Patient Information: 

DOB: 03/30/23 

Initial Visit: 12/7/23 

Birth History: Induced delivery one day after due date, suffered hypoxic ischemic encephalopathy during birth, initial APGAR scores 2 and 1 respectively, required resuscitation, intubation, epinephrine administration, and penicillin treatment due to birth complications. 

Clinical Examination Findings: 

1. Myoclonic Seizure Activity: The patient exhibited multiple myoclonic seizures during the evaluation. 

2. Delayed Motor Development: There was evidence of delayed gross and fine motor development. 

3. Tonic Neck Reflex: The presence of the tonic neck reflex was noted, which can affect motor coordination and posture. 

4. Increased Moro Response: The Moro response was increased, indicating heightened neurological sensitivity. 

5. Closed Anterior and Mastoid Fontanelles: Both anterior and mastoid fontanelles were found to be closed, which may indicate abnormal cranial development. 

6. Atlas Restriction to the Left: Restriction of the atlas to the left was observed, suggesting misalignment in the upper cervical spine. 

Presenting Symptoms: Myoclonic seizures (several dozen per day), delayed motor development, utilizing G-tube since 6-week NICU stay. 

7. Severe Head Lag: Severe head lag was noted, indicating poor head control and muscle tone. 

8. Left Sacral Crease: The presence of a left sacral crease was observed, suggesting sacral asymmetry. 

9. Cervical Stair-step Locked on First Step: The cervical stair-step was locked on the first step, indicative of cervical spine misalignment. 

10. Right Short Leg: A right reactive short leg was identified, in the prone and supine position. 

11. Sluggish Direct Light Reflex Bilaterally: Bilateral sluggishness of the direct light reflex was noted, indicating potential optic nerve dysfunction. 

12. Sluggish Eye Convergence Bilaterally: Bilateral sluggishness of eye convergence was observed, suggesting impaired oculomotor function. 

13. Left Internal Frontal Subluxation: Subluxation of the left internal frontal bone was observed, which may affect cranial nerve function. 

14. Left Occipital Compression: Compression of the left occipital bone was noted, potentially impacting cranial nerve function and spinal alignment. 

Chiropractic Adjustments: 

• Initiated chiropractic spinal adjustments and cranial adjustments at a frequency of 2 times per week for 8 weeks. 
• Initial focus on addressing atlas restriction, occipital compression, and sphenobasilar dysfunction. 
• As her pattern began to change anterior sacrum and frontal subluxations were also addressed. 

Treatment Progression: 

• 3rd Visit: Reported improvement in tummy time ability and head control while sitting. 
• 4th Visit: Transitioned to feeding without G-tube. 
• 6th Visit: Significant reduction in intensity and frequency of myoclonic seizures; only minor seizures noted. 
• Diagnosed with cerebral palsy during the first month of care 
• Continued treatment at 2 times per week for 8 weeks, currently the patient is being seen 1 time per week. 
• 3/14/24 Update: Three weeks seizure-free, improved ability to sit up, maintain head control during tummy time, feed orally, and demonstrate crawling motion while on stomach. 

Outcome: 

• After approximately 3 months of consistent chiropractic care, significant improvements observed in seizure activity, motor development, and feeding abilities. 
• Achieved several developmental milestones despite initial prognosis of severe birth complications and cerebral palsy diagnosis. 

Conclusion:

• This case illustrates the potential benefits of chiropractic care in pediatric patients with neurological and developmental challenges, highlighting the importance of addressing structural misalignments and promoting neurological function through gentle adjustments. Regular chiropractic care may contribute to improved quality of life and functional outcomes in such cases.