A 5-year-old boy presented with his parents for evaluation of chiropractic treatment options for ADHD. The patient had been referred to a mental health practitioner by his family physician who diagnosed the patient with ADHD 1 year prior. Following biomedical treatments, the patient's parents were seeking alternatives because they thought that previous treatments had not been completely successful in managing his subjective signs of acting out, ability to follow instructions, and poor home and school performance. They reported that their son had scored high on information processing and concentration testing and that there were no reports of nocturnal enuresis, sleep apnea, or Tourette syndrome. They said that the patient often woke in the night, but that those episodes were generally related to asthmatic symptoms. The parents had noted low self-esteem in their son but that he was a normal, active child as compared with his friends and peers. He slept approximately 11 to 12 hours per night (normal toddler/preschool sleep duration, 11.9 [9.9-13.8] hours per night11
The medical history included a scheduled Cesarean delivery (birth weight, 3685 grams) following an uneventful full-term pregnancy. He reportedly met all physical and vocabulary developmental milestones and had no reported musculoskeletal complaints. Medications included daily fluticasone propionate oral inhaler for his asthmatic symptoms, with albuterol, fluticasone nasal, and montelukast (oral) used intermittently. No medications for ADHD were being used at the time of chiropractic assessment.
On physical examination, the patient had normal posture and no abnormal spinal curvatures. Cervical spine ranges of motion were full and painless. Results of orthopedic testing of the cervical spine were as follows: Kemp test result was positive for pain bilaterally at C2/3/4; compression, Jackson, Maigne, and Houle test results were negative bilaterally. Palpation of the cervical spine revealed joint tenderness and restrictions at C2/3/4 on the right and C2/3 on the left. The paraspinal muscles at the corresponding levels were hypertonic and tender to palpation.
Lumbar spine active ranges of motion were full and painless. Result of orthopedic testing of the lumbar spine was as follows: straight leg raise was 90° bilaterally with no pain reported; Thomas test, Patrick-FABERE test, Gaenslen test, Yeoman test, and sacroiliac compression test results were all negative bilaterally, whereas posterior-anterior pressure at the thoracolumbar junction elicited local pain. Palpation revealed hypertonicity and trigger points in the paraspinal muscles at the thoracolumbar region with local pain.
A preliminary diagnosis included cervical and thoracolumbar facet joint irritation with concurrent muscle hypertonicity. A treatment plan of spinal manipulative therapy, soft tissue therapy, and myofascial release therapy was initiated. The treatment plan included 3 treatments per week for a period of 6 to 8 weeks, with a reevaluation at weeks 4 and 8. Treatment began in mid-June, with 11 treatments provided over the remainder of the summer because of scheduling conflicts. With the beginning of school in September, a more regular schedule was possible. The patient was reevaluated; and treatments were provided 2 to 3 times per week through November, with 4-week reevaluations (total treatments provided, 21). Between December and May (study completion), treatments were provided on an average of twice monthly (total treatments, 13).
Chiropractic treatment included palpation to determine locations of facet joint fixation and trigger and tender points in hypertonic musculature. Chiropractic spinal manipulation (diversified technique) was provided, with the most consistent locations of facet joint irritation being the upper cervical spine, interscapular region, and thoracolumbar region. Paraspinal muscle hypertonicity was common in the upper cervical spine, although rarely in the suboccipital region, and at the thoracolumbar junction. In general, little muscle hypertonicity was noted in the lumbar spine region or the gluteal/pelvic regions. Over the course of 1 year, no adverse effects were reported. No significant illnesses or injuries were reported by the patient's parents during the duration of the study, nor were there any changes in overall health status. Over the course of a 1-year treatment period, the parents reported that a marked improvement was noted in the patient's ADHD-associated symptoms (acting out, ability to follow instructions, and poor home and school performance).