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From the Townsend Letter
July 2007


Applied Kinesiology: An Effective Complementary Treatment for Children with Down Syndrome
by Scott C. Cuthbert, BA, BCAO, DC

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Author's Note: "Down's syndrome" was a term formerly used to describe these patients, but that is no longer the proper terminology. The use of People First Terminology is important when working with these patients and their families and advocates. People First Terminology encourages us to refer to the person first and the disability second. The Down syndrome does not define these children or adults. It is not their identity. It is only one thing about them. So we do not say "a Down syndrome child." We say "a child with Down syndrome" today.

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Scott CuthbertI have been very fortunate this year to work with 15 families whose children have Down syndrome. This essay will describe these children's' histories, their clinical findings, and their evaluation and treatment using applied kinesiology methods.

People with mental and physical disabilities are the largest minority group in this country. They outnumber Latinos, African-Americans, and Asians. People with Down syndrome are now living at home within our communities. They are growing up with their peers at school and at play, working side by side, dating and living independently, and growing old. Their lives now present new opportunities and challenges to conquer for themselves and for those who work and live with them every day. People with physical and mental disabilities are going to be seen, increasingly, as the individuals they are, with individual abilities that are going to be nurtured and enhanced. I think we are going to recognize that they have individual personalities to be appreciated, individual lifestyles to be lived fully and with gusto, just like everybody else. And, frankly, with our gifts in the evaluation and treatment of neurologic disorders, chiropractic and other holistic physicians with skills in the cranial arts should be on the front lines of the coming renaissance for these people. If you can make contact with a few of these patients or their advocates in your community and increase their level of health by your service, you will open a doorway that will increase your reputation and your practice in your community.

There is evidence in ancient art and literature that people with trisomy 21 have long been part of the human race. In 1866, Dr. John Langdon Down first remarked on the facial similarities of a group of his mentally retarded patients. With the identification of the chromosomal basis of Down syndrome in 1959, a gradual process of acceptance of trisomy 21 as being a variation of normal began to remove some of the handicap and end the uninformed debates over the "humanity" of people with Down syndrome. Down syndrome is the most common readily identifiable cause of intellectual disability, accounting for almost one-third of all cases. It occurs equally in all races with an overall incidence of approximately one in 800 births; approximately 4,000 children with Down syndrome are born each year. This is much lower than the actual conception rate due to a high incidence of spontaneous and surgical abortion. Congenital heart disease affects 40% of these babies. Severe congenital heart disease remains a major killer of children with Down syndrome, despite advances in surgical treatment. In the absence of a congenital heart defect, the majority of children can expect to live into their sixth decade. Up to 15% of children with Down syndrome will have radiological evidence of instability of the atlantoaxial joint, but in only a handful of cases will this instability result in an impingement of the spinal cord with resultant neurological signs. Many reasons have been proposed in the literature about the causes of the improper cell division that leads to Down syndrome (Trisomy 21); genetic predisposition, maternal age, hormonal abnormalities, X-ray exposure, immunologic problems, potent drugs, and viral infection may be involved in these patients' history.

People with Down syndrome now compete in the nation's work force. They used to live in segregated day programs of which there are, even today, over 7,000 in the US. Real work is now commonplace for these patients. This is a program called "supported employment." The basic notion involves the use of a trained staff person who accompanies the person with a disability into a paid placement in the workplace. Between 1985 and 1995, there was growth of this program from less than 10,000 people with disabilities in supported employment to over 150,000.

Children with Down syndrome will be developmentally slower than their siblings and peers and have intellectual functioning in the moderately disabled range, but the range is enormous, and the distance from their peers is the crucial factor where chiropractic and cranial therapeutics can make a profound difference.

Neuromusculoskeletal Disorders in Down Syndrome
The cranial structure of the child with Down syndrome presents certain variations from the normal anatomic pattern that result in the characteristic slanting eyes, undeveloped nasion, infantile features, and so on. In children with Down syndrome, the head has been described as brachycephalic, which is a shortening of the anteroposterior diameter with flattening of the occiput. Brachycephalic heads produce an anterior displacement of the condylar parts of the occiput into the facets of the atlas. The posterior arch of the atlas vertebra may also approximate the odontoid process of the axis. The vertebral canal may be narrowed, with possible impingement of the medulla and increasing tensions upon the craniosacral reciprocal tension membranes (RTM). This one primary cranial distortion produces profound consequences throughout the spine and pelvis. Usually the heads of children with Down syndrome are smaller than in age-equivalent children who do not have Down syndrome; thus, the cranial capacity is reduced. The nasal bones are poorly developed, and the maxilla as well as the sphenoid has been described as hypoplastic. Frequently, the palate is narrow and short, which, together with the maxillary hypoplasia, results in a small oral cavity. These features may be improved with proper cranial therapy.

