This is the chapter Dr. Sheehan co-wrote with Dr. Julie Mayer-Hunt on Upper Cervical Care for Infants and Children that was published this year by Lippincott Textbooks. It is in the “Pediatric Chiropractic” 2nd edition.
Atlas Orthospinology and Atlas Orthogonal: A Specific UPPER CERVICAL Approach for Pediatric CARE
JULIE MAYER HUNT, DC, DICCP, Atlas Orthospinologist & Laura Sheehan, R. N., D.C. Atlas Orthogonalist
ATLAS Orthospinology AND ORTHOGONALITY: A Specific UPPER CERVICAL Approach for Pediatric CARE
The Atlas Orthospinology and Atlas Orthogonal procedures (AO) are based on the Grostic model of upper cervical analysis and vectored adjustment. Dr. John Grostic developed a scientific based light-force, three dimensional chiropractic adjustment, that is vectored and in which corrections can be duplicated with high inter-examiner reliability. From Dr. Grostic’s work, Atlas Orthospinology and Atlas Orthogonality and NUCCA were created. (1) Due to the light force of the correction and the precision of the adjustment, they are well-suited for the sensitive nature of infant and toddler anatomy. For pediatric consideration, the adjustive force is less than one pound of pressure in the Orthospinology procedure and 3-6 lbs at one 25th of a second in Orthogonality procedures, which are generally not even felt by the patient. (1) These Chiropractic programs are quite similar and differ in the size of the stylus mounted in the table; minor variations in X-ray as well as nomenclature of the radiographs and subluxation types. (1) Grostic and Nucca stand apart in their adjustment approach as it is done by hand. Orthogonal is an adjective having to do with or involving right angles; mutually perpendicular. The cranium should be vertical over the neck, the atlas should be level and the cervical spine should be vertical to be in an optimal and neurologically sound “Orthogonal position”. (4)
There are many other higher force Upper Cervical Techniques. These are HIO, Modified Toggle, Grostic, Blair, Knee Chest Table, and Applied Biophysics to name a few. However, this chapter is dedicated to Atlas Orthospinology and Atlas Orthogonality procedures.
The case studies presented utilize a straightforward AO protocol and employ extrapolated biomechanical considerations when X-ray films were not reasonably obtainable.
The development of upper cervical evaluation
In the low-force, vectored upper cervical programs, it became vital for the founders to develop an accurate and reproducible way to determine the atlas plane line in relation to the upper central skull line and the cervical spine. Atlas laterality is determined by their relationship. The inferior attachments of the lateral masses were chosen where they intersected the posterior arch because this is the primary growth center of the atlas and is most reliable. “In infants it is not fully developed and an injury or subluxation early in life could retard the symmetrical growth of these centers.” (2) The inferior aspect of the transverse process of C1 was chosen over the superior because of the position of the vertebral artery and any anomalies there.
There was great care taken in development of the stylus used to interface with the patient in the AO procedures. The Orthogonality stylus is thin, cylindrical, narrower in circumference than a pencil and scientifically tested alloy metal to insure a consistent transmittal of predictable energy. The Orthospinologist’s stylus is larger, and more like a thicker version of the Orthogonality stylus with a rubber tip. The proper material and firmness of the headpiece is essential for a successful atlas correction and is still being experimented with. The mastoid support of the headpiece needed to be quite firm so that the mastoid resting just above the edge could allow the atlas free movement with which to change position once the compressional wave was released into the stylus. When the AO correction vectors are calculated, the leg length balance is checked, neurological scanning is performed at the C1 and C2 nerve roots. If in agreement, the atlas correction goes forward and the head piece is set at a specific height and angle. The patient is placed on the mastoid support, adjustment factors are set up on the AO instrument. The shoulder is placed to enhance the correction. The compressional wave is then released into the stylus. Currently, these developments took over 50 years of experimentation and refinement. Without the dedication and work of Dr. Roy Sweat and Dr. Cecil Laney, the development of these chiropractic programs would have halted.
The upper cervical orthogonal approach is based on specific X-rays taken with a three-dimensional focus. These X-rays give invaluable information. This is the basis of a protocol for correcting the upper cervical subluxation complex that is methodical and produce remarkably consistent results. With very small children and toddlers, the protected mom is often used to help steady the child during radiographic procedures. However, there will be times when taking X-rays is not possible because of lack of parental consent due to misinformation and fear about radiation in childhood. And, obtaining good radiographs of a three year old child with a fever who is fussy or uncooperative can be a challenge. Therefore, it is important to have an alternative plan. This chapter presents an overview of Pediatric AO procedures including a method of atlas correction protocols. In addition, where X-rays are not easily obtainable, this chapter offers biomechanical evaluations that may lead to the Atlas listing.
The Biomechanics of the Occipito-Cervical Junction in A Newborn
Considerations must be given to the developing anatomy of the infant as well as extrapolations of known biomechanical patterns of the upper cervical spine. Adult and pediatric spines are differentiated by the elastic properties of the ligaments and wide cartilaginous beds. The angles of the pediatric spinal joints have articulating surfaces which are flatter and more horizontal when compared to an adult occipito-atlanto articulation as shown in Figure 31.1 (2).
In a study by Biedermann [3], “more than 1000 x-rays from the first year of life were reviewed and found to have an almost horizontal plane of the frontal angle of the occipito-atlanto articulation.” This statement refers to laterality of the Atlas and not to the rotational Y axis of the subluxation as this becomes more of a factor when the joint beds ossify at age 2. Stability of the upper cervical region is comprised of soft tissue inclusive of the tectorial membrane, the alar, apical and cruciate ligaments as well as anterior and posterior musculature. In the pediatric spine, the greatest mobility occurs at C1 and C2 versus the adult spine wherein the greatest mobility is at C5-C6. (4) The C2-C3 region in the pediatric spine is hyper-mobile mostly due to joint capsule and ligamentous laxity compounded by the weight of the head and underdeveloped muscular support. The odontoid is separated from the C2 body and neural arches by a broad cartilaginous band that does not ossify until three to six years of age. (2)
In the pediatric spine the angles of the upper cervical facet joints have been noted to change with age, beginning as low as thirty degrees infancy and have been recorded to gradually change to fifty-five or sixty degrees by age twelve. (2) This change with age is demonstrated in Figure 31.2 because the articular beds of the developing infant are thick; the vectored adjustments calculated by the upper cervical protocol have some flexibility in their angles. Subluxation patterns become increasingly complex as the spinal joints ossify and are less cartilaginous.
As the pediatric spine ossifies the specificity of vectors will become critical, therefore as soon as radiographs can be attained using the three dimensional setups, an accurate vectored adjustment can be preformed. Figure 31.3 depicts the three angles of radiographs required for AO analysis using the right handed Cartesian system.
In a gravitational field, the weight of the head upon the spinal column is a biomechanical factor to be considered in understanding upper cervical subluxation patterns. Think of the occiput, the atlas and the axis as three rings that sit upon one another. If one is tilted one way and the other tilted another way then there will be altered blood flow through the vertebral artery, the spinal cord and the position of the occiput. There are four typical patterns of cervical misalignment recognized in the AO approach for the upper cervical region. In Figure 31.4a,b,c,d these are typical high contra lateral, contra lateral low, typical ipsilateral low and ipsilateral high. There are 4 atypical listings. High and low are references for the Atlas Frontal Plane line. Two of the four recognized primary patterns of adjustment in the Orthospinology program are the lever and pure wedge (figure 31.5) which will be discussed in a Pediatric application.
