting alarms as well, which react when bedding becomes damp to allow the child to get up and use the bathroom.

Children who have difficulties with bedwetting can benefit from a physical evaluation from a physician to determine if there is a structural problem that is causing the issue. A chiropractor may also utilize imaging studies to check the structure of the child’s genitourinary system, as well as perform a laboratory analysis to check for hormones that may be deficient, such as anti-diuretic hormone. Often, an older child with this issue may also feel embarrassed and isolated when the bedwetting prevents overnight outings or sleepovers. The child may feel stigmatized and self-conscious by being required to routinely clean up soiled bedding or wear disposable undergarments to bed at night. Discussion of the problem and its consequences before and after chiropractic treatments can help the affected child feel understood.

Problems with bedwetting could be related to subluxations that have developed in the cervical spine or in the lumbar region of the spinal column. When the vertebrae in the neck are out of alignment, it may affect the phrenic nerve, which is located at levels C3 through C5. The phrenic reflex is triggered when there is an increase in carbon dioxide in the bloodstream,

45 nursece4less.com nursece4less.com nursece4less.com nursece4less.com which could occur during a period of very deep sleep. Increased serum carbon dioxide causes smooth muscles to relax, including the smooth muscles that control bladder tone and that retain urine. The relaxation of these muscles leads to an involuntary release of urine. Normally, this reflex develops as kids mature and are able to control their urine, but some children are slower than others. Subluxation in the cervical spine that compresses or irritates the phrenic nerve could also affect this reflex, leading to increased instances of bedwetting.77

Some children also develop subluxations in the lumbar or sacral regions of the spine, which could also contribute to nocturnal enuresis. Several nerves in the lower back, including the pelvic nerve, pudendal, and hypogastric nerves, play roles in communicating with the brain the need to urinate as well as controlling the sphincter muscle of the bladder to release urine. When vertebral subluxations are present in the lower back, they could irritate or place excess pressure on these nerves, which can impact how well a child is able to control urination.77 It should be noted that some children who are seen for chiropractic care of bedwetting do not necessarily respond to spinal adjustments alone; the chiropractor may determine the child’s phrenic nerve is still undeveloped and that spinal manipulation will not necessarily correct this. However, there are some children who have benefitted from chiropractic care of bedwetting, particularly when combined with other strategies to reduce the instances of enuresis, such as by keeping a voiding diary and controlling fluid intake before bed.

A case report published by Instebo, et al., in the Journal of Chiropractic Medicine discussed a case of an 8-year-old girl who sought chiropractic treatment for management of nighttime bedwetting that was unresolved after instituting lifestyle changes as well as prescription desmopressin. The

46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com patient had previously tried bedwetting alarms and restricting fluid intake without success and her primary care physician had not identified any physiological abnormality or reason why she continued to experience nocturnal enuresis. The patient was examined by a chiropractor who found no subluxations or abnormalities, but who did locate tenderness when palpating the sacroiliac joint in the lower back. After one treatment of gentle manipulation of this joint, the patient experienced one full week without any bedwetting episodes, and after a total of three treatments, the patient’s episodes of bedwetting had decreased significantly to the point where she rarely had any more episodes and was able to spend more time with friends with little fear of having urine accidents.78

Obviously, this is only one case of successful treatment of bedwetting through chiropractic care, although there are many parents who also report success in helping their children overcome enuresis by undergoing spinal manipulation therapy. It should be noted that approximately 15 percent of children with regular enuresis overcome the condition on their own without any treatment.78 Nevertheless, when the problem is significant enough that it is disruptive to a child’s social and personal success, parents may want to consider chiropractic care for their child.

Another common issue that often affects toddlers, children, and teens and that can cause embarrassment and shame is chronic constipation. The condition can affect children of any age, including infants, and when it is serious, it often requires treatment. Constipation is technically defined as the passage of hard stools, passing stool with difficulty, or having less frequent bowel movements. There is not one set number of bowel movements per day or week that is thought to be normal in children; however, when parents notice that their child is having infrequent bowel movements or is straining

47 nursece4less.com nursece4less.com nursece4less.com nursece4less.com to pass stool, constipation may be present, regardless of the total number of stools passed in a particular time period.

Constipation causes more than an average amount of straining for a child to pass stool. Parents should be aware of the average number and frequency of stools their child has and note whether this amount has decreased. Some children have a small amount of blood in their stool when they do have a bowel movement if there is a rectal fissure present that causes minor bleeding. At times, a child with constipation may have stool in the intestinal tract that is impacted. When this happens, the child may actually have diarrhea and can be incontinent of stool when runny stool passes around the impacted area. The affected child may also experience abdominal pain, poor appetite, lethargy, nausea, and restlessness.

