Manual Therapy in Children

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Manual Therapy in Children Manual Therapy in Children presents a comprehensive conceptual approach to the subject of manual therapy for children of different ages. This approach considers the relationship between the neuromusculoskeletal structure and function at different stages of development and places strong emphasis on the prevention of problems as the child develops as well as on their safe and effective treatment and management. Edited and largely written by a leading European orthopedic physician, the book also includes contributions from over 20 leading practitioners in the field. The contents are grouped into 5 main sections: •

The Basics: summarizes the essential

theoretical base (anatomy and physiology, neuromotor development of the first 5 years crawling to walking, surface anatomy). •

•

Clinical Insights: looks at issues which may affect the neuromotor development of the child and approaches to management, e.g. birthing interventions, birth trauma, differential diagnosis of central and peripheral neurological disorders, asymmetry. Pradical Aspects

of Manual Therapy

in Children: includes advice on interaction with parents and children; guidance for examination and treatment; considerations to be bome in mind when treating different joints and spinal regions.

•

Radi o l o gy in Manual Therapy: describes

the functional radiology of the spine in the young child and how to take, interpret and document radiographs in infants and young children. •

Making Sense

of It All: outlines the clinical

picture including functional disorders (such as KiSS syndrome), neurological and biomechanical disorders, and looks at the long-term consequences of untreated functional disorders in the first year.

Manual Therapy in Children is soundly based on the latest evidence. Written by an established author with contributions from a large team of clinical experts, the text is supplemented with almost 250 high quality illustrations. It presents a fresh and well­ considered approach to the management of a wide range of paediatric problems. All practitioners working with children with neuromusculoskeletal conditions will find this a clinically relevant and practical resource. Heiner Biedermann is a Practitioner in

Conservative Orthopedics, Cologne, Gennany, and Member of the European Workgroup for Manual Medicine. He was fonnerly a surgeon at the Surgical Department of the University of Witten-Herdecke and Schwerte Hospital, Germany. This book is appropriate for: •

•

•

/'i\ .I� iUi

•

•

CHURCHILL LIVINGSTONE

•

•

Manual therapists Pediatricans Osteopaths Chiropractors Orthopedic physicians Primary Care Physiotherapists

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9 780443 100185 Copyrighted Material

Manual Therapy inCh i Id ren

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Manual Therapy Child ren

•

Edited by

Heiner Biedermann

MD

Practitioner in Conservative Orthopedics, Cologne, Germony, and Member of the European Workgroup for Manual Medicine. Formerly Surgeon at the Surgical Department of the University of Witten-Herdecke and Schwerte Hospital, Germany

/�\ ..I� &1

EDINBURGH

CHURCHill LIVINGSTONE LONDON

NEW YORK

OXFORD

PH ILADELPH IA

ST LOU IS

Copyrighted Material

SYDNEY

TORONTO

2004

CHURCHILL LIVINGSTONE An imprint of Elsevier Limited © 2004, Elsevier Limited. All rights reserved. The right of Heiner Biedermann to be id e n ti fie d

as

editor of this work has been

asserted by him in accordance with the Copyr i gh t, De s igns and Patents Act 1988. No part of this publication may be reproduced, stored in a retri eva l system, or t rans m i tted

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request on-line via the Elsevier Limited homepage (http://www.elsevier.com). by selecting 'Customer Support' and then ' Obtaining Permissions'. First published 2004 ISBN 0 443 10018 7 British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice

Medical knowledge is constantly ch angin g . Sta nda rd sa fety p r eca u tions must be

followed, but as new research and clinical experience broaden ou r kn ow l edg e , a pprop r ia te .

changes i.n treatment and drug t he rapy may become necessary or

Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. [t is the responsibility of the p ractit i o n e r, relying on experience and knowledge of the

patient, to determine dosages and the best treatment for each individual patient. Neither the publishers nor the eclitor and contributors will be liable for any loss or damage of any nature occasioned to or suffered by any person acting or refraining from acting as a result of relia.nce on the material contained in t his publication.

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Contents

vii

Contributors Preface

8. Birth trauma and its implications for R.Sacher

1. Introduction: reviewing the history of

9. Differential diagnos i s of central and

manual therapy in children

peri phera l neurological disorders in

H. Biedermann SECTION 1

85

neuromotor development

ix

The theoretical base

L. Babino, H. Biedermann, S. lIiaeva

9

10. Manual thera py from a pediatrician s

2. Sensorimotor development of newborn and

'

H.Kiihnen

11 11.

H. Biedermann

15

R. Huang, B. Christ 4. Develop ment of the central nervous system

The influence of the high cervical region on the autonomic regulatory system in

3. Development and topographical anatomy of the cervical spine

113

viewpoint

children from the viewpoint of manual therapy

99

i nfants

29

A. Hori

125

infants L. E. Koch 12. Attention deficit disorder and the

133

upper cervical spine R. Theiler

5. Adaptive properties of motor behavior

45

J.-M. Ramirez

,

apparatus and dentition in children

6. N e uromoto r devel opment in infancy and early childhood

13. Asymmet ry of the posture l ocomotion 145

H. Korbmacher. L.E. Koch, B. Kahl-Nieke 57

S. Huber SECTION 3 SECTION 2

Clinical insights

73

7. Birthing interventions and the newborn cervical spine D. Ritzmann

The different levels: practical

aspects of manual therapy in children

1 61

14. Practicalities of manual therapy in 75

children

163

H. Biedermann

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v

vi

CONTENTS

21. Measuring it: different approaches to the

15. Manual therapy of the sacroiliac joints and 173

pelvic girdle in children F Huguenin

documentation of posture and coordination H. Biedermann, R. Radel, A. Friedrichs

1 6. Manual therapy of the thoracic spine 185

in ch i ldren H. Mohr, H. Biedermann

spine in children

SECTION 5

Making sense of it all

205

H. Biedermann

for manual therapy

0. Radiology in manual therapy in 213

18. Functional radiology of the cervical spine in children

215

H. Biedermann

235

of newborns and children H. Biedermann

24. The KISS syndrome: symptoms and signs

285

H. Biedermann 25. KIDD: KISS - ind u ced dysgnosia and dyspraxia

26. The family dimension

303

243

313

H. Biedermann 27. Epilogue

20. Radiological examination of the spine in Peter Waibel

281

Gunturkun

H. Biedermann

19. The how-to of making radiographs

children and adolescents: pictorial essay

275

M. E. Hyland, H. Biedermann 23. The big, the small, and the beautiful

children

273

22. Complexity theory and its implications

17. Examination and treatment of the cervical

SECTION 4

259

321

H. Biedermann Index

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327

Contributors

Susanne Huber Dipl Phys Dr rer nat

Lilia Babina, MD Professor, Neuropediatric Department, Pediatric

Research Fellow, Friedrich-Miescher Laboratory of the

Rehabilitation Clinic, Pjatigorsk, Russia

Max-Planck-Society, Tiibingen, Germany

Heiner Biedermann MD Practitioner in Conservative Orthopedics, Cologne, Germany and Member of the European Workgroup for Manual Medicine

(EWMM). Formerly Surgeon at the

Surgical Department of the University of Witten­

Freddy Huguenin MD Former Consultant at the University Clinic of Physical Medicine and Rehabilitation of Geneva, Switzerland

Herdecke and Schwerte Hospital, Germany

Bodo

Michael E. Hyland BSe PhD BCPsyehol

E. A. Christ MD

Professor, Institute of Anatomy and Cell Biology, University of Freiburg, Germany

Amd Friedrichs

Department of Psychology, University of Plymouth, Plymouth, UK

S. Iliaeva MD

Friendly Sensors AG, Jena, Germany

Rehabilitative and Physical Medicine, Cologne, Germany

Onur Giintiirkiin PhD(Psyehol) Professor of Psychology, Faculty of Psychology, Ruhr-University Bochum, Bochum, Germany

Barbel Kahl-Nieke PhD DrMed(dentl Chair of Department of Orthodontics, College of

Akira Hori MD

Dentistry, University of Hamburg, Hamburg,

Professor, Research Institute for Neurology and Psychiatry, National Nishi- Tottori Hospital, Tottori,

Germany

Japan L. E. Koch DrMed

Ruij in Huang PD DrMed

General Practitioner and Member of the European

Institute of Anatomy and Cell Biology, University of

Workgroup for Manual Medicine

Freiburg, Freiburg, Germany

Eckernforde, Germany

Copyrighted Material

(EWMM),

vii

vii i

CONTRI BUTORS

Heike M. Korbmacher DrMed(dent)

Dorin Ritzmann DrMed FMH(Gynecology/Obstetrics)

Associate Professor, Department of Orthodontics,

CertMedHypnosisTraumaTherapy (EMDRFrancineShapiro)

College of Dentistry, University of Hamburg,

Zurich, Switzerland

Hamburg, Germany

R. Sacher MD Hanne Kuhnen DrMed

Private Practitioner and Member of the European

Pediatrician, Kevelaer, Germany

Workgroup for Manual Medicine (EWMM), Dortmund, Germany

H. Mohr Physiotherapist and Member of the European Workgroup for Manual Medicine

(EWMM), Manual

Therapist and Lecturer, Ede, The Netherlands

Reinhard W. Theiler DrMed FMH Pediatrician (neuro-rehabilitation) and Member of the European Workgroup for Manual Medicine (EWMM), Trimbach, Switzerland

R. Radel MD Orthopedic Surgeon, Herne, Germany

Peter J. Waibel MD

Jan-Marino Ramirez PhD

Kinderspital, St Gallen, Switzerland

Chief of Section, Radiology Department, Ostschweizer

Professor of Anatomy and Neurosciences, Department of Anatomy, The University of Chicago, Chicago, Illinois, USA

Copyrighted Material

Preface

'I don't like writing

-

I like having written' -

Dorothy Parker once said. This holds true for

took

an

interest in the potential of manual therapy

without actually practising it. Some of them con­

almost every writer and certainly for me. To com­

tributed material to this book, others offered valu­

prehend the pleasure felt at this moment (all the

able hints and pointed out weaknesses in the

chapters have been sent to the publisher and the

arguments.

only thing left to do is to write these short lines)

The quest to be up to date is as unviable as the

might be difficult for somebody who was not (yet)

search for the end of the rainbow - but both may lead to insights not reached otherwise.

in this position. It is more than five years since English and

T he

inevitable delay between the submission of the

Dutch friends proposed writing a book on manual

manuscript and the finished book has to be

therapy in children. Soon it became clear that this

accepted stoically if one wants to avoid endless

rapidly developing field was too vast to be dealt

addenda.

with by one author alone. The search for contribu­

The basic tenets of what is presented here have

tors willing to share their competence began, and

stood the test of time and in publishing these find­

I am immensely grateful to all of those willing to

ings, we hope to encourage others to comment

sacrifice their rare spare time to write their

and criticize in order to use this as a base for fur­

chapters.

ther improvements. admirable was the patience of those

All those around somebody working on a book

on the publisher 's side who waited unweary­

Almost

suffer - from the different forms of neglect the

as

ingly while the complex material was rearranged

concentration on such a long-term project implies.

over and over again to gain a satisfactory form

To thank one's wife and offspring for their com­

and structure. Needless to say the initial dead­

prehension is but a shallow recompense for it, and

line for

this book

was

exceeded

by

many

as formulaic as it may be, it inevitably opens the 'thank you' section.

months. During these years, several congresses brought

All the colleagues who helped with their advice

countless discussions. All those questions and

and criticism come a close second, to be followed

criticisms helped to create a coherent concept out

by the team at Elsevier who endured the long

and constant alterations. Representing the

of the observations of the practical work with chil­

delays

dren. The friends and colleagues of the European

first group Editha Halfmann, Uli Gohmann and

Workgroup for Manual Medicine are exemplary

Bruno Maggi have to be mentioned; at Elsevier I

in that regard, but also all those pediatricians who

want to thank especially Mary Law, Dinah Thorn

Copyrighted Material

ix

x

PREFACE

and Joannah DW1can for patience and the entire

tion and for making available all the material and

production team, encouragement and all their

photos used in this book - their book, in a way. 'Tritt frisch auf - tu's Maul auf!- hor bald auf!'

helpful remarks. Jenny Fox rendered the text a bit more compre­ hensible with her 'native speaker' advice and her

Martin Luther once said; we tried to heed that advice.

proofreading. Last but not least I want to thank my young

Heiner Biedermann

patients and their families for feedback, motiva-

Antwerp 2004

Copyrighted Material

Chapter

1

--�------�--��-- ----�

Introduction: reviewing the history of manual therapy in children H. Biedermann

'DO YOU HAVE TO KNOW PHILOSOPHY TO

CHAPTER CONTENTS

PLAY THE PIANO?'

'Do you have to know philosophy to play the piano?'

1

The lessons of MTC for manual therapy in general

2

The role of the therapist

4

5

MTC depends on supporting therapies

about neurophysiology or anatomy to

manipulate - but to reach a certain professional

The long tradition of MTC - and where we are heading for

And, translated into the lingo of manual therapy: You do not have to know about the history of our trade,

4

MTC influences body and soul

'No, but it helps' might be an appropriate answer.

6

level, it helps

- a

lot.

Nobody with any knowledge of music doubts the idea that you need to understand the cultural and philosophical context of a piece of music you want to interpret. If playing music was as simple as copying the notes onto an instrument, you could feed a given score to the computer and plop! - the perfect music is played. But it is the interpretation of the player which turns bit of notation into

a

a

sterile

work of art. And as the soci­

ety in which one plays one's tunes evolves, so does the interpretation of the great compositions. There will never be the 'ultimate' interpretation of Beethoven's 9th or Schubert's Forellenquintett. The same is true for manual therapy. The way we interact with our patients is crucially depend­ ent on an exact appraisal of their physical and psychological condition. Teclmiques that were well established in the 1930s would be considered a bit brutal today. With small children the situation gets even more complex, as we have to take into account an entire family, i.e. the parents and siblings present

Copyrighted Material

REVIEWING THE HISTORY OF MANUAL THERAPY IN CHILDREN

2

at the consultation. How much of a success an

ination. This may get a bit tiring sometimes -

individual treatment will be depends at least as

but it is for them that this book is intended.

much on the good

contact between therapist

and family as on the technical know-how of the

THE LESSONS OF MTC FOR MANUAL

former. Any contact

between two individuals has

THERA PY IN GENERAL

effects on both of them. For the purposes of this book, we can limit the scope by defining manual

What we find is what we are looking for - this is

therapy as the deliberate touching of the patient

nowhere more true than in medical research. As a

by a trained therapist with the intention of

young student one enters the arena with the some­

improving the patient's condition. Seen from close

what naive thought that what we are pursuing is

enough, manual therapy (and even more so man­

the truth, and nothing but the truth. But we are

ual therapy in children - MTC) is a simple mechan­

condemned to deviate from this noble goal from

ical procedure. One might be tempted to confine a

the beginning, and have to embrace the constraints

treatise to the bare necessities, a 'how to' of the

of our neurophysiological input capacity and the

different t�chniques available.

limits of our budget - to name but two of the more

This approach

would be an antidote to the sometimes lofty

extreme obstacles on our way to 'the truth'.

explanations offered for some of the methods

When trying to present a paper about a medical

available today. Quite a few books are organized

problem, we end up more or less with the advice

according to such a scheme. The reader is offered

the Economist's editor gave to a young employee

a short introduction about the history of the spe­

'Simplify, then exaggerate!' . There seem to be two

cific method presented in the text, and then page

ways out of this dilemma, and they have, almost

after page showing a therapist, his/her patient

always, opposite directions. The traditional 'scien­

and the different positions possible.

tific' approach is to partition the complexity of the

Such a Kama-Sutra of manual techniques has

clinical picture till we arrive at a level where the

some merits - to remind the experienced of what

task seems to be clear enough to be cast into a lin­

is possible - but it cannot replace the real thing,

ear question of 'what if'. This is basically the realm

i.e. learning by observing and in close contact

of the evidence-based medicine (Sackett et

with a proficient teacher. So we shall not avoid

so much in vogue now. This approach is

those 'how-to' pictures entirely, but these parts

lent tool to decide questions like 'If I want to treat

of the book are few and not the most important

cystitis with

ones.

best?'

In teaching and demonstrating manual therapy in children, one encounters two principal reactions:

an

a11997)

an

excel­

antibiotic, which one would be

One is reminded of the statement of the bio­ chemist A. Szent-Gyorgyi

(1972):

'I moved from

anatomy to the study of tissues, then to electron •

One group of colleagues - the bigger one -

mechanics. This downward journey through the

language expresses very clearly the idea that

scale of dimensions has its irony, for in my search

they have seen it all. As it looks so simple - just

for the secret of life I ended up with atoms and

a little push on the side of the neck - why waste

electrons which have no life at all. Somewhere

any more time! These guests leave the consulta­

along the line life has

tion and my address book equally quickly. •

microscopy and chemistry, and finally to quantum

watches and after an hour or two their body

run

out of my fingers.'

When we try to simplify - and simplify we

A second, smaller group looks more closely and

must in order to get to grips with the complexity

these colleagues more often than not start to ask

of disease and disorder - we have to keep in mind

a lot of questions about the details of the exam-

what we do. And we have to keep in mind that the

Copyrighted Material

Introduction

questions we can ask in a reductionist context are

what we are confronted with is not necessarily the

not necessarily the most relevant.

whole spectrum of complaints. And - as stated in

The second approach, as exemplified by manual therapy in the non-trivial sense (see Chapter

22),

the beginning - the socio-cultural context we are working in plays an important role, too.

aims at re-establishing a functional eq�ilibrium

This dilemma occurs as soon as we look for

which renders its effects dependent on a multitude

long-term effects of any given therapeutic inter­

of other influences, psychological as well as physi­

vention. Maybe this is the reason why that kind of

cal. Such an approach has to be based on the

research has been so neglected. Applied to manual

results of reductionist research, but it takes into

therapy this means that it is much easier to evalu­

account the complex interaction with other levels

ate the effect of a lumbar manipulation on low

of maintaining the homeostasis and these mecha­

back pain than that of a cervical manipulation on

nisms are in most cases not quantifiable by 'hard'

the wellbeing of a baby. But is it the most relevant

science. This is one reason why the treatment of

question?

small children is of such importance to us. Here we

The first studies we shall be able to complete

find a situation which we can define much better

will be about problems that are suitable for a

than the far more complex pictures in older chil­

rather restricted protocol. And, yes, it is necessary

dren, let alone adolescents or adults. In babies we

to do such research - not because the questions we

deal with a rather clear-cut pathology, the two

can answer in such a way are the most pressing

main factors being genetic predisposition and the

ones, but because it helps to breach the wall of

history up to the moment of the first examination

incomprehension that separates the majority of

- which means in almost every case the details of

pediatricians from manual therapy. If we can

delivery, if we do not take into account the tiny

demonstrate the efficiency of MTC in such a nec­

number of cases with trauma after birth.

essarily very restricted context, this first step

Therefore it is possible in these cases to bridge

opens the possibility of entering into a construc­

the gap between a rigorous enquiry on the one

tive discussion beyond those who are already con­

hand and the taking into account of all relevant

vinced or at least interested. In the context of manual therapy in children,

factors on the other hand. As soon as the individual history starts to

two different but interrelated topics have to be

On the one hand, there is a clinical

diversify, such a synthetic view becomes almost

dealt with.

impossible. In order to gain meaningful state­

and pathophysiological concept which needs to

ments we have to simplify more than may be good

be defined in order to become a useful diagnos­

for the task at hand. Take, for example, something

tic tool. To this end, the two acronyms of KISS

as 'simple' as headache - an indication

par

excel­

and KIDD were proposed and will be discussed

24 and 25. On the other hand, one

lence for manual therapy and excruciatingly com­

in Chapters

plex in its web of causal dependencies.

has to choose the optimal method to deal with

If we were honest and serious we would have to take into account all the other contributing fac­

such a disorder once the diagnosis has been confirmed.

tors relevant for the development of these com­

It seems to be useful to make it clear from the

plaints. The professional and private situation is

beginning that there is no stringent connection

but the most obvious one of these contributing

between the diagnostic and the therapeutic level.

factors. Other medication, endocrinologic details

Most forms of manual therapy propose one method

and quite simply the age and type of the patient

as the best (and only) solution, very often dismiss­

playa role, too. Last but not least we have to take

ing other, similar techniques as vastly inferior. For

into account that not everybody considers a given

the naive observer it is sometimes astonishing to see

problem serious enough to go and see a doctor, so

that the methods proposed by the different schools

Copyrighted Material

3

4

REVIEWING THE H ISTORY OF MANUAL THERAPY IN CH ILDREN

are indeed very similar and that a distinction is

present on both sides - and it is a mistake to think

sometimes a little bit artificial, to put it mildly.

one can empathize with everybody. Manual ther­

There is - on the other hand - indeed a cormec­

apy

necessitates

an

intimate

bodily

contact

tion between the theoretical considerations and

between two strangers and the therapist as well as

their practical realization inasmuch as certain pro­

the patient should have the right to refuse.

cedures seem to be more promising than others. But the bottom line of all advice about the recom­ mended techniques for manual therapy in children

MTC INFLUEI\lCES BODY AI\lD SOUL

should be: Do not touch the cervical spine too often! The closer one gets to the occipito-cervical junction,

Since the famous 'je pense, donc je suis' of the seven­

the more time this highly volatile system needs to

teenth-century philosopher Descartes

adapt to the - therapeutic, but nevertheless irritat­

exploration of the natural world has gradually been

ing - input. Speransky

wrote extensively

freed from the constraints of religious dogma,

about the 'second hit phenomenon'. He pointed out

thus enabling the ever faster development of the

(1950)

(15%-1650),

that a sensitive structure - today we would talk

natural sciences we see today. It is on the basis of

about a network - can handle a quite severe trauma

this liberating Renaissance thought that all our

once, but decompensates if a similar second, much

research stands (and it should not be forgotten

weaker trauma is encountered too soon afterwards.

that even Newton, living a generation later than Descartes, still devoted the bulk of his writing to parts of science like astrology, i.e. topics we do not

THE ROLE OF THE THERAPIST

classify as such nowadays). The liberating influence of the Renaissance on

Observing different practitioners of manual ther­

philosophy and science (till then considered as

apy - be it chiropractors, doctors or physiothera­

one) can hardly be overestimated. But it came at a

pists - one quickly realizes that there are almost as

price. As a preventive measure to avoid too much

many techniques as people practicing them. Apart

scrutiny from the church authorities, Descartes

from the purely physical level, there is the 'philo­

postulated the separation of the spiritual realm

sophical' level, too. A 2 meter tall man with a

and the body - the latter being accessible to our

background of orthopedic surgery will use differ­

investigation. The eternal soul was said to be dis­

ent techniques from a petite woman of

connected from the body's function and thus

1.6

meters

who trained initially as a neuropediatrician. All these different people may pretend to fol­

beyond our reach. An invisible barrier fenced off everything connected to the 'soul'.

low the same procedures, but what a difference.

In the nineteenth century another boost to the

And let us not forget that in order to succeed,

scientific understanding of our body came with

manual therapy has to rest on a base of confidence

the ideas of Virchow

and trust. The empathy necessary to achieve such

pathologist who founded cellular pathology, thus

a solid person-to-person contact should come

postulating a microscopically detectable alteration

spontaneously, but has to be fostered. It is better

of cells as the basis of any pathological process

(1821-1902),

a German

not to treat somebody where one senses a lack of

(Virchow

trust. Already, therefore, it is indispensable to

progress in hy giene and in the understanding of

1865).

This approach led to enormous

have more than MTC at your disposal. Such a sit­

infectious and degenerative diseases - but again

uation arises only very rarely, but I consider it to

at a price: functional disorders had almost no

be of paramount importance to be able to shrink

place in this system.

from applying a manipulation when this basic

An examination of these two milestones of

trust seems to be missing. The empathy has to be

Western thought regarding the health sciences is

Copyrighted Material

Introduction

beyond the scope of this chapter, but it helps to

THE LON G TRADITION OF MTC

be aware of the context we work (and argue) in.

WHERE WE ARE HEADIN G FOR

-

AND

Repercussions of the separation of body and soul in Western thinking abound, and in connec­

Manual therapy in children is

tion with the postulate

of a morphological

of the caregiving in almost all cultures, albeit with­

pathology at the root of every medical problem

out explicit mention as a treatment of spinal disor­

an

old craft and part

this creates an unconscious censorship. 'Hard­

ders. Leboyer

ware problems' fit into this pattern of thinking,

about Indian baby massage where many treatments

'software problems' much less - and to accept

have a striking similarity to techniques of MTC or

that a functional disorder can lead to a morpho­

soft-tissue osteopathy. Andry'S seminal book on

logically

fixed

pathology

requires

an

even

greater effort.

(1976)

published a beautiful book

orthopedics (published in

1741)

contains entire

chapters about the treatment of newborn babies with

A good example is the ongoing discussion

postural asymmetries and similar practices are doc­

about 'difficult' children. One indicator of the

umented in books about massage (Baum 1906) or

trickiness of

general healthcare (Cramer et aI1990).

this

problem

is

the

changing an

With the 'scientification' of medicine in the

entire collection of three-and four-letter words

nineteenth century the earlier oral history of 'Be­

has been proposed over the years (MCD - mini­

handlung' (the German word for therapy, literally

nomenclature applied to these children:

mal cerebral damage, POS - psycho-organic syn­

translated: 'something done with the hands') in

drome, etc. ). Now the fashionable label is ADHD

the sense of manual therapy began to be recorded

(attention deficit hyperactivity disorder) and

in textbooks, albeit under various headings such

again we encounter a field much too big to be

as massage, kneading the nerves, improving cir­

handled exhaustively here. But the problems

culation. At that time, most explanations were

associated with and labeled as ADHD have a

based on mechanical models. At the end of the

close connection with many of the phenomena

nineteenth century the paradigms used to under­

we observe in children with problems originat­

stand the effects of these therapies were based on

ing in functional spinal disorders. In treating

hydraulic or electric schemas. In the second half of

these children successfully one can at least alle­

the twentieth century the accent shifted to cyber­

viate the situation and thus give the families a

netic or rather 'informatical' models - small sur­

new perspective.

prise. The Zeitgeist inspires fashion in science, too.

The appeal of seeing metabolic problems as the

So if one looks hard enough, there are morsels of

basis of these disorders can be traced back to the

MTC to be found even a few centuries back, and

elegant possibility of not looking into the interde­

these scattered pieces of a big mosaic have many

pendence of mind and body, of individual and

resemblances to the kind of MTC we support today.

environment, of nature and nurture. This bigger

The basic difference can be found in the conceptual

view involves the observer in the process, be it the

frame. The idea of a certain subgroup of children

worried parents or the therapist trying to help.

tending to react distinctively to functional disorders

As in the treatment of migraine, we cannot get

of the cervical spine came only after observing many

to the structural roots of the problem - we influ­

babies and their families and taking into account

ence trigger mechanisms and aggravating circum­

their long-term development. We realized that the

stances. But in doing so, manual therapy can more

same trauma does not at all cause the same reaction

often than not help these cruldren and their fami­

in every child (and even less so in adults). We called

lies and provide the leeway necessary for a turn­

these babies 'KISS kids' to indicate\ that their prob­ lems were at least partly systematic. The patterns

around. Theiler, in Chapter these observations.

12,

deals with some of

we found first took us back to the moment of birth

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5

6

REVIEWING THE HISTORY OF MANUAL THERAPY IN CHILDREN

as an important trigger for these pathologies. Later on we realized that to understand the situation fully,

MTC DEPENDS ON SUPPORTING THERAPIES

one has to go back further, i.e. take into accOlmt the prenatal development and the disposition inherited

In the following chapters we try to present those

from the parents too - genetic or epigenetic.

parts of manual therapy in (small) children that

Alerted by the early onset of vertebrogenic disor­

are different from the manual therapy we know in

ders, we started systematically to screen the case his­

adults and to develop the rationale for the con­

tories of older children. The picture that evolved led

ceptual framework we propose for MTC. The

us to the formulation of KIDD, i.e. a sensorimotor

main emphasis is on the systemic impact of appro­

KISS

priately applied manual therapy, thus preparing

disorder based on an early (and untreated)

pathology. As these children are of school-age and have encountered many more external influences than the babies suffering from

KISS, their web of

the ground for

(re- )educating the sensorimotor

system by means of ancillary specialties such as speech therapy or 'classic' physiotherapy.

pathology is much more complex. Whereas the

To a superficial observer this manual therapy

KISS (Chapter 24) deals with a rather

does not look very different from other forms of

chapter about

well-defined symptomatology, the KIDD chapter

contact treatment. We shall try to explain the crucial

(Chapter 25) discusses a much more complex Gestalt.

distinctions which necessitate, on one hand, a

Two pieces of circumstantial evidence make us

much more precise evaluation of the patient to be

surmise that

KISS and

KIDD influence the later

course, too. We see a lot of parents with their prob­

treated and, on the other hand, sufficient time for the patient to adapt to this therapeutic impulse.

lems after the babies have been treated success­

There is no sharp distinction between this vari­

fully, and we see the same patterns in these

ety of manual therapy and other therapies dealing

problems. It goes without saying that in adults the

with small children and using the upper cervical

situation is even more complex and difficult to

spine as a primary starting point - quite a lot of

decipher than in adolescents, but with the knowl­

what we have to say is valid for these methods,

edge of what we found in their children, some

too. But it would be imprecise to put all these

if the parents were

methods in one big bag and treat them as inter­

T he gender of the parent who comes to seek

differences - not least from the viewpoint of the

treatment is by no means accidental- which is the

family concerned - is our intention to minimize

second clue. When the baby is a boy it is far more

the impact of manual therapy on the small chil­

details are more evident than treated independently.

changeable options. One of the most important

probable for the father to come later on, and the

dren we treat as much as possible. Any therapist

same is true for daughter and mother. Quite often

has to strive to be as unobtrusive as possible.

this gender-related predisposition extends into

After more than 20 years of practical experience

the entire clan, viz. the uncle or the grandfather of

we can say with some confidence that in the great

a baby boy who shows up.

majority of cases very few treatments suffice (see

These interesting observations are very difficult

Chapter

17). This does not mean that there is no

to verify in the context of a private consultation. But

additional therapy

they are so clear-cut that even then one cannot but

effect of manual therapy; but these therapies fol­

complementing the initial

notice them. Much research needs to be done along

low different procedures and are better summa­

these lines and it seems more than probable that this

rized under the broad label of re-education. These

might help us to align our indications for manual

approaches do indeed need frequent and long­

therapy in general and MTC more particularly with

term application . Often the parents (or to be more

the framework of mainstream pediatrics.

honest: the mothers) are trained to treat their chil-

Copyrighted Material

Introduction

dren on a daily b asis in order to make these

environment an equally amazing influence on

approaches work.

the developing neuromotor organization. We are

The most important aspect of this is to keep in

about to learn how much our epigenetic pattern

mind that the situation in newborn babies is fun­

is for med in the perinatal period and how these

damentally different from what we know about

few months determine large parts of the biogra­

adults or even from the situation in adolescents or

phy of an individu al (Lopuhaa et al

older children. We shall not be successful in the

boom et al

analysis and treatment of the problems of the

phenomenon time and again, as it influences

newborn if we are not aware of this.

nearly all aspects of our interaction with these

H is not only the anatomy that is radically dif­

2000).

2000,

Rose­

We shall have to go back to this

small human beings.

ferent. The most important discriminating factor is

This book tries to bridge the gap between the

the absence of all 'learned' p atterns apart from the

'small' push on one side of the upper cervic al

few acquired in utero and during birth. This clean

spine of a child and the vast effects triggered by

slate is an opportunity and a threat at the same

this intervention at a crucial spot and an equally

time, enabling the newborn infant to develop very

crucial point in time. The broad r ange of contribu­

rapidly - in both good and bad directions.

tors should give the interested a firm foundation

Neurophysiological research suggests that we

from which to get to grips with this complex situ­

start life with a far greater amount of neurons

ation. We leave a lot of loose ends, and in the 3

and synapses than those we use as an adult. The

years it took to finalize the book, quite a few bits

structuring depends on the appropriate use and

of new information and ideas turned up to com­

non-use of these connections ('use it or lose it'),

plete - and sometimes even correct - the concept.

thus giving the newborn baby an amazing vari­

In that sense we present 'work in progress' - but

ety of possible developmental p aths and the

in medicine, who doesn't?

References Andry de Bois rega rd N 1741 L'orthopedie ou l'art de

Roseboom T J, van der Meulen

prevenir et de ca r riger dans les en£ants les difformites du co rps Vv Alix, Paris .

Bum A 1906 Handbuch der Massage und Heilgymnastik.

Urban & Schwarzenberg, Berlin/Vienna

Verl ag Werner Saenger, Berlin

tr adi ti onel : Ie massage des

prenatal ex posure to famine. Thorax 55:555-561

Szent-Gyorgyi A 1972 What is life? Biology Today 24-26 Virchow R 1 865 Die Cellularpathologie in wer B egr u n dung

enfants. Seuil, Paris Lopuhaa C E, Roseboom T J, Osm ond C et al2000 Atopy, lung function, and obstructive a irw ay s disease after

Dutch famine, 1944-45. Heart 84:595-598 Sackett D, Richardson W, Rosenberg W et al 1997 Evidence­ based Medicine. Elsevier S ci enc e, New York

manuellen Medizin. Springer, Berlin un Art

Osmond C et al 2000

Speransky A D 1950 Grundlage n der Theori e der Medizin.

Cramer A, Doering j, Gutmann G 1 9 90 Geschichte der Leboyer F 1976 Shantal a ,

J H,

Coronary heart di sease after p r ena ta l exposure to the

auf physiologische und pathologische Gewebelehre. A Hischwald, Berlin

Copyrighted Material

7

SECTION 1

The theoretical base

SECTION CONTENTS 2. Sensorimotor development of newborn and children from the viewpoint of manual therapy

11

3. Development and topographical anatomy of the cervical spine 4. Development of the central nervous system 5. Adaptive properties of motor behavior

15

29

45

6. Neuromotor development in infancy and early childhood

57

9

Copyrighted Material

Chapter

2 ----�----�--��-

Sensorimotor devel o p m ent of n e wborn and children from the viewpoint of manual therapy H. Biedermann

On oublie rien de rien, on s'habitue, c'est tout ... Jacques BreI All neurological development falls into two broad categories: pattern generation and pattern recogni­ tion. Most of the internal processes are dependent on a base rhythm, be it breathing or digestion. These are two examples with extremely different frequencies, the latter being coupled with the diur­ nal pattern and the former dependent on an inter­ nally generated pattern which undergoes multiple adaptive influences until it is finally carried out. It is of basic importance to come to grips with the complexities of such a system based on an internal pattern generator and the external modi­ fiers acting on it. The chapter by Ramirez (Chap­ ter

5) takes us to the cutting edge research of

micro-neurophysiology, and tries to unravel some of the intricacies of pattern generation. These mechanisms are very old and shared between most vertebrates with only minor differ­ ences. The contribution of Huber (Chapter

6) on

the other side deals with the complexities of pat­ tern recognition and the surprising proficiency of very small children in decoding complex visual clues. From Huber we learn how early these abili­ ties are trained and how a basic pattern recognition is established quite early in childhood. It is not too surprising that the research group Huber belongs to has not y et taken into account the influence that

Copyrighted Material

1 1

12

THE THEORETICAL BASE

the proper functioning of the upper cervical spine

in situations where other forms of therapy would

has on proprioception and head movement - these

not work because the amount of discipline and

insights have only just reached neuropediatric

persistence they require is not likely to be forth­

research. But Huber's chapter gives us some clues

coming from the families concerned.

as to how disturbances in proprioceptive input

Immersed in the treadmill of our daily work we

complicate the computation of spatial information.

tend to forget what we learned during our studies

In Chapter 25 we examine some of the implications

- and are not even aware of all the new informa­

of this concept for the treatment of behavioral and

tion produced since we left university. One moti­

neuromotor problems in schoolchildren.

vation behind this part of the book was to help in

The basic phenomenon - and the reason why dis­ turbances in the early stages of neuromotor devel­ opment exert such a wide-ranging influence -lies in

overcoming this. The chapters

by Huang and 3) and Hori (Chapter 4) present the state-of-the-art information concerning embry­

Christ (Chapter

the realization that we rarely 'unlearn' an acquired

ological development in the cervical area and the

pattern. As Jacques Brei says in his famous 'chan­

central nervous system and its deviations.

son', we don't forget anything, we just get used to it.

This information should enable a better under­

So patterns acquired in early childhood can influ­

standing of the context in which we

ence our behavior years and decades later.

solid knowledge of the basic facts about anatomy

This

are

working. A

makes the understanding of neuromotor develop­

and neurophy siology will help us to improve our

ment at the beginning of our life so important. The

diagnoses and especially to develop the 'sixth-sense'

postnatal period is paramount for our understand­

which alerts the diagnostician when

an

unusual

ing of this process, as it is the first time we are able

situation is encountered. In discussions with col­

actively and directly to influence these develop­

leagues about the - rare - occasions when they found severe problems while examining children,

ments. Onto this basic level of interaction many other

almost all of them admitted that before they actually

influences are added, from the primal needs of

identified the diagnostic problem they had had a

food and drink, to warmth and support in the all­

hunch that something was not quite as it should be.

important immersion in a stable and loving atmos­

The information contained in the following pages

phere in the baby's home, with as much bodily

should help to alert one to these unusual cases.

contact as possible (Cattaneo et a11998, Cleary et al

Or to put it another way, the chapters

in Sec­

1997, Feldman et al 2002, Fohe et al 2000, Luding ­

tion 1 can be seen as an antidote against too much

ton-Hoe et a11991, Simkiss 1999, Tessier et aI1998).

confidence of the style '1 am so successful that I

To cast the net even wider, one has to evaluate the

don't bother about the details'.

socioeconomic status of the family and its social

ing ourselves how much there is to know about the

If we keep remind­

integration in a local community (Wilkinson 1996,

incredibly complex web of dependencies we will

Wolf and Bruhn 1997) - a dimension of wellbeing

maintain a healthy fear of overlooking something.

often overlooked or underestimated.

This is even more important in MTC than in other

Even if we were able to take these aspects into

specialties as there are times when one 'simple'

account when evaluating the child's future, we

case seems to follow another, and lulled into a false

would not be in a situation to do much about it.

sense of security with our 'diagnostic auto pilot' we

The big advantage of manual therapy in early

might overlook the small sign that should warn

us.

childhood is that it gives us an opportunity to

Last but not least, these chapters (and Hori's in

improve the situation of a child without interfer­

particular) remind us about the differential diag­

ing with the other forms of help available and -

nosis of all the phenomena that may comprise

last but not least - without a big investment in

KISS - but may be a sign of quite another

time and energy. We are able to help children even

lying pathology, too.

Copyrighted Material

under­

Sensorimotor development of newborn and children

References Cattaneo A, D a v anzo R, B ergm an N et al1998 Ka ng ar oo mother care in l ow - income countries. International Network in Kangaroo Mother Care. Journal of Tropical

Pediatrics 44(5):279-282

Luding ton- H oe S M, Hadeed A J, And erson G C 1991 Ph ysiologic responses to skin-to-skin contact in hosp ital ized prem a ture in fants. J ournal of Pe rinat ol ogy 11(1):19-24

(Kangaroo care) promotes self- regulation in premat ure

Simkiss D E 1999 Kangaroo mother care. J ournal of Tropical Pedi atrics 45(4):192-194 Tessier R, Cristo M, Velez S et al1998 Kan garoo mothe r care and th e b onding h yp oth es is . Pediatrics 102(2):e17 Wilkinson R G 1996 Unhealthy societies : the afflictions of

infants: sleep-wake cy clicity, arousal modulation, an d sustained expl oration. Developmental Psychology

Wolf S, Bruhn

Cl ea r y G M, Spinner S S, Gibson E et al 1997 Skin-to-skin

parenta l contact with fragile pret e rm infants. J ournal of

the American Oste op athi c Association 97(8):457-460 Feldman R, WeUer A, Sirota Let al 2002 Skin-to-skin contact

inequality. Routle dge, London

JG

1997 The power of clan: the influence of

human relationships on heart disease. Trans action,

38(2): 194-207

F ohe K, Kropf S, Avenarius S 2000 S kin- to-skin contact improves gas exc hange in premature infants. Journal of

London

Perinatology 20(5):311-315

Copyrighted Material

13

Chapter

3

--------�-- �

Development and topographical anatomy of the cervical spine R. Huang, B. Christ

'The neck,

CHAPTER CONTENTS Prenatal development

ing element of the neck is the cervical spine ( cer ­

16

Primary segmentation and somite

format i on 16 Secondary segmentation (resegmentation) and somite differentiation Segmental identity

cervix (collum), is a mobile connecting

structure between head and trunk. The supp or t ­

18

20 Postnatal development 21 Ossification of the cervical vertebrae 21 Development of the uncovertebral joint 22 Development of curvatures of the cervical spine 22 Topography 23 Conclusion 26

vical spinal column), the most cranial part of the vertebral column. The vertebral column and parts of the cranium represent the axial structures of the human body. The vertebral column comprises 33 vertebral segments,

vertebrae, connected to each

other by fibrocartilaginous intervertebral disks, ligaments and muscles. Its function is to support the trunk and protect the spinal cord. The cervical spine provides a morphological basis for sive freedom of head movement.

an exten­ In addi tion, the

cervical vertebral column serves as a bridge for numerous blood

and l ymphati c vessels and limb.

nerves, link ing head, trunk and upper

Developmental abnormalities of the cervical vertebral column can affect these

functions. For example, the Klip pel-Feil syndrome, in which a short cervical vertebral column develops, is char­ acterized by a red uction

of head mob ility, mig r a in e

headache and paresthesia of the ar m and hand. Further examples

of vertebral abnormalities are

cervical ribs and spina bifida, atlas assimilation and fused vertebrae. In the thoracic vertebral column, the costal processes grow laterally to

form a series of ribs.

The costal processes normally do not extend dis­ tally in the cervical vertebral column, but occa­ sionally they do so in the case

of the seventh

cervical vertebra, even developing costovertebral

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15

16

THE THEORETICAL BASE

joints. Such cervical ribs may even reach the ster­

'vertebrae', the definitive structures of the verte­

num. Neural arches and their ligaments form a

bral column. The development of the vertebral

protective roof over the vertebral canal for the

column reveals a primary segmentation

spinal cord. Occasionally the coalescence of verte­

somite formation) and secondary segmentation

(the

bral laminae is incomplete, a cleft of variable

(resegmentation of the vertebral coluum). The

width being left through which dura and arach­

specification of the vertebrae is controlled by a

noid mater may protrude. Part of the spinal cord

genetic program, namely the Hox genes. The pri­

with its pia mater also commonly projects, a con­

mary and secondary segmentation and the seg­

dition known as spina bifida.

mental specification will be discussed in the next

The malformation is more common in the lum­

section.

bosacral regions, but may also occur at thoracic or cervical levels. Fusion of two or more vertebrae

Primary segmentation and somite

may occasionally be observed in the developing

formation

vertebral column. The atlas, normally forming an articulation between the cranial end of the verte­

The occipital bone, the vertebral column and their

bral column and the head, may fuse with the

skeletal musculature develop commonly from a

occipital bone, so-called atlas assimilation or

compartment of the intermediate layer (meso­

occipitalization of the first cervical vertebra. An

derm) (Fig.

understanding

and

mesoderm, intermediate mesoderm and the lat­

topography of the cervical vertebral column could

eral plate mesoderm. The paraxial mesoderm

of

normal

development

3.1). This can be divided into paraxial

help in understanding the basis for such vertebral

flanks the axial organs (neural tube and noto­

abnormalities and their symptoms.

chord). It consists of a preotical part, located cra­ nially to the ear placode, and a postotical part, extending caudally from the ear placode into the

PRENATAL DEVELOPMENT

neck and the trunk. The postotical paraxial meso­ derm becomes segmented, while the prcotical part

The most specialized part of the cervical vertebral

does not. Segmentation of the paraxial mesoderm

column is the cervico-occipital transitional region.

is characterized by somite formation. The somites

segmental units. from

Striking features of this region are already appar­

are the first clearly delineated

ent during development. Although the posterior

They are formed in pairs by epithelialization

part of the cranium and the vertebral column

the paraxial mesoderm. The first somite pair

derive from the same primordium, a boundary

arises directly behind the ear placode and the fur­

develops between the head and the neck. The pri­

ther somites develop one by one in

mordium located cranially to this boundary is

direction.

a

craniocaudal

New mesenchymal cells enter the

included in the development of the head. The cer­

paraxial mesoderm at its caudal end as a conse­

vico-occipital transitional region represents a very

quence of gastrulation. The newly formed parax­

special body part that not only provides the mate­

ial mesoderm is not immediately segmented. The

rial for the formation of the axial skeleton but also

part of the paraxial mesoderm prior to somite for­

participates in the development of essential

mation is called the segmental plate or presomitic

organs such as heart, gastrointestinal tract, and

mesoderm.

kidney.

The fundamental prerequisite for somite forma­

The vertebral column develops from somites,

tion is the growth of the paraxial mesoderm. This

the first visible segmental units of the embryo. In

growth is controlled by gastrulation genes and the

older papers the somites have been called 'pro­

fibroblast growth factor

tovertebrae' and therefore have been related to the

in the caudal part of the segmental plate. The

Copyrighted Material

8 (FGF-8) that is produced

Develo p m ent and to p ographica l anato my of the c ervica l spin e

c

A

Figure 3.1 A: Pax-l expressio n in t h e som ites of a 2-day-old chick embryo. The arrow marks the boun dary between the newly formed so m ite and the seg m ental plate. B: Tran sverse section th roug h a cervical somite. C: Transverse section thro u gh a 3-d ay-old chick embryo. Division of the somite in a derm omyotome (d m ) and a scleroto m e (sc). Expression of Pax-l in sclerotome. ao, aorta; ec, ectoderm; en, endoderm; n c, notochord ; nt, neural tube; S, so m ite; w, Wolff's duct; Ipm, lateral plate m esod erm .

quantity of FGF-8 secretion determines the size of the developing somite (Dubrulle et al 2001). Segmentation was found to be controlled by a molecular mechanism called the 'segmentation clock' (Pourquie 20(0). This clock contains molec­ ular oscillators that are characterized by the rhyth­ mic production of mRNAs. The hai ry, lunatic fringe' gene and genes of the Delta-Notch signal­ ing pathway belong to these segmentation genes. The expression pattern of these genes appears as waves that roll through the segmental plate from its caudal to its cranial end, and each wave is initi­ ated once during formation of one somite. This means that these genes are expressed 12 times in '

each segmental plate cell before it becomes inte­ grated in a somite at its cranial end. The gene oscillation leads to a maturation of the segmental plate. Morphologically, this matu­ ration is characterized by a cell condensation and a mesenchymal-to-epithelial transition of the cells in the cranial part of the segmental plate. The epithelialization requires the ex p ressi on of the bHLH gene paraxis (Burgess et al 1996). Epithe­ lialization of the segmental plate mesoderm and somite formation are severely affected in para xis n ull mutant mice. As a consequence, these mice develop a vertebral column that is not regularly segmented.

Copyrighted Material

17

18

THE THEORETICAL BASE

Secondary segmentation (resegmentation) and somite differentiation

Remak (1850), who was studying whole mount chick embryos, made the observation that the boundaries of the definitive vertebrae are shifted one half segment as compared to those of the 'protovertebrae' (somites). This so-called 'Neug­ lieder ung (resegmentation) was observed in vari­ ous species and was thought to be achieved by a new combination of somite halves. A secondary segmentation appears within each somite: an intrasegmental fissure divides its ventral compart­ ment, the sclerotome, into a cranial and caudal half and marks the boundary of the definitive ver­ tebra. This means that the fusion of the caudal half of one sclerotome \vith the cranial half of the next one forms one vertebra. Two neighboring verte­ brae are thereafter articulated by an intervertebral disk whose primordium is situated caud ally to an intrasegmental fissure, the so-called von Ebner fis­ sure (von Ebner 1889). Muscle cells develop from the dorsal compartment of the somite, the der­ momyotome, and are not affected by this craniocau­ da! subdivision. Muscles derived from one somite are therefore attached to two adjacent vertebrae. This means that resegmentation is required for appropriate movement of the vertebral column. To form a functional vertebral column, so mites undergo a dorsoventral and a craniocaudal com­ partmentalization. Newly formed somites are masses of mesodermal cells with a small cavity in the middle, the somitocoel (Fig. 3.1). The cells are arranged epithelially and radially arround the somitocoel, which is occupied by mese nchymal cells. Extracellular matrix connects the somite to adjacent structures (neu ral tube, notochord, ecto­ derm, endoderm, aorta, Wolffian duct). A continu­ ous cell layer connects the lateral portion of the somite to the intermediate mesoderm and thus indi rectl y to the lateral plate mesoderm. Under the influence of ventralizing signals such as Sonic hedgehog (Shh) from the notochord and the floor plate of the neural tube, Pax-l and Pax-9 become '

expressed in the somitocoel cells and the ventral somite half (Fig. 3.1). This leads to an epithelio­ mesenchymal transition of this somite part. Their cells form the mesenchymal sclerotome which gives rise to basioccipital bone vertebrae, inter­ vertebral disks and ribs. Dorsal signals are derived from both the surface ectoderm and the dorsal neural tube, which belongs to the Wnt fam­ ily of genes. Wnt-l and Wnt-3a are expressed in the dorsal neural tube and Wnt-6 in the ectoderm. These signals promote the devel opment of the dorsal compartment which keeps its epithelial structure and forms the dermomyotome. Pax-3 and Pax-7 are expressed by their cells. Cells located in the four edges of the dermomyotome de-epithelialize and elongate in a longitudinal direction. These cells differentiate into myogenic cells and form a cell layer, the myotome, between dermomyotome and sclerotome. Both ventral ( Shh ) and dorsal signals (Wnt proteins) are required for the specification of myogenic cells in the epaxial domain of the somite. The sclerotome divides into a cranial and a cau­ dal half along the longit u dinal axis (Fig. 3.2). Determination of this craniocaudal polarization is acquired prior to somite formation in the cranial portion of the segmental plate and depends on the Delta/Notch signaling pathway. The prospective ,

Figure 3.2 Sag ittal section s throu g h the m etam eric primord ium of th e sp i nal gan g lia (A) an d the spinal n e rve s (B). The nerve placod e is visualized with an tibody d m , dermomyotome; m, myotom e; the brackets mark the cau dal sclerotome ha l ve s an d th e arrows the bound ary between two adjace n t somites.

Copyrighted Material

.

Development and topographical anatomy of the cervical spine

somitic halves can be identified by the expression

form the dorsal mesenchyme which contributes to

domains of various genes. Delta 1, Mesp1,2 are

the dorsal part of the neural arch and the spinous

expressed in the caudal half and EphA4 in the cra­

process. Msxl and

nial half of the prospective somites in the cranial

expressed in this mesenchyme and to be con­

part of the segmental plate. The craniocaudal

trolled by the roof plate of the neural tube and

compartmentalization is indispensable for the

possibly the surface ectoderm via BMP4 signaling.

Msx2 have been found to be

development of the metameric vertebral column

Interruption of this cross-talk could be one of the

and for the secondary metamerism of the periph­

reasons for the malformations of the dorsal verte­

eral nervous system. Different genes are activated

bral

in the cranial and caudal sclerotome halves. The

expressed in the dorsal neural tube and in Splotch

column,

such as

spina bifida.

Pax-3

is

transmembrane protein ephrin and the Eph recep­

mice in which the homeobox domain of the Pax-3

tors are important molecules of these compart­

gene is mutated, the development of the dorsal

ments. Eph receptor is situated in the cell membrane

neural tube is affected, resulting in the formation

of the migrating neural crest cells, while ephrin is

of a spina bifida.

expressed exclusively in the caudal sclerotome

The fate of the cells in the ventrolateral angle of

half. The interaction between ephrin and its recep­

the sclerotome remains to be studied. These cells

tor stops the migration of neural crest cells. So the

are located in the transitional region of the parax­

axons of motor nerves and the neural crest cells

ial to the intermediate mesoderm and might con­

forming the dorsal root ganglia invade the cranial

tribute to kidney formation.

half-segment whereas the caudal half-segment acts

cells could represent a cell population that partic­

as

ipates in the development of the ribs. Recent stud­

a

barrier to axon and neural crest cell invasion.

In addition, these

Uncx4.1 is expressed in the caudal sclerotome

ies have suggested a two-stage model of rib

half and is essential for the formation of the neu­

development. In the first instance, Shh emanating

ral arch. When Uncx4.1 function is lost experi­

from the axial structures induces the development

mentally, the neural arch cannot be formed and

of the sclerotome and also the expression of Fgf-S

the dorsal root ganglia fuse together to form an

in the myotome.

unsegmented cell mass next to the spinal cord.

domain of the sclerotome becomes expanded, con­

As discussed above, the sclerotome is the deriv­ ative of the ventral half of the somite epithelium

Secondly, the ventrolateral

trolled by FGFs secreted by myotome cells. The vertebral disks located between adjacent

and the mesenchymal somitocoel cells. Ventral

surfaces of vertebral bodies from

signals are able to induce the expression of Pax-1

sacrum are the main junction between the verte­

and Pax-9 in the sclerotome. However, it has to be

bral bodies. Each disk consists of an outer lami­

fibrosus

C2 (axis) to the

kept in mind that only the ventromedial part of

nated annulus

the sclerotome continues to express Pax-1 and Pax

pulposus. The intervertebral disk is derived from

-

and an inner nucleus

9. Sclerotome cells that do not express these Pax­

somitocoel cells (Huang et a11994, 1996). The cells

genes are situated at the ventrolateral and the

of the intervertebral disk still express Pax-I when

dorsomedial angles of the sclerotome. Pax-I-posi­

it is already downregulated in the vertebral body

tive cells of the ventromedial sclerotome migrate

anlagen. Pax-1 expression is most likely to pro­

into the initially cell-free perinotochordal space to

mote proliferation of disk cells (Wilting et aI1995).

form the mesenchymal perinotochordal tube,

An early downregulation of Pax-expression is

which develops into the vertebral bodies and

observed in the basioccipital germ, in which the

intervertebral disks.

disk primodia degenera te leading to a fusion of

The fate of the cells in the dorsomedial angle is

the chondrogenic vertebral anlagen. Pathologi­

not quite clear. Grafting experiments indicate that

cally fused vertebrae can occasionally arise after

these cells migrate in a dorsomedial direction to

an early downregulation of Pax-I expression. In

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THE THEORETICAL BASE

the late development, the notochord disappears from the vertebral bodies and expands into the condensed mesenchymal primordia of the inter­ vertebral disks. In the adult, the notochord persists as nucleus pulposus, while somitocoel-derived mesodermal cells form the annulus fibrosus of the in tervertebral

disk. The morphogenesis of the vertebral column reflects the development of the vertebral motion segment. The vertebral motion segment is a func­ tional entity consisting of two adjacent vertebrae, the intervertebral disk, ligaments, and muscles that act on the segment (Schmorl and Junghanns 1968). Therefore, one vertebra is part of two adja­ cent motion segments. The motion segment also includes spinal nerves and blood vessels. The rela­ tionship between the somite and the motion seg­ ment has been investigated by using the biological cell tracing method of quail-chick chimeras (Huang et al 1996, 2000a, 2000b). Skeletal ele­ ments, ligaments, muscle, and connective tissue of a motion segment originate from one somite. Somitocoel cells give rise to primordial material of the intervertebral disks and are positioned in the articulation part of the motion segment. The inter­ segmental muscle is made up of myogenic cells from one somite, whereas the superficial segment­ overlapping muscle consists of myogenic cells from several somites. Segmental identity

The vertebral column consists of 7 cervical, 12 tho­ racic, 5 lumbar, 5 sacral and 4 coccygeal vertebrae. The cervical vertebrae show very special charac­ teristics. For example, the seven cervical vertebrae are typified by a foramen in each transverse process. The vertebral artery and its vein run through the foramina. Furthermore, the cervical pedicles and laminae enclose a large, roughly tri­ angular vertebral foramen, forming a channel for the spinal cord. Comparing the seven cervical vertebrae with each other, one can find conspicuous differences in size and shape. In particular, the first (atlas) and

second (axis) have special features and differ greatly from the other cervical vertebrae. The atlas consists of two lateral masses connected by a short anterior and a longer posterior arch. The trans­ verse ligament retains the dens against the ante­ rior arch. The transverse processes are longer than those of all cervical vertebrae except the seventh vertebra. They act as strong levers for the short neck muscles, making fine adjustments for keep­ ing the head balanced. The axis is an axle for rota­ tion of the atlas and head around the dens, which projects cranially from the axis body. The third to sixth cervical vertebrae have small, relatively broad vertebral bodies, and short and bifid spin­ ous processes. The seventh cervical vertebra has a long spinous process. As described above, each cervical vertebra has its own identity, so-called segmental identity. The segmental individualization of sclerotomal deriv­ atives along the craniocaudal axis is already deter­ mined in the segmental plate. When cervical somites are grafted into the thoracic region, ribs and scapula do not develop in this thoracic region (Kieny et al 1972). Each newly formed somite is identical to every other somite, in so far as it gives rise to the same cell types (muscle, bone, dermis, endothelial cells). The developmental fate of somites at differ­ ent axial levels has been found to be determined by the Hox genes, which include at least 38 mem­ bers representing 13 paralogous groups aligned in four clusters (a-d). Expression of the Hox genes begins dynamically in the prospective somites and persists stably in the somite until the begin­ ning of chondrification in the primordia of the vertebrae. Hox genes show a cranial-to-caudal expression pattern with a sequence of cranial expres­ sion boundaries that corresponds to their align­ ment on the chromosomes (Duboule and Dolle 1989). The identity of the vertebrae may be speci­ fied by a unique combination of Hox genes, called the Hox code (Kessel and Gruss 1991). For example, in the mouse the atlas is charac­ terized by the expression of Hoxb-l, Hoxa-1, Hoxa3 and Hoxd-4. The axis is specified by these four,

Copyrighted Material

Deve l op m ent and top ographical anatomy of the cervica l s p ine

plus Hoxa-4 and Hoxb-4. Changes in Hox gene expression lead to a homeotic transformation of the vertebrae. When Hox-l.l transgene was intro­ duced into the germline of mice, the cranial part of the vertebral column was posteriorized. The base of the occipital bone was transformed into a verte­ bra (proatlas), and the atlas was fused with its cen­ trum, resulting in an axis that did not possess an odontoid process. The question of how Hox genes are regulated and how they act on the behavior of sclerotome cells remains to be studied. It has been shown that retinoic acid controls the activity of Hox genes. Application of retinoic acid can cause cranial or caudal level shifts in the overall segmental organ­ ization of the vertebrae. It has been suggested that Hox genes regulate downstream genes that control the level-specific identity. These genes determine the proliferation, apoptosis, migration and differ­ entiation of sclerotome cells. As discussed above, the basioccipital bone and spine generally develop from the somites. The boundary between these two axial structures is located in the middle of somite 5. Thus, sclero­ tome of the first 4.5 somites lose their segmental characteristic and fuse to form a skeletal mass, the basioccipital bone. This process coincides with a downregulation of Pax-l in the intervertebral disks (Wilting et al 1995). The atlas and the axis differ not only in their morphology but also in their development from the typical vertebra. The typical vertebra is formed by two adjacent somite halves. However, the atlas is formed only by the caudal half of somite 5, while the axis arises from three somites: the caudal half of somite 5, the whole of somite 6 and the cranial half of somite 7. So the axis can be considered as the result of the fusion of two vertebrae. The cranial part of the axis derives from the caudal half of somite 5 and the cranial half of somite 6, while the caudal part originates from the caudal half of somite 6 and the cranial half of somite 7. The fusion of these two vertebrae is due to the degeneration of the original intervertebral disk between them during develop­ ment (Huang et al 2000a, Wilting et al 1995). The

notochord between the basioccipital and the dens axis forms a ligament, the apical ligament of dens. The third, fourth, fifth, sixth and seven cervical vertebrae derive from sclerotome halves of two adjacent cervical somites, respectively.

POSTNATAL DEVELOPMENT The structure of the vertebral column undergoes progressive change in the postnatal period, affect­ ing its growth and morphology. This process con­ tinues in adulthood. Vertebral column morphology is influenced externally by mechani­ cal as well as environmental factors and internally by genetic, metabolic and hormonal factors. These all affect its ability to react to dynamic forces, such as compression, traction and shear. The postnatal development of the cervical spine will be dis­ cussed here from different aspects, such as ossifi­ cation, uncovertebral articulation and curvatures. Ossification of the cervical vertebrae A typical cervical vertebra consists of hyaline car­ tilage with three separate primary ossification centers, which appear in the ninth to tenth week after birth. One is located in each half of the verte­ bral arch and the other one in the body. Centers in the arches appear at the roots of the transverse processes and from there the ossification spreads backwards, forwards, upwards, downwards and laterally into the adjacent parts of the vertebra. The major part of the body, the centrum, ossifies from a primary center located dorsally to the noto­ chord. The atlas is normally ossified from three cen­ ters. Each lateral mass has one ossification center at about the seventh week. Both centers extend gradually into the posterior arch and fuse together between the third and fourth year. The third center appears in the anterior arch at the end of the first year and fuses with the lateral masses between the sixth and eighth year. Ossifi­ cation of the axis is more complex (Ogden 1984).

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21

22

THE THEORETICAL BASE

9

It has five primary and two secondary centers.

fissure begins to form first at the age of

years.

Each vertebral arch and the body is ossified from

The annulus fibrosus is torn in its lateral part

one center, as in a typical vertebra. The two cen­

under the influence of gliding by vertebral rota­

ters in the vertebral arch appear about the sev­

tion. This tearing occurs in normal tissue and can­

enth or eighth week, and the one in the body

not be considered a degeneration phenomenon of

about the fourth or fifth month. The dens is ossi­

the intervertebral disk. It seems to be a prerequi­

fied from two primary and two secondary bilat­

site for the extensive cervical vertebral rotation.

eral centers. The primary centers of the dens

The tear extends from the peripheral to central

appear about the sixth month and are separated

region. Finally the cells of the nucleus pulposus

from the center in the vertebral body by a carti­

come out of the disk through the fissure. While at

laginous region. The primary centers of the dens

the age of

and the body most often fuse between the fifth

intervertebral disks in the cervical vertebral col­

and eighth years, but sometimes even later, at

umn, after the age of

about the twelfth year. Before fusion of these

vertebral disk reveals a fissure.