Figure 31. 5 Lever and Pure Wedge Type Subluxation Patterns
Anatomically, if one evaluates the spinal segments from C2/C3 thru the L5/S1 region, they all interlock at the facet joints. From the joints of Luscha in the cervical spine through to the mamilary processes of the lumbar spine, as segments rotate, there is a point where the articular bed are flush against the boney facet of the upper or lower segment. The Atlas has articular beds without boney interlocking facets, no intervertebral disc, and biomechanically can become subluxated and/or dislocated, causing compensatory fixations throughout the spine in an effort to keep the body balanced and upright in a gravity-based environment. (4) Figure 31.6 shows an example of occipito-atlanto-axial potential mobility and complete luxation.
The Upper Cervical exam of the Pediatric Patient
Static palpation of the first and second Cervical Nerve Roots
Palpation of the pediatric patient in infancy can done with the infant held in the parent’s lap
seated, with one hand supporting the chest. The other hand would support the back. The
practitioner will support the head. Another approach for the newborn is supine position resting
on the adjusting bench. If supine, lighter palpation should occur because muscle tension will
be less in a supine position.
A child over the age of 4 months can sit to have their neck lightly palpated. Upon inspection,
one can notice contracted muscles in the upper neck are usually unilateral. The doctor will
approach the back of the head with the 5th digit pad. Figure 31.7
The AO procedure is done by first palpating the first and second nerve roots which exit the
foramen and are not palpable any where else in the cervical spine.(13) Figure 31.8 In an
infant, this tiny area must be palpated with the 5th digit pad and is easily missed if the
practitioner is unfamiliar with this area.
If the C1 segment is subluxated, there will be a palpable nodule felt under the occiput just lateral
to the Rectus Capitus Posterior Major. The next level down, C2 will be palpable and tender just
lateral to the C1 nerve root and will have a larger nodule than C1. In an infant, the nodule may
be only the size of a tip of a pencil or small pea, in the adult population by contrast, may feel pea
sized or like a marble. This is not to be mistaken with inflamed lymph nodes which are much
more lateral on the neck. (4) Figure 31.9
Interexaminer reliability studies have been done regarding palpation of the upper cervical spine,
and the clinical data analyzed found 97% agreement among palpators for accuracy.(4)
Supine leg length assessment
A supine leg length assessment is one of the hallmark tools of upper cervical procedures. In the pediatric population, leg length asymmetry is usually apparent for discrepancies of greater than one-half inch. Dr. Kirk Eriksen [2] notes the following hypothesis regarding the short leg theory: “The spinocerebellar tracts are located along the lateral edge of the spinal cord and are located at the most probable site of maximal mechanical irritation via the dentate ligaments. The proprioceptive tracts are primary pathways for regulating muscle tone and joint position sense. The spinocerebellar tracts are arranged in a laminar fashion (although somewhat angulated) with the most lateral fibers innervating the most caudal structures (i.e., legs, sacral, lumbar, thoracic, cervical [very limited]). Irritation of these tracts could lead to muscle tone imbalance of the pelvic girdle resulting in a functional short leg.” Figure 31.10a,b depicts the proximity of the dentate ligaments to the peripheral cord tracts and how dentate ligament tension may distort their form and function. This could represent a lateral atlas subluxation. (2) The concept of leg length asymmetry is shown graphically in Figure 31.11.
Figure 31.11 Suppine leg check
A supine leg length examination is a valuable evaluation tool and can be used in conjunction with palpation of associated paraspinal erector spinae muscles. When checking leg length, start by observing the entire leg from the hip to the heel. It’s possible that hip distortion can be visualized with larger leg length differences. With the early toddler, be sure to observe all skin folds of both legs as well as differences at the heel and ankle. For infants under the age of six months, leg length asymmetry may be difficult to determine, therefore palpation of the erector spinae muscles is utilized as a secondary evaluation tool.
If leg length asymmetry is apparent in conjunction with erector spinae muscle spasm, then there are two considerations for determining atlas laterality. In a child where Radiographs are not obtainable, a modified upper cervical exam of atlas laterality can be used which is discussed in a case study later in this chapter.
With the infant six months or older, it is important to stabilize the legs at the kneecap area with the thumb placed superior to the patellar region helping to assess leg length. Pressure to the patella regions should be equal during a toddler leg check. If the child is squirming during the evaluation, check for unequal skin folds above the knee cap as shown in Figure 31.12. Skin folds will be unequal if incorrect leg stabilizing is done. The medial malleoli may be used in the stead of calcaneous if leg length is still unclear. Be sure to have the feet hanging off just at the edge of the adjusting table with the patient supine if the child is over a year.
In a supine position the presence of a lateral atlas will present with a short leg. 2 Paraspinal hypertonicity may be found present in the thoracic spine. Placing the patient in a supine position and palpating the erector spinae muscles, specifically the upper dorsal longisimus group should be symmetrical in tone compared to the other side if no subluxation is presenting the upper cervical spine. Figure 31.13 The doctor will have to rule out a possible thoracic subluxation causing the hypertonicity as well. If a spasm is noted, it is recommended to perform an “atlas challenge’. The practitioner places a light finger tip of the fifth digit on the transverse process of the atlas producing a mild pressure, approximately a nickels weight from lateral to medial or right to left and vice versa. (Figure 31.14) The side of the atlas challenge that decreases erector spinae tonicity is the side of atlas laterality. Correcting atlas laterality, improves disturbances of interactive reflexes elicited by altered vestibular, visual and proprioceptive signals. Many afferent proprioceptive signals originate from the cranio-cervical junction. (4) The short functional leg will lengthen visibly within seconds of an Atlas correction. Figure 31.15
Upper cervical radiographs are recommended to measure upper cervical alignment and discern vectors of correction.
Radiographs in the AO Procedures
Most times, radiographs can be obtained with assistance from a lead-shielded parent. There are many circumstances where an X-ray is necessary to facilitate an accurate adjustment vector, and it may require one to two visits to procure such films with a toddler or a child 3 months to 3 years of age. A positive experience will ensure that the toddler is cooperative on subsequent visits. Special needs children, i.e. Autistic children, may require repeat visits to achieve quality X-rays. Radiographs should not be taken if it is clear they will be of poor quality.
Examples of how to achieve X-rays of the three planes of view to coordinate a vectored adjustment are illustrated in Figures 31.16. The Lateral view is recommended to rule out bony anomalies or pathology. For example, a child with Platybasia would not receive an atlas adjustment. The atlas saggital plane line can be obtained off the lateral X-ray by drawing a line through the posterior arch anteriorly through the facial structures. Place a protractor at the edge of the film and note the degrees from 90. This gives the Chiropractor the number of degrees to tilt the X-ray tube to take the Nasium view with. The Nasium view shows Atlas high or low, on which side, the upper and lower angles specifically head tilt and the lower cervical spine relationship to the upper angle. It helps to have the parent hold the child’s hands down and out of the view. The Vertex view is the most challenging to position, but the data obtained from this view is invaluable as it shows if there is any y axis rotation of C1 on C0 and C2. Even 0.75 degrees can cause neurological symptoms. 4, 5
Note the stuffed animal above the patient and the mom holding the hands down. In the
Nasium view, note that the mom has not changed position from the Vertex view and she is able
to hold the child’s hands out of the X-ray field of view. The doll is used to encourage the child’s
cooperation. (Figure 31.16)
A detailed description of the procedures used to set up radiographs can be found in the Basic
Modules one and two of the Atlas Orthogonal Chiropractic Program book. (4) and Chapter 3 of
Orthospinology procedures book also has this information. (2)
MODIFIED UPPER CERVICAL ADJUSTING
In a case where upper cervical X-rays are deemed too difficult to obtain, the next best protocol is to determine if the young child has a lever or a wedge type subluxation pattern to make a modified upper cervical correction.