Constipation can develop for a number of reasons; it is often classified as being idiopathic, in which it is caused by dietary changes or holding in stool, or as a result of another condition that affects gastrointestinal mobility, including side effects of medications or due to neurological conditions.79 Most children with chronic constipation can be treated by making changes in the diet to include more fiber and to drink more fluids. In significant cases, a child may need to take laxatives, many of which are formulated for pediatric use.

In one case report published in the journal of The Academy of Chiropractic Orthopedists, constipation caused by primary vesiculoureteral reflux disease was treated successfully through chiropractic care of a pediatric patient. Vesiculoureteral reflux occurs when urine flows backward toward the kidneys. Children with this condition often have some degree of bowel dysfunction as well and are likely to have some amount of constipation. The

48 nursece4less.com nursece4less.com nursece4less.com nursece4less.com child in the case study had undergone several tests to determine the extent of the reflux as well as the degree of the constipation present; she also had a manual examination by a chiropractor. She underwent manipulative therapy by the chiropractor, utilizing both manual and instrument-guided treatments and abdominal massage, and she was placed on probiotic therapy. Following 13 weeks of care, in which the child had chiropractic treatments as well as routine massage and probiotic therapy at home, her parents reported that her constipation had resolved and she had regular bowel movements.81

Chiropractic medicine may also resolve constipation in some children and it may prevent further constipation from developing. Chiropractic care may work through spinal manipulation or by promoting other lifestyle changes, such as changes in diet, to relieve constipation in children. It is thought that spinal adjustment may promote healthy bowel function to resolve constipation and stimulate intestinal motility.

Chiropractic care is thought to treat constipation by promoting the work of the autonomic nervous system, which unconsciously controls body systems. Subluxations that occur along the spine, particularly within the lumbar region of the back, can contribute to constipation because the misaligned vertebrae affect the nerves that innervate the colon.80 As discussed, children could develop subluxations for a number of reasons and the effects may not be immediately apparent. Infants with lumbar subluxations that developed during birth may have difficulties with constipation, even if they eat normal amounts of milk or formula and are otherwise healthy. Children who are engaged in strenuous activities, including sports, may have subluxations and misalignments that can be corrected to improve chronic constipation and to prevent future episodes.

49 nursece4less.com nursece4less.com nursece4less.com nursece4less.com If a parent takes a child to a chiropractor for treatment of constipation, an X-ray or imaging studies may be done if the child has not been examined through imaging studies previously. A simple X-ray of the abdomen can show if there are large pockets of stool or excess air in the bowel that contribute to constipation and abdominal pain. The

X-ray can also show whether impaction is present, which would need further treatment to prevent some significant complications. Following an X-ray, the chiropractor may also discuss the child’s diet and lifestyle habits to determine if there are other factors that may be contributing to the constipation, and may ask about other factors, such as the presence of chronic disease, whether the child is taking medications, and how many bowel movements normally occur.

Correction of constipation is often done manually through spinal adjustment to correct nerve impingement and to promote the work of the nervous system. Following manual treatment, the chiropractor may also discuss the important elements of the child’s diet and may make recommendations about what foods and nutrients to include each day. A child should have a well-balanced diet with plenty of fiber, as fiber prevents excess uptake of water in the colon, ensuring that stool does not become hard and dry and is able to be passed easily. Foods with fiber are relatively easy to add into the diet; they include many fruits and vegetables, as well as whole grains.

50 nursece4less.com nursece4less.com nursece4less.com nursece4less.com A previously discussed review by Angus, et al., in the Journal of the Canadian Chiropractic Association showed that chiropractic medicine can treat constipation in children and listed the results of several studies that supported this. Included in the review were instances of several studies where toddlers and school-age children were treated for constipation through high-velocity low-amplitude thrust for spinal manipulation that was appropriate for age. All of the studies listed supported the use of chiropractic manipulation on children for the successful treatment of constipation.64 Additionally, chiropractic care will consider all elements that could be contributing to a child’s constipation because chiropractic medicine maintains a holistic focus on care.

Diet is one area to examine to determine if the child’s diet could be changed to increase fiber intake and to add healthy foods to prevent further constipation. The chiropractor may also institute other alternative and complementary measures that would aid in controlling constipation. For example, probiotics may be useful in preventing constipation and promoting normal intestinal health. The chiropractor may make recommendations to parents about how to incorporate more fermented foods or food items that contain probiotics into the child’s diet. This advice, in combination with physical therapies provided by the chiropractor, can support children who struggle with problems of elimination, such as through bedwetting and frequent constipation.

Growing Pains

Some children suffer from occasional aching or throbbing pain in the legs that is unrelated to illness or chronic disease. Referred to as growing pains, this type of pain can affect up to 40 percent of children; it most commonly occurs during preschool and school-age years in children ages 3 to 5 years

51 nursece4less.com nursece4less.com nursece4less.com nursece4less.com and again in children ages 8 to 12 years.82 Growing pains are not just a myth, but they can actually cause enough pain in affected children that they require visits to a physician or hospital for diagnosis. Unfortunately, aside from some home remedies and over-the-counter pain medication, there is no treatment for growing pains.

