Foundations of Pediatric Chiropractic Care

Why Do Children Need Chiropractic Care?

Think about how delicate a baby is, and then imagine the stress the birth process places on a tiny spine. The damage birth does to the spine is one of the most overlooked health problems in our society, for two simple reasons: there are no obvious symptoms and no visible trauma.

A child's health and the health of their spine are intimately related. Even a so-called ‘normal’ birth places tremendous stress on the spine and is a primary cause of vertebral subluxation. As the child grows, that subluxation progressively interferes with proper body function, limiting their ability to express optimum health — and left uncorrected, it will have a lasting effect on their life.

A Few Points Worth Considering

• Our children deserve the best chance to express health and reach their peak potential.
• A child's nervous system drives their development, so for that development to go well, the nervous system must be working at its best — which means subluxation-free.
• Children are designed to be healthy and vital throughout life; subluxation limits that expression.
• We must understand the difference between the medical paradigm and the chiropractic paradigm: salutogenesis versus pathogenesis.
• If we view chiropractic only as treatment for a musculoskeletal condition, why would we care for children at all?
• Do we truly understand the devastating effects of vertebral subluxation on children?

“As the twig is bent, so grows the tree.”

Before a child bears weight, the spine is most adaptable to correction. Adaptation does happen before weight-bearing begins, but once it does, the bones, muscles, and ligaments respond to the stress of upright posture — and adaptation to subluxation, rather than healthy spinal development, is the result.

Why Should We Care for Children?

• Correct subluxations early. Early correction means better prevention.
• Focus on children for a better future. Less dis-ease, less imbalance, less criminality.
• Emphasizing children also relates to the inner child of the adult.

The First Subluxation

Vertebral subluxation in adults is generally attributed to three causes: physical, emotional, and chemical stress. But at what age does a person first become susceptible?

Research supports the chiropractic position that spinal stress from micro- and macro-trauma occurs in-utero and because of the birth process itself. Even “normal” delivery procedures are now suspect — reflected in the growing popularity of midwives, doulas, and birthing centers.

Causes of Subluxation

• The normal birth process, or birth trauma from unnecessary intervention
• Everyday activities (changing diapers, tossing a baby in the air)
• Contact sports
• Emotional, postural, and chemical stress
• Heavy backpacks
• Motor vehicle accidents
• Non-accidental injury — shaken baby syndrome, burns, dislocations (chiropractors are responsible for reporting suspected abuse)

Subluxation can arise in countless ways throughout life, but birth-related subluxation is, in this author's opinion, the most devastating of all for two reasons: it is the most overlooked, and there is rarely any visible evidence of a problem to the parent or doctor.

Birth, In-Utero Positioning, and Subluxation Risk

At approximately 37–38 weeks of gestation, the fetus turns and engages in the birth canal. As labor begins, the fetal spine settles into a C-shaped (kyphotic) curve — the primary spinal curve that offers the fetal spine the most protection as it descends the birth canal, and that allows for crowning as the head presents through the cervix.

In-Utero Constraint

Constraint places excessive force on the fetal spine and can lead to subluxation before birth even occurs. Suspect fetal positions include:

• Breech and transverse lie (third trimester and labor) both create excessive hyper-flexion or unnatural hyper-extension forces on the cervical and fetal spine, due to uterine contraction. Either can cause permanent spinal damage and often leads to surgical intervention.
• Facial and brow presentation (labor and delivery) places excessive, unnatural hyper-extension on the cervical spine. This hyperextended position is a common cause of an AS occiput subluxation.

Birth Trauma

Since everyone is born, everyone has experienced some form of birth trauma.

Birth trauma is the micro- and macro-trauma caused by the birth process itself and by the interventions used to assist it. The spine — especially the cervical spine — is the chiropractor's primary concern, since obstetrical procedures (whether by hand, forceps, or vacuum extraction) place excessive, unnatural force on the fetal/infant spine.

