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Chiropractic Journal of Australia : CJA March 2013
16 Chiropractic Journal of Australia Volume 43 Number 1 March 2013 Following the birth of her child, the infant's mother indicated that her daughter had a head lean to the right side, and preferred the left breast to feed. No treatment was given and no plagiocephaly was noted. The patient was also diagnosed with congenital hip dislocation at birth and was in a brace for 3 months from 7 weeks of age. At 5 months of age, the patient's eyes were noticeably not "straightening up" and was referred to a eye specialist who prescribed an eye patch to be worn from 6 months of age for 15 minutes every second day. The patient had bilateral esotropia with the left eye more dominant. However, depending on the angle of her head lean, there was a noticeable difference in her eyes suggestive of accommodation esotropia. After the use of the eye patch, glasses were prescribed and the patient continued to wear these glasses 2 years later. Bilateral medial rectus recession surgery was performed thereafter and post-operatively, the patient's left eye appeared to improve despite the right eye appearing more prominent with esotropic features. The patient crawled at 10 months of age and walked at 23 months. Postural examination revealed the patient's right pelvis and right shoulder were more elevated compared to the left. Her left foot also had noticeable external rotation compared to the right. Neurological examination revealed primitive refexes Galant's and Moro as retained. No abnormalities were detected with the rooting, palmar, plantar, tonic neck, and Babinski's refex. Pupillary and accommodation refex unremarkable. The 6 positions of cardinal gaze revealed diffculty of the left eye with upward movement and abduction, the right eye revealed slowed and awkward movements throughout the entire test. Inspection of the eyes revealed bilateral esotropia. Upon interaction with the patient, she was withdrawn and shy. When playing with toys, she had a preference to use her right hand for 90% of the tasks. Chiropractic examination revealed the following subluxation listings: C1 and S2 vertebral bodies as right posterior with cranial listings of the occiput in extension on the right with sphenoid torsion on the right. Based on the history and physical examination fndings, the patient was diagnosed with vertebral subluxation complex of the spine and cranial-sacral system complicated by strabismus. The patient's mother consented to a trial of chiropractic care. Adjustments utilizing the Activator instrument were performed along with cranial sacral therapy at weekly frequency of 4 weeks and the fortnightly adjustments for 10 months. A medical examination suggested no need for a second surgery and a greater improvement in the patient's eye alignment and vision. Given the patient's positive response to care, the patient's adjustment frequency was scheduled to three weekly and the patient continues to receive chiropractic checks at this intensity. The patient's mother was very keen to have her daughter continue to receive chiropractic adjustments for wellbeing. The patient's mother prior to beginning chiropractic care understood a guarded prognosis. After the third adjustment, the patient's right eye was centralizing and did not have obvious esotropic features. Examination of the patient's cardinal gaze found ease of movement and fuidity in both eyes. During the trial of care, the patient’s posture had also improved. The patient was reported by her mother as sleeping better and overall was a happier little girl. Approximately 6 months into care, the patient's eyes had improved in their appearance and the 6 positions of cardinal gaze demonstrated no lag time or diffculty with superior movement and abduction. The patient was using her glasses with less frequency and skilled tasks had improved with both hands. Her balance and coordination had improved with greater propensity to maintain a standing upright posture. Upon neurological and primitive refex examination, both Galant’s and Moro’s refexes were no longer present. According to the patient's mother, the patient's medical specialist examination resulted in great improvements in her testing with no need for further surgery that was previous thought to be required. The patient's vision continues to improve and as well as her overall socializing with other children. The patient's parents were very pleased with the results of chiropractic care, as was her ophthalmologist. DISCUSSION Strabismus is a leading risk factor for the development of amblyopia, the partial of complete loss in visual function due to inadequate or abnormal stimulation during the development of the visual system and undetectable structural abnormalities. This relationship between amblyopia and strabismus differentiates pediatric from adult- onset strabismus, where visual function is less likely to be irreversible. The importance of addressing strabismus during childhood cannot be overstated to decrease the occurrence of amblyopia, maximize stereopsis function, and improve the visual axes of the eyes for cosmetics. The general etiologies of strabismus are many and beyond the scope of this manuscript to fully address. General causes include primary myopathies (i.e., due to trauma) of the extraocular muscles, disorders of the connective tissues that comprise the globe's gimbal system (i.e., dysfunctions in EOM insertions and pulley action), peripheral disorders of nerves controlling the muscles of the eyes (i.e., acquired peripheral ocular motor neuropathy), and central disorders of fusional vergence commands (i.e., intermittent exotropia, accommodative esotropia.12 With respect to the diagnosis of strabismus in the pediatric population; from a chiropractic perspective, the importance of early detection and co-management for the initiation of treatment to prevent the consequences of strabismus (i.e., amblyopia and decreased quality of life cannot be overstated are of paramount importance in pediatric care.13 In the physical examination and diagnosis of the child presenting with possible strabismus, a simplifed and practical approach to determine the normality or abnormality of the motor and sensory system, both in the primary as well as other positions of gaze is paramount. Towards these efforts, we acknowledge and recommend to the reader the article by Thomas.14 According to Thomas, the aim of the clinical examination is to address the following questions: 1. Is fusion present under "real life" conditions?; 2. Is there a deviation (phorialatent squint; or tropia manifest squint); if so, what, if any are the compensatory mechanisms (fusional vergence) that the patient uses to compensate for the deviations? CHIROPRACTIC AND STRABISMUS PARISIO-FERRARO • ALCANTARA
CJA December 2012
CJA June 2013