The first component to determine the type of atlas subluxation is the atlas challenge and palpation of the paraspinal musculature.
The second component of determining a wedge or lever type atlas subluxation includes palpation of the lower cervical spine at C7-T1 region in the supine position to determine if the C7-T1 spinous process is rotated left or right of the episternal notch.
If the C7-T1 spinous processes are to the same side of atlas laterality, the correction would be for a wedge type adjustment. If the C7-T1 spinous process is opposite the side of atlas laterality, the adjustment would be for a lever type adjustment.
Pediatric table placement
The upper cervical correction is accomplished with the pediatric patient lying on the uninvolved side, stabilized by a parent in that position. With an infant, a thin receiving blanket can be used on the headpiece to minimize the child’s reaction to a table adjusting surface and it will take two hands to stabilize them in position. With the patient on their side, head resting on the headpiece, the cervical spine should be level. The thoracic, lumbar and pelvic regions should be parallel to the adjusting surface as shown in Figure 31.17.
The mastoid process of the uninvolved side should be placed one-eighth inch above the edge of the head piece. The head should never be rotated with nose up or nose down. The external auditory meatus is to be placed in line with the zero on the headpiece protractor. (Figure 31.18) The eyes should be straight ahead. Moving the lobe of the ear on the uninvolved side forward or avoiding folding the earlobe as the mastoid is placed can alleviate ear pinching. It is recommended the parent look at the child from eye level keeping them slightly distracted. Additionally, they can assist in securing and stabilizing the child’s side posture by holding their legs during the adjustment.
THE LANEY ADJUSTING INSTRUMENT
For example, if the side of atlas laterality and the lower cervical angle were both to the right,
the adjustment would be a zero line of drive with the headpiece set for a wedge type of
adjustment. If the lower angle is on the opposite side of the atlas subluxation, the headpiece
would be set for a lever type of adjustment with a mild to moderate cephalad line of correction.
In Orthospinology procedures, a chiropractor has the option of adjusting by hand, by hand-held instrument (the Laney Instrument, Figure 31.19a), or by a table-mounted adjusting instrument. For the pediatric population, the Laney instrument is ideal to adjust a small contact area and allows the Chiropractor to adjust to the toddler’s movement. The force of the instrument can be adjusted to less than one-half pound, which is well suited for infants and children. (1)
The AO Precision Adjusting Instrument
In the Atlas Orthogonal procedure, the Atlas Orthogonal handheld precision adjusting instrument is utilized in making the adjustment on a portable head piece. (Figure31.20) This allows the Chiropractor to allow for any motion the child may make. Two solenoids hit each other and a compressional wave is emitted from the handheld device. (12) The x, y and z vectors are in the design of the equipment making it possible to eliminate the angles calculated on the Radiograph. The z vector is accomplished by tilting the stylus until the level on the handheld unit is at the desired number of degrees from 10 to 30. The Y is a protractor on the headpiece and the child’s head is placed at zero in the middle of the protractor. The x vector is on a level at the side of the portable head piece allowing the Chiropractor to set the tilt at 15-25 degrees. If Radiographs have not been obtained, the stylus is always kept at zero on the protractor for the y axis at the head piece when making the adjustment. A neutral adjustment for a child without Radiographs is 25 on the Z vector. (4) The standing table is more precise in correcting subluxations of C1 and C2 pictured here in figure 31.21.
Case Studies
THE SISTERS CASE STUDY
An established patient brought her daughters, ages three and five, for a spinal check up. Upon examination, both daughters revealed leg length discrepancy in the supine leg check. The X-ray findings, confirmed the presence of the atlas subluxation.
SISTERS CASE STUDY: THE FIVE YEAR OLD
The five-year-olds’ birth history included a collarbone fractured during the birth process. Her early childhood history was only significant for left ear infections from ages one to two years. Supine leg length assessment (Figure 31.22a) suggested a short leg due to neurological causes. Further examination findings included erector spinae spasms on the right at T10 through L3 and gentle digital examination of the cervical spine (Figure 31.22b) revealed right articular tenderness at C2/C3. It should be noted that increased tonus of the erector spinae muscles will be perceived as a tickle sensation in a prepubescent child but the post pubescent patient may experience tenderness or pain. A postural observation suggested an elevated right shoulder (Figure 31.22c).
Cervical spine X-rays were exposed including lateral, vertex and nasium views.
Figure 31.23 depicts the patient’s positioning for the three views. Note that lead
shielding was used during the actual exposures. The resulting X-rays are shown in Figure 31.24
The lateral X-ray view was analyzed using the Orthospinology protocols discussed in Orthospinology Procedures [2], Chapter 4. The findings included a severe reversal of the normal lordosis of the cervical spine. The nasium X-ray view was analyzed utilizing protocol from Orthospinology Procedures [2], Chapter 5. The findings indicated a right wedge type subluxation of the Atlas measuring 2.5 degrees right laterality relative to the vertical plane of the skull. The axis measured right 2.5 degrees laterality and the rotation of C2 spinous was 2.5 degrees. The atlas plane line measured below the horizontal plane at the lateral jaw ramus one-sixteenth inch and the lower cervical angle measured right eight degrees. The vertex film was analyzed (Orthospinology Procedures [2], Chapter 6) and found to reveal a right posterior five degree atlas rotation.
Geometric measurements of the occipito-atlanto-axial joint surfaces, the atlas plane line, and the configuration and magnitude of the side of atlas misalignment relative to the lower cervical spine were used to formulate a line of correction for a vectored adjustment (Orthospinology Procedures [2], Chapter 7).
Atlas specific adjustments were initiated, and a leg check done (figure 31.25a,b). Evaluation of the upper cervical spine was done initially three times a week for 2 weeks. The schedule then became 2 times a week for 5 weeks. As the patient made progress, exhibited by resolved supine leg length asymmetry and diminished erector spinae hyper tonicity, care was decreased. There was a gradual reduction of right articular pain and tenderness at C2/C3 vertebrae. She was released from acute care after being checked for seven and one-half weeks requiring a total of sixteen visits. She was then evaluated once per month for another six months. After this time her frequency was once every two to three months.
A comparative Lateral film was taken three weeks into care revealing a diminished cervical kyphotic curve, and the film exposed at seven and one-half weeks suggested a return to a near normal lordotic curve. Figure 31.26 shows the comparative X-rays.
Parents’ comment post treatment was that the five-year-olds’ immune function was markedly improved and that her personality was measurably different. She had always been quiet, shy, and timid but now her parents and teachers note that her behavior has changed and she is participating openly in classroom settings. The only traumas the parents could suggest as a cause of the cervical spine reversal was a trampoline accident several years ago wherein their daughter fell off headfirst.