It has been postulated that children with Down syndrome have an intrinsic defect of their connective tissue that is responsible for the observed general ligamentous laxity. Recently, it has been shown that fetal heart collagen is encoded by two genes mapped on the distal part of the long arm of chromosome 21.1 There are specific musculoskeletal disorders such as atlantoaxial instability, hip dislocation, patellar subluxation, and others that deserve special attention. The pelvic bones of infants with Down syndrome usually show flattening of the acetabular angle, widening of the iliac wings, small ischial rami, and coxa valga of the femur.

However, because muscle tone and neurological disorganization can be corrected so quickly using proper cranial and other natural health care procedures, the question of whether these genetic disorders are the cause of these problems should be investigated in every patient.

In most of these cases of Down syndrome, I found that the occiput was deformed to a greater or lesser degree. This interosseous cranial fault of the occiput, called the universal cranial fault in applied kinesiology, has been described by Drs. Goodheart, Walther, DeJarnette, Sutherland, Magoun, Arbuckle, Frymann, Upledger, and many others. (See Figure 1.) The amount of this deformity has shown some correlation with the extent and severity of the disabilities in the child.2-9

Occiput and CerebellumFigure 1: The Occiput and Cerebellum in Down Syndrome
The interosseous distortion of the occiput (the universal Cranial Fault) changes the position of the condyles, the shape of the foramen magnum, the position and shape of the jugular foramina, the elasticity of the tentorium, the drainage of blood from the head, the movement of cerebral spinal fluid (CSF) through the interstices of the brain, the shape of the cerebellum itself, and increases the tension upon the cranial membranes throughout the skull. This distortion is transmitted to all the other bones of the skull. *

The growth of the brain is definitely affected by the resistance it meets. As the skeleton and muscles give the body its shape, so do the cranium and dura help maintain the shape of the brain as it checks, guides, and coordinates the brain's movement. With many children who have extensive cranial structural anomalies and faults, it would not be possible for either the cerebellum or the frontal lobes to grow symmetrically without proper cranial corrections.

Flattening of the occiput on one or both sides was a common finding in these patients (approximately 90%). The head was shortened in its anteroposterior diameter and very wide transversely. The lateral angles of the flattened occiput produce a spreading pressure upon the parietal bones. The petrous portions of the temporals was also put into external rotation, thus putting extra tension on the tentorium and pulling the falx down. Whenever we see a flattened occiput in a patient, it is vital that we evaluate for cerebellar disturbances.

Confusion of the basilar bones as a result of the flattened occiput produces abnormal tensions in the membranes that may cause crowding of the cerebellum low in the posterior cranial fossa, forcing the medulla and pyramidal tracts against the basilar portion of the occiput. (See Figure 2.) If the medulla and motor tracts of the cord as they leave the medulla have been forced low in the posterior cranial fossa against the rim of the foramen magnum, imagine then what kind of additional tensions will be created for the little child with a subluxation of the atlas vertebra.

Figure 2: Cranial Base Superior View Cranial Base Superior View

Almost every major nerve pathway from the brain to the body and from the body to the brain pass through the space contained within the developing portions of the occiput. Besides the effect of the pressure of this crowding upon the cerebellum and brainstem, and cranial nerves 9-12, there will also be dramatic changes in the spaces through which cerebrospinal fluid must pass.

This is where the hypoglossal nerve to the tongue and the vagus nerve to the digestive tract pass out through the skull. These are the areas that are the first to show the stress of birth (vomiting, an inability to suckle, spitting up). Deformities of this area of the skull were very common in the children with Down syndrome I have treated, and the injury to the nervous system found there varied from the child who had mild spitting-up difficulties to the child who was very passive to the child who was hyperactive, aggressive, with behavior problems, and so on. This is a very critical area, one that we should always evaluate when we treat newborn babies.

