Classe des

maîtres« Master class »Lise Hestbaek PhD

Professeure-chercheure

Chantal Doucet DC MSc

Professeure-clinicienne

Faculty disclosure

• Relationships with commercial interests:

Nothing to disclose

• Disclosure of commercial support: none

• Potential for conflict of interest: none

How to communicate

– the balance between

unfounded claims and

nihilism.

Dr. W. Edwards Deming

Evidence Based Practice

Research evidence

A case report

What are you

drawing,

Tommy?

I am

drawing

God

Now listen, dear.

You can’t draw

God – nobody

knows what he

looks like

Soon they

will all kn

ow!

Striking the balance

Feeding issues

Infantile colic / Excessive crying

Asthma

Headache

Feeding issues

Predictors of

breastfeedin

g duration

Mother

s

factors

Baby’s

factors

Psychologic

al

Healthcar

e relatedSocio-

demographi

c

Breast-

feeding.

MSK

Cond.

Low

birth-

weight

Birth

trauma

Breech

presentatio

n

Pre-

maturity

MSK

Cond.

Red flags

Neurologica

l issues

MSK

conditions

Congenit

al

torticolis

TMJ joint

imbalance

Facial

asymetriesFractured

clavicle

Plagiocephal

y

Sucking

problems

Brachial

plexus

palsy

Grummer-Strawn (2008), Hauck (2010), Agboado (2010)

MSK factors: Breastfeeding barriers Congenital muscular torticollis (CMT)

Common MSK newborn

4 types :

SMT sternomastoid tumor

MT muscular torticollis

CMT postural , sterno mastoid imbalance

Positional torticollis

Red flag

Incidence : few days to 3 months 16%

Etiology : unclear

intrauterine malposition, infection, ischemia,

traumatic birth, compartment syndrome, post

natal positioning

Ferrance (2010), Stellwagen (2008), Haugen (2011) et Heidenreich (2018).

Why it’s important ?

Early detection is the key.

Older child , neck muscles become less elastic, gain better

head control and the responsiveness to conservative care

progessively decrease.

If untreated body of evidence short term and long term consequence

High risk developing plagiocephaly and facial asymetry

Developmental delay and achieve motor milestones later

Contracture and facial asymetry persist: dental and visual issues

Kaplan (2013) et Lee (2017)

What to do?

Broad range of non –surgical non-pharmacological interventions

modes : Evidence-based practice guidelines

Manual therapies

Infant positioning and handling

Exercices , active movement

Soft neck braces

Taping

Acupuncture

Multimodal approach

Haugen (2011), Kaplan (2013), Dunning (2014) et Kim ( 2016)

Literature suggest…

Specific health history factors :

age initial visit,

delivery history,

birth presentation,

breech = variables associated symptomresolution and duration of treatment

Examine activity and development:

little or no time in the prone position is a riskfactor

Prognosis factors :

age initiation of treatment,

severity,

intensity of intervention,

presence of comorbidities,

rate of change,

adherence to programming

First choice of intervention:

neck PROM,

trunk AROM,

symetrical movement,

environment adaptations,

parents education.

Some evidence:

KT,

microcurrent

Support :

reassessment for severe case

Type of CMT not a predictor for neurodevelopment delay ….further studiesneed to be done

Kaplan ( 2013) , Schertz (2013), Heidenreich (2018)

What’s your take?How would you approach this with your community?

Suggestion:

Parents:

Breast feeding is important for your child’s development. Problems

with breastfeeding can have many causes, some of which relate to

pain or decreased movement in the child’s neck. Your chiropractor

can examine your child and determine whether your child has neck

problems and if that is the case, help you solve them.

Medical community:

Congenital muscular torticollis can be a contributing factor to

breast feeding problems. The chiropractor will treat this by

fascilitation of neck movement, parent education and adaptation

of the environment

Infantile colic

Infantile colic?

Excessive crying

other

parents

muskulo-skeletal

cardio-vascular

neuro-logical

gastro-intestinal

nutrition

Chiropractic manipulative therapy?

Treatment of dysfunctions in the

musculoskeletal system

Infantile colic?

Excessivecrying

other

parents

muskulo-skeletal

cardio-vascular

neuro-logical

gastro-intestinal

nutrition

Evidence?

Dobson et al, Cochrane 2012

Risk? High-velocity, low-amplitude thrust (HVLA) SMT was applied in 10 of the 15 cases of

serious adverse events.