18-20

years, one can still find intact

20

years, each cervical inter­

three centers, the synchondrosis between them is

The uncinate process develops almost synchro­

situated below the level of the atlantoaxial joints.

nously with the uncovertebral fissure. At the age

It must be distinguished from a fracture, which

of

9

years the bone tissue of the neural arch rises

usually spreads along this structure in infants and

up adjacent to the lateral lip of the upper surface

children. Two secondary ossification centers, so­

of the vertebral body. At the end of the prolifera­

called ossiculum terminale, appear in the apex of the dens at terminale

8-10

with

tion period, the uncinate process has a shovel­

years. Fusion of the ossiculum

shaped bony ridge and fuses with the vertebral

the rest of the dens occurs

body. Thus the superior surface of the vertebral

between the tenth and thirteenth years.

body is saddle-shaped, while the inferior surface is flat or minimally concave. The intervertebral

Development of the uncovertebral joint

disk, which is split into cranial and caudal halves by the uncovertebral fissure, forms

a

gliding sur­

face on the two adjacent vertebral bodies. So an At birth the intervertebral disks are composed

uncovertebral joint forms betvveen two adjacent

mainly of the nucleus pulposus. It is a large, soft,

vertebral bodies.

gelatinous structure of mucoid material with a

extensive mobility of the cervical spine easier.

This articulation makes the

few multinucleated notochord cells, invaded also by cells and fibers from the inner zone of the adja­ cent annulus fibrosus. Notochordal cells disap­

Development of curvatures of the cervical spine

pear in the first decade, followed by gradual replacement of mucoid material by fibrocartilage,

In the normal vertebral column, there are no lat­

mainly derived from the annulus fibrosus and the

eral curvatures, but 5-shaped curvatures are seen

hyaline cartilaginous plate adjoining vertebral

in the sagittal plane.

Curvatures appear as a

bodies. The nucleus pulposus becomes much

response to fetal movements as early as 7 weeks in

reduced in the adult as the annulus fibrosus devel­

utero. Primary thoracic and pelvic curves are due

ops. A further characteristic feature of the devel­

to the bending posture of the embryo. Muscle

oping cervical vertebral column is a gradual

development leads to the early appearance of sec­

appearance of a cross-fissure in the intervertebral disk (Tbndury

1958).

After examination of over

150 cervical vertebral columns, Tondury made observation that

ondary cervical and lumbar spinal curvatures. However, the vertebral column has no fixed cur­

the

vatures in the neonate. It is so flexible that when

this so-called uncovertebral

dissected free from the body it can easily be bent

Copyrighted Material

Development and topographical anatomy of the cervical spine

into a perfect half circle. The cervical curvature develops when the head can be held erect from 3 months of age onwards and the lumbar curvature when walking starts from 1 y ear of age onwards. In adults, the cervical curve is bent forwards form­ ing a lordosis. It extends from the atlas to the sec­ ond thoracic vertebra, with its apex between the fourth and the fifth cervical vertebrae.

TOPOGRAPHY The neck is the bridge between head and trunk. Great vessels and nerves as well as the visceral structures run through the neck. The vertebral arteries, the important arteries of the brain, are topographically the closest vessels to the cervical spine. The vertebral artery arises from the subcla­ vian artery, ascends caudocraniaUy, and finally enters the foramen transversarium of vertebra C6. The artery passes through the foramina of the cer­ vical transverse processes of CIi-C1, curves medi­ ally behind the lateral mass of the atlas and then enters the cranium via the foramen magnum. OccaSionally, it may enter the bone at the fourth, fifth or seventh cervical transverse foramen. Its vein passes through the same pathway as the artery. The cervical spinal nerves are also topographi­ cally very closely related to the cervical spine. Their dorsal rami originate just beyond the spinal ganglion and pass backward on the side of the superior articular process. They supply the skin and the deep (intrinsic) muscles of the back. Deep muscles of the back developed from the epaxial my otome (see above in the section on secondary segmentation and somite differentiation) are found dorsally to the cervical vertebral column. The topography of these muscles is shown in a dissection of a fetus (Fig. 3.3). The splenius muscle (Fig. 3.3A) wraps around the other deep muscles in the neck, as its name implies (Latin: splenius a bandage). It arises from the lower half of the lig­ amentum nuchae and from the upper thoracic spinous processes. The muscle separates into two =

parts: splenius cervicis and splenius capitis. The splenius cervicis muscle joins the levator scapulae muscle to share its attachments to the transverse processes CCC4. The splenius capitis shares the attachments of the sternocleidomastoid muscle to the superior nuchal line and the mastoid process. The semispinalis capitis muscle is located beneath the splenius muscle. The semispinalis capitis mus­ cle passes from the upper thoracic and lower cer­ vical transverse processes (C4 to T 5) to the occipital bone between the superior and inferior nuchal lines. The semispinalis cervicis and the suboccipital muscles are located beneath the semispinalis capi­ tis muscle (Fig. 3.3B). The semispinalis cervicis muscle arises from the transverse process of T 6-C7 and inserts into the cervical spinous processes (C6-C2)· The suboccipital muscles are shown in Figure 3.3B and C. The rectus capitis posterior minor muscle arises from the posterior tubercle of the atlas, the rectus capitis posterior major muscle from the spinous process of the axis. These two muscles are attached side by side to the occipital bone between the inferior nuchal line and the foramen magnum. The obliquus capitis inferior muscle passes from the spinous process of the axis obliquely upward and forward to the tip of the transverse process of the atlas. The obliquus capi­ tis superior muscle passes from the tip of the transverse process of the atlas obliquely upward and backward to be inserted between the two nuchal lines of the occipital bone. The four suboccipital muscles are very well innervated (Voss 1958). They have many more muscle spindles than other neck muscles and are able to precisely inform the position of the head in relation to the neck. These muscles are innervated by the suboccipital nerve, the dorsal ramus of the first cervical spinal nerve. It emerges between the occipital bone and the atlas, and then reaches its target muscles. The great occipital nerve, the dorsal ramus of the second cervical spinal nerve, emerges between the posterior arch of the atlas and the lamina of

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24

THE THEORETICAL BASE

the axis (Fig.

3.30), below the inferior oblique

externa. Ca udally they have a discontinuous

muscle (Fig. 3.3C). It then ascends between the

attachment to the clavicle. Both of them are

inferior oblique and semispinalis capitis muscles,

enveloped in the superficial lamina of the cervical

and pierces the occipital attachments of the semi­

fascia.

spinalis capitis

and the trapezius muscles. It sup­

plies the skin of the scalp as far as the vertex. The trapezius and the sternocleidomastoid

The ventral rami of the upper four cervical spinal nerves form the cervical plexus. It supplies some neck muscles, the diaphragm and areas of

muscles are superficial cervical muscles of the

the skin in the head, neck and chest. The superfi­

neck. Both

cial branches of the cervical plexus perforate the

of them are split from one sheet of

embryonic muscle that originates from the higher

cervical fascia behind the sternocleidomastoid

cervical somites. Both muscles are innervated by

muscle to supply the skin of the occipital and cer­

the accessory nerve. Cranially, these two muscles

vical region, while the deep branches (ansa cervi­

have a continuous attachment extending

from the

calis and phrenicus nerve) supply infrahyoid and

mastoid process to the protuberantia occipitalis

diaphragm muscles. The s uper ficial branches are

Figure 3.3

Dissection of a fetal neck. A: Semispinalis capitis muscle

(1).

B: Suboccipital muscles

(4-7).

C, D:

Topography of the great occipital nerve (arrows). 2, caudal part of transversally cut semispinalis capitis muscle;

3, semispinalis cervicis muscle; 4, rectus capitis posterior minor muscle; 5, rectus capitis posterior major muscle; 6, obliquus capitis inferior muscle; 7, obliquus capitis superior muscle; Ax, the spinous process of the axis; At, the posterior arch of the atlas; 0, occipital bone; S, scapula.

Copyrighted Material

D e v e l op m ent a n d topogra ph i c a l ana tomy of the ce rvi c a l sp i ne

lesser occip i tal

(C2),

grea ter auricular

transverse cu taneous nerve of the neck and supraclavicular nerves

(C2, C3), (C2, C3)

the p revertebral cerv ical fascia l a terally to the omohyoid muscle. Our study of the developmen t of avian tongue muscles showed th a t the inirahy­

(C3, C4) .

The ventral rami of the lower four cervica l and

oid muscles a re formed b y the myogenic cells

the first thoracic sp inal nerves tie into the brachial

migrating from the occipital and higher cervical

plex us, which supplies the sho ulder gi rdle and

somites, like the in trinsic tongue m uscles (Huang

1999). Th us they a re innerva ted by the

upper limb muscles . The brachial p lexus emerges

et al

between the sca leni an terior and medius tha t arise

hypoglossal nerve and the ansa cervica lis.

from the upper cervical transverse processes and

The carotid shea th is a condensation of the pre­

descend to the fi rst rib . Inferior to the bra chial

tracheal lamina of the cervical fascia a round the

plexus, the subclavian artery also p asses through

common and internal carotid ar teries, the in ternal

the gap between the sca leni anterior an d med ius.

j ugular vein, and the vagus nerve. The common

In the case of a cervical r ib the scaleni gap could

carotid arteries originate from the brachiocephalic

become narrow, leading to a compression of the

trunk (righ t carotid artery) and direc tly from the aortic arch (left carotid artery). The carotid a r teries

brachial pl exus. While the dorsal neck muscula ture i s rela tively

ascend to the thyroid car tila ge'S upper border,

compact, the ven tral one is d ivided into several

where they divide in to ex ternal and internal

la yers and enveloped by three lamina o f the cervi­

carotid arteries. The internal j ugular vein collects

cal fa scia . The superficial lamina of the cervical

blood from the skull, brain, face and neck . It begins

fascia is con tinuous with the ligamen tum nuchae.

at the cranial base in the j ugular foramen and

It forms a thin covering for the trapezius muscle,

descends in the caroti d shea th, j oining with the

covers the posterior triangle of the neck, encloses

subclavian vein . The vagus nerve descends verti­

the s ternocleidomas toid musc le, covers the ante­

cally in the neck in the carotid sheath . After emerg­

rior triangle of the neck and reaches forwards to

ing from the j u gular foramen the vagus has two

the midline . Here i t meets the corresponding lam­

enlargemen ts, the superior and inferior gangl ion .

ina from the opposite side.

The prevertebral lamina of the cervical fascia

The pretracheal lamina of the cervical fa scia is

covers the deep anterior vertebral m u scles and

very thin, and provides a fine fascial shea th for the

exten d s la terally on the scalenus an teri or, scalenus

infra hyoid muscles. The fo ur paired infrahyoid

medi u s and leva tor scapulae m u scles . Deep ante­

muscles a re dep ressors of the larynx and hyoid

rior cervical m u scles a re the longus colli (cervicis)

bone. The sternohyoid and omohyoid muscles

and longus capitis muscles. The longus colli m us­

a ttach side by side to the hyoid b ody. The s ter­

cle extends from the body o f the third thoracic ver­

nohyoid runs down to the posterior aspect of the

tebra to the anterior tubercle of the a tlas, and i t is

capsu le of the sternoclav icular joint and adjacent

a ttached to the bodies of the verteb rae in between .

bone. The omohyoid muscle leaves the s ternohy­

The longus capitis muscle arises from the third,

oid m uscle abruptly below the level of the cricoid

fourth, fifth and six th anterior tubercles and

cartilage, passes benea th the sternocleidomastoid

ascends to the basioccipital bone to b e a ttached

muscle, and crosses the posterior triangle to the

behind the plane o f the pharyngeal tubercle.

upper border of the scapula. The th yrohyoid mus­

The cervical sympa thetic

trunk is

an

upward

cle extends upward to the grea ter horn and the

extension of the thoracic sympa thetic nerves . It

body of the hyoid bone . The sterno thyro id muscle

ascends through the neck between the longus colli

converges on i ts fel low as i t descends, until their

muscle and the prevertebra l lamina of the cervical

medial borders mee t at the cen ter of the posterior

fascia. It has three in terconnected gangli a . The

surface of the manubri um. The pre tracheal cervi­

superior cervical ganglion is located at the level o f

cal fa scia envelops these m uscles and attaches to

the second and third cervical verteb rae . The mi ddle

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25

26

THE THEO RETICAL BASE

one is usually found at the sixth cervical ver tebra

cricoid cartilage corresponds to the level o f the

and seventh is considerably

level. The third one i s the cervico-thoracic gan­

intervertebra l disk between the sixth

gl ion, which lies between the seventh cervical

vertebrae. In childhood, the larynx

transverse process and the neck of the first rib .

higher than in the a d u l t. Before birth the cricoid

The viscera cord, consisting o f the pharynx,

cartilage corresp onds to the level of the fo urth cer­

esophagus, larynx and trachea as well as the thyroid

vical verteb ra bo ttom . Owing to the grow th o f v is­

gland,

cera l cranium and descen t of the thoracic and

runs

through the space between the pretra­

cheal and prevertebral lamina. The whole larynx is

cervical organs, the larynx descends du ring post­

located at the axial level between the hyoid bone

nata l

and the cricoid cartilage in adult men. These three

schema tically illus trated in F igure

structures e xtend over three cervical vertebrae (Fig.

the larynx reaches the adult position .

development. The descen t of the larynx is 3.4. In pu berty

3.4). The hyoid bone is a t the level of the interverte­ bral disk between the fourth and the fifth vertebral bodies. The upper border of the laryn x is about one

CONC LUSI ON

vertebral body deeper than the hyoid bone and thus located

at

the level of the intervertebral d isk

between the fifth and the sixth vertebral bodies. The

In summary, our

review shows tha t the morpho­

logical and topographical complexity of the cerv i­

lower b order of the cricoid cartilage is nearly a t the

cal spine a ri ses from i ts regional specific and

level of the boundary between the cervical and tho­

gene tically

racic vertebral column. The larynx of adul t w omen is placed a b i t higher than i n m e n . The lower border of the

well-coordinated development. This leads to the ability for wide a n d p recise move­

ments and, on the other hand, guaran tees the function of the s tructures situated in it.

M

M

A

Baby

B

Position of the la rynx a t d i fferen t a g es ( a d a pted fro m von La n z a n d Wachsm u t h 1 9 55). Ax, a x i s ; C s ' t h e cervica l vertebra ; h , hyoid bone; T, thyro id ca rtila ge; m , m a n d ible.

F i g u re 3 . 4 fift h

6-7 yea rs o l d

Copyrighted Material

Deve l o p ment and to p ographic a l anatomy of the cerv i ca l s p i n e

8

o

M

M

o o C

o

1 0- 1 2 y e a rs o l d

F i g u re 3 . 4

1 5- 1 7 years o l d

Con tinued

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cervi ca l regi o n s in avian e mb ry os . Ana tomy and

Biology 28 : 1 42-1 6 1 Ogden

Schmor! G, J ung h a nns H 1968 Die gesLln d e und d i e kranke

155 :231-241

Huang R, Zhi

the somite m e soder m a s s t udied by the d evel opment o f

and vertebrate s omi toge ne s i s .

Em bryol ogy ( Berlin ) 190(3 ) : 243-250

Q, !zpisua-Be l m o n te ) -C

Kieny M, Manger A, Seng e l P 1 9 7 2 E a r l y region a l iza t ion of

Po u rq u ie 0 2000 Segme n tation of the parax i a l mesoderm

wmitocoele cells in a vi a n embryos. Anatomy and

H u a ng R, Zhi

89- 1 04

Radiology 1 2(3) : 1 69-1 77

.

R, Zhi Q,

H o meoti c t r a n s for m a t i ons

t h e a x i a l skeleton of the chi c k embryo. Developmenta l

con trols som i te bo u n d a ry pos i tion and reg u l a tes

H uang

M, G r uss P 1 99 1

of mu rin e vertebrae and concomi tant a l teration of Hox codes ind uced by retinoic acid . Cel l 67( 1 ) :

Duboule D, Do l le P 1 9 89 The s t r uc t u ra l and functiona l

8(5) : 1 497-1505

Kessel

von Ebner V 1 889 Urw i rbel und Neugl iederung der

Wi r be l sa ule . SitzLlngebera tungen Aka d e m isc h en Wissenscha ften, W i en 97: 1 94-- 206 von Lanz 1, Wa c h s m u th W 1 955 Pra k tische Anatomie . In: Der H a l s . Sp ringe r, B er li n

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27

28

THE TH EORETICAL BASE

Voss H 1958 Zahl und Anordnung def M uskelspindeln in den un teren Z ungenbeinmuskeln, dem M. sternocleidomastoid e u s und d e n Ba uch-und tiefen

Nackenrnuske ln . Ana tomischer Anzeiger 105:265-275

Wilting

J,

Ebensberger

C, M u ller TS et al 1995 Pax-l in the

development of the cerv ico-occi p ital transitional zone. Ana tomy and E m b ryolo g y (Berlin) 1 92:221-227

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ChaQter 4

______����____���

Development of the central nervous system A. Hori

CHAPTER CONTENTS Introduction

Maternal diabetes, hyperthermia and epilepsy

29

Early development of the CNS Neural tube formation

30

30

Neural tube defect: dysraphism

30

41

Maternal infection and trauma

41

Intrauterine radiation exposure

42

Conclusion

42

Anencephaly and encephalocele: dysraphism in the brain

31

Spinal dysraphism

I NTRO[)UCTI ON 32

Cerebral lateral differentiation

32

It is 32

Normal development of the forebrain Holoprosencephaly

34

Migration

nation. These anomalies can be induced by either

35

intrinsic or exogenous factors, or both.

35

The specificity of exogenous factors does not

Cortical differentiation, heterotopia, double cortex, and agyria (lissencephaly) Micropolygyria

u sually

36

infantile period

ence of these factors that is decisive. This principle

37

teratogenetic termination time 39

(the time point after

which the effect of the pathogens can no longer

39

result in a certain malformation). The experimental

Pathological myelination: status marmoratus (marbled state) of the basal ganglia Nuclear jaundice (kernicterus)

39

40

Embryofetopathy due to maternal disease or 40

Fetal alcohol syndrome

influ­

ence the development of a certain malformation) or

37

Multicystic encephalopathy

medication

is termed the teratogenetic determination period (the time span during which pathogens can

Fetal brain disruption sequences and hydranencephaly

determine the type of CNS malformation

but rather it is the time and/ or period of the influ­

36

Brain anomalies identifiable in the neonatal and

Porencephaly

possible to specify the critical time

nervous system (CNS) by morphological exami­

Migration and cellular differentiation in the brain and its pathology

u s u ally

period of the onset of malformations of the central

administration of ethanol at different stages of pregnancy produced different types of brain mal­ formations in fetuses of rats (Sakata-Haga et al

2002). While the teratogenetic determination time is relatively easy to estimate, the pathogenic fac­

40

tors are, on the other hand, not always identifiable with modern diagnostic tools such as

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in situ 29

30

THE THEORETICAL BASE

hybridization or immlmohistochemistry due to the complexity of both the intrauterine and post­ nati11 environment . In addition, the mother often did not notice anything unusual or had not felt ill at the teratogenetically suspicious period. Endogenous disorders such as chromosomal anomalies usually affect the brain heterochro­ nously and result in typical, though not specific, morphological changes which do not provide any clues to the teratogenetic determination period. Recent advances in molecular genetics have shown that normal and pathological neuroembry­ onal developmental mechanisms at molecular lev­ els are closely related to genes and their product proteins. In this chapter, however, clinical neu­ ropathological aspects will be emphasized and the molecular genetic embryology will only be dealt with briefly. Malformations are easily understood by compar­ ison with the features of normal CNS development. Therefore, several malformations will be described after brief review of each embryofetal developmen­ tal stage. The most frequent malformations are neural tube defects, disturbance of lateral differenti­ ation of the brain, and migration disorders, which we will review here. Further CNS anomalies, largely caused by environmental factors, will be described separately for the various developmental stages. Maternal factors or disorders which influ­ ence the environs of the embryo/fetus such as alco­ hol consumption, drug intake, state of nutrition, hormonal imbalance, diabetes mellitus, etc., may result in unspecific malformations since the influ­ ence of these exogenous factors is not limited to a certain period but usually continues throughout embryonal! fetal developmen t.

EARLY DEVELOPMENT OF THE eNS

Neural tube formation

The central nervous system (CNS) is the first organ that appears in the embryonal stage. The nervous system begins to develop from the neural plate

that forms the neural groove, which is present until the eighteenth gestational day, on the dorsal side of the embryo. A scheme of neural tube formation during ontogenesis of CNS is provided in Figure 4.1. The primary neural tube is formed from the neural plate via the neural groove between the twenty-second and the twenty-eighth gestational day (neurulation). Fusion of the dorsal raphe of the neural groove, beginning at the level of the mes­ encephalon, does not occur in a zipper fashion uniformly along the entire spinal cord, but rather at different points simultaneously. This explains the individually different sites of the spina bifida. Clinically well-known neural tube defects such as spina bifida or anencephaly may occur as early as in the fourth week of gestation. The dorsoventral differentiation of the neural tube is an essential development of the CNS since the motor neurons arise from the ventral and the sensory neurons from the dorsal part of the neural tube. Both areas are sharply divided by the limit­ ing sulcus at the lateral wall of the central canal. The development of the ventral part of the neural tube is inducted by sonic hedgehog protein (Shh), which is produced by the notochord, and later by the floor plate . Sensory motor differentiation is also regulated by several genes such as dorsalin-l (drs-l ). Neural tube defect: dysraphism

Dysraphism varies greatly in intensity. The most common locations of dysraphism are the lumbar and lumbosacral areas at the spinal level, and the occipital area at the cranial level (Hori 1993). Different manifestations of the dysraphism in the cranial and spinal areas are summarized in Table 4.l. The morphogenesis of the dysraphism is con­ sidered to be a disturbance of the closure of the neural tube as proposed for the first time by von Recklinghausen in 1886. This disturbance may also be induced by a local amnion adhesion. The classic observations by Marin-Padilla (1970) on

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Deve l o pm ent of t h e central nervous system

the reduction of the number of neuroblasts at the rim of the neural groove in normal human embryos as well as by Patten (1952) on the 'over­ growth of neuroectodermal tissue' (i.e. overpro­ duction of neuroblasts) causing disturbance of the neural tube closure, may be an anomaly of devel­ opmentally programed cell death (apoptosis). Another hypothesis on the morphogenesis of dys­ raphism is the secondary reopening of the dorsal neuraJ tube after its closing by embryonal 'hydromelia' (Ikenouchi et a12002), which has also been induced experimentally by cyclophos­ phamide, resulting in necrosis of the dorsal neural tube (Padmanabhan 1988). Although the causes of neuraJ tube defects are still not clear, foEc acid deficiency is considered to

be one of the most important factors in neural tube defect formation. Prophylactic evidence has been shown by giving folic acid to a group of women at risk (see later section on maternal diabetes, hyperthermia and epilepsy, p. 41). Anencephaly and encephalocele: dysraphism in the brain

If the dysraphism occurs in the cranium (Fig. 4.28), the brain is exposed to the amniotic fluid , an 'exencephaly'. Such a brain is also more or less dysraphic and the basicranium (chondrocranium) is usually dysmorphic. An exencephalic brain will be destroyed during intrauterine life. Destroyed tissue fragments are occasionally swallowed by

�+---+--H�- 3 --'I--'r--+-+-t-- 4

--+++---j-+--- 5

� o

E

\:JG

NT 3 Figure 4.1

4

5

Schema of an embryo at the later phase of neural tube formation. Different stages of the neural tube

formation are observed on the cut surfaces. 1, Neural plate structure; 2 and 3, neural groove structure (neural groove does not close like a zip-fastener, but closes multilocularly); 4 and 5, complete neural tube structure. E, Ectoderm; G, ganglion; NE, neuroectoderm; NCh, notochord; NC, neural crest; NT, neural tube.

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31

32

THE THEORETICA L BASE

Table

4.1

Neural tube defects in the cranial and

spinal region e NS

Neural tube defect/dysraphism

Brain

Anencephaly Exencephaly Encephalocele Meningocele

Brainstem

Encephalocele Meningocele Chiari anomaly type 2 Tectocerebellar dysraphy Dandy-Walker anomaly

Spinal cord

Myeloschisis Myelocele Chiari anomaly type 3

the continuing existence of the pharyngeal pitu­ itary (Hori et aI1999). Encephalocele is a partial dysraphism in the cranium, appearing as a protruding sac, usually seen on the midline in the occipital or frontal areas. The contents of the sac may be a part of the brain tissue (encephalocele), or merely lep­ tomeningeal tissue without protrusion of the brain (meningocele). Encephalocele may occur in the frontal base area , resulting in the protrusion of the cerebral tissue into the nasopharyngeal cavity. This condition is often diagnosed as nasal glioma, not meaning a neoplasm, but a malformation. Spinal dysraphism

Myelocystocele Meningocele Diastematomyelia Dermal sinus Spina bifida Cyst of the terminal ventricle Tethered cord

the fetus together with amniotic fluid, in some rare cases resulting in a heterotopic brain mass in the buccal cavity, lung or gastrointestinal tract (Okeda 1978). Exencephaly is most likely a pre­ stage of anencephaly, although anencephaly can manifest without exencephalic stages. The destruction of the dysraphic brain is fol­ lowed by tissue repair with intensive proliferation of the connective tissue, especially by vasculariza­ tion, resulting in the meshwork of proliferated vessels and remaining dysplastic brain tissues, called 'area cerebrovasculosa', which was earlier incorrectly believed to be an angiomatous malfor­ mation. In about 50% of anencephalic babies the pituitary gland is lacking, with corresponding adrenocortical hypoplasia and endocrinological anomalies. The absence of the pituitary was also incorrectly believed to be due to agenesis of the pituitary. However, the pituitary is in fact also destroyed during the intrauterine period in anen­ cephaly and replaced by connective tissue. Agen­ esis of the pituitary in anencephaly is excluded by

The listed dysraphisms of the spinal regions differ only in the severity of the defects (Table 4.1 and Fig. 4.2A). Myelocystocele is a type of myelocele in which the contents of the cele sac include the dilated central canal of the spinal cord. If the sac does not contain the spinal cord tissue but only the leptomeninges and/ or dura, this is termed a meningocele, analogous to that of the cranial region. The dysraphism may be limited within the spinal col umn without protrusion of the spinal cord tissue, which remains inside the dura in the spinal canal. This condition is known as a spina bifida occuita. Patients with spina bifida occulta may occa­ sionally complain of lumbago, motor disturbance and other symptoms, but this condition can be clinically silent. The author knows personally an athlete who has an asymptomatic spina bifida occulta. A focal trichosis or skin pigmentation on the lumbosacral midline may indicate an occult dysraphism.

CEREBRAL LATERAL DIFFERENTIATION

Normal development of the forebrain

After neural tube formation , the brain vesicles at the oral end of the neural tube develop further,

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Development of the central nervous system

Figure 4.2

Examples of different eNS

diseases. A: Neural tube defect at the spine: spina bifida aperta lumbosacralis. B: Neural tube defect in the cranium: anencephaly. C: Multicystic encephalopathy with hydrocephalus (frontal cut slices). D, E: Fetal brain disruption sequences with microcephaly and posthemorrhagic hydranencephaly in a newborn resulting from a severe maternal trauma in the later fetal phase.

F, Porencephaly (from Hori 1999, with permission of Igaku-Shoin Ltd).

G: Microcephaly and cyclopia (holoprosencephaly) in swine littermates due to intrauterine mercury poisoning at the gold mine region in Brazil (courtesy of Dr S. U. Dani, Sao Paulo).

G

rendering telencephalic hemispheres (cerebrum), diencephalon, mesencephalon (midbrain), rhomben­ cephalon (hind brain cerebellum and brainstem), and myelencephalon (spinal cord). It is during this period that brain malformation such as holoprosen=

cephaly, rhombencephalosynapsis, agenesis of the corpus callosum or cerebellar vermis develop, namely anomaly of the brain organogenesis. The correlation of normal organogenesis and its mal­ formations in this phase is shown in Table 4.2. The

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33

34

THE THEORETICAL

Table

Brain organogenesis and possible malformation

4.2

Normal

BASE

brain

development

Lateral differentiation of the forebrain

(eighth

An om a lies

Subtypes of anomalies

Holoprosencephaly

Alobar holoprosencephaly

week of gestation)

Semilobar holoprosencephaly Lobar holoprosencephaly ( according to the severity)

Lateral differentiation of the metencephalon ( fifth week of

Fusion of thalami

(unithalamus )

gestation ) Lateral differentiation of the

Rhombencephalosynapsis

rhombencephalon ( fifth week

Typical and incomplete forms of rhom bencephalosynapsis

of gestation) Commissural fiber formation

(beginning

at the fifth week of

Agenesis of the corpus callosum

Total and partial agenesis with anomaly of the gyral pattern of the medial surface of the

gestation, completed in the

cerebral hemispheres

sixth month) Differentiation of cerebellum

Agenesis of the cerebellum

Agenesis and hypoplasia of the cerebellum

Agenesis of a part of the

Agenesis of the cerebellar vermis

cerebellum Twin

Duplication as an

Craniopagus, including Janus anomaly

incomplete form of duplicitas Duplication of a part of the brain, e.g. pituitary, cerebellum, brainstem and spinal cord Sulcus and gyral formation

Lissencephaly ( agyria)

Lissencephaly Partial agyria

formation of the cerebral sulci and gyri also belongs to organogenesis, but occurs much later (from the fourteenth week of gestation, intensively after the twenty-first week). In this section, only holopros­ encephaly is reviewed. Hol oprosencephaly

Holoprosencephaly is a relatively common mal­ formation of the brain which is due to distur­ bance of its lateral differentiation, occurring around the eighth week of gestation. The brains of typical cases display no divided hemispheres and a single ventricular system. The meten­ cephalon (thalamus) is also not divided but is singular. The eye is also single, being termed cyclopia. T he olfactory bulbs and tracts are lacking. This was why holoprosencephaly was

synonymously - and incorrectly - termed arhi­ nencephaly. Different craniofacial anomalies are frequently accompanied by holoprosencephaly. A typical manifestation is a spectrum of hypotelorism, including cyclopia or proboscis instead of a nose (Table 4.3). Since a typical holoprosencephaly dis­ played typical facial anomalies, the principle 'face predicts brain anomaly' was proposed earlier. However, because of the broad morphological spectrum of the intensity of the malformations in craniofacial as well as brain anomalies, this princi­ ple is no longer of use. In our own archives there are two cases of (lobar or semilobar) holopro­ sencephaly without craniofacial anomalies. In holoprosencephaly, some non-obligatory facial anomalies may be complicated such as different intensity of cheilopalatoschisis.

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Developm ent of th e central nervous system

Table 4.3

Morphological spectrum of the intensity of brain and craniofacial anomalies in holoprosencephaly Severe anomaly

Slight anomaly

Synopia

Cyclopia

Normal eyes

Hypotelorism

Normal nose

Only one opening of the nose

No nose but nostril ( proboscis) above

Lobar holoprosencephaly

Semilobar holoprosencephaly

Alobar holoprosencephaly

Corresponding to the clinically broad spec­ trum of the intensity of holoprosencephaly (Table

4.3), many different genes play a complex

MIGRATION AND CELLULAR DIFFERENTIATION IN THE BRAIN AND ITS PATHOLOGY

role in constructing this abnormal morphology. Some of the genes of familial holoprosencephaly

Migration of neuroblasts is an essential part of the

(,HPE' 1�5) are identified and located on the

histogenesis of CNS. In principle, organogenesis is

chromosomes. For example, sonic hedgehog

followed by histogenesis, although both phases

HPE3), which was found to produce dou­

overlap. In the early phase of neurulation, a stem

ble formation in an individual, is located on

(5hh

cell wall attaches to the central canal side with one

=

5hh

end and reaches the mantle side with the other

was considered to be one of the causes of holo­

end. The nuclei of these stem cells shuttle inside

chromosome 7q36. Haploinsufficiency for

prosencephaly (Roessler et a11996, 1997). A com­

the elongated cytoplasm between the central canal

5hh pathway, the receptor PTCH

side and the mantle side (,elevator movement') in

(Patched-1), was recently identified, a mutation

accordance with the cell cycle: the nuclei display

of which can cause holoprosencephaly (Ming et

mitosis and division while they are situated in the

ponent of the

al

(M phase) and DNA synthesis is

2002).

central canal side

On the other hand, extrinsic factors may also

active while they are located in the outer surface

cause holoprosencephaly as described in the litera­

side of the neural tube

(S phase).

ture, for example anhepileptics taken by the mother (Homes and

Harv ey 1994, Kotzot et al 1993, Rosa

Migration

1995), maternal alcohol abuse (Bonnemann and Meinecke 1990b) or intrauterine cytomegalovirus

During and after their production in the periven­

infection (Byrne et al 1987). In a gold mining dis­

tricular zone, the neuroblasts migrate along the

trict in Brazil, holoprosencephaly occurs fre­

radial glia towards the brain mantle in the phase

quently in cattle, probably due to the mercury

of brain vesicle formation. The speed of the neu­

4.2G), although intrauterine mer­

70 in the region of the olfactory bulb (Tama­ maki et aI1999). In the mantle zone, the cortical cell

pollution (Fig.

cury intoxication does not cause holoprosen­ cephaly in humans but developmental anomalies

roblast migration is estimated at a maximum of

�m/h

of motoric nerve bundles and commissural bun­

layers are formed where neuroblasts differentiate

dles (e.g. fetal Minamata disease due to industrial

to the nerve cells. The neuroblasts migrate along

pollution in Japan).

the radiating glia from the subependymal zone in

Clinically, patients are severely or very severely

the direction of the marginal mantle zone where

handicapped due to the prosencephalic malfor­

Cajal-Retzius cells are found. Cajal-Retzius cells,

mations. In less severe cases, it is possible to sur­

the first differentiated cells containing neurofibrils,

vive to adulthood.

recognizable as early as the forty-third gestational

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35

36

THE THEORETICAL BASE

day (Marin-Padilla and Marin-Padilla 1981) and

ular nodular heterotopia, filamin 1 (FLN1) muta­

constantly observed from the fiftieth day on, pro­

tion was identified as a genetic defect causing the

duce the extracellular protein 'reelin' that inacti­

hereditary nodular heterotopia (Fox et al 1998).

vates the migration of the neuroblasts. The next

Familial nodular heterotopia is linked to the gene

migrating neuroblasts pass over the neuroblasts

located in chromosome Xq28 in females. In males,

that have already arrived at the cortex and ceased

the same Xq28 gene is considered to be responsi­

to migrate, until they come in contact with reelin.

ble for bilateral nodular heterotopia combined

In this manner the outer cortical layer is formed

with frontonasal malformation (Guerrini and

by newcomer neuroblasts: 'inside-out law'. The Cajal-Retzius cells reduce in number by

Dobyns 1998). Pathomechanisms of the migration disturbance can be explained by the disruption of

apoptosis in the peri- and postnatal period. Exces­

the radial glia along

sive residual Cajal-Retzius cells were previously

migrate from the subependymal to cortical zone

which

the neuroblasts

discussed as one of the possible causes of seizures

(Santi and Golden 2001). This condition may

in epileptic patients.

explain a non-hereditary occurrence of nodular

Disturbed migration results in heterotopically

heterotopia.

located nerve cell groups; heterotopia refers to a

Laminar (band) heterotopia is a diffuse arrest

nerve cell group that is found in anatomically

of migration and is found in the (subcortical)

incorrect regions such as the subependyma or the

white matter as an additional nerve cell layer

subcortical white matter and have either nodular

(hence, double cortex syndrome). The gene DeX

or band form. These anomalies may be caused

is located on the X chromosome and produces the

by genetic defects as well as by many kinds of

protein named doublecortin. The mutation of this

extrinsic factors such as intrauterine exposure to

single gene is the cause of two different types of

radiation (see section on intrauterine radiation expo­

migration disturbances: double cortex syndrome

42), fetal circulatory disturbance (see section

in females and lissencephaly in males. In females

sure, p.

on micropolygyria below).

(karyotype XX), mutant X disturbs the neuronal

Cortical differentiation , heterotopia,

migration, i.e., some of the neurons migrate regu­

double cortex, and agyria

larly but the migration of others is disturbed and

migration; however, non-mutant X forwards the

(l issencephaly)

they therefore make up the subcortical hetero­ topia in a laminar form. This condition is termed

In males (karyotype

The neuroblasts that arrived in the cortex then dif­

'double cortex syndrome'.

ferentiate to the cortical nerve cells with a topo­

XY), the migration is completely disturbed by

graphically typical laminar structure, usually

mutant X so that a severe form of lissencephaly

consisting of six layers.

occurs,

but

no

double

cortex.

Another

A migration anomaly results in nodular hetero­

lissencephaly, morphologically identical to the

topia (periventricular heterotopia), subcortical

hereditary ones, is caused by the LIS1 gene,

laminar (band) heterotopia (double cortex syn­

located on chromosome 17.

drome), and agyriajpachygyria (lissencephaly)

Clinically, lissencephaly and laminar heterotopia

(Schull et al 1992). Nodular heterotopia is a focal

(double cortex synruome) form a morphological

arrest of migration, usually identified in the

substrate for severe psychomotor retardation.

periventricular areas as single or multiple nodules of nerve cell accumulation, and clinically may be a

Micropolygyria

focus of epileptic discharge. In our experience, there is silent single heterotopia in 0.7% of routine

Micropolygyria (or polymicrogyria) is not a pre­

necropsy series. In X-linked dominant periventric-

cise description although the term is generally

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Development of the central nervous system

accep ted since the cortical surface of this anomaly

group

does not consist of

Warburg syndrome (linked mostly

small gyri.

The gyri them sel ves a re ra ther pachygyric and the s u rface has the appea ra nce of

a

cobble stone

of m us cle-eye-br a in d isea ses, Walker­

to chromosome 17q) or the Fukuyama type of muscle dystrophy

(linked to chromosome 9q31-33), known as auto­

pavement. His tological ly, the cortical surfa ce is,

somal recessive hereditary diseases,

corresponding to its gross appearance, very irreg­ randomly in t o the leptomeninges through the bro­

exogenous. Clinical manifestations of microp olygyria gen­ erally consist of psychomotor reta rda tion and

ken

subpial l imitin g glia l membra ne. The co rtical architecture is also abnormal, with small i slets of neuronal mass, and the v ir tua l molecular la yers are irregularly confluent. A no ther typical cortical

typically seizures .

BRAIN ANOMALIES I DENTIFIABLE IN THE

feature is a four-layer p a t tern due to an in terme­

NEONATAL AND INFANTILE PERIOD

ularly configured and the s urface neurons inv a d e

diate nerve fiber la yer between the neuronal layer (I, molec ula r layer; 2, ex ternal nerve cell layer; 3,

and is not

ex ogenous

Brain a n omalies recog ni z a b le in the postna tal period may have occurred either d uring intrauter­ ine life or in the perina tal as well as postnatal period. The majority of these anom alies a re due to an encephalocla s tic process of ex trinsic cau s e s, for

cause in micropolygyria, although end ogenous

example birth trauma, perina ta l hypoxia, infec­

i crop ol yg yr ia may also be focally limited. The lesions a re, in the m a j o ri ty of cases , not diffusely distrib uted but localized or coex is tent with o ther lesions such as porencephaly (see later section on

tion , etc . Complica tions in twin concep tion ( such

nous in the strict sense of the word . The disorders

porencephaly, p. 39). A representati ve case is that

described in this section include different syndromes

of a 27-week-old fetus in which micropolygyria

and diseases which are not grouped

was limi ted to the dis turbed supplying area of the

and which exclude brain

myelina ted nerve fiber l ayer; 4, internal nerve cell la yer) The abnormal .

cortical la yer may show a n

ab rupt bound ary t o the intac t six-layered cortex. This sugges ts foca l injury and

thus

an

m

as

fetofetal transfusion synd rome) may also be

incl uded in this group although they are not exoge­

systematically malformations.

middle cerebral a rtery (Richman et al 1974). Fur­ ther reports of in trauterin e

CO intoxica tion at the fifth gestational month or at the twenty-fourth week (Bankl and Jellinger 1967) confirm an ex oge­

Fetal brain disruption sequences an d hy dranencephal y

nous cause of micropolygyria. In tra uterine infec­

This clinical concept includes a ll encephalocl a s tic

tion with cytomegalovirus

processes which involve

(CMV) is known to cause

a brain

malformation (micropolygyria, micren­ is other evidence that micropolygyria in congenital CMV infection is a result of circulatory disturbance (Marques Dias et al 1984). Small focal micropolygyria may also be observed in endogenous CNS anomalies such as cephaly). However, there

a collapse of the skull or microcephaly with organic brain da mage in men t ally and physic a l l y h a n d i c apped b a b ies (Fig . 4 2 D). Etiopa thogenetically, these disorders may occur .

in every embryofetal s tage from very differen t

causes, such as viral

or parasi tic infection or circu­

thana tophoric dysplasia (Hori et al 1983). The ter­

la tory dis turb ances in la ter fetal stages, analogo u s

a togenic determination period is though t to be

to hydranencep haly. The

between 17 and 26 weeks of gestation (Golden 2001) .

cases are

Micropolygyria accompanied by widespread pachygyria

(pachygyric micropolygyria) is termed in the

lissencephaly type 2. This type 2 is typical

maj ority o f the rep orted

sporadic. However, Alexander repor ted occurrence in sisters, suggesting some gene tic componen t (A lexander et aI1995). In this con tex t, an

a recessivel y inherited vasculopathy resul ting

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in

37

38

THE THEORETICAL BASE

hydranencephaly-hydrocephaly disorder (Harding

tic processes. The brain shows only a contour of the

et a11995) should also be included in this group of

cerebral mantle

disorders.

since the majority of the telencephalic structures are

Microcephaly or overlapping sutures is a typical clinical manifestation (Fig.

4.20). The baby has a nor­

mal craniofacial appearance. Hydrocephalus may also occur but is not obligatory. Sonographic

and

and is filled with cerebrospinal fluid fluid (Fig. 4.2E). In

destroyed and replaced by

extreme cases, only the molecular layer and residual parts of the cerebral cortex

are

is practically no white matter

preserved, but there

or

internal structures.

radiological examination as well as transillumination

The brain substance is destroyed by colliquation

of the head confirm the diagnosis. Neurological

necrosis.

symptoms include seizures, spasticity, myoclonus,

ally survives for a short time.

If the brainstem is preserved, the fetus usu­

cortical blindness and optical atrophy. Prognosis is

Hydranencephaly can occur after the fourth

very poor and most patients die shortly after birth.

gestational month, though usually after the sev­

Surviving babies are severely handicapped.

enth month (gestational week

The brain changes largely include hydranen­

28) when the brain

is formally 'completed' (though immature), since

4.2E) and/or cerebrocortical damage.

cortical dysgenesis such as micropolygyria or

Hydranencephaly is essentially not a type of mal­

migration disturbances and other kinds of brain

formation but a residual state of the encephaloclas-

malformations are usually lacking in hydranen-

cephaly (Fig.

Unknown causes

24.1%

37.1%

Circulatory disturbances

30.2%

N

=

116

Intracranial hemorrhage 2.6% Other exogenous causes 6.0%

Figure 4.3

Different causes of hydranencephaly. based on the a n alys is of cases reported in the literature as well as

from the author's own archives. Note that a quarter of all cases of h yd ra n enc epha l y are caused by intrauterine e n cephalit i s .

Copyrighted Material

Development of the central nervous system

cephaly. The cortical gyral structures are nor­ mally recognizable although the subcortical structures are totally or subtotally destroyed. Normal configuration of the ventricular system is therefore radiologically or sonographically often not detectable. The causes of hydranencephaly vary greatly; for a majority of the cases, intrauterine encephalitis and trauma are responsible (Fig. 4.3). No matter what the initial cause is, an additional circulatory disturbance of the brain followed by diffuse necro­ sis plays a major role in establishing hydranen­ cephaly. A recessively inherited vasculopathy is another cause of hy dranencephaly, as already cited (Harding et al 1995). In a few cases, hydranen­ cephaly may occur after birth as a result of cerebral infarction complicated by widespread meningitis and/or intracerebral hemorrhage (Lindenberg and Swanson 1967). Neonatal (including perinatal) meningitis is often complicated by focal or multiple infarction, followed by hydrocephalus due to absorption dis­ turbance of the cerebrospinal fluid if the patients survive the acute phase of the infection . Intrauter­ ine meningitis is extremely rare. We observed one such case with evidence of the transplacental infection (Hori and Fischer 1982). Multicystic encephalopathy

Multicystic encephalopathy is one of the severest cerebral disorders with multiple cavity formation in the cerebral hemispheres due to encephaloclas­ tic processes (Fig. 4.2C). This condition is usua lly accompanied by hy drocephalus and lack of sep­ tum pellucidurn. The remaining cortical ribbon is very thin. Basal g ang l ia, thalamus or even brain­ stem may also show microcystic changes and there is severe nerve cell depopulation or calcification of dead nerve cells. As a result of the parenchymal destruction, glial scar formation (including ule­ gyria) is usually observed. Severe circulatory disturbance during the late intrauterine and/or neona tal phase is the main pathogenesis of this condition, for example steno-

sis of the carotid arteries. However, the causes of the cerebral circulatory disturbance resulting in multicystic encephalopathy are very different birth trauma, intrauterine viral infection, etc. Sev­ eral twins with this condition have been recorded in the literature. The majority of patients are neonates with different neurological manifestations since the brain changes occur usually in the perinatal phase. Rarely, surviving 'shaken baby syndrome' patients also manifest multicystic encephalopathy together with other typical signs of the syndrome. Porencephaly In contrast to hydranencephaly and fetal brain disruption sequences, porencephaly displays congenital, partial cerebral destruction (Fig. 4.2F). Porencephaly is defined as a communication between the inter na l and external cerebrospinal spaces due to partial destruction of the brain, occurring in the middle and later fetal stages. Post­ natal porencephaly is an exception (Cross et al 1992). The lesions are usually seen bilaterally and often in the central to parietal regions. The tissue of the lesion shows glial scar formation and sometimes micropolygyric changes in the cortex at the mar­ gin of the destructive lesion (Tominaga et aI1996). Rarely heterotopic neurons are observed near the lesion. However, the micropolygyric or hetero­ topic changes are interpreted as secondary, since the encephaloclastic damage is thought to be a result of extrinsic causes at the time of migration. In some cases of porencephaly, however, this con­ dition is observed in successive generations or in twins and a genetically defined etiopathogenesis has also been considered (Brewer et al 1996, Jung et aI 1984).

Pathological m yelination: status m arm oratus (m arbled state) of the basal ganglia

Normal my elination begins in the second fetal trimester in the brainstem. In the spinal cord, the sensory fascicles show earlier myelination than

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39

40

THE THEORETICAL BASE

the motor fascicles, but the motor spinal roots are

related to differences in the topographical devel­

myelinated earlier than the sensory spinal roots.

opment of the blood-brain barrier. Choreoa­

The cerebral white matter myelination is com­

thetotic movement disorders and psychomotor

pleted by 1 postnatal year. The complete myelina­

retardation are major clinical manifestations of

tion of the reticular formation may be as late as

this 'nuclear ' jaundice.

puberty. Status marmoratus (marbled state) of the basal ganglia, occasionally also of the thalamus, repre­

EMBRYOFETOPATHY DUE TO MATERNAL

sents glial scars with irregular hypermyelination

DISEASE OR MEDICATION

associated with neuronal loss. This indicates that the disorder is not a congenital malformation but

Fetal alcohol syndrome

an acquired condition. Since the myelination in the basal ganglia commences at the sixth month of

Maternal chronic or excessive alcohol consump­

postnatal life, the status marmoratus is thought to

tion, in particular in the first trimester after the

occur around this period at the sites of the scars

conception, can lead to the unspecific congenital

that may have occurred earlier than 6 months of

anomaly of the baby, an (embryo)-fetal alcohol

age. The clinical features of patients prior to this

syndrome. Not only ethanol itself, but also its

critical period include birth complications such as

intermediate metabolite acetaldehyde is consid­

asphyxia as well as cyanosis, resuscitation and

ered to be embryo toxic.

convulsions. These complications result in dam­

The newborn baby is small for dates, which

age to the basal ganglia and thalamic regions. In

may be recognized during in utero examination,

older infants, rigidity or choreoathetosis is a com­

and shows

mon clinical manifestation. Mental retardation or

authors describe the craniofacial anomalies in

movement disturbances such as spastic paraple­

fetal alcohol syndrome as typical: short eyelids,

craniofacial

dysmorphism.

Some

gia may also manifest. The average life expectancy

broad nasal root, flat and long philtrum, thin

of children with status marmoratus is approxi­

upper lip, occasionally blepharophimosis and

mately 12 years of age.

anti-Down eyelids. Generalized malformations in these patients are usually not remarkable. Slight

Nuclear jaundice (kernicterus)

craniofacial dysmorphism may partly regress by

Severe neonatal hyperbilirubinemia may result in

normalize while the lower IQ remains unchanged.

'nuclear jaundice'. One of the major causes of this

However, a long-term prognostic study showed

disorder is megakaryocytosis due to Rh incompat­

that adequate education may improve learning

ibility. However, the nuclear jaundice is merely an

ability since the postnatal development of these

the time of adolescence; the body weight may also

unspecific 'bilirubin encephalopathy', regardless

patients varies (Streissguth et al 1991). Recorded

of the cause of hyperbilirubinemia.

brain anomalies are various and unspecific in con­

Since the

blood-brain barrier is still immature in neonates,

trast to the relatively uniform craniofacial anom­

bilirubin reaches brain parenchyma so that the

alies: hydrocephalus, cerebral heterotopia, agenesis

caudate nucleus, putamen, globus pallidus, sub­

of the corpus callosum, dysraphism, or poren­

thalamic nucleus, hippocampus, cerebellar den­

cephaly;

tate nucleus and olivary nucleus are selectively

recorded (Bonnemann and Meinecke 1990a).

even

holoprosencephaly

has

been

and bilaterally yellowish colored and nerve cells

Experimentally, reduction in the number of

undergo degeneration. The different distribution

pyramidal nerve cells (Barnes and Walker 1981),

of the changes in patients of different ages may be

depression of glutamate release and decrease in

Copyrighted Material

Develo p m e n t of t h e ce n t r a l n e rvous system

gl u ta m a te binding (Farr et a 1 1 988), and changes

The incidence of malforma tion among infants of

in neu ro troph i c a c t i v i ty (Hea ton et a l 1 9 95) of

epileptic m o thers who w ere not ta king antiepilep­

the hippocampus a re d emonstrated, the la tter

tic drugs was 4 . 8 % . In trau terine head gro w th was

being an important a rea for memory fu nction. In

correlated to the number of antiepileptic d rugs

animal experiments, d i fferent brain malforma­

taken by mothers (Battino et a l 1 992) . Serum and

tions

cerebrospinal fluid levels of folate were reduced in

were p r o d u c e d in b o th the c e reb r u m

(incl u d i n g

leptomeningeal

hete r o t o p i a )

and

a high percen tage of epilep tic pa tients trea ted

cerebell u m by i n trau terine e x p o s u re t o e thanol.

with antiepileptic drugs ( Raynolds

Sched u l e d

at d i ffe rent

known to b e an important factor in p reventing the

times in the p regna ncy induced d i ffere n t types

risk of neural tube defect, so tha t mothers who

of cereb ral malforma tion in fe tuses (Saka ta-Haga

already have dys raphic babies are advised to take

e t al

alcohol

c o n s u m p tion

2002 ).

1973 ) . Fola te is

folic acid as a prophylaxis, even prior to the planned conception . Therefore, it is likely tha t

Ma terna l dia betes, h ypert h erm i a a nd

antiepi lep tic-drug-rela ted fa c tors predomina te

epilepsy

over genetic predisposition as the cause of ma lfor­ mation in cases of ma ternal epilep sy. Howev er,

Ma ternal diabetes mellitus p ossibly influences the

the m o ther ' s convulsion i tself should also be

m orphology of embry os / fetuses. Babies born to

regarded as a possible teratogenic factor (Leppert

diabe tic mothers a re usually large for d a tes. A

and Wieser 1 993)

in a d d i tion to the genetic factors.

high incid ence of anomalies such as Down syn­ drome (Narchi and Kulayla t 1 997), preaxial poly­ d a c tyly (Slee and Goldblatt 1 997)

regression syndrome (Passarge a n d Lenz 1966, Willia mson

197 0)

M atern a l infection a nd traum a

or c a u d a l In cases of ma ternal infection, virus or bacteria

have been recorded in the litera­

may be transported v ia the placenta to the fetus

tu re . O ther mal forma tions have also been sporad­

and feta l CNS . Cytomegalovirus is know n to

ically reported . Early in tellectual developmen t in

cause micropolygyria wi th microcephaly; how­

children of diabe tic mo thers is p oorer than in

ever, the teratogenic d e termin a tion period is lim­

those of non-diabetic mo thers (Yamashita et al

i ted to the la ter migration phase ( till the end of the

1996). The tera togenic mechanism of m a ternal dia­

fourth gestational month; see sec tion on micro­

betes mell itus is not known; however, n o t only

polygyria, p .

d i abetes melli tus, b u t also the effect of medical

fe tal period, e . g . herpes v irus, are known to cause

control of diabetes should be discussed.

severe encephaloclas tic processes such as hydra­

36) .

O ther viral infections in the l a ter

Ma terna l hyperthermia is shown to result in

nencephaly (see section on fe tal brain d isrup tion

embryofetal malformations experimentally (Shiota

sequences and hydranencephaly, p . 37) . However,

1 988, Sh i o ta et al 1988) . Several case repo r ts

other factors such as circulatory disturbances are

describe dysraphism or facial dysmo rphism in

assumed to play a much more important role in

humans.

the p a thological morphogenesis than the virus

Epileptic mothers have a risk of gi ving b irth to malformed children with or without CNS anom­

i tself. Severe ma ternal trauma w i th u te r i ne inj u r y

a lies. According to the study by Canger et al

a n d / or b l e e d i n g m a y also ca use fe tal anomaly.

( 1 999), the overall incidence of malformations (not

Hydranencephaly is documented

only CNS malformations) in sib lings b orn to

ture as well as in our archives) as one of the

epilep tic mothers was 9 . 7% . The maj o r i ty o f the

re s u l ts

mothers were treated with an tiepilep tic drugs.

mo ther.

Copyrighted Material

of

accidental

s e v ere

(in the litera­

tra u m a

to

the

41

42

THE THEO RET I CA L BASE

I ntra u terine radiation exposure

CON C L USION

Therapeutic or accidental exposure to irrad iation

Knowledge of the process of normal neuroembry­

as well as nuclear bomb exposure during embryo­

onal development helps in interpreting the malfor­

fe tal l ife may also cause CNS anomalies.

mations of the cen tral nervous system, especially

Much traged y was seen in children born to sur­

in cases of neural tube defec ts (including anen­

viving pregnant victims of the atomic bombs (ion­

cephaly), holoprosencephaly and migration anom­

izing rad iati o n ) in Hiroshima and Nagasaki .

alies such as lissencep haly or heterotopia. These can

be induced endogenously by

Significan tly, frequent men tal re tardation and

anomalies

microcephaly was observed in such children

genetic errors and also by environmental (exoge­

(Otake e t al 1989) exposed to atomic bomb irradi­

nous) factors . Exogenous factors, such as infection,

ation before the twenty-six th ges tational week,

trauma, in toxication and other maternal condi­

an d mostly b e tween the eighth and fifteen th

tions, may ind uce differen t malformations, mostly

week . The children who were exposed in the

independent of the factors but dependent on the

eighth and n in th weeks of gestation showed men­

pathogenically effec tive

tal re tardation as a result o f bilateral periv en tricu­

effects of exogenous

lar

time p e r i o d . Chronic

fac tors or chromosomal

by

anomalies may produce unspecific though typical

magnetic resonance imaging. The fetuses that

anomalies due to their heterochronous pathome­

were exposed to the atomic bomb during the

chanis m . Clinically severe brain d isorders may be

twelfth / thirteen th week of ges tati on showed no

produced by encephaloclastic processes due to

heterotopia b u t pachygyria. Even low-dose ioniz­

hypoxia, circulatory dis turbance, trauma, and

he tero topia

which

was

ascertai ned

ing irradiati on in utero resulted experimentally in

many o ther causes mos tly during the perinatal

migration anomalies (Fushiki et al 1994, 1996).

phase as well as in the latest fe tal stage. Despite

Intrauterine X-i rradiation was expe rimen tall y

having the same etiopathogenetic factors, pheno­

ascertained as the cause of a deceleration in the

typically different brain anomalies may

m i gration

cortical

duced depending on the time of onset of the

Therapeutic or prophylactic X-ray irradiation to

porencephaly and polycystic encephalopathy due

of

neuroblasts

(including

be pro­

causes, for example a series of hydranencephaly,

derangement) (Fushiki et aI 1997) .

disturba nces. The search for

the head in leukemic children is known eventually

to brain circulatory

to resul t in meningiomas (or gliomas and other b rain

possible causes of CNS anomalies should lead to

tumors) about 10 years later as a delayed side effect.

the prevention of the d isorders.

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Schull W, Nishi tani H, Hasuo K e t a 1 1992 Bra in abnorm a l i ties among the menta l ly retarded prena tally exposed a tom.ic bomb survivors , RERF Technicak Report Series 1-16 Shiota K 1988 Induction of neura l tube defects and skeleta I m a l formations in mice follow ing b rief hyperthermia in u tero. Biology of the Neona te 53(2) :86--97 Shiota K, Shionoya Y, Ide M et al 1 988 Tera togen ic interaction of ethanol and hyperthermia in mice. Proceed ings of the Society for Experimenta l Biology and Med icine 1 87(2) : 1 42-1 48 Slee J, Goldblatt J 1 997 Fu rther evidence for p rea xia l hall ucal polydactyly as a ma rker of diabetic embryopa thy, Journal of Med ica l Gene tics 34(3) :261-263 Streissguth A P, Aase J M, C larren S K e t a l 1991 Fe tal alcohol syndrome in ado lescents a nd adu lts. Jou rnal of the America n Med ica'! A ssocia tion 265(15) : 1 961-1967 Ta mamaki N, Sugimoto Y, Ta n a ka K e t a l 1999 Cel l migration fro m the gang l iOnic eminence to the neocortex i nvestiga ted by labeling nuclei with UV irradiation via a fiber-optic cable. Neu roscience Resea rch 35(3) :24 1 -251 Tominaga 1, Kaihou M, Kimura Y et a.l 1996 [Cy tomega lovirus feta l infec tion, Porencepha l y with p olymicrogyria in a 1 5 -ye a r- old boy] , Rev ue Neu rologique (Paris) 152(6-7) :479-482 von Recklinghausen F 1 886 U n tersuch u n gen i.i.ber die Spina bifida , Virchows A rchiv 105: 243-330 Wi l l iamson D A 1 970 A syndrome of congeni ta l ma lformations possibly d u e to maternal dia betes, Developmental Medicine and Chi l d Ne ur ology 1 2 ( 2) : 1 45-152

Ya mashita Y, Kawano Y, Ku riya N et al 1 996 Intellectual development of offspring of d iabetic mothers, Acta Paed ia trica 85 ( 1 0 ) : 1 1 92-1196

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Ch a pter 5

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Ad a ptive p ro p e rti es of m oto r b e h avi o r J . - M . Ra m i rez

I NTRODUCT I ON

CHAPT ER CONTENTS Introduction

45

Th e genera tion of rhythmi c activity: the concept of a central pa ttern generator ( C P G )

46

The role of proprioceptive input in the gene ra tion of rhythmic activity

48

Sta te-dependent modulation of reflex pa thw ays

50

Neuromodulation and reconfiguration of rhythm-genera ting networks within the central nervous system

50

The development of motor neural networks Conclusion s

52

52

The ability to walk and to maintain posture depends on a complex integration of many intrin­ sic and extri nsic fac tors . The basic w alking rhythm is generated by a neuronal network, which is located within the spinal cord (Kiehn and Kj aerulff 1998). This network is capable of gener­ ating reciprocal neural activity, which is sent via motor neurons to the periphery where it activa tes muscles that produce al terna ting limb move­ ments. Each of these l imb movements is the result of a complex activation of numerous antagonis tic and agonistic muscles that lead to the genera tion of a step, which consists of a swing and stance phase . The exact timing and also the shape of ac ti­ vation of each of these muscles is highly influ­ enced by the properties of the muscles and the activation of sense organs loca ted within the mus­ cles and tendons of each limb, the so-called pro­ p r iocep tors . The activa tion of proprioceptors feeds back to the neuronal network located w i th i n the central nervous system, which a djusts the intrinsically genera ted motor activity in a cycle­ by-cycle manner to the constantly changing extrinsic conditions, s uch as the surface of the ground (McCrea 2001, Pearson and Ramirez 1997). Besides these rapidly occurring adaptive processes, long-term changes are also very charac­ teristic and essential for normal locomotor behav­ ior. The timing of proprioceptive feedback has to

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46

THE TH EORETICAL BASE

be adj usted to long-term changes in body size. In the developing child, new locomotor m ovements are learned, or exis ting movements are refined as the chi ld is growing . This motor learning will be associa ted with a complex change in the activation pa ttern of individual muscles (Okamoto et al 2001 ), in neuronal networks located within the spinal cord (Nakayama e t al 2002), as well as com­ plex changes in the afferent feedback (Ronces­ valles and Woollacott 2000). Adaptive processes are not only cri tical during development, but also important in the adult as body weigh t may change drastically over weeks and months (Barbeau and Fung 2001, Pearson 2000). Inj ury will also change the gain of propriocep tive reflexes over several mon ths, which will affect not only locomotion, but also posture (Barbeau et al 2002, Bouyer et al 200 1, De Leon e t al 2001 , Rossignol 2000, Whelan and Pearson 1997) . Vice versa, changes in posture may affect s tep size and timing during locomotion. Many of these long- term changes may be explained by changes in the response of the cen­ tra l nervous system to afferent inpu ts from pro­ priocep tors or by changes in the excita tory drive to proprioceptors tha t derives from gamma motor neurons, which can change the gain of reflexes in a sta te-dependent manner (Lam and Pearson 2002, Pearson 2000, 2001, Prochazka 1 989) . An important role in these adaptive changes can be attribu ted to neuromodula tors, which are sub­ stances tha t alter membrane properties of neurons involved in the genera tion of rhythmic motor activi ty. In inj ury, for example, endorphins are released . These peptides can potentially alter not only reflexes, but also membrane and synaptic properties of neurons within the central nervous system, thus resul ting in long-term changes in wa lking behavior. This chapter will review concepts and princi­ ples tha t have been established in various animal models in order to explain how the nervous sys­ tem prod uces a locomotor behavior. Many of the principles tha t are directly relevant for human locomo tion have been established in a v ariety of animal models, which were used to study not only

locomotion, but also other rhythmic behaviors. Here I will summarize these genera l principles of rhythm generation, which are applica ble not only to how the nervous system produces walking in particular, b u t rhythmic activity in genera l.

