The truth behind chiropractors for children

In October 2013, a sensational headline surfaced from the Australian press: “Chiropractor Breaks Baby’s Neck!”  It turns out, a pediatric chiropractor fractured a child’s vertebrae while trying to treat torticollis. About a year before that, a baby with torticollis actually came to me after receiving brief treatment from a chiropractor.  The chiropractor had recommended physical therapy treatment to the family after a few chiropractic adjustments, because she realized it was outside her scope of practice. I was surprised a parent sought the help of a chiropractor to begin with. I was thankful that the chiropractic referred out when she did. When I followed up with her to see what adjustments she performed on the child, she declined to comment. At the time, I did not think chiropractic care was evidence-based to support treating children.  A year later, after much inquiry into the world of chiropractic care, I still do not recommend spinal manipulations for children.

Child with chiropractorAsk any physical therapist what the diagnostic and treatment process entails for the children they see, and you will soon learn that physical therapists are considered musculoskeletal experts. We are movement specialists. If a child comes to see us for recovery after injury, a congenital condition, or any array of health problems that limit their mobility, our focus will primary be on helping them regain their function. Much like chiropractors, we focus on alignment and imbalance. But that’s where our similarities end. Unlike chiropractors, physical therapists focus on the muscles, the movements across joint structures, the movements of the body as a whole, and the neuromuscular connection. In the case of babies and toddlers, we analyze their premature or developmentally lagging movement patterns and help them reach their milestones. How do we do that? By teaching them the best way to move given their condition, using exercises to allow for strength and fluidity behinds their movements, to encourage proper alignment and growth in the years ahead. If we have to put our hands on their growing joints and muscles, it is to facilitate, to cue, to help position them by gentle stretching and gentle stimulation of their young musculoskeletal and neurological system.

In recent years, a new crop of chiropractors are on the rise. Pediatric chiropractors. Ask any chiropractor what chiropractic care means for children, and you will hear terms like “subluxation,” “spinal adjustment,” and “joint manipulation.”  Instead of teaching patients and families the physiology behind their symptoms and limitations. Chiropractors allow patients to be passive receivers of care. Adults with back pain often seek chiropractic treatments for a “quick fix.” A few readjustment and a few “maintenance” episodes later, symptoms are supposedly diminished. If you ever watch a chiropractor in practice, treatment is full of quick high-velocity thrusts to the spine. Pediatric chiropractors believe that this type of manipulation is necessary to help alleviate a slew of childhood health complaints linked to cranial-sacral misalignment, including but not limited to: ear infections, colic, sleep issues, allergic reactions, chronic infections, and even serious conditions such as cerebral palsy. The truth is, there has been no evidence to support the benefits of chiropractic manipulations beyond treatment for acute, uncomplicated, low back strain in adults. In fact, there have been numerous studies linked to manipulation-related injuries in children. Complications can be as serious and fatal as brain hemorrhages or paraplegia. Because chiropractic readjustment often mask pain and symptoms, harm can also be created by delayed diagnosis of serious conditions such as cancer or meningitis.

The battle between physical therapists and chiropractors is a well-established one. However, much of the evidence against chiropractic treatment of children comes from not just physical therapists, but orthopedists, pediatricians, radiologists, and even chiropractors themselves. The spine of a small child or newborn baby should never be manipulated using chiropractic techniques. Chiropractic manipulations are considered invasive and hardly justified by science or literature. The idea that chiropractic treatments can correct spinal trauma attained at birth or during regular play activities is based on the “subluxation” theory. Which is just that, a theory. In the case of torticollis, more than 97% of the cases can be treated by conservative, non-invasive means involving exercises and stretching. In the case of ear infections, colic, and other bothersome childhood ailments, many of them are self-limiting conditions. Evidence shows that chiropractic corrections in these cases are due to nothing more than a placebo effect.

