Chiropratic Medicine

Chiropratic medicine involves restoration of the spinal biomechanical balance which affects the musculoskeletal, neurological, and vascular health systems aof the body.Treatment is applied by manipulation of the spine to remove mechanical stress.The main reason for chiropratic treatment is relief of pain and reduction of tightness especially of the neck and spine.

                The origination of chiropratic medicine is credited to Daniel David Palmer who opened an office of osteopathy and magnetic flow in the 1880s.In 1895 Palmer perfomed vertebral manipulation on a junior who had been deaf for many years and restored hearing that had been lost 17 years earlier.Palmer reasoned that improper alignment of the spine presses on nerves that leave the spinal column at various levels to supply virtually every organ in the body.This disrupts the normal flow of nerve impulses which results in organ dysfunction.Correction of the misalignment releases the pressure on the nerve and restores health.

                There are various categories of chiropractors.The “straights” contend that virtually every illness id due to subluxation and therefore can be corrected by correction of these slippages.The “mixers”understand that other factors are involved in disease and add nutrition, massage, and other holistic measures for treatment.A third category, as yet unnamed, restricts their therapy to nonsurgical musculoskeletal disorders.

                There are 50,000 licensed chiropractors in North America, and it is the fourth largest health profession (after physicians, dentists, and nurses).There continues to be difference of opinion between chiropractors and medical doctors.The latter consider that it is unlikely that subluxation of the spine contributes to many non-skeletal conditions.

Acupuncture and Chinese Medicine

Chinese medicine  dates  back several thousand years.It comprises acupuncture, diet, exercise, and herbal therapy.Traditional Chinese medicine shares similar philosophies with other older medicines, including Japanese, Indian (Ayurvedic), and Greek, primarily the concept of life force as a living energy that embodies the organism and its spirit.The Chinese refer to this as qi, or chi, the Japanese call it ki, the Hindus refer to it as prana, and the Greeks call it pneuma.When the life force is blocked or weakened, the energy is reduced in the tissues and organs.This leads to disease and healing results from correcting the blockage.

                It is difficult to compare Western medicine to traditional Chinese medicine because the concepts are so different.Yin and yang refers to the balance of positive and negative forces.Yin is passive, cool and moist, and is female.Yang is active, hot and dry, and is male.Nuch of life relates to opposites and disease is related to imbalances.Qi flows through the body in 26 meridians (12 paired and two single) or channels althought no anatomic structure has been identified.Figure 6-1 shows the five Chinese seasons and the elementsthat are associated, and the relationships between them.Traditional acupuncture involves insertion of needles at specific sites depending on the problem with 10-30 needles that are in place for about 20 minutes.

Figure 6-1

WOOD                  FIRE                       EARTH                   WATER                 METAL

East                        South                    Center                         North                    West

Dawn                    Midday                  Late afternoon              Midnight                Dusk

Awakening         Wakefulness              Transition                     Slumber                Quieting

Spring                   Summer                  Late summer                Winter                   Autumn

                The most benefical indication for acupuncture is pain and so the pratice does have the potential to be useful in many chronic illnesses that result in pain.Succes is often increased with skill of the acupunturist.In Eastern medicine, acupuncture is used to treat all manner of disease states and illnesses.There are plenty of studies to document that acupuncture works in many conditions.The list of conditions includes adult-onset diabetes, sinusitis, asthma,high blood pressure and so on, althought the effects are variable.In some cases acupuncture treats symptoms and in others it alters the course of the disease.It is probably reasonable to consider a trial of acupuncture and if there is no improvement after six treatments it is unlikely that it is very beneficial.It is a safe treatment and most therapists use disposable needles, reducing the risk of infection.

                There are differences in the training and ability of acupuncturists.Many states do not have formal licensing procedures.Medical doctors are allowed to pratice acupuncture without formal licensing whereas licensed (fully trained) acupuncturists undergo thousands of hours in training.

Complementary Medicine

The title was chosen rather than alternative medicine although the NIH has a section of complementary and alternative medicine (CAM).Alternative medicine can be defined as that which is not usually practiced by traditional physicians or taught in Western medical schools.Complementary medicine can be defined as therapies that supplement conventional treatments so that they are utilized in addition to, rather than instead of, conventional treatment.CAM has become sufficiently widely used that is important that clinicians are aware of the benefits and risks.It is clear that we do not  understand whether many treatments are useful, do not have any benefit, or are harmful.Integrative medicine implies that CAM and allopathic (Western) medicine are combined to provide optimal health.