THE SISTERS CASE STUDY: THE 3 YEAR OLD
The three-year-olds’ films suggested a normal lordosis. The Nasium/Frontal and Vertex/Horizontal views suggested a mild to moderate occipito-atlanto-axial subluxation complex. The adjusting protocol for this patient was five visits weekly. At which time she was released from corrective care and is checked once every six months unless a health concern or injury occurs.
CASE STUDY: FOUR MONTH OLD WITH ACQUIRED TORTICOLLIS
A child presenting with acquired torticollis will have sudden onset and typically awaken with neck pain [5]. This will usually follow strenuous activity or mild trauma. Marked spasm of the sternocleidomastoid muscle (SCM) and articular tenderness will be noted on the uninvolved side. A Nasium/Frontal X-ray will suggest a significant curvature in the mid-cervical region. Some pediatric textbooks list the most common cause of acquired torticollis as rotational subluxation of the atlanto-axial complex [5]. R.A. Hoekelman in Primary Pediatric Care[6] stated: “Sudden difficulty in rotating the head to one side, accompanied by torticollis and muscle spasm, may occur as a result of rotational subluxation of the atlas (C1) on the axis (C2) or C2 on C3.” Different etiologies of torticollis can include intervertebral disc calcification, retropharyngeal infections, osteomyelitis of the cervical vertebrae, drug reactions, spinal tumors or atlanto-axial instability as seen in Morquio’s and Down’s syndromes. Acquired torticollis in older children can result from upper cervical subluxation with associated muscle and ligamentous involvement. Improved vertebral joint movement will be noted with the first atlas correction. The Chiropractor must rely on the mother’s perception of her child’s pain. With the first Atlas correction, there should be some improvement in the child’s pain.
A mother presented with her four month old daughter who had right neck tilt (Figure 31.27) with constant spasmodic flexing to the right. The infant’s history included an event at two months of age where the mother slipped while holding the child on her left shoulder and fell on top of her. The infant was brought to the hospital ER facilities for constant crying, and fever without positive change in her clinical picture. The uncontrollable neck spasms started two days following the injury concurrent with nose bleeds which occurred two to three times per day for two weeks post trauma. X-rays from the hospital were negative for fracture and or dislocation. In addition to the radiographs available from the hospital, a Nasium/Frontal X-ray (Figure 31.28) was obtained because of the acute trauma.
Since the infant was too young to use the normal Nasium/Frontal setup seated in a chair, an alternative methodology was employed to position the infant for the X-ray. The film cassette was centered under the tube on the floor (Figure 31.29a), the cassette was covered with a thin receiving blanket (Figure 31.29b), and the infant was placed in a supine position with the mother assisting in stabilizing the child’s head while at the same time distracting their attention for the best patient placement. (Figure 31.29c). Orthospinology analysis of the X-ray suggested a right atlas lever type listing and an adjustment was performed using the Laney instrument. The adjustment produced an immediate release of the uncontrolled spasms and her head posturing improved. A series of five adjustments over a three week time frame resolved the acquired torticolllis condition.
CASE STUDY: ACQUIRED ADOLESCENT TORTICOLLIS
A 15 year old high school student was injured on the soccer field by flipping over another player and landing on his head in a pile driver motion presented with acute acquired torticollis. Examination findings revealed severe right head tilt and opposite rotation attendant with severe articular pain and tenderness of the right C2 thru C5/6 articular pillars. X-rays were taken before the adjustment. A post Nasium/Frontal film was taken after the atlas adjustment. Two days later (Figure 31.30) radiographs revealed a measurable change in head posturing and lower angle of the neck was now straight vertical. Cervical range of motion which was severely restricted prior to the atlas adjustment improved as well. The patient’s neck complaints completely resolved within a 72-hour time frame, with three adjustments.
Figure 31.30 Pre and Post Nasium Views With Atlas Adjustment
CASE STUDY: Cerebral Palsy complicated by motor vehicle trauma in a nine year old:
A nine-year-old female presented post trauma following an automobile accident as a rear seat passenger side occupant. The patient reported being jarred forward and backward at the time of impact. Her past history included a cerebral palsy diagnosis resulting in physical therapy for flexibility and occupational therapy for writing. She had been treated successfully as an infant for ear infections with Chiropractic. Her current complaints included mid-to-low back pain. Range of Motion tests revealed cervical extension and right lateral flexion to be painful and restricted 20 degrees. Dorsolumbar range of motion was noted to be restricted in extension, right lateral flexion and right rotation. Digital palpation revealed marked tenderness of the left articular pillars at C2 and posterior arch of C1 with muscular hypertonicity on the left hand side.
Cervical spine X-rays were exposed utilizing Orthospinolgy protocol and the analysis revealed a left atlas and axis laterality of one degree, requiring a lever type adjustment. The lower cervical angle measured right one-half degree. Atlas rotation measured from the Vertex/Horizontal view was four degrees posterior with respect to the atlas being left.
Adjustments were initiated weekly for 3 weeks then suspended. The schedule then was monthly and then every 3 months. Follow-up examination at the one month mark revealed normal cervical and dorsolumbar range of motion without pain and leg length discrepancy was resolved.
A standing Lumbar spine X-ray examination was performed on this same child at the beginning of care. (Figure 31.31a) The radiograph revealed a fourteen degree dextroscoliosis centered in the lumbar spine which increased from a scoliosis examination. Five months later, a comparative postural survey was performed with the radiologist noting the curvature was reduced to five degrees (Figure 31.31b).
Additional notation by the mother and the child’s teacher is that the child’s stumbling has measurably decreased. In the teacher’s written report, she notes that in past years the child fell several times a week, and now it has diminished to one or two times a month. The mother further reports that her daughter’s demeanor is measurably improved and states that, her daughter is not teased or bullied as she had been in the past at school, for “being clumsy and falling all the time.” She states the physical and occupational therapists are both amazed at her progress over the past five months with respect to her physical challenges and developmental milestones.
CASE STUDY: SEVEN YEAR OLD WITH MIGRAINES
A seven-year-old male presented with a history of migraines occurring four to six times monthly for the past two and one-half years. His birth history was ‘noncontributory’ and he did not participate in organized sports. Family history was positive for his paternal grandfather and uncle for migraines. His trauma history included a fall out of a van requiring stitches of his head. Positive findings of objective testing included a supine leg check revealing a right leg discrepancy of one-half inch with palpable increased right erector spinae (longissimus group) tonus. Digital palpation of the upper cervical spine on the right revealed articular swelling and tenderness at C2. There were also palpable paracervical spasms. Cervical range of motion was moderately restricted in right lateral flexion and right lateral rotation. Cervical spine radiograhs were exposed (lateral, nasium and vertex) and findings revealed a right wedge type upper cervical subluxation. The upper cervical analysis suggested a neutral right to left vector with one degree of anterior rotation. (Figure 31.32a) The patient was checked for subluxation twice weekly and adjusted for four weeks at which time a subjective interim assessment showed a notable ninety percent improvement in his migraine pattern. Objectively the leg length discrepancy, erector spinae spasms and cervical articular pillar joint swelling/tenderness and paracervical spasms were diminished and/or resolved. The patient’s cervical range of motion was now within normal limits. The patient was clearly holding his adjustments for weeks so his frequency was diminished. He reported he was migraine free. He continues to be evaluated every eight weeks with four adjustments noted in the past eighteen months (due to various typical minor childhood traumas). A comparative Nasium/Frontal cervical spine X-ray (Figure 31.32b) revealed a markedly reduced upper cervical subluxation.