• By hand: when the head is delivered facing posterior, the doctor often assists rotation of the shoulders by turning the child's head and neck, sometimes adding lateral flexion. This has its greatest effect on the upper cervical spine.
• Forceps cause excessive rotational force; vacuum extraction causes excessive traction force.
• Cesarean birth is often assumed to be gentler, but similar extraction forces are involved — making a typical cesarean just as traumatic to the child's spine as a vaginal delivery, whether performed as an emergency or an elective procedure.

A prolonged labor position is a detriment to both mother and baby. The bottom line: even a normal, natural, unassisted birth places extraordinary biomechanical stress on the fetal spine and is itself a cause of subluxation. Subluxation can result from as little as 10–30 lbs. of pull — well within the range of a routine ‘natural’ hospital birth. Every child, born by any method, should be checked for subluxation at birth to support proper spinal development and neurological expression.

Building Trust With Young Patients

Dealing with Fear

• Maternal instinct begins with conception, bringing fear of injuring the fetus. Lying prone is preferable to supine for the fetus, and drop tables can be frightening for a first-time pregnant patient.
• Ignorance about childbirth creates fear. Be ready to educate and support your patients through the birthing process.
• Parents often fear chiropractic care for a newborn, assuming adjusting techniques are the same for children as adults. Many simply don't understand why a newborn would need care at all.
• Your attitude is paramount to the care of a newborn. If you accept the honor that comes with a parent's trust, make sure you show them how you feel it.

How Fear Gets Created in Children

TouchPoint Muscle Palpation™

TouchPoint Muscle Palpation: The Confidence of Knowing

TouchPoint muscle palpation is a tonal approach to subluxation analysis, evaluating paravertebral muscle response to proprioceptive input.

Physiology Behind Working Muscles

TouchPoint muscle palpation is an applied muscle palpation technique, and a tonal approach to the analysis of vertebral subluxation offering a unique insight regarding vertebral position and thus proper line of correction. The style of muscle palpation, as presented in this class, was first used by Reggie Gold, DC. TouchPoint muscle palpation is based upon analysis of the tone of specific para-spinal muscles in response to proprioceptive input from the central nervous system.

TouchPoint muscle palpation is the art of evaluating paravertebral muscle reflex response to a loss of proper vertebral joint alignment and subsequent joint restriction. The para-spinal muscles of the spine attach directly to the vertebral processes and are stretch sensitive due to their inherent muscle spindles. The stretch reflex causes contraction of the stretched muscle, thus attempting to restore proper joint alignment.

This is a very local response — under the control of the CNS — and differs from a spastic or injured muscle, which presents as a more general response (e.g., due to injury, muscle spasm, splinting, or repetitive use). Correct joint position is maintained by muscles, tendons, ligaments, and joint capsules through the neurological phenomenon of proprioception. When vertebral subluxation occurs, proprioceptive receptors send sensory information to the brain, which then determines proper joint positioning and creates the appropriate muscular response to maintain proper joint position.

We will casually call these ‘tight’ muscles. The body innately attempts to correct vertebral subluxation by increasing the tone of specific para-spinal muscles. The vertebral muscles are said to be in an active tonal state rather than a resting tonal state. These muscles are referred to as ‘working’ — meaning working to restore and maintain proper joint alignment.

Proprioception: Our Silent Sixth Sense

Muscle palpation is a tonal approach to subluxation analysis, evaluating paravertebral muscle response to proprioceptive input. Also known as joint position sense, it is the ability to sense stimuli arising within the body regarding position, motion, and equilibrium.

The brain is ‘aware’ of the biomechanical dysfunction of vertebral subluxation, including:

• Inappropriate muscle length
• Compressive loads on joint surfaces
• Distortion of intervertebral discs
• Joint capsule stretch and deformity
• Vertebral displacement
• Aberrant motion

Proprioception-based control prevents excessive joint loads and excessive vertebral displacement. This is a natural, primordial function within the spine and is accomplished through increased tone of specific paravertebral muscles. The subtle increase in muscle tone is recognized as a ‘corrective response’ by the CNS to subluxation.