                CAM is used or tried by one-third to one-half of the population including many children.The use of conventional (Western) medicine for chronic illness has not been as useful as it has been for acute medicine and surgery.Alternative medicines are often used by cancer patients; in fact, it is estimated that $ 10 billion is spent on unproven cancer therapies every year.Heart disease, diabetes, asthma, and cancer have been helped by conventional medicine but there are many areas where complementary medicine can be useful, although much of the information regarding efficacy and safety has been from adult studies and there are relatively few studies of children.

                It is clear that alternative medicine therapies are being used by many families with a view to improving the medical condition and/or the quality of life.There are various reasons for this; some are sensible and many are not.It is likely that there are alternative therapies that will improve how the patient feels but whether they alter the course of the illness is often difficult to establish.

                The reason people turn to alternative medicines include:

·         Frustration with conventional medicine.

·         Awareness of the usefulness of nutritional, emotional, and lifestyle strategies.

·         Desire to avoid side effects of conventional medications.

Complementary or alternative therapies are chosen for ailments ranging from stress to life-threatening illness.It is an axiom that unless one can scientifically prove that a therapy is beneficial it should not be used as a treatment.By this criterion acupuncture should not be used to treat  asthma, and indeed many practitioners do not believe that it should.Despite the fact that there are few studies that confirm that acupuncture benefits asthma, both the World Health Organization and the National Institutes of Health consider acupuncture to be a complementary therapy for asthma.

                Children with chronic illness may well receive alternative treatment, particularly when there is a perception that conventional medical treatment is not going to alter the course of the illness.Specific recommendations are difficult to make because of the diversity of childhood illness.It is considered that the clinician should keep an open mind because some therapies are beneficial in ways that we do not understand.It is important that the communication between family and caregiver be good.If it is perceived that the practitioner is firmly againts alternative medicine and the family wishes to try something, it is likely that they will not inform the practitioner because of the anticipated response.This is obviously hazardous if there is a potential conflict between the various therapies that the child is receiving.It makes sense that there is good communication that will allow the therapies to complement one another.As previously noted, we do not understand how or whether many therapies work, and we also do not have data in many cases of the relationship between standard and complementary treatments.This means that the clinician has to weight the benefits against the potential harm.

                Although many physician are unaaccepting of alternative medicine because of the lack of scientific data to support its use, there are many who embrace alternative medicine and recommend therapy for their patients.

                Conventional medicine tries to be evidence-based which implies that there are vaid scientific studies that document the efficacy of the treatments.Complementary medicine works on the principle that if it seems to help it has the potential to be useful.This is exemplified by acupuncture, a pratice which has been around for thousands of years and seems to work.The qualifications of alternative medicine doctors are difficult to understand and the credentials vary from an advanced oriental medicine doctoral program to a certificate given following a Caribbean cruise.

                The approach to CAM is holistic, which views health as the whole person and includes body, mind, and spirit.Many of the approaches to CAM utilize the natural ability of the body to heal itself.The most commonly used CAM treatments are vitamins and health foods, herbal therapy, chiropratic, relaxation techiques, massage, and acupuncture.

                One of the advantages of CAM has been suggested to be prevention.In reality, conventional medicine has played an important role in prevention although it has not always been embraced by the agencies who pay the bills for medical care.Considerations for prevention for conventional medicine include immunizations, screening test, and physicals.Exercise and change in health habits, with smoking cessation and cholesterol reduction as examples, are commonly recommended.

                One of the major problems with CAM is the lack of controls and safety of alternative medicine.It would be wrong to say that, by definition, alternative or natural medicines are safe.Many natural substances and herbal remedies interact with prescription medicines and the actual effect in an individual patient may be difficult tp predict.As more natural treatments are used it is likely that some of these interactions will be identified.Examples that are important include herbal medications taken at the same time as anesthetic agents, which can be a dangerous combination.

                Medicine manufactured in certain countries may be contaminated and the dosage is not always accurate.Also the claims of the effects of CAM treatments are not always truthful.

                It is sensible to discuss with the treating (conventional) physician CAM treatment that are considered before they are tried.If they are tried without prior consultation and symptoms develop it is important to “own up” to what is being taken because keeping quiet may be detrimental.It is important to be able to identify herbal treatments and secret ingredients should be considered to be hazardous.Injections of alternative treatments are unusual and may be unsafe.