A preexisting but undetected underlying pathology was present in 8 of the 15 cases of

a serious adverse event

Three deaths were recorded, and 2 of these were in infants under 3 months of age who

had previously been healthy.

Todd A, J Man Physiol Ther 2014

No compensation claims reported in Denmark or Norway (2004-2014) for patients under

the age of 18.

Jevne J, Chir Man ther 2014

Alternatives?

Conventional medicine has manifestly failed to provide satisfactory treatment for

infantile colic.

Other treatments with some evidence of effectiveness are hypoallergenic diet, soy

milk, reduced stimulation and herbal tea; the quality of the evidence is however

generally poor

Underwood M, Int J Clin Pract 2009

What’s your take?How would you approach this with your community?

Asthma What’s up ?

Most common chronic disease of

childhood

6 million in USA, 13 % United Kingdom,

20% Australia

Most common cause of coughing

older than 3 years old

Difficult to evaluate:

misdiagnosed (allergic history)

Reactivity in response of many triggers:

environmental allergens pollens,

animal danders or molds

viral infections,

odor,

smoking,

medication,

exercice,

airway inflammation,

weather

GI reflux

NHIS (2005), Strachan (2004), Australian Center for Asthma (2008)

Asthma What’s up ?

Difficult to evaluate:

misdiagnosed (allergic history)

Standard for diagnosis:

include pulmonary function testing

Main treatment :

acute exacerbations the use of inhaled beta-agonists,

chronic long acting medication,

IgE modulators

Multiple studies in the 90’ on the use of chiropractic :

Conclusions little impact on objective markers may subjectively improve in patient ( Balon, 1998; Nielsen, 1995; Nilssen 1998)

Johnston (1991), National Asthma Education and Prevention Program : Guidelines 2007

Asthma What’s up ?

Furthermore ….

Conflicting evidence :

Narrative review and case studies: manipulatives techniques

Increase motion of thoracic cage

Mobilize the ribs and thoracic spine

Enhance arterial supply and lymphatic drainage

For a variety of onstructive airways including asthma

Asthma: What’s up? Body of evidence :

Cochrane review Hondras et al., 2005

Conclusions : postulated superior benefit of manual therapies not supported by

their results

From small number of trials, methodology quality poor, pooling of results not

possible:

different populations, interventions, outcome measured used

Having said that!

Theorizing improvement from spinal manipulation:

Improvement in thoracic cage restriction

ease breathing pattern, restrictive lung disorders

Quite different :

obstructive disorders such as asthma being improved by thoracic biomecanics in itself

The patient quality of life and subjective symptoms may still be positively impacted

Place for further clinical research… who will embark this journey ?

Bronfort (2001), Fedorchuk (2007) et Gibbs (2005)

What’s your take ?

How would you approach this with your community?

Headache

Headache in children

>80% of older schoolchildren

Ranked #3 as reason for school absence

Ranked #2 as reason to seek chiropractic care

Physical pain & psychological distress

Reduced participation

Often persists into adulthood

Large degree of self-medication

Headache

Other

Abuse

Trauma (msk)

Comor-bidity

SleepPsychi-

atriccondi-tions

Diet (vit D, meals)

Caffeine

Medi-cation

Stress

Evidence for manipulative

treatment?

None!

1 RCT of cervicogenic HA

Evidence for alternative

treatments?

Acupuncture Promising, but only 2 small studies

(1 observational trial (OT), 1 RCT)

Homeopathy None (1 OT, migraine)

Nutritional supplements

Q10 Pos. in 1 OT but neg. in 1 RCT

Riboflavin Pos. in 1 OT but neg. in 2 RCTs

Herbal preparations

Butterbur Promising, 1 OT and 1 RCT

Feverfew None

Headache

Other

Abuse

Trauma (msk)

Comor-bidity

Sleep

Psychi-atric

condi-ions

Diet (cola,

caffeine, vit D)

Medica-tion

Stress

Adverse events?

Missed diagnoses

Adverse events from medication, e.g.

amitriptyline

Collaborators?

Headache

Other

Abuse

Trauma (muskuloskeletal)

Comor-bidity

SleepPsychia-tric condi-

tions

Diet (cola,

caffeine, skippingmeals)

Medica-tion

Stress

What’s your take ?

How would you approach this with your community?

Interdisciplinary discussions

PATIENTS

BENEFITS

Clinician everyday life ….

http://jaoa.org/article.aspx?articleid=2094395

2018