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Chiropractic Journal of Australia : CJA March 2012
23 Chiropractic Journal of Australia Volume 42 Number 1 March 2012 In terms of motor development for the child presented in this case report, at 11 months of age she should have the ability to pivot in a sitting position, cruise furniture using one hand, stand for a few seconds on her own and walk with one hand held. Rather, the child’s mobility was delayed and developed the strategy of “bottom shuffing” rather than crawling prior to walking. As described in the case report, the child remained in the sitting position and moved by wriggling their buttocks and unilateral hyper- fexed hip and knee to move forward. This is also referred to as hitching or scooting. This bottom shuffing or hitching or scooting is utilized approximately by 5–21% of infants for mobilization10, 11 and when examining children with delayed walking, the incidence of bottom shuffing increases to 30%.11-13 Bottom shuffing is said to develop at approximately two to three months following the child’s ability to achieve unsupported sitting. This method of mobilization by the child is so successful that its been theorized to delay the development of walking by a few months as it delays the development of muscles required for weight bearing and decreases the incentive for the child to mobilize by other means.11-13 However, a study by Fox and colleagues11 to examine the incidence of “shuffebottoms” and their age of frst walking (compared to a control of “walkers”) found that “walkers” were more likely to walk later than shuffebottoms. According to Robson13 bottom shuffing on the part of the child may indicate an underlying hypotonia which may explain, in part, the use of this non-crawling strategy. According to Fox and colleagues11 bottom shuffing shows a familial preponderance. Although the exact mode of inheritance is unclear, they theorise it more than likely involves an autosomal dominant gene with incomplete penetrance. Given this mode of heritability, Fox and colleagues11 commented that some families may have derived their surnames based on demonstrating this uncommon characteristic. Implications of Chiropractic Care To provide context to these discussions on the chiropractic care of a child with a “shuffebottom” strategy to mobilise, we performed a selective review of the literature using MANTIS [1964-2011], Index to Chiropractic Literature [1984-2011] and Pubmed [1966-2011] using the search terms “bottom shuffing,” “hitching” and “scooting” and related words in the context of chiropractic. To the best of our knowledge, no study thus far has been published as defned in our literature search. Therefore, to the best of our knowledge, this is the frst description in the scientifc literature of a child that transitioned from a bottom shuffer to crawling immediately following chiropractic care. The motivating factor for the parents to present their child for chiropractic care was their concern for their daughter not crawling as they observed in other children and the possibility for any underlying pathology for their daughter’s bottom shuffing. Following the frst visit, the patient’s mother reported a relatively quick response to care in the patient crawling on all fours within hours following the frst chiropractic visit. As exemplifed in this case report, the phenomenon of bottom shuffing as a strategy for mobilization in infants has been observed for years. However, the medical paediatric literature is lacking in this and non-existent in the context of chiropractic. As such, we can only theorise on the effects of the chiropractic care provided. Numerous theories have been offered to explain the effects of the chiropractic adjustment14 but a common theme of many of these theories is that changes in the normal biomechanical dynamics of the spine can adversely affect function of the nervous system.15 In the case reported, the child was cared for with adjustment to the sacrum and cervical spine. The frst reference frame used for the organisation of balance control during locomotion is the pelvis, especially in young children.16 The effects of the adjustment in the case reported may therefore involve biomechanical changes such that function (i.e., pelvic asymmetry, fxations in the SI joint, etc.) is restored in the pelvis. Consequently, the adjustment also alters the infow of sensory signals from paraspinal tissues in a manner that improves physiological function.17 In a study investigating the occurrence, frequency and characteristics of alternative locomotor strategies in children from the age of one to two years and the elements possibly infuencing the long-term psychomotor/locomotor outcome, Bottos and colleagues12 found that shuffers and creepers (and late crawlers >10 months when considered as a different subgroup) walked at a later age compared to crawlers and to children who just stand up and walk. It should be qualifed that crawling is not a pre-requisite to walking. Rather, it is the ability to pull up to stand that leads a baby to take their frst steps.9 Additionally, the success of the “Back to Sleep”18 campaign to protect babies from sudden infant death syndrome has resulted in children less likely to be placed in the prone position to sleep and therefore less likely to develop the skills of head control, active cervical spine extension, trunk rotation and shifting weight. Such skills promote a natural progression to crawling based on the ontogeny recapitulating phylogeny concept.11 Regardless of the mechanisms and the causes involved in delaying crawling, chiropractic care may provide a means of mitigating this delay and ultimately, facilitate bipedal motion in infants. For the child and his/ her family, the ability to walk and its positive consequences cannot be overstated. Independent locomotion in the child changes affective expression,19 their ability to explore their environment and learn,20 their personality21 and overall, their motor and mental development.22 In closing we caution the reader on the generalisability of case reports. Given the limited sample size and lack of control, cause and effect inferences are challenged by regression to the mean, the results of placebo, and the non-specifc effects of the clinical encounter (i.e., the demand characteristic and subjective validation). With respect to the natural history of bottom shuffing; despite the limited data available (i.e., one study), there are indicators that bottom shuffers have delayed development to bipedal motion. As discussed above, there are consequences for the developing child. CONCLUSION This case report described a child that transitioned from bottom shuffing to crawling following chiropractic care. We encourage further research in the possibility that chiropractic adjustments may mitigate delayed locomotor development in infants. BOTTOM SHUFFLER AND CHIROPRACTIC BERNARD • ALCANTARA
CJA June 2012