INTRODUCTION

Studies have shown that the pattern of spinal injury in children is related to age and also the mechanism of injury. “While traffic-related incidents are a leading cause of injury across all age groups and account for approximately one third of all spinal trauma and half of serious injuries, emphasis on fall prevention is needed for younger children. Older children, particularly boys, are sustaining spinal trauma in sporting and recreational activities.1”
The cervical spine was the most frequently injured region, with thoracic and lumbar spine injuries becoming more common with age. The upper cervical spine was more commonly seriously injured in young children, and the lower cervical spine was involved more often in older children. The frequency of minor soft tissue neck injuries increased substantially above the age of eight.1
Numerous biomechanical factors increase the chance for cervical injury in children. Two of the main ones are:
• The diminished development and strength of various spinal musculoskeletal components.2 Children’s spines are weaker and more flexible than adults, allowing more joint impingement during traumatic impacts.
• The more unfavorable head diameter to neck diameter ratio, as compared to adults.2 Children have larger, heavier heads in relation to their bodies than adults.
I would like to present a case study involving the structural and functional rehabilitation of a soft tissue neck injury in a 12 year old boy. In contrast to what the insurance industry thinks, these are not self-limiting disorders in many cases and need proper treatment management and documentation.

CASE STUDY
A 12 year old boy presented for evaluation after a neck injury that occurred earlier in the day. His mother stated that “he was rolling around on the ground and somehow twisted the left side of his neck.” He described having constant severe, dull left-sided neck/upper back pain for the last 5-6 hours that was increased to a sharp pain with any motion of the head or neck. He rated his neck pain on the initial examination day as a seven to nine on a 0-10 point Numerical Pain Scale. He rated his average neck pain as a seven and his worst neck pain as a nine on the Numerical Pain Scale. He has never had a neck injury like this before.
A pain questionnaire should also have been administered, but my usual (Vernon-Mior) Neck Pain and Disability Index form is not really applicable to children. A much better choice to establish how a child’s pain is affecting their eight domains of health (physical functioning, role limitations due to physical health (role-physical), bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems (role-emotional) and mental health) is the SF-10™ for Children. This is a new short form that contains items adapted from the CHQ™. With just 10 items (questions), the SF-10™ for Children can be easily integrated and administered and is particularly applicable to large-scale child population surveys. This questionnaire can be found on the Outcome Assessment CD Rom and can be purchased at CBP® seminars or off the www.idealspine.com web-site.
On this young boy’s initial physical exam, he had severely restricted cervical extension (33 degrees), lateral flexion (rt. 34/lt. 18 degrees), and mildly restricted left rotation (70 degrees). This resulted in an eight percent whole body impairment (AMA guidelines). Increased pain was elicited on the foraminal compression test bilaterally, especially on the left with no radiation of pain into the upper extremities, indicating a facet joint inflammation most pronounced on the left.
The initial postural exam demonstrated a mild forward head posture. The initial lateral radiograph revealed a military cervical spine with 17 millimeters of forward head translation and a reduced C-1 angle of 9-1/2 degrees (See X-ray #1). The AP view showed minimal displacement of the cervical spine from mid-line and was generally unremarkable as was the AP posture.






Treatment was started on the initial visit due to the patient’s severe pain levels. During the first two treatments, the young boy received vaseo-pneumatic interferential electric muscle stimulation to improve circulation, diffuse metabolite toxins, decrease inflammation/pain and stimulate healing. No cervical manipulation was performed due to the acute inflammation and soft tissue damage. On the third visit, the patient’s pain levels had decreased to a three to four on the 0-10 pain scale so gentle diversified manipulation was introduced as well as low level, supine motorized cervical extension compression traction to restore the normal lordosis and reduce the forward head posture (See Picture #1).


The motorized traction was applied for two minutes for the first treatment and slowly increased to 12 minutes sessions over the next six treatments. The traction was gradually increased to a 15 pound low pull/27 pound high pull intensity. Due to the absence of any notable postural aberrations, no mirror-image exercise was applied.
After 15 treatments (13 with traction), the patient was re-evaluated and a new lateral cervical x-ray was taken. His new range of motion revealed notable improvement of extension, lateral flexion and rotation to normal values, resulting in a zero percent whole body impairment. The foraminal compression test was now negative and his forward head posture visually appeared reduced.


The new lateral cervical x-ray showed a restoration of the cervical lordosis to 31 degrees. A common mistake that many clinicians make is to try to induce an adult’s 40 degree cervical lordosis to a child’s neck. Children have a reduced cervical lordosis compared to an adult. Table #1 denotes the normal amount of lordosis that children of different ages should have.3 A reduction of the forward head posture to 11 millimeters and an improvement of the C-1 angle to 19 degrees were also observed (See X-ray #2).




In spite of the nice structural and functional (ROM) improvement, the young patient still reported having daily morning neck pain that he rated at a two level on the 0-10 point Numeric Pain Scale. Because of the soft tissue fibrosis of repair that occurs in children as well as adults, residual pain can often be present even after structural rehabilitation has been accomplished if no Mirror-Image® or range of motion exercise has been performed. Realizing this, full range of motion, progressive resistance exercise was initiated with this young boy using a head halter and Medi-Cordz™ surgical tubing for the progressive resistance. After just five additional treatments that included continued diversified spinal manipulation and the progressive resistance exercises of bilateral rotations and lateral flexions, this young boy was pain free and released.
CONCLUSION
Post-traumatic chiropractic care of the pediatric patient is often questioned by the insurance company as not likely to be reasonable or necessary. Proper documentation of your young patient’s structural and functional deficits as well as how their pain is affecting their overall physical and emotional health are a necessity in the modern health care arena, if the doctor expects to be paid for his care.
Involved in the treatment of this case was a new type of motorized, intermittent cervical extension traction that combines the benefits of functional and structural soft tissue rehabilitation. By constantly varying the traction force, my new CTBox™ provides a dynamic variation on preexisting corrective spinal traction application and, because of its increased patient comfort level, can be utilized sooner in the patient’s rehabilitation then static applications of extension traction. To my knowledge, this is the first motorized, intermittent extension traction device to receive FDA approval for resale to Doctors of Chiropractic.

REFERENCES
1. Bilston LE, Brown J. Pediatric spinal injury type and severity are age and mechanism dependent. Spine 2007; 32:2339-2347.
2. Murphy DJ. Pediatric Chiropractic. Ed: Anrig C, Plaugher G. Williams and Williams, 1998.
3. Harrison DE, Harrison DD, Haas JW. CBP® Structural Rehabilitation of the Cervical Spine. Harrison CBP® Seminars, Inc. 2002. Ch. 3, Table 1, p 63. (Further referenced to a Spine 1996 published study by Kasai et al.)