What are the factors to be considered when deciding which spinal adjusting technique to use for a child? Last month in this column, we discussed the growth and developmental characteristics of the spine.In this issue, we will look at how variations in the development of the child's spine should affect the choice of an appropriate technique for the pediatric patient.
The pediatric spine has two special characteristics which need to be considered when choosing an appropriate adjustive technique: bone strength and ligament laxity.
The development of the spine takes place gradually until approximately age 35. During this time, the spine undergoes secondary ossification, i.e., the development of new centers of ossification which were not evident at birth. These secondary ossification centers gradually develop to unite with primary centers, i.e., those which were present at birth. Secondary ossification takes place throughout the cartilage matrix which provides the future shape of each bone. Since cartilage has greater elasticity than bone, these areas of secondary ossification will have increased flexibility when compared to that of a completely ossified bone.
How strong then are the bones in the pediatric spine? This question is best answered in two ways. The bone matrix, otherwise as the trabeculae, in immature bone does not have the degree of brittleness that is characteristic of the geriatric spine and therefore is less likely to crumble under pressure. On the other hand, the presence of increased cartilage in the bones of the pediatric spine provides increased flexibility, especially under a load such as that applied with an adjustive thrust.
It can be concluded therefore that immature bone, such as that present in a child's spine, is unlikely to fracture when subjected to an adjustive thrust, provided that the thrust is appropriately modified for the age and size of the child. It is particularly recommended that the depth of thrust applied to the pediatric spine be reduced to an amplitude no greater than a half inch. In most cases this is sufficient to restore normal function.
Ligaments are the elastic fibers responsible for holding the joints together. They are therefore substantially responsible for the elasticity which is present in the spinal joints. A joint can be moved through its ranges of motion, first actively, then passively to the point at which the ligaments resist any further movement. A light thrust at this point will usually be sufficient to restore the joint, in the case of the spine known as the spinal motion segment, to normal function.
In children, ligaments have a higher degree of elasticity than that which is present in adults. Therefore, as a result, children's joints can be expected to have a greater range of motion than that seen in the mature spine. In order to apply the same rules for adjusting a joint, as described above, one would need to take the child's joint through a significantly greater range of motion than is necessary for the adult patient. This would be undesirable, especially in the region of the cervical spine. Therefore, spinal adjusting in the pediatric spine should be performed at a point somewhat before the end of the passive range is reached.
Another factor which needs to be considered is the degree of specificity necessary for working with the pediatric spine. Because the size of the vertebrae are so much smaller in a child, the doctor needs to use precise palpatory techniques, firstly to identify the spinal structures and secondly, to detect any palpable anomalies present.
Having identified the areas of concern, the doctor makes a precise specific contact with the finger tip or point of the thumb, in order to apply the appropriate thrust.
Cavitation of a joint frequently produces a simultaneous "popping" sound. This sound is generally considered to be due to the release of a slight vacuum which forms within a joint structure. This sound is a regular phenomenon heard when the spinal joints are adjusted. However, in the child, due to the developing nature of the joint, this sound may not be heard as frequently. The absence of the "popping" sound during joint cavitation in the pediatric spine can be considered a normal finding.
To summarize, one can say that the child's spine may need attention just as frequently as that of the adult, and in some instances possibly more frequently, due to the traumas of daily living. Adjustment of functional problems which can develop in the child's spine can be corrected by using modified specific adjusting techniques. These techniques require a decreased depth of thrust, reduced range of motion in spinal pre-stress and a generally higher degree of specificity.
Peter N. Fysh, DC
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