Most children who suffer from growing pains develop pain in the legs, typically focused behind the knee, in the calf, or in the front of the thigh. The pain is muscular in origin and usually does not affect the joints or the bones. Many children with growing pains complain of the pain most often at night, which can interrupt sleep. There is no particular cause of the pain and it is not related to another chronic illness or acute disease. It is believed that children who are active and athletic tend to be more likely to experience growing pains, as the pain seems to be related to increased muscle use. Typically, parents can help their children who experience growing pains by promoting rest and massaging the affected muscles.

Over-the-counter pain medications such as acetaminophen may also be helpful, as well as warm packs applied to the affected areas. Growing pains are self-limiting and they tend to resolve on their own. Fortunately, they also do not seem to occur on a daily basis and are usually only sporadic in nature when they do happen.

Although growing pains are temporary, not related to other chronic diseases, nor a sign of a serious health problem, some parents may want to seek further medical advice for help in controlling the painful symptoms. Parents who take their child to a physician because of growing pains may learn that there is not a problem with the muscles in the child’s legs and there are no structural problems in the extremities that could be contributing to the pain.

52 nursece4less.com nursece4less.com nursece4less.com nursece4less.com An X-ray of the legs can point out if there is an issue with the joints or bones that is causing the pain and that it is not growing pains. A chiropractor can also help with diagnosis and management of growing pains, and treatment through chiropractic care may be a worthwhile option for some kids who have enough pain that it affects sleep or other activities.

Chiropractic care of growing pains involves an assessment of the child’s pain, including its location in the legs and its intensity, as well as the child’s activity levels and whether other medical problems are present that could also be contributing to pain. For instance, pain in the legs that is manifested as growing pains could actually be the result of another condition, such as a muscle strain or joint inflammation, and an examination of the legs and the spine is necessary to rule out other causes.

A child who is very active could develop subluxations in areas of the spine that can affect the nerves innervating the muscles in the legs to contribute to growing pains. Additionally, a child may have an orthopedic issue associated with the joints, such as a small injury that has gone unnoticed but that later manifests itself as muscular pain of growing pains. The fact that active children are more likely to experience growing pains seems to be related to the stress or wear and tear on the muscles and joints that can eventually cause pain in the legs.

According to de Beer, et al., in the Journal of Interdisciplinary Health Sciences, growing pains are thought to occur as a result of one of three theoretical circumstances. The anatomical cause of the growing pains reveals that the child suffers from pain because of poor posture or orthopedic problems in the bones, joints, or muscles that have been previously unrecognized. The fatigability theory states that the child feels

53 nursece4less.com nursece4less.com nursece4less.com nursece4less.com pain after increased activity when there is a greater likelihood of increased metabolic waste accumulating in the muscle tissue, which may more likely explain why some children experience growing pains more often after being active. The third theory states that growing pains occur because affected children have psychological predispositions toward experiencing the pain and if a family history is present, they may be more susceptible to pain from family tendencies.83

The same authors also performed a study that was published in the journal that evaluated the effects of chiropractic care on children suffering from growing pains. In the study, part of the children recruited underwent lumbar spinal manipulation therapy for treatment, while the other group had no chiropractic treatment but did have help from parents in the home for the pain, such as through massage. The study found that spinal manipulation therapy was beneficial as treatment, based on subjective responses from the parents.83 While other measures, such as massage and home remedies may also be helpful, spinal manipulation could reduce the amount of time that an affected child suffers from growing pains.

The chiropractic standpoint of the treatment of growing pains is based on a physiological mechanism that is contributing to the pain, whether it is from orthopedic trauma or damage to the joints and muscles, or whether the child feels pain specifically because of increased activity levels.84 Chiropractic treatment can relieve some of the pain of growing pains by relieving pressure on the nerve roots in the spine when subluxations are present, as well as by assisting the child with stress reduction that can negatively impact the nervous system. Increased stress can affect posture and movement, which in turn could affect how the vertebrae influence the nerve roots in the spinal column. Additionally, when trauma to the spine has occurred, such as

54 nursece4less.com nursece4less.com nursece4less.com nursece4less.com during birth or because of significant activity, the child’s spinal vertebrae may be putting excess pressure on the nerve roots and causing irritation to the nerves.

The leg pain that the child feels because of growing pains can come from vertebral impingement on nerve roots in the lumbar region that innervate the hamstrings, calf muscles, and quadriceps. Misalignment in the pelvic region can affect how the child is able to distribute weight on the legs, carries the body when ambulating, and the child’s overall stance, which could cause pain in the lower legs and feet as well.84

Chiropractic correction of growing pains often involves spinal manipulation therapy to align the spinal column and take pressure off of the nerves innervating the legs. It also includes assessment of the joints in the back, the pelvis, hips, and legs to look for problems that could be contributing to pain and then making adjustments when necessary. Other exercises may include stretching the leg muscles and performing range-of-motion exercises in the legs and hips to improve muscle strength and flexibility.

