Spinal development and balance of children

QUENTIN SHAW D.O.

This article is aimed especially at osteopaths that are actively grappling with children’s physical development through their phases of growth and maturation. The particular emphasis of this paper is placed on childhood spinal development and balance, for it is only by trying to understand certain developmental milestones and by observing the children in our care that we can begin to be in a position to make appropriate, informed clinical judgements and decisions. Research studies across Europe, the UK and America have found a direct correlation between the mechanisms responsible for establishing a child’s physical balance and learning abilities. The studies have been done on three groups of reflexes, which support the child through its first 3 ½ years of life. These reflexes provide the initial foundation of balance and coordination, as they are practiced, transformed and integrated within the motor cortex, the child will demonstrate various motor skill milestones e.g. learning how to sit, roll over, crawl, creep on hands and knees, stand and walk.

The 3 groups of reflexes are:

Intra-uterine reflexes which develop at 5-7 weeks post conception that are initiated from the brainstem level, with a characteristic withdrawal response or slight straightening of the foetus to stimuli applied to the feet, hands or lips as well as noxious stimuli. Primitive reflexes are developed by full term (40 weeks) and are inhibited or modified between 6-12 months post natal which are also mediated by the brain stem. Postural reflexes emerge after birth and gradually take over the functioning of the primitive reflexes over the course of the first 3 ½ years of life and then remain for life. Osteopathically the primitive and postural reflexes are of particular interest to us as they have a tonic effect on the body’s muscular system and are instrumental in the development of the spinal arches. There are many Primitive/Postural Reflexes however an understanding and recognition of the ones listed below is essential, as retention of these reflexes can hinder treatment progression. This will then require a specific assessment of neuro-developmental delay with appropriate developmental exercises and remediation techniques prescribed. Moro Reflex: – is inhibited and modified at approximately 4 months. Triggers for this reflex are sudden unexpected changes of position, particularly head support as well as a reaction to sudden change of vision/ auditory/ tactile and olfactory stimuli. This reflex assists in the first breath, activates the fight and flight response and gradually as higher cortical control takes over this reflex it matures into the startle response. The Moro reflex action to any of the above stimuli is a rapid extension or straightening of the spine, arms and legs. It is a distress reaction that may adversely affect the curve formation of the spine and the flexion / extension muscle group action if the reflex persists beyond its normal period of activity (4 months). Asymmetrical tonic neck reflex (ATNR):– should be inhibited at approximately 6 months. The function of this reflex is to assist the babies exit through the birth canal and the development of cross pattern movements and early hand eye coordination. Osteopathically the ATNR competence is essential for the development of the cross tension neruo-muscular mechanism of the body, i.e. correlation between right upper extremity and left lower extremity and vice versa. The typical characteristic of the ATNR is seen when the baby rotates the head to one side and there is a corresponding straightening of the arm and leg on the side the head is turned, and flexion of the arm and leg on the opposite side. If this reflex is not inhibited by the cerebral cortex within the first year of life, bilateral integration and coordination of movement and postural balance will be adversely affected in a variety of ways. The Symmetrical tonic neck reflex (STNR):– Should be inhibited between 9-11 months, the function of this reflex is to align the pelvis and occiput through the extensor spinal muscles in preparation for the upright stance. This is developed by causing the upper and lower halves of the body to perform opposite movements. When a baby moves its head up, the arms straighten and legs bend, if the head moves down, the arms bend and legs straighten. This sequence of reflex movements is the preparation for the integrated movement of crawling and eventually standing and walking. Retention of this reflex affects upper and lower body integration, coordination of movement and control of postural balance. The Tonic Labyrinthine Reflex (TLR):– takes up to 3 ½ years to be fully inhibited by the cerebral cortex. This reflex provides the basis for head control and postural stability. It helps to straighten the body from the flexed foetal position by facilitating contraction and extension of major muscle groups, this is particularly important in the development of the spinal curves. It is typically recognised when the baby is held supported on its back if the head is lowered below the level of the spine – the baby’s arms and legs will straighten and if the head is raised above the level of the spine – the arms, legs and body flex. Spinal Galant Reflex (SGR):– Takes 9 months to be inhibited. Its main function is to assist in the birth process. It is recognised by stimulation of the skin on either side of the lumbar spine causing flexion of the hip and side-bending of the lumbar spine to that side. Retention of this reflex can cause exaggerated external hip rotation on walking, hypersensitivity of the lumbar erector spinae and scoliosis.

