Post on 05-Jan-2016
transcript
ADHD Overview
• History• Preliminary Diagnosis• Examination• Diagnosis• Treatment• Outcome Assessments
History• A mother presents to your office with her
8 year old son. Her primary complaint concerning her son is academic/behavioral issues and she has noticed he is clumsy compared to other children his age. She states he seems to run in an odd manner and has noticed he constantly bumps into furniture when walking and has poor eye contact. She was given a case history and a 7 day food diary to fill out and present at her next visit with her son.
History Continued
Upon review of the intake forms, her son had a previous diagnosis of ADHD but had only taken medication for a few months. He is up to date on his vaccinations as recommended by his pediatrician.
History Continued
• Motor Characteristics– Clumsiness and odd posture, muscles
seem floppy, runs oddly, fidgets excessively, poor eye contact, when he began walking he would walk on his toes when he was younger
• Sensory Characteristics– Poor spatial orientation, bumps into
things when walking, extremely picky eater, likes to swing, spin, and go on rides
History Continued
• Emotional Characteristics– Worries a lot, face lacks expression,
uptight, has several phobias
• Academic Characteristics– Poor math reasoning, poor reading
comprehension, takes everything literally, impatient, poor nonverbal communicator
• Immune Characteristics– Allergies, asthma, craves certain foods,
especially dairy and wheat products
Relevant Hx Questions
• How long have these behaviors been going on?
• How much exercises does your son get each day?
• Have you noticed certain times of day when behaviors are worse or after eating certain foods?
• How much time does your son spend watching TV/playing video games?
• How has this affected family life & his social life?
Exam
• Posture Findings– Anterior head carriage– Internally rotated shoulders– High left hip– High left shoulder– Slumped/stooped posture
Exam Continued
• Palpation & Listings– C6 Spinous Left– T4-T8 extension restrictions– Left AS– Tender nodules at base of skull– Tender nodules in rhomboids bilaterally
• Cervical ROM– Flexion 40/50– Extension 40/60– (L) Lateral Flexion 20/45 (R) Lat Flex. 20/45– (L) Rotation 55/80 (R) Rotation 55/80
Neurological Exam
• Motor– Cervical Flexion 2/5– Cervical Extension 2/5– Muscle Testing• C5 Anterior: 4/5
Middle: 4/5
Posterior: 3+/5• C6 – 4/5 C7 – 4/5• C8 – 4/5 T1 – 4/5
Neurological Exam Continued
• Sensory – WNL• Reflexes:– C5: 2-– C6: 2+– C7: 2+
• Romberg’s Sway: Falls to the left• Mittlemeyer’s March: Turns to the left• Tandem Gait: Falls to the left with eyes
open and even more so with eyes closed
Neurological Exam Continued
• MMS– Tight/Facilitated Muscles
• Pectoralis major/minor, Upper Traps, Levator Scapula• Bilateral SCMs/Scalenes
– Weak/Inhibited Muscles• Deep Neck Flexors, Lower/Middle Traps, • Posterior neck extensors, & Rhomboids
– Functional Movement Assessment:• Sit to Reach – Tight hamstring, knees buckled• Lunge – Falls to the left during lunge• Squat – Excessive swaying and wobbling
X-Rays
7 Day Food Diary
7 Day Food Diary
• Monday:– B – Chocolate milk and cereal– L – Lunchable, 3 Little Debbie cookies, Coke– D – Meatloaf, nacho cheese chips, 2 Coke’s
• Tuesday:– B – Chocolate milk, 3 Twinkies– L – Lunchable, Snickers, Dr. Pepper– D – TV Dinner, homemade brownies, Coke
7 Day Food Diary
• Wednesday:– B – Chocolate milk, leftover brownies– L – Butterfinger’s, Dr. Pepper– D – McDonald’s chicken nuggets, Dr. Pepper
• Thursday:– B – Chocolate milk, cereal– L – Hamburger & Fries, 4 cookies, Coke– D – McDonalds quarter pounder, Dr. Pepper,
Apple Pie
7 Day Food Diary
• Friday:– B – Chocolate milk, pancakes, blueberry
muffins– L – Chicken nuggets, brownie, Coke– D - On the Border Burrito, 3 Dr. Peppers,
Brownie fudge Sunday
• Saturday:– B – Chocolate milk, 9 doughnuts– L – PBJ, 2 Butterfingers, 2 Dr. Peppers– D – 4 slices of Pizza Hut pizza, half liter of
Coke
7 Day Food Diary
• Sunday:– B – Chocolate milk, 5 doughnuts & saussage– L – McDonald’s chicken nuggets w/Coke– D – Hamburger Helper, chips, 3 peanut butter
cookies, 2 Dr. Peppers
Working Diagnosis
Acquired Cervical Kyphosis 737.10
Additional Tests & Labs
• TOVA – Test of Variables of Attention www.tovatest.com
• NutrEval from Genova DiagnosticsBased on information from food diary a test assessing nutritional/functional status of patient was ordered
Test results
Test results
What is ADHD
• ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development.