THE GEN E RATION OF R H YTHMIC A C T I VIT Y : T H E CONCEPT OF A C E NT RAL PATTERN GENERATOR ( C PG)

As mentioned above, the nervous system gener­ a tes not only w alking, but many forms of rhyth­ mic activi ty, which dominate our daily l ife . When we become tired in the evening, this is not only because we are physically exhau s ted. More likely, it is because our 'internal clock' tells us tha t it is time to sleep (KulJer 2002, Zisapel 2001). In the morning we wake up, beca use our internal clock 'reminds' us, tha t it is time to get up . We do not necessarily wake up because we regained our physical strength d uring the sleep, as everybody knows, who cannot go back to sleep in the morn­ ing, even if the preceding night was highly dis­ turbed. A similarly common experience is the jet-lag that affects people who travel overseas (Boulos et al 1995, Brown 1 994, Zisapel 2001), or the problems associated with sh ift work (Rajarat­ nam and Arend t 2001). The internal clock tha t is responsible for these phenomena has been identi­ fied as a small neuronal network, loca ted in the so-called supra-chiasma tic nucleus (SCN, Cheng et al 2002, Reppert and Weaver 2002). This net­ work is both su fficient and necessary for generat­ ing the circadian rhythm . Isola ted from the remaining central nervous system, the SCN main­ tains a 24-hour rhythm even in a Petri dish (Gille tte and Tischkau 1999, Weaver 1998) . This experiment indicates tha t the SCN is sufficient to genera te a 24-hour rhythm and that this rhy thmic activity is generated endogenously by the central nervous system, and does not depend on the pres­ ence or absence of light. The SCN con trols various circadian rhy thms and is responsible, for example, for the generation of circadian fluctuations i n hor-

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A d apt i ve prope r t i es of motor beh a v i or

mone levels (e.g. the growth hormone) or for rhythmic changes in body temperature. Lesions of the SCN abolish these circadian rhythms in other­ wise in tact animals (Weaver 1998), ind ica ting that this network is necessary for generating circadian rhythms. Neural networks tha t are capable of gen erating rhy thmic activity in the absence of a sen­ sory input (e.g. a visual input, light) are called central pattern generators or CPGs (Marder and Calabrese 1996). The SCN is only one of many central pattern generators in the central nervous system. The thal­ amus generates rhy th ic activity, which highly influences our cortical activity. The thalamic rhyth­ micity is s ta te depe nd ent, and associated with well-known changes in neuronal properties of thalamic neurons (McCormick 2002) . The transi­ tion from being rhythmic to non-rhythmic is con­ trolled by inputs from the brainstem and cortex, which play important functions in regulating the role of the thalamus as a relay nucleus in sensory processing. As described for the SCN, isolated slices from the thalamus are still capable of gener­ ating rhythmic activity (McCormick and BaI 1997). Knowing how the thalamus generates rhythmic activity is not only important for understanding the transitions from wakefulness to sleep, but this unde rsta nding is also clinically relevant. Rhythmic ac t i v ity generated by the thalamus can be patho­ physiological and thalamic oscillations have b een associated with the generation of absence seizures (McCormick and Contreras 2001 ) . The cortex also exh ibits various forms of rhythms, which can be used to characterize differ­ ent states of sleeps and wakefulness (McCormick 2002, Steriade 2001, Steriade and Amzica 1 998, Steriade et al 1 994) . The generation of rhythmic cortical activity has been associated with con­ sciousness, as well as psych ia tric d isorders (Llinas et al 1999). As already mentioned for the thalamic ­

m

-

oscillations, pathophysiological forms of cortical rhy thms un d e r l i e various forms o f epileptic seizures (McC ormick 2002). Understanding how these rhythms are generated by the nervous sys­ tem is therefore essential to the development of

rational therap ies for t rea t in g epilepsy and men ta l d i s orders

.

Various rhythm-generating networks also exist in the brainstem. Rhythms controlled b y the brain­ stem include chewing, licking, swallowing, vomit­ ing, sneezing, coughing and b re a thing. Best understood is the neural network which controls breathing. Respiratory neurons are distributed in a neuro nal colwnn within the ventrolateral medulla, which is called the 'ventral respiratory group', VRG (McCrimmon et aI 2000) . One area within the VRG that is of particular importance for the genera tion of the respiratory rhythm is the so-called pre­ Bbtzinger complex (Smith et aI 1991) . As in the case SCN, this nucleus is both sufficient and nec­ essary for generating respiratory rhythmic activity. Lesions of the pre-Bbtzinger complex in an intact animal abolish respiration, indicating its necessity for breathing (Ramirez et al 1 998) . Isolation of the pre-Bbtzinger complex in a brainstem slice prepara­ tion retains respiratory rhythmic activ ity (Ramirez et al 1996 , Smith et aI 1991), thus indicating that this of the

nucle us

is sufficient for generating a respiratory rhythm (Fig. 5 . 1 ) . More recently it has been demonstrated that the pre-Bbtzinger complex is important for the genera­ tion of different forms of breathing including 'eup­ nea', gasping and sighing (Lieske et al 2000). The transition from eupnea to gasping and the genera­ tion of the sigh are generated by the same neuronal network, which is, however, reconfigured in a state-dependent manner (Lieske et al 2000).

As alre ad y mentioned in the introduction, the generation of the walking rhythm depends also on a neural network, which is located in the spinal cord (Kiehn an d Ki aerulff 1 998). The same princi­ ples as established for other rhythm-generating neural networks also apply for the central pattern generator for walking. The rhythm-generating network responsible for the generation of w al king can b e isolated in a sp i na l cord preparation from neonatal rats. Even after isolation , this network is still capable of generating a 'fictive' locomotor rhythm (i.e. neuronal activity that represents a locomotor rhythm in the absence of a c tu a l

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48

T H E THEO RETICAL BAS E

F i ctive i n s p i ratory activity Fig u re 5. 1

M ed u l l a ry s l i ce g e n e rates fictive res p i ra t i o n . PBC, pre - B i:i t z i n g e r co m p l ex.

l o c o m ot or mo v e m en ts) , in di ca ting that the cir­ cuitry loca ted within the spinal cord is sufficient for generating a locomotor rhyt h m (Fig. 5.2). Studying fictive lo co m ot o r acti v ity in these spinal cord preparations h a s led to important new in s ig ht s into the mechanisms that underlie the

gene ra tion of walking. For further d e tai ls see var­ ious reviews (Hamm et a l 1999, Jordan et al 1 992, Kiehn and Kiaerulff 1998, Kiehn and Tresch 2002, Kiehn et al 2000, Schmidt and Jordan 2000). One i m p o rt a nt take-home message is that these ' in vitro' e x pe r imen ts indi cate tha t the isolated spinal cord is c ap ab le of generating locomotor activ ity in the absence of sensory (proprioceptive) inp u t.

it must be emp hasi zed tha t thi s is only the case under artificial conditions, for example following deafferenta tion, or following t he isolation of a net­

in vitro conditions. In th e presence of actual movements, this is certainly not the case, and sensory feedback will highly influence the generation of rhythmi c acti v ity In the example of the circa d i an clock, da yl i gh t constantly resets the circadian rhy th m so we wake up in the m o r nin g, when daylight shines int o our bedroom. Intense light exposure he lp s to overco me j e t-lag and it has been used t hera pe utic a lly in shift-workers t o h el p them overcome problems associated w it h con­ stant changes in the sleep-wake cycle. The lack of sensory s timula tion is a maj o r p rob le m fo r blind w o rk under

.

people, in whom d aylig ht does not constantly

THE ROL E OF PROPRIO CE PTIV E I N P U T I N THE G ENERATIO N OF RHYTHMIC ACTIVITY

Alth o ugh central pattern generators can genera te rhythmic ac ti vi ty in the absence of sensor y in pu t,

reset the circadian clock. These individuals have maj o r p ro b le m s with their 'free-running' circadian clocks. Circadian changes in b o d y temperature and in ho rm o ne levels are non-synchronized, which great ly a ffec ts the daily life of bl in d p eop l e

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.

A d a p t i v e p r o pert ies of m oto r b e ha v i or

N M DA, se roto n i n F i g u re 5 . 2

Isolated brainst e m spinal cord g e n e rates fictive l oc o m o t i o n .

Sensory inp u ts a l so pl a y a very important role in the genera tion of wal kin g (Rossignol 2000, Pear­ so n and Ram irez 1 997) . It i s now well established tha t sensory inputs contribu te to the generation and maintenance of the rhythmic activity. Phasic sensory inp u t initia tes major phase transitions from swing to s tance and from stance to s win g phase. Sensory inputs are important in re g ulatin g the mag nit u de of the ongoing motor activity. The concept that p ro p r i ocep tiv e in p u t can regulate the transi tions from one ph ase to another has been demonsh'a ted in various studies (Andersson and Grillner 1 983, Grillner and Rossignol 1978, Kriel­ laars et aI 1994) . The propriocep tors responsible for these phase transitions seem to be muscle spindle afferents that are located i n hip flexor muscles (Hiebert and Pearson 1999, Hiebert et al 1996) . However, Golg i tendon organs are also important for reg u l a tin g phase transitions. Located in exten­ sor muscles, input from these so-called Ib afferents has, du ring locomotion, an excitatory effect on extensor motor neurons (Pearson and Collins 1 993, Pearson et aI 1998) . Interestingly, s timul a ti on of the same tendon organs has an opposite effect in the standing animal, indic a ting tha t reflexes are state­ dependent, a phenomenon tha t is also known as

'reflex-reversal' (Hess and Buschges 1 999, Kn o p et 2001 , Pearson et al 1 998). This h a s important implica tions as it indica tes tha t different regula­ tory mechanisms contribute to the neura l control of posture and walking. In w alking , the regulation of phase tra nsitions and the dura tion of a step are directly correlated. For example, electrica l s timulation of group I afferen ts from knee and ankle extensor muscles during the ex tensor phase, prolongs the s tance phase in wal king, decerebrate c a ts (Pearson and Ramirez 1 997) . The u nl o a din g of extensor muscles is therefore thought to be a necessary condi tion for the initiation of th e s w in g phase during normal walking. This sensory signal is produced by a decreased a ctiv ity in the tendon organs of extensor muscles. The role of proprioceptors in re g u lating the timin g of pha s e transitions is functionally very a d a p t i ve. This regulatory mechanism guarantees that p ha s e transi tions are p reci s el y timed accord­ ing to the specific in ternal and environmental con­ d itions. Proprioceptors are ideal for a ssuming this role as they synthesize information from the sta te of the mov in g body and from t h e s ta te of the environmen t. al

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50

TH E TH EORETICAL BASE

STAT E - D E P E N D E N T M O D U LAT I O N O F

brains tem (Kiehn et al 2000 ) . There are reasons to

R E F L E X PAT H WAYS

believe that these find ings also apply to the ne u ral control of walking in humans (Calancie et a 1 1 994,

The sta te-dependency of propriocep tive integra tion

Dimitrij evic et a 1 1998, Duysens an d van de Crom­

was already mentioned in the contex t of the reflex

mert 1 998, Lamb and Yang 2000) . If this is the ca se,

reversal. Increasing evidence indica tes that reflexes

these fin dings have important impl ications for

are not as simple as initially thought. Reflexes can

various for ms of spinal cord inj uries . In spina l

drastically change due to a direct modula tion by

cord inj ured people, the in ability to walk is often

efferent ganuna-inn ervation, which is highly state­

due to the interruption of descending inp uts from

dependent (Prochazka 1 989). However, reflex path­

higher brain centers, which are necessary to in iti­

ways are also chemically modulated within the

a te and ma intain locomotion . If the absence of

central nervous system. For the respira tory system

these descending in pu ts is indeed responsible for

it has been demonstrated tha t pulmonary reflexes

the loss of locomo tion, an impor tan t consequence

are transmi tted to the central respira tory network

is tha t the spinal network responsible for generat­

via the nucleus tractus soli tarius

an area tha t

ing the walking rhy thm sho u ld s till be 'in tact' .

contains numero us neuromodulatory substances

Therefore, it sho uld theore tically be possible to

(NTS),

( Bonham 1 995, Maley 1 996, Moss and La ferriere

replace these mi ssing descending inp u ts ph arma­

2002) known to play

cologically in order to a c tivate the dormant walk­

an

important role in modulat­

ing breathing. These modulatory substances (sero­

ing

tonin,

endorphins,

chemica l messengers released from descending

thyrotropin-releasing hormone (TRH)) are known

neurons include sero tonin, dopamine and nora­

substance

P,

ace tylcholine,

rhy t h m -genera ting

ne twork.

Important

to affec t membrane proper ties of respiratory neu­

drenaline (norepinephrine) and, in theory, exoge­

rons ( Dekin et al 1 985, Telgkamp et al 2002) and

nous applica tion of these amines sho uld ac tiv a te

hence transm ission of re flex p a thway s . When

locomotion . It is well established tha t exogenous

released during hypoxia, the modula tors may con­

applica tion of either of these subs tances can evoke

tribute to an increased ventila tory drive by a ltering

forms of locomo tion in cats following spin a l cord

transmission in reflex pathways from afferents of

transection . And in fa c t it ,vas possible to ini ti ate

the carotid body (Wickstrom et aI 1 999) .

s tepping movements in paraplegic pa tients using aminergic substances ( Remy-Neris e t al 1 999, Rossignol et a1 1 996, Wainberg et a I 1990).

N E U R O M O D U LAT I O N A N D

Why is the rh ythm genera tor for walking inac­

R E C O N F I G U R AT I O N O F R H YT H M ­

tive in the absence of descending inp uts and how

G E N E R AT I N G N E TW O R KS W I T H I N T H E

can amines activate a rhythm-genera ting neuronal

C E N T RA L N E RV O U S SYST E M

network? One p ossible explanation is tha t descend­ ing inputs provide a tonic exci tation, which is nec­

Neuromodula tory processes also play important

essary to activate the neural network for walking. If

roles in controlling the rhythm-generating network

this were the case, any exci ta tory stimulus th at

within the central nervous syste m . Altho u gh, the

depolarizes the membranes of locomotor neurons

spinal cord is cap able of genera ting fictive loco­

should initia te locomotion. This is, however, not the

motion in the absence of higher brain centers, they

case. For example, raising the potassium concentra­

are not capable of genera ting l ocomotion sponta­

tion in an isola ted spinal cord would depola rize

neou sly. To ini tia te fic tive locomo tor activity it is

locomotor neurons, but this trea tment will not initi­

necessary to apply sero tonin and NMDA exoge­

a te locomotion. It is necessary to apply aminergic

nously, presumably in order to compensa te for the

substances in order to activate the rhythm-generat­

missing descending a minergic inp u t from

ing neural network . How could a mines such as

the

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A d apti ve prope rti es of m oto r b e havi or

serotonin or also dopamine lead to the activa tion of a rhythm-generating network? There is a huge body of literature indicating that amines act as neu­ romodula tors in neuronal network, leading to the modulation of membrane properties and synaptic transmission (Nusbau m et al 200 1 ) . Some of these properties are known to play important roles in the generation of rhythmic activity. Membrane properties that are very important for the generation of mos t rhythmic activities are the so-called plateau potentials or pacemaker p roperties. P acemaker properties have been demonstra ted in neu rons of the thalamus (Lu thi and McCormick 1 999) , SCN (Nitabach et al 2002, Wang et al 2002), cortex (Brumberg et aI 2002), and p re-Bo tzinger complex (Thoby-Brisson and Rami rez 2001; Thoby-Brisson et al 2000) . In many cases, it has been demonstrated tha t these pace­ maker properties are dependent on the presence or absence of neuromodulators, such as serotonin (Pena and Ramirez 2002) . This is very well docu­ mented for rhythmic activity in thalamic relay neurons, which can be ind uced or suppressed depending on the presence of sero tonin or adren­ aline (epinephrine) (McCormick and Pape 1990). Pacemaker properties can also be induced by NMDA . This has been demonstra ted in spinal cord neurons, thus explain ing the abi li ty to induce fictive walking in isolated spinal cord prepara­ tions (Parker and Grillner 1999 ) . In many motor sys tems, it has a l s o been demonstrated tha t amines can induce long-lasting constant discha rges, which are due to the activa­ tion of so-ca lled plateau-potentials. The induction of plateau-poten tials by serotonin has been demonstra ted in spinal motor neurons (Houn­ sgaard and Kiehn 1993) and there is good evi­ dence that these plateau-poten tials are important for the control of posture (Kiehn and Eken 1997) . Presumably the most important synaptic mech­ anism for the genera tion of rhythmic activity is reciprocal inhibi tion . The so-called half-center model predicts that two groups of neurons, which are connected via synap tic inh ibition and which receive a tonic excitatory drive, become bi-stable

and are capable o f generating reciprocal rhythmic ac tivi ty. Indeed, comp utational models have demonstrated tha t tw o groups of neurons can generate rhythmic activity if the neurons contain certain membrane proper ties, such as for example the so-called Ih current (Sharp et al 1996). The concept of a half-center network has been very influential and has been adopted to explain the genera tion of rhy thmic motor activities in many motor sys tems, such as the swimming movements in lamprey (GrilIner et al 2000), locomotion in Xenopus (Tunstall et al 2002), and the breathing movements in mammals (Richter and Spyer 200 1 ) . Similarly, reciprocal inhibition seems t o play a role in establishing the differen t phases of locomotion in spinal cord preparation of neonatal rats. Synap­ tic interac tions, such a s those necessary for estab­ lishing rhythmic motor activity, are known to be targets of neuromodulators like serotonin and dopamine (AyaJi et al 1998). Thus, it can be assumed tha t descending aminergic drive may influence the generation of walking by modulat­ ing synaptic in teraction between rhythm-genera t­ ing neurons in the spinal cord . An important concept derives from these and many other findings obtained in rhythm-generating neuronal networks (e.g. Pearson and Ramirez 1 997) : a rhythm genera ting neural network is not 'hard-wired', but flexible. In the p resence of neu­ romodula tors, pacemaker properties and synap tic transmission can be modulated, changing the char­ acteris tics and connectivity of rhy thm-genera ting networks . This is highly relev ant as we have to envision tha t a rhythm-generating network is embedded in a 'soup of neuromodulators' which are released in a state-dependent manner from descending as well as local neurons and which constantly change the properties of the network and the propriocep tive pathways as discussed in the previous paragraph. The exact composi tion of this 'soup of neuromodulators' will not only be state-dependent, b u t it will be highly variable in different individuals and will also change dramat­ ically du ring ontogenetic development. This characteristic may at least partly explain why the

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51

52

THE TH E O R ETICAL BASE

deta i l s of locomotion, and also the details of pos­

the ex ternal env ironment, in body size and in body

ture, will not be the same in any two individuals.

weigh t . However, these changes may not only be adap tive and one migh t specula te tha t a behavio r may become maladap tive

T H E DEVELO P M ENT O F M OTOR N E U RAL NETWOR KS

if any of these cha nges is

disturbed, either in i ts time course or in its magni­ tu de. Such on togenetic changes at the molecular level may explain why many d iseases are very

There is increasing evidence tha t synaptic and

characteristic for a certain s tage of ontogenetic

membrane properties change drama tically during

development. There a re numero us examples, such

p o s tn a ta l developmen t . For exa mple, the composi­

as sudden infan t d e a th synd rome (SIDS), schizo­

tion of the glycine receptor changes postna tally

phrenia, manic disorders or Al zheimer ' s disease,

2002). These changes are associ a ted

which occur or begin typically in very specific age

(Laube et al

with physiological changes in the properties of

groups . Unders tanding which molecular fac tors

synap tic transmission . As the gl ycine receptor is

are maladap tive will be one of the impor tant chal­

abundant in the spinal cord, these changes may

lenges in fu ture medica l resea rch .

play

an

imp ortan t role in establishing reciprocal

a c tivity during walking. However, the changes in the glycine recep tor are only one example, and

CONCL USIONS

simi lar on togenetic changes have been described for most o ther transmi tter recep tors and ion chan­

In this chapter, principles were summarized tha t

nels, indicating tha t presumabl y most neural net­

are relevant not only for the genera tion o f walk­

works undergo drama tic, ontogenetic changes.

ing, but for the gen eration of rhythmic ac tivity in

This will presumably res u l t in stri kingly different

genera l. One of the mos t important messages is

adaptive properties of most behaviors. However,

tha t these networks are highly flex ible .

we are far from understanding the details of how

of the motor behavior, locomo tor c ircuits and

In the case

these postnatal changes at the molecula r level

reflex pathways can rapidly adapt a mo tor behav­

transla te into changes in behavior. This lack of

ior to changes i n the ex ternal environment. As

unders tanding is partly due to the complexity of

imp ortant, however, are long- term changes tha t

developmental changes. For example, the time

a l ter network properties an d reflex pathways to

course of any of the known postnatal changes d i f­

a dj us t a motor behavior to ch anges in body size

fers in different regions of the bra in . Postnatal

and weight. In particular, d u ring on toge netic

changes described in one cortical layer may be d i f­

developmen t, these a djus tments are essen ti al to

feren t from postnatal changes that occur in another

guaran tee a well-adapted mo tor behavior. Long­

layer of the cortex. The same p resumably applies

term changes occur also in associa tion with motor

to all o ther parts of the cen tral nervous system .

learning, a form of plastici ty tha t i s par ticu larly

Despite this complexi ty, and d espite the lack of

relevan t for a developing chi l d . Th is chap ter has

a concrete understand ing of how these molecular

summarized possible neural mechanisms tha t

and cellular changes translate into changes a t the

c o u l d contribute t o long- term a n d short- term

behaviora l levels, these findings emphasize tha t

changes and emphasized the po tential role of

t h e central nervous system h a s t o be considered as

chemical modula tors in reg u l a ting membrane

a very pla s tic entity, which undergoes dra m a tic

properties and syn a p tic tra nsmission. These mod­

short- term and long- term changes. These changes

ulatory changes can res u l t in varying degrees o f

will res u l t in drama tic changes in behavior, which

changes in the network configuration, which c a n

for the most part will be adaptive, adj usting the

lea d t o a complete reconfiguration of a neural net­

organism to changes in postnatal development, in

work, such as in the case of the resp ira tory net-

Copyrighted Material

Ad a p t i v e p ro p e r t i e s of m o t o r b e h a v i o r

genera te s i g ni fi c antly differen t as ga sping or sighing. Ne twork reconfi g u r a ti ons, howe ver, occur not only in re s p o n se to the release of neuromodula­ tors . Dra m a tic ch anges can also occur as p a r t o f a genetic pr o g r am d u r in g on t oge n etic de v e l op­ ment. It is ,·vell es t abl i shed tha t all mol ecul a r com­ ponents of a neural network u n de rg o dramatic changes a n d re o rgan i z a ti ons tha t translate into de v el o p men ta l chan g es of a m o t o r behavior. Thus, an imp o r ta n t lesson learned from these studies is tha t neuronal n e tw orks are amazingly plastic and con tinuously changing depend in g on work

where i t c a n

fo rms of b rea thin g, such

the developmental, in te rn a l and external cond i­ tions. It i s therefore not surprising tha t the po st u re and walking behavior of any ind i vidual will differ from that of a n o th e r individual. Given th e com­ p lexi t y and plasticity of these neural networks it is indeed s ur p ri s ing tha t m ost in div id u a l s m an a ge t o prod uc e a we l l adapted 'normal' l ocomotor behavior and p o s ture. This in dica te s t h a t s tro n g sel f re gula ting mechanisms must exist tha t con­ s tan tl y ad j u s t neuron a l network pro per ti es in o r de r to avoid major deviations from a 'normal' beha v ior -

-

.

Refe ren ces A ndersson 0, G r i l l ner 5 1 9 83 Peripheral co n t ro l of t he ca t s s tep c y c l e 11. E n tr a in men t of the cen tr a l pattern generato rs for locomotion by sinusoidal hip mo v e m e n t s d u r i ng f i c ti ve loco motion ' . Acta P h y s io lo gi ca '

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Chapter

6

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Neuromotor development in infancy and early childhood s. Huber

I

'J.MI:I'

INTRODUCTION CHAPTER CONTENTS Introduction

57

Brain maturation and myelination Development of motor skills

60

60

Biomechanics, practice and environment Perception and motor development Eye-hand coordination in the first year of life

64

Motor development beyond the first year of life

68

Cognition and perception Summary

70

69

62

61

Learning complex motor skills up to their virtuoso performance is a very long and protracted process wh ich normally extends over several years. If we compare motor control in child ren and adults, young adolescents still show substantial differ­ ences in efficiency and accuracy of performance in motor tasks. Even elementary motion sequences like srnihng, grasping of an object, sitting, walking and speaking take mon ths to years to be per­ formed efficiently. The movement of newborn s, in contrast, appears very uncontrolled and variable. For a long time, it was cons i dered as fact that brain mat u ra ti on alone is responsible for the development of motor skills. The theory of matu­ ration, which was predominant during the 1920s to 1940s, was mainly developed and pushed for­ ward in the domain of motor develop ment by Gesell (1933, 1946) and McGraw (1945, 1946). They assumed that the regulari ties that can be observed in the process of motor development reflect the development of brain maturation, i.e. the unfolding of a genetic program that was sup­ posed to be the same in all infants. The underlying idea of their theo ry was that the maturation of motor skills reflects the hierarchy of the central nervous system: When an infant matures, higher brain areas of the motor cortex take over the tasks of the subcortex and inhibit the subcortex. Reflex­ ive and immature motion patterns are rep lace d by Copyrighted Material

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THE THEORETICAL BASE

coordinated and directed movements controlled by the cortex. The theory of maturation also

to be planned on a much more abstract level, as it

assumed that there is a fixed sequence of motor

system to program all the local and context­

development in which practice and the environ­

dependent, dynamic variables in advance. Bernstein thus described movement as a prob­

ment play only a subordinate role. Phenomenological experiments have been con­ ducted to support this view. Catalogues were developed with lists of stages (Gesell 1933, McGraw 1945, Shirley 1931) detailing age-specific behavior as well as how children gain control over their movements. For throwing objects, for instance, 58 stages were specified, for rattling 53 stages, etc. One of the studies cited repeatedly as evidence for the maturation theory was a culture

would be far too complex for the central nervous

lem of coordination, i.e. as the coordination of a cooperative interaction of many partners to gain a uniform result. The problem, according to Bern­ stein, is how the organism with its almost indeter­ minable number of combinations of body segments and positions finds a solution to enable all parts to work together harmoniously and efficiently, with­ out every step being programed in advance. This

study, dating back to 1940, on the development of

new way of thinking about movement control has led to a rethinking of the principles of motor devel­

walking in infants of Hopi Indians (Dennis and

opment, resulting in theories that put forward

Dennis 1940). Infants from the Hopi community spend most of their first year of life wrapped up tightly in a cradle and carried around on their

multicausal view of motor development (Newell 1986, Thelen 2000). These theories assume a

mothers' backs. According to this study, although these babies can hardly move, they learn to walk

opment of the perceptual system, biomechanics

only slightly later than infants from Western tradi­ tions. The fact that these infants were only slightly delayed in learning to walk despite an apparent lack of constant practice was cited as evidence that behavioral changes in motor control are directly linked to changes in the brain. This view of a direct causal link between matu­ ration of the brain and behavioral changes is highly plausible and is still held today to some extent. Until the mid 1980s, this view of motor development was actually predominant. It was onl y when Bernstein's new way of looking at motor coordination became known that a para­ digm shift occurred (Bernstein 1967) (for review see Sporns and Edelman 1993). Bernstein (1967) challenged the view of a 1 : 1

a

dynamic system where the environment, the devel­

and muscle power complement the maturation of the brain as principal components. These more recent theories (e.g. dynamic systems theory Thelen 1995, 2000) assume that due to only few movement restrictions at the beginning of life, the infant can draw upon a large variety of motion patterns to execute spontaneous move­ ments. This variety of motion patterns implies that all possibilities of motor control can be explored. At the same time it makes these patterns -

suitable for a changing environment. The infant learns to restrict this variability as more functional motor programs develop. Practice, as gained by the increasing experience of the motor system as well as the sensory system, plays a crucial role in the development of specific motor skills. Visual, vestibular and proprioceptive

mapping of neural code, firing of motor neurons

information allows the infant to fine-tune balance,

and actual movement, which had been postulated

head and body control as well as grasping move­

by brain maturation theories. He took a fresh look

ments on the basis of visual, tactile and kinesthetic information. This integration of new motor strate­

at the problem of motor development, suggesting that a movement can be caused by a variety of dif­

gies is brought about by a process of neural selec­

ferent motion patterns, and the pattern of how movement is executed can, in tum, be executed in a variety of ways. This implies that movement has

tion. At the beginning, the infant executes spontaneous movements which are subject to high variability. Motion patterns can be evaluated via

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Neuromotor development in infancy and early childhood

sensory feedback and connections can be selected which an

fulfill ClUrent needs or which seem to lead to

important skill for the futlUe. Finally, neural con­

nections that are related to the most efficient motor patterns are strengthened and others are inhibited.

"'

,....

m�.

But why does motor development take so long? based on a highly complex nervous system with a huge number of connections. These connections send out motor signals, but provide a continuous

(1999)

ment control with a simple example: When a

-.i

Thalamus

t

J

nucleus caudatus,

6.1).

illustrates the problem of move­

motor area, premotor cortex

Basal ganglia

feedback about the ClUrent state of the system, too, Eliot

�

Primary motor cortex, supplemental

(

One reason is that motor control is only possible

during the movement being executed (Fig.

Motor areas of the cerebral cortex

putamen, globus pallidus, nucleus, subthalamicus, substantia nigra

straightforward arm movement is executed, the biceps bends and the triceps is stretched at the same time. The command of such a voluntary movement is generated

in

the motor area of the

cerebral cortex. There are three motor areas which are all located in the back part of the frontal lobe:

�(

, .

L Bramstem

Cerebellum

the primary motor cortex, the supplementary

{

motor area and the pre-motor cortex. The primary motor cortex triggers voluntary movement, while the other two operate on a higher level and control

Sensory receptors

more complex sequences of motion. The motor

j

Spinal cord

distorted upside-down map of the body, the

( Muscle contraction and movement L

trol the muscles of the head and the face, the mid­ dle regions control the arms and hands, and the medial regions are in control of the legs and feet (Penfield and Rasmussen

1950).

Figure 6.1

r

!

cortex -like the somatosensory cortex - contains a homunculus: the lateral regions of this area con­

J

]

Motor circuits involved in the execution of

voluntary movements (Ghez 1991).

This distorted

map allocates bigger areas for those body parts -

of the movement, the muscle undergoes changes

such as hands and the face - that possess more

in tension and length, which again are perceived

muscles, since they have to execute more complex

by special sensory neurons, the proprioceptors.

movements than for example the trunk or the legs.

Proprioceptive information feeds back to the

If a voluntary movement of the arm is executed,

spinal cord, where the firing of muscle motor neu­

the neurons of the arm region of the left motor cor­

rons is modified, and on to the cerebral cortex

tex send action potentials to the spinal cord, which

where the arm position is perceived. Propriocep­

is connected via the corticospinal tract. In the

tive information allows the movement of the arm

spinal cord, the neurons of the corticospinal tract

to be felt and to be fine-tuned millisecond by mil­

excite motor neurons, which send out their axons

lisecond. All this is most likely to happen parallel

via peripheral nerves to reach the muscle fibers in

to hand and finger movements. In addition, infor­

the arm. The electrical excitation leads to a con­

mation is integrated from the visual system, which

traction of the relevant muscles. At the beginning

provides information about the arm position to the

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59

60

THE THEORETICAL BASE

motor cortex in order to control muscle contraction and relaxation. Highly elaborate tasks, such as walking or postural balance of the whole body, where dozens of muscles are involved, are even more complex tasks for the motor control system. The cerebellum is mainly responsible for the precise coordination and timing of all these move­ ments. It receives input from the motor cortex (i.e. information about the kind of movement that is to be executed) as well as from different sensory sys­ tems, such as vision, hearing, balance and pro­ prioception (i.e. information about the actual movement). The cerebellum controls and times the movements by comparing the incoming informa­ tion, and modifies the motor commands to achieve the best possible result for the execution of the movements. The basal ganglia play a central part in movement control, too. Here motor actions and inhibiting involuntary movements are selected. Patients with Parkinson's disease or Huntington's disease, for instance (who show disorders in the basal ganglia), have great problems initiating vol­ untary movements. They often have difficulty talk­ ing or walking, or their movements are very slow. In contrast to patients suffering from paralysis, however, they move quite a lot, though most of their movements are involuntary. The basal gan­ glia also have a strong connection to the thalamus, which receives sensory as weU as motor informa­ tion (from the cerebellum, the spinal cord and the basal ganglia) and sends it on to the cortex.

BRAIN MATURATION AN D MYELIN ATION

It cannot be denied that maturation of the central nervous system plays a crucial role in the devel­ opment of motor skills, although it is clear today that there is no exact mapping between the two because of the environmental influences that have just been described. The motor cortex undergoes a great deal of modification during the first year. The most important neuromotor changes, which lead to a predictable sequence of development of motor skills, are described below.

The higher areas of the brain are hardly devel­ oped at birth. Maturation of the brain areas develops from caudal to cranial areas and from dorsal to ventral areas (Grodd 1993, Staudt et al 2000): motor connections in the spinal cord mature first, long before birth, followed by the neurons of the brainstem and the connections in the primary motor cortex. Finally, the higher brain areas located in the frontal lobe attain maturation. The motor neurons which leave the spinal cord are among the first fibers in the brain to myelinate (by mid-gestation). Myelination of the motor areas in the brainstem starts in the last trimester of pregnancy. The fibers and connec­ tions of the primary motor cortex b eg in to myeli­ nate around birth. Myelination in this area takes about 2 years. The myelination in the frontal lobe progresses very slowly. The fibers of the pre­ motor cortex and the supplementary motor area, for instance, do not begin to myelinate until about the age of 6 months and then continue to do so for several years. With the brainstem maturing early, the order of motor development is from central to peripheral body parts, since the muscles of the trunk and the head are mainly controlled by the motor connec­ tions in the brainstem, whereas the muscles of the peripheral body segments are controlled by the motor cortex. In fact, infants are able to control their trunk and their head muscles before they can control their arms and legs or their hands and fin­ gers. The maturation of the primary motor cortex also influences the sequence of motor develop­ ment. Myelination and maturation start in the lower areas of the primary motor cortex and progress upwards, i.e. control over the muscles of the face is gained before that over ha nds or feet. Infants, therefore, can tum their head and smile before they learn to grasp, crawl and walk.

DEVELOPMEN T OF MOTOR SKILLS

Neuromotor development is a long-lasting process. It sets in some weeks after fertilization

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Neuromotor development in infancy and early childhood

and then continues several y ears after birth until reaching completion during puberty. Thanks to the advanced use of ultrasonic imaging, there is now a fairly clear and comprehensive under­ standing of the prenatal development of motor skills. The fetus is active from the 8th to 10th week of gestation, showing spontaneous activity as well as structured activity patterns from the very begin­ ning (Prechtl 1985, 1993). Initially these are move­ ments of the whole fetus, spontaneous arches and curls, but very soon the limbs themselves move and initiate entire body movements. Isolated arm and leg movements start at about the 10th week, finger movements set in 2 weeks later. From the 11th week onwards, the fetus starts to bring a hand to its head, but it only starts to suck its thumbs after approximately 5 months. Other astonishing motor skills which develop in the first 3 months are hiccups, stretching, yawning, swallowing and grasping. These movements are already highly coordinated right from the start. In the second half of pregnancy, the fetus commences with continuous breathing movements. The lungs, at this point still filled with liquid, start to expand and compress together with the diaphragm and thorax in a rhythmic and coordinated fashion. Sucking and swallowing become more coordi­ nated from the 28th week onwards. From week 33 onwards both swallowing and sucking are coordi­ nated with breathing movements. These processes seem to be at least in part an expression of the launch of activity of the developing neural system. In addition, some of these behavioral patterns also fulfill functions of adaptation, provide behavioral patterns for later use (such as breathing and suck­ ing) or constitute precursors of later movement patterns (Hall and Oppenheim 1987).

BIOMECHANICS. PRACTICE AND ENVIRONMENT

Recently, a number of studies have been con­ ducted to show which other factors besides the

maturation of the brain have an impact on motor development. The organism, biomechanics, and muscle power are said to play an important role at every step of motor development. Already in 1931, Shirley documented that differences in infants' physical growth, muscle tone, and energy levels were related to differences in the onset of various motor skills. Physical dimensions, biomechanics and move­ ment styles are still seen as an important part of motor development (Thelen 2000). The influence of biomechanics has been studied by Thelen and her colleagues in a series of experiments testing walking skills. If newborns are lifted up so that their feet touch the ground while being supported under their arms, they will readily show step-like movements which have a close resemblance to the walking pattern of older infants. It is astonishing how coordinated these movements are already in newborns, who can hardly control their head. After a few weeks, this reflex disappears, only reappearing later in the year when the infant is ready to learn to walk. Traditionally, the disappearance of the step-like movements, the so-called walking reflex, in new­ borns after just a few weeks was explained by the fact that the first subcortically driven reflex is inhibited by the developing motor cortex (McGraw 1945). This inhibition is only suspended if the motor cortex is mature enough to take over control of the subcortically driven processes in a coordinated way. Investigations of the rhythmic kicking behavior of infants who are just a few months old and lying on their back show, however, that the walking reflex does not disappear at all. The kicking move­ ments directly match the rhythmic step-like movements of newborns. The only difference is the position in which the infant's body experi­ ences the effect of gravity: infants lying on their back can lift up their legs more easily than those in an upright position. Thelen and her colleagues showed that infants that seem to have lost their walking reflex also start to show the pattern spontaneously when

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THE THEORETICAL BASE

their legs are under water (Thelen et al 1984). Underwater gravitation has less effect due to buoyancy. They also demonstrated that younger infants do not show this walking pattern if their legs are made heavier with little weights (Adolph and Avolio 2000, Thelen et al 1987). Infants, thus, seem to stop showing the stepping reflex because their weight gain during the first months of life is not matched by an increase in muscle mass or force, therefore depriving the infants of sufficient power to lift the legs in an upright position. This interaction between intrinsic and environmental constraints has also been studied in the domain of reaching by Savelsbergh and van der Kamp (1994). They showed that body orientation with respect to gravity has an effect on the quantity and quality of infants' reaching behavior. Besides the influence of biomechanics and body layout, important factors are the possibilities to practice motor control, and perceptual stimulation from the environment. New insights in motor development strongly emphasize the role of explo­ ration and selection in the acquisition of new motor skills. The infants' first step is to discover configurations that enable them to perform a cer­ tain motor task; these must then be fine-tuned to the required smoothness and efficiency. Thelen (1994) demonstrated that by the age of 3 months infants can, given an appropriate and novel task, already transform their seemingly spontaneous kicking movements into new and efficient motor patterns. Thelen and her colleagues investigated the kicking movements of 3-month-old infants who were allowed to control the movement of an over­ head mobile by means of a string attached to their legs. In one group, the infants additionally had their two legs tied loosely together at the ankles. The soft elastic allowed the infants to move their legs in any coordinated pattern of alternating, sin­ gle, or simultaneous kicks, but simultaneous kicks provided the strongest activation of the mobile. All infants kicked more often as well as faster when their kicks activated the mobile as com­ pared to when their kicks did not have any effect.

However, only the infants with loosely tied legs moved their legs in an increasingly simultaneous pattern. The study suggests that infants at the age of 3 months can discover and learn a match between inter-limb coordination patterns and a specific task. Acquisition of new motor skills, thus, seems to depend on learning processes such as these, rather than autonomous brain 'maturation' (Thelen 1994). At the age of 3 months infants are already able to quickly solve new tasks in which, for instance, cer­ tain knee positions (such as bending and stretching of the knee) have gained positive feedback (Angulo-Kinzler et al 2002). Another example comes from a study by Goldfield et al (1993). They investigated how infants learn to use a Jolly Jumper (a baby seat attached to elastic ropes): infants started with only a few bounces, which had irregu­ lar amplitudes and periods. As the weeks passed, infants increased the number of bounces and at the same time decreased their period and amplitude variability, settling in on a frequency which was consistent with the predicted resonant frequency of the infant-bouncer-spring system.

PERCEPTION AND MOTOR DEVELOPMENT

Recent advances in the understanding of human movement control have enabled developmental psychologists to discover unique patterns of organization and control in infant motor behavior and development, and triggered new interest in this topic. The tuning of movement patterns shown in several examples above is most proba­ bly established through repeated cycles of perception and action as well as through the con­ sequences of the action in relation to the goal. We will come back to this in the next section where we consider the development of eye-hand coor­ dination in detail. Besides perception influencing the development of action, some researchers pos­ tulate not only that motor development is sup­ ported by perceptual development but also that motor development may play a predominant role

Copyrighted Material

Neuromotor development in infancy and early childhood

in determining

developmental

sequences

or

'timetables'in the domain of perception (Bushnell and Boudreau

1993). Specifically, they argue that

depth perception. In both cases, there is a high degree

of

fit

between

the

developmental

sequence in which certain perceptual sensitivities

particular motor achievements may be integral to

unfold and the age of onset of corresponding

the development in the domains of haptic and

motor abilities (Fig.

Static contact (temperature)

Figure 6.2

6.2).

Enclosure (volume and size)

Lateral motion (texture)

Pressure (hardness)

Unsupported holding (weight)

Contour following (exact shape)

Hand movement patterns which have been found to be most suitable for apprehending specific object

properties (from Lederman and Klatzky 1987, with permission of Elsevier Science).

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63

64

THE THEORETICAL BASE

0-

Figure 6.3

Experimental setup and stimulus material in an experiment on haptic perception

-0

(from

Streri and Spelke

1988, with permission of Elsevier Science).

Evidence for these connections is found, for instance, in experiments conducted

by

Streri and

see also Wilkening and Krist

1998). Eye-hand

coordination undergoes profound development

(1988; Streri et al 1993). They investigated

throughout the first year of life , when children

4.5-month-old infants' perception of the unity

learn how to grasp for objects and how to manipu­

and boundaries of haptically presented objects

late them. Besides the development of efficient

Spelke

(Fig. 6.3) .

When infants actively explored the two

motor programs, the development of object percep­

handles of an unseen o bjec t assembly, perception

tion as well as proprioceptive and visual perception

of the

un ity

of the assembly depended on the han­

dles' motion.

Infants perceived a single, connected

of the hand play important roles

in

developing

skilled motor control of the arm, hand and fingers.

object if the handles moved rigidly together, and

For newborns, arm and hand movements are

they perceived two distinct objects if the handles

closely linked. The bending and stretching of the

underwent vertical or horizontal motion.

arm is often accompanied

by

the bending and

stretching of the hand. Only at about the age of

2

months does this coupling disappear. At this age,

EYE-HAND COORDINATION IN THE FIRST

the hand

YEAR OF LIFE

is stretched. Especially at this age

is

mostly formed to a fist when the arm

(2 to 4 months),

the hand possesses an important function for per­ In this section we take a closer look at the devel­

opment of a

special

skill , eye-hand coordination,

motor development (for

an

in the haptic experience of objects.

Hand and eye work more or less independently

investi­

from each other at this age. Infants often fixate one

overview

object with their eyes and investigate another

which is probably the most intensively

gated field in

ception, i.e.

Copyrighted Material

Neuromotor development in infancy and early childhood

one with their hands (Hatwell 1987). At the age of 3 months, infants resume opening their hand while stretching the arm, when they fixate an object. But infants younger than 4 months are gen­ erally not able to target and grasp a seen object. Infants, on the other hand, who are about to start grasping are not interested anymore in just hapti­ cally exploring the target object (HatweU1987). Because of this developmental sequence, the belief was widely shared for a long time that initially eye and hand are controlled independ­ ently from another. Only at about the age of 3 or 4 months, when infants begin to grasp, does the coordination of eyes and hands start. However, recent studies show this view not to be correct. Although the spontaneous arm movements of new­ borns seem to be aimless under supporting condi­ tions - one of which is support of the body of the infant - studies show that the movements depend on the direction of the visual goal. Von Hofsten (1982) was able to demonstrate that 5--9-day-old infants already show a rudimentary eye-hand coordination. As the arm movements of new­ borns typically consist of several uncoordinated sub-movements, von Hofsten chose only the sub­ movements that brought the hand nearest to the aimed target. He compared the direction of move­ ments where the infants fixated the target with their eyes with direction of movements where they did not fixate the target. The results showed that infants miss the target with fixation by on average 320 and without fixating the target by about 5T Thus, eye and hand do not work independently of each other in newborns. Eye-hand coordination is, however, only rudi­ mentary in newborn infants. Newborns direct the arm approximately by fixing the goal. This ballistic movement is triggered by the visual input. Infants at the age of 5 months, on the other hand, start to move their hand under constant visual control and systematically move their hand nearer to the target. The movement is visually guided (Bushnell 1985). Before infants start to guide their move­ ments visually, it can be observed that they show an increased tendency to fixate their hand and fol-

low the hand with their gaze (Piaget 1973, 1975b, White et al 1964). Only from the age of 5 months onwards do infants, when reaching for an object, show a better result if they can see not only the target but also the grasping hand (Lasky 1977, McDonnell 1975). This is not to mean, however, that coordinated grasping attempts are executed solely under the visual guidance of the hand. Important empirical evidence comes from a number of studies on grasping in the dark and grasping for moving objects. Infants aged 4 to 7 months can grasp for objects in the dark even if they can only be located by sound, if they glow in the dark or if they were located before it got dark (Clifton et aI 1973). Nevertheless, if continuous sight of the object is available, infants use vision during the reach. How­ ever, they can still reach for an illuminated object even if it is darkened during the reach (McCarty and Ashmead 1999). These results are astonishing in light of the fact that infants from this age until the age of 8-9 months do not reach for an object if it disappears behind another object in front of their eyes (Piaget 1975b). Diamond showed that it seems to be important that the object can be reached on a direct path without having to plan detours (Dia­ mond 1990). Taken together these results indicate that infants do not necessarily have to guide their hand visually when reaching for an object. Experiments on reaching for moving objects have been conducted mainly by von Hofsten and co-workers (von Hofsten 1980, 1983, 2002). Von Hofsten and Lindhagen (1979) examined infants between 12 and 30 weeks of age once every 3 weeks as to their development in reaching for moving objects. An object was moved back and forth in front of the infant such that it got into reaching distance for a certain amount of time. At the same time as infants learned to reach for static objects, they successfully reached for moving objects. At the age of 18 weeks, they successfully grasped for objects that moved at about 30 cm/s. At this speed, they had to start the reaching move­ ment before the object was in reaching distance. Thus, the infants at this early age anticipated the

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65

66

THE THEORETICAL BASE

intersection point and pl ann ed the movement

behavior was still present when confronting the

accordingly. The visually triggered movement that

infants several times with the non-linear object

is observable in adults when they grasp accurately

movement. Further s tudies show that infants from

for all k inds of obj ects is, therefore, already present

the age of 5 to 7.5

m on ths

reach for moving objects

in infants and does not devel op from visually

that glow in the dark. Thus, even in such a com­

guided reaching. Von Hofsten (1983) also showed

plex reaching task the p rop rioceptive information

that at 34 to 36 weeks of age, infants can already

and the sight of the obj e ct are sufficient for

catch

object, even if it moves at 120 cm/s.

infant to successfull y reach for the object. Again

Recent studies investigated which critical vari­

the reaching movement is directed towards an

an

ables guide the e x tr apolation of object movement

a n ticip ated

an

intersection point (Rob in et aI1996).

(von Hofsten et al 1998). Six-month-old children

In follow -up studies, von Hofsten et al investi­

were sitting in front of a screen when objects were

gated what happ ens if the target is occl u d ed at the

presented to them which came into grasping dis­

point of crossing in the b rief period before it

tance on four different paths (Fig. 6.4); two were

comes within reach (von Hofsten et al 1994).

linear and crossed each other in the middle of the

Infants now either tended to reac h for the object

screen and two contained an ab rup t chan ge in the

only rarely or they interrupted the grasping move­

direction of the crossing. The reaching movements

ment very often. When presented with the same

a nd gaze direction of the children showed that the

movement several times in a row (in a linear or

infants ex trapol a ted the object

non-linear fashion ), 6- month-old infants showed

motion

alon g a lin­

ear p ath, acc o rd in g to the laws of inertia. This

predictive gaze behavior after just a few trials for

Plotter -----_+_ Screen ------\:\ Plotter head

---�

Object -------

Infant seat ---\:-

Schematic view of display screen showing four different motion paths and reaching areas (dashed elipses)

The experimental apparatus (side view)

Figure 6.4

Experimental setup in

a

a

Top view of a subject reaching for the object

grasping experiment (from von Hofsten et al 1998, with permission of Elsevier

Science).

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Neuromotor development in infancy and early childhood

linear object motion (von Hofsten et al 2000), whereas the ability to predict non-linear object motion is only learnt slowly. Further studies have shown that reaching behavior did not improve if the occluder was transparent such that the object could be seen behind the occluder. Thus, reaching behavior was not reduced due to perceiving the occluder as a barrier for reaching (Spelke and von Hofsten 2001). The influence of the visual control of the hand wanes during the second half of the first year in favor of pre-programed movements, but it does not disappear completely. During this phase, infants, just like adults, use the visually perceived relation between hand and target to reach for the target precisely in the final phase of the movement and to compensate for unexpected replacements of the target (Ashmead et al 1993). The more pre­ cisely the reach can be pre-programed by the infants the less dependent they are on other cor­ rection mechanisms. In fact, after already a few months of reaching practice, the infant is able to reach for objects with one quick arm movement. Nevertheless, difficulties may still arise if increasing demands are made on the motor skill. It has been confirmed time and again that infants of 5 to 6 months can reach and grasp for a free­ standing object, but fail to retrieve the same object if it is mounted on top of a larger object. Studies by Diamond and Lee (2000) suggest that the findings can be explained by the lack of fully developed motor skills. If infants reached for the upper object but - due to an imprecise movement - touched the lower object, they could not inhibit the reflex of grasping the lower object instead of continuing to reach for the upper object. If the demands on the motor skill, however, were reduced by decreasing the possibility of the infant accidentally touching the base object (by just using smaller base objects), infants successfully retrieved the upper object. These new results replaced the long accepted view according to which infants do not understand conceptually that the object continues to exist when placed on another object and, therefore, stop grasping for it.

Apart from the tendency to grasp for an object that is accidentally touched, systemic one- or two­ handed motor tendencies in the reaching behavior of infants seem to be in conflict with the develop­ ment of efficient grasping skills. Corbetta et al (2000) addressed this issue by investigating 5- to 9-month-old infants' reaching and grasping behavior for objects of different sizes and textures. Only infants older than 8 months were able to scale their actions according to the visual and hap­ tic information available to them about the object. Younger infants seemed to be locked into one motor pattern: they could not select and switch between one- and two-handed reaching behavior. A number of studies show that the ability to pre-program anticipatory hand and finger move­ ments develops mainly in the second half of the year. At that time infants not only learn to open and close their hand at the right moment but they also start to consider the orientation of the hand with respect to the object and other spatia-temporal aspects of the movement (Lockman 1990, von Hofsten 1989, von Hofsten and Ri:inquist 1988). For example, they start to use a two-finger grip at about the age of 9 to 10 months. Infants at this point in time are able to coordinate thumb and index finger such that a small object can be grasped and lifted between the finger tips. The role of postural adjustment during sponta­ neous and goal-directed reaching behavior has been investigated for example by van der Fits et al (1999). They investigated particularly whether the immature postural control of newborns and young infants is responsible for the relatively poor quality of pre-reaching movements. Parallel to the development of the reaching and grasping behavior, changes in postural control can be observed. Newborns are already able to adapt their posture to the current position, 3-month-old infants can stabilize head and trunk and by the age of 6 to 7 months, infants can sit upright with the help of arm support. At the age of 9 months, infants sit upright even without support. In lying and sit­ ting adults, voluntary arm movements are accom­ panied, in particular, by activity in the neck and

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67

68

THE THEORET I CAL BASE

trunk muscles. The neck and upper tnmk muscles seem to be responsible for opposing reaction forces which a re generated by the reaching movements and the lower trunk muscles serve to stabilize the center of mass. Fits et al fOlmd that in pre-reaching in fan ts the spontaneous arm movemen ts are accompanied by postural muscle activity which is highly variable (van der Fits et al 1 999) . As the infa nts get older, successful reaching and adult-like temporal characteris tics of the pos­ tural adj ustment seem to emerge in parallel . These results suggest a fundamental coupling between arm movements and pos tural control .

MOTOR DEVELO P M ENT B EYO N D THE FIR ST YEAR OF LI FE

The abil ity to pre-program and execute the move­ ment efficiently increases up to young adoles­ cence continuously (see also Wilkening and Krist 1998) . Firstly, this is due to increased speed of planning, preparing and performing movements. Secondly, this is closely connected to the ability to plan the movemen t accurately. The more accurate the pre-programming, the fewer and less signifi­ cant are the correc tions tha t have to be made dur-

ing the movement's execution . Both spa tial and temporal accuracy as well as speed of the move­ ment seem to improve with age. However, there are some notable excep tions for certain tasks which are related to qual itative changes in the way of con trolling the movement, as these quali­ tative changes seem to be correlated to s tra tegic changes in movement control (Connolly 1968, Ha y 1 984) . Hay tested 5-, 7-, 9- an d ll -year-old children in a pointing task (Hay 1 984) . Children had to point to one of several target points which lit up randomly on a horizontal line, the view of hand and arm being occl u ded by a screen . Chil­ dren, thus, had to pre-program the arm movement or use proprioceptive informa tion to adj ust arm and hand position with respect to the target. Mean accuracy was high for 5- a nd ll-year-old children but low for 7- and 9-year-old chi ldren . How ever, 5-year-olds produced a high intra­ individual variabili ty, which decreased consider­ ably with age. Taking movement time into account as well, it can be seen that the movement pattern prod uced by the d ifferen t age groups differs con­ siderably (Fig. 6.5). Five-year-olds produced a bal­ listic-like pattern with very sudden acceleration and decelera tion phases. A t the age of 7 and still at the age of 9 years, the poin ting movement consists

%

70 60 50

JI /

40

/

/

/

/...... ,

'

....

II

III

30

. .............

... . . . . . . . . . .. . . .

.

.... .

.

.......

.

20 10 O �-----'----r-o

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7

9

11

Age (yea rs) F i g u re 6.5 ©

Pe rce n ta g e of e a c h type of vel ocity patte rn per age (from Hay 1 984, with pe rm i ss i o n of S p ring e r-Ve rlag ,

Spri n g e r-Ve rl ag).

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Neuromotor development in infa n cy a n d ear l y chil dhood

of several sub-movements with braking activity and processing of (proprioceptive) feedback, whereas some 9-year-olds and especiaUy the ll-year-olds again produce a ballistic movement in which feed­ back control is now concentrated a t the end of the movement sequence and all parts of the movement are better coordinated. Another experiment with 6- to 1 0-year-old chil­ dren and ad ults on sequential pointing revealed a simila r non-linear development (Badan et al 2000 ) . Badan et a l manipula ted the task difficulty b y changing the number, size and spacing of the tar­ gets in the sequences. Children's temporal and spatial parameters of the motor sequences showed large age-dependent trends, but did not reach the adult values. This is consistent with the view tha t the neurophysiological mechanisms med ia ting percep tual and motor functions are well devel­ oped at the age of 6 and improvements are due to a continuing process of fine-tuning the system. However, the au thors also found tha t increasing the difficulty of the task did not affect behavior in a similarly uniform fashion. The performance of the 7-year-olds, in particu lar, showed tha t the motor planning stra tegy characteristic of older children seems to emerge at this age, though it has not yet superseded the less effective planning mode adop ted a t earlier s tages of development. Thus, i t seems tha t motor development is not a lmiform fine-tuning of stable stra tegies. Instead, each stage of development is best characterized by a set of strategic components potenti ally available at that stage, and by the age-dependent rules for the selection of components in a given con text. Pellizzer and Ha uert (1996) conducted a study to gain in forma tion abou t the origin of the tempo­ rary decrease in visuo-manual performance occur­ ring around the age of 7 and 8 years. They assumed tha t cha nges occurring on a behavioral level are consequences of those taking place on the neu­ ronal level . They tested children between the age of 6 and 10 years in a visuo-manual aiming task. Results showed non-monotonic changes, which were linked to age, spa tial accuracy, reaction time and movement time. Spa tial accuracy in the right

visual field decreased between 6 and 8 yea rs and increased afterwards. Reaction time and move­ men t time decreased with age, except at the age of 8 years when both tended to increase. The same children participated in two control tasks which showed that the non-monotonic trend is not present if reacti on time is tested where no spatial processing is required and vice versa if spatial processing is tested but reaction time is not a constraint. The authors concluded that this asymmetry in the d ata seems to be due to differ­ ent processes involved in each task and tha t these processes undergo a quali ta tive change at the age of 8 years. Moreover their results seem to suggest tha t the prevailing processes tha t are transformed are loca ted in the left cerebral hemisphere (Pellizzer and Hauert 1996) . In fact, this observed asymmetry is compatible with studies indica ting that homologous regions of both cerebral hemi­ spheres develop asynchronously (Rabinowicz et a1 1977, Thatcher et a l 1987) .

COGNITION AND P ERCE PTION

For many years, motor skills and cognition were believed to be unrela ted, since many studies have shown only a modest correlation between motor and intellectual development (Piaget 1 975a, Shirley 193 1 ) . Piaget, on the o ther hand, believed that cognition comes about from perception and action. Nowadays it is agreed tha t the cognitive development of children also plays an important role in the development of motor skills. This is par­ ticularly true with complex skills where not only practice of a single movement is essential, but other factors, too, such as general leaming ability, the ability to use feedback, processing capacities, planning stra tegies, making decisions on which information is essential and which is not, etc. The rela tionship between percep tion, action and cognition is rather complex and not comple tely understoo d . Sometimes there a re aston ishing discrepancies between percep tual-motor compe­ tencies and the corresponding cognitive knowl-

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69

70

T H E T H E O R ET I CA L B A S E

edge (Frick e t al

2003, Huber e t al 2003, Kr i s t e t a l in o ther cases cognition a n d con­ cepts guide our ac tions (Krist 200 1 ) . 1993),

whereas

direction; these chi ldren released the ball clearly be fore being exac tly above the ta rge t .

The ques tions t o be raised are whether concep­ tual knowledge

guides a c tions, whether con­

S U MMARY

cep tual knowledge is derived from actions (as Piaget would a rgue) and whether j udgments and ac tions

Maj or developmental changes in motor control are

represent forms of knowledge that are insepara­

observed in p articular d uring the first

2 years of life.

ble. One field where these questions were inten­

This is mainly due to the fast progression of neural

sively studied is the field of intuitive physics ( i . e .

development during this time. We have seen, for

people's intui tive c oncep ts a b o u t simple phenom­

instance, that maturation and myelination of partic­

ena o f motion), where knowledge expressed in

ular brain areas are strongly related to the develop­

perceptual-mo tor tasks can easily be assesse d . Kris t et al

ment of motor control over specific body segments.

investigated, f o r instance, chil­

Motor development in children and young adoles­

dren's knowledge about projectile motion. They

cents can best be characterized as a fine-tuning of

asked children from the age of 5 years onwards to

accuracy and speed of movement, but also as a

( 1 993)

propel a ball from various heights onto a target on

development of movement control s tra tegies which

the floor at various distances . Besides the action

cause characteristic qualita tive changes .

condition, a j udgment condition was used in

For the dev elopmen t of specific motor skills i t

which, for each c ombination of platform height

h a s been claimed that sensory stimulation and

and targe t dis tance, the speed of the ball had to be

practice are as essential for the development of

j u d ged on a graphic rating scale. According to the

neural p a thways as brain maturation i tse lf. This

laws of physics, speed in this si tuation is a direct

new multic ausal view of motor development has

function of distance ( the farther, the faster), and an

opened a rich field of research investigating the

inverse function o f height ( the higher, the slower) .

different influences and effects of various environ­

Child ren's speed prod uctions reflected these

mental, biomechanical, cogni tive, percep tual, an d

principles very well, with virtually no age trend

neural factors on motor dev elopment.

from the youngest children up to adults. In the

However, a profound understanding of the ir

j u d gment condition, however, 5-year-olds failed to

rel a tive impor tance is sti l l missing . In this respect,

in tegra te the relevant dimensions, and many

the field of developmental cognitive neuroscience

1 0-

year-olds ( and even several a d ults) showed strik­

is a particularly vigorous and rapidly growing

ing misconcep tion s . Most of these children seemed

field of research (Nelson

to hold an inverse-height heuristic : tha t the ball

used various approaches for a be tter understa nd­

200 1 ) .

Scientists have

should fall fa ster the higher the platform of release.

ing of neural correla tes of motor developmen t.

o ther tasks, however, children used their

Neuroimaging techniques are not well adapted to

concep ts to drive their a c tions . Krist con d u c ted a

the study of movement skills and they are often

study in which children moving at constant speed

not s u i table for studying normal young human

were a sked to hi t a target on the floor by dropping

subjects. Therefore researchers study, for exa mple,

In

a ball (Krist

Those children who held the

infants (many of whom are born prem a turely)

concept ( assessed in a j u d gment condi tion) tha t an

who have suffered perinatal brain lesions (Thelen

o bj e c t d ropping from a moving carrier fa lls

2000).

straight down, dropped the ball significantly l a ter

recovery of function, nevertheless many of them

200 1 ) .

These infan ts do not always atta in full

(above the target) than those who had the correct

show

knowledge tha t the object falls in the forward

Elman et al

Copyrighted Material

considerable

1996

functional

for a review ) .

o u tcomes

( see

N e uromotor deve l opment in i nfancy and early ch ild h ood

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in infan ts' reaching toward

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in the

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7: 82-100

Corbetta D, Thelen E, Johnson K 2000 Motor constraints on the d evel o p ment of perception-action matching in infa nt reac hin g. Want Behavior and Development 23:35 1 -374 Dennis W, Dennis M 1940 TIle e ffect of crad ling practices upon the onset o f wal k ing in Hopi c hi ld re n . Journ a l of Genetic Psyc h ology 56: 77-86

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Diamond A 1 990 Deve l opmental time course in human

Lasky R E 1977 The effect of visual feed back of the hand on

in fants and infant monkeys, a n d the neura l bases of

the reaching and retrie v a l behavior o f young infan ts .

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Child Deve lopmen t 48 : 1 1 2-117

Academy of Sciences 608:637-676

Led e rma n S

Diamon d A, Lee E Y 2000 I n a b i l i ty o f five-mon th-old infants to retrieve a contiguous object: A fa i l u re of conce ptual understand ing or of control o f action? Child

J, K1atzky R L 1987 Hand m ovemen ts: A

window into haptic obj ec t recognition. Cogni tive Psychology 1 9 : 3 42-368 Lockman

JJ

1 990 Percep tu o motor coord ina tion in i nfa ncy.