Signs and Symptoms – which may indicate balance problems as a result of retained primitive reflexes.

Breech presentation / Caesarean / instrumental delivery.
Delay in achieving head control and other dependent milestones. such as sitting, crawling and walking.(STNR / TLR )
Postural instability and poorly developed muscle tone (hypotonia). (TLR / STNR)
Poor alignment of the pelvis to the occiput (STNR)
Problems crossing the midline of the body if head is turned to one side. (ATNR).
Poor balance and coordination. (Moro / TLR)
Frequent falls.(TLR)
Walking on toes after the age of 3.5. (TLR / Plantar Reflex)
Scoliosis (SGR)
Exaggerated hip rotation (SGR)
Avoidance / fear of movement. (Moro / TLR)
No fear of heights / Excessive fear of heights (TLR).
Excessive rocking or spinning (attempt to provide stimulation to an under active system). (TLR)
Poorly developed sense of body image (MORO).
Motion sickness above the age of 8 years (TLR).

These reflexes form the neruo-muscular basis for the child gaining control of their body and during the first 9-12 months of life, vital neural pathways are being formed between the lower and higher centres in the brain, which are necessary for the child to gain muscle strength against gravity. The child’s ability to stand in balance with the force of gravity requires repeated movement opportunities in many different positions during the first months of life in preparation for the upright posture.

Polygon of forces

Balance equilibrium, static or dynamic is a feedback loop of signals between the vestibular apparatus, cerebellum, cerebrum and skeletal muscles, together responding to motion in vertical, horizontal and diagonal planes. This neuro-physiological mechanical interplay of forces is fundamental to the classical osteopath, which is represented by the Polygon of force model, a three dimensional diagram of spinal unity and balance, that is the resultant of the bodies vertical, horizontal and diagonal axes. The anterior / posterior line of the Polygon represents cross tension, and the posterior / anterior line represents internal cavity pressures i.e. the spine is held up counteracting gravity by the balance of cross tensions, pressure and a series of soft interrelated anterior / posterior curves. During the child’s first 9 months we are particularly concerned with the development of head and body control in the prone position. Control of balance and coordination begins with the head and gradually works down the neck and upper torso. At the same time spontaneous movements of the legs help the baby begin to know where its body begins and ends. As muscular strength and postural tone increase, the baby spreads from the head down to the trunk and from the feet upwards. By the end of 12 months integration and coordination of upper and lower body movements through the trunk of the body should have occurred, the child should also recognise front and back, left and right. In the classical osteopathic framework of the polygon of force, this upper and lower body integration and correlation is represented by the upper and lower triangles, with the apex of both triangles located anterior to the 4th dorsal vertebrae. D4 is fundamental in the neuro-physiological developmental processes and represents the centre of heart and lung function, deep and superficial circulation, emotion, with the sum total representation as a centre of vitality. Lesions at this point in the spine are common as a result of birth traumas, retained Moro reflex activity, dysfunction of the vital processes listed above, all of which can affect the developmental movement milestones from the child lying on its back, rolling onto its front / creeping / crawling / sitting to standing. Secure balance is inseparable from the development of postural control The body’s proprioceptive mechanism supplies the brain with information regarding body position in space. This information gives a child its sense of “centre” in space, described by A.J.Ayres as gravitational security. Postural control is centred in the spinal column, the dorsal and sacral curves are your original primary embryonic curves, the lumbar and cervical curves are an accessory to physical development and appear only when the child begins to assume the upright posture and forms the basis of the locomotive activity of the body. This means that all postural conditions or disturbances of the posture centre in the activity of the cervical and lumbar segments.