The junction of the medulla oblongata and the spinal cord at the level of the occipito-atlantal articulation is crucial to normalize in these patients. The pyramidal tracts above this level and the decussation of the pyramidal tracts just below rest upon the basilar portion of the occiput. The extra pyramidal tracts situated laterally at this level are involved with muscle tone. Hypotonia (the "floppy baby" phenomenon, which is a very common finding in children with Down syndrome) may be the manifestation of dysfunctions at this level.

The occiput originates from four parts at birth, and these are not fully united into a single bone until the child is around six years of age. Because these multiplicities of articulations are held in place primarily by the membranous tensions in the meninges, it is imperative that we correct cranial faults as early in life as possible. Any interosseous distortions that remain in a child after the age of six are much more difficult to correct. The consequences of leaving them uncorrected may be the difference between normal and abnormal development of the entire central nervous system. Any of the twenty-four cranial nerves can be affected by interosseous distortions of the cranium.

The four developing parts of the occiput circle the large hole of the foramen magnum, through which the brain stem passes. When the occiput is flat or its squama, condylar, or basilar portions are warped (posterior on one side and anterior on the other), you can assume that the foramen magnum will not be symmetrical, and that it is narrowed on one side compared to the other. Applied Kinesiology challenge procedures to the condylar portions of the occiput can determine this.

The strain created within the cranium by the universal cranial fault is transferred to the central joint of the skull, between the sphenoid and the occiput, called the sphenobasilar joint. The tension placed upon the pyramidal tracts, the medulla, and the cranial nerves at the base of the skull can be imagined if you visualize the sphenobasilar articulation from above. If there is a turning, twisting, or side-bending of this joint, and if the joint is additionally in flexion or extension, as is so often the case, then the added strain on the overlying pyramidal tracts, medulla, cranial nerve foramina, and the cerebral aqueducts should be apparent. (See Figure 3.)
Universal Cranial Fault

Figure 3:
The Universal Cranial Fault

The universal cranial fault produces counter-rotation of the sphenoid and occipital bones. The sphenoid is the most complex bone in the body. Twelve of the twenty-four cranial nerves pass through or over it. The pituitary gland is cinched into the sphenoid by the roof of the tentorium cerebelli. The sphenoid has extensive muscular attachments to the temporomandibular joint. Because of the interleaving of the reciprocal tension membranes, any fault of the sphenoid will create tensions throughout the cranial mechanism, and vice versa.

The slanting eyes commonly found in children with Down syndrome are a developmental distortion of the sphenoid. (See Figure 4.) The myopia or cross-eyes are due to the same distortion, thereby displacing the origins of the extrinsic muscles of the eyeball around the optic foramen in the roots of the lesser wing of the sphenoid.

Figure 4: Sphenoid BoneSphenoid Bone
Another factor relating to the growth potentials in children with Down syndrome may be the pituitary gland, whose neural, endocrine, vascular, and cerebrospinal fluid components are modified by the dural investments, which cinch it into place from at least four directions laterally, and from above and below as well.

The dura, the diaphragma sella, the falx, and the tentorium all bring the pituitary into a fundamental mechanical relationship with the sphenobasilar joint (synchon-drosis). Any tilting of the sphenoid (producing the slightly slanted eyes in children with Down syndrome) will be transmitted to the diaphragma sella, attached to the clinoid processes, and blended with the contiguous and surrounding dura mater. (See Figure 5.) This tension may be transmitted to the infundibulum, which connects the pituitary to the hypothalamus.

Cranial SystemFigure 5: Cranial System
Eighty percent of the nervous system operates within the mobile compartments shown below. Hundreds of research studies have now demonstrated the movement potentials and neurological consequences of immobility in the cranial system.10 Dural tension anywhere in the cranial-sacral system can be transmitted to the pituitary gland and hypothalamus and may affect growth or endocrine function. Cranial tissue tension and organ function is thereby mechanically related to cranial respiratory function.

According to Best and Taylor, 100,000 fibers pass through the infundibulum. The shape of the sphenoid and the position of the sphenobasilar synchondrosis will influence the position of, and the tension upon, the foramen in the diaphragma sella through which the infundibulum passes. This mechanical fault at the center of the autonomic and endocrine systems is crucial to normalize if possible. Insistent and prolonged molding of the cranial base and freeing of the sutures to stimulate pituitary action can be of considerable significance in these cases. Case 9 below demonstrates this phenomenon.