So the next time a chiropractor advises you to attend “routine alignment checks” for you or your child, just say, “no thanks.” Chiropractor education is limited to 1 year or so beyond college. To become a “pediatric chiropractor,” practitioners are not even required to have hands-on pediatric clinical experience.  Compare that to a doctor of physical therapy degree, which requires 3 years of clinical and institutional training after college. It is a no-brainer whose expertise to seek in times of pain or injury. Pediatric physical therapists also have residencies, fellowships, and a national exam to participate in to become a certified specialist.  There is a reason physical therapists make up a huge portion of medical professionals in any healthcare setting, and chiropractors can only be found in private clinics that are rarely covered by insurance.  If childhood asthma, ear infections, cerebral palsy, torticollis, and developmental delay could be treated by a simple readjustment of the spine, chiropractors would be the first people pediatricians refer to, and they are not.

Also visit:

Essential Competencies of a Pediatric Physical Therapist

Do you have experience with chiropractors that you would like to share? Please leave a comment.

References:

Novella, S.  Chiropractor Breaks Baby’s Neck- A Risk vs. Benefit Analysis.  Science-Based Medicine.  Available online athttp://www.sciencebasedmedicine.org/chiropractor-breaks-babys-neck-a-risk-vs-benefit-analysis/ (Accessed June 23, 2014)

Ohm, J. Why Should Children Have Chiropractic Care? Pathways to Family Wellness. Issue 5. Available online athttp://www.icpa4kids.org/ (Accessed June 23, 2014)

Homola, S. Should Chiropractors Treat Children? Skeptical Inquirer. Volume 34.5, September/October 2010. Available online at http://www.csicop.org/si/show/should_chiropractors_treat_children/ (Accessed June 23, 2014)

Homola, S.  Pediatric Chiropractic Care: Scientifically Indefensible? Science-Based Medicine. Available online athttp://www.sciencebasedmedicine.org/pediatric-chiropractic-care-scientifically-indefensible/ (Accessed June 24, 2014)

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Acupuncture for Children – A Physical Therapy Perspective

I recently recommended acupuncture treatment to a client with an especially challenging case of idiopathic toe-walking. Instead of giving me the raised eyebrows I usually see when recommending alternative medicine to children, her mother eagerly set up an appointment with a well-researched practitioner of her choice. Within a month, the weekly acupuncture sessions in combination with weekly physical therapy sessions paid off. My little client, after years of walking on the balls of her feet 100% of the time, was now only toe-walking 5% of the time.

I know what you are thinking. Sticking multiple needles in children? How could I even suggest such a thing?

The practice of acupuncture has been around for thousands of years. Not only has it been greatly accepted in China and eastern cultures, it has also been gaining ground in the United States. In 2011, more than a third of pain clinics across the country utilized some sort of acupuncture as therapy for various ailments. Though acupuncture has been found to be effective in treating adults, research on its efficacy in children is still in the beginning stages. Boston Children’s Hospital, one of the leading institutions for pediatric care, has an entire service designated to acupuncture. Treatment is performed by a physician trained in both western medicine and eastern medicine, making the approach highly integrative and highly effective.

The term “acupuncture” might register thoughts of needles piercing the skin, but it actually describes a family of treatment options that stimulate anatomical points along the body. Licensed acupuncturists are actually trained in multiple components of traditional eastern medicine. They, much like pediatric physical therapists, are taught to treat the child holistically, taking into account family and medical history, developmental factors, and severity of condition. In my client’s case, she was treated with a technique called “cupping,” which worked to stimulate muscle relaxation and improve circulation to areas restricting her motion. Whether through needles, cups, heat, or through other techniques, the basis of acupuncture is to encourage blood flow and promote healing.

Acupuncture has been successful in treating chronic pain and certain systemic conditions without significant side effects. The majority of pediatric patients are seen for everything from headaches and dental pain to back pain, from constipation to gastritis, from side effects of chemotherapy, to cystic fibrosis. Recent research has even supported the treatment of ADHD, lazy eye, and nausea in children. A specialized acupuncturist in pediatric alternative medicine often uses a variety of techniques to treat the child as a whole. The needles used in acupuncture therapy are small, sterilized, nontoxic, and tightly regulated by the US Food and Drug Administration (FDA). They are nearly painless and have very little complications.