Initially, it was thought the muscular system acts to protect spinal joints by preventing extreme joint loads and intervertebral displacement, and that the response is a simple reflex. According to Moroney et al., proprioception-based control occurs with low muscle forces and at low joint loads. In fact, even while joint compressive forces remain below threshold, paraspinal muscles were activated — low joint loads consistent with vertebral subluxation, hence the subtle increased muscle tone is in response to vertebral subluxation.

Vertebral Subluxation Causes

• Inappropriate muscle length
• Compressive load forces on joint surfaces
• Distortion of intervertebral disc
• Vertebral displacement and distress
• Joint capsule derangement and deformity
• Biomechanical dysfunction
• Neurological insult

Mechanoreceptors

Mechanoreceptors are proprioceptive receptors found in muscle spindles, facet capsules, intervertebral discs, articular surfaces, tendons, and ligaments throughout the spine, constantly sending information to the brain regarding joint position and muscle tone.

Mechanoreceptors within the muscle spindles send information to the brain regarding proper joint position. Thus, proper vertebral alignment is maintained intelligently via proprioception through these mechanoreceptors within the para-spinal muscles, associated ligaments/tendons, and joint capsules. Vertebral subluxation causes a loss of proper alignment, thereby stretching muscles attached to the vertebral processes.

There are four types of mechanoreceptors found in the spine which provide afferent input from the muscle spindle and Golgi tendon:

• Pacinian corpuscles
• Meissner corpuscles
• Merkel cells (discs)
• Ruffini nerve endings

Robert McLain, MD, Department of Orthopedic Surgery, Cleveland Clinic, found mechanoreceptors throughout the spine — most numerous in the upper cervical region, suggesting proprioceptive control in this region is more refined than in any other.

McLain also found mechanoreceptors in spinal facet joints, stating: “The presence of mechanoreceptors in facet capsules proves that even these tissues are monitored by the CNS,” which implies neural input from these facets is important to proprioception.

Our innate response to subluxation includes a proprioceptive response to compressive loads due to displaced segments, and a mechanoreceptor response to capsular derangement, disc distortion, and aberrant muscle stretch as evidenced through EMG. This is not simply a reflex — it is an intelligent response to neurological insult. Essentially, the CNS responds to vertebral subluxation.

Is It Possible to Have Subluxations and Working Muscles Without Pain?

Guyton's Textbook of Medicine notes that it is well known that localized, palpable muscle bands are found in individuals who have no subjective pain complaints. Nociceptors have much higher thresholds than mechanoreceptors, which explains why a subluxation triggering a muscle response occurs without pain.

This is a pure innate response — literally a window into the innate workings of the body. It is a subtle sensation, and practice is essential to refine these tactile skills.

The Procedure

• The child should be as relaxed as possible.
• Palpate gently across the muscle fibers.
• Note the tone of the muscle, comparing it to the opposite side.

In Summary

Muscle Response to Misalignment

• The intrinsic muscles of the spine attach to the vertebral processes and are stretch sensitive due to muscle spindle fibers.
• The mechanism which causes the muscle to respond is called the stretch reflex.
• The muscles are attempting to restore proper juxtaposition to the joint.

Working Muscles

• A working muscle is more “active” and maintains a subtle increase in tone.
• They are found by comparing them to the tone of the same muscle on the opposite side.
• When found, a subtle asymmetry in tone and tension will be noted.

Muscle Response to Subluxation

• Sensory receptors in joint capsules send joint-position information to the brain, enabling one or more para-spinal muscles to respond by increasing tone.
• The body thereby attempts to correct the subluxation by the action of specific vertebral muscles, where the tone of these muscles will be increased above the “normal” tone of the surrounding musculature.
• Correction of a misalignment may occur, either by natural forces of movement during daily activity, or as the result of a force introduced by a chiropractor.
• While muscles, tendons, ligaments, joint capsules, and the vertebra's bony structure dictate position due to anatomical construction, it is the innate wisdom of the body through muscle action that ultimately determines vertebral position.