Applied Kinesiology Chiropractic: A Profile
Applied Kinesiology (AK) is a method of chiropractic founded by George J. Goodheart, Jr., a chiropractic physician practicing near Detroit, Michigan. AK has been in the chiropractic profession for over 42 years and is now used throughout the healing professions. In a survey by the National Board of Chiropractic Examiners in 2000, 43.2% of respondents stated that they used AK in their practices, up from 37.2% of respondents who reported they used AK in 1991,11-13 with similar numbers reported in Australia.14 The general public's awareness of manual muscle testing (MMT) and AK has also been increased worldwide by virtue of the patient education program Touch for Health (T4H), designed by an International College of Applied Kinesiology (ICAK) diplomate, John Thie. T4H was one of the first public self-help programs and is the fastest growing "body work" program in the world, used by over ten million people. The Touch for Health book is the largest selling complementary health book in the world, with 12 million copies sold in over 40 countries.15

AK employs manual muscle testing (MMT) as a major part of evaluating patients in conjunction with standard natural health care evaluations and diagnostic modalities. Successive diagnostic and therapeutic procedures were developed for the objective testing (MMT) of neurolymphatic reflexes, neurovascular reflexes, and cerebrospinal fluid flow, from ideas originally described by Frank Chapman, DO, Terrance J. Bennett, DC, and William G. Sutherland, DO, respectively. Later, influenced by the writings of Felix Mann, MD, Goodheart incorporated acupuncture meridian therapy into the AK system. Additionally, the vertebral challenge method (1972) and therapy localization technique (1974) were added. The correlation of nutritional influences on muscle physiology has also been extensively studied. The myofascial ideas of Fulford, Jones, and Travell are also an important part of the AK system.16 The work of Major B. DeJarnette, DO, DC, and founder of the sacro-occipital technique (SOT), is also a major part of AK's diagnostic and therapeutic procedures.4

During an AK examination, the doctor looks for patterns of inhibition (weakness) and facilitation (strength) in the nervous system. MMT evaluates the anterior horn motor neurons to a muscle, and a treatment that improves the facilitation (strength) of a muscle also improves the function on the final common pathway to muscles in the anterior horn motor neurons of the spinal cord, as well as the motor portion of the cranial nerves. Because of the communication systems in the body between the nervous, circulatory, and muscular tissues, a disturbed portion of the muscular system can impair the function of other tissues and organs, especially those with which it is neurologically and anatomically most closely related. The overall tone of the nervous system is thought to be evaluated and treated using these methods. Since 1964, the AK community of physicians worldwide (members of the International College of Applied Kinesiology) has continued to test various therapeutic approaches using manual muscle testing as a clinical parameter for the measurement of physiologic response and the restoration of normal muscle function.

AK is a novel diagnostic and therapeutic chiropractic technique that has support within the chiropractic, dental, biofeedback, acupuncture, veterinary, and other health care modalities. Even with the wide popularity that MMT has achieved among chiropractors and other physicians in the United States and around the world, few practitioners are familiar with the laboratory research underlying AK MMT procedures.17-65 AK uses a method of diagnosis with specific methods of MMT to guide treatment and to validate the effectiveness of care rendered to the patient.

As with most chiropractic techniques, the research is ongoing and in the developmental phase, however, there is mounting evidence of its clinical effectiveness and greater studies are warranted.66-68 Hopefully this paper has stimulated the desire to review the current AK literature and become an effective user of and contributor to chiropractic AK research.69-71

It is very difficult to localize and distinguish between the various palpated and tested tissues in the cranial area. Only by having a thorough knowledge of both the external and internal anatomy of the skull can this be accomplished. However the internal cranial tissues can be specifically tested using non-invasive AK MMT procedures, and the muscle changes found can be anatomically interpreted by the physician as to the location of the primary involvement: cranial bone involved, foraminal and cranial nerve entrapment suspected, extra-cranial muscular involvement, and so on.2-3 Specific cranial and vertebral challenges and MMT offers us the best way to differentially diagnose a cranial bone problem from many other problems in this wonderfully complex area. Using MMT, a physician can make rapid, accurate, and highly specific assessments of the cranio-sacral mechanism. Adding this mode of evaluation and treatment to your daily patient visits should expand your scope of practice and your reputation among your patients.

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