An article published in Pathways to Family Wellness that evaluated the chiropractic care of children with growing pains also provided recommendations that the chiropractor may give to parents to help their child at home in addition to undergoing chiropractic techniques. Recommendations from the chiropractor included having the child drink plenty of water and other fluids to avoid dehydration, which can impact muscle tissue, taking a vitamin supplement that contains adequate calcium and magnesium, performing stretching exercises for the back, thighs, knees, and lower legs, and monitoring stress levels in the child to avoid postural or

55 nursece4less.com nursece4less.com nursece4less.com nursece4less.com activity changes that could place excess stress on the child’s frame, possibly contributing to the pain.84

Growing pains are a real phenomenon, with some children routinely struggling with pain and discomfort when they occur. As with other conditions that cause pain, parents may want to consider chiropractic care for relief of this common complaint.

Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is not entirely limited to children, but it is commonly diagnosed and managed during childhood. The condition is a brain disorder that causes difficulties with concentration and impulsive behaviors. Some children may be hyperactive and have difficulties with settling down; they may be constantly moving and may talk excessively without much purposeful interaction with others through conversation. ADHD also leads to inattention, in that the affected child is frequently distracted and has trouble focusing on the topic at hand. The child may be very disorganized and often have trouble completing any work. Impulsivity is also often associated with ADHD in that the affected child seems to lack the ability to control reactions to situations and does not stop to think before acting. The child may have difficulty with social relationships because his or her actions can be harmful to others and the child cannot think about behavioral consequences.

Not all children with ADHD will exhibit impulsivity, hyperactivity, and inattention, but these three traits are common elements that are associated with the definition and diagnosis of the disorder. Children affected by ADHD may have trouble with one or more of these components, at varying levels of severity.85 ADHD is challenging for both the affected child and the child’s

56 nursece4less.com nursece4less.com nursece4less.com nursece4less.com family. The child often is unable to complete routine tasks because of problems with focus and concentration, consequently, there are often issues with school work or chores that are rarely completed.

The child with ADHD may feel isolated and lonely, having difficulties making or sustaining friendships because other children often do not understand the behavior or do not want to put up with it. The child may even be unintentionally hurtful toward others because of impulsivity, which alienates the child with ADHD from other children who do not understand.

For parents, having a child with ADHD can be particularly trying. They may struggle with helping their child to complete normal activities and to stay engaged in events and work for school or hobbies. It can be frustrating to watch a child struggle to make friends and to be alone because of having trouble controlling behavior. The parents may have problems disciplining the child because he or she may have trouble listening and does not respond to structure. Parents may have difficulties with staying calm and not becoming angry when their child repeatedly breaks the rules. It is important to understand that when a child has ADHD, he or she is often not trying to be difficult and hurtful, but simply is unable to adequately process a situation. Importantly, parents need to realize that the condition has not developed because of overstimulation or faulty parenting. Of note, adults also can have ADHD and it is often a lifelong condition that the affected person must cope with once diagnosed, whether diagnosed as a child or whether the condition was later discovered during adulthood.

Most children diagnosed with ADHD are treated with prescription medications to control many of their behaviors. Prescription stimulants paradoxically seem to work well for children with ADHD to help them to slow

57 nursece4less.com nursece4less.com nursece4less.com nursece4less.com down and focus by affecting brain neurotransmitters. Some children also require counseling and psychotherapy to better learn how to recognize when their behaviors are off and they need to get back on track. Psychotherapy can aid with helping children to learn to finish tasks and follow through with activities to completion. Counseling is also quite helpful for the parents of children with ADHD to better enable them to learn to manage their child’s behaviors, to respond appropriately to negative behaviors, and to instill discipline properly.

In addition to the medications, counseling, and support groups available for ADHD, children may also benefit from chiropractic care. It may seem surprising that chiropractic medicine can positively affect a brain disorder such as ADHD, since the practice is often associated mostly with management of musculoskeletal-related conditions. However, more parents are looking into complementary and alternative treatments as adjunct treatment for ADHD when their child needs further help. In fact, some parents choose chiropractic care as a natural form of ADHD treatment instead of trying to force their child to take medications.

As discussed, chiropractic medicine is focused on holistic care of the patient. The chiropractor who sees a child for treatment of ADHD will not just focus on the child’s activities or behavior, but will also consider and ask the parents about other factors that can be affecting how well the child is able to relate to others and to perform in school. For example, the chiropractor may perform a physical assessment on the child, but will also be interested in finding out about the child’s sleeping patterns, diet, social activities, allergies, exposure to environmental stimulants, stress levels, and relationships with friends and family.