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cogni tive, perceptuo-mo tor, and neuropsychological perspectives. North-Holland, Amsterdam, p 85-1 1 1 McC a r t y M E, Ashmead D H 1 999 Visua l control of reaching

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and grasping in infa nts. Develop menta l Psychology

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F rick A, Huber S, Reips U-D, Krist H 2003 Ta sk speci fic knowledge about the law of pend u l um motion in c hildre n a nd adults. Manusc r i p t s ubmitted for p u b l i ca tion G hez C 1991 The control of movement. In: Kandel E R, Schwartz

J H, Jessell T M (eds) Princi ples of neural

science. Pre n tice H a l l, London

McDonnell P 1975 The d evelopment of visually guided reachin g. Percep tion and Psychophysics 1 8 : 1 8 1 - 1 85 McG raw M B 1 945 The n e uro m u s c u l a r m a tu ra tion of the h u man infan t. Ha fner, New York McG raw M B 1 946 Ma tura tion of behavior. I n : C a rmichael L (ed) Ma n u a l of chi l d psychology. Wi ley, New Yo rk, p 332-369

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2001 H a n d book o f develop menta l c ogn i ti v e neu roscience . MlT Press, C am b r idge Newell K M 1986 C on str a in ts on the development o f coordination. In: Wa de M G, W i t in g H T A (eds) Motor deve lopment in c h i l d r e n : aspects of coord ina tion and control. N ijhoff, Boston, p 341-360 Pellizzer G, Ha uert C A 1996 Visuo-manual aim ing movements in 6- to l O-year-o ld chil d re n : Ev ide nce for an a s y m m etric and a s yn chrono u s dev elop ment o f info rma tion processes. B r a in a nd Cogni tion 30:1 75-193 Penfield W, Rasmussen T 1 950 The cerebra l cortex of man: a c l ini c al st udy of localiz a tion of function. Macmill a n Nel son C

h

J 1973 Das Erwachen der Inte l l igenz beim Kin d e . Klett, S t u t t g art Piilget J 1975a Das Erwachen der Intelligenz beim Kinde; Gesa mmel te Werke, Studien-Ausgabe. Vol l . Klett, Stu ttg ar t Piaget J 19 75b Der A ufb a u der Wirk l ichkeit beim Kin d e . Kle tt, S t u t tga r t ( or i g ina l l y p u b lished 1937) Prech t l H F R 1985 U l traso und stud ies of human fe ta l behavio u r. Early Hum an Development 1 2 :91-98 Prec htl H F R 1993 Pr inc i p l es of early motor d evelopment i n t h e h uman. In : Ka lverboer A F, Hopkins B (eds) Motor d evelopment in early and later childhood : Lo n gi tu d in a l a p p ro a c hes . E u ropean N e twork on Longitudina l Stud ies on Ind i v i d ual Development (EN LS) . C a m br i d ge University Press, New York, p 35-50 Ra binowicz T, Leuba G , Heumann D 19 77 Morpholog ic maturation of the bra in: A q u a n t i t a t i v e study. In: Be re nb e rg SR (ed) Brain, fetal and infant. Ma rtinus Nijho ff, The Hague, p 2&-53 Rob in D J, B e rthi e r N E, Cl ifton R K 1996 Infan ts' predictive reaching for m o v ing objects in the dark. Developmen tal

32:824-835 Sa v e l s b e r gh G J P, van der K a mp J 1994 The effec t of body orientation to gr a v i ty on e a r ly infant rea ching. J o u rna l o f E x p er im ent a I C hi ld P s yc ho l o g y 58:510--528 Shi r l ey M M 1931 The first two yea rs, a study of twe n ty - five babies: 1. Pos t u ra l and locomo tor develop ment. Uni v erity of M innesota Press, Minneapolis, MN S pel k e E S, von H o f s te n C 2001 Pred ictive reaching for Psychology

occ l uded objects by si x-month-old infants. Jou rnal of Cogni tion and D ev e l o p men t 261 -282 S po r n s 0, Edelman G M 1993 So l v in g Bernstein's p ro blem : A proposal for the development of coordina ted movement by selecti o n . Child Developmen t 64:960-981 Sta u d t M, Kr a g e l oh - Mann 1, G rodd W 2000 D i e norma Ie Myelinisierun g des kind J ichen G e hi rns in der MRT - eine M e ta ana ly s e . [ N or m a l mye l in a tion in chi ld hood brains u sing MRI - a meta an a lys i s ] . For tschri t te a u f dem Gebiet der Ron g tenstrahlung und der Neuen bildgebenden Ve r fa hren

1994 3 month old i nfa n ts can learn ta s k - spe c i fi c Science 5 : 280--285 ll1elen E 1 995 Mo tor development - a new syntheS i S . A m e r ic a n Psy c h o l o g i st 50:79-95 Thelen E 2000 Motor development as fo un da tion a nd fu t u re of developmenta l psyc h ology. Interna tional J o u r n a l o f Behavioral Develop ment 24 :385-397 Thelen E, Fisher D M, Rid ley-Johnson R 1984 The rela ti onship b e twe en p h y s icil l gro w th a n d a new born reflex. Infant Behavior and Dev e l opment 7:479-493 Thelen E, Sk a l a K, Kelso J A S 1 987 The d ynamiC na t u re o f pa tterns of inter-limb c oo r d i n a ti o n . P s y c h o l o gi c a l

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172:802-8 11 1988 Ha pt i c p erc e p ti o n of obj ects in infancy. C ogn iti v e Psychology 20:1-23 Streri A, Sp e l k e E, R a m ei x E 1 993 Mod a l i ty s pe ci f ic and a mod a l aspects of o bjec t perc e p t ion in infancy - the case of a c tive to uch . C o gni ti on 47:251-279 Tha tcher R W, Wa l ker R A, G i u d i ce S 1987 Hu ma n cerebra l hemispheres develop at diffe re n t ra tes and a ges. Science 236 :1110-1 113 Streri A, Spe lke E

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von Hofsten C, Feng

Paris

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Copyrighted Material

SECTION 2

Clinical insights

SECTION CONTENTS 7.

Birthing interventions and the newborn cervical spine

8.

Birth trauma and its implications for neuromotor development

9.

Differential diagnosis of central and peripheral neurological disorders in infants

10. Manual therapy from a pediatrician's viewpoint

75 85 99

113

11. The influence of the high cervical region on the autonomic regulatory system in infants

125

12. Attention deficit disorder and the upper cervical spine

133

13. Asymmetry of the posture, locomotion apparatus and dentition in children

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145

73

Birthing interventions and the newborn cervical spine D. Ritzmann

': li,I"

I

,

" ,

i

I

INTRODUCTION CHAPTER CONTENTS Introduction

Why shoul d an obstetrician write a chapter in a book about manual therapy? As we know today, problems in newborn babies, children and adults can have their roots in pregnancy and birth, and the risk of damage to the newborn brain durin g birth has been the ta rget of research for many years. Amongst manual therap ists and obstetri ­ cians, pat holo gis ts and neurologists there is now growing interest in th e newborn cervical spine and its possible damage during birth.

75

Short history of European obstetrical research and inventions

76

The gynecoid pelvis The android pelvis

77 77

The anthropoid pelvis

77

The platypeloid pelvis

77

Research about the function of the female pelvis

77 78

Risky situations during birth Arrested parturition

Extremely rapid delivery Breech delivery

This introductory section outlines different

78

vie ws

78

79

in Europ e and the research on the function of p el vis during birth. This is followed by an explanation of r isky situations and in terventions during birth. T he final section looks at the special anatomical and physiological situation of the newborn head and spine and the possible damage tions

The delivery of children with deflected heads

Pressure from above Traction from beneath Rotatory forces

79

79 79

80

The dangers for the newborn cervical spine Pressure forces

80

Traction forces

81

Rotatory forces Conclusion

the

79

Risky interventions during birth

82

81

on childbirth; the next two sections describe

the development of obstetric research and inven­

80

to these structures during birth.

go through birth is a funda­ mental experience for both mother and child. We know today that successful childbirth depends on other factors as well as the a n a tomy of the pelvis, the diamete rs of the child's head and the power and timin g of the contractions. For more than a hundred years, researchers have been working on To give birth and to

the function of the pelvis during birth, the move­

ments of the j oints, the stretching of the ligaments Copyrighted Material

75

76

CLINICAL INSIGHTS

and the interdependent changes in the move­

obstetricians entered this field which until then

ments of the mother and the unborn child. More

had been the domain of 'wise women' (the French

recently, researchers have also been looking at the

term for midwife 'sage-femme' - 'wise woman'

psychological dimensions of giving birth and of

literally translated - reflects this). New instru­

being born. We are learning more and more about

ments were invented and introduced. At the end

this subtle teamwork between mother and unborn

of the seventeenth century, two members of the

child, especially how to empower and how not to

English family Chamberlen (Hugh and Paul) spoke of an instrument that would enable every

disturb it. There are many different views on giving birth. Some of the most important are the following three: •

Giving birth and being born is fundamentally a mechanical problem between the pelvis of the mother and the head or breech of the child (tra­ ditionally European).

•

Giving birth and being born is fundamentally a p rob le m of rhythm and of disturbances of rhytlun (traditionally shamanistic approach).

•

Giving birth and being born is fundamentally a problem of not being disturbed (new and very old views of Christian belief).

woman to give birth to a living child, but there is no

picture of

this instrument.

In

1721 the

renowned Belgian surgeon Johannes P. Palfijn

(1650-1730) showed a new instrument, which was called 'the iron hands of Palfijn'. It was the first known and depicted obstetric forceps. During the eighteenth century there was a growing interest in the medical community in learning more about the female pelvis during birth. William Smellie

(1697-1763) wrote

in

1754

about the possibility of learning more about the inner

pelvis

by

touching

during

birth.

He

described how it was possible to turn the child's

Because this chapter is concerned with birthing

head with gentle pressure during birth. He also

interventions and their effects on the newborn cer­

postulated that the unborn child usually enters

vical spine, we will concentrate on the traditional

the pelvis transversally, the only person to do so

Western view of mechanics . All the same we

for about

should not forget that in practical obstetrics the

until the beginning of the tvventieth century, when

150 years. This fact was not accepted

rhythm and the absence of disturbances is much

Christian Kielland

more important. Gradually this finding has led to

(1871-1941) came to the same conclusion (Parry Jones 1952). His instrument, the

the now more widely held view that there is no

Kielland forceps, is still used today.

sense in measuring the outer pelvis with a

In

1934 Dr Eugene

W. Caldwell

(1870-1918),

pelvimeter, or the inner pelvis using hands, X-ray

professor of radiology in New York, used X-rays to

or MRI (magnetic resonance imaging) to assess the

prove that Smellie and Kielland were correct. Dur­

prospects for giving birth. It is only in the situation

ing the nineteenth century, especially in France,

of a breech presentation that cliin cs

number of obstetricians tried to construct better

or MRI of the pelvis to help in planning the birth.

forceps to obtain the best traction direction. There

a

was much sophisticated work in this field. But the same famous men did not accept the minimal

SHORT HISTORY OF EUROPEAN

hygienic standards proposed by Dr Ignaz Semmel­

OBSTETRICAL RESEARCH AND

weis, the famous trailblazer for hygiene in surgical

INVENTIONS

wards, nor did the high mortality of mother and child in connection with interventions lead them to

In Europe, a change occurred in obstetric practice

be careful in promoting their use.

during the sixteenth and seventeenth centuries.

As pathology and radiology developed, the

Alongside a decline in female knowledge as a

female pelvis became a target of research. Four

result of politics and church prosecution, male

types of female pelvic forms have been described

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Birthing i nt er v en t i on s and the newborn cervical spine

since the nineteenth century, and were classified in 1934 by Caldwell and Moloy: the gynecoid type, the android type, the plat ypeloid type and the anthropoid type. This classi fic ation of female pelvic types is still used today. The gynecoid pelvis

This is the t ypical transversally l arge inlet. The b aby 's head enters the pelvis in the transverse position. In obstetric books, it is considered the pel vis. Nevertheless Borell and Fernstr om found it in onl y 25-30% of a northern European popula tion du rin g birth. We can see here the t ypical way of e ntering the pelvis trans­ versally in Homo sapiens sapiens. It seems that for 4 million years starting with Australopithecus the pelvis has been get ting a transversal l y larger inlet in females. With this usual birth position at the pelvic inlet the unborn baby has to rum 90 degrees with head, shoulders and rump. This sc rewing movement is typical for hu man birth. In four­ footed animals the pelvis is s tr ai ght and no screw­ ing movement is necessary. most usual female

The android pelvis

This is the typical male pelvis. Borell and Fern­ strom found it in about 10-20% of women during birth. The b a by ' s head enters the pelvis in the oblique di a meter. The anthropoid pelvis

Anthropoid relates to the primates who have this typic a l large sagi tt a l inlet of the pelvis. Rad iolo gi­ cally it is found in between 5 and 73%, the wide range indicating the clashes of opi n ion on how to de fine it. The baby's head enters the pelvi s in the sa gittal diameter. The platypeloid pelvis

This is the typical flat pelvis, found in women with rickets. It has a gynecoid form, but is very

narrow in the sagitt al diameter. It is found in vary­ ing frequencies from 1 to 56% (note, again, the wide range of reported incidences). Often the baby's he ad cannot enter the pelvis, as the radi ­ ographic analysis might sugge st . If it c an enter, it lies in the o bli que diamete r. Research on the different forms of female pelvis decreased as cesarean sections became more fre­ quent. Some special pelvic forms have been thought to be associated with special risks during birth, for example the so-called long pelvis described by Kirchhoff. Later srudies showed that these pel vic fo rms are frequent in normal births as well, so the postulated risk is not proven (Borell and Fernstrom 1957) With the reduction in rickets and poliomyelitis in Europe, the pelvis is very sel­ dom a problem for birth.

RESEARCH ABOUT THE FUNCTION OF THE FEMALE PELVIS

At the end of the nineteenth cenrury, researchers started to describe the function of the pelvis, and were p artic ularly interested in the joints and liga­ ments. Walcher (1889) and von Kiittner (1898) described a s agittal opening of the pelvis of about 8 to 12 mm through stretching and bending of the hips of dead mothers (Borell and Fernstrom 1981). The y concluded that the sacroiliac joints allow this opening. Du ring pregnancy there is a relaxation of the sacroiliac joints which can lead to recurrent blockages of these joints with p a i nful conse­ quences. To study these joint movements d urin g birth is nowadays n e ar ly impossible. From manip ulations during birth to get blocked sacroil­ iac joints back to their normal function we can assume that the movement in the sacroiliac joints is important for a norm al birth. In h uman birth, all the space between the pelvis and head of the baby is needed. When a joint cannot move smoothly the birth can be distur bed. The relaxation of the pelvic li gaments and joints is triggered by the hormone relaxin. This hormone also has an influence on the ripening of

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77

78

CLINICAL INSIGHTS

Risky situations are:

the cervix and on the connective tissue in vessels and the skin (Sherwood

1994). Radiological

examinations in the middle of the twentieth cen­ tury demonstrated

a

relaxation of the sacroiliac

joints of some millimeters and a relaxation of the symphysal joint from about

4

mm

to usually

8

mm at the end of pregnancy (Borell and Fern­ strom

1981). This is reversible

3 to 5 months after

birth. The movements of the pelvis during birth are described by Borell and Fernstrom: when the baby's head enters the pelvis, the symphysal joint descends.

In

mid pelvis

the symphysal joint

moves cranially and at the pelvic outlet even more. This cranial movement can reach several cen timeters. To allow the pelvis to move in such a way dur­ ing birth it is essential that the mother is as undis­ turbed as possible. It seems that the Indian way of birthing (described by Moyses Paciornik in

1985)

in the squatting position reduces the necessity for

interventions to a minimum. Paciornik reports a frequency of under

5% for forceps delivery. In the

squatting position the pelvis is 'freely hanging'. It is logical that the joint movements can work undisturbed in this pOSition. The movement of the pelvis during birth seems to be related to the posture of the mother and to the tightness of the muscles, which are influenced by fear and psychological tension. This would

• •

extremely rapid delivery

•

breech delivery

•

delivery of children with deflected heads.

Arrested parturition Arrested parturition is a very frequent situation, especially in obstetric clinics. Often it leads to inter­ ventions such as hormone injections to accelerate the frequency of contractions or to instrumental or cesarean deliveries. Different underlying problems can lead to an arrest , but often the cause is not clear. In this situation the obstetrician uses the term 'dis­

proportion

between

pelvis

and

head'.

More

research is needed in this field. Often it is not clear why the contraction forces vanish, why the unborn baby does not enter deeper into the pelvis or why a normal birth turns suddenly into

an

arrest.

Could factors such as changes in staff, lack of inti­ macy, or ongoing disruption of this very intimate process of giving birth due to the technical controls and the emotionally uninvolved staff be the cause of the immense problem of disturbed births? There is always

an

underlying problem that

leads to an arrest of birth. This could be a mater­ nal problem such as: •

weak labor (exhausted mothers, mothers in fear

•

uncoordinated labor pains (induced births,

•

anatomical problems of the pelvis (seldom).

explain why it is important to give support throughout birth so that the level of operative

arrested parturition

or grief, disturbed mothers)

interventions is kept to a minimum.

preterm births, pain and fear)

Arrested birth can also be due to a problem con­

RISKY SITUATIONS DURIN G BIRTH

cerning the unborn baby sllch as:

To give birth and to go through birth is a funda­

•

transverse or breech presentation

mental experience for both mother and child.

•

dorsoposterior presentation

There are situations that by themselves are risky

•

a deflected head.

for mother and child or are followed by risky maneuvers by the obstetricians or midwives. We

Extremely rapid delivery

now take a closer look at the impact of these situations and interventions, especially for the

Extremely rapid delivery can cause problems to

newborn cervical spine.

the baby because of the immense power the con-

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Birthing interventions and the newborn cervical spine

tractions exert on the baby's head and neck. The

RISKY INTERVENTIONS DURING BIRTH

baby can rush through the pelvis, pushed by con­ tinuous contractions. A certain percentage of babies

All interventions during birth are risky, if not

with problems related to the cervical spine have

done carefully and with respect for the special

this birth history.

situation of the mother and the unborn child. Risky interventions are the following:

Breech delivery Breech deliveries are special deliveries. Even in communities far away from modern obstetrics (as

•

pressure from above

•

traction from beneath

•

all rotatory forces.

e.g. in the country side of Nepal) women do not give birth alone with mother and husband

if there

Pressure from above

is a breech delivery. A midwife will be present at Pressure from above can increase in fast deliveries,

birth in this situation. The risk of a higher morbidity and mortality

but also through all kinds of interventions in

relates not only to the baby but also to the mother,

arrested births. These interventions can be the

especially in poorer countries where no antibiotics

traditionally exerted external direct forces by

or instrumental interventions are available. Breech

means of cords and bags, in Western obstetrics the

deliveries are often more protracted than vertex

so-called 'Kristeller fundal pressure'. Initially

(1820-1900) proposed a soft

deliveries and have a higher risk of arrest and

Samuel Kristeller

damage to the baby.

pressure by hand, nowaday s it is most often a very

Interestingly, Leonardo da Vinci drew only dead

powerful pressure. In the original publication, this

mothers with unborn babies in breech presentation

maneuver was advocated as an aid for multiparae

because he had to base his anatomical research on

where the abdominal muscles were atrophied and

autopsies of mothers who died during childbirth.

thus not functioning normally any more. The most frequently

The delivery of children with deflected heads

used augmentation

of contraction

forces nowadays is labor-inducing medication.

Traction from beneath Unborn babies with deflected heads usually lie in the dorsoposterior vertex presentation. The dorso­

Traction from beneath has a long history: Before

posterior presentation describes an unborn baby

1700 there had been nets and strings to get the

with its spine turned towards the mother's spine.

child from beneath. In the early eighteenth cen­

In this position the head is often deflected and is

tury the newly invented obstetric forceps some­

less able to bend during parturition. Quite often

times replaced these older traction forces. In

the birth takes much longer than usual or is even­

Tage G. Malmstrom proposed a new traction

1954

tually arrested. In this unfavorable situation the

instrument, the vacuum extractor. This instrument

labor forces cause more stress to the unborn baby

is now replacing the obstetric forcipes.

and the risk of injury increases. Frequently it is

At the begirming of the twentieth century,

necessary to deliver the baby by forceps, so the

Hermann

(1868--1960) invented

risks of this intervention augment the overall risk

John Martin Munro Kerr

of the deflected head. Babies in breech presenta­

new surgical techniques to make cesarean sections

tion with deflected heads have a very high risk of

safer. At the end of the same century, Michael

morbidity. Nowadays this is an indication for a

Stark proposed

cesarean delivery.

cal option, the so-called 'soft cesarean'.

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a

shorter and less traumatic surgi­

79

80

CLINICAL INSIGHTS

All these different interventions have their par­ ticular risks to the newborn spine and head, even

THE DANGERS FOR THE NEWBORN CERVICAL SPINE

the cesarean section. Problems with the newborn spine can result from a long birthing process which

We can differentiate between pressure forces, trac­

in the end is terminated by an instrumental deliv­

tion forces and bending forces. These different

ery or a cesarean section, but there are also some­

types of forces have different effects on the new­

times problems if the baby has been delivered by a

born cervical spine and head.

planned cesarean section. Often to get the baby out of the uterus the incision needs quite a powerful

Pressure forces

pressure from above. So even this intervention can be harmful to the baby. It would be best to prevent

During normal birth the unborn baby is protected

all types of interventions, but here we need more

from direct forces by the amniotic fluid. The fluid

research.

causes a distribution of the uterine muscle forces.

Rotatory forces

or by intervention, the forces exerted on the baby

With the opening of the amniotic cavity, by itself lead to a direct pressure on head and neck in the

If the

vertex presentation. If the baby is turning cor­

head of the unborn baby does not turn in the best

rectly through the pelvis, it will not get stuck and

position and stays in the wrong diameter, it may

will move slowly downwards. If there is an arrest

be possible to turn the head by hand as Smellie

in labor, the contraction forces will press the spine

proposed in the seventeenth century or by Kiel­

against the suboccipital region.

Rotatory forces are now seldom exerted.

land forceps as proposed in the early twentieth

These pressure forces, whether due to strong

century, but this must be done without force. If

contractions, manual pressure (Kristeller), or hor­

any force is exerted on the head, the cervical

monal augmentation of the natural contractions,

spine can be injured and the result can be delete­

can occasionally lead to a subluxation of the atlas

rious. Rotatory interventions are difficult and

into the foramen magnum with disruption of the

dangerous.

cerebellum. The atlas of the neonate is much

Today the distribution of modern techniques

smaller in relation to the foramen magnum than in

depends more on politics and tradition than on

adults. With pressure, it can protrude into the

medical reasoning. The cesarean section rate

foramen magnum.

varies from under 6% in Italy to over 50% in

Axial pressure is the force usually encountered

Brazil; it also varies from region to region and

in a normal birth. The neonate's anatomy and bio­

from hospital to hospital. The vaginal interven­

mechanics correspond to the special requirements

15% in

of birth. The cervical spine has horizontal joint

Switzerland. T here are countries with low inter­

facets, enabling better adaptation to bending

vention rates and others with higher rates but

forces; the small processi uncinati do not hinder

tion rate is 1-2% in Italy but more than

with similar newborn morbidity or mortality

the compensating movements of the vertebrae

rates.

during birth. The center of rotation of the cervical

There has been an overall lowering of newborn mortality and morbidity in the last century, but independently of the frequency of instrumental interventions. It seems more connected to the health

situation

countries.

of women

in

rich

Western

spine in sagittal movements is the high cervi­

C2-C4, not the deeper one as in adults CS-C6 (see Chapter 3). This situation allows the

cal region

unborn baby to hold the neck quite stretched with

a flexed head. On the other hand, the region C2-C4 is more vulnerable to traction and rotatory forces

Copyrighted Material

Birthing interventions and the newborn cervical spine

in the newborn baby.

if the head is in an extremely

the spinal cord can only withstand 0.7 cm exten­

flexed position (as in dorsoposterior flexed vertex

sion before it ruptures. It is about

presentation) the high cervical region is under

we saw fractured vertebrae during childbirth, but

100 years since

massive pressure (Sacher 2002; see also Chapter 8).

spinal cord damage is nonetheless possible. A

If other forces than axial pressure are exerted

description of spinal cord injuries without radi­

during birth - e.g. rotatory or traction forces - the

ographic abnormality in children has been pub­

weak ligaments cannot prevent the spinal cord,

lished by Osenbach and Menezes

(1989).

the vessels and nerves from being damaged. The ligament of the dens axis is weak and cannot pro­

Rotatory forces

tect the brainstem from extension. The special anatomy of the newborn cannot pro­

Traction forces

tect the spinal cord, the vessels and nerves from rotatory forces. These are the most dangerous

Traction forces during birth.can lead to damage to

manipulations

the spinal cord, the spinal nerves, the vessels of

The horizontal joint facets of the cervical verte­

the cervical spine and the brain. Often no damage

brae allow more movement possibilities during

to the osseous structures is seen on radiography,

birth, but are not adapted at all to rotatory move­

but there is extensive damage to the soft tissue of

ments. The interconnected nerves and vessels in

the spinal cord, the nerves, vessels or even the

the cervical spine and the weak ligaments can lead

brain. Modern techniques of MRl or PET can

to a disruption or stretching of these structures.

reveal these lesions more precisely.

The arteriae basilares are especially at risk from

The arteriae cerebri mediae and the sinusoidal veins are at special risk under traction forces. They

rotatory forces.

If stretched or ruptured, subdural

and intracerebral bleeding can result .

can rupture and cause intracerebral and subdural

As different structures may be involved in

bleeding. If this happens, they can bleed profusely

cervical spine injury and brains tern damage,

or create adhesions, which can squeeze the spinal

the symptoms vary in signs and extent. The main

cord.

symptoms of intracerebral bleeding are early

What extent of traction power is exerted on the newborn cervical spine?

death, breathing depression and epileptic cramps. Nowadays ultrasound of the brain allows early

Few physicians since Samuel Kristeller have investigated this question. Kristeller, in

diagnosis. The leading symptom complex of spinal cord

1861, 15.9 kg by forceps. A hundred years later Laufe (1969) reported an average of 7.7 to a maximum of 19 kg by forceps. Interestingly in 1990 Justus Hofmeyr

symptoms can be spasticity, paraplegia and an

reported exactly the same traction force by the

atonic bladder. Injuries of the upper cervical spine

measured an average traction power of

injuries is the so-called 'spinal shock'. Early symp­ toms can be early neonatal death, respiratory depression, gasping and hypotonic muscles. Late

metal suction cap of the vacuum extractor as

can also lead to gastrointestinal kinetic problems

15.8 kg (Hofmeyr et al 1990).

such as spasms of the pylorus, gastroesophageal

The weaker silicon suction cap exerted a some­

back flow and hypotonic jejunum. A possible effect

Samuel Kristeller:

what smaller power. In

can be relapsing pneumonia, a symptom that can

1874 Duncan examined the spines of new­

born dead babies and reported the following data:

lead to the diagnosiS of high cervical injury (see Chapter

8).

the vertebral spine of a newborn dead child can

If the spinal nerves are stretched or rup­

5.6 cm before it breaks, but

tmed, paralysis of the plexus brachialis (cervical

suffer an extension of

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81

82

CLINICAL INSIGHTS

with 1984).

plexopathy) can result, very often combined

breech presentations, twins, arrested births and

torticollis on the same side (Suzuki et al

deflected heads during birth

They are the main symptoms of damage in the

BUlow

(Buchmann and 1983, Seifert 1975, Biedermann 1999).

upper cervical spine. This can be the more fre­ quent Erb-Duchenne upper plexopathy

with

injuries to neural structures CS/C6 or the less fre­ quent Klumpke caudal plexopathy with injuries to spinal nerves C7/T1, sometimes combined with a Horner syndrome.

CON CLUSION We begin to understand how vulnerable the structure of the newborn cervical spine is. Further

The real incidence of damage to the upper cer­ vical spine and brainstem structures is not known.

insight into this complex problem will surely influence the way we regard birthing.

Giving birth

Some authors have published data on the fre­

under water or in a squatting position, for exam­

quency of missed diagnosis in child neurology

ple, alters the stress exerted on the cervical spine.

a nd pathology, which are quite high (10% to over 50%) (Towbin 1964, Rossitch and Oakes 1992).

ing birth is an important issue in reducing the

Not to disturb the rhythm and the intimacy of giv­

Studies of newborn babies that had a special inter­

incidence of arrested births and therefore the risk

est in high cervical function revealed a high fre­

of damage to the newborn. These are just two of

quency

(about

30%) of functional impai rment .

many areas where the work of obstetricians inter­

This seems to be connected with traction forces

sects with the work of those engaged in

and special risks as mentioned above such as

therapy.

manual

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GlazenerC

M A et al 1995 Postnatal maternal morbidity:

extent, causes, prevention and treatment. British Journal

vacuum extraction. Singapore Medical Journal

of Obstetrics and Gynaecology102:282-287

35:605-608 Annibale D J et al1995 Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated

Govaert P et al1992 Vacuum extraction, bone injury and neonatal subgaleal b leeding . European journal of Pediatrics151:532-535

pregnancies. Archives of Pediatric and Adolescent

Govaert P et a11992 Traumatic neonatal intracranial

Medicine 149:862-867

bl eeding and stroke. Archives of Disease in Childhood

Avrahami E et al1993 CT demonstration of intracranjal haemorrhage in term newborn following vacuum

67:840-845 Gra ig W S1983 Intracranial hemorrhage in the newborn.

extractor delivery. Neuroradiology35:107-108 Bhagwanani S G et a l 1 973 Risks and prevention of cervical cord injury in the management of breech presentation with hyperextension of the fetal head. American Journal of Obstetrics and Gynecol ogy 115(8):1159-1161 Biedermann H. 1993 Das KlSS-Syndrom der Neugeborenen und K1einkinder. Manuelle Medizin31:97-107

A study of diagnosis and differential diagnosis based upon pathological and cLirucal findings in 126 cases. Archives of Disease in Childhood13 :89-123

Greis J Bet al1981 Comparison of maternal and fetal effects of vacuum extraction with forceps or caesarean deliveries. Obstetrics and Gynecology57:571-577

Bjerre I et al1974 The long term development of child ren

Hibbard B M et al1990 The obstetric forceps- are we using

delivered by vacuum extraction. Developmental

the appropriate tools? British Journal of Obstetrics and

Medicine andChild Neurology16:378

Gy naecology97:374-380 HillierC EM et al1994 Worldwide survey of assisted

Bresnan M Jet al1974 Neonatal spinal cord transection secondary to intrauterine hyperextension of the neck in breech presentation. Journal of Pediatrics84(5):734-737 Brey J et al 1956 Vacuum extractor with special reference to earl y and late infantile injuries. Gebhilfe und Frauenheilkunde 22:550

vaginal delivery. International Journal of Gynecology and Obstetrics47:109-114 Jensen T S et al 1988 Perinatal risk factors and first year vocalizations: influence on preschool language and motor performance. Developmental M edicine andChild

Buchmann J et al 1992 Asymmetrien in der

Neurology30:153-161

Kopfgelenkbeweglichkeit von Kindem. Manuelle

Johanson R et al1989 North Staffordshire/Wigan assisted

Medizin30 9 : 3-95

delivery trial. British Journal of Obstetrics and

Cardozo L D et al1983 Should we abandon Kielland's

Gynaecology96:537-544 Johanson Ret al1993 A randomjsed prospective study

forceps? British Medical Journal287:315-317 Carmody F et al 1986 Follow-up of babies delivered in a randomised comparison of vaculun extraction and

comparing the new vacuum extractor policy with forceps delivery. British Journal of Obstetrics and Gynaecology

forceps delivery. Acta Obstetrica Gynecologica

100:524-530

Scandinavic� 65:763-766

Johanson R et al1999 Maternal and child health after

Chalmers j A 1989 Commentaries(The obstetric vacuum

assisted vaginal delivery:

extractor is the instrument of first choice for operative

randomised controlled study comparing forceps and

vaginal delivery). British Journal of Obstetrics and

ventouse. British Journal of Obstetrics and Gynaecology

Gynaecology 96:505-509

106:544-549

Chiswick M L 1979 KieUand's forceps association with

Johnson N et al1995 Variation in caesarean and instrumental delivery rates in New Zealand hospitals.

neonatal morbidity and mo rtality. British Medical joumal i7 : -9 Dell DL et al1985 Soft cup vacuum extraction:

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delivery. South African Journal of Obstetrics and

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Gynaecology 2:1-3

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Obstetrica Gyn ecol ogica Scandinavica65:75-80

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Gachiri J Ret al Fa'till and maternal outcome of vacuum extraction. East Africa Medical Journal1991; 68:539-546 Garcia J et al 1985 Views of women and their medical and midwifery attendants about instrumental delivery.

GiUes F H et al1979 Infantile atlantoccipital instability. American Journal of Diseases ofChildren 133:30-37

delivered by vacuum extraction on maternal indication. Acta Paediatrica Scandinavica69 :625-631 Ludwig B et al 1980 PostpartumCT examination of the head

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1 03 : 1 68-1 70

Men t i cog lo u S M et a l 1995 H i gh cerv i c a l spinal cord inj ury

in n e o n a tes d e l ivered w i th fo rc e ps : report o f 15 c a ses . Obs tetrics a nd Gyn e co l o gy 86(4) :589-593 Meyer C et al 1 972 Rega rding neuropsychic resi d ua of infa n ts d e li v e red by a Sw e d is h ventouse. Rev Neuro ps ych iatr Infant 20:343 M i d d le C et al 1995 La b o ur a nd delivery of n orm a l p r i mi p a ro u s w om e n . B r i tis h J o u r n a l of Obs tetrics and

in prim a ry h e a l th ca re. WHO B u l letin OMS 69: 779-789 Simon L e t a l

1 999 Letters to the E d i to r ( C l in ical and

r a d i ol og i ca l d i agnosis of the s pi na l cord b i r th inj u r y ) . A rch ives of D i sea se in C hi l d h ood . Fetal a n d Neona ta l

Edition

81:F235-236

Sultan A H e t a l 1 993 Anal-s phinc ter d i s ru p t i o n d u r in g v ag ina l d e l i ver y. New England J o u rn a l of Med icine 329 : 1 905-1 9 1 1 Ta kahashi l e t a l 1 994 Rota tional occl u s i on o f the verteb ra l

a r tery at the a tlantoa xial j oi n t : is i t truly p h ys i olog i c a l ? N e u rorad io logy 36:273-275

Taylor H C 1948 B reech p r es en t a ti on w i th hyperextension o f

G yn aeco log y 1 02 : 9 70-977

M oo l goa k e r A A 1979 Compa rison of d i ffe re n t methods of i nstru mental d el iv e r y ba sed on e l ec tro nic m e a s ure me n ts of compression a n d tr a c tio n . Obste trics and Gynecology

the n e c k a n d in tr a u te rine d i sloca tion of ce r v i ca l v ertebrae. America n J o u rn a l

of Obstetrics a nd

Gynecology 56(2):38 1 -385

Tow bin A 1 9 69 L a tent spin a l cord and

54:299

Nelson K B e t a l 1 9 8 4 Obste trical complica tions a s risk fac tors in cerebra l pa l sy or seiz ure d i s ord e r. Journal of the American Med ica l Associa tion 25 2 : 1 843-1848 N i lsen S T e t a l 1 984 Boys born by for ce p s and va c u u m e x t r a c t i o n examined a t 1 8 ye ars o f a g e . Acta Obs te tr ic a e t Gynecol ogica Sca n d in a v i c a 63:549-554 Notzon F C et al 1990 In tern a tiona l d i fferences in the use of obs t e t r i c a l interven tions. J o ur na l of the A m e ri c an

brai nstem inj u ry in

ne w bo rn infants. Developmen tal M ed i c in e and C h i ld N e u r o l o gy 1 1 : 54-68

Vacca A et a l 19 83 P o r ts mo u th op e r a t i v e d e li v e ry t r i a l . B ritish J o u r n a l of Obs tetrics and Gynaecol ogy 9 0 : 1 1 07-1 1 1 2

Voj ta

V e t a1

1983 Der geb u r tstrauma tische To rt i c ol l i s

myogenes und seine kranken gymnas tische Behand l u ng

n ach Voj ta . Z eitsc hr i ft

fur Kra nkengymn a s ti k

35(4) : 1 9 1 -197

Med i c a l Association 263:32 86-329 1

O'Discrol l K

et al 1 9 8 1 Tra u m a ti c in tr ac r ani a l ha e m or rh a g e in f i r stb o rn infants and d e l iv er y w i th obstetric force p s . B ri t i sh J o u r n a l of Obs tet ric s a nd G yn ae c o l o gy 88:577-5 81 Pa razzini F et a l 1994 Va gin a l op e r a tive deliveries in I ta l y. Acta Obs te t ri c a et Gynecologica Scandinavica 73: 69&-700 Plauche W C et a l 1 979 Fetal c rani a l inj u ries rela ted to de l i v ery w i th the Ma lmstroem v a c u um extractor. Obstetric s and Gynecology 53: 750-757

Punnonen R e t al 1986 F e ta l a n d m a terna l effects of fo r ceps and v a c u u m extrac tion. British Jou rna l of Obstet r ics and

Gynaeco l ogy 93 : 1 1 3 2 - 1 1 3 5

Pu sey J

Vo l p e J 1974 Neona ta l in t r a c ra ni a l h em or rh age : i a t rog e ni c e ti olo g y ? N e w En gl a n d Journa l of Med i c ine

2 91 :

43-45

Wil helm R 1 955 Die F r i.i.hb e h an d l un g der SkoJ iose, eine d ringl iche F ord e r un g . Zeitschri ft f u r Or tho padie 86:221

W i l l i a m s M C e t a l 1 9 9 1 A ra ndomi sed comparison of assisted v ag ina l d el i ve r y. Obstetrics a nd G yn eco l o g y 78: 789-794

R S K et a l 1 983 Foc'l l n ec r o s is of the s p in a l cord in u tero . A rc hiv es o f N eu ro l ogy 40: 654-655

Young

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Chapter

8

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Birth trauma and its implications for neuromotor development R. Sacher

We begin by outlining the risks to the infant cervi­

CHAPTER CONTENTS

cal spine as a result of birth trauma from the gyne­ cological point of view, and then proceed to

85

The infant cervical spine

examine aspects of manual therapy

85

Anatomical aspects

When considering injuries and dysfunctions of

87

Biomechanical aspects

'Classical' injuries to the (cervical) spine from 87

birth trauma

ceding and following the birth are thus of concern

89

The clinical picture

Diagnosis and differential diagnosis

.

89

Functional biomechanical disorders of the 90

upper cervical spine

Craniocervical blockages in newborn and infants

91

The craniocervical transition zone in embryology and developmental anatomy

91

Neurophysiological aspects of upper cervical dysfunctions 92

Clinical investigations

Cesarean section

93

in

a

wide

range of specialties, who have begun to study the risks associated with pregnancy and delivery The aspects to be considered therefore include not only the specific stresses on the infant spine associated with pregnancy and birth, its particular anatomical and biomechanical features, and the neurophysiological mechanisms of the cervical region, but also such matters as developmental physiology

THE INFANT CERVICAL SPINE

93

Additional risk factors Conclusion

not only to gynecologists and pediatricians, but also to practitioners of manual therapy

92

Spontaneous birth Extraction aids

92

frequently misinter­

during birth and in the months immediately pre­

88

Additional risk factors

resulting symptoms

preted. The consequences of trauma to the baby

88

Mode of delivery

cance of birth trauma is often underestimated, and the

87

Frequency of occurrence

the spine and its associated structures, the signifi­

93

95

Implications for practice

96

Anatomical aspects The spine of the fetus and yOlmg child has a num­ ber of special biomechanical and anatomical fea­ tures to enable it to adapt to the physiological

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85

86

CLINICAL INSIGHTS

demands of the birth process. It is largely carti­ laginous. The size and weight of the head after birth result in an increased inertia load on the upper cervical spine (Baily 1952, Fielding 1984, Papavasilou 1978, Townsend and Rowe 1952). But during birth, too, the large head inevitably means an increase in the leverage exerted on the cranio­ cervical transition zone and in the demands placed on it, which may involve rotation, anteflex­ ion and retroflexion (cephalic presentation of occiput or face). The horizontal orientation of the joint surfaces in the frontal plane, especially in the upper cervi­ cal region, allows greater translational mobility (CateU and Filtzer 1965, Melzak 1969, Papavasilou 1978). In the sagittal plane, however, the joint sur­ faces - in terms of the individual vertebrae - in the newborn are more steeply aligned than in the young child, resulting in a more inclined position­ ing of the cervical spine (von Kortzfleisch 1993). Meanwhile, the articulating surfaces of the verte­ bral bodies, and the jOints, are still relatively small and so increase segmental instability. The wedge shape of the vertebral bodies and the still incom­ pletely formed uncinate processes give greater adaptability to the demands imposed by the mechanics of the birth process, but these features, combined with the weak muscles and ligaments of the newborn, produce a greater tendency to subluxation (Babyn et al 1988, Catell and Filtzer 1965, Fielding 1984, Menezes 1987). The spinal cord structures and meninges are eight times as vulnerable as the postural connective tissue struc­ tures, owing to a lack of elasticity during longitu­ dinal traction (Leventhal 1960), a force that is not anticipated in the physiological features designed to withstand the birth process. This may be one of the reasons that many injuries of the spinal cord from birth trauma produce radiographic studies with no visible evidence of injury to the spinal col­ umn (spinal cord injury without radiographic abnormality - ScrWORA (Osenbach and Menezes 1989».

condyles in the newborn and in early infancy is about 50% of the adult measurement, and the axial angle of the atlanto-occipital joint (Fig. 8.1) is consequently considerably flatter than in adults (1530 versus 1240 in men and 127" in women) (Sacher in press, Schmidt and Fischer 1960). The angle formed by the axis of the atlanto-occipital joint with the sagittal plane (the average orienta­ tion) is markedly more obtuse (Fig. 8.2) (Lang 1979).

Figure 8.1

CoIC1

• • • • • • •

b .. • • • • • •

Figure 8.2

The suboccipital region also has various special morphological features; the height of the occipital

Angle of condyloid joint axis

Atlanto-occipital axis in the sagittal plane;

dotted lines show situation in the adult (a in the newborn (b

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=

28').

=

35Sl.

black

Birth trauma and its implications for neuromotor development

Biomechanical aspects There are four main biomechanical features: •

on lateroflexion (frontal plane) the atlas does not normally move into the concavity as it does in adults, but into the convexity (Biedermann 1999)

•

the infant cervical spine appears much more extended in the sagittal piane (von Kortzfleisch 1993)

•

the main pivot for movements in the sagittal plane is not in the

CS/C6 segment as in the adult, but at C/C3/C4 (Catell and Filtzer 1965,

Hill et a11984, Nitecki and Moir 1994) •

paradoxical tipping of the atlas: anteflexion of the head occurs only in the craniocervical joints when nodding, accompanied by ventral sliding of the atlas (Biedermann 1999).

This biomechanical adaptation must have the pur­ pose of providing protective mechanisms for the associated nerve structures. The question as to whether such features are already effective in the newborn has been little investigated as yet. How­ ever, the radiological findings of Ratner

and

Michailov (1992) suggest the existence of such a link. The cranial shifting of the main pivot for move­ ments in the sagittal plane enables optimum transmission of forces during labor, exerted by the axially directed contractions on the head as it moves downwards in cephalic presentations. This enables a much more extended positioning of the lower cervical spine. Meanwhile, increased ante­ flexion at

C2/C3 causes

increased ventral tipping

of the dens axis, which makes it necessary for the atlas to slide ventrally. The upper cervical spine has to absorb directly the

Figure 8.3

Occipitoposterior presentation.

There are also particular features associated with breech presentations, owing to the increased traction stresses on the spinal structures. Since the upper cervical spine mainly has to deal with the biomechanical demands of the head position, it is now the cervico-thoracic transition zone that has to respond to the demands placed on it by the presenting parts of the fetal anatomy. Again the decisive factor is the higher location of the rota­ tional axis for anteflexion and retroflexion. The spinal structures of the lower cervical spine and the cervico-thoracic transition zone have only so much resilience, and the limits are soon reached. Additional

traction

or rotation will quickly

exhaust the reserves of tension in this area. The most unfavorable situation is that of breech pres­ entation with hyperextension of the head.

adaptations in head position brought about by the dynamics of the birth process and at the same time to transmit the major part of the expulsion forces to

'CLASSICAL' INJURIES TO THE (CERVICAL) SPINE FROM BIRTH TRAUMA

the head. The direction producing the greatest tissue tension of the cervical spine is anteflexion of the

Frequency of occurrence

head, while retroflexion produces the least. The upper cervical spine is therefore subjected to particular

The incidence of injuries to the spinal column and

stress in the occipitoposterior presentation (Fig. 8.3).

spinal cord from birth tr auma is still not fully

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87

88

CLINICAL INSIGHTS

known. One reason for this may be the clinical pic­

cance of damage to the thoracolumbar spinal cord.

ture, as the diagnosis is not always easy (Men­

Over 55% of the children in their patient cohort

inj u ri es

to the spinal cord in the tho­

ticoglou 1995). Rossitch and Oakes (1992) have

developed

documented how rarely trauma to the structures

racic and lumbar regions of the spine. This, how­

of the spinal column is considered. They report

ever,

false diagnoses (including pediatric neurology) in

catheteriza tion of the umbilical artery that could

included children who had undergone

four out of five cases where there was severe

have caused damage to the spinal cord by throm­

injur y to the spinal cord. The fact that the struc­

boembohsm.

tures of the spinal cord are also not routinely

Injuries to spinal structures at the lower cervi­

included in autopsy is equally surprising (Ratner

cal or upper dorsal levels are more frequently

1991b , Towbin 1969). Towbin (1970), in an autopsy

found in breech deliveries (Bresnan and Abroms

(N

600), found relevant

1973, Caterini et al 1975, MacKinnon et al 1993).

injuries to the spinal cord and brainstem in 10% of

The hyperextension of the fetal head plays a par­

study on this question

=

these injuries, and is seen in about

cases. These consisted of spinal epidural hemor­

ticular role

rhages, meningeal tears and injuries to blood ves­

5% of all breech deliveries. Up to 25% of these

in

sels, the muscles and ligaments, and the nerve and

vaginally delivered babies developed spinal cord

bone structures.

injuries (Bhgwanani et al 1973, Bresnan and

Damage of this sort can also be observed in

Abroms 1973, Caterini et al 1975). E ven

when the

normal births, where it is hardly expected to

child was delivered by cesarean section, a small

occur (Ratner 1991b). There is considerable varia­

proportion suffered serious complications at the

tion in the pattern of clinical symptoms on

upper cervical level (Cattamanchi et al 1981,

In these

account of the vascularization in the region of the

Maekawa et a11976, Weinstein et aI1983).

vertebral artery, and for this reason it is easily

cases it remains to be shown how far intrauterine

overlooked.

injuries res ult ing from subluxation an d disloca­ tion in the upper cervical region could have

Mode of delivery

caused blood vessel damage to the vertebral arter­ ies (Gilles et al 1979, Maekawa et al 1976, Wein­

The spinal column is subj ected to a variety of dif­

stein et aI1983).

ferent sh'esses by longitudinal traction or compres­

Forceps deliveries may involve an increased

sion of the spinal column and associated structures,

risk of injury to the upper cervical spinal column

if combined with torsion, flexion and

and spinal cord (Mackinnon et al 1993, Pschyrem­

hyperextension, depending on the mode of deliv­

bel 1966, Rossitch and Oakes 1992, Ruggieri et al

especially

ery (Towbin 1964). It is not possible at the present

1999). The misapplication of these and similar

time to distinguish with certainty the role played

extraction aids (forced traction/rotation; in the

by the 'normal stress' of the particular delivery

worst case, rotation in the wrong dire ction ) can

mode and that of inadeq uate or inappropriate tech­

cause upper cervical complications.

ni que in assisting delivery.

There is presumably a limit to iatrogenic struc­

Approximately 30% of the peripartum spinal

tural damage caused by vacuum extraction, as the

column injuries described in t h e literature were

vacuum device becomes dislodged if too much

observed in deliveries of cephalic presentations

force is applied.

(Allen 1970 , Shulman et aI1971). A major British/Irish study (Ruggieri et al

Additional risk factors

1999) found no significant differences with regard to mode of de liver y and the location of spinal col­

Further risk factors for spinal column and spinal

umn injuries. It also drew attention to the signifi

cord injuries occurring at or around the time of

-

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Birth trauma and its implications for neuromotor development

birth appear to be: intrauterine position, prema­

In their clin.ical and aruma I studies, Michailov

delivery, multiple fetuses,

and Aberkov (1989) found associated gastrointesti­

ture birth, precipitate

limb prolapse, shoulder dystocia, hypoxia, birth­

nal signs in cases of upper cervical birth traumas.

weight above 4000

Disruptions of vertebrobasilar circulation produce

g and postmaturity (De Souza

and Davis 1974, Hasanov 1992, Menticoglou et al

secondary spastic-hypotonic

1995, Ratner and Michailov 1992, Ruggieri et al

small intestine, pylorospasm and g a stroesophag eal

1999, Towbin

reflux. Michailov and Aberkov found swallowing

1969).

dyskinesia of the

disorders, constant regurgitation and frequent

The clinical picture

nausea as well as aspiration pneumonia. Where there

The extent and location of the spinal cord injury determine the clinical picture (Adams et al 1988,

Babyn et a11988, Bresnan and Abroms

Allen 1970,

are

recurr ing

infections of the respiratory

system, the possibility of a spinal cord lesion should therefore be considered. The same applies to repeated infections of the urogenital tract.

1973, Mackinnon et a11993, Ratner and Michailov

Significant lesions of the upper cervical spin a l

1992, Ratner 1 991a). Severe injury to the upper

column and cord are associated with a high post­

cervical spinal cord is associated in particular with

natal mortality

respiratory insufficiency, hypotonia, quadriplegia,

1993, Menticoglou et aI1995). Infants who survive

absence of pain reactions in the derma tomes

this type of trauma of the spiml medulla develop

below the lesion, areflexia,

related

and in certain cases

(Babyn et a11988, MacKinnon et al

n eurol og ica l

patterns over

a

period of

also insufficiency of the anal sphincter after

months suggesting involvement of the first and

birth. Absence of the g r a sping , s uckin g and

second motor neuron. The neurological diagnosis

corneal reflexes

indicates the segment involved.

may indicate involvement of the

brainstem.

It is for example possible to diagnose conditions

Towbin (1964) points out that newborn babies

involving the area of the trig e mina l nuclei (extend­

are not necessarily dependent on the presence and

ing to C2/C3) and injuries to the upper brachial

function of the brain, s i n ce anencephalic infants

plexus (Erb-Duchenne palsy) (Fig. 8.4), where the

can live for weeks and even months. The decisive

Cs and C6 nerve roots are damaged, immediately

factor is the integrity of the upper cervically

after birth. Lesions of the lower plexus (C7-T1) (Klumpke's palsy) are rarer and sometimes occur

located vital centers. Brea thing dysfunction during the first 4 weeks of life is therefore seen as the cardinal symptom of

inju ries in this location. If segment C4 is involved, paralysis

of

the

phrenic

nerve

with

raised

diaphragm can occur.

together with lesions of the sympathetic nervous system (Horner's syndrome - Fig 8.5). .

T horburn's pos ture represents a particular form, in which a lesion of the lower cervical cord also leads to hypertonia of the interscapular mus­

Hypoxia following trauma in the cervico­

cles - or to bilateral abduction of the upper arm

occipital transition zone has been described in

and weakness of elbow flexion (Renault and

other states

Duprey 1989).

as well as birth tr au m a. Around three­

quarters of deaths following sh aking traumas were caused by apnea (Coghlan 2001). (The Apgar

Diagnosis and differential diagnosis

score to assess respiratory effort, heart rate, mus­ cle tone, response to stimulation, etc. in the deliv­

T he significance of spinal cord injuries for differ­

ery room is in essence a neurological assessment,

ential diagnosis in peripartum asphyxias and the

primarily to test the irritability of or the presence

development of cerebral paresis has been empha­

of

inj u r ies to the brainstem and upper spinal cord

(Towbin 1964).)

sized by several authors (Clancy et al 1989, Mor­

gan and Newell 2001, Sladk y and Rorke 1986).

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89

90

CLINICAL INSIGHTS

Figure 8.4

Erb-Duchenne palsy (right hand side).

Figure 8.5 (from Bing

The pediatric neurological examination is useful across a wide range of conditions and the neuro­ logical patterns observed can be identified with increasing precision with the advancing age of the child. Laboratory tests, muscle biopsies and elec­ tromyography (Allen 1970, Lanska et a11990, Rug­ gieri et al 1999) are mainly of use in differential diagnosis. Opinions are divided on the use of imaging procedures. Plain film X-rays, my elo gr a phy and computed tomography (CT) (Adams et al 1988), magnetic resonance i maging (MRl) and ultra­ sound are all used. Lanska et al (1990) emphasize the value of MRl, whereas Rossitch and Oakes (1992) p oint to false negative results obtained by MRI. An ultrasound examination of the peri­ medullary structures should be carried out to pro­ vide additional information or as an alternative (8 ab yn et al 1988, De Vries et al 1995, MacKinnon et al 1993, Simon et aI1999).

Klumpke's palsy and Horner's syndrome

1953).

FUNCTIONAL BIOMECHANICAL DISORDERS OF THE UPPER CERVICAL SPINE

The spine has a number of functions: support, posture, perception, movement and protection. This means that peripartum traumas to the sp i ne may have either a direct effect, by destroying skeletal structures, or an indirect effect by causing secondary reactions in the spine. It must at least be concluded that pronounced hemorrhage (8abyn et al 1988, MacKinnon et al 1993, Menticoglou et aI1995), atlanto-occipital dis­ locations (Adams et al 1988, Allen 1970, Men­ ticoglou et al 1995, Rossitch and Oakes 1992), ruptures of the spinal cord (8abyn et a11988, Lan­ ska et al 1990, Menticoglou et al 1995) and dislo­ cated fractures of the spinal column (MacKinnon et al 1993, Menticoglou et a11995) will lead to local muscular reactions and in certain cases forced pos-

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Birth trauma and its implications for neuromotor development

tures. Although such neuro-orthopedic findings have not been described, it is not clear whether such symptoms were not present or simply not recorded. Ratner (1991b) is the only author to report forced attitudes (torticollis) and paraverte­ bral muscular reactions in association with moder­ ate and mild lesions of the spinal column and cord. We must also ask whether the special anatomi­ cal and biomechanical characteristics of the infant cervical spine with which we began might not, in combination with the problems of childbirth and assisted delivery mentioned above, be capable of causing isolated injuries and/or dysfunctions of the spine. Slate et al (1993), in a study of congenital mus­ cular torticollis, describe 12 cases with upper cer­ vical subluxations and negative neurological findings. The authors traced these subluxations to problems of intrauterine position or birth trauma. However, no details were given of the timing of the neurological examination. Craniocervical blockages In newborn and infants

Mechanical obstructions of the functioning of ver­ tebral joints, termed 'blockages', occur in all age groups, with infants and the newborn being no exception. Among this group, injuries from birth trauma are most frequently discussed as the cause. Seifert (1975) found 298 individuals with dys­ functions in the craniocervical region among 1093 randomly selected newborn infants. A significant correlation with postural asymmetries was found. Buchmann and Bulow (1983) found upper cer­ vical dysfunctions in about one-third of newborn infants (N 683) studied. The incidence of cranio­ cervical blockages in those with forceps deliveries was greater than can be accounted for by chance. Information on problems of intrauterine position or indications for cesarean delivery was not avail­ able. This, together with the small number of cases, makes it difficult to draw even a cautious conclusion about the connection between the birth process and dysfunction of the spinal col umn . =

Biedermann (1999) was also able to demon­ strate a connection between birth traumas or forced intrauterine positions and the occurrence of reversible arthrogenous dysfunctions of the spine in infants and the newborn in the course of his extensive investigations. Artificial means of assisted delivery (forceps, vacuwn extraction), multiple pregnancies, breech presentations, pro­ longed expulsion period and transverse lie are particular risk factors. The craniocervical transition zone in embryology and developmental anatomy

A brief look at the phylogeny of the craniocervi­ cal joints will help give an insight into their nature. Vertebrates evolved in water, and at that stage they possessed a comparatively unarticulated notochord or spine rigidly connected to the head with no intervening joint. Head and body formed a single functional unit, and the control of func­ tions such as orientation and balance was entirely directed by the sense organs located in the head (Hassenstein 1970). As differentiation progressed and the joint connection between trunk and body developed, it became necessary to acquire propri­ oceptive information about the relative position of head and body, and to integrate control mecha­ nisms. This task fell primarily to the craniocervical region, which includes the occipital condyles, atlas, axis and the C2/C3 motor segment together with its associated structures. In humans, the spe­ cial place of the craniocervical transition zone is partly a consequence of embryonic development. Cells from the neural crests of this zone colonize parts of the gastrointestinal tract, the primordial heart, the urogenital tract (Wolff's duct), and the thymus. A similar process underlies the develop­ ment of the musculature of the tongue, pharynx, larynx, esophagus and thoracic girdle (Christ et al 1988). Numerous special features are also found in the neurophysiology of this region (Abrahams et al 1990, Tayler and McCloskey

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91

92

CLINICAL INSIGHTS

1988, Traccis et al 1987, Wolff 1996, Zenker and Neuhu bber 1994). In this context the exception­ al l y dense provision of muscle spindles in the

CLINICAL INVESTIGATIONS

suboccipital musculature and the close link with the sy mpat hetic trunk (superior cervical gan­

risk prof iles given above for the class i cal cervical spine injuries caused by birth trauma are also

glion) and the tri gem inal nuclei (extending to

responsible for causing craniocervical blockages

C2/C3) are relevant.

of ear l y infancy

A study

involving 403

infants confirmed that the

i n s y mp tom a tic individuals

(Sacher 2003). The details recorded included the route (vagi­

Neurophysiological aspects of upper

nal/ cesarean section) and mode of d el iv ery (spon­

cervical dysfunctions

taneous / assisted extraction; elective/ emergency cesarean section), birthweight >4000 g, post-term

birth (41 weeks)

place in the first year of lif e involves tactile, pro­

abnorm al fetal position during pregnancy or

prioceptive and vestibular information, since

birth, occipitoposterior cephalic presentation,

or premature

these typ e s of perception are directly connected

short expulsion period, prolonged

with movement, as well as for ming the basis for

hours), and use of Kristeller's maneuver.

l abor (>24

establishing the ideal pattern of movement and proprioception, and for subsequent differentia­

Spontaneous birth

tion, not only of the motor system but of the sen­ sory system, too. The afferent imp ulses of the cervical receptor region are integrated into the motor system for control of body support (Wolff

1996). For infants, including the newborn, these tonic reflexes of position and support are pa rticu­ la rly impo rtan t (other aspects of perception being still immature). These reflexes are an expression of the genetically programed motor repertoire on which individual learning is based.

Barely 30% of the infants with craniocervical blockages who fell into this category had no pre­ viously suspected risk factors. Th ree infants in this group had fractures of the clavicle as evidence of force affecting the fetus during birth, one in com ­ bination with Erb's palsy and one with cephalhe­ matoma. Two further infants had pronounced cephalhematomas. Spontaneous birth does there­

fore hold a potential for trauma that should not be

The neurophysiological system here, together

underestimated, even when there are no other

with the immaturity of the sensorimotor system in (early) infancy, means that craniocervical block­ ages in infants and the newborn have special

known risk fac tors

potency. There is an association with reactions of

was the use of Kristeller's maneuver, which was

the afferent aspect of proprioception, in which the

applied in more than half the deliveries in this cat­

.

Risk factors were found in more than two-thirds of the spontaneous deliveries. The main risk factor

im p airm e nt of receptive performance and the dif­

egory. This maneuver was origi nally designed to

ference in the flow of information to the receptors

be used in multiparous women whose lax abdom­

from each side caused by the blockage must play

inal wall (dia st as is recti abdominis) meant that

a part (as is the case in the labyrinths) (Hii lse et al

they were no longer able to exert proper abdomi­

1998). Blockage also leads to the known nocicep­

nal muscular pressure. It is dangero us to apply it

tive, vegetative and myofascial reactions and

to a uterus that is not in labor or where the abdom­

effects on joint mechanics. Predisposed infants

inal wall is tensed hard (Rockenschaub 2001). The effect of Kriste ll er's maneuver is to increase

develop a set of symptoms that extends beyond

the local effects of craniocervical blockage, known

the intra-abdominal expulsion pressure to such an

as KISS syndrome.

extent that the presenting pa r t of the fetus is

Copyrighted Material

Birth traum a and its i m p l ications for neuro m otor d e v e l o pment

pushed out past any hindrances or resistance that

cesarean section of 18-19% in Germany (Schiick­

may be present. In a normal birth with no extra­

ing 1999), an above-average number of infants

corporeal augmentation of pressure, the head

delivered by cesarean section appeared in the

passes through the birth canal by means of slight

study cohort. The large number of cases of abnor­

repetitive sideways inclination of the head which

mal fetal position may account for this.

forces it gradually deeper - a physiological

Another reason for the high proportion of

process known as asynclitism (Rockenschaub

cesarean sections is the vulnerability of the upper

2001). If

cervical

Kristeller's maneuver is applied, this

structures

when traction

tension

is

gradual, force-reducing downward movement of

applied. The physiology of the birth process does

the presenting fetal part will no longer happen,

not allow for traction in the upper cervical area, and so the human fetus does not have adequate

and the potential for trauma rises. High birthweight and short expulsion period

protective mechanisms for this. However, every

were further risk factors frequently encountered.

cesarean section involves considerable traction

Five infants suffered trauma consisting of lesions

force on the spine and its associated structures,

of the upper brachial plexus as a consequence of

regardless of whether the fetus is taken out by the

spontaneous delivery; two of these infants were

head or the legs.

above normal birthweight, two were born after a

The conclusion must be drawn that elective

short expulsion period, with shoulder dystocia in

cesarean section seems to increase rather than

one case. Kristeller's maneuver was used in the

reduce the risk of developing craniocervical block­

delivery of one infant with an upper brachial

ages of infancy (as opposed to severe upper cervi­

plexus lesion.

cal injuries). The most severe birth injuries were observed

Extraction aids

with emergency cesarean section.