                It is important to separate the placebo effect from a treatment effect.The placebo or sugar pill effect is improvement that results from the power of suggestion.This effect is very powerful and in an individual patient may result in effect that are mistakenly attributed to the actions of the drug.This is more likely in children than adults.

Constipation and Encopresis

Constipation

Constipation is one sympton of many disorders.In the majority of children with constipation the cause is functional or behavioral.There is no one definition of constipation but a combination of reduced frequency, discomfort or difficulty in passing stool, or a feeling of incomplete evacuation.Breast-fed babies may not pass stool for 5-10 days and it is normal for babies to strain to try to pass stool.Children may have large stools every 3-4 days and in the absence of abdominal distension or discomfort and no soiling it is probably normal.

Encopresis

Toilet training leads to bowel control before blsdder control.By age 4 years, 95 percent of children have attained bowel control.The intentional or involuntary passage of feces in inappropriate places (e.g., clothing or floor) after the age of 4 years is encopresis.The definition requires at least 1 event a month for 3 months.Primary encopresis implies that there has not been a 6 month period of bowel continence and secondary encopresis results when continence precedes the symptom.

                Encopresis is by definition not due to a general medical condition except through a mechanism involving constipation.Fecal incontinence can be categorized as soiling with or without fecal retention.Table 5-3 lists some of the causes that may be present.For most of these conditions encopretic symptoms are unlikely to be the only or presenting symptom.

                The major cause of encopresis is overflow incontinence.Stool is retained in the distal colon and rectum and the internal sphincter becomes dilated and functionally incompetent.The external sphincter cannot hold the impacted stool and there is leakage.

TABLE 5-3. CAUSES OF CONSTIPATION THAT MAY LEAD TO ENCOPRESIS

Functiona (non-organic)

Organic

   GI

      Hirschsprung disease (congenital aganglionosis)

      Anal defects (e.g., fissure, stenosis)

      Colonic stricture

   Neurologic

      Cerebral palsy

      Meningomyelocele, spina bifida

      Hypoptonia

   Endocrine

      Hypothyroidism

      Pregnancy

   Psychological

      Depression

      Anorexia nervosa

      Stool withholding

   Dietary/pharmacologic

      Inadequate fiber intake

      Antacids

      Iron

      Opiates

      Bismuth

The child may be unaware that soiling has occured.Any condition that causes persistent constipation may be associated with fecal soiling.Children with encopresis tend to have large stools that may block the toilet.Soiling tends to occur in the afternoon and is less likely to occur at night.Non-organic encopresis may occur with oppositional (defiant) behavior pattern, toilet phobia, and anismus.Anismus is dysfunctional anal sphincter control in which the anus contracts rather than relaxes on defecation.

                A careful history should be taken and the examination includes the rectal exam and evaluation of the external sphincter.Evaluation of neurological function is important and plain abdominal X-ray may confirm the presence of constipation.The treatment starts with education of the parents and child.Explanation of the circumstances is important because there is considerable stigma placed on the problem.Treatment is directed toward clearing the bowel and then reestablishing good bowel function.The maintenance program may take several months particularly if the bowel dilatation has been severe.The maintenance regimen involves dietary changes including a high-fiber diet with increased fruit and vegetables, grains, and cereals.Mineral oil with vitamins, because of fat-soluble vitamin malabsorption, or another stool softener may be useful.Young children benefit from a regimen of sitting on the toilet after the morning and evening meal to get into a routine of keeping the bowels clear.

Enuresis

Enuresis is the repeated voiding of urine in inappropriate places that may be voluntary or involuntary.Toilet training is a ritual and results in behavior that urine is voided in the toilet rather than in the clothes during the day and the bed at night.By definition, enuresis does not exist until the chlid is 5 years old. Primary enuresis occurs if the child has never been “dry” and secondary enuresis implies that there has been a period of “dryness” (at least 1 year) followed by “wetting.” Again by definition, enuresis is functional in etiology and therfore is not caused by a medical condition.The major cause of enuresis or delay in toilet training is conflict over the use of the toilet between the child and the parent.

                Non-functional enuresis is also called organic enuresis and is urinary incontinence on the basis of a medical explanation.Table 5-2 lists some of the organic causes of enuresis and these should be ruled out in a child who present with enuresis.Mental retardation is a major cause of primary enuresis and psychopathology and stress are important causes of secondary enuresis.Enuresis may be the presenting symptom of a urinary-tract infection and it is more common if diuretics are being taken.