• This pattern usually becomes evident in the preschool or early elementary years.
SymptomsFrontal lobe syndrome
• Inattentive symptoms:• easily distracted, forget things, and frequently switch from
one activity to another• Have difficulty maintaining focus on one task• Become bored with a task after only a few minutes, unless
doing something enjoyable• Have difficulty focusing attention on organizing and
completing a task or learning something new• Not seem to listen when spoken to• Daydream, become easily confused, and move slowly• Have difficulty processing information as quickly and
accurately as others• Struggle to follow instructions.• Hyperactive-impulsive symptoms:• Talk nonstop• Dash around, touching or playing with anything and
everything in sight• Have trouble sitting still during dinner and story time• Have difficulty doing quiet tasks or activities.• Impulsivity symptoms:• Be very impatient• Blurt out inappropriate comments, show their emotions
without restraint, and act without regard for consequences• Have difficulty waiting for things they want or waiting their
turns in games
AD/HD• Cognitive symptoms• Short attention span• Poor working memory• Poor short term memory• Difficulty in planning and reasoning• Emotional symptoms• Difficulty in inhibiting emotions, anger,
excitement, sadness etc...• Depression, possibly due to above.• Occasionally, difficulty in understanding others
points of view, leading to anger and frustration.• Behavioural symptoms• Utilization behavior• Perseveration behavior• Inappropriate aggression
M/C Treatments
• Ritalin and Adderall = Stimulants• All stimulants work by increasing dopamine
levels in the brain—dopamine is a neurotransmitter associated with pleasure, movement, and attention.
• Effects = they suppress appetite, increase wakefulness, and increase focus and attention.
• Ritalin = cocaine • Adderall = speed (amphetamine)• Addictives? Tolerance? @ 8 y/o?
Ritalin side effects• Common Side Effects• Addiction• Nervousness including agitation, anxiety and
irritability• Trouble sleeping (insomnia) • Decreased appetite • Headache• Stomach ache• Nausea• Dizziness• Heart palpitations
• Other Serious Side Effects Include• Slowing of growth (height and weight) in
children• Seizures, mainly in patients with a history of
seizures• Eyesight changes or blurred vision
• Less Common Side Effects• High blood pressure • Rapid pulse rate (and other heart problems)• Tolerance (constant need to raise the dose) • Feelings of suspicion and paranoia• Visual hallucinations (seeing things that are
not there)• Depression• Cocaine craving • Dermatoses (infected or diseased skin) • Urinary tract infection• Infection or viral infection • Elevated ALT enzyme levels in the blood
(signaling liver damage)
• This is why it carries the BLACK BOX label. (Highest warning available by the FDA) Meaning that can cause sudden death.