CASE STUDY: WELL CHILD CHECK UP WITH MODIFIED UPPER CERVICAL ADJUSTING
A thirty-four month old presented for a well child checkup. In the previous 12 months, she had
numerous evaluations that only once required an atlas adjustment. It should be noted that prior to
that one adjustment she was manifesting multiple colds. Four weeks prior to her most recent well
child visit she had been hospitalized for rotavirus. Since then the toddler had experienced several
bouts of colds and fu. The current examination revealed a physiological left short leg and lumbar
paraspinal evaluation revealed increased tonus of the right erector spinae muscles.
A left atlas challenge brought the left short leg down temporarily and supine C7/T1 palpation revealed a left spinous deviation below the child’s episternal notch suggesting a left atlas wedge pattern. An adjustment was made with the Laney instrument (Figure31.33) with an observable balance of leg length and release of erector spinae hypertonicity (Figure 31.34). Follow-up was a week later then 2 weeks later she was still clear of subluxation. She is currently being evaluated monthly.
CASE STUDY: ELEVEN MONTH OLD
A mother brought her eleven month old daughter in for an evaluation. Her presenting complaint was her child was not meeting developmental milestones. The infant was not crawling, not pushing up on all fours, and was unable to roll over. She was examined and it was noted when lying on her back, she showed very little arm or leg motion. Nor could she hold her head up while on her stomach. The mother reported that she had a normal pregnancy and vaginal delivery. The mother reported her daughter was eating and sleeping well although the mother noted that the child became easily constipated. Her nursing history included three months of breastfeeding and she had since been bottle-fed. The constipation occurred soon after formula was given.
Examination findings included right erector spinae hypertonicity that cleared temporarily with a left atlas challenge. The spinous of C2 palpated right and supine evaluation of the lower cervical spine suggested a left spinous process rotation and overall suggested a wedge type subluxation pattern.
A left wedge type atlas adjustment was performed and the erector spinae spasms hypertonicity decreased. A return visit was scheduled for five days later and again, an adjustment was performed. The patient was then scheduled for a follow-up appointment a week later and the evaluation revealed the following: a normal supine leg evaluation, no hypertonicity of the erector spinae and no tenderness at the cervical articular region. There was no adjustment given at this appointment. The mother said her daughter was now holding her head up and moving around on her stomach in an army crawl maneuver. Two weeks later, the child sat up for the first time and during the next two months, she was checked approximately every two weeks. Five months after starting care she had met all developmental milestones appropriate for her age. She is now checked every three months and her “slow development” has been resolved. The pediatrician involved had originally recommended physical therapy, but the mother said Chiropractic care was so effective, she declined all other therapies.
Case Study: TORTICOLLIS IN A FIVE-WEEK OLD
The next case studies involve congenital torticollis which can occur from birth trauma in the neonate. Typical causes of Torticollis include trauma to the atlanto-occipital or atlanto-axial articulation, or may be due to congenital anomalies of the cervical spine, such as hemivertebra or spinal tumor. Studies suggest that nearly fifty percent of all cases of congenital torticollis involve the cervical spine (8). Figure 31.35 The most common area of subluxation is at the C1 – C2 level with the majority (ninety-two percent) having anterior rotation of C1 on the side opposite the side of the SCM contracture [8]. If the condition is resistant to improvement, cervical spine X-rays should be obtained to more accurately identify the cause of the problem. Usual medical treatment consists of a referral to Physical Therapy for months of ‘stretching and retraining’ the hypertonic Sternocleidomastoid muscle (SCM), and strengthening of the opposite SCM (11).
Case study: Male infant with Torticollis
A five week old male presented with torticollis following a cesarean birth. He was unable to turn his head to the left and was experiencing difficulties with breastfeeding. He also presented with mild respiratory distress and a stuffy nose. A leg length discrepancy was not conclusive. Palpation of the erector spinae muscles revealed right erector spinae hypertonicity of the lower dorsal and upper lumbar regions. A right atlas challenge temporarily released the erector spinae hypertonicity noted and formulated a basis for an atlas listing, atlas laterality right.
The infant was placed with involved side up and the atlas was adjusted with a neutral vector shown in figure 31.36. A neutral vector means there is no y axis rotation of the instrument. Immediately following the atlas correction the infant began turning his head and was able to breastfeed on either side without difficulty. Five follow up visits over a three month period included three adjustments. Prior to seeking Chiropractic care, the parents had been instructed by their pediatrician to force their son’s head as much as possible to the restricted side. They had very little success and felt they caused much discomfort to their son.
CASE STUDY: FOUR-WEEK-OLD WITH TORTICOLLIS
A four-week-old female presented with torticollis following an emergency C-section with breech presentation. The infant’s head was tilted and rotated to the right and she was unable to breastfeed bilaterally. Figure 31.37 Supine examination revealed right erector spinae hypertonicity of the lower dorsal and upper lumbar region. A right atlas challenge temporarily suspended the spasmed right erector spinae and therefore a right atlas lever subluxation pattern was considered. The infant was placed on the uninvolved side (left) and a Laney hand held instrument was utilized for a right Transverse Process contact to bring the atlas left for the correction. This is a straight lateral move.
Immediately, the baby was able to move her head both directions and the mother was able to breastfeed her on either side. Follow-up visits included five checkups over three months requiring only one more adjustment to the atlas. Subsequent evaluations were scheduled every three months.
Case study: Severe head lag, neck hypotonia
A four week old male infant came in with his mother sent to us by a lactation consultant at a local hospital for latch issues. Mother described purpose of the visit was for “neck issues” to be explored, and for resolving a traumatic birth injury. The birth was ten days late and he was posteriorly positioned in-utero, and OB induced mother into labor. She labored for forty hours with little progress and some pushing. There were some decels on the fetal monitor so an emergency cesarean was performed. He was born with a swollen and bruised face. His head size was at the upper (100) percentile. Hydrocephalus was suspected. Neurosurgeons tried to prepare the mother that the head lag was likely due to brain damage. A neck and head CT was performed. Results were negative for brain damage. No infarct in-utero had happened. Pediatricians were unable to explain the head lag. A “wait and see” attitude was adopted by the primary pediatrician however they were very guarded about his development.
Infant presented on exam with unequal coronal sutures, 3-1/2 cm larger on right. While lying supine the infant was arching the entire spine off the table. The left leg was contracted 1 inch, large nodule palpable at C2 on the left and unequal skin folds around neck when viewed A-P supine. There was an unusual amount of extra skin on the anterior neck and the thyroid cartilage appeared much more prominent than that of other infants his age. Atlas posterior arch was prominent on the left. Right head tilt noted. When lifted by arms off the table from a supine position, the head markedly lagged behind. Mother had to use a nipple shield for a very “loose and sloppy suck”. Nail beds were purple and not pink, arms and hands were mottled. Normally in very pale infants mottling of the skin is somewhat normal. There was marked mottling of the skin.
Cervical spine X-rays were exposed including lateral, vertex/horizontal and nasium/frontal views. Atlas plane line was high on the right 12mm, with an atlas rotated 3 degrees anteriorly. Anteriorlisthesis of C5 was noted on the lateral. The adjustment was made with his right side up, stabilized by mother and by another upper cervical colleague who stabilized the head in neutral to avoid head extension during the adjustment. Immediately after the adjustment the infant lifted his head for the first time and the head lag appeared to be gone. Leg length evened. He breast fed well that day. Nail-beds were pink immediately after the adjustment. He was seen two days later and evaluated for an atlas subluxation. His upper cervical spine was ‘holding’. His adjustment stayed in place at visits one week later and two weeks later. His arching diminished. He was then checked monthly for 3 months. At the 3 month visit he was negative for an atlas subluxation and met all developmental milestones. He was seen for further craniosacral therapy to deal with remaining head asymmetry and birth trauma.