During the

delivery of one post-term infant with excess birth­

In 38 cases it was necessary to use artificial means

weight, the uterus was ruptured when Kristeller's

of extraction for vaginal deliveries. It is worthy of

maneu ver was performed and an emergency

note that Kristeller's maneuver was applied in

cesarean followed. One infant was later found to

71% of these cases.

have a brainstem hemorrhage. Another infant was

The risk of birth trauma appears to increase

delivered by emergency cesarean section without

when extraction aids are used, especially if there

any further risk factors being present, yet peri­

are additional risk factors. Three newborns (two

partum upper

with birthweight

suspected.

>4000

g) had fractures of the

cervical

trauma

was strongly

clavicle. Kristeller's maneuver had been used.

Additional risk factors Cesarean section Additional risk factors were present in a large Cesarean delivery had been performed in

35%

of

number of births.

the cases. The main risk factor in elective section was abnormal fetal position, which occurred in 40% of the infants delivered by this means. However,

30%

of the group under study exhibited none of the

Breech presentations First deliveries appear to be

a

predisposing factor

for breech presentations (Boos 1994, Rayl et al

assumed risk factors (e.g. elective cesarean sec­

1996). It is therefore assumed that the firm abdom­

tion) but still developed dysfunctions of the cran­

inal wall of primiparous women and the fact that

iocervical joint.

the uterus has not previously been stretched make

Assuming an average rate of

Copyrighted Material

93

94

CLINICAL INSIGHTS

spontaneous turning more difficult. Multiparous

mechanical stress for the fetus (e.g. abnormalities of

women are at similar risk for the opposite reason:

the pelvis or of engagement) (Schmitt-Matthiesen

low tension of the uterus wall and too little pres­

1992) and so involve greater risk to the craniocer­

sure from the abdominal wall muscles offer too lit­

vical transition zone.

tle resistance to support the turning movement, aided by the extremities (Feige and Krause 1998). Abnormal fetal position is often associated with

Short expulsion period

(24

been bom prematurely and had craniocervical

hours)

blockages after elective cesarean section was rela­

Prolonged delivery is frequently associated with

tively high. This is pOSSibly connected with the

increased birth risks that can result in

indications for elective section as opposed to vagi-

an

abnormal

Copyrighted Material

Birth t r a u m a and its i m p l ica tions for neu r o m oto r d e v e l o p m e nt

nal delivery, which are fairly generously framed

this group was therefore recorded together. Most of

for the premature birth group. Another point is

the

that four

premature

intubated

involved uncomplicated instances, since the care

following

elective

postnatal

records did not document the fact. The compara­

Children born considerably before term spend

study cohort was, however, surprising. Such events

infants were

section,

making

causes a possibility.

10

cases assigned to this group must have

tively high incidence

some time without full head control. Increased

(2.5%)

are described as happening in

1995).

of this feature in our

0.05-0.1% of all births

postnatal inertia load on the upper cervical struc­

(MandIe et al

tures can therefore be considered in such cases.

reported to be particularly affected.

Infants born to multiparae are

However, the small number of premature babies delivered spontaneously and without further risk factors contradicts this as an explanation. At

Conclusion

5%

this percentage was within the expected range for

In conclusion, each mode of delivery contains its

premature births. It is more probable that infants

own specific risks to the upper cervical region,

whose gestation period is markedly shorter are

irrespective of the presence of additional risk

more likely to develop craniocervical blockages

factors.

on account of the risks associated with this.

Additional risk factors for the development of craniocervical blockages in infancy could be assumed in more than two-thirds of all sympto­

Post-term births

matic infants. These include the use of Kristeller's

Normal term was exceeded in just

11

cases. This

maneuver, high birthweight

(>4000

g), short

risk factor was only encountered once on its own in

expulSion period, intrauterine forced or abnormal

combination with elective cesarean section;

positions, occipitoposterior position or prolonged

in most

instances these post-term births were accompanied by high birthweight (a total of

4)

or the delivery

called for manual and/ or artificial assistance.

delivery an

(>24

hours), prolapse or presentation of

extremity, shoulder dystocia and postpartal

traumas such as intubation. Premature birth, post­ term delivery and twin pregnancies appear to be co-factors that often occur together with the above

Occipitoposterior position A total of

10

risk factors.

infants presented in the occipitoposte­

The contention that birth trauma plays the pre­

all included

dominant role in the pathogenesis of craniocervical

infants with cephalic presentations. However, from

blockages of early infancy (i.e. that perinatal trau­

its incidence in the average population, one would

mas are the main cause) is not without its critics

expect to find the occipitoposterior position in

(Buchmann and Bulow 1983). As in adults, other

0.5-1 %

causes for dysfunctions of this type are logically

rior position, a figure that was just 3% of

of all cephalic presenta tions (Pschyrembel

and Dudenhausen

1991).

Since the position is unfa­

pOSSible and may in fact be responsible. In particu­

vorable for the upper cervical region, this aspect

lar, the cause may be reactions that are visceral or

may once more constitute a predisposing factor here.

static-dy namic in nature; or the dysfunctions may stem from cerebral errors in the control of the motorsensory system. The young age of the study

Limb prolapse/presentation

cohort, however, makes these causes less likely.

It was difficult when taking the history to differen­

If the risk profile for the development of classi­

tiate between actual prolapse of arm or hand and

cal upper cervical lesions, which was mentioned

presentation of the extremity, or between complete

at the beginning, is compared with the risk factors

and incomplete prolapse of the fetal extremity, and

presented here for the occurrence of reversible

Copyrighted Material

95

96

C L I N I CA L I N S I G HTS

a rti cular dysfunctions of the craniocervical joints

rics,

in symptoma tic infants, the common elements

Kno wledge of these risks makes i t p ossible to

cal ling

fo r

a p p ropria te

obs tetric

sk i l l .

cannot be ignored. Where the causative mecha­

avoid them in the context of p reven tive obstet­

nism is the same, only the degree of trauma or

rics, and also enables imp rov ed assessmen t of the

a d d i ti onal ind ividual factors will determine the

birth trauma inv olved, w i th the necessary type of

extent of the cervical lesion .

a ftercare .

Birth is a ttended by risk of tra uma independently of the mechanism of childbirth and even obstetric

I M P L I CAT I O N S F O R P R A CT I C E

practice in s trict conformity with accepted principles can do no more than minimize the risk. Seen in this

Each mode o f d e l ivery carries ind iv i d ual risks,

light, obstetrics becomes both the price of our evolu­

b o th in i tself and in the implica tions for obstet-

tion and the challenge with which it presents us.

Refe re n ces Abra h a ms V C, Rose P K, Rich mond

FJ R

1 990 Properties

Cate l l H S, F i l tzer 0 L 19 65 Ps eudos u b l u xation and other

and control of the neck m u s c u l a t u re . In : B in d e r M,

normal variants in the cervica l s p ine in ch i l d ren. A study

Mendel l L (eds) The segmen t a l motor syste m . Oxford

o f 160 c hi l d re n . Jour n a l of Bone a nd Joint Surgery 47 : 1 295-1 309

U niversity P ress, New York, p 5 8-71

Adams C, Babyn P S, Logan W

J

1 988 Spin a l cord b i rth

inj u r y. Va lue of com p u ted tomogr a p hic mye l o graphy.

JP

1970 B i r t h

injury

J

C, Dev a nesa n M, Pe losi M

1 975 Fe ta l risk in hypere x tension of the fet a l head in b reech p resenta ti o n . American Journ a l of Obstetrics and

Ped ia tric Neu.ro logy 4:1 05-109 A ll e n

Caterin i H, Langer A, Sama

to the s pin a l cord. North wes t

Gynecology 1 2 3 : 632�4 Catta m anchi G R, Ta maska r V, Egel R T e t a l 1981

Med i c ine 5 : 323-326 B ab yn P S, C h uang S H, Danema n A, Davidson G S 1988

I n tra uterine q u a d r i plegia assoc i a ted w i th breech

Sonographic evalua tion o f s p inal cord b i rth tra uma w i th

p resentation and hyperex tens ion of fe ta l hea d : a case

p a th o logic corre l a ti o n . American J o u rn a l o f

report. Ame rican Journal of Obstetrics a nd G ynecology

Roe n tgenology 1 5 1 : 763-766

1 40 : 83 1 -833

Ba i l y D K 1 952 The n o r m a l ce rv ic a l spine in in fa nts and

zervico-occ i p i talen Oberga ngsregion. In: H o h m a nn D

chi l d re n . Rad i ology 59:71 2-719

Bhgwanani S G, Price H V, Laurence K M, G i nz B 1973 Risk a nd p re v entio n of cerv ica l cord inj u r y in t he ma n a gement of breech presentation w i t h h yperex tension of the feta l head . A m erican J o u rn a l o f Obstetrics and B i edermann H 1 999 Manualtherapie bei Kindem . Enke, Stu ttgart

und a n tepa r ta les Verha l ten . H a b i l ita t ionsschri ft, Med i z in i sche F a k ultat der Univers i tat des Saarl and es, Homburg

F 19 73 Neona tal s p in a l cord

transsection secon d a r y to in tra u te r i ne hyperex tension of the neck in breech p rese n t a ti o n . Fetal a nd Neona ta l

of Neu rology 25 : 1 85- 1 89 1 6 :4-5

JA

1974 S p inal cord da mage in a new­

born infa nt Archives o f Disease in Chi ldhood 49: 70-71

Eu ropean J o u rna l of Ped i a trics 1 54 : 230-232 Fe ige A, Kra use M 1998 Beckenend l a ge. U r b a n & Sch wa rzen berg, M un i c h

Field ing J W 19 84 Inj uries o f the cerv i c a l spine i n chi ldren. In : Rockwood C A J r, Wi lkins K E, Kin g R E (eds) F r a c t u res in child ren. L i p pincott, P h i l a d e l p hi a , p 683-705 G i lles F H, Bina M, Sotrel A 1979 lnia n t i l e a tla nto-occipital

Med icine 84: 734-737

instabi li ty: the po tenti a l of extreme exte nsion. A m erica n

B illow B 1983 F unk tionelle

Journal

Ko p fgelenksstorungen i m Z u sa mmenh a n g m i t Lagere a k tionen und To n u sasymmetrie. Ma n u e l le Med i z in 2 1 : 59-62

L B. H ypoxic- isch emic

i m a ging of severe cervica l spina l cord b i rth tra u ma.

p erina tologischen Da ten, ultra sonogra p h i s c he Beiunde

j, Abrom s I

1989 Rorke

De Vries E, R o b b e n S G, van den An k e r J N 1995 Ra diologic

R uckenma r k s d i a gnostik . Schwa be, Basel

Boos R 1 994 Die Beckenend l a ge - An a l yse der

J,

JT

spin a l cord i nj u r y foll o w ing per i n a ta l asphy x i a . Ann a l s

De Souza S W, Da v i s

B in g R 1953 Ko m pe nd i u m der topi schen Gerurn-und

B u c hmann

(ed) N e u ro-Orthop iidie 4. Spr inger, B e r l in Clancy R R, S l a d k y

Cogh l a n A, Le P a ge M 200 1 Gen tly does it. New Scientist

Gynecology 1 1 5 : 1159-1161

Bresnan M

Christ B, J a cobs H , Sei fe r t R 1988 Ub e r d i e E n t w i c k l ung d e r

of Diseases of Children 133:30-37

Goerke K, Val e t

A

2000 K u rzlehrbuch Gyna ko logie und

Gebu rtshi l fe . Urban & Fischer, M unich

Copyrighted Material

Bi rth t r a u m a a n d i t s i m p l i c a t i o n s fo r n e u ro m o t o r d e v e l o p m e n t

Hasanov A A 1 992 Das Gebu rts t rau m a d e s Neugeborenen

(rus).

Ha ssenstein B 1 970 Biologische Kybernetik. Quelle & Meyer H i l l S A, M i Ller C A, Kosn i k E J et a l . 1 984 Ped ia tric nec k inj u ries. A c l in ica l stu d y. J o u rn a l of N e u ros u r g ery

1 9 9 1 a Spatfolgen gebu rtstra u m a tischer Uisionen

385-391

R a tner J 1 99 1 b Zur p e r ina t a le n Sch a d i g ung des zentra len Nervensystems. DeI Kinderarzt 2 2 : 29-34

60:700-706

Hu lse M, N e u h u be r W L, Wolff H D 1 998 De r kranio­ zerv i k a l e Dbe r ga n g . Spr i n ge r, Be rl in Lang J 1979 Ko pf . Tei ! B; Cchi rn u nd A ugensc h ad e l . tn: v o n Lan z T, Wac h s m u th W ( e d s ) Pra k t i sc h e Ana tomie. Sp r in ger, Be r lin La nska J M, Roess m a lUl U, W i z n i tzer M 1 990 M a g n etic resonance im a g ing in cerv i c a l cord b i rth inj u r y. Pe d i a t r i cs 85:760-764 Leventhal H R 1 9 60 B i r t h i nj u r ies to the s p ina l cord. Jou rnal -

of Ped i il trics 5 6 : 44 7-45 3

J A, Pe rl m a n M, Ki rp a l a n i H et al 1 993 Spinal inj ury a t b i r t h : d i a gno s tic a nd p rognos tic d a ta in

M a c K innon

twenty-two p a t i en ts Journa l of Ped i a tr ics 1 2 2 : 43 1 -437 .

Maekilwa K, Masa ki T, K o k u b un Y 1 976 Fe t a l spinal cord inj ury seconda ry to hyperex tension of the nec k: no effect of cesa rean section. Deve lop m en ta l M e d i c in e and C hil d

Neu ro l o g y 1 8 : 22 9 23 2

M a ndie C, Opitz-Kre uter S, Wehl ing A 1 995 Das

Befunde bei g e b u rtstra u m a tischen Ver l e tz ungen d e l' Ha lswirbelsa u le. D e r Kindera rzt 23:81 1-822 Rayl J, G i bson P J, H i c k o k D E 1 996 A pop u l a ti o n ba sed ca se-co n t rol s t u d y of risk fa ctors for bre e c h p resen ta tion .

Ame rican Journal of Obste t r ics and Gy n e colo g y 174:28-32

Rena u l t F, Du prey

J

1989 La postu re de

F r a n .,.

B

Iliac symphysis left Sacral cavity left

Figure 15.17 Areas of irritation of the pubic bones on the pubic quadrilateral.

functional pathology of the atlanto-occipital joint and

c

of the pelvic girdle. Immediately after treatment of both dysfunctions, the baby raised her arms for her mother to lift her up.

Iliac symphysis right Iliac symphysis left Sacral cavity left

TREATMENT OF THE JOINTS OF THE PELVIC GIRDLE Figure

15. 18 shows the constitution of the zones

of irritation of the symphysis, movement of the iliac wing, the symphysis and sacroi l i ac axial according to Huguenin is

practically

always

(1991).

The symphysis

involved

in

sacroiliac

dysfunction. The therapies use the right ( healthy) iliac wing as a lever for mobilization in the direction oppo­ site to the pathology. The actual treatment of the pelvic girdle is based on the knowledge of the functional axes (Fig.

15.19). This also includes sus-

Figure 15.18

Constitution of the zones of irritation of the sy mphy sis , movement of the left iliac wing, the symp hysis and sacroiliac axial according to H ugu enin (1991). The arrow indicates the movement of dysfunction of the left iliac wing of which the symphysis carr ies the zone of irrit at ion. A: Anterior seesaw (P , ) . B: Di stortion between the il iac wings (P2). C: Posterior seesaw (PJ The therapies use the right he althy i li ac win g as a leve r for mobilization in the direction opp osi te to t he p ath ol ogy.

Copyrighted Material

18 1

182

PRACTICAL ASPECTS OF MANUAL THERAPY IN CHILDREN

P3 Figure 15. 19 in

Direction of the movements to make the healthy iliac wing restore the congruence of the pubic bones accordance with the diagnosis of Pl, P2 or P3.

pected dysfunctions caused by palpable myo­

•

Treatment of the left P3 (Fig. IS.2IA and B). The stationary hand, the right hand in the example,

geloses (painful hardening of muscles due to hypoxia) on the iliac crest for any syndrome last­

is pressing on the pectineal line of the side of the area of irritation. The treating left hand

ing more than 3 weeks.

presses on the upper edge of the opposite iliac

Treating children (newborn to puberty) or preg­ nant women has to take into account the special

wing, at the level of the antero-upper iliac

anatomical situation of these patient groups. Dif­

spine, and causes a lateral opening movement

ferent treatments are done according to diagnosis

and a dorsal rotation of the right iliac wing

of the pubic bones, which always decides the

(arrow). Mobilization limi.t is 12°.

direction of the treatment. Clinical findings show us that treating the pubic bones always corrects a sacroiliac dysfunction.

•

Treatment of the left P2 (Fig. IS.22A and B). The right hand is stationary, in the example by maintaining the iliac wing below the antero­ upper iliac spine. At the same time, it causes a lateral distraction by supporting the thenar,

DIRECT TREATMENT OF THE SYM PHYSIS

allowing the pubic bones to open. The left hand does the pushing and manipulation in

The patient lies on his back. He must be very relaxed. Holding points of fixation and treatment must be done gently.

the dorsal direction and in the direction of the P2 rotation (arrow). Mobilization limit is 10°. All these treatments are done by a more or less

•

Treatment of the right P1 (Fig. IS.20A and B).

limited sliding of the healthy iliac wing on the

The stationary hand holds the booster iliac

booster iliac wing of the area of irritation .

wing of the area of irritation (in the example:

Especially after verticalization - i.e. after the

the therapist's left hand) while the right hand

first birthday - the proper functioning of the

presses on the pectineal (pecten ossis pubis)

pelvic girdle assumes an increasing importance

line, causing a rocking motion in the caudal direction (arrow), thus bringing the left Pl in

the growing infant. The techniques described here

for the development of mobility and orientation of

congruence with the ventralized right Pl' Mobi­

complement the treatment of the craniocen1ical

lization limit is greatly reduced to 2°.

area, the other pole of the vertebral spine.

Copyrighted Material

Manual therapy of the sacroiliac joints and pelvic gird le

Figure 15.20

(A and B)

Figure 15.21

(A and B) Treatment

Treatment of the right Pl.

of the

left P3.

Copyrighted Material

183

184

PRACTICAL ASPECTS OF MANUAL THERAPY IN CH ILDREN

.' .--

o

A

Figure

15.22

A and B:

Treatment of the left P2'

References 0, Hansen JH 1984 The axial sa c ro iliac joint. Clinica 6:29-36 H uguenin F 1 991 Medecine orthopedique, D i agnostic Bakland

-

Anatomica

Masson, Paris Lavignolle B, Vital

J M, Senegas J et a l 1983 An

topographique. Masson, Paris ap p roach to

the fu nctiona l anatomy of the sacroiliac joints

in vivo.

Sutter M 1973 Beitrag wr Kennmis des spondylogenen pseudoradikularen Syndroms Ll. Manuelle Medizin 11:43-46

Anatomica Clinica 5:169-176

H 1858 Die Halbgelenke des menschlichen Karpers. G R ei mer, Berlin Pauwels F 1948 C ontrib ution it I'explication de la sollicitation du bassin et particulierement de ses Luschka

.

articulations. Zeitschrift fLir Anatomie und Enl'wicklungsgeschichte 114:167-180 Rouviere H 1932 Anatomie hurnaine d escr ip t iv e et

Sutter

M 1975 Wesen, Klinik und Bedeutung spondylogener fLir Medizin

Reflexsyndrome. Schweizerische Rundschau 64(42):1351-1357

Testut L, J a cob ° 1893 Traite d'anatomie topographique. Doin, Paris

Copyrighted Material

16

Chapter

Manual thera py of the thoracic spine in children H. Mohr, H. Biedermann

CHAPTER CONTENTS Interdependence of function and morphology

186

Anatomical considerations

1 88

Anatomical and functional aspects of the ribs

1 90

Breathing

1 90

Problems of respiratory biomechanics

1 92

Functional consequences of KISS" in the thoracic region

1 93

Some clinical pictures

1 94

Acute thoracic vertebral blockage Mechanical dyspnea syndrome

194

195

Sternal stress syndrome (Brugger) as a result of a kyphotic posture Tietze syndrome

1 95

196

Idiopathic kyphosis (Scheuermann's disease)

196

Functional problems of the thoracic spine due to scoliosis and/or cerebral palsy

1 97

Integration of thoracic examination and treatment

197

Details of the thoracic examination Therapy

198

200

Soft tissue techniques

200

Mobilization techniques for ribs and vertebrae

201

Embedding manual therapy of the thoracic spine in a broader approach

202

Manual therapy in infants and small children is challenging and exciting for a number of reasons, not least the much clearer p ict u r e one gets of the influence of functional diso rde r s beyond their immediate vicini ty. In newborns it is safe to declare the occipitocervical (OC) junction by far the most i mporta n t part of the vertebral spi n e with a potential for functional disorder vastly greater that its size. No other part of the vertebral spine plays a significant part in neuromotor devel­ opment at that stage. The region coming into focus next is the iliosacral junction with its influence on the functioning of the abdominal muscles and autonomous regulation (see Chapter 15). The thoracic spine manifests its role much later - and more discreetly. We see impaired function in the thoracic region as soon as there are coordinated movements, i.e. 4-6 weeks after birth, and we can release these blockages during the exarnina tion. Studying the normal development of newborn babies, it seems very probable tha t any such impair­ ment of the function of the thoracic spine would resolve spontaneously, too, albeit after some time Infants and elementary school p u pils seldom present specific thoracic complaints. However, d u ring early p uber ty, there is often a tendency towards in terscap ular pain, poor si ttin g posture, thoracic kyphosis and a poorly developed equilib­ rium when sitting, with a resultant insuf f icien t si tting posture. The kyphotic Sitting posture often .

Copyrighted Material

185

186

P R A CTICAL A SP E CTS OF MA N UA L THERAPY I N CHILD R EN

develops as a result of KISS II; in such cases, the

thoracic region because the child seldom presents

positional reflexes and the extension functions of

with orthopedic complaints and

the spinal column have not developed efficiently.

these complaints are more likely to be seen in the

The complex interaction between this biomechan­

setting of internal disorders.

if noticed at all,

ical level and the input via the autonomous regu­

During the evaluation of the case history we

latory network is still poorly understood. Suffice it

often discover that children with poor posture and

to say that the pseudo-dorsalgia caused by gastric

inadequate motor functions have a previous his­

irritation (Kunert 1963) plays as important a role

tory of KISS I and/ or KISS II. As the child grows

in adolescents as it does in adults.

older, both the insufficient posture and the com­

So the thoracic spine plays a part in the patho­

plaints arising from the autonomic nervous sys­

genetic context of functional disorders, but not as a

tem (ANS) increase, with headache and fatigue

prime mover. The dysfunctions situated on the tho­

being the most marked. As the thoracic spine lies

racic level have in many cases a strong tendency to

in the intersection

disappear after the underlying structural problem

spinal irritations and ANS disturbances originat­

is taken care of. But this process can be speeded up

ing from the epigastric zone, it serves as a stage

by treating those local problems simultaneously.

for referred pain from other areas. These external

between the biomechanical

Inefficient breathing in the upper thorax is often

irritations can be the cause of thoracic joint dys­

the inevitable result of a kyphotic sitting posture.

functions which in turn lock the entire process

Asymmetry, caused by KISS I, is in itself often the

into a feedback loop.

cause of asymmetrical breathing patterns, which develop as a result of asymmetrical motion of the ribs. The literature refers to osteoarthritis of the first

INTERDEPENDENCE OF FUNCTION AND

rib in 20-year-olds (Nathan et al 1964). This phe­

MORPHOLOGY

nomenon is only conceivable as the result of a faulty use of these structures over the years, e.g. due to

Functionally, the thoracic spine is the stable inter­

KISS 1. Similarly the

mediary between the cervical and the lumbar lev­

vertebral osteochondrosis (Scheuermann's disease)

els. The cervical spine, the craniocervical junction,

asymmetry as a consequence of

is in our view connected to a previous KISS II symp­

the lumbar spine and the pelvis are those areas

tomatology . As with KISS, these developments have

where

to be seen in the context of a genetic predisposition.

within broad frameworks of motion.

More often than not we find the same posture in

there

is three-dimensional

movement

During the first few months, a C-scoliosis can

father and son, and for good measure the cousin

often be observed in the unburdened horizontal

displays the same stance as well. The complex

state. In the case of KISS

interaction between the genetic base and individual

direct the entire spinal column, including the

development leaves enough room for therapeutic

pelvis and hip joints, into such an asymmetry. The

I, the tonic neck reflexes

maneuvers, and knowing about a predisposition

resulting pelvic distortion and oblique transverse

does not mean there is no point in the therapist tak­

pelvic inclination is frequently the cause of an

ing any action.

asymmetrical base for verticalization and walk­

In young children, internal organ pathology has far less influence on the structures and func­

ing. This can cause the C-scoliosis to increase dur­ ing initial verticalization (Meyer 1991).

tions of the thorax when compared to what is

Scrutinizing the course of the reflex-induced

often observed in adults (Kunert 1963). Instead,

C-scoliosis in the non-weight-bearing state and

the result is usually poor posture and restricted

the resultant compensatory S-scoliosis in the ver­

breathing motion. In pediatrics, little attention is

ticalization phase requires the attention of the

paid to these complex functional disorders of the

manual therapist in order to employ adequate

Copyrighted Material

Manual therapy of the thoracic spine

oblique inclination of the transverse pelvic line,

therapy in the earliest possible stage: i.e., before

an

the beginning of the child's third year. Due to the

with the left side pOSitioned lower.

limited three-dimensional movements of the spine

Influenced by the left ATNR component, exten­

during the first 2 y ears of life the shapes of the

sion in the left leg will be stronger. This extension

joint structures and the vertebrae come to be

of the stronger left leg will then be utilized during

defined by these asy mmetrical functions.

verticalization. The left leg will thus become the

At a later stage, the morphology of the vertebral joints largely defines the adverse functions. In other

'privileged' weight-bearing leg and this will cause the sacrum to tilt.

words, the scoliotic posture in the cradle is trig­

The

pelvic

distortion

becomes

more

pro­

gered by reflex patterns defined at the OC junction,

nounced, as a result of a dorsal tilt of the iliac

and later the morphology maintains the asynune­

bone, and the left leg becomes relatively shorter

try. The initially functional pathology determines

(Cramer

the morphological fate - later the acquired mor­

weight-bearer as it is relatively shorter, but also

phology determines the function . The pathogenetic

because it has a higher muscular tone under the

potential of such

influence of the persisting left ATNR component.

an

asymmetry might only become

apparent when other, non-related factors come into play, i.e.

an

asthmatic crisis in the case of a thoracic

functional disorder or an irritation of the auto­

1956). The left leg becomes the main

The existing left convex lumbar scoliosis - until now purely functional - is then maintained and will eventually become fixed.

nomic nervous sy stem via epigastric problems -

The left psoas muscle reflectorily neutralizes

often of psychosomatic origin.

the phy siological left rotation of the lumbar verte­

In the case of KlSS I a lateral flexion of CO-C1 and C2-C3 can usually be found. This lateral flex­

contraction, the left psoas muscle will become

ion is then adopted by the cervical spine, often

shorter and hypertonic, resulting in a slight fixa­

even by the whole spine.

tion of the femur in external rotation within the

During the testing of the neck reflexes, this lat­

brae (Michele

1962). Due to its constant state of

hip joint. The whole left leg is then prematurely

eral flexion of the cervical spine will remain more

and constantly burdened, and optimal function is

or less fixed. In the case of this specific lateral flex­

hardly possible.

ion, the sternocleidomastoid muscle causes

a

het­

During examination of the left side, the follow­

erolateral rotation of atlas and occiput in order to

ing details are observed in a situation like the one

neutralize this lateroflexion and keep the head

mentioned above:

horizontal. Neurologically, the left asymmetric tonic neck reflex (ATNR) will be more active, if not

•

with further shortening of the leg (occasionally

dominant, so that extension in the arm and leg is often observed. The homolateral side of the trunk will have more muscle tone. With lateral flexion of the whole spine to the right, the quadrate lumbar muscle will actively maintain the lateral flexion of the lumbar spine to the right. Simultaneously, the right quadrate lum­ bar muscle will fix the inferior ribs on the right in expiration. Because of its insertions on the iliac bone, the quadratus lumborum will exert a cra­ nially directed force on the pelvis.

valgus of the foot and even extreme pes planus a slight valgus of the knee can be observed)

•

limited hip function (internal rotation/ exten-

•

left sacroiliac joint blocked

•

contra-nutation in the right sacroiliac joint

•

poor equilibrium while standing on the left leg,

•

limited function of C2--C3 on the right side

•

elevated state of the first four ribs on the right,

sion and hypertonic psoas muscle)

due to disturbed sensory function of the joints

with limited function.

A left convex C-scoliotic posture is the logical

The functional asymmetry of KlSS in the cervical

consequence of this. The lumbar scoliosis causes

spine and below has, as a consequence, asymmetry

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188

PRACTICA L A SPECTS OF MA N UA L T H ERAPY IN CHI L D R EN

of the pelvis and lumbar spine. Neumann remarked

important, and the rotation of the head is the most

that this process of scoliosis must be neutralized

important component for rapid spatial orientation.

far in advance of the third year of age, because at

The lumbar spine, on the other hand, is typically

approximately that time the ossification of verte­

defined by another type of three-dimensional func­

1960). He

tion, combining extensive stability with motion

bral sh·uctures is complete (NeumarUl

proposed manual therapy as the appropriate

and only slight mobility in each segment. These

treatment in these cases, while problems which

are also the key movements contributing to lateral

arise after the third year of age more often than

flexion.

not should be treated by orthopedics . In relation

In a biomechanical sense, the thorax constitutes

to KISS, orthopedics is not the up-to-date treat­

the 'stable' center of the body. Many movements

ment option; nor are any other modes of remedial

take place relative to the thorax, and this region

exercising or postural correction advisable before

buffers and stifles

the basic problem - a functional disorder of the

motion. Integrated into a web of the more than

both lumbar and cervical 170

upper cervical spine - is taken care of.

joint and cartilage cormections, it has only limited

Diagnosis within the framework of the KISS syn­

mobility compared with the cervical a.nd lumbar

drome consists of the sort of subtle diagnosis that is

regions. But for this very reason the motion pat­

characteristic of manual medicine, namely acknowl­

terns are extremely complex, and even more so at

edging and distinguishing reversible limited func­

the thoracic level. The biomechanics of this area

tions of joints. It is with this four-dimensional

are thus more difficult to describe than those of

framework (i.e. taking into consideration the time­

the cervical or lumbar spine, which have

line) that we can bring some structure to the other­

ger range of movements.

a.

far big­

wise confusing symptoms and come to a viable

Within their phYSiological barriers, the cervical

diagnosis. This implies that manual therapy in very

and lumbar vertebrae function in three-dimen­

young children should be applied during the first

sional freedom. Due to the cormections of the ribs

year of life, in order to prevent a morphological

and the sternum, the dorsal vertebra is restricted

fixation

and future orthopedic problems.

in its movements with obvious restriction in its

To balance the head and bring it into a horizon­

range of movements. The thinness of the dorsal

tal position, the cervical C-scoliosis has to be com­

intervertebral disks does not allow for much inter­

pensated elsewhere by a counterswing, resulting

segmental motion, thus providing a stable envi­

in

an

S-scoliosis. This process starts at the begin­

ronment for the vital organs, such as the heart and

1994). The thorax

the lungs, and solid points of attachment for the

ning of verticalization (Meyer

and the thoracic spine have an important role in

respiratory diaphragm, as well as for the shoulder

this process because of the length of this part of the

girdle.

spine and also because of its adaptability. The cer­

A good example for this role as a stable base for

vically initiated asymmetry and the consequent

the adjoining structures is its function for the

occurrence of lumbar asymmetry due to pelvic dis­

shoulder girdle, for breathing, and for regulating

tortion must be negotiated in the thoracic region in

blood pressure, and also as an intermediary

the compensatory search for equilibrium.

between the cervical and lumbar spine. The upper thoracic spine acts as a transition area between the free movement of the cervical

ANATOMICAL CONSIDERATIONS

spine and the stability of the middle and lower dorsal segments.

The cervical spine has extensive three-dimensional

In a functional sense, the fourth dorsal vertebra

mobility, partly in order to facilitate spatial orien­

is considered to be the base of the cervical spine.

tation and motion. The rotations are especially

For this reason, T4 (D4) is often nicknamed the

Copyrighted Material

Manual therapy of the tho racic spi n e

'sacrum of the cervical spine'. T4 is actually the

The dorsal (thoracic) vertebrae have oblique joint facets in a transverse plane. These joints, by

least mobile of all vertebrae. The articular connection of the ribs lends addi­

nature of their position and shape, have a minor

tional stability to the thoracic region. Figure 16.1A

weight-bearing function. The joint capsule is

shows the first rib, completely bridging the inter­

strong yet elastic, and is provided with a stabiliz­

16.lB, depicting the

ing padding, which penetrates the joint from the

fourth rib, displays a slightly different biomechan­

dorsal portion of the capsule. The corpora have a

vertebral space T1/T2. Figure

ical picture. Here the articulation is confined to

considerable (static) weight-bearing task, espe­

one vertebral level.

cially in the case of a kyphotic posture and during

The rib cage and its

12 vertebrae can be subdi­

• •

TeT3: cervicothoracic transition T4: stable base for the cervical spine; least mobile vertebra of the spinal column

•

•

T4-TlO forms the kyphosis, of which 08 is the most dorsally situated T11-T/2: lower end of the thoracic cage.

sitting. Due to the position of its facets, T12 usually

vided into four functional groups:

functions as a transitional vertebra to the lumbar spine, and its inferior facets display a more lum­ bar alignment. The thoracic intervertebral disks become thicker and wider as we move down­ wards. The thoracic disks are less vulnerable than the lumbar disks for a number of reasons: interverte­ bral mobility is strongly limited by the ribs; the disks are relatively thin; and the rotational axes of the vertebrae are situated within the disks. Fur­ thermore, the thin segmental nerve root exits through a large intervertebral foramen, above the level of the disk. As a result, disk-nerve root prob­ lems are scarce in the thoracic level. There are numerous joint connections in this area: intervertebral, costovertebral, costotrans­ verse, costosternal, intercostal, sternoclavicular joints and the intersternal connection (manubrium corpus). Due to this complexity, a considerable range of distortions is possible. This allows for the breathing movements, and the constantly chang­

A

ing postures and positions that occur in daily life, and many types of sports. Within this complexity of joints, minor dys­

functions frequently occur, together with limited function and segmental pain points. In respect to

KlSS-KlDD children we can objectify this at a very early stage, namely by the asymmetrical sit­ ting posture, caused by a previous or persisting torticollis. Even the slightest torticollis (with

ATNR component) causes asymmetrical regula­ tion of movements in the lower portion of the trunk. In these cases, asymmetrical rib functions

B Figure

16.1

The costovertebral joints.

are evident. The long levers of the blocked ribs

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189

190

P R A CTICAL A S P E CTS OF MANUA L TH E R APY I N CHILD R E N

consequently have a limiting influence on the

(the cervical and lumbar region) we view the tho­

intervertebral joint functions.

racic area as a biomechanical 'transmission station' from the lumbar level up to the craniocervical level and vice versa. The thorax with its relative stiffness

ANATOMICAL AND FUNCTIONAL ASPECTS

lacks muscles like the sternocleidomastoid and the

OF THE R IBS

psoas major. The psoas major moves the rib cage

The ribs articulate with the dorsal corpora and

toid, which moves the head three-dimensionally in

three-dimensionally, just like the sternocleidomas­ disks at the following attachments (Fig.

16.1):

space. The middle portion of the spine, from which

•

first rib head attaches to the corpus of T 1

•

the second rib head attaches to the edges of the corpora of Tv T2 and the intervertebral disk

•

this pattern is repeated for the third through to the tenth ribs; and at the same time, the rib articulates with the transverse process of the vertebra of its own level

•

the second through to the tenth ribs form dou­ ble-chambered synovial joints.

the thorax is suspended, is largely upon

a

dependent

well-functioning lumbar spine to maintain

equilibrium, integrating influences from the cervi­ cal and lumbar area. The thoracic spine constantly bears the weight of the head, arms, thorax and the mass of the internal thoracic organs, hence the necessity for stability. This stability, in conjunction with little mobility, renders the thoracic spine sus­ ceptible to static and dynamic overload and mus­

The superior ribs suspend from the concave

cular dy stonia. This is the case when foot, hip

transverse processes by their costal tubercles,

and/or pelvic function are functionally disturbed.

which allows for a considerable range of rotation. This is necessary for the raising of the thorax dur­ ing inspiration. The seventh through to the tenth

BREATHING

ribs 'rest', as it were, on the transverse processes, Because of the orientation of the costovertebral

allowing for more sliding motion. The ventral attachment of the ribs varies widely.

and costotransverse joints, the superior

ribs

W hereas the first rib articulates with the manubrium

induce a sagittal plane for a thoracic enlargement.

sterni only, the ventral fixation of the second rib is

Within rib joints

more complex, being attached to the transition area

that of a bucket-handle: i.e.,

between manubrium and corpus stemi - an unstable

ment of the thorax occurs. The position of the tho­

6-10 there is a movement like a

transverse enlarge­

connection. The middle part of the thoracic spine

rax in the sagittal plane is of great importance for

connects rather uneventfully to the corpus stemi via

the rib functions: in the case of a thoracic ky phosis

the cartilaginous part of the rib. The lowest ribs have

we observe a limited breathing movement, mainly

increasing degrees of freedom, costae 8 through to

10

due to decreased function of the costotransverse

connected to the cartilage of costa 7 and the last two

joints (,sterno-symphysal overload' - Brugger

(costae 11/ 12) without any anterior attachments to

1977). Breathing (Fig. 16.2) requires uninhibited

the sternum.

thorax dynamics, which depends upon optimal

The costotransverse joint is a joint with a sliding

functioning of the vertebral and rib joints (Bergs­

1982, Eder and Tilscher 1985). Free

motion, whereas there is more of a rotation within

mann and Eder

the costovertebral joints. The rib has the effect of a

and sy nchronous breathing in both halves of the

long lever on the costotransverse joint and a short

thorax (symmetrical function) is the basis of eco­

lever (collum costae) on the costovertebral joint.

nomical breathing. One dysfunction within this

three­

complex neurophysiological chain can unsettle

dimensionally mobile areas of the spinal column

the whole pattern. Because of the vulnerability of

Between

the

two

'sensory'

and

Copyrighted Material

Manual therapy of the thoracic spine

inspiration the muscle tone increases and on expira­ tion this tone decreases. However, it has been shown that the intercostal muscles also have a con­

stant base activity without any rhythmical increase or decrease in the base tone. As a result of this base activity, the ribs remain at a constant distance from each other, both on inspiration and on expiration, a function which passive connective tissue mem­ branes could not perform as they would overstretch on inspiration. The scalenus functions require good mobility of

A

the upper ribs and thoracic vertebrae, but are also dependent on the optimal functioning of the occiput and upper cervical spine complex. Func­ tional restrictions or a fixed position of the upper four rib joints when breathing in can easily lead to an insufficient respiration pattern. This is because restrictions in the upper cervical spine interfere with proprioception and with the base functions of the respiratory muscles, which in tum drive the base functions of the respiratory process. This illus­ trates the functional connection between the cran­ iocervical junction and the upper thoracic region.

B Fig u r e 16.2

Whereas the scalenus muscles make it possible

Breathing mechanism (Fick 1911). This

classical model shows inspiration

(A)

and expiration

(B).

The strings are symbolic representations of the

for the thorax to expand in cranial, sagittal and lat­ eral directions, the diaphragm initially enables this in the lower part of the thorax at a later stage

intercostal muscles.

of

the

respiratory

movement.

At

rest,

the

diaphragm takes care of the majority of the respi­ the joints of the thorax (poor posture), breathing

KISS will provoke

muscular reactions in the upper thoracic structlUes, for example: torticollis with

an

functions,

amounting to approximately

70%. At this point the scalenus muscles are not

can rapidly become impaired. Craniocervical problems as in

ratory

opisthotonic com­

being exerted. In order to move the sternum cranially, the tho­ racic spinal column needs to perform a stretching

ponent. Even in early childhood, this can lead to

function. As a consequence, the erector trunci tho­

asymmetry of the ribs, in conjunction with blocked

racalis, in particular, has an important part to play

joints, especially in ribs 1-4. The total thoracic bal­

in respiration.

ance of function can become deregulated at a very

spinal column is extended and on expiration it is

On inspiration, the upper thoracic

inflected. This involves small movements among

early age. The respiratory movement of the thorax is a com­

the vertebrae themselves, which are nonetheless

and the

important as these movements make it possible

joints, in which the base tone of the scalenus and

for the 'rigid' thorax to remain the ever-mobile

plex event involving the nerves, the muscles

an important part. The

part of the body. The influences on the thoracic

scalenus muscles help in the process of moving the

region from the movements of the lumbar spinal

first and - to a lesser extent - the second ribs. On

column and from within the upper extremities

intercostal muscles plays

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191

192

PRACTICAL ASPECTS OF MANUAL THERAPY IN CHILDREN

and the neck require a great deal of coordination

because C2-C3 will be functionally restricted as a

on the part of the thoracic structures.

result of the functional restrictions in CO-C1. This restriction in the lifting function of the occiput will

The anatomy of the sympathetic nervous sys­ from

have its own influence on the extensor functions

between Cs and T2, is important; Hansen and

of the thoracic spinal column. So, in the biome­

tem,

which

originates

almost

entirely

(1962) have clearly shown the ortho­

chanicaI sense, as well as in the neuromotor sense,

sy mpathetic influences. As a result, thoracic func­

the extensor function of the thoracic spinal col­

Schliack

tional disturbances lead to irritation and muscular

umn can become insufficient and deteriorate into

hypertonus of the shoulder girdle and the cervical

thoracic kyphosis, also referred to as the sternal

area (cervicogenic tension headache), while pain

stress position.

in the abdomen and the lower part of the body is

Thoracic kyphosis entails a forced expiration

often related to lower thoracic functional restric­

position of the ribs, and as a result of the ante­

insufficient sitting posture

rior position of the head, the cervicothoracic region

can gradually develop these types of symptoms,

is constantly overburdened because the ribs have

too.

to facilitate inspiration. This is why a loss of func­

tions. Children with

an

As in craniocervical problems in small children,

tion can be observed in the upper thoracic area of

the question is only rarely one of orthopedic

the intervertebral disks as well as in the rib joints,

abnormalities on the thoracic front, and if this is

as a result of which the scalenus muscles become

the case, these can always be diagnosed using radi­

hypertoniC and shortened by the extra burden.

ology. Thoracic functional disorders in the form of

This is referred to as T4 syndrome, also described

bad posture and restrictions of movement are easy

as 'serratus anterior syndrome'.

to diagnose and can be linked to growth processes

As a result of the fixed expiration position of

and related neck pains and headaches. Lumbar

the thorax, particularly in the sitting position, the

symptoms and pelvic problems also play their

diaphragm will not be able to function properly

part in thoracic functional disorders, and all of

either, which means the already heavily burdened

this means that observation, inspection and func­

and hypertonic scalenus muscles will be taxed

tional examination by means of palpation should

even further to aid upper thoracic respiration. In addition to the constantly stressed scalenus mus­

be carried out with great care.

culature, the cervicothoracic junction is also heav­ ily burdened by the anterior position of the head

PROBLEMS OF RESPIRATORY BIOMECHANICS

which, although it actualJy weighs 4 kilograms, exerts a force of between

15 and

20 kilograms at

that point as a result of the lever effect. As a result of a prolonged opisthotonic position in

The cervicothoracic junction is thus constantly

lI), the growing

overburdened and the consequence is that the

the craniocervical region (KISS

child will have to compensate for the fixed dorsal

schoolchild sitting in kyphosis is continually

inflection position of the head by means of

breathing superficially and insufficiently. The

increased thoracic kyphosis when lifting the head .

kyphotic expiration position is the position of a

This is because the somewhat upturned head

weary and depressed person, a position which is

position is compensated for by a more pro­

not right for anyone, and even less so for a young

nounced thoracic kyphosis, thus allowing the

child. The present-day television and computer

child to look horizontally. If there is a case of dor­

culture is a constant negative factor, which induces

sal inflection obstruction in the CO-C1 motion seg­ ment, then it will not be possible for the baby's

a kyphotic sitting position: the 'laissez-faire' posi­

lifting reactions to take place optimally, in part

tained long enough, favors the development of a

tion. It seems obvious that such a position, if main­

Copyrighted Material

Manual therapy of the thoracic spine

juvenile kyphosis with the classic Sdunorl's nodes (Schmor! and Junghanns

1968).

We often see that with a KISS I child the asym­ metrical posture in the craniocervical junction is

Inspiration is an active muscular event, while

the cause of increasing asymmetrical steering in

expiration is mainly passive, in particular because

the motor apparatus covering the entire spinal col­

means

umn, and pelvic and hip jOints, and can even lead

of the elasticity of the rib cartilage, which

that little effort is involved in bringing about the

to asymmetrical functioning of the feet.

The

expiration pOSition. The kyphotic sitting position

left-right imbalance then expresses itself in C­

is a permanent expiration pOSition for the school­

scoliosis and one-sided pes planus (flat-foot), a

child; in this fixed position further expiration is

restricted functioning of the hip and a unilaterally

either not at all possible or extremely restricted.

blocked sacroiliac joint. In the process of standing

Because of the fixed expiration position of the

up, this asymmetry will translate itself in thoracic

thorax, physiological inspiration is almost impos­

terms into compensating S-scoliosis, a left/ right

sible, in particular because the weak abdominal

asymmetry in the rib positions and asymmetry in

wall cannot use the stomach as a fixed point,

the vertebral and rib functions. It is well known

which means that there is no support pOint for the

that with thoracic functional disorders, an asym­

transversus thoracis of the diaphragm. As a result,

metry in the ANS balance can also arise, opening

proper abdominal respiration is almost impossi­

a further negative feedback loop.

ble, which is why caudolateral thorax expansion cannot take place. Because abdominal inspiration is insufficient, subconscious use will be made of

FUNCTIONAL CONSEQUENCES OF KISS II IN THE THORACIC REGION

upper thoracic respiration. The functional restriction of the first ribs results in the cranial thorax being incapable of expanding

The anteversion of the head following KISS II causes a load increase on the segments TcT4' hypertonic scalenus muscles and

laterally, and the upper

thorax in particular

(together with the scalenus

and sternocleidomas­

hypertonic dorsal (postural) muscles. This pos­

be heavily taxed. These com­

tural anterior positioning of the skull, as well as a

toid muscles) will

combining

the

paratively small muscles will then have to lift the

previously experienced KISS II phase, are

entire thorax, just at the time when it is fixed in an

causes of poor extension of the thoracic spine and a reflexive hypotonia of the muscles of the cervi­

expiration position. If this situation persists for too long, both expi­

co thoracic area. As

a result of KISS

II, the righting

ration and inspiration will become superficial,

reflexes of the head and extension of the thoracic

with small inadequate thorax and rib movements,

spine will be laborious and even lagging. This is

while the child will have to produce extra muscu­

how the foundation of a kyphotic posture is deter­

lar effort in order to achieve proper ventilation.

mined

Therapeutic manipulation measures and specific remedial therapy are definitely indicated in this case. If a history of KISS can

be found, treating

small and growing children with therapeutic

early

on.

Fa thological

afferen t

joint

impulses cause insufficient efferent postural regu­ lation - and this is revealed in the thoracic area. An accentuated and fixed dorsal kyphosis is in

effect a posture in a permanent

state of expiration,

manipulation (combined with remedial therapy

resulting in

and posture advice) is usually

breathing muscles) during inspiration, which creates prob­

an

adequate solu­

tion. It is just this combination of unblocking a

a

further burdening of the already

hypertOnic scalene muscles (auxiliary

a base) and re­

lems in the upper thoracic area. Lumbar problems

education of the postural and breathing automa­

influence the lower thoracic structures (psoas, res­

tisms which achieve a lasting result. Neither of the

piratory diaphragm, the quadrate lumbar muscles

t\vo measures alone will bring therapeutic success.

and the erector spinae). In the whole thoracic area

restricted range of movements (as

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194

PRACTICAL ASPECTS OF MANUAL THERAPY IN CHILDREN

there is a close interdependence between internal

•

pronounced limited arm, shoulder and neck

organs and their accompany ing thoracic segments

functions in the case of upper thoracic fLmc­

(Kunert

tiona I limitations (Janda

1963).

There is a broad consensus that thoracic prob­

1968, Lewit 1985)

•

neurovascular compression syndromes in vari­

KISS/KIDD history, poor

•

pseudo-anginous complaints

posture, and a history of sensorimotor problems

•

nocturnal tightness in the chest and stifling of

•

distinct costosternal complaints.

lems in children are much less evident than in adults. However, a clear

ous forms

breathing

with poor results in school, attention deficiency, autonomic

instability

(such

as

headache

and

fatigue), justify an extensive examination of the child and, in most cases, subsequent treatment with manual therapy. In most of these cases the disorders

SOME CLINICAL PICTURES

found on the thoracic level are secondary to the problems originating at the cranial or caudal junc­

The developments outlined above are encoun­

tion of the spine, but their neglect can lead to long­

tered in various clinical contexts which are not

lasting problems of posture and function, too.

necessarily orthopedic. More often these problems

The biomechanical complexity and vulnerability

of a dysfunctioning thoracic spine and rib cage are

of the thoracic area, and frequently an enduring

hidden behind internal or pulmonary disorders.

hyperactivity of the autonomous nervous sy stem,

In this regard the transition between the situation

are often reasons for the child's descent into a

in children and in grown-ups is fluent, and most

vicious circle of vertebrogenic and autonomous

of what we encounter and treat on the level of the

nervous functional disorders, thus keeping the child

thoracic spine follows the same rules found in all

in an unbalanced state. These complexities have as

relevant textbooks.

KISS situation, developing

This collection of commonly encountered prob­

slowly, but surely. Many pediatricians claim that

lems is intended to shed some light on the thoracic

colic and torticollis neonatorum will recover spon­

pathology without intending to present

taneously, but it seems probable that these form the

line. But it should show that one special aspect of

one reason an initial

basis for later problems (Biedermann

2000).

a

full out­

functional problems of the thoracic region lies in the

Thanks to the improved documentation of chil­

chronic character of these ailments. Even those prob­

10) we are now

lems (such as an acute blockage of a rib joint), where

much better able to relate biomechanical functions

we can help immediately, have a strong tendency to

of the elementary schoolchild to the earlier occur­

recur, and thus need more than just a manipulation.

dren's development (see Chapter

KISS symptoms during infancy. Whereas

It goes without saying that in all cases of thoracic

the craniocervical area is the most important cause

dysfunction we have to consider the OCand lum­

rence of of

KISS sy ndrome, in the case of

KIDD the tho­

racic spine play s important roles both autonomi­ cally

and

biomechanical1y.

Therefore ,

bosacral junction, too, as most of the problems gain their chronicity from extra-thoracic influences.

the

examination and treatment of the thoracic spine in

Acute thoracic vertebral blockage

schoolchildren with their perplexing complaints is more than justified.

This is brought about by sudden, uncoordinated

Thoracic problems in adults present pronounced

movements (e.g. sport), whereby it is possible to

patterns of complaints which have been discussed

observe movement restrictions and hypertonic

in numerous publications. In children, this sympto­

musculature. It can be treated by careful manipu­

matology is less pronounced and usually scarcely­

lation or mobilization. In children, it is sometimes

if at all - present. These sy mptoms include:

difficult to elucidate the trauma component as the

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M a n u a l t h e r a py of t h e t h o r a c i c s p i n e

onset of the discomfort may be delayed . Wherea s

rosternally. The s ternum is literally cons tantly

in a dults w e often find a more ventrally si tua ted area

overb urdened by the pressure o f the ribs on the

of referred pain (the classic 'pseudo-stenocardia')

s ternocostal connec tions, while the carrying func­

the local iza tion of the chil dren's pain s tays mostly

tion of the thoracic vertebrae is transferred to the

close to the spmal midl ine . These p roblems fall

cos tosternal connection s . The s ternoclavicular and

m to the category of trivial man u a l therapy (see

the five upper costostemal connections are painful

Chapter

when press u re is applied.

22)

and are often treated on the fly, i . e .

they do not last l o n g enough to necessita te a d e d ­

A ch ild does not usually complam abo u t the

ica ted visit t o the specialis t . But we find them

pain there, b u t this is exactly why palpation p ro­

often while screening for other problems and

vides o bj e c tivity m this situation . When the child

would adv ise trea tmg them accordmgly.

i s si ttmg up s traight, these points a re less sensitive to pressure than in the kyphotic sitting posi tion.

M e c h a n i c a l d y s p n e a sy n d r o m e

It is quite possible that this s ternal s tress syn­ drome is at least partly caused by KISS II m the

Mechan ical dyspnea syndrome is frequen tly the

beginnmg of the sensorimotor d evelopmen t. The

resu l t of a ( trauma tic) blockage of one or more

s ternal s tress position m turn, because of the ante­

thoracic vertebrae and the costoverte bra l j o m ts m

rior position of the head, main tams this dorsal

the vicm i ty. Symptoms include one-sided thoracic

inflection of the occip u t and the ch ild gets into a

pain, occasional intercostal pain, and pam while

vicious cycle of biomechanical and neurovegeta­

lifting, coughmg and strain mg . The relevant cos­

tive imb alance . The therapy in cases with l a te KISS

totransverse j oint is sore when p ressed . There is a

II (a fter the second birthday) mus t then encompass

feeling of brea thlessness and the affec ted rib is

trea tment of the whole spmal column, s upple­

usually

mented w i th m uscle-s treng thenmg exercises and

in

the inspira tion position.

Therapy

involves manipula ting the rib j om t carefully, and

advice on pos ture .

then mob i l izing the rib back to the insp iration

The remnants of the Galant reflex (a deep abdom­

position . These blockages are more important m

mal reflex in which contraction of the abdominal

children with m ternal breathing problems like

m uscles occurs on tappmg the an terior s uperior

asthma or obstructive bronchitis, as they tend to

iliac spine) can be observed m a new b o rn infa n t

worsen an already precarious si tuation, certamly

un t i l t h e fi fth mon th after birth, and may con tinue

if combmed w i th a kyphotic posture.

to persist m a growing child to s uch an ex tent tha t

The main difference to the situa tion m adults is

hypersensi tivity of the skin of the thoracol umbar

still have a chance to infl uence the mdivid­

area can be observed durmg the examina tion . Thi s

tha t we

ual's postural pattern before the gro w th process is

segmen tal hypersen siti v i ty c an be caused by tho­

termmated, albeit to

racolumbar kyphosis, as described by Brugger

a

lesser degree after the begm­

nmg of the teenage years. It is imperative to com­ bme the elim i n a tion of the acute problems with a

( 1 977) (possible KISS II) . If (as a resu l t of KISS

I)

an asymme trical posi­

re-education of the postural balance . This asks for

tion of the pelvis is caused, resulting m a pelvic

q ui te some d iplomatic skills, as motiv a tin g an ado­

con tortion, then on the anterior rota tion side the

lescent to do exercises is a fa r from easy task .

shortened quadra te lumbar muscle can maintain

S te r n a l s t r e s s sy n d ro m e ( B r u g g e r) a s

position of the ribs on that side of the body.

a r e s u l t o f a ky p h o t i c p o s t u r e

child remains m such a scolio tic si ttmg position for

Symp toms include m terscapu lar p a m and a press­

the v ital functions of the diaphragm and the cau­

ing, heavy, sometimes b rea thless fee l i n g ret-

dal rib movements; for children who rem a in in this

the pelvic contortion as well as the expiration

If the

years, then this may well have an adverse effect on

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1 95

1 96

P R A CT I CA L A S P E CT S O F M A N U A L T H E R A PY I N C H I L D R E N

scoliotic sitting position for hours on end a t school, chronic problems will eventually develop. Phrenic respira tion being insufficient, the cranial part of the thorax is called on to perform an extra effort. As the child often a lready has an ins ufficient sit­ ting posture and hypertonic scalenus muscle, the vital capacity of the lungs as well as the child's overall vitality will deteriorate significantly. Restoring the lumbothoracic kyphosis to lordo­ sis is of essen tial importance and requ ires, again, a lot of tact and sensitivity in proposing the therapy. When one looks at a fam ily as a connec ted whole, one realizes how the child ren are often only an exaggerated version of the parents ' behavioral and cultural patterns. To motivate a young ado­ lescent to do sports without including the parents renders this endeavor much less efficient.

tions from CO-C3 up to T6-T7. Mumenthaler and Schliack see one of the causes of these problems in the subscapular musculature (Mumen thaler 1980, Schliak 1 955), while Lewit (1 985) believes the cause is mainly to be found in the costotransverse joints. Maigne (1 968) is of the opinion that the interscapular pain is caused in the segment C6-C7. If there is also a question of a history of KISS I, then these ftmctional restrictions will also develop in asym m e trical pa tterns. In adults the shortening of the sca lenus group is often caused by temporomandibular problems. This has to be taken in to account in older adoles­ cents, certainly if orthodontic appliances have been employed recently. The in timate interde­ pendence between orthodontics and the func­ tional situation of the cervico thoracic j unction is grossly tmderestima ted (see Chap ter 1 3 ) .

T i etze s y n d ro m e I d i o p a t h i c ky p h o s i s ( S c h e u e r m a n n ' s

This is actually a segmental equivalent of the ster­ nal stress syndrome. This usually involves the cos­ to transversal joints on one side only. As a result of a rotational blockage of T2, T3 or T4, the ventrally rotated processus transversus will exert pressure on the rib and this pressure will be passed on to the costosternal connection. Furthermore, the cos­ tosternal connection of the second rib is the most lill s table connection on the jtmction between cor­ pus and manubrium sterni. The sternal connections are swollen and painful to pressure in this situation and there is also intercostal pressure pain. It is therefore tmderstandable tha t careful p alpation of a possible rotation position of the vertebra in ques­ tion must be carried out, and tha t specific remedial therapy must be given. The vertebra must be rota ted back into the neutral position in order to take the pressure off the costosternal connection. Many thoracic symptoms are accompanied by cervical problems but arthrogenous functional restric tions in the CO-C3 area also have their res tricting influence on ribs 1 and 2 as a result of the scalenus muscula ture. Over time, a child (KISS II) with a kyphotic sitting posture and anterior posi tion of the head builds up ftmctiona l restric-

d isease)

When one tries to see the postural development of children in a long-term perspective, the Jinks between the kyphotic posture of a teenager and an initial KISS symp toma tology become evident. A quantita tive analysis is a lmost impossible to achieve as we do not always have a de tailed and reliable da tabase of the first years. One clear ind i­ cator can be fotmd in the photo album of the first years: time and again one sees the same postural details at a very early stage. Again it has to be stressed that the in terac tions between the genetic predisposi tion and the indi­ vidual's development are far from Simple, b u t a t least w e have to try to infl uence this i n as positive a way as possib le. The therapy is basically one of re-educa tion and motiva tion for sports and move­ ment. It is almost too trivial to mention it, but it is important to take into account the family context when advising for specific schedules. In one family there is a sports tradition and it is perfectly possible to encourage father and son to go swimming together on a regular basis; in another family the daughter can be encouraged to fol low a girlfriend

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M a n u a l t h e r a p y of t h e t h o r a c i c s p i n e

If it seems th a t sport is not

and in conseq uence to

an

a symme trical brea thing

too popular with the family in ques tion, there a re

p a ttern . The effec ts of

an

idiopathic scoliosis a re

always o ther options: singing in a choir does won­

very similar on the thorac i c level .

to her ballet lessons.

ders for the pos ture and the brea thing technique

In b o th cases, it is highly a dvisable to allevia te

choi r motiva tes some

the symptoms of the problem at the root o f the

children to improve their posture much be tter

p a thology by trea ting the - secondary - fun c tional

tha n an u n loved sp orts lesson .

impairmen ts o n the level of the intercostal or cos­

F u n ct i o n a l p r o b l e m s o f t h e t h o r a c i c

d ynamic than in adults, so one can assume tha t a

necessary to p a r take i n a

tovertebral joints . In children the situation is more

s p i n e d u e t o s c o l i o s i s a n d /o r c e r e b r a l

regular u n b lock i ng of these func tion al impa ir­

p a l sy

ments helps the developing b o d y to

at lea s t

become less fixed in its asymmetry than w o u l d be Ve ry often the major reason for rec urring func­

the case o thenv ise. M a n ual therapy is p a r t of

tional p roblems on the thoracic level lies in a neu­

pale tte of adj uvan t meas ures and has to be inte­

wi ll

grated into a total concep t encompa ssing, for

rol ogical or morphological p a thology which

not s ubside. A cerebral palsy is almost always

exa mple,

accompanied b y an a symmetrical postu re and th us

pa tient exercises and other activitie s .

p h ys i o thera p y

and

sports

a

the r a p y,

an asy mmetry of the thoracic spine. This leads to

Here, a s a lways, we should t r y to work as effi ­

side d i fferences in the movement range of the ribs

ciently as possible. As a rule, manipula tions can be spaced

2-3

mon ths apart even in cases where

the chronicity of the underlying problems necessi­ ta tes repea ted in ten'entions.

I N T E G R AT I O N O F T H O R A C I C E XA M I N AT I O N A N D T R E AT M E N T A s mentioned earlier, child ren will seldom com­ plain d irectly of sp ina l pain. It is thu s up to the ther­ apist to find the ca usal connections between the often ra ther general symp toms and their spinal hmc tional component. It is often appropri a te to treat the child's thoracic spinal col umn if the exam­ ination de tec ts restricted movements in these areas . I f o n top o f tha t we see in the case history tha t the child has suffered from KISS syndrome in the past or is currently suffering from KIDD,

an

ins u fficient

posture, or an a u tonomic imbalance accompanied by headaches, the link between these general com­ plain ts and the func tional impairment on the tho­ F i g u re 1 6. 3

Th o r a c i c m u s c u l a r hypoto n i a co m b i n e d

w i t h a hype r l o rd o s i s a n d m u sc u l a r h y p e rte n s i o n i n t h e s u bocci p i ta l reg i o n . Th ese c h i l d re n h a v e a

racic level is plausible eno ugh to j ustify trea tmen t. Few small children will put their physical prob­ lems into words; at most, a fter treatment they may

d i s p ro p o rt i o n a t e l y h i g h i n c i d e n ce of K I SS I I i n t h e ea rly

sometimes

p h a s e of t h e i r d eve l o p m e n t

KIS5-KIDD symp toms recognized by the parents

.