BIOMEDICAL RISK FACTORS FOR ADHD
• 1) Food and Additive Allergies and Sensitivities• 2) Heavy Metal Toxicity • 3) Low-Protein, High-Carbohydrate Diet • 4) Mineral Imbalances • 5) Essential Fatty Acid and Phospholipid
Deficiencies• 6) Amino Acid Deficiencies • 7) Thyroid Disorders • 8) B Vitamin Deficiencies
Case Type:Ritalin vs. Nutritional supplements• Table 1a. Supplements Used in the Alternative Treatment Group• Gastrointestinal and Immune Support (Risk Factor #1)• (1) Lactobacillus acidophilus and bifidus• (2) Lactoferrin (5 mg)• (3) Silymarin (5 mg)• Sulfur-Containing Supplements and Glycine (Risk Factor #2)• (1) Taurine (275-425 mg)• (2) Glycine (700-1830 mg)• (3) Methionine (25-75 mg)• (4) N-acetylcysteine (NAC) (0-10 mg)• (5) L-cysteine (0-25 mg)• (6) Glutathione (20 mg)• (7) alpha Lipoic acid (5 mg)• (8) Garlic extract (200 mg)• Amino Acids (Risk Factors #3 and #6)• (1)Tyrosine (900-1800 mg)• (2) Histidine (25-75 mg)• (3) Glutamine (600-1400 mg)• (4) alpha Ketoglutarate (AKG) (25-75 mg)• (5) L-carnitine (30 mg)• Minerals (Risk Factor #4)• (1) Magnesium (as magnesium glycinate) (220-480 mg)• (2) Calcium (as calcium ascorbate) (110-170 mg)• (3) Potassium (as glycerol phosphate) (46-70 mg)• (4) Chromium (as nicotinate) (140-200 mcg)• (5) Selenium (as methionate) (26-32 mcg)• (6) Zinc (as monomethionate) (9-15 mg)• (7) Manganese (as arginate) (2.5-4 mg)• (8) Boron (as citrate) (1200-1800 mcg)• (9) Copper (as tyrosinate) (1.2-2.4 mg)• (10) Silica (4 mg)• (11) Molybdenum (as chelate) (5-40 mcg)• (12) Vanadium (chelate) (2-20 mcg)• (13) Iron (as glycinate) (1-2 mg)
• Table 1b. Supplements Used in the Alternative Treatment Group
• Essential Fatty Acids and Phospholipids (Risk Factor #5)• (1) Salmon oil 1000 mg (EPA 180 mg; DHA 120 mg)• (2) Borage oil 200 mg (GLA 45 mg)• (3) Purified Soy Lecithin (Phosphatidyl choline 50-150 mg; Inositol 20-25• mg)• (4) Choline bitartrate (2.5-7.5 mg)• Agents to Support Thyroid Functioning (Risk Factor #7)• (1) Iodine (from kelp) (25-150 mcg)• (2) Tyrosine (900-1800 mg)• B Vitamins and Phytonutrients (Risk Factor #8)• (1) Vitamin B1 (as thiamine and thiamine pyrophosphate) (22.5-27.5 mg)• (2) Vitamin B2 (as riboflavin and riboflavin phosphate) (22.5-27.5 mg)• (3) Vitamin B3 (as niacin and niacinamide) (75-140 mg)• (4) Vitamin B5 (as D-calcium pantothenate and pantethine) (50-70 mg)• (5) Vitamin B6 (as pyridoxine and pyridoxal-5-phosphate) (43-86 mg)• (6) Vitamin B12 (cyanocobalamin) (90-175 mcg)• (7) Folic acid (435-760 mcg)• (8) Biotin (20-400 mcg)• (9) PABA (22.5-27.5 mg)• (10) Vitamin E (140-200 IU)• (11) Vitamin C (750-1000 mg)• (12) Vitamin A (as vitamin A and beta carotene) (2000-4500 IU)• (13) Vitamin D3 (40-100 IU)• (14) Vitamin K (20 mcg)• (15) Royal bee jelly (source of biopterin) (75-150 mg)• (16) Dimethyl glycine (10 mg)• (17) Citrus bioflavonoids (10-20 mg)• (18) Proanthocyanidins (grape seed) (5 mg)• (19) Bilberry extract (20 mg)• (20) Soy constituents (saponins, isoflavones, phytosterols) (20 mg)
• Ritalin: All children in the Ritalin group received prescribed doses of 5-15 mg Ritalin 2-3 times daily, as determined by the prescribing physician.