Case study: 3 month old with developmental delays
A grandfather brought his grandson (with parental permission) for evaluation of developmental delays. Parents were present but stayed more in the background. Grandfather’s occupation is a speech pathologist. History: Cesarean due to questionable ‘small’ vaginal canal and uterus per OB. It was reported that his shoulder was “stuck” during delivery making a vaginal delivery impossible. This 3 month old was unable to track objects or faces. It was reported that his suck was weak, hearing acuity appeared weak and he had general stiffness of the trunk and arms. His use of his right arm was markedly more limited than left.
Mother had to pump breast milk due to inefficient suck initially after birth. At exam the infant had a right contracted leg 1 and ½ inches, circumoral cyanosis, mottled skin, cold arms and legs, a prominent posterior arch with pea sized nodule by C2 done seated. Para spinal musculature was hypertonic at left upper dorsal longissimus group. Palpation of the TMJ revealed large knotted nodule on right masseter muscle. Figure 31.38 shows innervation of glossopharyngeal nerve to masseter muscle. Note close proximity of C1 vertebrae and its ganglion of nerves. Right atlas challenge temporarily evened short right leg, relaxed masseter muscle and temporarily relaxed paraspinal musculature.
The right occiput was flattened and he had a left sacral rotation. The right arm had diminished movement.
Parental agreement was obtained to adjust infant with portable Atlas Orthogonal Precision Adjusting Instrument. X-rays were not obtained at this time due to lack of parental consent. The patient was placed on his uninvolved side, head neutral, stabilized by mother and grandfather at the head. The right transverse process was contacted with styloid and a compressional wave was released from the trigger. After the infant was placed seated, he immediately displayed tracking objects for his parents, his color improved in his arms and legs and the circumoral cyanosis was about 80% gone. Leg length was equal.
The following week his sacrum was still rotated. He was free of cyanosis and there was no prominence of the posterior arch of atlas. Craniosacral therapy was initiated and was done weekly for 2 weeks. Two months later the Grandparents brought the boy in for evaluation. Parents allowed this visit but felt he would ‘grow out’ of any of the remaining problems. The patient had decreased circulation in extremities, and the neck had tightened. No palpable nodules at C1 or C2, but paraspinals were hypertonic again at the upper left dorsal longissimus group. Leg was ½ inch short. Another atlas correction was made utilizing the same listing as was made initially. The right shoulder was found to be subluxated and another approach was used to correct this. After the adjustment, paraspinal muscles were more symmetrical in tone, hands and feet became pink and the mottled appearance of skin was gone. Leg length evened.
Response was a general relaxation of neck muscles and upper dorsal paraspinals. Craniosacral therapy was done weekly for a month with upper cervical evaluations. Then the schedule lessened to once a month. He has been evaluated and adjusted if needed monthly since that time. In the past six months he has had an upper cervical correction three times with other modalities used on a talus subluxation of the right foot, right ribcage and right humerus.
Most upper cervical pediatric patients are evaluated every 3-4 months once the initial acute stabilization and correction period is over. This schedule usually follows developmental milestones. However, parents are encouraged to bring their children in monthly for better spinal health.
Case study: Severe reflux, eczema in a 5 month old
A male child was brought in by his mother because of a new problem of spitting up. He was delivered by caesarean, mother was told her pelvis is platypelloid. This pelvis type often has labor ending in C-section. (11) At birth he had difficulty breastfeeding but that was no longer the case. Mother stated her son would awaken every two hours from spitting up. During the day the spit up was 3-4 times per hour. Figure 31.39 shows the location and innervation lower in the GI tract of the Vagus Nerve. The vomit was not projectile. On exam he had decreased left head rotation, favored right neck rotation, gluteal fold curved to the left, even gluteal creases. Left atlas challenge supine check evened right short leg. His left eyelid appeared lower than the right. A nodule was present at C1 and C2 on the right with heat palpable, and a left sacral rotation was seen. Eczema was present in all the skin folds and back of neck. This is a usual location of eczema in infancy and childhood. (11) The occiput was visibly larger on the left than the right and suboccipital muscles were hypertonic on the left. Radiographs were obtained. A lateral cervical X-ray showed an anteriorly displaced atlas (anterior of the odontoid line) and posterior arch of atlas was ‘jammed’ up under the occiput. Infants with this presentation on the lateral radiograph often have a history of seizures. This boy did not have seizures. The atlas frontal plane line was high on the right measuring 10 millimeters, with lower cervical spine contralateral. The y axis showed rotation of 1 degree anterior on the right. He was adjusted with the involved side up with the portable atlas orthogonal precision adjusting instrument. Mother and colleague stabilized body and head while the adjustment was made. Right short leg evened. No apparent other change was noted. Mother traveled for two weeks immediately after the adjustment. Two days later the mother reported slight worsening of the spit up and then two days later it stopped altogether. At the next visit there was a report of only rare spit ups and only small amounts. A post lateral view was done as well as Nasium and Vertex views. The atlas was no longer in an aberrant position. The posterior arch had space between it and the occiput. The high atlas on the right was now level and there was still .25 degrees on the y axis. Posteriority of the occiput resolved after the first atlas adjustment. This child had what appeared to be a left posterior inferior illium. Upon closer inspection, the pubic ramus on the anterior of the body was low on the left. A diagnosis of pelvic shearing from the birth was possible. The pubic bone would even out if the atlas was corrected and this appeared to correct the distortion in the illium. Despite using a pediatric modified drop piece on the illium, with a superior to anterior cavitation with the child in a prone position, it would not correct if the neck was unbalanced.
He was evaluated weekly for one month, then monthly for 2 months and required an atlas adjustment each time. Evaluation at every three months and no upper cervical spine subluxation was present. When he started to walk at one year, his left foot was ‘toeing out’ and other chiropractic programs were initiated after the upper cervical spine was evaluated. His eczema was non-existent as long as his upper cervical spine was clear of subluxation.