Both the World Health Organization (WHO) and the National Institutes of Health (NIH) have recognized acupuncture as effective in treating a wide variety of health conditions. Acupuncturist training is at the Master’s degree level, which is the entry-level degree for the profession. With growing research on the effectiveness of and the mechanism behind acupuncture, insurance companies often cover the treatment when it is associated with specific medical conditions. More often than not, acupuncture is used in conjunction with more traditional therapies. I have seen its benefits in numerous individuals with some challenging chronic conditions.

Health care providers, such as physical therapists and primary physicians, serve as resources to help parents determine if alternative treatments are right for their child. Talk to your pediatrician if you have concerns that haven’t been remedied by traditional methods alone. Find a qualified and licensed practitioner who meets the education and training standards set by the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM). Keep an open mind when you bring your child to see an acupuncturist who specializes in pediatric care. Remember, a child’s progress depends on a multitude of factors, and his well-being relies heavily on his health providers staying on the same page about his plan of care.

Do you have questions or experiences with alternative therapies? Please let me know.

References:

  1. Acupuncture, an introduction. National Institute of Health. National Center for Complementary and Alternative Medicine. U.S Department of Health Services Website. Accessed at http://nccam.nih.gov/sites/nccam.nih.gov/files/Backgrounder_Acupuncture_02-20-2013.pdf on June 12, 2014.
  2. Pediatric Acupuncture. Psychology Today website. Accessed at http://www.psychologytoday.com/blog/real-healing/201107/pediatric-acupuncture on June 12, 2014
  3. Acupuncture. Boston Children’s Hospital website. Accessed at http://www.childrenshospital.org/health-topics/procedures/acupuncture on June 15, 2014
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To helmet or not to helmet, that is the question.

In a recent study published by the British Medical Journal and the New York Times, helmets used to correct flat heads on babies were deemed ineffective. See below for my response to that study.  Because physical therapists like me have zero association with helmet companies, doctors’ offices, or orthotists, our recommendations are purely based on the child and family’s needs. There are some proven long term implications and neurodevelopmental delays in children with untreated plagiocephaly. I am here to help parents make informed decisions instead of knee-jerk reactions based on one misleading study. In my clinical experience, I’ve never had a parent regret the decision they made, whether it was to seek out a helmet evaluation or to forgo helmet therapy.

via Babies, Misshapen Heads, and Plagiocephaly Helmets: a Physical Therapist Perspective.

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Gait Development In Children

Walking is an important part of growth and locomotion. It is a complex task that requires musculoskeletal and neurological system maturation and cohesion. Read here on how early gait develops in children.

via Gait Development In Children.

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The Different Types and Presentations of Cerebral Palsy

In last month’s blog about cerebral palsy (CP), I talked about the neurological condition and what can be improved by working with a physical therapist. This week, I am going to delve deeper into the condition and explain why some kids with CP are so different from one another.

Cerebral palsy has many classification systems. Medical professionals use these systems to understand and manage a child’s symptoms and help plan their treatment.

As stated previously, cerebral palsy describes a brain lesion that occurred in utero or around the time of birth.   Much like a brain injury, CP can be classified based on severity level, location of lesion, body part affected, change in motor control, and how gross motor function is affected.

body map

Classification of CP Based on Level of Severity:

This is a common method of categorizing children with CP, used by doctors and parents alike, though it provides relatively little information. Parents and doctors use this classification system as a simplified communication tool to describe the exact level of impairment.

  • Mild: Having mild CP means a child can move independently and without assistance from people or equipment. He can complete his daily activities without any limitations.
  • Moderate: A child with moderate cerebral palsy will need braces, medical interventions, and adaptive equipment to do functional things, such as walking and keeping up with peers.
  • Severe: A child who will require a wheelchair and who will need quite a bit of assistance to accomplish daily activities is said to have severe CP. Often times, severe cases have multiple equipment needs, and simple things such as eating or sitting alone can be a challenge.
  • No CP:  Some children display cerebral palsy signs though the brain injury occurred after the time of birth, and therefore is classified under traumatic brain injury or encephalopathy.