Importance of the development of spinal arches

During childhood spinal development we are looking for the 4 arches to develop which provides the greatest amount of strength and elasticity with the least amount of shock transmission. The distribution of weight in the erect body without excessive tension at any point depends on the spine operating as a unit with the 4 arches of the spine properly balanced in relation to each other and the centre of gravity line.

Spinal areas to assess

Vulnerable areas to assess that carry the burden of the arch to arch formation and developments are: D4 and corresponding ribs D9 and corresponding ribs L3 D4 represents the terminus of downward pressure and torsion of head movements and the point of greatest strain. Lesions at D4 will tend to destroy the correlation of the triangles to each other and is a critical point in terms of normal postural development or failure. D9 is a keystone / a stress point and a pivot. Three parts to play rolled into one. The strength of the arch between D5-L2 will depend particularly on the inter-articulation above and below D9. If they fail to articulate properly the arch is considered weak not strong and you will find the entire arch between D5-L2 segmentally broken down into a series of short lateral curves. L3 the centre of gravity line passes through the vertebral body of L3 and this becomes the centre of gravity for the entire spine and body. It is a point of greatest strain because all the postural conditions of the body depend on this point either for a base or for support. It is the weakest point, because weight and tension antagonise each other here. L3 is the most important point in the spine and is the commonest seat of lesioning. The two points of greatest importance in the correlation of the spinal column are atD4 and L3. The key to adjusting the body and stabilising it is by way of a process of integration. This is the fundamental principle of classical osteopathy. We use the polygon of force as the framework and guide to integrating the spine and pelvis. The body adjustment routine is our treatment that enables us to appeal to the lines of force i.e. the polygon. So rather than working specifically on a problem area the application of the treatment occurs through the body lines and triangles so the individual vertebrae and spinal arches function in relation to the polygon of force, and only offering specific emphasis where it is necessary.

How do we do this?

Firstly assess and treat the pelvis as an integrated unit, 6 points must be correlated; Two hip joints / coccyx / 2 SI joints / L5, this is the baseline of the polygon. It is essential to treat the individual and combined articulation of these joints and establish movement translation through the 6 joints. Assess and treat the condition and position of L3 bearing in mind and hands that L3 is your centre of gravity and point of maximum strain. Assess and treat the central arch D5-L2 this is a double arch with a balance of alternate tension and compression forces and the strength of this region depends on the inter-articulation between the vertebrae. The structural and functional stability of D4 to the occiput and L3 to the pelvis depends on the mechanical form and function of this primary, central double arch D5-L2. Throughout the developmental milestones of a child we look for any segmentation of vertebral groups or arch- to- arch breakdown. Bearing in mind that a child aged between 0-7 years is erecting its centre of gravity line and the mechanisms that provide balance structurally and functionally in relation to this line. From 7-14 years if this balance mechanism is not secure and struggling to develop and mature, compensatory mechanisms take over, so at puberty and beyond the body begins to harden with all its lesion patterns and irregularities.

How often to treat the patient

Frequency of treatment will vary from child to child depending on the acute nature, chronicity and severity of the child’s condition. John Wernham used to advocate for the chronic case, approximately a year of treatment for every 10 years of life, and that is not necessarily every week, practitionership skill should determine the period of time between treatments. Finally in my 17 years of practice I have seen many children and adults who have suffered as a result of spinal developmental breakdown. Through the classical osteopathic approach of restoring the body equilibrium and preventing further deterioration we are able to give children and adults a more positive experience of the bodies they live in.

References:

Goddard Blythe S. The well balanced child. Hawthorn Press; 2004.
Goddard Blythe S. What babies and children really need. Hawthorn Press; 2008.
Glockler M , Goebal W. A guide to child health. Floris books; 2007.
The Institute of Classical Osteopathy. 1985/ 2001 Year Books.
Guyton & Hall. Textbook of Medical Physiology; Harcourt Brace; 1996.