58 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Chiropractic medicine is focused on treatment and management of conditions that affect the neurological system, which can include ADHD. Chiropractors attest that when subluxations are present in the cervical region of the spine, they can affect the nerves that innervate the brainstem and can cause some of the behavioral issues associated with ADHD. The areas of C1 through C3 vertebrae are particularly vulnerable for these problems. When the chiropractor corrects the subluxations found in these areas, it is thought that this correction may resolve some of the behaviors seen with the disorder.86

The overall goal of chiropractic care for ADHD management is not to cure the ADHD, but instead to improve nervous system function by identifying subluxations and other issues that may be contributing to nervous dysfunction.87 Chiropractic care may also work to help a child who is struggling with processing of sensory input, which may contribute to symptoms of ADHD. For example, if a child is unable to process information through sensory means – what is heard, seen, or tasted – or if the child’s brain has difficulty with proprioception, which is the recognition of the positioning of the body within a space, this may relate to difficulties with ADHD symptoms. Sensory processing can be affected by subluxations in the cervical spine if misaligned vertebrae affect nerve roots that innervate the parts of the brain that affect the vestibular or proprioceptive systems. It is possible that by correcting vertebral subluxations in the cervical spine, as well as in other regions of the spine that are connected to sensory processing, the child’s neurosensory system may function more efficiently and the child with ADHD may be able to function better.88

In addition to performing physical treatments of ADHD, the chiropractor may also make some suggestions to families about interventions they can

59 nursece4less.com nursece4less.com nursece4less.com nursece4less.com incorporate at home to better help their child with behavior and activity. The chiropractor may make suggestions about helping the child and family to deal with stress and can help them learn to incorporate stress relief measures. The chiropractor may also make suggestions about dietary changes to ensure that the child gets enough vitamins and minerals in the diet; this may include taking an herbal supplement or also avoiding fast food and foods with high amounts of sugar, additives, and fat. While there is no evidence that sugar intake is related to ADHD symptoms, the child can benefit from reducing sugar intake in order to eat foods that are healthier instead.

Summary

Children can certainly be candidates for chiropractic care and they often respond well to many of the techniques used in chiropractic medicine. Children often heal at a faster pace when compared to adults, and the 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.

Unfortunately, there is a lack of research about the effectiveness of spinal manipulation on newborns and the effects of adjustments on controlling symptoms of colic, reflux, or sleeping difficulties in babies. However,

60 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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.

Chiropractic care that is directed specifically toward children has several benefits. A mother may seek chiropractic care for some issues even before her child is born, as chiropractic techniques can be performed on pregnant women and are considered to be safe and effective. Sometimes the effects of birth trauma can be remedied with gentle chiropractic care. Some infants are born with health conditions that affect their abilities to grow and develop normally or that even put them at risk of acquiring other conditions that can impact their general health or that could cause illness. Many studies have shown that chiropractic care delivered to children with health conditions, whether they occurred before birth or they developed during infancy and childhood, is beneficial and therapeutic.

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61 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. True or False: 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 a better overall behavior and attitude.

a. True b. False

2. Congenital spinal abnormalities are birth defects that affect the spine

a. and the spinal cord. b. and that develop before a baby is born. c. and that can eventually affect other areas of the body. 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. The ______eventually harden through ossification as it/they become bones and the notochord ultimately forms the intervertebral discs.

a. cartilage b. neural tube c. annulus fibrosus d. somites

5. ______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. Spina bifida c. Anencephaly d. Paresthesia

62 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. 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.

7. Women who are pregnant or are even thinking of becoming pregnant are advised to increase their intake of ______, as it has been shown to reduce the risk of neural tube defects such as spina bifida.

a. iron b. Vitamin D c. zinc d. folic acid

8. 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

9. Spina bifida occulta is a type of spina bifida that

a. is severe, causing back deformities and poor mobility. b. not obvious and a patient may be unaware of the condition. c. is so severe it causes paralysis. d. is nonexistent but the patient exhibits some of its symptoms.

10. Which of the following statement(s) is/are true regarding spina bifida occulta?

a. It can cause muscular weakness and bladder dysfunction. b. It affects less than 1% of the population. c. It cannot be treated by a chiropractor. d. All of the above

63 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11. Congenital scoliosis is described as the spine having

a. an abnormal rounding, “hump,” on the back of the spine. b. the lumbar spine curve inward toward the abdomen. c. a nevus in the lumbar region of the spine. d. a curvature to the side instead of its usual vertical structure.

12. True or False: The Growing Spine Committee recommends manual manipulation therapies and stretching exercises to treat and manage congenital scoliosis.

a. True b. False

13. ______is a condition that causes an abnormal rounding of the spine that produces a hump in the back; on appearance, the child may seem to have a hunched back.

a. Lordosis b. Kyphosis c. Congenital muscular torticollis d. Scoliosis

14. 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 toward the abdomen. d. is bowed forward at an angle.