Classification Based on Topographical Distribution (Body Part Affected):

When trying to plan treatment protocol for a child newly diagnosed with CP, many therapist and pediatricians like to know which body parts are affected and how they are affected. Is one limb weakened (paresis) or paralyzed (plegia)? How many limbs are affected that way?

  • Monoplegia/monoparesis – Only one limb is affected.
  • Diplegia/diparesis – When the legs and the lower body are more affected than the arms
  • Hemiplegia/hemiparesis – The arm and leg on one side of the body are affected.
  • Paraplegia/paraparesis – Only the legs are affected.
  • Triplegia/triparesis – When 3 limbs are affected, or 2 limbs and the face
  • Double hemiplegia/double hemiparesis – All four limbs are affected, but one side of the body is more affected than the other.
  • Tetraplegia/tetraparesis – All 4 limbs are affected, but three limbs are more affected than the fourth.
  • Quadriplegia/quadriparesis – All four limbs are impacted.
  • Pentaplegia/pentaparesis – All four limbs involved, as well as the neck and head.

Classification Based on Motor Control:

What is motor control? It is the body’s ability to voluntarily control limb and joint motion.  Muscles are controlled by the nervous system and abnormal contractions (too much or too little) often occur with brain lesions. Cerebral palsy is often a complex condition. It is possible to have variable muscle tone or a mixture of motor control presentations.

Spastic CP – indicates increased muscle tone, the most common type of cerebral palsy.
Non-Spastic Cerebral Palsy – characterized by low muscle tone or fluctuating muscle tone, or involuntary movements.

When muscle tone is affected, the movements and power needed to move the joints are often affected as well.

Hypertonia/hypertonic – describes increased muscle tone and is often associated with spastic cerebral palsy.  The child may present with stiff limbs, muscles that seem tight, or decreased ability to open his hands or straighten a limb.
Hypotonia/Hypotonic – often used to describe low muscle tone, and can be seen in diagnoses outside of CP. A child’s limbs or trunk may seem hard to control and “floppy.”

Some children’s cerebral palsy can actually be mixed in presentation, where some limbs are affected by spasticity and others are non-spastic.

Classification Based on the Gross Motor Function Classification System (GMFCS):

The last system of categorizing CP is a five-level system that describes the severity of impairment and limitations a child experiences with the condition.  Higher numbers mean a child is able to achieve less activities on his own.

GMFCS Level I – the individual walks without limitations
GMFCS Level II – walks with some limitations, including long distances, running, jumping, and balancing.  They may need devices when first learning to walk, up to age 4, and may need wheeled mobility when travelling long community distances.
GMFCS Level III – walks with an adaptive device.  Assistance is needed to walk indoors and wheeled mobility needed outdoors.  The individual can sit independently or with some external support.
GMFCS Level IV – the child is independent with powered mobility (motorized wheelchair) though need support when sitting. He may be unable to push himself in manual wheelchair.
GMFCS Level V – the individual shows significantly limited head and trunk control. Much of his mobility will need assistive technology or physical assistance.

A more expansive copy of the GMFCS system can be viewed here.

Why so many classification systems?

Most cerebral palsy specialists, health professionals, and parents will need guidance and direction when approaching a child with cerebral palsy. Knowing whether or not a child has low or high tone will determine equipment needs. Knowing the severity level will help physicians plan out need for future treatments and care options.  Understanding whether a child has spastic or non-spastic CP will help tell neurologists and neurosurgeons which part of the nervous system is affected. Having a better grasp on the type and location of lesion will help the medical team prepare for long term associated conditions of cerebral palsy, such as hip dislocation, scoliosis, joint contractures, or seizures.   It is important for therapists to know whether a child with CP has difficulties with muscle tone, muscle control, hand-eye coordination, balance, stiffness, or muscle strength.