Facts• Did you know that a child taking a psycho-
tropic, psycho-stimulant drugs like Ritalin after the age of 12 is ineligible for military service?
• Did you know that the subjective checklists that are being used as criteria for diagnosis are very similar to the checklists used to determine Gifted and Talented Children? These two checklists are almost identical.
• One toy might be recalled if 1 or 2 children die from it. How many children have to die from these drugs before we realize and put an end to this horror.
• Source: www.ritalindeath.com
Treatment Plan: Mix Fix Set
• Phase I of Treatment – Frequency: 5x/wk for 2 weeks
• Goals: – Reduce global somatic dysfunction by reducing
kyphosis• Patient is to undergo another complete set of films
at the end of Phase II
Treatment Plan Cont.
• Increase cervical range of motion– Flexion – 40 ⁰ to 45 ⁰– Extension – 40 ⁰ to 50 ⁰– L lat flex. - 20 ⁰ to 30 ⁰– R lat flex. - 20 ⁰ to 30 ⁰– R Rotation - 55 ⁰ to 75 ⁰– L Rotation - 55 ⁰ to 75 ⁰
Treatment Plan Cont.
• Decrease abnormal posture– Activate and strengthen core muscles
(Transverse abs, Int. and Ext. Obliques)• Planks with cervical extension
– Stretch shortened muscles• Bilateral Pecs• Bilateral SCMs/Scalenes
– Strengthen weak/inhibited muscles• Posterior neck muscles• Upper, middle & lower traps• Posterior deltoids
Treatment Plan Cont.
• Whole body extension exercises– Supermans
• Coronal Plane Exercises– Bilateral overhead arm raises– Side to side 2 foot jumps
• Increase proprioception from left side of body– Increase time standing on left leg on vibe
• Nutritional Support– See protocol below
Treatment Plan Cont.
• Mix (Warm up)– One legged stands recorded first thing
bilaterally– 8 minutes of wobbling in wobble chair (all
planes of motion)– 50 prone neck rotations
• Fix (Adjustment)– Post to Ant. Prone cervicals along the planes of
the facets– Spinous contact C6/C7 Left Lat Flexion
Restriction– Ant. Thoracics to correct hyper-flexion of
thoracic spine– Left AS Ilium
Treatment Plan Cont.
• Set (stabilize soft tissue)– Assisted one legged stands on vibe for 3x 1
minute on left leg– Post-isometric Relaxation on hypertonic
muscles– Vibe platform for 10 min while wearing
glasses with tape covering the top half of lens
– Right Shoulder weight– Right posterior and left anterior hip weights
Treatment Plan Cont.
• Exercises– 3 sets of 20 reps bilateral standing overhead
arm raises– 3 sets of 8 reps lateral cervical flexion– 3 sets of 20 second prone extensions aka
superman exercises– 3 sets of 20 second prone planks with head held
in extension– 3 sets of 10 2 footed hops to Left and 5 to Right
in coronal plane– Repeated 1-legged stands – bilaterally recorded
time
Re-evaluation/Outcome Assessments
• Retake ranges of motion• Take into account weekly grade report from
school• One legged stands – both should be improving,
left catching up to right• Go over weekly food logs with pts – make
recommendations as necessary• Brain balance tests – mittlemeyer march test,
heel to toe walk eyes open and closed, rhombergs
• Recheck previously weak muscles and grade• Functional movement assessments – see exam
Phase II Treatment Plan Cont.