Over Time

• Imbalance of muscle length contributes to chronic fixation and permanency of subluxation.
• Chronic misalignment and associated hypomobility lead to damaged muscles and connective tissues.
• Decreased mechanoreceptor stimulation and dulled nociception diminish proper neuromuscular responses.
• Permanent structural adaptation occurs — a good reason to begin chiropractic care early in life.

Muscle Palpation Procedure

• Palpate gently and across the belly of each muscle.
• Make a note of the tone of each muscle, comparing it to its counterpart on the opposite side, and decide which one has greater tone.

Isolation Tests

• Isolation tests are used to learn where the muscle is and how it might feel when it is working or tight.
• Isolation tests are NEVER used during an exam of an actual patient.

The Cervical Muscles

Cervical TouchPoint Muscle Scan

The Thoracic–Lumbar–Sacral–Pelvis Muscles

Thoracic–Lumbar–Pelvic TouchPoint Scan

Visual Assessment & Motion Palpation

Visual Assessment

Visual assessment is performed when the child is too young for a standing postural analysis, and looks for positional/postural imbalances as evidence of vertebral subluxation. Because many children cannot adapt to your needs in chiropractic analysis, visualization may become one of your primary analysis tools. Visual assessment focuses primarily on the non-ambulatory infant, approx. 0–12 months, and is observed with the patient supine. The visual/postural position of the infant most closely reflects the position of the spine, since postural muscles are not yet fully developed.

Prone Visual Observations of the Infant

Posture can be analyzed prone on an infant below 3 months of age. Place the infant prone without a face piece. The child will automatically turn their face right or left.

• If the face is turned to the left, the thoracic spine should curve to the right.
• If the face is turned to the right, the thoracic spine should curve to the left.
• The arms and legs should be flexed symmetrically.
• The legs and knees should be flexed symmetrically.
• When you turn their head, the thoracic spine should adapt accordingly.

Dynamic Visual Assessment

Children and infants are constantly on the move; therefore, much of our analysis and technique must adapt. Dynamic visual assessment is observed while the child is moving. Each time they stop, look for a consistent pattern of posture or body position — not unlike observing gait analysis.

As noted above, posture can also be analyzed prone on an infant below 3 months of age: place the infant prone without a face piece. The child will automatically turn their face right or left, and the thoracic spine will curve to the contralateral side, extending at times to the sacrum.

The Pediatric Leg Check

Leg checks are not subluxation-specific and are used for pattern. Keep in mind that legs often grow asymmetrically, so interpretation is very different than with adults. Infant leg checks look for a change pre- and post-adjustment.

Supine Leg Checks

• If needed, have the parent hold an object above the child's head.
• Hold the child's feet with your thumbs on the medial malleoli, and gently bicycle the child's legs until you feel relaxation, then pull down to complete the check.
• Place the thumbs above the knees to keep the legs in extension.
• With newborns, their legs will be flexed at the hips and knees. Gently pull their legs down to an extended position and let go. Then pull down and perform the leg check as noted above.

Prone Leg Checks

Infant leg checks can be performed prone as well — gently pull the legs to an extended position and perform the leg check as noted above.

Motion Palpation of the Pediatric Spine

The objective of motion palpation is to identify motion restrictions of the vertebral segments of the spine and pelvis. Subluxation will always exhibit some degree of aberrant motion. Our motion palpation evaluation includes general P-A glide restriction, as well as specific segmental motion palpation.

Joint motion is assessed in the child by feeling a soft, gliding motion as the joint is gently moved through its range of motion. If there is joint restriction, a subtle resistance to movement will be felt. The most important point to note when using motion palpation in the child's spine is to never assess ‘end play’ — the joints of the child's spine are not fully developed, so end play is strongly discouraged and not recommended.