15. Kyphosis is a spinal condition

a. that most often develop in utero. b. in which the vertebrae fully separate into distinct bones. c. that most often occurs in older adults. d. in which the spinal curve is normal but the vertebrae do not full separate.

64 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16. Chiropractic spinal adjustments to treat kyphosis or lordosis

a. will realign the spine to correct the curvature. b. is not recommended. c. could help control associated pain and inflammation. d. will exacerbate the condition.

17. A baby may be born with spinal subluxation because of birth trauma, which may lead to

a. muscle weakness. b. poor development. c. difficulties with feeding and sleeping. d. All of the above

18. True or False: Chiropractic care may be utilized to improve range of motion, function, and flexibility among infants with nerve damage due to birth trauma.

a. True b. False

19. Chiropractic care may help to prevent the onset of some symptoms of sore throat, a cold or related viral infection, by specifically improving

a. the flow of lymph fluid. b. posture and mobility. c. feeding and sleeping patterns. d. muscular tone and strength.

20. In children, occasional aching or throbbing pain in the legs that is unrelated to illness or chronic disease, referred to as growing pains,

a. is a myth, not a physical condition. b. is most common after age 12. c. can affect up to 40 percent of children. d. All of the above

65 nursece4less.com nursece4less.com nursece4less.com nursece4less.com CORRECT ANSWERS

1. True or False: 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 a better overall behavior and attitude.

a. True

“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.”

2. Congenital spinal abnormalities are birth defects that affect the spine

a. and the spinal cord. b. and that develop before a baby is born. c. and that can eventually affect other areas of the body. d. All of the above [correct answer]

“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, the person can eventually have problems in other areas of the body, including the kidneys or urinary tract, as well as difficulties performing routine activities of daily living.”

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

“During embryonic development, the spinal cord begins to form within a couple of weeks after conception with the initial growth of the neural tube.”

66 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4. The ______eventually harden through ossification as it/they become bones and the notochord ultimately forms the intervertebral discs.

d. somites

“The somites eventually harden through ossification as they become bones and the notochord ultimately forms the intervertebral discs.”

5. ______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.

b. Spina bifida

“… spina bifida, in which a portion of the spinal cord protrudes through the vertebrae when the neural tube does not close properly during development;....”

6. When the neural tube fails to close during fetal development, the child can develop an encephalocele if

b. a sac containing part of the brain and the meninges protrudes through an opening at the base of the skull.

“Neural tube defects are some of the more commonly understood congenital anomalies involving the spine … and an 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.”

7. Women who are pregnant or are even thinking of becoming pregnant are advised to increase their intake of ______, as it has been shown to reduce the risk of neural tube defects such as spina bifida.

d. folic acid

“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.”

67 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8. 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

“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.”

9. Spina bifida occulta is a type of spina bifida that

b. not obvious and a patient may be unaware of the condition.

“Spina bifida occulta is a type of spina bifida in which the neural tube closure is not obvious; in many cases, the patient may be unaware that the condition exists. Spina bifida occulta occurs most commonly in the lumbar region of the spine and it could cause difficulties with walking or moving, as well as back pain, vertebral disc herniation, and nerve dysfunction.”

10. Which of the following statement(s) is/are true regarding spina bifida occulta?

a. It can cause muscular weakness and bladder dysfunction.

“Although spina bifida occulta is the mildest form of the condition, it can still cause muscular weakness and bladder dysfunction for some people...”

11. Congenital scoliosis is described as the spine having

d. a curvature to the side instead of its usual vertical structure.

“Congenital scoliosis is described as the spine having a curvature to the side instead of its usual vertical structure.”

68 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12. True or False: The Growing Spine Committee recommends manual manipulation therapies and stretching exercises to treat and manage congenital scoliosis.

d. False

“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.... 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.”

13. ______is a condition that causes an abnormal rounding of the spine that produces a hump in the back; on appearance, the child may seem to have a hunched back.

b. Kyphosis

“Kyphosis is a condition that causes an abnormal rounding of the spine that produces a hump in the back; on appearance, the child may seem to have a hunched back.”

14. Lordosis is a spinal anomaly that is described as an abnormal curve in the lumbar region of the back, in which the lumbar spine

c. curves inward toward the abdomen.

“Lordosis is a spinal anomaly that is described as an abnormal curve in the lumbar region of the back, in which the lumbar spine curves inward toward the abdomen.”

15. Kyphosis is a spinal condition

c. that most often occurs in older adults.

“Kyphosis ... most often occurs in older adults after years of wear on the spinal column that leads to compression of the intervertebral discs and compression fractures.”

69 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16. Chiropractic spinal adjustments to treat kyphosis or lordosis

c. could help control associated pain and inflammation.