TABLE 5-2. ORGANIC CAUSES OF ENURESIS

Urinary-tract infection

Neurogenic bladder

Spinal cord anomalies

Hypospadias (ectopic urethra)

Constipation

Diabetes

Sickle cell diseaseor trait

Psychosocial/emotional disorder

                The prevalence of enuresis decreases during childhood so that 15-20 percent of 5-year-olds, 5 percent of 10-year-olds, and 2 percent of 12-14-year-olds have nocturnal enuresis.Boys are twice as common as girls to have noctural enuresis but girls more commonly have daytime enuresis.A genetic component seems likely because 70 percent of enuresis children have a firstdegree relative with the disorder.

                Enuretic episodes typically occur at night during the first 4 hours of sleep.The evaluation should include a careful history, including family history, and physical examination.The majority of children with functional enuresis are not emotionally disturbed, and the majority of children with emotional problems are not enuretic.There is higher incidence of enuresis among emotionally disturbed children which might be expected if one of the factors causing enuresis is stress.The most common problems are anxienty, family stress, and immaturity.

                Treatment for functional enuresis involves waiting for spontaneous improvement, which occurs with time.Behavioral therapy includes resricting fluids before bedtime, bladder training exercises, and midsleep awakening for toilet use.Rewarding “dry nights” may be helpful in some children.Night alarms consist of electrodes that activate a buzzer or bell when they become wet.They have been succesful in many cases (50-90 percent) but there is a high relapse rate (25-40 percent) when they are stopped.

                Pharmacologic treatment is useful in the management of enuresis and imipramine (Tofranil) has been widely used.Initial  improvement (50-90 percent) may be followed by relapse (20-60 percent) when stopped.Tricyclic antidepressants require monitoring of drug levels and electrocardiogram,and the may have significant anticholinergic effects resulting in urinary retention, constipation, orthostatic hypotension, and sedation.There could be a risk of accidental or intentional overdose by the patient or sibling.Treatment with anticholinergic agents such as oxybutin,propantheline, or terodiline may be beneficial for those patients with small bladder capacity or an irritable or neurogenic bladder.The synthetic analogue of the antidiuretic hormone vasopressin (desmopressin) has been shown to be useful in the treatment of enuretic symptoms and may help some cases.

Failure to Thrive

The diagnosis of failure to thrive (FTT) is made when weight is less than the 3rd and 5th percentile or there has been significant deceleration in the rate of growth and crossing of 2 major percentiles on the growth curve.Causes are nonorganic, which includes calorie deprivation that is often associated with neglect, and organic.Nonorganic FTT may be from financial constraints,lack of understanding of child feeding needs, poor feeding habits, or a combination of factors.Care of infants and children should include measures of growth at each clinical encounter.

                Growth is rapid during the first year of life and failure to gain weight requires early identification.Type I growth deficiency is associated with normal head growth and greater depression of weight than height.It usually results from an inadequate calorie intake but may also result from excessive loss or utilization of calories.Type II growth deficiency is accompanied by proportional reduction in heigth and weight with preservation of head growth.Causes incluce genetic disorders, endocrine disorders, as well as constitutional growth delay.Type III growth deficiency results in depression of height, weight, and head circumference.It is associated with central nervous system abnormanilities, chromosomal defect, and insults that occur during fetal life or the perinatal period.

                In most cases, the history and physical examination suggest the diagnosis.It is usual to avoid a costly work-up and a complete blood count, urinalysis, and electrolytes will serve as a good screen.If there is potential for physical abuse, a chest X-ray may be indicated.The principal causes of organic FTT include chronic renal disease, congenital heart disease, and thyroid disease.

                The best way to differentiate nonorganic FTT is to provide an appripiate environment and allow the child to feed a decent calorie intake.In all but the most severe cases, there will be weight gain.If the child returns to the same environment, close follow-up is indicated because relapse is likely.A multidisclipinary approach is beneficial in the management of FTT.

Obesity

The definition of obesity is difficult to establish and most consider that greater than the 90th percentile for weight is appropriate.Eighty percent of normal weight cjildren are obese as adults.There are many health risks related to obesity including orthopedic problems, amenorrhea, growth delay, glucose intolerance, and elevated blood pressure and cholesterol.

                Only about 5 percent of case of obesity are related to endocrine and other medical conditions.Genetic, psychological, and environmental conditions account for most of the development and continuation of obesity.Many children have obese parents and their food consumption is greater and activity level less than non-obese children.

                Management involves behavioral modification which is more likely to succed if there is parental involvement, reduced calorie intake over a long period of time, and an exercise program.