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say,

' Tha t

feel ing

has

gone . '

The

1 98

P R A CT I C A L A S P E C T S O F M A N U A L T H E R A PY I N C H I L D R E N

are therefore more significant than whatever few

•

How does the child sit down (kyp hosis, asym­

•

How is the h e a d held, in a stra i gh t posture or

•

Is there a la teroflexion of the cervica l spine (pos­

metry, e tc . ) ?

words the child may be able to utter. The case his­ tory taken by the therapis t often con fi rms the suspi­ cions of the parents, while the physical ! functiona l examina tion should provide further details . In the clinical situa tion

tilted an teri or or posterior?

the therapi s t m u s t take into

sible minimal torticol lis and upper position of the homola teral rib s ) ?

accoW1t the child's candor, their preparedness to 'wait and see' and their vulnerability. Often the tol­

•

D o e s the child h a v e c o l d h a n d s (au tonomic

•

Wha t i s the respira tory pattern l i ke at rest

imbalance)?

erance of children for long-term burdens is grossly underes timated. It is only after this stress is lifted

( u pper thoracic ) ?

that they perceive the difference. When the child and therapist mee t each o ther, there must

•

be mu tual tru s t, and the therapist then

Is

there

rap i d

up per

thoracic

respi ration

( s tress ) ?

explains the aim of the therapy clearly and simply

•

Is the upper thoracic resp iration asymme trical?

to the chi l d . Many doc tors are o f the opinion tha t

•

Is respira tion superficial?

KIS5-KIDD child

•

Is there an emphasis on resp ira tion (associa ted

•

Are the a rms rotated inwa rds?

i t i s unnecessary t o trea t a

because the child does not really complain and i t therefore seems a s tho ugh therapeutic manip ula­

w i th depression)?

tion i s not necessary. However, when obj ective exa mination of s u ch a child takes place, func tional

The child should be exa mined whi le s tanding

restrictions can be foun d from the OC junc tion to

up and assessed in rela tion to the lumbar spine and the cervical spine, un i l a tera l lifting of the

the hip j oints . The therapist should first take a case his tory,

should er, kypho s i s-lordosis p o s t u re, scoli osis

and sho u l d then inspect the child, un der take pal­

(assess pelvic positi on) sca p u lae ala tae, shortened

pa tion, perform a segmental functional examina­

pec toral muscles and

tion and tes t the muscles .

(rota ted o u t w a rd s / i n w a rds, symme trically or

The case his tory focuses on signs indica ting a

the p osition of the feet

only on one side) . These observations are part of

I t may en tail autonomic

the overa ll exa mina tion and have to be checked

imbalance, organ p roblems, cold or sweaty hands

against the local func tional capabilities of - for

a n d feet, heada ches, tense neck muscles, stomach

example - the thoracic spine.

KISS / KIDD p roble m .

pains and vague pains in the lower back, p o s tural ins u fficiency, trauma, clumsiness at sports and games . As a lw a ys the fin al d iagnosis d epend s a t

D ETA I LS O F T H E T H O RA C I C EXA M I N AT I O N

lea s t a s much o n lis tening carefully t o the s tories told by the pa rents and the child tha n on the clin­ ical fin d ings . Withou t the guidance o f the p reced­ ing interv iew we would lose our orientation in the j ungle of consp i c u o u s d e tails of the clinical examination. B u t before the active examin a tion s tarts we

o f the anatomy and i ts func tions m a kes i t d ifficult to decide whether the problems have been ca used by vertebral or by rib prob­ lems, although it is usually a combination of the tw o. Within the framework of the overa ll fW1c­ The complexity

tional diagnosis, exa mination of the l umbosacral

1 6.4) .

o b serve the chi ld, observe how i t w a lks into the

area and the cerv ical spine is carried out (Fig .

room or how it behaves on the paren t's lap.

As a result of palpa tion and func tional examina­ tion of the thoracic spine, many p rob lems often

•

What is the child's sitting posture in the w a i ting

come to light involving the restricted inflection

room?

function of the thoracic spine, and painful areas in

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M a n u a l t h e r a py of t h e t h o ra c i c s p i n e

F i g u re 1 6 .4 W h a t t h e b a c k c a n te l l y o u . J u st by l o o k i n g at t h i s tee n a g e r we g e t i n fo r m a t i o n a bo u t t h e

Fi g u re 1 6. 5 C l a s s i c exa m i n a t i o n of seg m e n ta l m o b i l i ty, c o n s i d e ri n g t h e i n terve rte b r a l a n d t h e costove rte b ra l

l u m b a r a sy m m etry a n d a n i m press i o n of a fa i rl y g o o d

a s pect.

m u scu l a r b a l a n ce of t h e t h o ra c i c a re a . T h e s h o u l d e r b l a d es a re w e l l atta c h ed to t h e t h o rax a n d t h e postu ra l

immedia tely adj u s t

m u s c l e s p ro v i d e c o m p e n sa t i o n fo r t h e b a s a l a sy m m etry.

The next s tep migh t be to ask the child to

its

pos ture to such a remark .

breathe

in deeply, thus ge tting an impression of the

the p a r a v er t e b r a l

s t r u c t u res

of

the

th o r a c i c

spine .

breathing

type

w h ile sitting (as compared to

the thorax movement in a s tanding position) .

Most of the examination perta ining to the tho­ racic spine is integra ted into

the general check-up,

but some d e tails m a y be w orth men ti oning sepa­

A fter the non-touch phase comes the segmenta l examin a ti on (Fig.

1 6 .5), first in neutra l p ositi on,

then moving the tnm k in flexion / e x tension a n d

ra tely. When exam in in g the child i n an upright

checking t h e segmen tal movemen ts indivi d u a lly.

position we have to lea v e time eno ugh for the child

Several tests

to a ttain a sta ble (or

unsta ble)

posture. Often dur­

ing the first secon ds an a !most normal postu re can be achieved and the

it

is onl y after

5-10 seconds that

p robl em s come to the sur face.

A fter this neu tral

stance we ask the ch ild to s tand on

one leg,

bend

1 0 ) . The examin a tion of part of this assessment . A fter having examined th e child in a s tanding posi tion we c o n t i n u e to check se g mentally, first in a si tting position, then l yi n g down. Again the first forward,

etc . (see

the thorax is j us t

Chapter

•

p os t u re . If we encounter a susp icious d e tail, for example a n asymmetry

child 's spontaneo u s

at our disp osa l :

p alp a ti on p e r segmen t of the painful areas: cer­ vical-thoracic and th oracic-lumbar j unctions

•

muscular p a inful areas ( localized p a in / ra dia t­

•

is there a twitch resp onse?

•

p ainful a reas in the cos to transversal, p a raverte­

•

costos ternal

ing pain)

one

moment i s reserved for an examin a tion of the

a re

bral and in terspinal

region

connections:

superficial ! deep

p a l pa tion of the tissue resistance •

intercostal musculature: trig ge r points,

excitability,

passive extension . Lying down

on the back gives an impression of

which does not fit i n to the overa l l pictu re, we can

the po s tu re w1influenced by gravity, and i t is often

child to stand up and si t down

surprising to see that the asy mmehy while standing

always ask the

again . One should refra in from commenting about

is maintained even then. The next item tha t is

the pos ture to the p a re n ts present, as the child will

vant for the evalua tion of the

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rele­ thoracic func tion is the

1 99

200

P R A CT I C A L A S P E CT S O F MA N U A L T H E R A PY I N C H I L D R E N

palpation sensitivity o f the upper abdominal area .

from an exact applica tion o f the necessary forces.

Children with signs of gastritis typically complain

Any trea tmen t on the thoracic level has to be pre­

about pain in the middle of the back - much like

ceded by a thoro ugh examina tion of the pivotal

adults . If we confine our therapeutic e fforts to the

areas of the spine, and even more so in child ren

manipula tion of the segments in ques tion our suc­

than

cess will b e temporary at best.

chronicity of the underlying problems d e termines

Departing from the mid-back

pain we proceed

to the epigas tric irritation, which may have its

in a d u l t s .

But

as men tioned above, the

the outcome o f the local treatment on the thoracic level .

origin in a difficult situa tion a t school or in the fam­

This should take place in rel a tion to the cerv ical

i l y - how we deal with th is is a differe n t question

(KlSS / KlDD) p roblems and tha t is why thoracic

and one w e cannot discuss here . But one has to be

thera p y occ u rs within the framework of a full

aware of the basic fac t that the thorax acts very fre­

trea tment . Ind eed, the complex ity of such thoracic

quently as a resonance board for problems origi­

problems means tha t treatment sho uld be as

n a ting well o u tside its confines.

broad a s possible. Not only d o complex biome­

Lyin g on the s tomach then gives a c cess to the de tailed examination of the resis tance of the skin

chanics play a big part in the literally palpable p roble ms;

the ortho-symp a th e tic deregula tion

many yea rs)

and subcutaneous tissues, complementing what

(which may have been going on for

w e found du ring the examina tion while s tanding.

also plays a significant role in the pa thology or

In addition to the bio­

The most impor tan t detail accessible in this posi­

'unwell-being' of the chil d .

tion i s the turgor of the skin and the sub c u taneo u s

mechanical d i s orders, there are also often ANS

tissues. The c omparison of the fin dings i n sitting

disturbances, which are frequen tly ass umed to be

and lying positions c an sometimes shed ligh t on

innocen t .

the role o f gra v i ty in local dysfunc tions and helps

For specific manipula tion techniques, readers

to differentia te between a more biomechanical or

should refer to the 'classic' textbooks ab out man­

a primarily reflective origin of

ual therapy. Here we mention those trea tmen t

sensibility (llli

a

zone of thoracic

techniques tha t are most useful and most effective

1949) .

for children.

S o ft t i s s u e t e c h n i q u e s

T H E R APY The most imp ortant aspect to keep in mind when

Soft tissue techniques are s i t u a ted i n the in ter­

comparing m anual thera p y of the thoracic spine

section between manual therapy and ' n ormal'

to tha t o f the cervical spine i s tha t the th oracic

phys i o therapy I massage. These techniques come

spine is much more fa u l t- tolerant than the cerv ical

in vario u s g u i ses, be i t conne c tive tissue mas­

spine. Whereas any therapeu tic maneuver a t the

sage

cervic a l level - and even more so at the OC j unc­ tion - should be planned and exec u te d w i th the u tmost reserve, the limits on a trial-and-error

(Kohl r a u s ch

1955), p e r i o s t e a l m a s s a ge 1 955) or the m o re 'modern' o s teop a th i c techn iques ( G reeman 1 996, Sco tt-Conner a n d Ward 2003). The forme r tw o methods d a te back (Vogler

approach a re much less s trict here . Due to its

to the fir s t h a l f o f the twentieth cen tury and -

restrained movements the thoracic spine is in gen­

especially in central and e a s tern Europe - many

era l well protec ted against mechanical overload,

sim i l a r methods were taugh t . The b a s ic tech­

b u t less so against tilt and bl ockages. Most of the

n i qu e s a re absolu tely i dentical to those applied

problems origina ting at the thoracic level can be

to adu lts and the only d i fference i s tha t in c h i l ­

resolved w i th fa irly simple techniques. Even these

d ren one h a s to use even less force tha n i n

' trivial' manipula tions (see Chap ter

22) profit

grow n-up s .

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Man u a l t h e r a py of the tho r acic spine

M o b i l i z a t i o n t e c h n i q u e s fo r r i b s a n d

nique is most effective during expira tion, so the

verte b r a e

child should be asked to breathe out slowly. The lower costovertebral joints are best dealt w i th

In a growing

child, forceful manip ula tion should

be a v o i ded .

Because o f o v e r a l l physiological

mobi l i ty i t is easy to d iagnose segmenta l func­

tech­ that the therapy hand is positioned on the angulus costae and the

tional res trictions and as

heterolateral processus transversus is kep t in a fixed

a

result it sho u l d be p os­

by using springy and oscilla ting trea tment

niques

in the ventral position, so

sible to opera te p u rely in segments.

position . This technique can be used either on just

Treatment techni ques of the thoracic area are qu i te sim i l a r to the ma neuvers used in a d u l ts . Fig­ ure 16.6A shows a mobiliza tion of the second and third rib, Figure 16.6B a dorsal manipulation of T4 /T5. M uch less force is needed than in adults.

one rib o r on several ribs at once.

In rela tion to the cenr ical spinal col umn the cer­

belongs with the cerv ical spinal three-d i mensional cervical functions run thro ugh up to T4, whi ch in func tion a l terms is the basis for the cervical spin a l column and is the

a

focused

manner. It is also p ossible to carry out the mobiliza­ tion in a gentle manner as the child brea thes out. Manipulation techniques, as described for adults, should not be used in tl1e treatment of children .

vicothora cic a rea

col u mn . The

As before, it is

important to p roceed gently, quietly and in

Mobilization of the intervertebra l j o in ts can take place in two direc tions .

In the s agittal area, neck, dor­

while the child's hands a re on his or her

sal inflection mobiliz ation can be carried out, so

least mobile of the spinal vertebrae. In the case of

that the underlying vertebra is kept in a fixed

cervical p roblems the cerv icothoracic j unction must a lso be treated . The most obvious therapy me thods

position. This techni qu e can be applie d up to T 1 O . A logical progression of this technique i s three­

for the upper thoracic area are mobiliza tion of the

d i mensional mobili zation in d orsal inflec tion car­

upper fo ur ribs and the intervertebral joints; mobi­

ried ou t while the child is sitting down. In the

li zation of the first and second ri bs can be carried

sitting position the thoracic spinal column is able

out in ei ther the sitting or the lying position.

to move as freely as possible in the space. While

A fter the rib j oints have been mobilized on the dorsal s i de, they can then be m ob ilized to the

ca rrying o u t this

expiration position via the s te rnum and the ante­

in other words, the child is not brought out of

rior ribs, tha t is to say via the long lever. This tech-

b alance

A Fig u re

technique the chi ld s tays seated

on the chair with his or her feet on the ground;

(Fig. 1 6 . 7) .

B 1 6.6

A:

M o b i l i z a t i o n o f t h e seco n d a n d t h i rd

rib. B :

D o rs a l m a n i p u l a t i o n of T4!Ts.

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201

202

P R A C T I C A L A S P E CT S O F M A N U A L T H E R A P Y I N C H I L D R E N

A F i g u re 1 6 . 7

B A a n d B : Th ree-d i m e n s i o n a l m o b i l i z a t i o n . I n u s i n g t h i s tech n i q u e t h e t h e ra p i st h a s a l o t of free d o m to

c h oose t h e m o st effective p o s i t i o n i n o r d e r to a c h i eve t h e m a n i p u l a t i o n w i t h t h e l east d i sc o m fo rt poss i b l e . T h e posi t i o n s h o w n i n p a rt A i s b e t t e r s u i te d fo r t h e costove rte b r a l j o i n ts.

When trea ting a child w i th a thoracic ky p ho tic

become a utoma tic for th e child. P o s tu r al stress is a

p osition accomp an ie d by insufficient respi­

source of thoracic p a in, while sitting is a s ta tic

ra tion, mobiliza tion of T7-T9 is very important, as

s tres s . Altho ugh children do not often complain

this is physiologically the highest part of the tho­

about p a in, i t is in the tho racic region in particular

sitting

racic kyphosis . Thi s is very common in child ren w i th a

medical h isto ry of KISS II.

tha t the

p ain threshold is often lowered, and this

frequently becomes c lear w h e n using provoca­ tions in painfu l areas: th is is a ll the more reason to

E m b e d d i n g m a n u a l t h e r a p y of t h e t h o r a c i c s p i n e i n a b r o a d e r a p p ro a c h

trea t these child ren . In trea ting the thoracic re gi o n of the

o rg a n Both chi l d ren and p a rents need to pay a t ten tion to

we are b u sy

w i th a n a rea wh ich

spinal d isplays

pa thologies than th e two spi ne, b u t one which needs atten tion, too. Here - more so than in the other a reas - m anual trea tmen t of the f u n c t i o n a l d isor­ ders ha s to go hand in hand with reha b ilitation, m uch less spec tacu l a r

thera py: conscious posture correc tion a n d mobil i zi n g, and m u scle­ s tren g then ing exerci ses for the b a c k . The most importa n t p o i n t, however, is to ensure that they a re a w a r e of the rel eva n t posture correc tion . A t h ome, a s \ve l l a s a t sc hool, mea s u res should b e ta ken t o promote a c o rre c t s i tti ng postu re (for exam p le, a ti l ting desk table is very effective) . These corrective m e a sures will have a p osit i v e

p ivotal regions of the

influence on pos ture s tress and the au tonom ic

quality of o u r the rapy will i m p ro v e and its results

i m b a l ance,

last longer.

the most imp ortan t part of the

and

such a u to- corre c tions should

re-ed uca tion and preventive meas u res. So, a l th o ugh the thoracic a rea is not of p rim ar y importance in the fu nctional pa thology of the spine, nevertheless if this i n c o n s p i c u o u s b u t basic part of the whole thera py is taken care of, the

Copyrighted Material

M anual thera p y o f the t h o rac i c s p i ne

Refe re n ces Bergsmann

0, Eder M 1 9 8 2 FWl k t i oneUe

S t u ttga rt

B iede rma nn H 2000 Primary and seconda ry cra n i a l asymmetry in KISS-chi l d ren. I n : v o n Piekartz H, Bryden L (eds) Crarriofacia l dysfunction and p a i n . Manu a l therapy, assessment an d m anage m e n t . Bu tterworth & H eine ma nn, London, p 46--62 Bri.igger A 1977 D ie E r k rank ungen d es Bewegu ngsapparates

A 1 956 Z u r F u nktion d e r l I i o- L u m bo­

M, Ti lscher H 1 985 Sch me rzyndrome d e r Wi rbelsa u l e R 1911 Handbuch der A n a to m i e und Mechanik der

Grec m a n 1 ' 1996 Princi ples of ma n u a l medicine. L i p p incott

& Wil kins, Phi l ad e l p hi a K, Schl i a k H 1962 Segmen tale Innerva tion. Th ieme,

WilL i a m s

A A 1 962 Il iopso a s . Charles C Thomas,

S p r ingfie ld, I L M umenthaler Nathan

M 1980 Der SchuJ ter- Arm-Sclunerz. H u ber,

H, Weinberg H, Robin G C , Av i a d J 1 964 The

J I l i F 1949 SOigner I e dos d e I ' e n fan t - c'est p reve n i r I e ' rh uma tisme' c h e z I ' a d u lte. Geneva J a n d a V 1 9 68 Die Bede u t u ng m usku l a rer Fehlh a l t ung a ls

in

a rth ritis. A rthritis and Rheu m a ti s m 7:228 Neu mann C 1960 Sull a Genesi d e l l a Scol ios i ne ll' et. evol u ti v a . Giorna le Samta 21 :451-452 Sch l i a k

Stu ttga r t

H 1 955 Zur Segmentd i a gnos t i k d e r M u s k u la tur.

Nervena rzt 26:471 Schmor!

G, J un g h anns H 1 968 D ie gesunde lmd d i e k ranke im Rontg e n b i l d Wld K l i n i k . Thieme,

W i rbelsa ule Stu ttga rt

pa thogenet ischer Fa k to r vertebragener S torungen. Archives of Phy s i c a l Thera p y 20: 1 1 3-11 6

R 2003 FOlmda tions for osteop a thic & Wi l k ins, P h i l a de l p h i a Vogler P 1 9 5 5 Perios tbehan d l u ng. Th ieme, Le ipzig, p 174 Scot t-Conner C, Wa rd

W 1 955 Reflexzone n m assage in M u s k u l a t u r und Bindegewebe. H i p p o k r a tes, S t u ttga rt, p 1 33

Kohlrausch

1991 M e t h o d i e k v a n M a n u e l e Th erapie. Rotte rda m, p 37 Meyer T 1 994 Das K ISS-Synd ro m . ( Kommenta r) . M a n u e i J e

Meye r T

costover tebra l j Oints: a n a tomico-c l i nica l obse r v a t i o n s

Gelenke . Fischer, Jena

Ha nsen

R 1 968 Do u le u rs d ' o r i g ine verteb ra le et tra i tments

p a r Ma nip u l a t ions . Expen s i o n Scien ti fique, P a r i s

Bern

H i ppokra tes, S t u t tgart Fick

motor sys tem . B u t terworths, London Maign e

M i chele

Sac ra lverb in d u n g . Erfa hru ngshe i lk 5:264-270 Eder

S t u ttga rt,

Medi z i n 31 :30

und seines Nervensystems. Fischer, S t u ttga r t Cram e r

W 1 963 Wirbelsa u l e u n d Inn ere Med i z i n . Enke, p 281 L e w i t K 1 985 Man i p u la tive therapy in rehabi l i ta t ion o f t h e K unert

Pa thologie und Kl ini k der Brustw i rbe lsa u l e . Fischer,

medicine. Lippincott W i l l iams

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203

17

Chapter

------�----�

Examination and treatment of the cervical spine in children H. Biedermann

The young physicia n sta rts life

CHAPTER CONTENTS Precautions

205

Less is more

207

with

20 drugs for each disease,

and the old physician ends life with one drug for

20 diseases Sir William

The 'twin-peak' phenomenon of manual therapy for children Treatment techniques

208 208

The standard position Sitting positions

209

Standing positions Lying position Conclusion

211

211

211

208

Osler

Every goldsmith, software engineer or surgeon is -depending on their observational skills -sooner or later confronted with the sa me baffling fact: of the multitude of procedures his teacher consid­ ered essential only a very few are used in every­ day practice. 'You need

10% of the code for 90% of

the end-user 's needs' is a standard quotation in software engineering - only to continue a second

90% of the code for the 10% of the user's needs'.

later with ' ... and the other last

We shall try to be a s encyclopedic as required - but not to the point where every possible tech­ nique is covered. Some will be left out an d my only excuse is to rely on the rea der 's crea tivity and encourage everybody to seek their own way.

PRECAUTIONS The principle nil nocere is as much the basis of planning of the procedure a s in any other context. The extensive litera ture of complications after manual therapy offers a few clues on how to proceed:

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205

206

PRACTICAL ASPECTS OF MANUAL THERAPY IN CHILDREN

•

optimize the fixation prior to ma nipulation

treatment, but viscerally they hate the moment of

•

do not use reclination a nd/or rotation unless

manipulation - as much as some adults, by the

absolutely necessary

wa y.

•

leave enough time to react and reach a new

•

•

a nd agreeable as possible without deceiving the

manipulate as fast as possible, i.e. with a n

child. I never tell them 'this won't hurt' -if it does,

impulse o f minimal dura tion

they a re rightly a nnoyed by my blata nt lie. So it is

use the minimal energy sufficient to a chieve the

better to sa y 'this might be a bit unpleasant for

thera peutic effect.

moment' -and do it quickly. Disrespect hurts chil­

These are the purely technica l considerations applicable to all manua l therapy. But especially in children and the newborn, three further important points have to be added:

a

dren much more than a short moment of pain. The smaller the child, the more it is essential to package examina tion a nd therapy in a play and cuddle situation.

If you tell the observing parents

'now I shall do the manipulation' you can be sure that their immedia te a pprehension is as quickly

•

win the confidence of the parents first

•

try to the best of your abilities to establish a pos­ itive communication with the young patient

•

So we have to make our intervention as smooth

equilibrium

immobilize the child reliably in the moment of

tra nsmitted to the child a nd results in a sha rp heightening of its muscular tonus. Therefore it is advisable to inform the pa rents beforehand that

treatment.

exa mination

a nd

trea tment

All this sounds quite obvious, but putting it

seems a ppropriate for the parents concerned.

together - or you create a fait

a re

performed

accompli - whatever bit surprised to

into practice is quite a different ma tter. Wirm.ing

Most parents do not mind being a

the parents' confidence starts well before the first

get the child back before they were able to observe

visit to the consulting room a nd could be classi­

an intervention, but there a re others where it is

fied under 'marketing' - it is something that ca n

better to inform them beforehand. I find it difficult

be taught to a great extent. How to interact with

to give a clear classification; to ma ke this distinc­

the young pa tients, on the other hand, is much

tion well is part of one's professional intuition.

more difficult to 'teach' and even more complex to learn. An irm.ate a bility to win the confidence of small children helps. I ha ve seen quite a few colleagues whose body

language signaled very clearly that to win this basic confidence was not their most obvious ta l­

A successful treatment comprises three basic steps: •

identifying the problem

•

defining the therapeutic steps

•

applying the treatment itself .

ent. It is not impossible to treat children who do

As very often when a specialist is involved in

not like you -but it is a lot more difficult than with

the fina l outcome, at lea st one initia l step depends

that magic connection as a base.

on the insight and initiative of a non-specialist:

Not tha t the children where there wa s a good

we can only help those who come to us. Realizing

contact at the beginning of the examination would

this motivates us to use the utmost effort to

not complain and be angry after the manipulation;

ensure the best possible information is

it is their unalienable right to be furious. Certainly

to those involved with children, in order to enable

those children who suffer from a neurological con­

them to think of the possibilities manua l therapy

dition which necessitates fairly regula r treatments

ca n offer for an existing problem in a child under

every few months do develop a love/hate rela ­

their ca re.

provided

tionship with the therapist: intellectually they

We did a -quite cursory -check of our patient

rea lize tha t their condition improves after the

databa se of the y ea r 2000 to see how many chil-

Copyrighted Material

Examination and treatment of the cervical spine

dren were referred to us with a clear indication for

In about two-thirds of cases the effect of the treat­

manual therapy.

ment shows in the first 48 hours after the manipu­

As it turned out there was

lation, but the other third of the successfully

roughly a split into three groups: About 28% were referred to us by general prac­

treated children need between 2 and 4 weeks to

titioners or pediatricians with a diagnosis and/or

display a change for the better, sometimes only

query referring to a functional problem of the ver­

after an initial rebound. This is especially frequent

tebral spine (,vertebrogenic headache',

in schoolchildren. We tell parents explicitly that

'KISS',

they might encounter an even more 'difficult'

'dorsa Igia', etc.). A second group of

41% of the children were

child in the first days after our treatment and that

sent by physiotherapists who treated these chil­

this aggravation of an already tirin g situation has

dren and realized after some of their own treat­

to be weathered by the family. It is tempting to try

ments that those children would profit from

to combine several other modes of treatment

a

to alleviate this phase - for example by using

specific manual intervention. The last group of patients basically came because the parents saw the effects of manual therapy in another child first and thus got the idea of trying this kind of therapy here too

(22%), (9%).

or

because friends and relatives proposed it

psychopharmaceuticals. As

far

as

our

experiences

indicate,

this

approach is ineffective. It seems better to allow enough time for the results of the manual therapy to take effect; they tend to be more profound and

However brilliant our therapeutic procedures

stable when the organism is given the chance to

may be, to prove their worth we first need the

re-adjust its functions to the post-manipulation

chjldren to be present with us and the consent of

situation without further stimuli.

the parents to treat them. Here, too, a little 'mar­

Again, tills proposition is based on the observa­

keting effort' may be helpful. So we try to provide

tions of the outcome of our patients. In the begin­

kindergarten personnel,

ning we routinely advised the parents to resume

teachers and

others

involved with children with information about

other therapies and treatments immediately after

how manual therapy can help them with some of

our intervention. This was in most cases physio­

their problems. But the best - and most convinc­

therapy and we took care to motivate the parents

ing - argument comes from non-professional

to continue with the exercises at home the next

sources, i.e. the stories other parents tell.

day and see the therapist soon afterwards. In a

Realizing this, we might use our waiting room

few cases our advice was not followed, sometimes

as a therapeutic tool. When we surmise that par­

because the family went on holiday, sometimes

ents coming for the first time may be very scepti­

because other problems were more pressing and

cal about our approach we give them some extra

prevented the mother from exercising with the

time in the waiting room; almost inevitably they

child. In even fewer cases tills 'non-compliance'

get involved in a discussion with parents who

was reported back to us, as it takes some courage

come for the check-up and who (we hope) dispel

and trust of the parents to tell this. In these few

anxieties much more efficiently than we could

cases the result of our treatment was mostly much

better than

ever do it ourselves ...

in children who followed the pre­

scribed procedure. By asking some parents to stop additional treat­

LESS IS MORE

ment in the weeks following our intervention we saw a trend in the data proving this counter­

Another problem of our approach in manual ther­

intuitive observation.

apy stems from the long delay between the treat­

Our standard procedure for patients undergo­

17.1).

ing manual therapy is thus to ask for a period of

ment and the ensuing amelioration (see Fig.

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207

208

PRACTICAL ASPECTS OF MANUAL THERAPY IN CHILDREN

2-3 weeks after manual

t herapy

before other

treatments are resumed and/or the effect of our treatment is evaluated. In a small minority of

impossible to take all the other con t ri buting fac­ tors into account. The main lesson one should draw from these

give the patients time to respond to a

patients it migh t be a d visabl e to shorten this

data is to

interval, most often in patients wit h a very low

manipu lation This is true for all age groups but is

general muscular tonus. In these cases the possi­

especially important in children. We do not aim at

.

bilities of manual therapy are generally more lim­

the mechanical level when we treat children, so the

ited, one e x trem e being patients with trisomy 21

improved mobility or the reduced pain level is j ust

(Down syndrome).

means to another end, which is in most cases a better

a

sensorimotor equilibrium. The timing of a therapy is

as important as the technique used.

THE 'TWIN-PEAK' PHENOMENON OF MANUAL THERAPY FOR CHILDREN TREATMENT TECHNIQUES Figure 17.1 shows a diagram analyz ing interviews with parents of 264 babies treated at our practice.

Some of the basics will be presented here, but with

Two reaction peaks are clearly visible. The first

the caveat that this chapter does not claim to be

peak is testable by the classic procedures advo­

more than an aide-memoire. Those of us used to

cated by evidenced-based medicine, but between

reading books about manual therapy are accus­

the treatment and the second peak lie more than

tomed to the chapters about treatment techniques

14 days and it is often difficult to convince parents

showing the therapist and the patient in more or

to refrain from additional therapies during that

less close contact, where the latter

time In the example in Chapter 21 showing the

the strict sense of the word) the manipulations

.

undergoes (in

documentation of movement patterns it was clear

exercised by the former. One is reminded of a

that the effect of

cookbook: if you know how to do it, such a

a

single manipulation lasted well

over 6 months, and that during that time an adap­

demonstration

tation to this new situation took place. Such a

memory, but for a novice it makes frustrating read­

might

help to freshen up one's

long-term effect can be documented by a multi­

ing. Having said that, we shall anyway try to illus­

tude of follow-up studies, but it is very difficult to

trate some of the techniques used here, but it must

verify this in a rigorous protocol, as it is almost

be emphasized that these pictures are not intended as a replacement for practical demonstrations.

100��----90 80

The standard position The majority of children can be treated in a relaxed and neutral position as shown in Figu re 17.3. T he therapist sits on the ex am ina tion bench and

the child lies on h is or her back in front of the ther­ apist. This position is the most relaxed for children and it permits the parents to hold the child. T here is always a trade-off between over-immobiEzation Day Figure 17.1

2-3 Days

4-5 2 3 Later Days Week Weeks Weeks Time since treatment

Effect of manual therapy relative to the

time of the manipulation (Biedermann

1999).

and annoying the child: the more persons partake in the task, the more irate the child tends to be. For

the beginner it is certa inl y the better option to ask the parents to help with holding the child. We

Copyrighted Material

Examination and treatment of the cervical spine

A 'massage'

c

B

Figu re 17.2

A few oldies. These pictures are taken from books published between 1860 and

( Li vre

d'or de la sante, Paris, 1864). B: 'Kneading th e nerves' (Bum 1906).

C:

19 10.

A: Tec h n i q ues of

'Enhancing circulation' ( Naegeli

1875). The idea behind the therapy has changed, but the modus operandi is much the same.

easier to comfort the little one a fter everything is a chieved.

Sitti ng positions Another possibility is to have the child sit on your lap. Depending on the direction of the manipula­ tion, there are two ba sic varieties and the posi­ tioning of therapist and chi ld is comparable to the

17.4). 17.4 shows the position for those cmldren

situation d uring examination (Fig. Figure

who need a la tera l im pulse, in this case from the left. This position allows a very tight control of the child's movements and we use this option often in children with ADD-like symptoms. These children a re especially sensitive to dose contact and even more so to an examination of the cervical spine. They oppose this very intensely and to be a ble to Figure 17.3

Treatment of small children is most easily

achieved as shown.

even examine them, one has to be prepared to use some coercion. It is essentia l to make sure before­ hand that the parents understand the necessity for

use this option very rarely and prefer to wait a lit­

such a procedu re and to go through with the exam­

relaxes his muscular tonus for

ination and tre a tm ent in one go. As soon as one

a moment . Tms procedure is not only more ele­

stops on the way, the child quite rightly assumes

tle bit till the child

gant, but it gi ves you better control over the reac­

that there is

tion of the chi ld to the manipulation and it is -last

and therapist and will use this to the maximum.

an

exploitable dissent between parents

but not least -less stressful for the child to be con­

In those ca ses where you ca nnot be sure that the

Finally it exculpates

parents agree, you will have to forego a ny attempt

in the eyes of the cmld, and makes it

to use a quick and efficient thera py. It is not

fronted with only one adult. the parent

Copyrighted Material

209

210

PRACTICAL ASPECTS OF MANUAL THERAPY IN CHILDREN

A Figure 17.4

A: Treatment of

B C1

in sitting position. Sometimes children refuse to lie down and it is easier to

accomm odate this wish. B: A more 'controlled' approach. This position gives a maximum of control and is useful in situations where the child does not want to be treated. For further explanation see text.

advisable to proceed against the will of the par­

A slight modification of this position is the

ents, even if you are sure that it would be for the best of the child. In some cases such a problem

'hugging' position. As in the last example the child sits face to face with the therapist on hi s lap.

arises only with one of them and it is sometimes

The therapist embraces the child's thorax and has

possible to resolve this by asking the more nerv­ ous partner to leave the room temporarily. In guite a fev,! cases this calms down the atmosphere con­ siderably, as the child loses his audience. Very often children, being much more sensitive to such non-verbal acts of communication, relax once the nervous parent has left the room, and a treatment considered impossible can go ahead. Figure 1 7.5 shows how we treat children in a sagittal direction: the child sits on the therapist's knees and faces the therapist directly. The two foreheads have contact and the two hands of the therapist are firmly positioned behind the trans­ verse process of the atlas. This procedure can be modified so that the patient sits on the bench and the therapist kneels in front of the patient or sits opposite him on a

stool. Sitting is more gentlemanly, and kneeling is

Figure 17.5

Sagittal manipulation of

C1/C2.

This

position gives the therapist good control and through the

more flexible, as one can adapt one's height more

skin contact with the forehead, a precise way of g auging

easily.

the necessary pre-tensioning .

Copyrighted Material

Examination and treatment of the cervical spine

Figure 17.6

The 'classic' treatment position for infants

and smaller children. A: The positioning of the baby. At the same time this makes it possible to test the mobility

Figure 17.7

The classic HID technique. Shown is the

treatment of C2. The mother's hand supports the forehead of the child, thus giving additional reassurance.

of the suboccipital region very exactly. B: The treatment.

good control of the some tim es

q ui te incompliant

CONCLUSION

young pati ent. One could classify the treatment positions non­

Standing positions

conv ent ion ally as those for cooperative children

This position lends itself to the trea tment of the

over 20 yea rs of dealing

lower cervical spine and th e cervicodorsal region.

it

and those for uncooperativ e ones. Looking back at

It is very similar to the classic techniqu es for grown-ups and the p recise application depends on

close coopera tion between ther a pist a nd

p atient . These techniques are thus ap plica ble

mostly in old er children - if they a re willin g to ta ke part in the effort.

is obvious that the

with infants and children techni qu es used did develop

in response to the constant dilemma of wanting to

be

as

soft

and kind as

possi bl e on one

However we label our treatment, the basics stay the same: transfer of

a mechan ic

Most babies wiU be trea ted ly i ng on their back with the head oriented towards the therapist. Fig­

ure 17.6 shows an example. Wh ich prefers

d epen d s on the width of

posture one

the exa min a t ion

al

im p u l se of

variable energy from the hand of the therapist to

call this chiroprac­ tics, manual therapy, a tl a s therapy, osteop athy a nd the like; basi ca lly this is it and the few exam­ ples shown here are intended to gi v e but an i mpression of the enormous variability of the tech­ niques app l icable . To end this chapter we show a 'classic' HIO (, hole in one', Palmer 1934), a tech­

the spine of the child. We

Lying position

h and and

ha ving to be in command, anyway.

can

bench and the flexibility of the hip joints of the

nique suitable only with older child re n who coop­

therapis t .

erate (Fig.

17.7).

References Biedermann

H 1999 KISS-Kinder: einc btamn es tische Untersuchw1g. In: Biedermann H (ed) Manualtherapie bei Kindem. Enke, Stuttgart, p. 27--42 Bum A 1906 Handbuch der M a ss a ge und Heilgymnastik. Urban & Schwarzenberg, Berlin

Naegel i 0 1875 Nervenleiden und Nervenschmerzen. Basel B J 1934 The subluxation specific - the adj us tme n t specific. Chiropractic Fountain Head, Davenport, fA

Palmer

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211

SECTION

4

Radiology in manual therapy in children

SECTION CONTENTS 18.

Functional radiology of the cervical spine in children

215

19. The how-to of making radiographs of newborns and children 20. 21.

235

Radiological examination of the spine in children and adolescents: pictorial essay

243

Measuring it: different approaches to the documentation of posture and coordination

259

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213

Functional radiology of the cervical spine in children H. Biedermann

THE STARTING POINT

CHAPTER CONTENTS The starting point

Defending the merits of classic radiological plates

215

How we use radiological information The functional analysis

in manual therapy poses its challenges nowadays.

216

On the one hand, there are those who pretend that

217

taking these plates is a completely superfluous

The projections most used in the cervical spine

Additional projections The a.p. view

exercise. Statistics are quoted which show that

218

examination of these plates does not improve the

218

detection of contraindications - so why bother?

219

The lateral projection

On the other hand, the 'modem' radiologists

223

Details in the a.p. projection

point out that magnetic resonance imaging

224

Form variations of the atlas

229

The lumbosacral junction

230

230

Pathogenetic relevance of form variations of the atlas The ALF triad

230

228

thorough one? Waibel's essay (see Chapter

20)

cov­

ers the more morphologically oriented radiology while this chapter deals with the functional interpre­ tation of the radiographs (for additional information see Swischuck's monograph [Swischuck

2002]).

Once in a while one finds papers about radio­ logical findings in the cervical spine related to

231

A never ending story

If radio­

logical examination is necessary, why not the most

227

Implications of form variants of the atlas

Hip region

gation of this anatomically complex region.

227

The OC region in the newborn

is

the state-of-the-art procedure for a detailed investi­

Radiological documentation of the effect of manual therapy

(NIRl)

232

functional disorders (Hartwig 1964), but they are few. Lewit and Gutmann stressed the importance of plates of the cervical spine as the basis of func­ tional examination at any age (Gutmann 1953, Lewit et aI1992).

In the following pages we shall concentrate on the cervical region of the vertebral spine, as it is the most complex and also the functionally most important in children. The analysis of the pelvic girdle and the lumbar spine - important as it is for

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216

RADIOLOGY IN MANUAL THERAPY IN CHILDREN

evaluation of the development of the hip joints plays a much less prominent role in manual ther­ apy in children. There are cases where an X-ray picture of the lumbar spine and the pelvic girdle is essential, but for the overwhelming majority of cases it is the cervical spine and its functional analysis that is the most rewarding. It poses the biggest problems, too, as its signs are subtle and have to be evaluated with care. Last but not least, the radiograph of the cervical spine is one of the most difficult plates to take at any age - and with babies (generally uncooperative partners) this task does not get easier. In Chapter 19, we shall try to be of help in this difficult task.

HOW WE USE RADIOLOGICAL INFOR MATION

Figure 18. 1

Cranial asymmetry in an MRI. This cut

shows the occipital flattening of a typical

The most commonly held idea about the use of X-ray plates is to look for morphological changes. In these cases one needs to define a standard, and any­ thing deviating from that standard is considered more or less pathological. I am not in a position to judge the validity of this assertion in all circumstances. For the purposes of orthopedic surgery - and even more so in dealing with problems related to the vertebral spine - it is safe to say that whatever non-standard facts can be extracted from a radiological picture (X-ray, CT scan, MRI, etc.), they have to be compared with and validated by the clinical examination. Publications abound which reiterate the well­ known (but often ignored) fact that there is no such thing as a radiological diagnosis of, for example, a discus hernia (Hollingworth et a11998, Murrie et al 2003, Penning et a11986, Wood et a11995) - a clin­ ically relevant hernia, one has to add to avoid use­ less squabbling. The radiological findings as such need the causal connection with the clinical picture to be validated and only then should they be accepted as a basis for clinical decisions (van der Donk et aI1991). Nowadays we are able to see with ever better quality the patho-morphology of a given region.

K ISS II

case.

These distinctive asymmetries allow a prima-vista diagnosis of cranial asymmetry which has to be examined for other possible causal factors. In the

overwhelming majority of cases, a functional background

(i. e KISS II) .

is the most probable reason.

But there is no straight and short path from this initial finding to a valid decision about what to do with the patient. Humans are visual; 'One picture is better than a thousand words'. But once in a while pictures are overloaded with a significance, when they can only constitute a basic framework for further eval­ uation based on the case history and the clinical evaluation, as is quite often the case in the mor­ phological radiology of the vertebral spine. One school of thought among those active in manual therapy takes the obvious and radical consequence to disregard X-ray analysis com­ pletely. This argument is facilitated by the fact that many of those applying manual therapy to the vertebral spine often do not have ready access to radiographs, as is the case for most physiothera­ pists. Departing from the just cause of putting the findings of radiological examinations into per­ spective, they extend this argument beyond its

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Functional radiology of the cervical spine in children

breaking point and disregard X-rays altogether, thus losing a valuable source of information.

THE FUNCTIONAL ANALYSIS

This chapter aims at restoring the balance between over-confidence and total neglect: on one hand those who do not bother to take radiographs at all, and on the other hand those for whom only an MRI or a CT scan suffices. In order to get to the middle grOLmd we shall first introduce a concep­ tual frame for radiological data extraction: the junctional analysis. This functional view is not completely alien to radiologists, in fact it is the basis for some of the newer research tools such as positron emission tomography (PET) scans which are used to analyze the momentous changes in the metabolic rates of different brain regions. So far, so good - but the idea that an 'ordinary' X-ray picture of the cervical spine can give us more than strictly morphological data has not yet reached the medical mainstream. But it is precisely the functional level which yields the most relevant data in dealing with vertebrogenic problems. The functional analysis is in no way a contradiction to a morphological approach, as we shall see in several examples here. At the end of this chapter it should be com­ prehensible that the evaluation of the functional implication acts - quite contrarily - as a catalyst to deepen insight into minor (and otherwise easily overlooked) patho-morphological details. In following the leads provided by the func­ tional approach of the X-ray analysis, our atten­ tion is often attracted to minor details which would have been easily overlooked without it. It is the interaction between morphological and bio­ mechanical levels which influences the function and for the brain this (impaired) function is all that counts (Lewit 1994). In young adults, and even more so in older per­ sons, this fabric of interaction can be very complex and difficult to decipher. Luckily the situation is much less complicated in dealing with children

and babies. Whereas the latter show a complex pattern of inborn and acquired features, the main morphological problems in newborns are congen­ ital malformations and/ or the anatomical variants found in this evolutionarily volatile region. A second aspect of the functional analysis of the X-ray pictures of small children is the dominance of functional over morphological details. In adults it is the morphology that determines the function: an arthritic joint facet diminishes the local range of mobility; an asymmetry of a vertebra induces an asymmetrical posture. In the small child - and even more so during the first year - it is more often the (mal-) function which determines the way the morphology will differenti­ ate. We see more and more examples where a timely intervention mobilizes the functional situation and the imminent morphological pathology could be averted (see Fig. 8.13). The functionally fixed pos­ ture results in a morphological response. This is one major reason why the functional analysis of the X-ray pictures is of such paramount importance in dealing with our young patients. The search for an optimal treatment of a baby's functional problems is much easier if we are able to read the signs correctly. And the problems involved are not confined to postural or kinetic phenomena only. The validity of this approach can only be determined by the improved quality of our interventions based on functional radiological analysis. It can be demonstrated that our therapy is more effective when using the functional analysis of standard X-ray pictures of the cervical spine, thus reaching the therapeutic goal with fewer treatments. Minor anatomical deviations are too elusive to be clinically recorded. So it is not possible to find out before, either in the medical history or in the course of the palpatory findings, where it would make sense to take a radiograph and where not. It is impossible to define 'risk groups' who then should have a radiographic examination, or to exclude groups of patients where, if a patient were to be manipulated, a prior radiographic examination would be unnecessary. Not even

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218

RADIOLOGY IN MANUAL THERAPY IN CHILDREN

block vertebrae can be made out during a palpa­

be determined

tory

enhance the information or if it is necessary to use

examination. (In an experiment during a

training course, several patients were examined by

costlier procedures such as

proven experts and the findings compared. Nei­

sufficiently precise diagnosis.

ther of the t"vo patients with block vertebrae was identified [Lewit 1980, personal communication].)

From month

CT or MRl to obtain

a

18 on we routinely take lateral

plates, too. At that point in time the child is used to the upright

position and the tonus of the neck

muscles is sufficiently developed to allow for an

THE PROJECTIONS MOST USED IN THE

upright positioning of the child, thus enabling a

CERVICAL SPINE

projection which shows the occipitocervical (OC) junction and the lower cervical spine uneclipsed

Any radiograph taken for diagnostic purposes has

by the occiput and the shoulders. When using the

to be justified by the information eventually

lateral projection in smaller children, there is a big

gained through it. Most authors of books on man­

chance that a morphological analysis is made

ual therapy put the emphasis on the contra­

impossible by the hy perlordosis of the cervical

indications of manipulation as the main justification

spine and the overlapping of the osseous struc­

for a standard X-ray picture of the cervical spine.

tures on the plate.

This is undoubtedly correct and important - but it is certainly not the whole picture. Standard radi­ ographs are not a very convincing tool in search­

ADDITIONAL PROJECTIONS

ing for tumors or neurodegenerative diseases, which are the most important contraindications

In our monograph on the functional radiology of

for manual therapy in infancy and early child­

the cervical spine (Gutmann

hood. Osseous malformations are easier to spot on

space was given to projections that are hardly

1981), quite some

conventional radiographs. At least as important is

used any more today. The ready availability of CT

the role of the functional examination of the radi­

scans or

ograph in order to fine-tune one's manipulation

deeper insight in the complicated topographical

technique and to improve the preciSion of the

situation of the upper cervical spine. Nevertheless

MRI makes it possible to gain a much

diagnosis - and make statements about the long­

it is sometimes important to be able to gain addi­

term prognosis, too.

tional information on the spot, be it only to pre­

Since we routinely take radiographs to examine

pare a more precise question for the additional

and treat small children we look for indicators

examina tion required or to decide immediately if

which might allow us to screen for those children

such an expensive and time-consuming examina­

where a radiography is not necessary. If there was

tion is necessary at all.

a clinical marker which gave a reasonably accu­

In (small) children these cases are very rare;

rate gauge to exclude those children where a radi­

whenever an atypical case history requires addi­

ograph is unnecessary, we could save some costs

tional diagnostics we first refer these children to a

and ionizing radiation. Regrettably no such criteria

specialist for further neuropediatric investigation.

have been found yet. This is why we advise taking

If our radiographs show signs that do not offer a

every child

clear diagnostic solution, the children in question

a radiograph of the cervical spine of

who undergoes a manipulation, regardless of the

are sent to a specialist. In most cases, MRls are the

technique used. In newborns, one plate of the cer­

method of choice for further investigation.

vical spine in an anteroposterior (a.p.) projection does suffice as

In referring patients, it is important to include

standard; whenever this plate

a concise explanation of their problem, as the OC

shows signs of a morphological problem, it has to

junction is a kind of no-man's land for radiologists,

a

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Functional radiology of the cervical spine in children

too. In examining the cervical spine the first focus of attention for an average radiologist is more often than not the intervertebral disks. If one asks for a CT scan of the cervical spine it is not uncommon to get a detailed examination of the disks C3-C6 but the OC junction is at best depicted cursorily. If one asks for an MRI of the skull, the examination stops at the foramen magnwn. Detailed instruc tions about what has to be depicted is therefore essential; sometimes a phone caU is the best way to convey this informa­ tion, which might otherwise be lost between the two classic fields intracranial or cervical spine. These examples are not meant to be exhaustive of the problems encountered at the OC junction but are intended to give a healthy fright lest one overlooks som e thi n g important in tak ing a too cavalier attitude towards an unclear situation. Let us be candid: there are quite a few cases where the solution is no t 100'},0 clear and where we proceed, anyway, in order to use the outcome of the manipulation to judge the validity of our ini­ tial diagn osi s . But even in those cases where an initial improvement made this diagnosis look cor­ rect, one has to be aware that a reappearance of the initial problems - certainly without plausible reasons (e.g. trauma) - has to alert us to other, much less frequent, but more serious possibilities. Two case histories illustrate this point: in both cases the initial picture was unclear or indicative of a functional problem wi th the 'appropriate' trauma present. In the first case the child improved after the first treatment only to relapse 4 weeks later (Gutmann 1987). After the second relapse, a CT scan revealed a tumor as the struc­ tural cause of the dizziness and headaches. The second case came to a specialist in manual therapy after several trial treatments with such an atypical clinical picture that he referred the child immedi­ ately to a neuropediatrician (Koch 1999). These cases admittedly represent only a tiny minority, but their mention should help to dispel any illu­ sion that we operate in a risk-free area. Low-risk it i s - until now no serious complication following manual therapy in children has ever been reported, and the one case study dealt with Vojta

physiotherapy (a physiotherapeutic system widely used in central Europe for the treatment of neurological disorders in children; Vojta 1992) and a baby with signs of circulatory problems (Jacobi et aI2001). The case reported by Jacobi et al (2001) is in fact very instructive, as the complications arose only after repeated treatments involving pronounced rotation and/or extension of the head. The relational analysis of the four parts of the OC junction is in some ways simpler in small chil­ dren than in adults. The osseous structures visible on the plates are much less developed, thus ren­ dering attempts to determine, for example, a rota­ tional component almost useless. The main information to be gained is abou t the sym m etry in the frontal plane and proper alignment in the sagittal plane. These two - essential - items are difficult enough to achieve in our small patients.

T H E A. P. VIEW

The approach in analyzing this projection is quite comparable to the one in adults. Initially we have to make sure that the skull is in a neutral position (see Fig. 18.5). If the septum nasi, protuberantia occipitalis externa and the middle of the incisors are on one vertical line we can be reasonably sure that the head is in a neutral position. The open mouth is essential to allow an unob­ structed view of the suboccipital area. Before the age of 5-6, it is almost impossible to get children to open the mouth voluntarily. This leaves two strategies: we can try to wait for the moment when the crying child opens the mouth wide to intimidate us or we force the mouth open, using a cork or the finger of one parent. We have to admit that the picture thus obtained does not fulfill the ideal of a spontaneous individ­ ual posture which would be ideal to judge the radiograph functionally. On the other hand, we have to take into account that the pathology we are looking for is in most cases so relevant that the

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219

220

R A D IO LO G Y IN M A NUAL TH ERAPY I N CH I L D RE N

Figure 18.2

A g o o d a . p . p i c t u re of t h e s u bocc i p i t a l

regi o n of a 3-m onth-o l d .

interference o f the parent's intervention is second­ ary and the picture can be analyzed, anyway, albeit with the necessary reservations. The biggest changes occur in the first 12-1 8 months, as a comparison between Figures 18.2, 18.3, 18.4 and 18.5 shows. One main difference is the size and orientation of the articular cartilage of the atlanto-occipital joint. We were able to show in an analysis of our radi­ ological data how the frontal angle changes from 1530 for the first 3 months t o 1450 at the first birth­ day and 1260 at the age of 10 (see Fig. 18 4). The sagittal angle changes from 36° for a newborn to 280 for an adult (Ingelmark 1947). These differences may explain two phenomena we see only in infants: .

The

movement

pattern

in

side-bending.

Figure 18.6A shows the normal situation in adults

Figure 18.3

An a .p. pict u re of a 15-month-o l d boy,

s h o w i n g a dys plast i c joint C1-C2

on

the r i g h t sid e.

(Jirout 1990, Kapandji 1974) In a lateroflexion of the head the atlas is forced by the inclination of the joints Co/C1 and C/C2 to shift towards the concave side. Examining the movement patterns with the head and neck in side-bending position, Jirout found this movement in 64°/r, of cases and called it the 'typical' pattern. In one-third of cases the atlanto-occipital relation did not change and only in 3% of cases C1 shifted to the concave side of the movement (Jirout 1990). The lateral shift forces the axis into a rotation which moves the processus spinosus C2 to the convex side. This movement pattern looks obvious considering the anatomy of the OC region and it was verified experimentally time and again. In small children, on the other hand, we consistently found the opposite pattern, i.e. that C1 moves to the convex side of the head (Fig. 18.7 A). This is only possible

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.

Functional radiology of the cervical spine in children

I

)il

o

7'\

-------------------------------------

Fig ure 18.4

An a,p, picture taken at the age of 10 years,

because the much flatter frontal condylar a n gle enables C1 to move like this,

The second observation is connected to this. It

is re mark able

su ffer much more often fixation of the head in retroflex­ ion (KISS II) and we wondered if there was an anatomical reason for this phe nom enon . Studying that infants

from a reflective

the literature we found

'.-------

-'\

R

I

--''.

-,=-r""'c- ,,�� --

I6 h)

•

n eurological d isorders

•

mouth is often open

birthweight birth length •

oblique presentation

•

twin

•

forceps/vacuum

•

posture an d movement

•

cesarean (why?)

•

language

Sensorimotor development slower than expected:

The first months: •

bad sleeper during first months - 6 to 12

•

concentration

•

social integration

Asymmetry:

months - later

visible immediately after birth?

•

did/does the child often wake up at night?

•

•

crying at n ight - how often ?

•

only later (when?)

•

fixed sleeping pattern

•

obstetrician/midw ife saw it

•

problems with breastfeeding on on e side

•

parents observed it first

•

localization:

•

sign s of colic

•

orofacial hypotonus

•

hypersen sitivity of the neck region

arm trunk head

Motor development: when did your child start to:

•

baby looks only to on e s ide

•

moves only on e arm/leg

crawl

•

face is smaller on one side

•

sit

•

back of the head flat on one side

•

pull himself/herself up and stand

•

has a bald spot on the back of the head

•

walk

•

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289

290

MAKING SENSE OF IT ALL

as we do need something to hold on to in order to

A WINDOW OF OPPORTUNITY

understand whatever new facts we find. One good example of this attitude towards chil­

The acquisition of any skill requires a learning

dren can be found in pharmacology: in order to

period and a predisposition to be acquired. The

find the correct dosage one is more often than not

optimal point in time for a specific ability is

asked to multiply the dosage per gram by the

embedded in the phylogenetically fixed develop­

body weight of the (small) patient. Studies about

ment pattern. Language acquisition is the example

the effects of drugs in small children are rare and

we are frequently and painfully confronted with: whereas our children absorb another language

hard to come by. An example closer to our topic is the heated dis­

without any effort, we grown-ups labor and toil

cussion about the kinetics of the upper cervical

and will never achieve the same level of effortless

spine, which arose after we published our findings

mastering our children grow into before puberty.

about the movement patterns of the upper cervical

All our capacities, be they concerned with

spine (Biedermann 1991). It is a well-known fact

movement or perception, build on physiological

that in adults, C1 moves toward the concave side in

and mental abilities learned beforehand. The ear­

bending of the head (Jirout 1990, Kamieth 1983),

lier a basic skill's learning phase is situated in the

but we saw a different pattern in small children. In

'normal' chain of events, the more its faulty acqui­

the vast majority of the small children we were

sition will interfere with cognitive or motor devel­

able to examine (more than 20 000 until now), C1

opments later on (Miller and Clarren 2000).

moves toward the convexity in side bending of the

Head control is situated very early on in this

head. This is counter-intuitive at first sight, but

chain of events, which is one reason why the long­

even in adults this pattern can be found, albeit in

term consequences of its malfunctioning are so

only a few cases (Jirout 1990). Even with a condy­

far-reaching. This is also the primary reason why

lar angle which is much less accentuated as in

we should check and treat even minor signs of

adults, the 'logical' movement pattern would be to

asymmetry of the posture or form of the head:

recede to the concave side (see Chapter 18).

they may not look very impressive at that stage,

As this is not the case we have to ask what

but they can cause a derailment of the kinesiologic

might be the reason for this pattern. For the time

development and thus necessitate much more

being, one can only offer an educated guess: dur­

extensive treatment in later years.

ing the first year the influence of gravity on the

Kinematic imbalances lead to behavioral and

cervical spine is much less pronounced than after

morphological asymmetries. 'Symmetric individ­

verticalization. The sensitivity of the newborn's

uals appear to have quantifiable and evolution­

spinal cord to mechanical irritation was brought

ary significant advantages over their asymmetric

to attention by some recent publications (Geddes

counterparts' (Moller and Swaddle 1997). We

et al 2001a, 2001 b). In the light of these facts it is

found signs of asymmetry and KISS in the new­

safe to say that the risk of injury to these structures

born period of 72% of the schoolchildren we saw

is commonly underestimated. Taking into account

(and treated successfully) for headaches, postural

this fragility, the paradoxical behavior of the cer­

and behavioral problems. The seeds of problems

vical spine makes sense. Moving the atlas to the

which surfaced at age 8 or 10 could be traced

'high' side of side-bending leaves more space for

back to KISS symptoms before verticalization, i.e.

the intraluminal structures and minimizes their

during the first year (see Chapter 25). This is the

side-bending. We were able to verify in a large

main reason why it is necessary to have a vigilant

number of our radiographs that the condylar

attitude

angle is much shallower during the first year (see

asymmetry in this first stage of neuromotor

Chapter 8), thus allowing this movement.

development.

Copyrighted Material

towards

minor

signs

of

functional

The KISS syndrome: symptoms and signs

Even successfully treated babies continue to

complications. Having traced back a lot of school­

carry the imprint of their initial asymmetry with

children's problems to initial asymmetries of pos­

them. In times of exhaustion or after periods of

ture (Biedermann

rapid growth they will display the former asym­

one can attribute much more importance to them

In

than their unremarkable symptomatology initially

most cases, these symptoms subside sponta­

suggests. Asymmetry in posture and cranial con­

if the

figuration are a symptom, a sign calling our atten­

metrical posture again, at least temporarily. neously and no treatment is necessary. Only

1996,

Miller and Clarren

1959),

asymmetry persists for more than a few days

tion to the underlying condition that might be

should one intervene therapeutically.

triggering it. By focusing on this prime mover we can successfully treat functional and morphologi­ cal asymmetry as well.

EVALUATING ASYMMETRY

When we began treating small children we did not draw a sharp line between different types of

It is very difficult to draw a strict line between

asymmetry; anything not symmetrical was con­

It was only after

'normal' asymmetry and its pathological variant.

sidered to be of the same kind.

For structures connected to sensory input, sym­

having seen enough cases that we were able to

metry is more than an embellishment: most of

distinguish between two types of asymmetry, one

the information has to be related to a three­

primarily located in the frontal plane - i.e. scoli­

dimensional

otic posture - the other in the sagittal plane - i.e.

analysis of

its

origin

and here

symmetry of the supporting structure simplifies

hyperextension or ophistotonic posture. This led

processing.

to the distinction between KISS

Strong

asymmetry necessitates

a

higher level of 'input-correction' and is therefore an evolutionary disadvantage. According to Fur­

I (fixed lateral

posture) and KISS II (fixed retroflexion). These two types of asymmetry can occur sepa­

'fluctuating asymmetry could

rately or together. The most common type combines

account for almost all heritable sources of vari­

a markedly scoliotic posture with a retroflexion

low et al

(1997),

IQ'. This is but one hint of the impor­

component . Again this does not necessarily mean

tance of asymmetry as a marker or cause of other

that this represents the majority of treatable cases,

more fundamental problems. The impairment of

only the most easily perceptible and thus diagnos­

sensorimotor development in KISS children seems

able clinical picture.

ability in

We see an interesting development in most of

to point to the same conclusions. Complete symmetry is empty, dead (Landau

the contacts between us and pediatricians: the ini­

A person or object needs a certain amount

tial group of babies sent to us represent a fairly

of symmetry to be considered beautiful, but the

'typical' collection of little patients with a 'classi­

1989).

I). After having seen the

addition of a little bit of asymmetry can really

cal' C-scoliosis (i.e. KISS

make us like what we see (Swaddle and Cuthill

effects of treatment on these children, our col­

1995). Strong asymmetry on the other hand is seen 'sick' (Parson 1990). Between these two extremes the ideal has to be fOlmd by intuition -

leagues are more aware of other signs connected

as

to the KISS syndrome but less obviously cervico­ genic at first sight.

or trial and error. A comprehensive treatment of

These babies are then referred to us based on

symmetry and its evolutionary role can be found

the less 'obvious' symptoms, but more specifi­

in Moller and Swaddle

cally. It is less the screening for asymmetries than

(1997).

One does not need to treat asymmetry in babies

for

the

secondary

symptomatology

which

as such. However, the timely treatment to achieve a

becomes the dominant feature in the collabora­

symmetrical posture and morphology goes a long

tion. These colleagues send babies with 'colic',

way to preventing both current problems and later

cry-babies

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or

children

who

have

problems

291

292

MAKING SENSE OF IT ALL

also a bit asymmetrical, but

congenital muscular torticollis remains a mystery

this asymmetry is not such as to make the mother

despite intensive investigation' is a commonly

go to the pediatrician or make the latter think

held view; like Davids et al (1993) most authors

about referring the baby for manual therapy. It is

still put the blame on the trauma to the sternoclei­

swallowing; they are

not exaggerating to say that these babies - suffering

domastoid muscle (Slate et al 1993, Suzuki et al

from KISS II related problems - have a more rele­

1984) - the most visible symptom was thought to

vant functional disorder than the

KISS I cases.

be the cause.