• Phase II of Treatment – Frequency: 3x/wk for 8 weeks
• Goals:– Reduce global somatic dysfunction by
reducing kyphosis/restoring normal cervical lordosis
– Patient is to undergo another complete set of films at the end of Phase II Tx plan
Phase II Treatment Plan Cont.
• Increase cervical ranges of motion– Flexion - 45 ⁰ to 50 ⁰– Extension - 50 ⁰ to 60 ⁰– L lat flex - 30 ⁰ to 45 ⁰– R lat flex - 30 ⁰ to 45 ⁰– R rotation - 75 ⁰ to 80 ⁰– L rotation - 75 ⁰ to 80 ⁰
Phase II Treatment Plan Cont.
• Decrease abnormal posture– Stretch shortened muscles as needed from last
re-exam• Bilateral pec major/minor• Bilateral SCMs/Scalenes
– Strengthen weak/inhibited muscles – increased sets and reps from Phase I• Post. Neck muscles• Middle and lower trap• Post. Deltoid
Phase II Treatment Plan Cont.
• Whole body extension exercises– Superman– Coronal Plane Exercises
• Bilateral overhead arm raises• Side to side 2 foot jumps
• Increase proprioception from left side of body– Increased time standing on left leg on vibe
• Nutritional Support– See protocol below
Phase II Treatment Plan Cont.
• Mix (warm up)– One legged stands recorded first thing bilaterally– 8 minutes of wobbling in wobble chair– 100 prone neck rotations
• Fix (adjustment)– Post. to Ant. Prone cervicals along the planes of
the facets– Spinous contact C6/C7 left lat. flexion restriction– Ant. Thoracics to correct hyperflexion of thoracic
spine– Left AS ilium
Phase II Treatment Plan Cont.
• Set (stabilize soft tissue)– Assisted one legged stand on vibe for 3x 1
min on left leg– Post-isometric relaxation of hypertonic
muscles– Vibe platform for 10 min w/glasses that
have tape on top half on lens– Right shoulder weight– Right posterior and left anterior hip weights
Phase II Treatment Plan Cont.
• Exercises– 4 sets of 20 reps bilateral standing overhead
arm raises– 4 sets of 30 second prone extensions aka
superman exercises– 4 sets of 30 second prone planks with head
held in extension– 3 sets of 10 2 footed hops to left and 5 to
right in coronal plane– Repeated 1-legged stands bilaterally and
record time
Phase II Treatment Plan Cont.• Re-evaluation – taken on 7 week of care– Retake ranges of motion– Take into account weekly grade report from
school– One legged stands, both should be improving,
left catching up with right– Go over weekly food logs with pts, make
recommendations as necessary– Brain balance tests – mittlemeyer march test,
heel to toe walk eyes open & closed, rhombergs– Recheck previously weak muscles and grade– Re-xray at the end of Phase II
Phase II evaluation X-rays
Re-evaluation/Outcome Assessments
• Retake ranges of motion• Take into account weekly grade report from
school• One legged stands – both should be improving,
left catching up to right• Go over weekly food logs with pts – make
recommendations as necessary• Brain balance tests – mittlemeyer march test,
heel to toe walk eyes open and closed, rhombergs
• Recheck previously weak muscles and grade• Functional movement assessments – see exam
Outcome Assessment• One Leg Stance: Unable to stand for
30/60 seconds on either leg without falling– Timed (eyes closed) Left leg stance – 4 sec. Right leg stance – 10 sec– Timed (eyes open) Left leg stance – 8 sec Right leg stance – 10 sec
• TOVA scores
Phase III Treatment Plan Cont.
• Phase III– Once goals are achieved continue with
regular weekly proactive maintenance
Nutrition & Lifestyle modification for ADHD
• Diet– Elimination diet helps detoxifying. Link between
GI system and behavior.• Ex. – sugar, additives, colors, and preservatives
– Impaired catecholamine control (Epi/Norepi) of sugar was found in children with ADHD and may be associated with worsening of behavior following a sucrose challenge.