Motion palpation is always performed after muscle palpation. Line of correction is never determined by motion palpation alone but must incorporate muscle palpation. General P-A glide motion is used to identify joint restrictions associated with subluxation in the lower cervical segments.

The following are motion palpation procedures for specific levels of the spine and possible misalignments associated with restricted motion:

Occiput

Use a gentle gliding motion, feeling for resistance to movement between the occiput and atlas. Be sure to isolate the occiput.

• An AS occiput will resist A-P glide.
• A PS occiput will resist P-A glide.
• A lateral occiput will resist L-M glide.

Atlas

Use a gentle gliding motion, feeling for resistance to movement between the atlas, occiput, and C2. Be sure to isolate the atlas.

• A lateral atlas will resist L-M glide.
• An anterior atlas will resist A-P glide.
• A posterior atlas will resist P-A glide.

C2–C7

Use a gentle P-A gliding motion by contacting the cervical articular processes. Be sure to isolate each motion.

• A posterior LPJ/TVP/MP will resist P-A glide.

Thoracic & Lumbar Spine

Use a gentle P-A gliding motion by contacting the TVPs or MPs. Feel for a gentle P-A gliding movement. Be sure to isolate each motion.

• A posterior TVP/MP will resist P-A glide.

Ilium

Grasp the PSIS and ASIS with one hand, and support the midline of the sacrum with the opposite thumb. Rock the ilium into flexion and extension, then glide the ilium medially, then laterally.

• A PI ilium / flexion malposition will resist extension.
• An AS ilium / extension malposition will resist flexion.
• An IN ilium will resist M-L glide; an EX ilium will resist L-M glide.

Sacrum

Place the pad of the thumb or index finger over the intermediate crest and gently push P-A.

• The posterior sacrum will feel restricted, because it is posterior and can't move from anterior.
• The anterior sacrum will feel restricted, because it is anterior and can't move any further anterior.

TouchPoint Light-Force Technique™

TouchPoint Light-Force Technique presented here draws on Gonstead, Diversified, and Logan Basic principles, refined into a specialized approach built specifically for the unique anatomy, development, and needs of infants and toddlers. Patient position, manual and segmental contacts, vectors of correction, thrust type, equipment, and the subtle variations of each technique all matter.

Basic Considerations

• Children are not just small adults. The structures are the same, only smaller, but the technique subtleties are real.
• Don't expect an audible cavitation. With infants and toddlers especially, adjustments are often silent — felt by the chiropractor rather than heard.
• Infant adjustments require very gentle force with little to no rotation; toddlers allow slightly more force with the same considerations.
• A child should never cry from an adjustment. Less is always more.
• A painful adjustment may mean the child never gets back on your table.
• Their first experience with a doctor likely wasn't pleasant — take the time to get to know them.
• You're also a stranger to them. Earn their trust, and once earned, never betray it.

Manual Contact Adaptations

Thrust Progression (Light to More Force)

Basic Rules for Adjusting Children

• Use only the force appropriate for the child's weight.
• Always err on the gentle side — less is more.
• The smaller the bone, the smaller the contact.
• The smaller the child, the smaller the force.
• Never, never, never adjust a child against their will.
• Have fun — if you're having fun, your patients will too.

Contraindications

• Hypermobility or instability
• Suspected or confirmed pathology of the involved bone
• Pathologic or non-pathologic fracture
• Infection at the contact site
• Congenital or iatrogenic dislocation

Types of Thrust for the Pediatric Patient

Always weigh the child's size, weight, and development when choosing thrust type and force. Core rules: (1) the smaller the child, the smaller the contact; (2) the smaller the child, the smaller the force; (3) always err gentle; (4) limit lateral flexion and rotation; (5) don't expect an audible.