We have to be alert to the range of problems

At least in the early phases the shortened and

originating from the malfunctioning of the cervi­

thick sternocleidomastoid muscle is so prominent

cal spine and the abnormal form of the cranium

that it is a 'natural' culprit. Late cases of infantile

before we can recognize its therapeutic potential.

torticollis often show a fibrosis of the sternoclei­

The postural asymmetry and its morphological

domastoid (Kraus et a11986, Ljung et aI1989). The

repercussions attract our attention to the cervical

two

symptomatology, but the taxonomic frame is

hematoma results in later fibrosis .

essential to be able to spot the problem. 'Words and

taxonomies

often

facts

were

then

easily combined:

early

Our experiences lead to different conclusions.

exert a tyranny over

There is no direct and linear connection between

thoughts. If you have neither a term nor a cate­

the initial hematoma and a late fibrosis. Children

gory for something, you may not be able to see it

with an initial hematoma do not have a greater

- no matter how largely or evidently it looms'

chance of developing a late fibrosis than new­

(Steven Jay Gould 1997) .

berns without a palpable tumor of the sternoclei­ domastoid. The connection between the two phenomena is much more intricate than such a

'MUSCULAR TORTICOLLIS' AND KISS I

linear concept suggests. The sternocleidomastoid is a co-victim of the underlying trauma to the

Asynunetry in newborn babies is a well-known

articular structures of the cervical spine and as

problem, and one which is often considered benign

such, it is not a good starting point for therapy or

and disappearing spontaneously if left alone for

analysis. It is far better used as an indicator of the

long enough. It is certainly true that we have to be

improvement brought about by other therapeutic

patient in the first days and weeks. After having

measures, as correct therapy of the suboccipital

passed through the birth channel, a realignment of

joints results in an alignment of the muscular

the asymmetrical cranial bones and a resorption of

tonus of the sternocleidomastoid.

soft-tissue edemas and/or hematomas takes time.

There is a controversy about how to react to a

An initially asymmetrical posture should be noted

fixed or asymmetrical posture in newborn babies.

and observed, not more nor less.

Some consider this a 'physiological scoliosis' and

If this asymmetry persists after 3-4 weeks, or

think it wears off without treatment (Bratt and

additional symptoms appear, it is advisable to

Menelaus

check if the range of movement of the head is

papers stress the importance of asymmetries in

impaired. This restricted movement is in most

perception and posture for the development of

1992,

Kamieth 1988).

More recent

cases a sign for a protective immobilization of the

more severe consequences later on (Keesen et al

upper cervical spine. For a long time this was

1993). Asymmetry is frequently found in testing

linked to a malfunction of the sternocleidomastoid

newborns (Groot 1993, Rbnnqvist 1995) and its

muscle, leading to the common diagnosis of 'mus­

clinical significance has to be carefully examined

cular torticollis' (Binder et al 1987, Entel and Car­

(Buchmann and Bulow 1989). Seifert (1975) pub­

olan 1997, Porter and Blount 1995, Robin 1996,

lished data from unselected groups of newborn

Tom et al 1987, Vojta et al 1983). 'The etiology of

babies where she found that more than 10% of

Copyrighted Material

The K I S S sy n d r o m e : symptoms and sig n s

them showed signs of asyrrunetry in the function­ ing of the upper cervical spine. In preparation for a study on MTC in newborns we examined a neonatal care unit and checked the 1-3-day-old babies for signs of impaired movement of the head or pressure hypersensibility at the neck. More than half of those examined showed one or both signs and it quickly became clear that such an early intervention would not be useful. As more than three-quarters of these babies recover sponta­ neously, a standard examination and treatment at such an early point in time cannot be recommended. If there are other signs warranting examination and eventual treatment, such as breastfeeding problems or colic, the situation is different. In these cases we can examine and try to help. Nobody advocates a treatment schedule where all these initially asymmetrical babies have to be treated routinely, but these babies should be re­ examined later on and treated if the functional deficit has not subsided spontaneously after 4-6 weeks. We would propose taking a large margin, especially as MTC is a low-risk procedure, quite uncomplicated and does not have to be repeated more than once or twice. Anything improving the symmetry of sensory input early on can only exert

Figure 24.3

a positive influence on the further development of the child. Keessen et al (1993) show that the accuracy of the proprioception of the upper limb is reduced in cases with idiopathic scoliosis and spinal asymme­ try. As we know that the proprioception of the arms depends heavily on a functioning suboccipi­ tal region (Hassenstein 1987), functional deficits in this region should be corrected as soon as possible. As is often seen in the history of medical knowl­ edge, our frame of reference changed over time: already in 1727 Nicolas Andry de BOisregard, who coined the word 'orthopedics', had mentioned the treatment of torticollis as one important field of this new discipline (Andry de Boisregard 1741). In going back to the roots we understand that good posture in children was at the forefront of orthope­ dic diagnostics and treatment: Ortho-Pedics 'rightening the young' was so important for Andry that he used this concept as the definition of the medical procedures he published in his book. This fundamental underpinning of the new discipline was lost in later centuries and Andry's eminently functional approach had to make way for the mechanistic paradigms which have dominated orthopedics in the last decades.

Two KISS babies

with their cranial asymmetries

.

Both pictures were taken by the parents and are reproduced here with their friendly permission They .

s h ow in both cases a right-convex

KISS situa t i o n with the accompanying cranial scoliosis, microsomy of the left side of the face, fla tt eni n g of the right occipital region an d a seemingly asymmetrical pos i t i o nin g of the ears. All these mor phological asymmetries need many months to subside. The i mportant sign at the check-up 3 weeks after the initial treatment is the free movement of the cervical spine.

Copyrighted Material

293

294

MAK I N G S EN S E OF IT ALL

PLA G IOCEPHALY A N D KIS S II

Influencing the morphology through treatment of the functional disorders takes time, the more so

if

Unilateral flattening of the head is an almost

the intended change affects osseous structures. The

II. The

cranial asymmetries are a good example of that.

inevitable symptom in children with KISS

amount of asymmetry can be quite remarkable

While we see changes in w1ilateral facial microso­

and it is understandable that parents are worried

mia in weeks, the same change on the occipital side

about this. In recent years we have seen more and

takes months. The facial asymmetry is primarily

more clinics advising parents to use helmets or

located in the soft tissue and seems to be controlled

bands to correct this (Aliberti et al

2002, Clarren et 1997, Teichgraeber et al 2002),

by asymmetrical activity of the ganglion stellatum.

while other authors stress that this treatment of

the soft tissue turgor and act relatively quickly. On

al 1981, Draaisma

Here the changes in autonomic regulation influence

non-synostotic plagiocephaly does not offer a

the other hand, the osseous structures of the occipi­

marked

tal bones have to adapt their morphology to the

improvement

advice (Bridges et al

over

simple

handling

changes in the muscular structures attached to them

2002).

In order to come to a proper assessment of

an

and

this process is closely linked to the growth of

skull, a synostotic plagiocephaly

the skult which leads to a time frame of months, or

has to be excluded, as this is a clear indication for

even years, for the normalization of the skull's form.

asymmetrical

surgical treatment. But the synostotic form is very

It demands a lot of confidence on the part of the

(1999) found only 1 in 115

parents just to wait. The idea that doing too much

cases of plagiocephaly - so it is safe to assume that

might endanger the final result is difficult to

the sign of plagiocephaly

grasp, even more so when such

rare - Mulliken et al

should first and fore­

most be a motivation to look for other symptoms indicating a functional vertebrogenic disorder, i.e. One reason why many orthopedic specialists

invasive ther­

We have to make a clear distinction between asymmetry

in most cases KISS II.

an

apy is proposed by authoritative proponents. as

a

symptom

of an

underlying

functional deficit and a residual asymmetry where

have such problems with this approach may be

the functional base was successfully treated. We shall

found in the ingrained preference of our colleagues

come back to the problem of relapsing asymmetries

for redressement as a basic therapy

(see Chapter

Figure 24.4

(Fig. 24.4).

25).

A: Treatment of a

baby with scoliotic posture in the 1950s ( Mau and Gabe 1962). The basic idea of redressement is clearly visible. B: The physiotherapy accompany ing this bedding followed the same lines. Anal yz i ng the pi ctures of the physi otherapy with h i ndsight one sees that some of the procedures advocate manual therapy of the subocci pital structures - these parts of the therapy may have been the most effective.

B

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Especially after having seen the

295

The K I S S syndrome: symptoms and signs

Figure 24.5

A typical case of KISS II with flattened

occipital area. These asymmetries are easy to observe but difficult to document on photos.

sometimes dramatic improvements

of their children, to be very anxious when they encounter even a modest relap se Good counseling is very helpful in prev en tin g this kind of overreaction. the parents tend

.

COLIC One e x ample

of symptoms not readily attributed to functional disorders of the vertebra l spine is c olic (Fig 24.6). Through the obse rv at i ons of the parents we had the idea to check systematically if and how much we were able to relieve the suffer­ ings of 'cry-babies' (i.e. colic ) Initia lly quite a few of these small chi ldre n were referred to us for treatment of postu ral asymmetries only and the accompanying colic was not mentioned by the parents during our inte r views But in the ques ti onn aire we ask the parents to send b a ck to us 6 weeks after their visit they men­

Figure 24.6

Two examples of babies with colic. Most

infants with colic belong to the group of KISS II children. Overextension

(A)

and the sleeping position (8) are fairly

typical.

.

tioned that the babies were much calmer and slept

In recent years there have been more publica­ tions about the role of p hysiother a py or MTC in the treatment of colic (Klougart et al1989, Olafsdottir et a1200l, Wil berg et al1999). T he least we can state is that this approach is worth trying, as one treatment suffices to see if any effect can be obtained. The patho mechanis m linking a d i sorde r of the

better.

upper cervical spine and colic seems to be the

.

Later on we

found in a simple retrospective eval­ uation tha t up to 55% of those who said that inces sant crying was one of the main reasons their child ­

was presented in our consultation, registered

an

imp rovement of more than two-thirds in the week 24.2) (Biedermann 2000).

after treatment (Table

faulty regulatio n of the abdominal muscles.

Most symptoms were successfully treated by MTC sh owed a KISS II s ympt omato l ogy, i.e. forced retroflexion of the he ad and trunk, orofacial hypotoni a and problem s in co nnection with swallowing and excessive v omi t ing Several

babies where co lic

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­

.

29 6

M A K I N G S E N S E OF I T A L L

Ta b l e 2 4 . 2

Resu l ts

of treat m e n t ( i n te rviews w i t h p a r e n ts) ( B i e d e r m a n n

1 9 99)

(Ve ry) good res u l t after: Sympton

1 day

1 week

2 weeks

3 weeks

Improved

No cha nge

Tot a l

Torticol l i s

78

28

33

19

40

25

223

O p h isthotonos

10

6

5

7

12

5

45

Restless/crying Fixed sleepi n g posture

26

5

6

2

6

7

16

3

3

6

4

studies of specialized pediatric clinics hint at least that muscu lar imbalance plays a part in the etiol­ ogy (von Hofacker et al 1999), even if these auth ors reject the idea that MTC might be an effective tool in the trea tmen t . The basic trigger which makes pediatricians send the babies to a specialist in m an u al therapy is the hypersenSitivity of the neck region in combination with a restricted range of movement of the head. Those who have already observed the success of manual therapy in ca ses of colic or feeding problems are looking actively for these signs to help them decide if it is advisable to refer these babies to a specialist. Others find it easier to first look for signs of asymmetry before they take man­ ual therapy as a treatment option into account. In both cases, it helps to have the pattern of typical KISS complaints present, even if not all symptoms can be found in an individual case. Restlessness and excessive crying are symp­ toms which make quantitative measurements dif­ ficult. Even the inter-personal 'standards' may be d ifficult to evaluate. Wessel et al (1954) postulated an average of over 3 h i day for more than 5 days as a defi n i tion, similar to Brazelton (1962) . Zeskind and Barr (1997) remarked tha t cry-babies have a phona torily different crying pattern (see Geertsma and Hyams 1989, Hi.ilse 1998). Betke (1997) and Spock (1944) drew attention to the dif­ ferent course of the baby's crying during the first 3 mon ths with a maximum during the sixth week . Most crying happens in the afternoon or evening, regardless of whether the children are breastfed or not, or a re the firs t-born or came la ter (St James-Roberts and HaIil 1991).

52 33

These contradictory observations put pedia tri­ cians in an unenviable situation. They do not have much to offer to those parents who come with col­ icky children . Small wonder, then, tha t the most often used line is 'wait and see', and it is not sur­ prising that one of the frequently used arguments of pedia tricians is the well-known 'over-anxious mother ' . The corollary of this line of reasoning is the disturbed mother-child relationship, another popular catch-all for functional problems without an a ttribu table morphology. As in the case of colic, this approach is not very satisfactory, to say the least. It puts the blame on the mothers and weakens (or destroys) the confi­ dence between parents and doctor. Some a uthors consider this excessive crying as something 'physiological' as it subsides in most cases after the third month without specific inter­ vention (Betke 1975), a similar argument as is used for the scoliotic posture of the newborn in general (e.g. GJadel 1977) . Even if one concedes that the crying stops one day, Lucassen's argument holds: 'I am too impressed by the parental feelings of helplessness and hopelessness, by their sentiment of anger and fright, their idea that something is seriously wrong with their child to be able to leave them a lone with this essen tially sel f-limiting p roblem' (Lucassen 1999). Brazelton (1962) and Wessel (1954) are the main points of reference in the classic approach to colic. Quite a few diverse factors are accused of being at the root of the problem. Lucassen (1 999) sees a cow­ milk allergy as the root cause while von Hofacker et al ( 1 999) d ispu te this. The American Academy of Pedia trics ( 1 989) discouraged the use of

Copyrighted Material

The K I SS syn d rom e : symptoms a nd signs

milk fo r years and Bra z elton a lread y written in 1 962 that it was bes t 'to k eep nutritional advice as vague as possible'. The best a p pro ach to this problem i s t o t a ke th e comp la in ts of the parents seriously. If a mother says she thinks her chil d is unhappy, restless and cries too much - believe her. There are a few cases hydrolyzed baby's

far it seems

h ad

upper cervical spine.

where

an

overly concerned parent is the main

problem, but even in these cases, it help s more

to take these co mp l a ints seriously than to ridicule the worried mother. It may sometimes j ust be enough to s upp or t the insecure mother with one's empathy and w il lin g­ ness to listen to her. If it helps to prevent tu rnin g her fear into a self-fulfilling prophecy - so much the better !

When we listen ca refu l l y to the reports of the we encounter a lot of symptoms remin d i ng us of KISS . Often the children hate to be put to bed, and their mothers have to carry them in their arms till they fal l asleep. Only then can they try to pu t them down ca refu lly, always hoping they do not wake up suddenly. Once they are asleep these children are restless, mov ing around in the i r bed. They often assume a stereotypical posture, most l y with a forced retroflexion of the neck and a tilt to one side. They wake up several times, crying, and have to be taken out of the bed and into the arms of the parents

The symptoms compiled by

Munich speci a lizin g

a p e d iatr ic clinic in

in the treatment of these cry­

babies support this (von Hofacker et •

aI 1999):

hypotonia o f the trunk

•

(unilateral) muscular hypertonia of one extremity

•

shou lder re tr a ction

• •

By f a r the most imp ortant argument to examine tha t we fo und episodes of crying at an early age in many cases where the children came years later for prob­ lems of cervico-cephalgia or sensorimotor disor­ ders. In an almost id ent i ca l manner t he parents of these children report excessive crying, colic and fixed posture du r in g t h e first yea r In a small sample of 100 babies who were referred to us with the initial d i agnosis of 'exces­ sive crying', we came up with the following results (Biedermann 2000) : and treat these cry-babies lies in the fa c t

.

•

were - as with KISS in g ener a l (58 : 42) 63 parents reported i m pro v e m en t after our

•

treatment •

thi s improvement them

w a s arb itr a rily quanti fied by as 81 % (median 80%)

•

the time-lapse between treatment and improve­

•

the

ment

•

was 4 days (median 3 days) average per iod of excessive crying before treatment was 4 weeks the average duration per day was 3-5 hours.

This list of results suffers from all the weak­ nesses of a retrospective compilati on, but it shows a tendency that is repor te d from others active in the field, too, and should be a d equate as a base for a rigorous prospective study. Those p e diatrici a n s who are already aware of the possibilities of MTC now routinely check their cry-babies for symp­ toms of KlSS, especially KlSS II.

D I F F E R E N TIA L D I A G NOSIS

p os tu r a l asymmetries impaired p ost u r al control

•

non-ideal quality of the spontaneous movements

•

tendency

to p re mat u re v ertical iz a tion .

boys

over- re p resente d

­

parent to calm dow n.

obvious to think about checking the

and

non-optimal

The least one can say is tha t these symptoms make a functional disord er of the sensorimotor apparatus a prime suspect. And once we get that

Asymmetry

at least tempora rily - is very often child's dev elopm en t . If it was the only d i a gnostic criteria to filter out functional problems of the vertebral spine we would be in a d iffic ul t situation. Luckily we have an assortment of clues to rely on for a reasonably precise d i agno­ sis. Nevertheless it is only after having eva lua ted -

present d u rin g the

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297

298

M A K I N G S E N S E O F IT A L L

the ev entual result of a manip ulation that the rel­

in the case history or in the clinical examina tion

evance of functional disorders of the suboccip i tal

which point towards an origin of the p roblems

region for a given problem can be assessed . The

beyond the functional level, a neuro-pediatrician

threshold for intervention is rela tively low as

should be consul ted . In a recent publication we summarized the

there are no known risks as long a s the proper procedure is followed .

i tems necessitating further diagnostics as follows

One o f the most important diagnostic problems is the de tection of spinal tumors. The severity of these cases and the need for timely intervention a t trib u tes much more importance to their de tec­ tion than the rarity of their occurrence might sug­ gest (5 / 1 00 000, of these 1 0-20% in child ren; Obel and Jurik 1 99 1 ) . Some of the signs are q u i te spe­ cific, e . g .

(Biedermann and Koch 1 996): •

ina dequa te trauma

•

la te onset of symptoms

•

multiple treatmen ts before fi rst presentation

•

crescendo of complaints

•

'wrong' palpa tory findings.

protrusion of the optic disk or impair­

Thi s last i tem is by far the most important and

ment of the pyramidal trac t . Others are far less

in those cases where I had to diagnose a tumor i t

specific and can easily be confused with func­

w a s this 'wrong' feeling which alerted m e . This

a

tional p roblem s . Even speci a l i s ts no te tha t a

impression is d iffic u l t to describe; one has to

wrong initial diagnosiS is the rule and not the

examine many necks to calibrate one' s hands

exception (Ma tson and Ta chdj inan 1 963) .

finely enough in order to fil ter ou t these cases. In

Quite often the first symptoms tha t attract a tten­

two of them the main area of pain sensi tivity was

tion are secondary problems due to functional d is­

unusually low, in another case the sensitivity was

orders, i.e. a torticollis (Bussieres et al 1 994, Shafrir

so extreme tha t even after trying to palpate gently

and Kaufman 1 992, Visudhiphan et aI 1 982) . These

the hyperes thes ia persiste d . These three children

symp toms are identical to those caused by primary

were referred to a neuropedia trician and the pre­

vertebrogenic fac tors and may even improve a t

opera tive diagnosis was mainly based on MRI. In 1997 / 8 we asked for MRI scans in 12 cases (of

first. G u tmann p ub lished such a case of a young boy

he

trea ted

- in i tia l l y

s uccessfully - for

a total of 23 1 6 children examined ) . In two cases a

headaches and neck pain (Gutmann 1987) . After a

tumor was found (1 hemangioma, 1 astrocytoma).

complete remission

It has to be added that most of the children we see

the problems reappeared,

seemingly after a minor trauma, as happens quite

have already been examined by a pedia trician and

frequen tly. When the boy came back a third time -

the normal waiting period for

again a fter some minor knock on the head - G u t­

2-4 weeks. This filters o u t a ll those c ases where the

mann insisted, nevertheless, on an MRI, which

rapid deterioration necessita tes immediate action.

an

appo in tment is

In our aim to find the few cases with a serious

resulted in the diagnosis of a tumor. One caveat is a crescendo of symptoms: most

background we cannot rely on an initial trauma as

func tional disorders show a fla t curve of develop­

an

ment and are often tra ceable back to an initial

these cases where we had to diagnose a tumor in

tra uma. If the pain pa ttern or the amount of dys­

the end, an 'appropria te' trauma was reported .

exclu sion criterion against tu mor. In several of

function shows a rapid increase, further diagnostic

A second important group are cases with an

measures are necessary. A s much as conventional

inflamma tory componen t. This is q u i te rare d ur­

X-ray p l a tes of the cervical spine are essential for

ing the first year b u t gets much more relevant

the evaluation o f func tional disorders of the spine,

from the second year on. A typ ical problem of the

they do not furnish the necessary informa tion to

childhood years is Grisel's syndrome. This condi­

diagnose intramedullary tllinors . MRl scans are by

tion was first described in 1 830 (Mathern and

far the best method . As soon as we discover details

Batzdorf 1989) and is much more frequent in chil-

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T h e K I S S sy n d r o m e : sy m p t o m s a n d s i g n s

dren than in adults (Martinez-Lage et a l 2001, Okada et al 2002, Robinson and De Boer 1981, Watson-Jones 1932) . The diagnosis of Grisel's s yn d ro m e is often done in the context of an AARF (atlanto-axial rotary fi xa tion) (Kawabe et al 1 989, Roche et al 2001, Waegeneers et al 1997) which produces signs of a fixed torticollis. Here the case his t ory is most valuable, as these children have a compara tively short duration of co mpl a in ts , no s i gni fic an t signs of KISS-related p rob l ems prev i o u sl y a nd often a his tory of tonsilli tis or otorhinological trea tmen ts (S a muel et al 1995) . O th e r d ia g n oses are even ra rer a t that phase of the develo pm e n t One fact often overestima ted at that age is the role of strabismus. Before vertical­ ization, this does not cause any relevant torticollis. Afterwards it is sometimes difficult to d istingui sh between cause and effect, as pr op ri oce p tive prob­ lems of the neck can worsen a hete rotropy at least as much as vice versa. Strabismus is in any case not an absolute contraindication for MTC . These 'hard' differential diagnoses have to be k ep t in mind p er m ane n tly. But at the same time it has to be em ph as iz e d that they are exceedingly rare. We see more than 2000 babies every year and abo u t one or two of these cases su rface. Besides these cases of tumor or inflamma tion (Grisel's syndrome) there are 'soft' contraindica­ tions for MTC . This group comprises osseous mal­ fo rmatio n s (see C h ap te r 18), neuromuscular s ynd romes and the large group of cerebral and sp ina l palsy. In the next chapter, some of these are discussed in more detail. Box 24.2 lists the absol u te and rela tive contra­ indications for MTC in babies. .

T H E ' S PO N TA N EOU S S U B S I D I N G O F T H E SYM PTO M S ' - A Q U E STION O F T H E VI E W PO I N T

The disappearance o f any clinical p rob le m around the first b irthday is one of the strongest arguments

Box 24.2

Absol ute a n d re l a tive c o n t ra i n d i c a t i o n s

fo r MTC i n b a b i es Abso l u te contra i n d ications : •

tumor

•

i n fl a m m a t i o n ( e . g . G ri se l 's synd ro me)

•

extre m e h y p e rm o b i l i ty

•

extre m e osseo u s m a lform a t i o n

•

t ra u m a a n d i n sta b i l i ty

R e l a t i ve co ntra i n d i ca t i o n s : •

syn d ro m es associated w i t h h y p e r m o b i l i ty (e . g .

•

c e rvi ca l fu s i o n syn d ro m e ( K l i p p e l - Fe i l )

•

c u rre n t i nfect i o n , espec i a l l y n a so - b ro n c h i a l

•

a n y t re a t m e n t o f t h e n e c k d u r i n g t h e p rev i o u s

Down syn d ro m e)

1 -2 weeks

of the school of thought which still treats many KISS-associated symptoms as 'physiological', be it the fixed posture, the initial colic signs or the delayed motor development. The second and third years of a child can be quite normal even after such a d iffic ult first year. Those problems encountered later on - coordination weakness, headaches or h yper a ctivi ty - are ra rel y seen in connection with the earlier signs of autonomic dysregu l a tio n , asym­ metry and proble m a ti c motor development. One of the main motivations for proposing KISS as a classification tool is just this l ong te rm view of a p parently disjointed phenomena . We do treat babies to help the par e n ts with their sorrows about colic or sleeping problems, but the deeper motiv a tion is the knowledge o f those long-term proble m s apparently connected with KISS. Today we cannot be sure that it is enough to make the initial KISS symptoms disappear to avoid these la ter d ifficulties, and i t is unlikely t h a t we wil l be able to ve ri fy this conjecture in a rig id scientific manner. We would have to diagnose KISS in newborns a n d j u s t wait - an unrealistic proposal. We toyed with the idea of using the ( few) children whose parents did not want a tre a t­ ment. But these cases are far too few to serve as a valid group and it would not be a random s amp l e b u t a very skewed group .

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-

299

300

M AK I N G S E N S E OF IT ALL

So one da y we shall probably be ab le to use epi­

In KIDD (KISS-induced dysgnosia and dys­

demiological tools to render weight to this argu­

praxia) the sit u a tion is m ore complicated . No t

ment . In the meantime it seems safes t to tre a t

only are the p atien ts older - between 4 and 1 5

those children who f in d their w a y to a specialist in

years a ppro x ima tely - b u t the external infl uences

MTC and keep an eye open for s ub se q uent prob­

which complicate the clini cal and nosological pic­

lem s . At leas t the pa rents of these children a re

ture are multila yered and much less easy to

a l rea dy alerted to the p o tent i a l of vertebrogenic

decode tha n in KISS . The ne xt chapter deals with

dis orders ( and their simple reme dies), a fac t

wha t we know - and with the many exci ting

which speeds up the eventual diagnosis of such

'loose ends' we hold in our h ands .

problems . The cessation of an apparen t symp toma tology a round the first birthday is one of the reasons we propose a differentia tion be tween KISS ( till a t most the second birthday) and KIDD (from preschool age

till the end of adolescence (see Chapter 25). KISS happens during an ontological stage where the func tional problems and the ensuing pa th o l o gy can be described with reasonable p re cision (Box

Box 24. 3

1 - 2 m o n t h s : dys p h o r i a , brea stfeed i n g p rob l e m s, co l i c 3 - 4 m o n t h s : a sy m m etry d eve l o ps, e . g . u n i l a tera l reta rd a t i o n of h i p d eve l o p m e n t 5 - 9 m o n t h s : s i g n s o f a sym m etry a n d reta rd ed s e n s o r i m o t o r d eve l o p m e n t

24.3).

The main symp tom - fi xed and asymmetrical pos­ ture - is clear enough and the effects of MTC can be seen in days or weeks .

Ty p i c a l seq u e n ce of KISS- re l a ted

sy m ptoms

D u ri n g a l l th i s t i m e s l e e p i n g p ro b l e m s p l a y a n i m porta n t ro l e , b e i t d i fficu l t i e s i n p u tt i n g t h e ch i l d t o s l ee p o r freq u e n t a w a ke n i n g d u r i n g t h e n i g h t

Refe re n ces A l i b e r t i F, P i t t o re L, R u gg i er o C e t a l 2 0 0 2 T h e treatment of the p os i ti on a l p l a g i o ce p h a l y w i th a new

und Kle i nkinder. Man ue l l e Medizin 3 1 : 97-1 07

t h e rm o p l a s t i c orthotic device. Childs N e rv o us Sy s t e m 1 8 ( 6-7) : 33 7-339 A merica n

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N u tri tion : hypoa l l e rg eni c fo rmulas. Pedia trics 83 : 1 069-1 086 Andry de B O i sr e g a rd 1 741 N L' o r t hop e d i e ou l'art de p re v eni r e t d e c or r i g er dans les enfa n ts les difformi tes du co rp s . Vv Alix, Pa ris A nrig C A, Pl a u g he r G 1 998 Ped iatric chi ropractic. Wil l i a ms

& Wil kins, B a l ti more Betke K 1 997 Rezidivierendes B a u ch w e h b ei Kin dem und

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Buchmann L B ill o w B 1989 Asymm e t r i sche friih kin d l iche Kopfgelenksbeweglichkeit. Sp ring e r, B e r l i n

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Copyrighted Material

KIDD: KISS-induced dysgnosia and dyspraxia How functional vertebrogenic disorders influence the sensorimotor development of children H. Biedermann

FROM KISS TO KIDD CHAPTER CONTENTS From KISS to KIDD The

Gestalt problem

Since we first used the term KISS internally in our

303

office some 15 years ago, it quickly turned into a

304

Symptomatology of KIDD

handy shortcut to describe a vertebrogenic prob­

305

KIDD is an aggravating factor but rarely the structural source of a problem Headache as a lead symptom

306

307

Commonly proposed pathogenetic concepts

308

Advice for the case history

310

KIDD as one component in a complex situation

311

lem. Later on, when the acronym was used in communications with other colleagues, too, they sent children for treatment with the remark: another 'KISS kid'. This label- originally intended only for smaller children - underwent an almost inflationary usage and had to serve as a catch-all for any functional disorder of spinal origin. But too much usage renders such a concept use­ less. In the 1990s we differentiated between KISS I

and II on the basis of the main symptoms these two types display, i.e. fixed lateroflexion for KISS I and fixed retroflexion for KISS II. This differenti­ ation loses its meaning after verticalization, as the influence of the upright stance modifies the basic conditions to such an

extent that the fixed posture

is almost completely abandoned. 'After the first birthday the children (seem to) recover sponta­ neously' (von Adrian-Werbung 1977, Glade11977) - which is the main reason why many pediatri­ cians have difficulties considering a fixed posture during the first year as warranting

Copyrighted Material

therapy. Like 303

304

MAKING SENSE OF IT ALL

colic, this is thought of as 'self-limiting' and a 'wait and see' attitude is recommended.

•

On the other

side are those who

use an

approach usually characterized as 'holistic', i.e.

The more subtle diagnostic tools of recent years

trying to grasp the complexity of the patient's

and the epidemiological tools used in the search for

situation and ailments as a whole. The advan­

long-term effects have shown that the underlying

tage of this approach lies in its openness, which

assumption does not hold true any more. Some

usually offers alternative choices for under­

publications link early plagiocephaly to later

standing and eventual treatment.

school problems (Miller and Clarren others show similar

2000) and

findings for asymmetrical use

Both approaches are valid and have to be used

of the extremities during the first year (Handen et

appropriately. There are situations where the scien­

al 1997, HatwellI987).

tific approach leads to

a

quick and efficient treat­

And those looking closely enough realized that

ment - think of a bacteriological infection - and

the infants did not lose their asymmetry altogether.

there are occasions where the second approach

Parents reported that they observed a head tilt or a

offers a better base. A prime example of

difference

diffuse problems many parents of schoolchildren are

in

shoulder

height

intermittently,

this is the

Tom Sawyer give an idea

mostly when tl1e children were tired or some other

confronted with. Books like

stress occurred. But the 'simple' phenomenology

of the amount of energy in boy s of school age and

of KISS mostly disappeared and what was left

their problems dissipating it a hlmdred years ago,

showed some connection to the initial asymmetry,

and times are not kinder to these boys today.

but the range of symptoms was much wider and even less precise than at the infant stage.

So what we are dealing with is a complex situ­ ation, an interdependence of external influences

With the knowledge gained about the first year,

and the several phases of development children

and the normalization we were able to initiate by

undergo before reaching puberty (not that it gets

removing functional disorders, new light was

any better, then). Kuhnen describes some cases in

shed on the disabilities of older children. To put

her chapter (see Chapter

this diverse information into a viable concept we

pages gives a first clue about what to look for.

first have to step back a bit and look at the con­ ceptual level of the problem.

10) and reading these

To find an appropriate name for such a complex disorder was not easy. First and foremost it had to reflect the interdependence of cervical function disorder, perception problems and the ensuing

THE GESTALT PROBLEM

motor phenomena which are

in most cases what

parents and teachers recognize first. Diagnostic procedures use basically two para­ digms:

We decided to call this disorder KISS-induced dysgnosia and dyspraxia

(KIDD) to highlight the

importance of the upper cervical spine for •

a

On one side is the 'scientific' approach which

smooth functioning of perception (gnosis/gnosia)

tries to find one parameter to validate the diag­

and motor control (praxis/praxia). Needless to

nosis. This being an often impossible quest, one

say that these two cannot be separated - there is

settles for the minimal combination attainable.

no perception of any kind without at least a mini­

This adaptation of Occam's razor to the medical

mum of motor control and vice versa. But for all

reality has its charm: if we are able to give such

practical purposes the perception precedes the

a standard solution to our diagnostic problems,

efferent impulses. The fascinating discovery was

all our work as members of the healing profes­

that there was a common denominator for many

sion can be put to a test, quantified and com­

apparently diverse problems, once they were

pared with others .

looked at with this concept in mind.

Copyrighted Material

KIDD: KISS-induced dysgnosia and dyspraxia

about 'difficulties with other children'. Sleep

There is no 'hard' test in screening children for an eventual involvement of the cervical spine . The item list offered here is but a very global frame­

disorders. Very rarely headaches. •

First school years: the lack of

fine motor skills

comes to attention; drawing and writing are

work and - as often - almost too all-encompassing to be usable without some qualifying remarks. It is

difficult for the child and often refused. Global

important to keep in mind that there are some

motor skills are also lacking; these children

'first-rate'

or

attract (negative) attention because they cannot

motional asymmetry) and some items in the indi­

symptoms

(primarily

postural

sit still, and their poor coordination at sports

vidual case history (KISS-related problems during

makes them the butt of jokes - or they try to

the first year of life) that are in the foreground, but

cover up by playing

even these have to be complemented by other

Headaches are mentioned

supporting findings to make a firm diagnosis of

•

Pre-adolescence:

the 'clown' themselves. more frequently.

difficulties regarding social

KIDD. At the end of the day, it is the success of the

interaction are in the foreground. The pupils

ensuing manual therapy which delivers the con­

are described as being unable/unwilling to ful­

clusive evidence. Lewit (1988) called this the test

fil the requirements of school. Headache is

manipulation.

almost always mentioned. When these children are examined for the first time, we find a whole range of symptoms (see also

SYMPTOMATOLOGY OF KIDD

Chapter

The second to fourth years in the life of a child are

10):

•

imbalance of the muscular coordination with

functional disorders. The development of children

•

shortened hamstrings

at that age is so rapid and yet so variable that a

•

kyphotic posture with hyperlordosis of the cer­

rather uneventful seen from the viewpoint of

asymmetrical tonus of the postural muscles

clear-cut pathology is rarely seen. This does not

vical spine and hypotonus of the dorsal mus­

mean that such problems are completely absent,

cles of the thoracic area, often accompanied by

but they do not manifest themselves in a relevant way. Children are mostly at home or in the pro­

orofacial hypotonia •

scoliotic posture in sitting and/or standing

•

shoulders at different height

•

sacroiliac

position

tected atmosphere of a kindergarten and any non­ standard

behavior

is

attributed

to

external

influences. In our statistics this age group forms a dip as compared to the first year or the period after

the

joint

mobility asymmetrical often

•

balance tests insufficient and mostly asymmet­

•

insufficient coordination of vestibular input,

rical

fourth birthday. Deliberately over-simplifying the situation, we can compile the following scheme:

(51)

with asymmetry of leg rotation

e.g. standing with raised arms and closed eyes •

difficult

First year of life: the classic KISS symptoms of fixed lateroflexion or fixed retroflexion with the

•

acoustic orientation laborious; locating the

•

combination of arm and leg movements diffi­

source of an 'interesting' noise difficult

accompanying symptoms of dysphorIa, swal­ lowing problems and asymmetrical motor development.

cult, e.g. jumping-jack test

•

Second to fourth years: the 'silent' period, i.e.

•

fidgeting and restlessness, sometimes tics

not many obvious problems reported.

•

using eye control to compensate for lack of pro­

•

Fourth to sixth years: complaints about 'clumsi­

prioception, refusing to lie down supine, cling­

ness' or slow motor development; first remarks

ing with one hand to the examination table

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305

306

MAKING SENSE OF IT ALL

•

decompensation when the close range is invaded by the examiner; wild resistance against palpation.

It is important to distinguish between the basic personality of a child and these superimposed functional disturbances. Depending on the char­ acter frame of an individual, one chjld may react aggressively and become uninhibited and hyper­ active while another child reacts to the same dis­ turbances by withdrawing. There is no score, no single test, but a Gestalt - and we can train our clinical view to recognize this. The four most reliable items to look for in order to validate the assumption of a KIDD component are: •

•

•

•

a case history with the relevant KISS symptoms during the first year asymmetry of posture and movement during examination a sufficient number of symptoms from the list above the palpation of restricted movement and hypersensitivity to palpation in the suboccipital area.

If these four items can be found, it is almost always worth treating the functional impairment of the upper cervical spine (item four on the list) and then seeing if and how much the other symp­ toms react to this. The older the children are the more time should be allowed after the manipula­ tion before any other treatments are resumed. In many cases the family comes back for the check­ up 2-3 months later and the parents report that 'nothing changed'. When we examine the children we often find that the initial asymmetry of the posture or the balance problems are not detectable any more. Once we point that out to the parents, they reply by saying 'well, he can bicycle now' or 'in the last month she finally got her swimming medal' - thus acknowledging improvements in coordination not mentioned initially. Coming back 2-3 years later for a routine check-up, the

same parents quite often say that 'since the first meeting the entire development went into fast track', or something similar. It is thus important to document the initial sit­ uation as precisely as possible in order to detect these gradual improvements which the parents often do not see because they are confronted with their children every day. Sometimes it is the remark by a visiting aunt who sees her niece only rarely that opens the eyes of the parents to the progress made since our intervention.

KIDD IS AN AGGRAVATING FACTOR BUT RARELY THE STRUCTURAL SOURCE OF A PROBLEM Usually we tell parents that we do not treat dyslexia or ADHD or headache. We try to influence the prevailing conditions and in eliminating some of the irritation in a complex system we create the more stable background against which children are able to re-equilibrate their homeostasis. The same is true for migraine: if our treatment is successful, the frequency and strength of the attacks is significantly reduced but the migraine rarely disappears completely. For all practical pur­ poses, this suffices and the children and their fam­ ilies are content. Once we see KIDD as an additional stress factor and not as the prime mover it becomes clearer that there is no such thing as a 'KIDD test'. It is good news and bad news at the same time: if we find signs of asymmetry and functional impairment we can be sure that there is a KIDD component to the problem at hand - but we cannot be sure how much of it will change once we have treated these functional impairments. There are many approaches which link the group of conspicuous symptoms to sensorimotor disorders. The Blythes (wWw.inpp.org.uk) pro­ pose the model of 'perSistent primitive reflexes' as the reason for quite similar symptoms, Harold Levinson (www.levinsonmedical.com) has a sim-

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KIDD: KISS-induced dysgnosia and dyspraxia

ilar concept. A lot of exercise-based treatments

HEADACHE AS A LEAD SYMPTOM

show improvements when the children are tested afterwards, and this extends to the effect of learn­

In small children it is the torticollis which alerts

ing to play an instrument or singing as a means to

doctors and physiotherapists to the idea that man­

connect the motor sp he re and the perceptive

ual therapy might be

level.

have in almost every case other problems, too,

Many educational systems took advantage of

an

option. These children

which were not reported on the first occasion as

the intimate connection between motor capabili­

the family surmised

that 'there is anyway nothing

ties. Montessori, Orff, Steiner and other eminent

to be done about it'

quite comparable to the rest­

figures in this field proposed combinations of

lessness of the newborn baby which was not men­

music, exercise and handiwork to help children

tioned in the beginning.

-

overcome their school pro b lems . So there are many roads which lead to Rome, and the one advantage of our proposition is that it acts fast and it does not interfere with other attempts which

m ay

be used to complement it.

We often reconunend these additional therapies, adapting to the possibilities and needs of the indi­ vidual children. One child may need a re-education of the orofacial muscles by specialized physiothera­ peutic protocols (e.g. Padovan or Castillo-Morales). Others can use a combination of sport and remedial medicine, e.g. hippo therapy or speech therapy.

All

these methods can be used to attain the goal of nor­ mal fW1ction and development more easily, and in many cases we ask the specialists who take care of the children to decide when another session of manual therapy may be necessary. The reason why we propose starting with the examination and eventual treatment of the spinal system is that these problems can be dealt with fairly easily by

an

experienced specialist, and this

initial removal of vertebrogenic disorders facili­ tates (and in many cases makes possible) the ensu­ ing therapies. These therapies have

training as

their main component and need to be repeated often in order to lead to a lasting improvement. Manual therapy based on the KIDD concept, on the other han d, has the big advantage of being dis­

Figure 25.1

creet. In mos t cases a yearly follow-up of our

changed after he was treated at the upper cervical spine

A and B: This boy's facial expression

to relieve his headaches. When the mother sent me these

yOW1g patients is enough. In addition to Klihnen's chapter (see Chapter

10) we want to elaborate on one of the main symp­

pictures she wrote in the accompanying letter: 'His face became alive'. This new dimension of non-verbal communication will help him to develop his social skills.

toms which makes parents bring their children for

The orofacial hypotonia is still evident even after the

our treatment: headache.

treatment, albeit clearly attenuated.

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307

308

MAKING SENSE OF IT ALL

So headache functions as a catalyst to facilitate

Using these statistics as a base, every manual

the contact between the young patient and the

therapist or physiotherapist would have to with­

specialist in manual therapy. Adults often project

draw timidly from treating headaches. But never­

on the young ones their own experiences with

theless these are - independent of the 'exact'

headaches. How questionable this might be can­

diagnosis, which was handed out elsewhere -

not be discussed here; but we know that lumbago­

next to dizziness, one of the most successful areas

like complaints by children and juveniles are

of manual therapy. It is always a question of the

assimilated completely differently from the way

point of view . . .

adults deal with them. Children say, for example,

The child whose parents are classical migraine

'it's tickling' and mean: this palpation hurts (see

patients and who is complaining about headaches

Harbeck and Peterson

has a high chance of inheriting vaso-frailty. One

(1992) for comparison);

they say 'I have headaches' and mean 'my neck

should not lament fatalistically this fate and

feels sore'.

retreat to drug therapy, but should search for

So, instead of a clear-cut definition we are now faced with a vague description: complaints by schoolchildren, whereby the main complaint is located inside their head.

other - and more accessible - co-factors and try to eliminate them. Without neglecting the other causes or even downplaying them, it seems realistic to claim that vertebral factors are by far the leading cause.

Commonly proposed pathogenetic concepts

Maybe a dentist would say the same about dental factors, the nutritionist would point out the influ­ ences of food, the allergenic specialist his specialty;

When dealing with juvenile headaches generally­

all true and all are right. In the individual case the

in the same way as with adults - a mainly vaso­

simplest approach to the problem will be chosen.

genic/migraine model is favored:

'Vasomotor

Together with Gutmann we reported on the dif­

headache and migraine are frequent among chil­

ferent kinds of vertebrogenic headaches (Gut­

dren, the former considerably more frequent than

mann and Biedermann

the latter .. . usually it affects bright, often ambi­

represent the largest contingent of headaches, but

1984).

In our view, they

tious, at the same time sensitive and unbalanced

even initial success of the manual therapy should

children, not rarely with different manifestations

not block the view on intracranial problems

of a "neuropathic" resp. neuro-vegetative diathe­

behind them (Gutmann

sis' (Schulte et al

1987).

The term 'school-headache' coined by Gutmann

1992). Lance et al (1965) found, when evaluating 2000 patients at a clinic dealing with headaches, 5%

occurring among adolescents - the anteflexion­

'diseases of the cervical spinal column and the

headache. The triggering mechanism is the forward

(1968) was especially created for those headaches

sinuses, systemic and psychiatric disorders' - i.e.

bending during reading or writing in order to bring

the remainder after migraine

the viewing axis into an angle of

headaches

(53%)

and tension

90· to the docu­

(41 %) had been deducted. Similar sta­

ment.Today this request of the eyes to look straight

tistics can be found elsewhere (e.g. Chu and Shin­

onto something is widely ignored; most schools

nar

procure flat tables. The good old school-desk with

1992, DiMario 1992, Sillanpaa et al 1992). In

none of these works is any thought given to a cer­

its inclined writing surface would do more good

vicogenic factor, while Rabending and Quandt

for the posture and muscular balance of the pupils

(1982) at least accept 'radiation from myogelotic

than 'anatomically adapted' chairs. If this is not

or cervical postural stress or spondylitic develop­

taken into consideration the supportive structures

ments' as the second most important factor after

of the neck are overloaded and react with pain. The

vasomotor dystonias.

younger the children, the less they will complain of

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KIDD: KISS-induced dysgnosia and dyspraxia

pain and the most visible sign that something is

makes the complaints chronic when applied too

wrong may be a slumped posture, fidgeting or

early. Children are especially vulnerable to this

reduced attention span.

overload. One should not have any illusions about pro­

The anatomical correlate of this is the nodding movement at the suboccipital level, stretching the

tective possibilities when fastening seatbelts for

interspinal ligaments and the linea nuchae. These

children (or infants); the smaller the child the

structures cannot take much when it comes to

higher the risk of a massive injury of the cervical

bending and shearing, and certainly not over

spine. A blockage of the occipitocervical joint after a trauma is obligatory and often triggers

longer periods of time. If the antet1exion of the head does not happen

symptoms only after a long incubation period.

harmoniously, kinking stresses occur, which can

This is also the reason why other authors are

rarely be tolerated.

much more reluctant in judging the importance

When does such a situation arise?

of traumas in the genesis of cervical complaints

One cause can be found in variations of the

(Kamieth

1990).

18). This uneven anterior sur­

Lumbosacral asymmetries can be caused either

face prevents the slipping of the frontal bow of the

by true differences in leg length or by asymme­

dens (see Chapter

atlas during antet1exion. This is not as rare as it

tries in the transitional zone between lumbar

appears at first sight; those children already con­

spine and sacrum. In children, there is in most

spicuous during the postnatal period, and who

cases a functional component, too, e.g. SI joint

were not treated at their cervical spine, seem to be

blockage. Not

predestined for it.

asymmetries, but every case like this ought to be

Block vertebrae in the area of the upper cervical spine lead to a disturbed harmony in movement (see Chapter

every migraine is caused by statical

checked, especially if signs of a hypoplastic arcus dorsalis C1 can be found (see Chapter

18). Through radiological changes

18).

Restricted movement of the thorax, e.g. a sco­

among older patients, it can be observed how the

liosis there, can lead to additional stress on the

surrounding segments of movement react with

cervical spine, forcing it to do more than it

structural loosening on the additional burden of

should.

work, be it the osteochondrosis of the interverte­ bral disk or arthrosis of the vertebral joints. Most

One problem in schoolchildren is that the symp­ toms of vertebrogenic origin are so multifaceted. Flehmig sums up these children as follows

of the time these secondary symptoms are not yet

(Flehmig and Stem

visible among children. The constitutional hypermobility leads espe­ cially with adolescents to a situation where main­ taining a posture with the head bent forward exceeds the abilities of the passive support struc­ tures of the neck. In these children we often find an interspinal pain when palpitating between the processi spinosi. The unfavorable ratio between the weight of the head and mass of muscles as well as age-related increased mobility make children

198 6) :

•

poor impression of themselves

•

quickly frustrated and attempt to avoid new sit­

•

frequently late, forget easily

•

easily distracted, unable to concentrate on one

uations

topic. When comparing these descriptions with the criteria which Schulte et al

(1992), for example, use

and juveniles (girls even more than boys) vulnera­

as a baseline for children likely to develop vaso­

ble to it.

motor headaches, it is obvious how much these

Trauma - e.g. accidents with frontal crashing -

groups overlap each other; with this evidence we

can cause this scenario, too. Even well-intended

would see KlDD as the most probable background

physiotherapy (isometric exercises or similar)

irritation.

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309

310

MAKI NG SENSE OF IT ALL

ADVICE FOR THE CASE HISTORY

ing; activities at home are frequently linked with

Frequently the children's ability to provide infor­

with it the same stress for the cervical spine, and

mation

the classical picture of the 'pure school-headache'

fine-motor and bending forward, which brings is

underestimated;

especially

when

relatives start talking and attempt 'to cut a long

blurs (Fig.

25.2).

story short', a lot wiU be missed. It is preferable to

Often statical complaints can be interpreted

obtain a written report from the parents first and

better and hence the differentiation between true

then to inquire from the children themselves what

differences in length of legs (occurs only when

their complaints are. The parents can then be con­

standing or walking on horizontal ground, not for

sulted again for details of the early infancy.

example when hiking) and lumbar-sacral asym­

Especially important are details of the delivery,

metries (complaints also when sitting).

early kinetic development, eventual traumas and

The accompanying symptomatic is multifac­

naturally the family history. Often the first suspi­

eted and does not yield much: besides neck and back pain, dizziness or problems in coordination

cious moments are already showing up. Caution is required if the complaints have a

may also be reported ('he is constantly falling

crescendo character; if these are increasing con­

down'). In principle all kinds of headaches ought

tinuously during the observation period, they

to be investigated for a cervicogenic component;

indicate an intra-cerebral event. Also complaints

even if they are not dominant for the individual

that are occurring constantly and do not alter

case, the complaints are at least lessened and/or

much when changing positions, or according to

other therapies made easier

the time of day or stress, should be treated with

with manual therapy.

if they are treated

Other pathogenetic factors should not be neg­

caution. These days the typical ante-flexing-headache is

lected. Manual therapy is generally the least time­

not limited to school any more; one can speak as

consuming treatment and therefore ought to come

well of a 'Gameboy' headache, to name just one

first. But, depending on the examination, other

example. Space for outdoor playing is often lack-

sites have to be taken into account, too:

Figure 25.2

(A

and

B)

Subtle signs of postural

I

disorders as in these two examples should alert the pediatrician to consider the musculoskeletal system when examining an adolescent, even if the symptoms reported by the family are on another level.

A

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B

KIDD: KISS-induced dysgnosia and dyspraxia

•

palpating a tension of muscles used for chewing

In a pilot study at a school for children with

and of the inner lower jaw, it is obvious to con­

learning problems we were able to show that prac­

sult a dentist or orthodontist

tically all children with KISS items in the case his­

•

when encountering hypotonic muscles, one

tory gained from manual therapy (Biedennann

thinks of specific targeted physiotherapy

2001). During the discussions with the teachers

•

if we find hypersensitive and/or hypotonic

which preceded the treatment of the children, the

abdominal muscles, dietetic measures should

argument of those professionals was that most of

be considered.

the children came from dysfunctional families, or

Prime candidates for treatment are - even more than with adults - the two poles of the spine. The suboccipital area and the

51 joints interact func­

tionally and we advise focusing on the cervical spine, first. If a correlate can be found there - e.g. restriction of mobility - the treatment should start here. After this initial manipulation, one should wait for around 3 weeks. The younger the patient, the more important it is to keep this rest period. It is astonishing how many of the other symptoms will have disappeared spontaneously.

had documented neurological deficits - so how did we think we could help them? We pointed out that we were indeed unable to improve the alco­ holism of the father or the fact that the divorced parents were constantly quarreling, but that we did intend to improve on the sensorimotor equi­ librium of the children. The follow-up showed that the school results of these children did actu­ ally improve. The logical consequence is to immerse manual therapy for chl i dren already mentioned above) and to keep in mind how simple such an attempt is. The

KIDD AS ONE COMPONENT IN A COMPLEX SITUATION

but it completes our therapeutic and diagnostic

The observations regarding headache should have shown how this 'established' indication for man­ ual therapy opened the possibilities to reach chil­ dren

whose

other

disorders

seemed

more

important for them, but nobody had considered manual therapy

an

KlDD concept does not claim to replace 12)

other approaches (see e.g. for ADS, Chapter

arsenal, thus giving all involved one more option to bring into play. And more often than not the improvement we can furnish motivates child and family to muster the energy for a more energetic push ahead.

option for their treatment.

References Biedermann H 2001 Manual therapy in children. In: Vernon

Gutmann G 1968 Schulkopfschmerz und Kopfhaltung. Ein

H (ed) The craniocervical synd ro me. Butterworths,

Beitrag zur Pathogenese des Anteflexions­

London, p 207-230

Kopfschmerzes und zur Mechanik der Kopfgelenke.

Chu M L, Shinnar S 1992 Headaches in children younger

than 7 years of age. Archives of Neurology 49:79-82 DiMario F J 1992 Ch i ld hood headaches: a school muse perspective. Clinical Pediatrics 31:279-282 Flehmig I, Stern L 1986 Kindesentwicklung und Lernverhalten. Child Development and Learning Behaviour. Fischer, Stuttgart Gladel W 1977 OberJegungen zur Spontanheilung der sogenannten Siiuglingsskoliose. Zeitschrift fur Orthopadie 115:633 Gutmann G 1987 Hirn tu mo r Atlasverschiebung und Liquordynamik. Manuelle Medizin 25:60--63

Zeitschrift fur Orthopadie und ihre Grenzgebiete 105:497-515

Gutmann G, Biedermann H 1984 Die Halswirbelsaule Part 2:

Allgemeine funktioneUe Pathologie und klinische

Syndrome. Fischer, Stuttgart Handen B L, Janosky J, M cAu liffe S 1997 Long-term follow-up of children with mental retardation/borderline intellectual functioning and ADHD. Journal of Abnormal Child Psychology 25(4):287-295 Harbeck C, Peterson L 1992 Elephants dancing in my head; a d evelopmental approach to children's concepts of specific pains. C hild D eve lopm ent 63:138-149

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311

312

MAKING SENSE OF IT ALL

Hatwell Y

1987 Motor and co gniti ve flU1ctions of the hand in infa nc y and childhood. International Journal of Behavioral Development 10:509-526 Kamieth H 1990 Das Schl eudert ra uma der Halswirbelsaule. WS in Forsch ung lU1d Praxis, Vol 111. Hippokrates, Stuttgart Lance J W, Curran D A, Anthony M 1965 Investigations into the mechanism and treatment of chronic headache. Medical Journal of Australia 2:909-914 Lewit K 1988 D is tu rbed balance due to lesions of the cranio-cervical junction . Journal of Or thoped ic Medicine 58-61 Miller R 1, Cl arre n S K 2000 Long-term developmental outcomes in p a ti ents with deformational plag iocephaly. Pediatrics 105(2):E26

Rab end ing G, Quandt J 1982 Kopfschmerz und Migrane. In: Quandt J, Sommer H (eds) Neurologie Grun dlage n und Klinik. Fischer, St u ttga rt Schulte F J, Spran g er J, Feer E 1992 Lehrbuch der KinderheilklU1de. Fischer, Stutt gart SiJlanp aa M, P iekk ala P, Kero P 1992 Prevalence of headache at p resch ool age in an lU1selected child population.

Cephalalgia 11:239-242 Adrian-WerblU1g H 1977 Beobachtungen an 108 Kindem mit Sauglingsskoliosen. Zeitschrift fUr Orthopadie 115:633-634

von

Copyrighted Material

Chapter

26

The family dimension How birth trauma and family history complement each other in facilitating functional vertebrogenic disorders il1 children H. Biedermann

Twelve years ago the etiology of KISS seemed to

CHAPTER CONTENTS

be clear: the entire problem was related to birth

The family way 314 KISS in the gene pool 315 Growth and development 318

trauma and the 'usual suspects' were all there: prolonged labor, breech position, extraction aids and twin pregnancies (Biedermann

1991). Time

and again we saw the same results when analyz­ ing our data (Biedermann while

another

1996, 1999). But mean­

puzzling

detail

came

to

our

attention: more and more often we saw the sib­ lings of the children we had treated - and they, too , had quite similar problems. In the beginning we attributed this to the fact that the parents involved had seen the effects of MTC and were therefore more prepared to think of vertebrogenic problems when dealing with whatever came their way. This notion certainly plays a part in the set-up, but contrary to that we noticed another little detail: we saw far more children of the same sex than those of the opposite sex. Had it only been an enhanced awareness on the part of the parents, this should not have played such a prominent role. In

an

ad-hoc compilation done between Sep­

tember and December 2002, we saw that Siblings of the same sex comprised

84% while a cross-over

(i.e. a sister coming after a brother had been or vice versa) occurred in only

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16% of the cases . 313

314

MAKING SENSE OF IT ALL

And it went even further than that. Almost

often one gets told that 'he had the same prob­

stereotypicaUy we are confronted with the question

lems', 'she was difficult with breast-feeding, too'

'do you treat adults, too?' - and when we say yes

or something in that vein. There are entire families

we get the panoply of problems of the parents. But

where it is known that they do not crawl before

here, again, a trend was perceptible: in the wake of

starting to walk or where certain movement pat­

the baby boy came the father, and after the little girl

terns reappear generation after generation.

was taken care of, the mother arrived with her migraine (Fig.

26.1). This trend was less pro­

nounced than in the siblings, but the ratio was by no means 50:50, more like one-third to two-thirds. What we are talking about here are trends,

In a family where there is a history of scoliosis

very carefully for an if we know that one mem­

we would screen the children asymmetrical posture;

ber of the family suffered from KISS-related prob­ lems we do the same.

impressions. It seems unlikely that there will ever be

Since we encourage this 'screening' by the par­

a database to test this hypothesis. But for all practical

ents and those in contact with the children - i.e.

purposes this does not matter too much. It is simply

kindergarten teachers, coaches or physiothera­

think about such a family trait when

pists - we see more children where the vertebral

worthwhile to

discussing functional disorders with the parents.

connection is not that obvious for the uninitiated.

As we ask for two adults to accompany the

Anybody whose sight is diminished tends to

infants we treat, we often see both parents. In

recognize people not only by their faces but by

quite a few cases, one of the parents cannot come

their gait and other movement patterns. These

and in these cases it is the grandparents who

people tell you that they sometimes have difficul­

accompany the young patients. If the 'right'

ties distinguishing between members of the same

grandparent is present we ask about the early

family as 'they walk alike'.

days of the father or mother, and it is striking how

Radiographs teU the same story: block verte­ brae are clustered in families and tend to stick to one sex (von Lanz and Wachsmuth 1955, Wacken­ heim

1975).

In the light of these insights we had to revise the

assertion made in the beginning: a birth trauma

and a genetic predisposition cooperate to produce KISS, and both aspects of this etiology combined give our diagnostic efforts a more solid base.

TH E FAMILY WAY Having said that, we tum to another dimension of the influence of family on the individual's health. Wolf and Bruhn

(1997) dedicated

an

entire mono­

graph to the influences that the family and social Figure 26.1

A fairly typical example of the 'family

dimension': after the little girl was successfully treated for her KISS-related problems, the mother came to have

environment have on the general health situation of an individual. Wilkinson applied epidemiological and statistical methods to do research on the level of

1996). These studies

her neck strain and headache examined. Both have a

entire societies (Wilkinson

similar facial asymmetry and the cross-bite of the

showed in convincing detail how much of the health

daughter should disappear in the following months.

and wellbeing of

Copyrighted Material

an

individual and even more so

The family dimension

of a child depends on the stability, warmth and

both of them. The results are sometimes astonish­

support of the inunediate and wider environment.

ing for all concerned.

Every day one encounters families where even an

outsider can feel the tension and 'bad vibes'

raging inside this little group. How much of the

KISS IN THE GENE POOL

jerkiness of the young adolescent, and how much of the migraine of the schoolchild is due to these factors, which are way beyond our influence?

Having got so far, one question arises: if there is a predisposition for KISS and if this predisposition

The very big and the very small - society and

is genetic - i .e. not induced by external factors

family - play important parts in determining the

such as living conditions - how come this short­

wellbeing of a child, and our contribution to that

coming was not weeded out by evolutionary pres­

wellbeing depends crucially on these external

sure? Or, to ask the other way round: what is the

factors.

positive side of this trait?

Some of these influences can at least be modified.

At first we thought that problems related to

A single child needs the contact in kindergarten

KISS were only apparent in our society of relative

or in

informal day-care group much more than

abundance. Deliberate search in other cultures

another one with several siblings; in town - and

demonstrated, however, that the torticollis neona­

an

even more so in high-rise apartment buildings - the

torum is by no means confined to industrialized

space for open play is much more restricted than in

societies. From the tikis of Polynesia, who display

a rural setting. We have to encourage the mothers to give their children a chance to play, even

if this

contains the risk of a few bruises once in a while. From primary school age on we encourage

the same symptoms (Fig.

26.2), to the baby mas­ (1976), exam­

sage in India described by Leboyer

ples abound to show that KISS is much older than the twentieth century.

sports and preferably sports together with the

Andry describes in detail the problems of the

6- or 8-

torticollis neonatorum and the amount of space

following judo or athletic

dedicated to this problem alone indicates that it

(in hav­

was important more than 250 years ago (Andry de

parents. It is much more reassuring for a year-old to be sporty

(in

courses) than to need constant treatment

ing to go to physiotherapy regularly). If the latter

Boisregard

1941).

is unavoidable it helps to try to 're-package' it as a thletics

or training, as well.

There are families - and certainly mothers where one look tells that they are already over­ stressed by their accumulation of responsibili­ ties. In these cases we have to take care not to further these stresses. In many other cases, it is advisable to design routines which integrate the parents into the therapy. This can be done by suggesting they do sport together with their child, or by asking them to join their child in out­ door activities. Certainly with hyperactive children, it helps to have the parents

draw up a weekly plan and look

at how many meals were taken together, how many hours of TV were noted and how many hours of 'quality time' their child had with one or

Figure 26.2

A Polynesian tiki. This photo from an art

fair shows a Polynesian amulet which allegedly displays a totemistic figure of a newborn baby with a tilted position of the head in order to protect against evil spirits.

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315

316

MAKING SENSE OF IT ALL

Our data and the research of others indicates that about a third of all newborn babies have reduced mobility of the head and cervical spine immediately after birth (Buchmann and BUlow

1983,

Giintiirkiin

2003,

Seifert

1975).

later this figure has reduced to about

Six weeks

10%.

After

simple remedies are used, such as changing the orientation of the bed relative to the window or favoring the other side for feeding the child, half of these infants return to a symmetrical posture and roughly

5%

of all infants need some form of

professional help. This is a sizable proportion. It should be noted that there is a distinction to be made between a postural preference and a fixed position. The former being a normal aspect of all infants, it is the latter which hinders neuro­ motor development and needs our attention. If a left-handed person writes about the bilateral

Figure 26.3

Fidgety Philip; the Struwwelpeter

( Hoffmann 1846)

contained an entire collection of

stories about 'difficult' children. It was published a hundred and fifty years ago by a medical doctor working

in a lunatic asylum. He hadn't yet heard of ADD ...

organization of the brain and its consequences, one can be sure that he will find some positive things to

fellow-sufferers - as I did with my son, who has

say - besides all the well-known facts of increased

inherited the same 'talents' and was delivered

mental disorders and all the accidents we left-han­

with the help of a vacuum extractor. The insight

ders seem to be so much more prone to than right­

of somebody who knows these problems from

handers (Goldberg

first-hand experience is helpful in getting a

2001).

A similar situation is true for the 'KISSed'. If one finds ample evidence in one's CV that fits the

feeling for the intrica te problems of children with KISS.