– Allergies and ADHD: may have an increase of EFA requirements. Mechanism: Inflammatory mediators and neuro-peptides have been shown to be increased in blood after exposure to a sensitizing food
Nutrition & Lifestyle modification for ADHD
• Essential Fatty Acids– DHA plays a critical role during pregnancy,
infant development, adult life and old age– Imbalance of EFA in the brain plays a role in
ADHD because EFAs are essential for normal neuronal structure and function, maintenance of membrane fluidity, impulse transmission, receptor sensitivity, and maintenance of adequate NT pool
Nutrition & Lifestyle modification for ADHD
• Omega – 3– Abnormalities of FA membrane phospholipids
metabolism play role in neuro developmental and psychiatric disorders. Some studies found that children with ADHD have a measurable decrease in tissue levels of Omega -3 FA when compared with age matched controls.
– 30ml/day of liquid concentrate EPA & DHA
Nutrition & Lifestyle modification for ADHD
• ADHD kids show an increase in oxidation of Omega 3, and impaired ability to synthesize DHA from regular diet.
• Recommendations to keep Omega 3, Omega 6 ratio 1:1 or 1:6 to maintain membrane and receptor sensitivity.
• Diets with high trans-fat causes a block on enzymatic conversion of vegetable derived Omega 3 and Omega 6 FA into critical long chain FA of DHA.
Nutrition & Lifestyle modification for ADHD
• Probiotics:– An increase in intestinal permeability due to
diet, antibiotic treatments and medications.– Bifidobacteria and Lactobacilli: to maintain
normal gut flora with normal species is important in preserving the mucosa barrier of the gut.
Nutrition & Lifestyle modification for ADHD
• Vitamins and Minerals– Zinc• Co-factor in metabolism of NT like dopamine,
and melatonin. For positive effects to be seen you need about 150mg/day of Zinc Sulphate• Improvement in impulsive behaviors and
socialization skills
– Magnesium• 100mg/day to improve behavior
Nutrition & Lifestyle modification for ADHD
• B complex– 500mg/day Co-factor in metabolism of NT
dopamine.
• Iron & copper– 2mg/day Co-factor in metabolism of NT
dopamine.
• Tyrosine– 1500mg/day Essential amino acid to
produce dopamine.
Nutrition & Lifestyle modification for ADHD
• Ginkobiloba & Panax Quinquefolious– 200mg/day to improve both school
performance and behavior in 74% of ADHD patients in 4 weeks
• L-theanine (amino acid found in green tea)– Recent double blind studies show that it
may improve dopaminergic activity, stabilize mood, increase concentration, decrease anxiety, and improve quality of sleep.
Nutrition & Lifestyle modification for ADHD
• Valerian– Helps you fall asleep– Most effective in children with hyperactive
behavior
• Melatonin– 5mg/day showed an increase in total sleep
time in children with chronic insomnia and ADHD
Nutrition & Lifestyle modification for ADHD
• Aromatherapy– Essential oils (EO) molecules interact with
receptors on nerves. When inhaled, the EO directly access the limbic system• Lavender
– Relaxing neurostimulant (computational speed and accuracy)
• Rosemary– Mild stimulant and increases computational speed without
decreasing accuracy
Nutrition & Lifestyle modification for ADHD
• Massage– Releases endogenous endorphins in the
body, improving short term mood and long term class behavior
– In adolescents with ADHD, more “on time and on task”
– A decrease in hyperactivity scores were reported by teachers
Nutrition & Lifestyle modification for ADHD
• Lifestyle Modification– Developing a routine and rhythms that help with
the regulatory disturbances that are described in children with ADHD
– Green surroundings widely effective in symptoms– Establish a sleep routine and limit TV viewing
• Less than 2 hours/day of TV is recommended by the American Academy of Pediatrics
• Lack of sleep and overstimulation are known to be associated with symptoms of inattention, hyperactivity, irritability, and aggression in children