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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
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ST LOU IS
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TORONTO
2004
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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
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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
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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
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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
Copyrighted Material
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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19
20
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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23
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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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
Copyrighted Material
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 .
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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
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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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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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49
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 '
.
'
Sca n d ina vica 1 1 8(3):229-239 Ayali
A, Johnson B R, Ha rris Wa rr ic k R M 1998 Do p amine -
modu l a tes g raded and spike- evok e d sy n a p t i c inhibition i n d epend e ntl y at single
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Chapter
6
--------�
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
57
58
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
Copyrighted Material
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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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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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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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
5
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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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
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J H, Jessell T M (eds) Princi ples of neural
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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
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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
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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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23 : 1 79-186 van der F i ts I B M, Kli p A W
J, van Eykern A, 1 999 Postural a d j u s t men t d uring sponta neous and goal- d irec ted arm movem ents in the first h a lf yea r of l ife . Behaviora l Bra in Resea rch 106:75-90 von Hofsten C 1980 Pred ictive re ac hing for moving obje c t s b y h um a n i nfants. J o u rna l of Experimen ta l Child Psychology 30:369-382 von Hofsten C 1982 Eye-hand coordina tion in the newborn. Developmenta l P sycho l o g y 18 :450-467 von Hofsten C 1983 C a t c h i n g ski l ls in infancy. J o u rn a l of Exper i m ent a l Psychology: H uma n Percep tion and Performance 9 :75-85 von Ho fsten C 1 989 M a s te r i n g re a c hing and grasping: The d evelo p me n t of manua l ski lls in in fa nc y. In: Wa l l a c e S A (ed) Pers pectives on the coord ina t ion of movement. North -Holland, Am sterd a m , p 223--258 von Hofs ten C 2002 On the d eve l op m e n t of percep tion and action. In: Val siner J K, Connolly J (eds) Handbook of develo p m enta l psychology. S a g e Publ ica tions, Lon don von Hofsten C, Lindhagen K 1979 Observa tions on the development of rea c hin g for movi ng objects. Journal of Expe rimenta l Child Psychol ogy 28:158-173 v o n Hofsten C, Ronnqv ist L 1988 Prep aration for grasping an object: A developmen ta l study. Journ a l of Hadders-Algra M
Experimenta l Psychology: Hu man Perce p t i on and
14:61 0--6 21 Q, Vi s h ton P, Sp e lk e E S 1994 P redi ct ive rea ching a nd head turning for partly occ l uded obj e c ts . In: Interna tional Con ference on Infant St u d i es, . Performa nce
von Hofsten C, Feng
Paris
von Hofsten C, Vishton P, Spelke E
S, Feng Q, Rosander K 1998 Pred ictive a c t ion in i nfa nc y : tra c ki ng a nd re a c hing for moving objects. C o gn i t i o n 67:255--285 von Hofsten C, Feng Q, Spel ke E S 2000 Obj e c t representa tion and p red i c tive a ction in infa n cy. Developmental Science 3: 1 93-205 White B L, Castle P, H e l d R 1964 Observa tions on the developme n t of visua lly gu id e d rea c hing . Chi ld Dev e l o p m ent 35:349-364 Wi l ke nin g F, Kri s t H 1 998 Enhvickl ung d e r Wahrn e h m ung und Psychomotorik. [ Perce p tu a l and motor devel opment] . In : Oerter R, M o n ta d a L (eds) Entwicklungspsych ologie, P s y c h o lo g i e Ve rlags- U n i o n : Weinheim
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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
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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-
Copyrighted Material
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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vacuum extraction. Singapore Medical Journal
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pregnancies. Archives of Pediatric and Adolescent
Govaert P et a11992 Traumatic neonatal intracranial
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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
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Hibbard B M et al1990 The obstetric forceps- are we using
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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
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Kopfgelenkbeweglichkeit von Kindem. Manuelle
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Cardozo L D et al1983 Should we abandon Kielland's
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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
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ventouse. British Journal of Obstetrics and Gynaecology
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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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Leijon 11980 Neurology and behaviour of newborn infants
of full term infants. Neuroradiology20:145-154 MacArthurC et al1991 Commentaries(Health after Childbirth) British Journal of Obstetrics and Gynaecology98:1193-1195
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Young
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Chapter
8
------�------�----�------------�----
�
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
Copyrighted Material
=
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
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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
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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
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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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187
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
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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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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
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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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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
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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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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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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
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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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215
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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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
Copyrighted Material
.
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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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.
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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
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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
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T h e K I S S s y n d r o m e : s y m ptoms an d s i g n s
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S K, S m i th 0 W, Han sen J W 1 9 8 1 H el m e t trea tment for p l a g i o ce p h a ly a n d c o n genti al m uscular t o r tic oll i s . Journal of Ped ia trics 1 :92-95 Davids J R, Wenger D R, Mubrak S J 1 993 Cong eni ta l m usc u l a r torticollis: sequela o f intra uterine or perinatal compartment s yn d ro me . Jou rnal of Pe di a tric Orth o p e d ics 1 3 : 1 41-147 Davies N 2000 C hiro p racti c pe d ia tr i c s . C h u rc hi l l C l a rren
Livingstone, Edinburgh
Draaisma
J
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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
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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.
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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
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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
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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),
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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:
Copyrighted Material
319
320
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
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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
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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
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Yawning,obs erv a tion of, 117