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Chiropractic Journal of Australia : CJA March 2013
Chiropractic Journal of Australia Volume 43 Number 1 March 2013 17 3. What is the measurement of the deviation (distance as well as near)?; and 4. Determine the existence and nature of the suppression mechanisms if any. In terms of the role of the chiropractor, we believe the determination of fusion, fusional vergences and deviations utilizing the cover tests (the cover/uncover test, the cover test and the alternate cover test) should performed. Further assessment to address the rest of the above questions listed should be addressed with a referral to the appropriate specialist for co-management. TREATMENT OPTIONS As outlined previously, the medical treatment options for children with strabismus span the conservative (i.e., non- surgical) to the not so conservative. The use of the eye patch8 aims to force the brain to interpret images from the strabismus eye, allowing the eye to become more functional. However, this approach will not change the angle of the strabismus. With corrective lenses, the child's line of sight is re-directed with the aim of straightening the eye. Botulinum toxin is used to treat spasms of the ocular msucles9-10 while surgery may be used to modify one or more of the extraocular muscles' position and/or length.7 The aforementioned treatment options have poor compliance8, questionable effectiveness9 and risk of adverse events.15 The care of the patient with visual problems is not without controversy. Even in mainstream healthcare. For example, consider behavioral visual therapy as performed most commonly by Doctors of Optometry. In a critical evaluation of the evidence supporting the practice of behavioural vision therapy, Barret16 concluded that a large majority of behavioral management approaches are not evidence-based, and thus cannot be advocated. The American Optometric Association however affrms its long-standing position that vision therapy is an effective therapeutic modality in the treatment of many physiological and information processing dysfunctions of the vision system.17 Similar to the optometrists, we are too keenly aware of the dissonance between the published assessment of clinical effectiveness to that of one's clinical experience/ expertise and the needs and wants of our patients. CHIROPRACTIC CARE As a further context to our discussions on the possible effectiveness of chiropractic care in the patient with strabismus, we performed a review of the literature by consulting Pubmed [1964-2012], MANTIS [1964-2012] and Index to Chiropractic Literature [1984-2012] using the search criteria "strabismus" and related words (i.e., esotropia, exotropia) in Boolean combination with “chiropractic.” Our inclusion criteria for review specifed chiropractic care in a pediatric patient (i.e., 0-18 years of age) with strabismus as a presenting complaint written in the English language. Our search found 4 articles with 2 satisfying our inclusion criteria involving children. Given the paucity of published literature, we decided to include all 4 articles in our review. Sweat and Pottinger18 recently described the care of a 75-year-old female presenting with strabismus in addition to gait ataxia, fatigue, blood pressure fuctuations, seizures of two weeks duration, and a history of concussion. The patient was cared for with Atlas Orthogonal Technique with reported resolution of the all the patient's presenting symptoms. Salminen and colleagues19 described the care of a 3-year-old boy with Joubert Syndrome presenting with tachypnea, occasional apnea, hemifacial spasm, nystagmus, delayed motor skill development, hypotonia and strabismus. The patient was cared for with the National Upper Cervical Chiropractic Association (NUCCA) technique. The patient's hemifacial spasm resolved with slightly improved coordination but no other signifcant change was reported as a result of the chiropractic care. Jamison and colleagues20 retrospectively examined a cohort of children presenting to an optometrist. The subjects consisted of 6 children referred for chiropractic care with another 6 children acting as controls. The main outcome measure was phoria as measured by the Prentice card system. Parametric t-test detected no statistically signifcant differences between the two groups but the more appropriate non-parametric testing (Mann-Whitney U test) did detect statistical signifcant differences. The authors briefy discussed the neuro-vascular and neurophysiological effects of the chiropractic adjustments to the cervical spine. The former involved irritation of the cervical sympathetic chain resulting in Barre Lieou syndrome that ultimately affects the vascular supply to the motor and pre-motor areas for gaze control. In the latter theory, it is theorized that facilitated/aberrant cervical proprioceptive afferents projecting into the vestibular and other pre-motor areas of the brain results in dysfunctional gaze control. Chiropractic adjustments presumably correct the irritation to the cervical sympathetic chain or the aberrant proprioceptive afferents. Wiener21 described the resolution of strabismus in a 2½-year- old girl secondary to infantile torticollis and chronic neck and head pain. The patient received chiropractic care utilizing the Neural Organizational Technique and advice on dietary restriction with the removal of sugar from the child's diet. Despite the reported improvements in the patient presented in this case report, we caution the reader on the lack of generalizability of case reports in general. Lacking a control group, the case report is fraught with competing possible explanations on the reported improvements seen in the patient. These include the placebo effect, regression to the mean, the effects of the natural history, the demand characteristics of the clinical encounter, and subjective validation challenge. Although a temporal association was observed (i.e., care provided with concomitant improvement in the patient’s symptoms), it is not suffcient to make cause and effect arguments on its own. CONCLUSION This case report provides for the possibility that a child with strabismus may beneft from chiropractic care vis a vis adjustments to both cranial and spinal structures. We encourage continued research in this area to examine the salutary effects of chiropractic care. ACKNOWLEDGEMENTS The authors thank and acknowledge the assistance of Ms. Barbara Delli Gatti, MLS from the Life West Chiropractic College Library for her expertise in the preparation of this manuscript. CHIROPRACTIC AND STRABISMUS PARISIO-FERRARO • ALCANTARA
CJA December 2012
CJA June 2013