“The treatments for congenital kyphosis and lordosis can vary, depending on the severity of the angle of the defects.... A chiropractor can also assist with some treatments for kyphosis or lordosis. Many studies have shown that helping patients with these conditions to work on their posture and to stand up straight have had no impact on the condition. Spinal adjustments made by chiropractors will not realign the spine to correct the curvature, but these adjustments could help to control some of the pain and inflammation of the condition.”

17. A baby may be born with spinal subluxation because of birth trauma, which may lead to

a. muscle weakness. b. poor development. c. difficulties with feeding and sleeping. d. All of the above [correct answer]

“A baby may be born with spinal subluxation because of birth trauma, but the effects may not be immediately seen. Problems with muscle weakness, poor development, and difficulties with feeding and with sleeping can all develop as a result of vertebral subluxations that occur during birth.”

18. True or False: Chiropractic care may be utilized to improve range of motion, function, and flexibility among infants with nerve damage due to birth trauma.

a. True

“In some cases, chiropractic care may be utilized to improve range of motion, function, and flexibility among infants with nerve damage due to birth trauma.”

70 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19. Chiropractic care may help to prevent the onset of some symptoms of sore throat, a cold or related viral infection, by specifically improving

a. the flow of lymph fluid.

“There are many situations where a child with a sore throat or with cold symptoms can be treated through chiropractic medicine. Chiropractic care may also help to prevent the onset of some symptoms and related viral infection. The goal of chiropractic care administered for treatment of colds or sore throat is to strengthen the patient’s immune system to better fight off the viral infection. Chiropractic medicine asserts that this type of care specifically improves the flow of lymph fluid through its channels, which ultimately supports the immune system to allow a child to fight off a cold or infection.”

20. In children, occasional aching or throbbing pain in the legs that is unrelated to illness or chronic disease, referred to as growing pains,

c. can affect up to 40 percent of children.

“Some children suffer from occasional aching or throbbing pain in the legs that is unrelated to illness or chronic disease. Referred to as growing pains, this type of pain can affect up to 40 percent of children; it most commonly occurs during preschool and school-age years in children ages 3 to 5 years and again in children ages 8 to 12 years. Growing pains are not just a myth, but they can actually cause enough pain in affected children that they require visits to the doctor or hospital for diagnosis.... A chiropractor can also help with diagnosis and management of growing pains, and treatment through chiropractic care may be a worthwhile option for some kids who have enough pain that it affects sleep or other activities.”

71 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Reference Section

The reference section of in-text citations includes published works intended as helpful material for further reading. [References are for a multi-part series on Chiropractic Care].

1. Adams, J., et al. (2017). The prevalence, patterns, and predictors of chiropractic use among US adults: Results from the 2012 National Health Interview Survey. Spine. 2017 Apr 28. 2. Gerstenkorn Family Chiropractic. (n.d.). Gonstead care. Retrieved from http://www.gerstenkornchiropractic.com/gonstead-technique 3. Herbst, R. (2014). Gonstead Chiropractic Science and Art. (2014). SCI-CHI Pulications. 4. Kemper, K. (2017). Complementary and alternative medicine in pediatrics. UpToDate. Retrieved online at https://www.uptodate.com/contents/complementary-and-alternative- medicine-in- pediatrics?source=search_result&search=chiropractic&selectedTitle=7 ~42. 5. Young, K. (2017). Historical influence on the practice of chiropractic radiology: part II - thematic analysis on the opinions of diplomates of the American Chiropractic College of Radiology about the future. UpToDate. Chiropr Man Therap. 2017 May 8;25:15. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/28503293. 6. The Pettibon System. (2015). How the Pettibon system works. Retrieved from https://pettibonsystem.com/about/how-pettibon-works 7. Xia, T., et al. (2017). Association of lumbar spine stiffness and flexion- relaxation phenomenon with patient-reported outcomes in adults with chronic low back pain - a single-arm clinical trial investigating the effects of thrust spinal manipulation. BMC Complement Altern Med. 2017 Jun 9;17(1). Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/28599647. 8. Muller, A., Murphy, E. Brownstein, S., Boyles, R. (2015). Effectiveness of spinal manipulation in the treatment of non-musculoskeletal disorders: a systematic review. Physical Therapy Research Symposium, Paper 8. 9. Physiopedia. (n.d.). Manual therapy techniques for the lumbar spine. Retrieved from http://www.physio- pedia.com/Manual_Therapy_Techniques_For_The_Lumbar_Spine 10. Seo, Y., Lee, J., Han, D. (2014). The effects of spinal mobilization with arm movements on shoulder muscle strengthening. J Phys Ther Sci. 27(11-13).