Case study: 11 year old with learning difficulties
A female patient was brought in by her mother for craniosacral therapy. School work seemed difficult to her and she required extra tutors. She always had a very small appetite reported since birth. She was referred by her birth assistant (doula). Her history involved a traumatic vaginal delivery born at 35 weeks gestation after the mother had suffered some kind of emotional trauma. The baby was only admitted to the NICU for four days. As a 2 year old she had a chronic cough. She wore glasses and was an avid swimmer and played volleyball. On exam she was found to have upper motor neuron testing differences. She had a surprising positive Romberg’s test off balance to the right almost falling over. Because of her learning difficulty she had already seen a neurologist so at this time it was not prudent to refer her to one because of the positive Romberg’s test. It was difficult for her to toe walk on the left side. Her heel to toe walk was very unbalanced and hand slap was markedly uncoordinated on the left. On the finger to nose test, the left hand was far off target. Postural analysis: she had a habit of slumping when seated with a right high shoulder and hip. Palpation of C1 found tender nodule on left and at C2 left nodule. C4 and C5 had tenderness at the articular pillars. Her right leg inequality was a half an inch. Vibration sense was diminished in the left medial malleoli. Cranial nerve VIII testing: Weber and Rinne tests were abnormal. Referral was made for Audiology. Three radiographs were taken of the cervical spine. The lateral showed greatly diminished space between C1 and C2. They did not appear to be fused congenitally. The Frontal X-ray showed atlas high on the right up 4mm, and the lower cervical spine ipsilateral to the upper angle. This is an atypical listing. The Vertex had the greatest degree of subluxation with 6 degrees of rotation posterior on the right. She was adjusted with involved side up on a high head piece with her shoulder pulled posteriorly 1 ½ inches to help move C2 which was 15 degrees to the left of center. Post films were taken 2 days later and on the nasium X-ray all angles had decreased by half. The vertex showed 2 degrees of rotation remaining. She was found to have no tender nodules and legs were even. She was able to heel/toe walk without difficulty. Her toe walk improved and finger to nose was now accurate. Romberg’s test was now negative. She ‘held’ her first adjustment for 2 weeks then required another correction. Mother reported a marked increase in the child’s appetite. She then was seen monthly and ‘held’ for 2 months and required another correction. She was seen monthly for one more year and required 4 more corrections during that time. It was reported that her school work was better and she was able to focus and get her work done without help. She did receive craniosacral therapy concurrent with the first 4 weeks of care. It is this author’s opinion to always provide the service which the patient asks for initially as long as it is not contraindicated with the current program of care.
Case study: Severe reflux and Nipple Aversion in a 11 week old
A mother did research on the internet for information on reflux and found a case study of an infant whose reflux was resolved with Chiropractic adjustments published in a prominent medical journal. Her 11 week old infant had been born by Cesarean due to a breech presentation and had severe reflux at week 6 of life. A milk allergy was suspected. He also had constipation and would not have a bowel movement for 4 days at a time.
Exam findings: appearance of head, very misshapen and large with flattened parietals on one side and opposite side flattened frontal bone. Abdomen distended with gas. Mild temperament. Cries soon after breast feeding and arches spine. He appears to be in pain after breast milk.
He has an aversion to the nipple during painful episodes after eating.
Spinal exam: Webster’s coronal suture measurement 1 and ½ cm difference side to side.
There were findings of C1 and C2 palpable nodules, posterior occiput on left, and a right contracted leg one inch. Right paraspinal muscles longissimus group 3+ hypertonic on a 1-3 scale. A TP challenge of C1 on right evened the right leg.
X-ray findings: High lateral right atlas subluxation, with a plane line of 7mm and a 6 degree y-axis rotation posterior. Treatment: Infant was placed on his left side stabilized by mother and the Atlas Orthogonal hand held precision adjusting instrument delivered the adjustment with the proper rotation to clear the listing. Immediate post Xrays were done which confirmed atlas plane line now was zero, and one degree remained on the y axis film.
Infant was seen the next day and the mother reported a 50% reduction in reflux with more comfortable rest periods between feedings and some nipple aversion still present.
He presented with a ¼ inch short leg and minimal paraspinal hypertonicity. He was not re-adjusted at that time. One week later the right neck musculature was hypertonic compared to left and the leg had shortened by a half inch. Right paraspinal longissimus group was more hypertonic than left. Decision made to re-adjust using original listing from X-rays. Response was a reduction of all the findings and general relaxation observable. Mother reported stools every 2 days instead of four days.
He had 2 more visits one week apart and appeared to be making progress as the reflux episodes were decreasing. Each visit he required an additional atlas adjustment. He was concurrently being worked up by GI specialist because blood was found in his stool.
Premature infant with Colic
A baby born 6 weeks early came to our office for colic symptoms. Mother reported between 4pm and 8pm constant crying which was inconsolable. Pregnancy history was unremarkable for adverse events which could have precipitated a premature delivery.
Infant was 5 weeks old adjusted age. She spent 4 weeks in the NICU. She was given antibiotics during her hospital stay.
Mother reported right head preference asleep and during the day if upright in car seat. Infant had sensitivity to noise and light and would become overwhelmed if stimulated more than 5 minutes at a time. This is a common finding in graduates of an NICU.
Infant had to sleep on her stomach with her head turned to either side or she would not sleep at all.
Exam: Premature head molding with very flattened temporal bones and high parietal bones; resembling a toaster. This is due to positioning in the NICU. Her eyes were somewhat exopthalmic. Abdomen was obviously distended with gas. Frequent expelling of gas noted. Due to gas pressure and a week bowel wall, an umbilical hernia was present. Right paraspinal musculature 3+ hypertonicity was noted. Contracted left leg one inch noted with a subluxated illium posterior and inferior on the left. Left leg lengthened temporarily with straight lateral pressure test (atlas challenge) of C1 TP on left. Visits were 2 x’s per week and a modified upper cervical adjustment was made the first week twice on the left which abated symptoms for 2 days at a time but left the parent frustrated that it wasn’t permanent. Decision was made by the family to have upper cervical X-rays taken of the infant. Xrays revealed a atlas plane line of 2mm on the left with a one degree posterior Y axis rotation of C1 on the Vertex.
Adjustment was made on the Atlas Orthogonal standing table with the patient on her right side, stabilized by the mother. Leg length evened and infant smiled for the first time. She was seen one week later and was “holding” the adjustment. Mother reported only mild fussiness at “her bewitching hour”. She was seen one more week then 3 weeks later had to be adjusted again. This time head preference to the right was corrected. At 12 weeks corrected age, she was completely free of any fussiness and was concentrating on growing. She is being evaluated monthly for upper cervical care.
Atlas Misalignments in the literature
A 1987 paper by Dr. G. Gutmann was published in Manual Medicine in Germany which was also reviewed by the Journal of Australian Chiropractic Association concerning blocked nerve impulses at the C1 level. It was determined by this prominent specialist that many clinical features, from central motor impairment to lower resistance to infections arose from blockages in this area of the spine. He found Chiropractic and radiological exams to be of “decisive importance” for the diagnosis of this problem. He found Chiropractic adjustments to bring about successful results because “the therapy is a causal one.” Dr. Gutmann reports examination and adjustments of more than 1000 infants with atlas (C1) blockage or subluxation. From this he concluded that approximately 80% of all children are not in autonomic balance and that many have atlas blockage or subluxation. His colleague, Dr. Frymann examined a random group of 1250 babies 5 days postpartum and found 95% of the group had cervical strains.
Two conclusions were reached: a. “Observations of motor development and manual control of the occipito-atlanto-axial joint complex should be obligatory after every difficult birth, and b. with any developmental impairment, this joint complex should be examined and if required, specifically adjusted. The success of the adjustment overshadows every other type of treatment.”14
In a literature review identifying approximately fifty-eight articles on chiropractic care of the pediatric patient, upper cervical care was identified as part of the treatment protocol in all cases. The review summarized twenty-five studies documenting the outcome of over 1000 children. Conditions cited which improved during Chiropractic care included infantile colic, glaucoma, irritability, head trauma, hemi-paresis, projectile vomiting, tonsillitis, sinusitis, bronchitis, nocturnal enuresis, allergies, sleep disorders, curvature, fever, otitis media, asthma, attention deficit hyperactivity disorder (ADHD), headaches, torticollis, and seizures.(9)
SUMMARY
Evaluation of the pediatric patient for subluxation should always include an assessment of the upper cervical region. Although pelvic rotations and inequalities of the illium will clear after an upper cervical correction; for those who exclusively practice upper cervical technique, other considerations and treatment protocols should be considered. For example, a child presenting with a hip, leg or foot distortion during gait or upon supine evaluation may reflect past intrauterine constraint, or hip subluxation. After correction of the upper cervical spine, other treatments may be required. Also, for the child with presenting torticollis and plagiocephaly, once the torticollis is resolved, craniosacral treatment can be extremely helpful in the pediatric patient’s recovery.