KISS pattern, it seems natural to look for the posi­

Most of what follows here is speculative. Even

tive side of it all. In the preparation of this book

though it is based on the many thousand young

Ramirez (see Chapter were

5) and I found out that we

fellow-sufferers in this regard:

clumsy

youths with a fear of heights, lots of problems with sports and other 'mechanical' activities - but

ones we saw during the last decades we do not have the rigorous protocol to be able to offer more than presumptions. The genetic makeup predisposing for KISS

nevertheless a reasonably successful journey

seems to contain

through life.

tisms and a difficulty in relegating acquired micro­

an

inability to develop automa­

The KISS predisposition does not entail long­

patterns to the subconscious level. The negative

term difficulties per se, which is one reason why

side of this phenomenon is that these patterns are

its effects on sensorimotor development took so

close to conscious control and have to be activated

long to decipher. As the above-mentioned mem­

at will, i.e. not automatically. This enables the bear­

bers of the author team of this book proudly

ers of these traits on the other hand to re-examine

assert, there is life bey ond KISS even without

these automatisms and improve them.

specific treatment. But, looking back at my own

Secondly, there is something one could call the

unhappy times in the gym or on the dance-floor

'Wilma Rudolph effect' - the famous sprinter who

(not to mention the terrible challenge of stair­

overcame a crippling polio infection to become a

I would go to

top athlete. Some KISS kids bite through their

great lengths to alleviate the fate of my young

obstacles, and, having got to the other side of that

cases, ladders or balustrades),

Copyrighted Material

The family dimension

challenge, they have a better control of this part of

chopharmaceuticals to their inherited genetic

their sensorimotor apparatus.

makeup.

This phenomenon is quite common in actors or

Let us get back to the problem of the left­

meas­

handed. Boys are over-represented in the KISS col­

musicians, too (and politicians, for good

for a KISS kid to be

ure). Like Demosthenes - who fought his stam­

lective, and it is more likely

mering by exercising his speech with a pebble in

left-handed, so it seems an interesting point of

his mouth - those with a challenge grow on it

departure to find out if there are other problems

while they fight it - if they succeed .

with the same profile. There we arrive at the 'ter­

But this positive line of events rests on a few

rain minee' of ADD. It is true that ADD - if ever

assumptions. The families and the school environ­

we accept it as a valid diagnosis at all - is found

ment have to be supportive to help the affected

predominantly in boys and that left-handed boys

children tackle the difficulties of their predisposi­

seem to be even more predisposed (Golderg 2001). Many publications about ADD and similar condi­

tion. As with dyslexic children, it would help a lot if

tions (MCD, POS, etc.) stress the fact that the

chil­

we were able to use the label 'attention deficit dis­

dren affected have problems with proprioception

order' (ADD) in a non-negative way. It is true that

and

these children are very often difficult to handle,

Faraone 1995, Shaywitz et aI1995). And, like KISS,

but it is equally true that they often display talents

ADD 'runs in families', i.e. a predisposing factor is

which we should not overlook. If we take into

very probable (Faraone et al1995, Schweitzer and

account how different the percentage of children

Sulzer Azaroff 1995).

movement

control

(DeGrandpre

1999,

diagnosed with ADD is in populations with very

Schoolchildren with an initial diagnosis of

seems at least far­

ADD represent the bulk of our patients of that

fetched to attribute ADD solely to a genetic factor.

age group. And in a sizable proportion, the dis­

similar genetic makeup it

runs

appearance of the functional vertebrogenic prob­

counter to the fact that ADD is diagnosed with a

lem helps sufficiently for them to reach a higher

steeply increasing frequency, without any change

level of self-organization. It seems fruitless to

under­

discuss if the initial diagnosis was wrong or if

diagnosing would hardly suffice to explain an

manual therapy can indeed help to alleviate the

This

one-dimensional

explanation

also

in the underlying gene pool. Even gross

over 100-fold increase in the use of Ritalin during

symptoms of ADD in general. As far as our

the last decade in the USA alone.

patients are concerned the most precise indicator

If the proponents of a genetic factor in ADD

that an attempt with manual therapy should be

were correct, the question immediately arises why

made is the early history. If signs of functional

this allegedly very negative item in our heritage

disorders are to be found, a closer examination

was not weeded out by evolution a long time ago.

should follow and - even if the other indications

Careful studies showed time and again that even

are quite inconclusive - a test manipulation (Lewit)

lethal genetic factors bestow competitive advan­

should be tried.

ane­

In all these years we could not find the item to

mia protects in a heterozygous carrier against

predict the outcome of our therapy. There were

tages on their bearers: the gene for sickle-cell

malaria, and the gene for cystic fibrosis increases

children who fitted the picture perfectly, a fixed

resistance against typhoid fever. If we were to

position during the first y ear of life, colic and

and last but not least the 'right'

accept that there is such a thing as 'genetic pro­

sleeping problems,

gramming' for ADD, we have to do our best to

segmental findings with irritable trigger points,

understand the eventual advantages such a gene

and movement restrictions in the occipitocervical

might carry as 'collateral advantage' lest we pre­

region. Everything seemed to indicate that the

vent the adaptation of children treated with psy-

treatment would be a success and change the

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317

318

MAKING SENSE OF IT ALL

�--------:-

situation profoundly - but, alas, nothing remark­

As soon as we accept the paradigm of develop­

able happened. At the follow-up examination the

ment, the pathways of the input come under close

segmental restrictions proved to be absent, but the

scrutiny. From the first cell division after fertiliza­

behavior of our young patient had not changed a

tion the specific environment of the developing

bit. Here the functional hindrance on the vertebral

organism plays an important part in this process.

level was clearly present, but irrelevant.

T he simplistic notion of a rigid genetic program

On the other hand, we had children who were

unfolding almost automatically was elegantly

(1984) who remarked on

treated more or less haphazardly - for example

refuted by J.-P. Changeux

because another family member had to come.

the impossibility of determining the structure of

Some of them showed amazing reactions to man­

1011 cells of the central nervous system with 1015 30000genes present

ual therapy. After many similar experiences we

connections by means of the

tend to treat as soon as we find at least some signs

in the human genome. A lot of this complexity is

of early asymmetry, a reduced mobility of the cer­

left to chance and even identical twins develop dif­

vical spine and local trigger points.

ferent neuronal structures a long time before being

Contrary to pharmacotherapy in ADD, which normally does not influence long-term perform­

born. Slight influences

in

this initial phase are

amplified by the extreme sensitivity of the devel­

ance, schoolchildren who react positively to man­

oping sensorimotor apparatus, and a minute alter­

ual therapy show improvement in their reports,

ation of the input may result in a dramatically

and more often than not, these improvements last.

different path of development - or may be

So, although we cannot offer a wonder cure for

adjusted by the internal stabilizing factors.

ADD, we do have a sizeable group of children usu­

Once the primal influence of the environment

ally labeled as ADD whose response to manual

for the development of the newborn is established

therapy gives them a chance to get onto a new track

the question of how this environmental factor

if

exerts this influence becomes paramount. During

in their development. This chance is even greater

the child in question shows symptoms of KISS or

the intrauterine period, chemical stimuli - trans­

has a sibling who was treated for it.

mitted via the placenta - are in the foreground. Every mother can tell stories of how the child reacted to food during the pregnancy. Many other

GROWTH AND DEVELOPMENT

stimuli are transmitted via endocrine messengers, e.g. the mother's adrenaline or other stress factors.

Studying the early months of human develop­

But even in the uterus, external sensory stimuli

ment focuses the attention on the very special sit­

are capable of reaching the fetus, as extensive lit­

uation of the individual. As long as we live we

erature documents.

develop, but much more so in this first phase.

The sensory stimuli gain a much bigger influ­

Simply taking into account the rapidly increasing

ence after birth. Basic reactions to noise and light

body mass - an admittedly rough yardstick - one

are easy to accept for the amazed observer, but it is

has to determine how this process is organized.

�ven more startling to realize that newborn babies

On one hand there is the notion of growth, i.e.

are able to react in a coordinated way to the com­

augmentation of cell mass and cell number tightly

plex stimulus of a smiling face, even imitating the

regulated by genetic control with minimal exter­

facial movements presented to them a few hours

nal input . Maturation is a similar concept, indicat­

after birth (Kugiumutzakis

1988). Eye contact with

On the other hand

the care-giver is an essential ingredient for this

'development is not just more than growth - it is

communication and the quality of sustained eye

more than maturation, requiring constant negotia­

contact helps, for example, to transmit the sooth­

ing a slightly different path.

tion with the environment' (Konner

2002).

ing gestures of a mother (Trevarthen

Copyrighted Material

1979).

The family dimension

The 'hardwired' mechanisms which allow a

we have already mentioned how a tense muscular

newborn baby to recognize a face as something

tonus in the newborn baby can hinder bonding by

important and which supply at least a basic mean­

giving the mother the impression that the child

ing to facial movements form the base on which

rejects her - something we heard time and ag ai n ,

the newborn starts its learning process.

especially as a relieved remark after the

Besides the skin sensitivity and the primary

improve­

ment a manipulation was able to bring.

sentiment of being protected by close contact, it is

As we know now how the feedback of the

the acoustic and optic input channel which deter­

mother's encouragement facilitates the acquisition

al 1997, Gold­ 2003, Tessier et al 1998, Teuchert-Noodt and Dawirs 2001) we realize how even a minor inter­

mines the amount and quality of the external

of all complex capabilities (Cleary et

input of the rapidly differentiating neural system

stein et al

of the infant. Here the quality of the cervical system comes into play, as a proprioceptive organ and as

an

effec­

ference in this primal relation can have wide-rang­ ing consequences.

If we are only able to improve this

tor of head movements directing eyes and ears

bond a tiny bit by taking away the muscular tension

imagine that a source of

of the newborn - not to mention nerve-racking con­

towards a point of interest. It is easy to

difficulties in locating and fixating such

ditions like colic - we can ease the first steps into life

interest impede the social and motor learning and

of our young patients considerably.

References And ry de BOisregard N 1741 L'orthopedie ou l'art de prevenir et de corriger dans les enfants les difforrnites du corps. Vv Alix, Paris Biedermann H 1991 Kopfgelenk-induzierte Symmetriestiirungen bei Kleinkindern. Kinderarzt 22:1475-1482 Biedermann H 1996 KISS-Kinder. Enke, Stuttgart Biedermann H 1999 KISS-Kinder: eine katamnestische Untersuchung. In: BiedermaIU1 H (ed) Manualtherapie bei Kindem. Enke, Stuttgart, p 27-42 BuchmalU1 J, B ulow B 1983 FunktioneUe Kopfgelenksstiirungen bei Neugeborenen im Zusammenhang mit Lagereaktionsverhalten und Tonusasymmetrie. Manuelle Medizin 21 :59-62 Changeux J P 1984 L'homme neuronal. Fayard, Paris Cleary G M, Spinner S S, Gibson E et al. 1997 Skin-to-skin parental contact with fragile preterm infants. Journal of the American Osteopathic Association 97(8):457-460 DeGrandpre R 1999 Ritalin nation . W W Norton, New York Faraone S V, Biederman J, Chen W J et al 1995 Genetic heterogeneity in attention-deficit hyp erac ti v ity disorder (ADHD): gender, psychiatric comorbidity, and maternal ADHD. Journal of Abnormal Psychology 104(2):334--345 Goldberg E 2001 The executive brain. Oxford University Press, Oxford Goldstein M, King A, West M J 2003 Social interaction shapes babbling: Testing pa.raUels between b irdsong and speech. Proceedings of the National Academy of Sciences USA, 2003, online Guntiirkiin 0 2003 Human behaviour: Adult persistence of head-turning asymmetry. Nature 421(6924):711

Hoffmann H 1846 Der Struwwelpeter. Literarische Anstalt, Frankfurt/Main Konner M 2002 Weaving life's pattern. Nature 418:279 Kugiumutzakis G 1988 Neonatal imitation in th e intersubjective companion space. In: Braten S (ed) Intersubjective communication and emotion in early ontogeny. Cambridge University Press, Cambridge, p 63-88 Leboyer F 1976 Shantala, Lm Ar t traditionel: Ie massage des enfants. Seuil, Paris Schweitzer J B, Sulzer Azaroff B 1995 Self-control in boys with attention deficit hyperactivity disorder: effects of added stimulation and time. Journal of Child Psychology and Psychiatry 36:671-686 Seifert I 1975 Kopfgelenksblockierung bei Neugeborenen. RehabiJitacia, Prague (Suppl) 10:53--57 Shaywitz B A, Fletcher J M, Shaywitz S E 1995 Defining and classifying learning disabilities and attention­ deficit/hyperactivity disorder. Journal of Child Neurology 10 (Suppl):50-57 Shaywitz B A, Fletcher J M, Shaywitz S E 1997 Attention­ deficit/hyperactivity disorder. Advances in Pediatrics 44:331-367 Tessier R, Cristo M, Velez S et al 1998 Kangaroo mother care and the bonding hypothesiS. Pediatrics 102(2):e17 Teuchert-Noodt G, Dawirs R 2001 MalfLmctional reorganization in the developing limbo-frontal system in animals: Implications for human Psychoses? Zeitschrift fiir Neuropsychologie 12:8-14 Trevarthen C 1979 Communication and cooperation in early infancy : a description of primary intersubjectivity. In:

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319

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MAKING SENSE OF IT ALL

BuJlowa M (ed) Before speech. Cambridge University Press, Cambridge, p 321-372

inequality: Routledge, London

von Lanz T, Wachsmuth W 1955 Praktische Anatomie 1/2: Der Hals. Springe r, Berlin

Wolf S, Bruhn

JG

1997 The power of clan: the influence of

human relationships on heart disease. Transaction, New

Wackenheim A 1975 Roentgen d ia gn osis of the cranio­ vertebral region Spr inger Berlin .

Wilkinson R G 1996 Unhealthy societies: the afflictions of

Brunswick

,

Copyrighted Material

Cha�ter

27

--------�--�--��-- ----�----��--�-

Epilogue H. Biedermann

Science is the art of not fooling yourself

CHAPTER CONTENTS

R. Feynman

The two flavors of manual therapy Requirements for a new concept Windows of opportunity

324

Keep it straight and simple

324

322 323

Working in several European countries, I am acutely aware how much the cultural and political context one works in influences what can be achieved. Manual therapy has different flavors in different countries, being a domain of neurolo­ gists in the Czech Republic and of rheumatolo­ gists in Denmark. In Belgium and the Netherlands most of the work is done by specialized physio­ therapists, and in the USA, chiropractors and osteopaths are in the foreground. As diverse as the professionals who treat chil­ dren (and adults) are the techniques used. For the moment the trend in manual therapy is towards 'gentle' procedures, admittedly a little more time­ consuming, but often achieving the same results. The remarks of Lynn Pryor

(1988) about the dif­

ferent cultures of looking at healing and disease are as true for our specialty. It is true, too, that the social environment plays an enormously important role. Wilkinson convincingly that 'social, rather are

(1996) argued

than material factors

now the limiting component in the quality of life

in developed countries'. The Dutch cardiologist

Dunning gives a nice example of the ideal beauty: 'the tail,

thin and brown of today as contrast to the

pale, pudgy and plump of Rubens and Rembrandt' (Dunning

1990). We have to keep these big' frames

of reference in mind in order to put what we can do

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321

322

MAKING SENSE OF IT ALL

for our patients in realistic proportions to the

cine, whereas it is at best a subordinate thera­

cultural context, limiting and enabling our work.

peutic modality in manual therapy in children

These are the constraints of medical work or

(MTC). Insight into the dialectics of functional

rather healing in general. For manual therapy with

stimulation and the resulting morphology opens up new approaches to problems seemingly Lmre­

its functional approach, another difficulty arises.

lated to vertebrogenic disorders . •

THE TWO FLAVORS OF MANUAL THERAPY

Manual therapy is a specialty whose practition­ ers are to be found in private practices - and that is where most of the research pertaining to

T he special character of manual therapy can be

this field comes from. This causes a visceral

seen from two points of view, giving it two very

mistrust in those members of the healing pro­

different flavors. From inside out it is a wonder­

fessions who are accustomed to consider uni­

fully all-encompassing variant of the healing pro­

versities as the source of knowledge.

fessions, enabling those proficient in it to solve problems from fields as far away from each other

Universities are by definition institutions which

1998),

have to convey generally accepted wisdom on to

as otorhinology (vertigo, tinnitus) (Hulse

internal medicine (pseudo-angina pectoris, vege­

the next generation. This leaves just enough space

1963) or - to approach the

for gradual changes, incremental improvements

tative dystonia) (Kunert

on an idea commonly accepted as valid. To

main topics of this book - pediatrics. Seen from the outside, this very ability turns

embrace a new point of view these institutions

manual therapy into an unwelcome guest (to use

need a hard push, which in turn requires a lot of

the least unfriendly definition) of one's own field of

energy and persistence from those who want to

work. 'How dare those people claim to solve prob­

bring about such

lems which have been hounding us for many years',

a

change.

Far from pretending to offer a radically new

these specialists exclaim, branding those intruders

view we tried to show that manual therapy in chil­

as confidence tricksters lmable and/ or unwilling to

dren can look back on a long history. What is

use a rigorous and 'scientific' approach.

comparatively new (and one of the main points of

where chiropractors are not as

discussion) is the much broader perspective

prominently in the picture and therefore attract

which is applied nowadays, conceding a much

much less criticism, this discussion is waged

deeper and more far-reaching influence to appar­

well inside the medical profession. Especially in

ently 'minor ' functional problems.

In Europe,

Germany, those doctors busy with manual ther­

It is in this light that the subtle interpretation of

apy are firmly inside 'mainstream medicine' and

functional findings in X-rays acquires a new role

not considered so much part of

as indicators directing the clinician's attention

an

alternative cir­

towards

cuit as in the UK, for example. Two

factors contribute to this

situation -

viewed as a challenge or a nuisance

(again

vertebrogenic

pathology,

and

that

pathologies of (for example) persistent primitive reflexes (Goddard Blythe and Hyland

1998) are

reinterpreted as caused by functional disorders of

depending on the viewpoint):

the cervical spine. When we propose a functional •

Manual therapy, if seen as more

than a minor

level to many pathologies it is not to replace what­

functional

ever concept might prevail in a given context, but

pathology and stands as such in a certain con­

to complement it with another one in order to

tradiction to the mostly patho-morphological

open additional therapeutic avenues. As this goes

viewpoint of more traditional medicine. More­

beyond the 'commonly accepted practice' such a

over, drug treatment is central in internal medi-

new concept has to prove its value.

treatment

technique,

deals

with

Copyrighted Material

Epilogue

RE QUIRE ME NTS FOR A NEW CONCE PT

well-established concept this new approach has to offer enough g ood arguments to abandon our

In order to be accepted, such a new mode of e xpla­

habitual view. One of the most convincing points

nation has - first and foremost - to facili tate the

in such a discussion is the capabi li ty of

treatm ent of the pati ents in question (more) suc­

ory to integrate facts wh ich were until then

cessfully th a n others.

bey ond the scope of a given theoretical frame.

Without this first step

a

new the­

nobody will even bother to think about droppin g

This inclusion should flow n aturally from the

an entrench ed point of view. S econ d ly the success

basic framework of such

in da il y practice has to be used to construct

be convincing - what one would call el e g an ce ,

a

a new

theory in orde r to

Any new medical theory should offer us a tool

work ing model of what happens and why.

laudable quality of the scien­

leading to a better the r apy. To achieve this, a

tifi c consensus, A new concept, be it therapeutic or

newly proposed concept has to offer tools to pre­

diagnostic, has to fulfill some min imum condi­

dict developments on the basis of a given cl inica l

tions in order to merit broader acceptance (Ruse

situation and to spawn new diagnostic and thera­

Inertia is a very

1999), The more general a new proposal is, the bet­

peutic insights. This fertility of a new concept is in

ter it has to fulfill them to overcome th e force of

my view the most attractive compon ent .

Only if we feel that a new way of classification

habit. These basic re quirem ents can be subs umed

mousl y complex clinical re ality we are confronted

under three main h e a dings : •

gives us a more lucid descr i ption of the enor ­

internal coherence and external consistency

•

uni fi c atory power and elegance (si mpli ci ty)

•

predictive ac cur acy and ferti lity.

with every day, do we make the effort to leave

well-known models behind and e mbark on the acquisition of somethin g n ew. We hope to have demonstrated that this can be

Coherence: Ideas and concepts have a tendency

applied to ou r model. It helps to expla in 'old'

to wear out. In the be ginning, one is confronted

problems fr om a new v iewpoint ( lik e colic or

with a clear-cut structure, black or wh ite and with

'muscular' torticollis) and the ther apy derived

no loopholes. Almost any classification sooner or

from this concept is successful and effici ent . We

later suffers from the fact that new knowledge

are now at a point in time where the publ icat i on of

necessitates fudging its p r i nci p les to accom mo­

this book seemed the right thing to do.

date the im pl ications of the new knowledge. The

H not overdone, the model of

KISS an d

KIDD

more we get used to a concept the easier we accept

should help to ask new and interesti ng questions.

these e x cept ion s. But when star ting out with a

This in

new way to explain everything, we would not

under stand in g of the interdependence of (mal-)

tum should help us to further im p rove our

function and the mor phologica l differentiation in

accept this.

Consistency: If we are asked to accept a new

adolescence,

expl anation for a well-known pro bl e m, the least

'The mark of a healthy research field is tha t

we can ask for is that the (n ew) ex pl an ation offers

there is never a good time to write a book about it'

a consistent mode of i nter p retation of the facts,

(B e n gtson

includ in g - for good measure - those facts which

children, too, In the 3 years it took to write and

2003) - very true for manual therapy

in

we had to classify as 'untypical' or ' non-rele vant'

compile this book, quite a few deta ils were added

in orde r to make the commonly established t h eory

to our model and I am sure that in the time pass­

ing between the subm ission of this text and the

fit the practical situation. This leads to the next item , the unifi catory

If someone pro­

facts will be uncovered. This book is one stepping

poses a new v i ew on problems we handle with a

stone on our way, and the nicest compliment one

power one asks of

a

new concep t.

act ual pu blica tion of the book, more in t eresting

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323

324

MAKING SENSE OF IT ALL

could get is a lot of critical and constructive remarks. We can only learn from them and, as A. H. Knoll put it, 'The absence of a definite punch line is why I get up in the morning'.

therapies while mmmuzmg the time and effort invested.

KE E P IT STRAIGHT AND SIMPLE WINDOWS OF OPPORTUNITY

MTC's biggest distinction, compared to manual therapy in adults, is its excessive effectiveness at certain points in time. We know today that the maturation and differentiation of the central nerv­ ous system depends on the correct quantity and quality of the stimuli at certain pivotal 'critical periods'. Complex coordinative capabilities can best be acquired at rather narrow windows in time and depend crucially on the social interaction and the quality of the environment (Goldberg 2001, Goldstein et al 2003, Teuchert-Noodt and Dawirs 2001, Wolf and Bruhn 1997). A smoothly functioning craniocervical junction plays an important part in this. On a lower level, it enables the correlation of optical and vestibular information with the whole body, on a more com­ plex level - to give but one example - a tense baby in fixed retroflexion triggers a different emotional response from a care-giver than an infant that is able to cuddle into the arms of its mother. T hese two observations may hint at how com­ plex this interaction is. We do not yet know for sure how to define those phases in which the development of the child is especially sensitive. Our experience indicates that the first year up to verticalization is one of them. The patterns laid down by the interaction between genetic makeup and individual fate determine the sensorimotor development for years and decades similar to the influence of the intrauterine environment for the long-term development of the individual (Lopuhaa et al 2000, Roseboom et al 2001). A vast area of research lies in front of us, far too big for one team (and one lifetime). A deeper understanding of these long-term influences should help us to maximize the impact of our

Having worked with this KISS concept for more than 15 years now, we are convinced that this tax­ onomy improves our understanding of the func­ tional pathology of vertebrogenic origin. It helps get to grips with the astounding complexity of symptoms which dominate the clinical picture at a given moment, and it aids in predicting the likely outcome of our interventions, making the prepa­ rations for additional therapy easier. It is easy to be carried away by such a potent concept and we have to keep reminding ourselves that KISS and KIDD are but two factors in the life of a young child. For us they are very much in the center of atten­ tion, whereas the situation seen from the child's point of view may have other priorities. Apart from all the other diseases and medical problems, there is the entire environment of the child. A youngster in a functioning and supportive family can handle a lot more pressure than one who has to cope with quarreling parents, an unsafe neigh­ borhood and dire financial straits. Keeping these constraints in mind, it is good to know that MTC does not depend on any external factor to have a positive influence. In a little pilot study we checked the effect of MTC on neuroder­ matosis. The skin did indeed look better in all those cases where there were signs of functional vertebrogenic disorders - not because we were able to administer a specific treatment, but because the general stress level was lowered a lit­ tle bit. Schoolchildren in a class of children with learning difficulties improved after MTC if their case history showed signs of KISS at an early age - regardless of whether they were living in a happy or dysfunctional family. So, MTC functions sometimes like the 'magic bullet' and it is comprehensible that some begin to overestimate the therapeutic possibilities. Maybe

Copyrighted Material

Epilogue

it helps to remember how some management con­ sultants define KISS: 'Keep

it simple, stupid!'

of manual therapy in the treatment of children

With this cold shower for the over-eager we will close this book and hope that it

age some readers to try the amazing possibilities and adolescents.

will encoUf-

References disease after prenatal exposure to famine. Thorax

Bengtson S 2003 B eneath the great divide. Nature

423:481-482

55(7):555-561

Dunning A 1990 Uitersten Besch ouw in gen over menselijk Goddard Blythe S, Hyland D 1998 Screening for

H Holt, New York

neurological dysf tmct i on in the speci fi c learning

Roseboom T J, van der

difficulty child. Journal of Occupational Therapy

15(3):220-225 Ruse M 1999 M ystery of mysteries: is evolution a social

Press, Oxford Goldstein M, King A, West M J 2003 Social interaction

shapes babbling: Testing parallels between birdsong an d

speech Proceedings of the National Academy of Sciences .

construction? Harvard University Press, C ambridge,

MA Teuchert-Noodt G, Dawirs R 2001 Ma lfun ction al reorganization in the developing limbo-frontal system in

USA; online Kopfgelenkbereiches, In: Hulse M, Neuhuber W L, Wo lff H D (eds) Der kranio-zervikale Dbergang. Springer, Berlin, p 43-98 Kunert W 1963 Wirbelsaule und Innere Medizin. Enke, Stuttga rt

C et al 2001

fam ine 1944-45. Paediatric and Perinatal Epidemiology

61(10):459-464

Lopuh aa C E, Roseboom T J, Osmond C et al 2000

Meulen J H, Osmond

Adult survival after prenatal exposure to the Dutch

Goldberg E 2001 The executive brain. Oxford University

Hulse M 1998 Klinik der Funktionsstbrungen des

Payer L 1988 Medicine and culture. Varieties of treatment in the United States, England, West G ermany and France .

gedrag. Meulenhoff, Amsterdam

animals: implications for human p sychoses ? Zeitschrift

fur Neuropsychologie 12:8-14 Wilkinson R G 1996 U nhealthy societies: the afflictions of inequality. Routledge, London Wolf S, Bruhn J G 1997 The power of clan: the influence of human rela tions hips on heart d isease Transaction, New .

Brunswick

A topy, lung function, and obstructive airways

Copyrighted Material

325

Index

Notes. Page numbers in bold refer to figures

and tables. Abbreviations used

in the index are: ADD attention d e ficit disorder; CNS central nervous system; MTC

manual

=

ther apy in children; OC occipi tocervica I.

=

neonates,86

Basioccipital bone,18,21

Atlas

Bilirubin,hyperbiliTubinemia, 40

assimilation/occipitalization,16

neuromotor development,61-2

during birth,80,86,87

newborn cervical spine,87

functiona I disorders, 90-2

hypoplasia, 228-30, 231

respiratory, 190--3

and lumbosacral d isord er s, 228-9 AbdomiJ�al examination, 104,200

and orthodontic anomalies, 150,

A d aptive processes,motor behavior,

45-53 Agyria,36 Alcohol,fetal alcohol syndrome,40-1 Amines,50-1,282

relation, 147-8,150

arrested parturition,78,82

ossification,21, 245,246

babies with deflected he ad s,79,82

pre n a t al developm ent, 20--1,91

birthweight above 4000g, 94

also Atlanto-occipital joint Atlas-lumbar-femur (ALF) triad,229, see

231-2

Attention deficit disorder

Aneury s mal bone cyst, 246

Angle classification,jaw-teeth

Birth autonomic nervous sy stem,126, 127

151,153

Analytical approach to therapy,276 Anencephaly, 31-2,33

Biomechan.ics

dorsal arc closure,226--7 form variations, 228-32, 247

A

movement control, 59, 60 status marmoratus,39-40

126--31

=

=

Basal ganglia

ADD, 135, 136, 138-9

and a uto n omic nervous system,

breech deliveries,79,82,87,88,93-4

case studies, 117, 118,119,120, 121 differential diagnoses of disorders,

(ADD),

5,

133-42,267-9,317-18 Auditory ability tests,117 Autonomic nervous system

101,110--11 extremely rapid delivery, 78-9,93, 94 female pelvis,75--8

Annulus fibrosus,19,22

and craniofacial asymmetry, 146--7

history of research into,76--7,81

Antiepileptic drugs,41

infants, 125-31

intubation,94

Apophyseal rings,248 Assessment of children, 114-17 case studies, 117-22

and thoracic spine, 186,193, 194

Kristeller's maneuver, 79,80,92-3

A xillary suspension res po nse, 108

limb prolapse/presentation,95

Axis

newborn cervical spine,75, 80-2

differential diagnoses,102-8

during birth, 81,87

drawing tests, 168-9, 170

ossification,21-2, 245, 246, 247

biomechanics,87

Gestalt problem,304-5

prenatal d evelo pment, 20-1, 91

clinical features of injury, 89

KIDD,310-11

see also Dens

craniocervical

parents' questionnaires, 168, 168-9,

b lockages,91,92,

93,94-5 cran.iocervical transition zone,

288, 289

with suspected ADD, 133-{)

B

91-2

delivery mod e-inj ury relation, 88,

thoracic spine,197-200 treatment precautions,206 Asymmetry see Craniofacial asymnletry;

anatomy,85-6

KISS syndrome

Athetosis,walking automatism,106 Atlanto-occipital joint

Babkin reflex,106

91,92-3,94-5,96

Back surface, 3-D measurement,263-5

diagnosing injuries,89-90,110-11

Ballga me tests,114

functiona I biomechanka I

Ballistic movement, motor development,65,68-9

Copyrighted Material

disorders, 90-2 incidence of injuries, 87-8

327

328

INDEX

Birth (con/d)

cerebral lateral differentiation,

risk factors, 88-9, 92-5

32-5

occipitoposterior presentation, 87,

cortical differentiation, 36

birth injuries, 75,80--2,85--96, 110 craniofa c ia l asymmetry, 146, 147, 150-1,152, 153--4

double cortex syndrome, 36

cu rva tures, 22-3

post-term births, 95

d y sraphis m in brain, 31-2, 33, 41

debate about kinetics of, 290

premature, 94-5

early, 30--2

pressure forces, 79,80-1,92-3

encephalocele, 31-2

developmental abnormalities, 15--16, 2 49 diagn OSis of neuro l ogical disorders, 103, 110 hmction ,15

95

prolonged labor, 94

fetal alcohol syndrome, 40-1

r i sky interventions, 79-80,91,92-3 risky s ituations, 78-9,82,87,88-9,

fetal brain disr uption se que n ces, 33,37--40 forebrain,32-5

headaches, 308-9, 310

rotatory forces, 80,81-2, 87,88

h eterotop ia ,36, 42

KlDD

traction forces,79-80, 81,82, 86,87,

kernicterus,40

KISS see KISS syndrome

91,92,93-5

88,93

Bowing test, 116 Brachial plexus, 25

see

KJDD

l i ssencep ha ly,36

movement measurement, 26 7-9

maternal disease/medication,

movement pattern in Side -ben ding,

40-2

220--3,290

MTC information leaflets, 164-5,

Brady ca rdi a, 126, 127, 128-9,130-1

microcepha ly, 33,38, 42 micropolygyria, 36-7

Brain

mu lticys tic encephalopathy, 33, 39

and o rthodontic anomalies, 146, 147,

birth trauma, 81-2,89,93

central pattern generators, 47

circad ian rhytluns,46--7 developmental anomalie s

neural tube dysraphisms, 30-2, 33,41

see

neural tube fo rmat ion,30--1

Central nervous sy stem (CNS),

neuroblast differentiation, 35,36

development

neuroblast mi gration, 35--6,42

dopamin e rgic sy stem, 282

neuromotor,57-61, 62,69,70

laterality, 145

nuclear jaundi ce,40

motor skill development, 57-8,

pathological m y e linatio n,39--40

59-60,61,62,69,70

myelination, 60 as netvvork system, 276--7

Bra in stem

porencep ha l y, 33, 39 pos tna ta ll y identifiable anomalies,37--40

radiation exposure, 42

birth trauma, 81,82,88, 89,93 neuromotor development, 59, 60

rhythmic activity generation, 45--6,52,53

spinal dysraphism, 32,33

Breathing

orthodontic an oma li es, 150, 151, 153, 154

thoracic spine, 186, 190-3, 195--6,

status marmoratus, 39--40 teratogenetic determination period,29-30

differe ntial diagnosis of disorders

197

Bru gger sy ndrome, 195-6

of, 99-111,288 neuromodulators, 50-- 1 , 282 rhy thmic activity g enerati on, 45-53

c

Central pattern generators (CPGs),

46-8 Cajal-Retzius cells, 35--6 Calcification, intervertebral disks,

250

Cephalograms, 147, 1 48, 149 Cerebellum, motor control, 59, 60 Cerebral cortex

166, 167 150-1,152,153-4

ossifica tion of vertebrae, 21-2, 245--6,247

postnatal development, 21-3, 245--6,

247,319 prenatal development, 16--21,85--6, 91-2

radiology, 215, 235-42, 245

a. p. view analysiS, 219-24, 220--4 analysis of lateral view, 224-7, 22.'H;

form variations of atlas, 228-32,

247 f lmcti ona l in terpretations, 215--32

malformations, 228-32, 249 movement pattern in side-bending, 220-3 n or mal variants,

247-8

OC region in neonates,227-8

in orthodontic diagnosis, 147 posterior line measurement, 253

predenta I d i stan c e, 253--4 tra uma, 253--4 a nd th oracic

Carotid arteries, 25

dopaminergic sy stem, 282

anatomy, 188-9

Carotid sheath, 25

motor control,59, 60, 61

function-morphology r el ation,

Case history-taking, 101-2, 114, 198, 310--11 Case studies, 117-22, 139--42, 180-1, 267-9

Central nervous sy stem (CNS) c ircadi an

rhythms, 46-7,48-9

development, 12, 29--42,60-1, 318-19 agyria,36

anencep hal y, 31-2, 33

Cerebral palsy, 103, 106, 108,197 Cervical plexopathy, neonates, 81-2, 89,93

Cervical plexus, 24-5

187-8,191, 192

resp irati on, 191, 192

rib m obi liz a tion, 201 topography, 23-6

Cervical ribs, 15-16, 25

treatment effect delay, 207-8

Cervical spinal nerves,23-5

treatment precautions, 205-7

Ce rvical spine

treatment techniques, 208-11

and ADD, 133--42 autonomic nervous system in

infants, 125--3 1

Copyrighted Material

tvvin-peak phenomenon of therapy, 208

uncovertebral joint, 22

Index

Cervical sympathetic trunk, 25--6

Dentition, asymmetry, 145--55

cervical spine, 209

Cervico-occipital transitional reg i on, 16

animal experime nts, 146-7

C hange,co nce ptua l,322,323--4

clinical exa min at i o n, 147-9

C hondrifi cation centers, 248, 249

functional box model, 154-5

Circadi a n rhythms, 46--7,48-- 9

im portance of diagnosis,147

Cobb's a ngl e,260

KISS syndrome, 153--4

Exencephaly, 31-2

Cognition

or thodo ntic discrepancies, 147-9,

Extrapolati ons,282

attention deficit dis orde r, 136--7, 138, 139

ne urolog ica l disorders, 102, 103-8 with suspected ADD, 133-6 thoracic spine, 197-200

E yes

150--4 rad i ogra phic examination, 147

examination, 104-5

complexit y th eory,276--7

soft tissues, 149, 152-3,154

radiation protecti o n,241

and motor skills, 69-70

and Tietze s y ndr ome, 196

strabismus,299

Colic,295-7 Communication,163--4

information for pa re n ts, 164--8, 169-72 C om pl ex ity theory, 275--9,282

Eye-hand coord ina t i on,64-9

tolerance of, 147 Derm o myoto m e,18

Descartes, R, 4 Desk d esign, 170-1 Development paradigm, 318--19

F

Co mpu te d tomog rap hy,244, 254

Diabetes, maternal,41

Facial anom ali e s,34

Computers, posture at, 171

D iadoch okinesia exercise,115

Facial asymmetry see C rani o fac ia l

Conce ptu al c ha n ge,322, 323--4

Di agnostic m e tho d s

asymmetry

Conse nt to t hera py,209-10, 237-8

Gestalt p ro blem,304-5

Contraindications to MTC in b a bi es,

ne uro l o gical disorders,99-111

Family traits, 288,313-19

a pediatrician's view, 113-22

Fetal alco h o l syndro me,40-1

299 Cranial ne rves, examination,104-5,109 Craniocervical bloc k a ges, 91,92,93, 94-5, 167 Craniocervical transition zon e, 91-2

Craniofacial asymm et ry, 145--55 animal exp e ri m ents, 146--7 clinical examination, 147-9

Facial nerve, 105

Disease, as sys tem error,277 Diskitis,

Fetal brain d is ruptio n sequences,33,

251

37--40

Fetal d eve l o p ment see Em b ryofeta l

Dop a m ine,282

rh yt hmic motor activ ity,50-1

Fibromatosis colli, ultrasound, 244

Draw ing tests, 1 68-9, 170 Dynamic systems th eory, neuromotor

Finger-thumb test, 115

definition, 146

development, 58 Dys gnosia,KISS-induced see

im po rtance of diagn osis,147

Dyspraxia, eva I.uation of MTC, 114-22

KISS syndrome, 153--4,293,294

Folic acid d ef ic i ency,31,41

Football test, 114

KIDD

functional box model, 154-5

o rt h odon tic discrepancies, 147-9,

deve l opment

Double cortex sy ndro me,36

see also KIDD Dysraphisms,30-2,33, 41

Foot gras p reflex, 106 -

Forebrain, development, 32-5 Fo ur- quad rant s cales,pos ture,262-3 Func tional box model, orofacial

150--4

function, 154-5

orthopedic dis cre pancies, 149-54 radi ograpi c examination, 147

Functional examination see Examining

E

children

50ft tissue s,149, 152-3, 154

Functional ver te broge nic disorders

and Tietze syndro m e,196

Effect of t rea tm ent,delay, 207-8

case studies, 117-22

tolerance of, 147

E mb ry ofeta l de ve l opment

differential di agno siS,99-111, 288

Crawling, motor d eve l o pment, 101-2 Cricoid cartilage, 26 Cultural contexts,321-2 Curva tures,spinal

central nervous system, 29--42,60-1,

see KIDD KISS see KISS synd rome

motor skills, 60-1

pol i tical contexts,322

KlDD

Cob b s angle, 260

Enceph alocele,32

p ostn atal develop ment, 22-3

E ncep halopathy,multicystic,33, 39

scolios i s see Scoliosis

Ephrin,19

'

Cyclopia, 33, 34

Cytomegalovirus (CMV) infection, 4 1

D

Epil e psy,36, 41, 47 Erb- D uch e nn e palsy, 82,89,90, 110 Ev a l uation of MTC, 317-18 in atte ntion deficit disorder,133--42 autonomic nervous system effects, 125-31

Delta/Notch signaling pathway, 17,

18-19 Dens and headaches,309

ossification,22,245,246, 247

fam il y dimension, 313-19

ce rvi cal spine,16--21,85-6,91-2

318

a pediatrician's view, 117-22

ra diological, 227 Ewing 's sarcoma, 246 Examining children, 114-17, 206 case studies,117-22

Copyrighted Material

thoracic s pin e,185-202 Fused vertebrae, 16, 19-20,226

G Galant reaction, 106, 195 Genes e mb r yo l ogica l

dev elop ment

central nervous system, 30,35,36, 37-8 cervi cal spine, 16-17, 18-21

KlSS, 314,315--18 Gestalt p ro blem,304-5

329

330

INDEX

Glioma,nasal, 32

I nfr a h y oi d muscles, 25

birth trauma, 92, 288

Gon adal p rotection ,radio grap h y, 236,

Intel ligen ce,compl exity theor y,

clinical m a rke rs , 287

276-7

245

colic,295-7

Gr as p reflex, J 06

Intelligent body hyp othesis, 277-8

concept formulation, 287-9

Gr as ping b ehavi or, develop me nt,

r n tervertebral disks

differential diagnosis ,297-9

65-6,67 Gris el's sy n d rom e, 298-9

diskitis, 251

tests, 101, 103,104, 105, 106,107,

p ostnat a l de velop ment, 22, 250 p renatal de velo p m en t, 18,19-20,21 thoracic spi.ne,188,189-90, 201

H

J08,109

evaluating asy mme try, 291-2 family d i m e ns i on , 313, 314-18 function-morphology relation,188, 193-4,289-91

Half-center model, rh y thmi c motor

history of MTC, 5-6

J

importa n c e of intervening ,290--1

activity,5J Janda's traction reaction, 108

Head

examination, 103, 104,107-8 pos t u ra l asy mmetry, 145-55

Jaundice, nuc le ar, 40

Jaw-spine relation, 150

information l ea flets, 164-6 MRI of cranial a sy mmetry, 216 m usc u la r torti col l is,292-3

Headaches, 307-9,310

Jaw-teeth relation, 147-9, 150

orthopedics, 188

Heart rate, 126,127,128-9, 130-1

Jugular vein,25

orthopedic-orthodontic treatment,

and cra ni ofacial asymmetry, 146 Hemangiomas,252 Hemivertebrae, 249, 256

153--4

Jumping tests , 115, 116

p ed iatrician' s evaluation of MTC,

Heel-walk test, 115-16

113-22

K

plagiocephaly, 294-5

Heterotop ia, 36, 42

sagittal c on dy l ar angle, 221-3

HIO (hole in one) technigue, 211

Kernicterus, 40

as s ingl e factor,324

Hip dysplasia, 105 Hip j oin ts,and the atlas,228-9, 230 Histor ic al background

KJDD, 300,303-11

spontaneous s u b s id ing of

MTC, 1-7,322

symp toms, 299-300

and ADD, 137-9 as an aggravating factor, 306-7,311,

thoracic spine

anatom y, 189-90

324

obstetrics,76-7, 79, 81

Gestalt p roblem, 304-5

examination,197-8

post u re measurement, 259-60

head aches ,307-9,310

function-morphology relation,

History-taking, 101-2, 114, 198, 310-11

H ol isti c approach to d iagnosi s,304 H ol op rosencep hal y , 33 H orner 's sy ndrome,82, 89, 90 Hox genes,16, 20-- J H ydranen ce p ha ly,33, 37-9,41 Hy oid bone, 26 Hyperbili rubinemia, 40 Hyperthermia, maternal, 41

history of MTC, 6 history - ta king, 310-11

MTC iniormation leaflets, 166-8 symptomatology, 305-6 thor aci c spine, 189-90, 194, 197-8

K1SS I (fixed lateroflexion), 287-8,291 clinical markers, 287

differential diagnosis, 104, 106, 107, 108,110

186-8,191,192,193-4

sternal stress syn d rome, 195-6 Tietze sy nd rom e ,196 to KJDD from, 300,303-4 typi cal symptom seguence, 300 KISS-induced dy sgno sia and dysp r axia see KJDD Klippel- Fei l sy nd rome,15,249 Klumpke's palsy, 82, 89,90

muscular torticollis,292-3

Know l edge , limits of, 281-3

scoliosis, 186-8, 193

K y ph osis, 256-7, 257

thoracic spin e, 186-8, 191, 193,

idiopathic see Scheuermann's

195-6, 197---S

K1SS II (fixed retroflexion),287-8, 291

IIiosacral (IS) blo ck age

clinical markers,287

case stud y, 122

colic, 295-6, 297

di fferen tial dia gnosi s, 105, 108, 111

di fferential diag n osi s, 103, 104, 106,

M TC information leaflets, 167

see also Sacroiliac joint(s)

disease thoracic, 192--4, 195-7

L

107, 108, 110

MRJ of cranial asy mmetr y,216

Labor see Bir th

Imaging methods see R adio l o gy

plagiocephaly, 294-5

Landau reaction, 108

I n fections

sagittal con d yl a r angle, 221-3

Larynx, 26

maternal,41

sternal stress syndrome, 195

l asegu e test, 116

rad iologic al signs, 246,251

thoracic spine, 186,192, 193--4,195,

Lateral tilt maneuver, 100, 108 L eafle ts see Information leaflets

Inflamm.ation

Grisel's sy n d rome, 298-9 rad i olo gi ca l signs, 246,251 Infor mation leaflets,164-8, 169-71 radiography, 164-5,237-8

196

Tietze sy nd rome, 196 KISS syn d rome,285-300

and ADD, 133, 134--42,317-18 autonomic nerv ous sy stem , J 26-31

Copyrighted Material

Leg movement

traction reaction, 108 Vojta rea c ti on,108 Leukemia, 252

Index

L igament sy stem, sacroiliac, ] 76, 176

diagnosing neurological disorders,

Li ne- wal kin g test, 115

differential diagn O SiS, 99-111, 288

101-2

examination, 102,103-8

Lissencephaly,36

dynamiC systems theory, 58

medical hi story, 101-2

Lissencephaly ty p e 2,37

e mbr y o fetal, 60-1

observation, 102-3

Longus colli muscle, 25

environmental factors, 61-2

sensorimotor system t ests, ]07-8

Lumbar spine

e xaminati o n

tests of muscular tonus,105-7,

movement measurement, 267-9 muscular tonus,106

in MTC assessment,

e ye-hand coordination, 64-9

neonatal birth trauma, 88, 111

KlDD,306-7

radiology

myelination,60

and form variants of atlas,

228,

229,230,231-2

perception,62-4, 69-70 practice, 62

malforma tions,2 50 , 251

rh ythmic

Mo v e men t

projections required, 245

109

133-6

Neuromodulators complexity, 282 motor behavior, 46, 50-3 Neuromotor development,11-12,

a ctivity generation, 45--5 3

57-70,91-2

examination in MTC assessment,

radiation protection,236

documentation, 260, 266-9, 270

Scheuermann's disease, 257

examina tio n in children, 114-22,

tu mo rs, 252

starting manual therapy, 110-11

133-6

Neuropsychologica I examination,

133-6

examination in infants, 102-8, 109

and thoracic

ADD,133-6 Ne w bor n s see Neonates

anatomy, 188, 189, 190

measurement,260, 266-9, 270

Non-trivial manual therapy,276

function-morphology re lat i on,

neuromotor development,57-70

Nuclear jaundice,40

rhythm-generating networks,45--6,

Nucleus p ulpos u s, ] 9,22

187,188,191-2, 193-4

L umbosacral disorders,and the atlas,

47-8,49,50--2,53

Mult i c y stic encephalopathy, 33, 39

228-9,230

Lying position

Muscle dystrophy, Fu k uyama type,37

examination of infa nts,103,104

o

Muscle reflexes, 1 0 5 Muscular tonus,105-7, 109, 118

Ob liq u u s capitis muscle, 23

Lying positions, for treatme nt,211

Myelination,60

Observa t ion of children

Lymph a tic leukemia, 252

Myelocele, 32

neurological disorders, 102-3

Myelocystocele,32

thoracic spine,198

thoracic spine examination, 199-200

My otome, 18, 19

M

Occi pital nerve, 23--4 Occipitocervical (OC) blockage, 111 case studies, 122, 267-9

Magnetic resonance imaging

(MRJ),

N

headaches, 309

90,219,244-5,254,298 Manual the ra p y

in ch i ld ren (MTC),

definition, 2

Marbled state of basal gan glia,39--40 Marching test, 116

Occipitocervical (OC) jLmction,

Nasal glioma, 32 Neonates

radiology, 218-19, 227-8, 231 Orofacial asymmetry see Craniofacial a sy mm etry

cervical spine autonomic nervous system,125--6

OrthOdontic-orthopedic cooperation,

Maternal disease/medication, 40--2

birth injuries,75,80-2,85-96,110

Mechanical dyspnea syndrome, 195

movement patterns,290

Ossiculum terminaJe, 22, 245

muscular torticollis, 292-3

Ossification,cervical vertebrae, 21-2,

Medical history-taking, 101-2, 114,

198,310--11 Meningocele,32 Mesoderm, 16-17,18-20 Metastatic lesions,252 Microcephaly,33, 38, 42 Micropolygyria,36-7 Mind-body dualism, 4-5 Moire tomo g rap hy,260, 263 Moro reaction, 103, 103, 106 Motor develo pme n t,57-70,318-19 a fter infa ncy, 68-9 and au tonomic nervous system, 126 biomechanics,61-2

occipitocervical region,227-8 radiography, 227-8, 236-7 diagnOSing neurological disorders

in, 99-111 64-5,67

radiography,235-42 Network systems, comp le xity, 276-9, 282

Osteochondroma,252 Osteochondrosis,juvenile see Scheuermann's disease Osteoid-osteoma, 246, 252 Outcome evaluation,317-18 attention deficit disorder, 133-42 a pediatriCian's view,117-22

Neural networks,rhy thm- generat in g,

radiological,227

45-53

Neural tube,30

dysraphisms, 30--2,33, 41 Neu roblasts, 35--6,42

brain maturation,57-8, 60, 61,62,

Neurodermatosis,324

cognition,69-70

245-6,247 Osteoblastoma, 246, 252

neuromotor development, 61-2,

bir t h tra uma,9 1 -2 70

146,150--5

Neurofibromatosis, 255 Neurological disorders, central

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p Pacemaker properties, neuromodulators,51

Pachygyric mic rop ol y gy r ia ,37

JJ1

332

INDEX

Parents

n eu rom otor development,67-8

consent to t herapy,209-10,237-8

radiography, 239

fa mi ly dimensions of KISS, 314

th orac ic sp ine, 185-8, 192-4,195-7,

infor matio n for, 164-8, 169-72, 206

220--3

questionnaires , 168, 168-9, 288,289 treatment preca utio n s, 206, 207

Pregnancy

P at ient -t he rapi st rela ti on,4 Pa tte rn-generat ing ne ural net wo rks, P a tter n reco gni t ion,neuro m otor de vel opmen t,11-12,57-70

Pax ge nes,17, 18,19-20,21 Pelvis manual therapy, 173-84 anatomy, 173-{), 174,

175, 176

articular stress ana l ysis,176, 177

OC regi o n in neonates, 227-8 pos itioni ng the child,219-20,239-40

projec tions req u ir ed ,218,238-9,245

de velo pme n t see

Birth

medical hi story -t akin g, 101 Prenatal developm e nt central nervous system,29-42,60--l,

P eipe r-Isbert reaction,100

normal variants, 246, 247-8

orthodontics, 147

fet al deve lo pment see Prena tal labor and de livery

1 1 ,45-53

MTC evaluation, 227 neuro fib ro matos is, 255

199-200,202

Pre- Botz inge r co mp lex,47 Prec aution s in treatme nt, 205-7

radiogra p h y,164-5,235, 237-8

movement pattern in side-bending,

radiation prote c tio n,236-7,241,245 Sc he uer mann 's disease,257 scoliosis, 255-7,257

sources of er ro r,240--1 tec hniques,2 19-20,245

318

ce rvica l sp ine,16-21, 85-6,91 -2

use of information from,216-17

motor skills, 60--1

vertebral trauma, 246,253-4

Primitive reflexes,105,109 Proprioception

vertebral tu mo rs,252

Radiology, 215-32, 243-57

axes of mobi li ty, 177-8,177-80

and birth trauma, 91, 92

case studies,180--1

cranioce rv ical transition zone,91

points of diagnosis,178-80,180--1

KISS s yndro me,293

developmental ana tomy,245-6

pubic bones, 175-{),180,181-2,

neu romotor developm ent, 59-{)0

diagnOSing bi rth injuries, 90

183-4

rhythmi c activity generation,45-6, 48-9

symphysis, 182,183-4 maternal,d urin g birth,75-8

Protover te brae

radiology, and the atlas,228, 230,

P ub i c b ones

231-2 and tho ra c ic spine, 186,187, 192, 1 95-{) Perception,motor development,62-4,

see Somite s

i.nd ic a ti o ns ,243

inflammation, 246, 251 juvenile osteochond rosis, 257

anatomy, 175-{)

malformations, 228-32,246,249-50

articular stress anal ysi s,176

movemen t patterns, 265-9

manual t herapy,181-2, 183-4

normal variants, 246,247-8

points of d ia g nosis, 180,180--1

Phase-triangulation device,post ure

posture measu reme nt,262,263

Scheuermann's disease, 257 technjques, 243-5 use of information from,216-17

measurement,264-5,265, 266 Photodocumentation, posture,260,

Rad iography,conventional

infections,246,251

Push/pull t hera pies,278-9

69-70

conventional r a d i og raphy sec

Q

vertebral tumors, 246,252 Ras terst ereomet ry, 263,263-4

262

P hy sica l exa min a t i o n see Examining

Questionnaires, for pa re nts, 168,

c hildren

168-9,288,289

Re aching behavior,development,65-8

Rec i pro cal inhibition, rhy t hmi c mo to r act i vi ty, 51

Pit u itary gland,an ence ph al y,32 Plagioc ephaly,294-5

P l a teau pot en ti als,neuro m o d ula to rs,

Rectus capitis poster i or muscle,23

R

Reflex pat hways,state-dependency,

51

49,50

Political contexts for MTC, 321, 322

Radiation exposure, intrauterine, 42

Poly microgyria, 36-7

Rad i o gr a phy,conventional, 235--42,

Po ren cepha ly,

33, 39

Pos ture behavior,46,52,53

early ch.ildhood, 105-7,109,110

w alking,61-2

243--4

a.p. view analysis, 219-24, 220-4

adap tive prope rties of moto r

Reflexes

Researching manual thera p y, 2--4,

ALF triad, 229, 231-2 a nalys i s of lateral view, 224-7,225-{)

281-3,322,323--4

ex trapo lation s,282

and autonomic nervous system,126

choice of proj ec tio ns,218-19

Rese g mentation ,cervical spine, 18-20

Cobb's an gle,260

consent to, 237-8

Respiration

correlation with pathology,263,265

diskitis,251

craniofacial asymmetry, 145-55,196

form variations of at l as,228-32,247

docum ent ing,259-65,270

function a l analysis,217-32

e xa m inati on in children, 114-22

helpful environments for,241-2

examin at i o n in infa n ts, 102-8

information for p a rents, 164-5,235,

familial factors,316

KISS

see

KISS synd rome

measuring,259-65,270

MTC information leaflets, 169-71

237-8

kyphosis, 256-7, 257 Radiography, conventional malformations,228-32,246 ,249-50

Copyrighted Material

orthodontic anomalies, 150, 151, 153, 154 tho racic sp ine, 186,190--3,195-{),

197 Respi ratory rhythm, 47,50 Rhythmic activity genera ti on , 45-53 Ribs cerv ic al see Ce rv i ca l ribs development, 19

Index

mob il i za t i on t echni ques,201

medical history, 101-2

Subocc ipital nerve, 23

and the thoracic spine, 1 88, 189-91,

Vojta's reactions, 107-8

SubOCCipital trigger poin ts,116

patte rn gener ation, 11,45-53

Subtle therapies,277--8,279

Risk factors in MTC, 238

pa tte rn recognition , 11-12,57-70

Suc k ing reflex, 105--6

Robus t t herapies,277,278,279

pediatrician' s evaluation of MTC,

Sudden infant death syndrome

192,193,194,195,196,197,201

Romberg test,116

113-22

(SIDS), 110, 129

spinal memory, 277 Sensori motor disorders, and KfDD,

s

Sy mpath etic nervous system, thoracic

Serotonin, 50--1

during birth,77--8 manual therapy, 173-82

Shoving on buttocks, 101-2

articul ar stress ana lysis, 176,177 axes of mobility, 177-8, 177-80

Si t ting

case stud i es,180--1

observation of, 116, 199 sternal stress syndrome, 195--6

consent issues,237--8

Social environment,314--15,321-2,

Soft tissue techniques, 200 Somites

Scalenus muscles, 191,192,196

differentiati on,18-20 formation, 16--17

segmental identity, 20-1

(Shh) g ene,35

Scientific approach to diagnOSiS, 304

Sonic hedgehog

Scient ific consensus, changing, 322,

Sonic hedgehog (Shh) protein, 18,30

cervical spine de v el op m ent, 18-19, 21,245,246

thoracolum b ar ano m a l i es,250 Scoliosis, 257

T T4 (se rr atus anterior) syn d ro m e, 192 see De ntition

Teeth

Scheuermann's disease, 186, 196--7 ,

Sclerotomes

282

324

treatment p recauti ons,205-7

323-4

Systems, complex.ity theory, 276--9,

Sitting positions,for treatment, 209-11

in i nfants , 130--1,219

257

183--4

SyntheS is, th erape u tic a pproach, 276--7

kyphotic position , 192-3, 195--6

points of diagnosis, 178--80, 180--1

also Iliosacral (IS) bloc kage

S y mphysis, treatment of, 181, 182,

Shovin g on knees test, 115 Siblings,288,313

see

function, 192

Serratus anterior (T4) syndrome, 192

anatom� 173-6, 174, 175,176

Sa fety of MTC

Sup porting therapi es,6--7 Suprachiasmatic nucleus (SeN), 46--7

306--7

Sacroiliac joint(s)

Supine test, 116

sonoSens,266

Tera togene t i c determination period, 29-30

TherapiSt ' s role, 4 Th orac ic sp in e, 185-202 acute thoracic vertebra'! blockage, 194--5

Soul -body dualism, 4--5

anatomy, 188-90

Spast i city, 106,110

brea thing,186,190--3,195,197

Spina bifida

BrUgger sy ndrome, 195-6

at cerv i c al level, 16,19

and cerebral palsy, 197

neural t u be formation,30, 33

conseq uences of KISS II, 193-4

Cobb's a n gl e,260

Spina bifida occulta,32, 247

examination, 197-200

f unction-morp hology relation,

S p inal cord

function-morphology relation,

186--8, 193, 197

KISS synd rome,287,291,294

neonatal birth trauma,81-2,86, 87-90,110-11

186--8,191-2,193-4,197 kyphosis, 192--4, 195-6

measurement, 260,261,263-4

neuromoto r deve l op m ent,59,60

mecha ni ca l dyspn ea synd rom e, 195

and orthodontic anomalies,151-2,

rhy t m ic ac tivity generation, 45-6,

movement measurement, 267-9

155

h

47--8,50--2

neonatal birth trauma, 88, 111

radi ograph y,255--7,257

Spinal dys raphism,32,33

and orthodontics, 196

sternal stress syndrome,195--6

Spinal memory, 277

radiolo gy

Sea rch reflex, 105

Spinal shock, neonates,81

malformations,250,251

Segmen t al identity,20--1

Spin al tumors,246, 252, 298

projections required, 245

Se gmenta l p l ate, 16, 17, 18--19

Splenius muscle, 23

radiation p ro tection,236

Segm enta tion

S pondylos i s,256

Scheuermann ' s disease, 257

cervical spine development, 16--21

Spreng e l de formi ty,249

thoracolumbar anomalies,250

S tamping test, 115

rib mobilization techni q u e s,201

Semisplinalis muscle, 23

Standing positio ns, for treatment,211

and the ribs, 188,189-91, 192, 193,

Sensorimotor developmen t, 11-12,

S tand ing tests, 115,116, 199

318-19

Status marmoratus,39-40

tumors, 252

194, 195, 196, 197,201

Sc h euer mann ' s disease, 196--7,257

birth trauma, 91-2

S tepp ing reflex,61-2

scoliosis, 186--8,193, 197

cervical area, 12,15-27,91-2,319

S ternal stress sy n drome , 195--6

serra tus anterior syndrome, 192

Sternocleidomastoid muscle, 24,25,

soft tissue tec niques,200

autonomic nervous system, 125-31

104,292

h

sternal stress syn dro m e, 195--6

CNS an o mali es, 12,29-42

Strabismus,299

T4' 192

diagnOSis of neurological disorders

Suboccipital muscles, 23

therapy,200--2

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333

334

INDEX

Thoracic spine

(contd)

Trivial manual therapy,275

Ti etze syndrome, 196

Tumors, vertebral,246, 252, 298

vertebrae mobilization techniques,

Twin-peak phenomenon, 208

'

intervertebral disks, 251

u

mat ernal, embryofetopathy, 41

Virchow, R, 4

Thu mb - f in ger test, 115

Tietze synd rome, 196

253-4 Vertebral rumors, 246, 252, 298

Vi ral infection

201 Thorax, examination, 104 Thorburn s posture, 89

Vertebral trauma, ra di ol og y, 246,

Ultrasow1d,244

Viscera cord, 26

Timing of MTC, 324

movement patterns,265-9

Voj ta s reactions, 100, 107-8,109

Tiptoeing test, 115

posture measurement, 262, 263-4

von Ebner fissure, 18

Tongu e flex ib il ity, 1 1 7

Unco vertebral fissure,22

Toni c neck reflex, 106-7

Uncx4.1 gene, 19

Torticollis

Universities,conceptual change, Upper cervical spine see Cervical

299

spine

Wal ker- Wa rb urg s yndrom e, 37 Wal kin g

motor de ve lop men t, 61-2, 101-2

and ort hod onti c anomalies, 151, 152,

rhythm-generating n e two rks , 45-6,

155

t h o ra ci c sp in e, 189-90

w

322

familial dimension, 315 KISS s y n drome, 287, 288, 292-3,

'

v

47-8,49,50-2,53

Walking a u t omati sm , 106

ultrasound examination, 244

Traction reaction, 107-8

VACTERL association, 250

Weight shifting test,115

Trapezius muscle, 24, 25

Va gu s nerve, 25

Trauma

Ve rt ebral arte ri es , 23

Windows of opportunity, 324 Wl1t genes,18

mate rnal , em bry o f etopat h y,41

birth trauma,88

m e mory of, 278-9

SIDS, 110

vertebral headaches, 309 radiology,246, 253-4 Treatment effect delay, 207-8

Writ te n cons e nt t o t h e rapy, 237-8

Vertebral column see Ce rvical spine; Lum bar spine; Thoracic spine

y

Vertebral fusion, 16, 19-20, 226 Vertebral motion s egm en t , 20

Copyrighted Material

Yawning,obs erv a tion of, 117