Legend

The Occiput

Occiput — AS, Supine, No Block

Occiput — AS, Supine — With Block or Rolled Washcloth

Occiput — AS; AS-RS/LS — Seated — With Block, Rolled Washcloth or Drop

Occiput — PS-RS/PS-LS — Supine

Occiput — PS-RS/PS-LS — Seated, No Drop

Occiput — PS-RS/PS-LS — Seated, With Drop

The Atlas

Atlas — Lateral / Anterior / Posterior — Supine

Atlas — Lateral — Seated, With Drop

Atlas — Anterior — Seated, With Drop

Atlas — Posterior — Seated, With Drop

Atlas — Lateral, Anterior, Posterior — Seated, No Drop

Toggle Adaptation — With Drop

Knee-Chest Adaptation

The Lower Cervical Spine (C2–C7)

Lower Cervical — PR/PL — Supine

Lower Cervical — PR/PL — Prone

Lower Cervical — PR/PL — Seated

The Thoracic and Lumbar Spine

Thoracic / Lumbar Spine — PR/PL — Prone, Bi-Manual

Thoracic / Lumbar Spine — PR/PL — Prone, Single TVP/MP

Thoracic Spine — PR/PL — Jump / Hug

Thoracic / Lumbar Spine — PR/PL — Prone (Newborn)

Thoracic / Lumbar Spine — PR/PL — Supine (Newborn)

The Lumbar Spine

Lumbar Spine — PR/PL — Prone, With Leg Extension

Lumbar Spine — PR/PL — Side Posture

The Sacral Spine

Sacrum — P-R/P-L/PIR/PIL — Prone, Bi-Manual

Sacrum — P-R/P-L/PIR/PIL — Prone, With Leg Extension

Sacrum — P-R/P-L — Side Posture

The Ilium

Ilium — PI / AS — Prone

Ilium — PI — Prone, With Leg Extension

Ilium — AS — Prone, Ischial Tuberosity Contact

Ilium — IN / EX — Prone, Rock & Roll

Ilium — PI — Side Posture

Ilium — AS — Side Posture

Ilium — IN — Side Posture

Ilium — EX — Side Posture

Logan Basic Technique for Infants

Logan Basic Technique was developed by Hugh B. Logan in 1923, focusing on the foundation of the spine specifically the sacrum. It is applied for correction of an anterior-inferior (AI) sacrum in the infant-toddler age group.

Logan observed that “the muscles radiating from the sacrum will be found in a tense, strained state, ready to return the sacrum to its proper location” — a concept consistent with Sherman's own teaching on muscle palpation and the effect of tight muscles on a subluxated vertebra. Logan Basic is an osseous correction of the anterior-inferior sacrum that uses the potential energy of tight, strained muscles and stretched ligaments. The correction works by assisting the child's innate intelligence with a light-force contact on the apex of the sacrum.

An anterior-inferior sacrum is common in infants, likely due to the compressive forces of uterine contractions as the pelvis passes through the birth canal during labor. While labor duration is a factor, the biomechanics and angulation of the sacroiliac joint suggest that compressive force on the pelvis drives the sacrum anterior and the ilia medial — a mechanism that may explain how common this subluxation pattern is.

The Procedure

Explain to the parents what you'll be doing. Infant adjusting is unfamiliar territory for most parents, so describe where you'll make contact and demonstrate the amount of pressure on the palm of their hand.

Place the infant on a blanket on the table, or on the supine parent. Head rotation is fine during the adjustment, but analyze the infant with the head neutral whenever possible. If the head is rotated during evaluation, check findings with the head turned both right and left — there should be no difference in findings with head rotation.

The Evaluation

Visual Assessment

• Deviation of the natal cleft toward the AI side.
• Inferior pelvis on the AI side.

Static Palpation Findings (Least Reliable)

• Anterior sacral base.
• Narrow distance between the 2nd sacral tubercle and the PSIS.
• Sacral base inferior on the narrow side.
• Apex deviated opposite the inferior sacral base.

Muscle/Ligament Findings (AI Side)

• Longissimus and gluteus maximus tightness.
• SI and sacro-tuberous ligament tension.

The Adjustment

References

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