It is the opinion of the authors that undertaking a serious study of the Upper Cervical region of the spine will be a very promising endeavor for the doctor and lead to more satisfying and rewarding outcomes for his/her pediatric patients.
References
- 1. Eriksen, K., Upper Cervical Subluxation Complex; A Review of the Chiropractic and Medical Literature, Lippincott Williams & Wilkins, 2006
- 2. Eriksen, K, Rochester, R, Orthospinology Procedure; An Evidence-Based Approach to Spinal Care, Lippincott Williams & Wilkins, 2007
- 3. Biedermann, H., Manual Therapy in Children: Proposals for an Etiologic Model, Journal of Manipulative and Physiological Therapeutics, Vol. 28, No. 3, March-April 2005
- 4. Sweat, R.W., Atlas Orthogonal Chiropractic Program, sixth edition, R.W. Sweat Foundation, 2007
- 5. Bouillot, P., Fuentes, S., et. al., Imaging features in combined atlantoaxial and occipitoatlantal rotator subluxation: a rare entity; J Neurosurg (Spine 2) 90:258–260, 1999
- 6. Fysh, P.N., Chiropractic Care for the Pediatric Patient, International Chiropractors Association Council on Chiropractic Pediatrics, 2002
- 7. Hoekelman, R.A., Adam, H, et. al., eds, Primary Pediatric Care, Third Edition, Mosby Year Book, St Louis, MO, 1997
- 8. Fallon, J.M., Fysh, P.N., Chiropractic Care of the Newborn with Congential Torticollis, Journal of Clinical Chiropractic Pediatrics, Volume 2, No. 1, 1997
- 9. Slate, R.K., Posnick, J.C, et.al., Cervical spine subluxation associated with congential muscular torticollis and craniofacial asymmetry, Plastic Reconstructive Surgery, Volume 91, No. 7, 1993
- 10. Prax, J.C., Upper Cervical Chiropractic Care of the Pediatric Patient: A Review of the Literature, Journal of Clinical Chiropractic Pediatrics, Volume 4, No. 1, 1999
- 11. Anrig and Plaugher, Pediatric Chiropractic, first edition, Lippincott Williams & Wilkins, first edition, 1998
- 12. Patronis, Eugene T., School of Physics, Georgia Institute of Technology, R.W. Sweat Foundation, Atlas Orthogonal Chiropractic Basic IV
- 13. Lu ,Jik e& Ebraheim, Spine Volume 23 #6 Anatomic considerations of C1 and C2 Nerve root ganglion, 1991
- 14. Gutmann,G., Manuell Medizin, Blocked Atlantal Nerve Syndrome in Babies and Infants, 1987
Figure 31.1a Horizontal orientation of the condyle-atlas junction from Biedermann (3).
Figure 31.1b In adulthood the angle is much steeper.
Figure 31.2 Cervical Facet Orientation Changes with Development
Figure 31.3 Three Angles of Radiographs Required for Orthogonal Analysis (figures modified for pediatrics from (2))
Figure 31.4 a,b,c,d The four types of misalignments (2)
Figure 31. 5 Lever and Pure Wedge Type Subluxation Patterns
Figure 31. 6 Three Dimensional CT Scan Depicting Double Axial Rotation of C1 and C2 and luxation (4)
Figure 31.7 Approaching the back of the head with 5th digit pad
Figure 31.8 Drawing of the first and second nerve roots that are palpable
Figure 31.9 Lateral lymph nodes of the neck
Figure 31.10 Left (a) Potential stress on spinal cord and nerve tracts induced by upper cervical subluxation via dentate ligaments. Laminar arrangement of spinal tracts is also shown (1)
Right (b) Atlas Subluxation Resulting in a Functional Short Leg (modified for pediatrics from (1))
Figure 31.11 Suppine leg check
Figure 31.12 Toddler Leg Check
Left – Correct Leg Stabilization Right – Incorrect Leg Stabilization Signified by Unequal Skin Folds
Figure 31.13 Suppine palpation of Paraspinal muscle longissimus group
Figure 31.l4 Suppine leg check, paraspinal palpation and Atlas lateral challenge
Figure 31.15 Supine Leg Length Check Before and After an Atlas Adjustment
Figure 31.16 The three X-ray views with doll assist
Figure 31. 17 Pediatric Table Placement
Figure 31.18 Pediatric Head piece placement, external auditory meatus in line with zero
Figure 31.19 A Handheld Laney Instrument (left) and the instrument being used to adjust the atlas of a toddler (right)
Figure 31.20 Atlas Orthogonal Portable Headpiece and hand-held instrument
Figure 31.21 Atlas Orthogonal mounted table
Figure 31.22a Leg Length Assessment Figure 31.22bParaspinal palpation
Figure 31.22c Postural distortion
Figure 31.23 Patient X-ray Positioning for Cervical Spine X-rays
Figure 31.24 Lateral, Vertex and Nasium Radiographs
Figure 31.25a Wedge Type Atlas Adjustment Specific for Patient’s Subluxation
Figure 31.25b Balanced Leg Lengths
Figure 31.26 Lateral X-Ray Views. Left is Pre-Care, Middle is Three Weeks of Care, Right is Following Seven and One-Half Weeks of Care
Figure 31.27 Infant with Head Tilt
Figure 31.28 Corresponding Nasium View
Figure 31.29a Film Cassettes on Floor Under Tube
Figure 31.29b Film Cassette Covered With Receiving Blanket
Figure 31.29c Infant in Position for Nasium X-ray
Figure 31.30 Pre and Post Nasium Views With Atlas Adjustment
Figure 31.31a Pre-Treatment – Fourteen Degree Lumbar Dextroscoliosis (left)
Figure 31.31b Post-Treatment – Five Degree Lumbar Dextroscoliosis (right)
Figure 31.32a,b Pre and Post Atlas Subluxation Alignments
Figure 31.33 Modified Atlas Adjustment Using the Laney Instrument
Figure 31.34 Post-Adjustment Balanced Leg Length Assessment
Figure 31.35 Artists rendition of Sternocleidomastoid muscle involved in Torticollis
Figure 31.36a,b Congenital Torticollis (left) with Infant Unable to Look at His Brother (right)
Figure 31.36c Relived Mother and Son
Figure 31.37 Infant Modified Atlas Adjustment
Figure 31.38 Drawing of glossopharyngeal nerve proximity to C1 nerve roots to masseter muscle
Figure 31.39 Drawing of Vagus nerve innervation for colic case study
Figure 31.40 Bill Ruch’s dissection of C1, C2 nerve roots next to Vagus nerve
Mayer Chiropractic
1400 Court Street
Clearwater, Fl 33756
727-446-6242 (office)
727-785-2218 (home)
727-433-2339 (cell)
727-446-5250 (fax)
Sheehan Chiropractic
915 Irving street
San Francisco, Ca. 94122
415-681-1031 (office)
415-681-3503 (fax)