72 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11. Russell, D. Kimura, M., Cowie, H., de Groot, C., McMinn, E., Sherson, M. (2016). Changes in quality of life in 7 older adult patients receiving activator methods chiropractic technique. J Chiropr Med. 15(1): 59-66. 12. Maiers, M., et al. (2014). Spinal manipulative therapy and exercise for seniors with chronic neck pain. The Spine Journal 14(9): 1879-1889. 13. Dougherty, P., Karuza, J., Dunn, A., Savino, D., Katz, P. (2014). Spinal manipulation therapy for chronic lower back pain in older veterans. Geriatr Orthop Surg Rehabil. 5(4): 154-164. 14. Galicia-Castillo, M.C. and Weiner, D.K. (2017). Treatment of persistent pain in older adults. UpToDate. Retrieved online at https://www.uptodate.com/contents/treatment-of-persistent-pain-in- older- adults?source=search_result&search=hip%20pain%20and%20chiropr actic&selectedTitle=2~150. 15. Mayo Clinic. (2017). Stretching: focus on flexibility. Retrieved from http://www.mayoclinic.org/healthy-lifestyle/fitness/in- depth/stretching/art-20047931 16. Taylor, F.R. (2017). Tension-type headache in adults: Preventive treatment. UpToDate. Retrieved online at https://www.uptodate.com/contents/tension-type-headache-in-adults- preventive- treatment?source=search_result&search=headache%20and%20chirop ractic&selectedTitle=3~150. 17. Moore, C., Sibbritt, D., Adams, J. (2017). A critical review of manual therapy use for headache disorders: prevalence, profiles, motivations, communication and self-reported effectiveness. BMC Neurology 17(61). Retrieved from https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-017- 0835-0 18. Mckay, T., Jenkins, K. (2016). Headaches. Retrieved from http://www.spineguys.com/health_conditions/headaches.asp 19. Silberstein, S. (2016). Migraine. Merck Manual. Retrieved from http://www.merckmanuals.com/professional/neurologic- disorders/headache/migraine 20. Chaibi, A., Benth, J., Tuchin, P., Russell, M. (2016). Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial. European Journal of Neurology 24(1): 143-153. 21. Knight, C., et al. (2017). Treatment of acute low back pain. UpToDate. Retrieved online at https://www.uptodate.com/contents/treatment-of- acute-low-back- pain?source=search_result&search=low%20back%20strain%20and%2 0chiropractic&selectedTitle=2~150.

73 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22. Schneider, M., Haas, M., Glick, R., Stevans, J., Landsittel, D. (2015). A comparison of spinal manipulation methods and usual medical care for acute and sub-acute low back pain: a randomized clinical trial. Spine 40(4): 209-217. 23. Wheeler, S., et al. (2017). Evaluation of low back pain in adults. UpToDate. Retrieved online at https://www.uptodate.com/contents/evaluation-of-low-back-pain-in- adults?source=search_result&search=ruptured%20disc&selectedTitle= 6~96. 24. Bridwell, K. (2017). Intervertebral discs. Retrieved from https://www.spineuniverse.com/anatomy/intervertebral-discs 25. Ehrler, M., Peterson, C., Leemann, S., Schmid, C., Anklin, B., Humphreys, B. (2016). Symptomatic, MRI confirmed, lumbar disc herniations: a comparison of outcomes depending on the type and anatomical axial location of the hernia in patients treated with high- velocity, low-amplitude spinal manipulation. Journal of Manipulative and Physiological Therapeutics 39(3): 192-199. Retrieved from http://www.jmptonline.org/article/S0161-4754(16)00060-9/fulltext 26. Horst Chiropractic. (2012). Chiropractic treatment for fractures. Retrieved from http://www.horst-chiropractic.com/chiropractic- treatment-for-fractures/ 27. Cedars-Sinai. (2017). Back pain during pregnancy. Retrieved from https://www.cedars-sinai.edu/Patients/Health-Conditions/Back-Pain- During-Pregnancy.aspx 28. Peterson, C., Muhlemann, D., Humphreys, B. (2014). Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1-year follow-up. Chiropractic & Manual Therapies 22(15). 29. Shekelle, P., et al. (2017). Spinal manipulation in the treatment of musculoskeletal pain. UpToDate. Retrieved online at https://www.uptodate.com/contents/spinal-manipulation-in-the- treatment-of-musculoskeletal- pain?source=search_result&search=headache%20and%20chiropractic &selectedTitle=1~150. 30. The Joint Chiropractic. (2017). Chiropractic care 101: whiplash! Retrieved from https://www.thejoint.com/california/encinitas/encinitas- 31006/chiropractic-care-101-whiplash 31. Rodway, I. (2015). Cervical radiculopathy (pinched nerve). Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00332 32. Aquaroli, R., Camacho, E., Marchi, L., Pimenta, L. (2016). Manual therapy and segmental stabilization in the treatment of cervical radiculopathy. Fisioterapia em Movimento 29(1). Retrieved from

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