The Gross Motor Function Classification System (GMFCS) is used by researchers and clinicians alike and is applicable to all types of cerebral palsy. While other classification systems describe what a child is limited by, the GMFCS places more emphasis on what a child can accomplish. Therefore, parents can use this system to understand how their children will progress over time.

Classification is very important in the treatment of the young child with cerebral palsy, and multiple classification systems help therapists and specialists create individualized plan of care for those children and families impacted by the condition.

Reference:
Types and Forms of Cerebral Palsy. MyChildTM at The Cerebral Palsy Organization website. Available from: http://cerebralpalsy.org/about-cerebral-palsy/types/; 2014 [accessed 18 March 2014]

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An Uplifting Syndrome

In light of World Down Syndrome Day, which was 9 days ago, I was preparing to write a work blog about the physical limitations of children with Down Syndrome and what we can do as therapists to help them lead better lives.

Then I stumbled upon this video. Created by an Italian advocacy group.

It gave me goosebumps. Because of the truth spoken by these wonderful children. Because the smiles on their mothers’ faces. It puts things in perspective; not just for families with children with Down Syndrome, but for families with children of all abilities.

“Sometimes, it will be difficult. Very difficult. Almost impossible. But isn’t it like that for all mothers?”

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WORLD HEALTH ORGANIZATION DEVELOPMENT STUDY RESULTS: GROSS MOTOR MILESTONES IN THE FIRST YEAR

The line between typical and atypical development can be a hazy one. There are standards that pediatricians, physical therapists, and developmental experts use to monitor growth and deviations from the norm, which allow us to recommend interventions when appropriate.  In 2006, the World Health Organization (WHO) released a whole new set of standards for evaluating and assessing the development of children from birth to 5 years.

 

Gross Motor Skills

What makes this new standard a great tool to monitor the change and growth of infants? This standard is based on data collected from healthy children, over multiple years, in six diverse geographic regions including Southeast and Southwest Asia, Europe, West Africa, North and South America. What is exciting about the new evaluation tool is that now, pediatric specialists have more than just reference curves for physical growth, but curves for motor development as well.

THE SIX GROSS MOTOR MILESTONES WHO EXAMINED IN BABIES WERE THE FOLLOWING:

1.    Sitting without support
2.    Standing with assistance
3.    Hands-and-knees crawling
4.    Walking with assistance
5.    Standing alone
6.    Walking alone

The “windows of milestone achievement” were organized into percentile rankings which pediatricians and physical therapists can use, much like a growth chart.

Without Delving Too Deep Into Statistics And Calculations, The Typical Age Range (In Months) For Each Milestone Is Listed Below:

1.    Sitting without support: 3.8 – 9.2 months
2.    Standing with assistance: 4.8 – 11.4 months
3.    Hands-and-knees crawling: 5.2 – 13.5 months
4.    Walking with assistance: 5.9 – 13.7 months
5.    Standing alone: 6.9 – 16.9 months
6.    Walking alone: 8.2 – 17.6 months

The Average (Mean) Age For Healthy Children Achieving Each Milestones Is As Follows:

1.    Sitting without support: 6 months (with 1.1 month standard deviation, SD)
2.    Standing with assistance: 7.6 months (with 1.4 month SD)
3.    Hands-and-knees crawling: 8.5 months (with 1.7 month SD)
4.    Walking with assistance: 9.2 months (with 1.5 month SD)
5.    Standing alone: 11 months (with 1.9 month SD)
6.    Walking alone: 12.1 months (with 1.8 month standard deviation)

(Click here to view this information in chart form from WHO.)

What is most interesting is that about 90% of the children studied met their milestones in a common sequence, and only 4% of the children skipped hands-and-knees crawling.  (Read here about the importance of crawling.)

As you read over these standards and timelines, remember that every baby develops differently from another. If you see your baby fall behind on any of the 6 gross motor milestones above, mention it to his pediatrician, and she will most likely recommend a physical therapist to help him along.

Reference:
WHO Multicentre Growth Reference Study Group.  WHO Motor Development Study: Windows of achievement for six gross motor development milestones. Acta Paediatrica, 2006; Suppl 450: 86-95.

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