Portland Chiropractic Group - Palmer College of Chiropractic

Transcription

7/11/15 History Taking, Physical
Examination and Clinical
Pearls for the Young
Pediatric Patient
Presented by
Elise G. Hewitt, DC, DICCP, FICC
© 2014 Elise G. Hewitt, DC
Portland Chiropractic Group
2031 E. Burnside Street
Portland, Oregon 97214
503.224.2100
www.PortlandChiropracticGroup.com
www.DrEliseHewitt.com
DrElise@PortlandChiropracticGroup.com
1 7/11/15 Overview
!  Is
chiropractic care safe for children?
!  How to modify adjusting technique for
children
!  History taking for the pediatric patient
!  Examination techniques for young patients
!  Red flags in the history and examination
!  When to x-ray the child
!  How to learn more about pediatrics
Is Pediatric Chiropractic Care Safe?
! 
Cassidy et al looked at incidence rates of VBA
stroke following visits to a chiropractor compared
to visits to a primary care physician (PCP).
"  Looked at all VBA strokes from 1993-2002 (818 strokes over
100 million person-years).
"  Concluded: “We found no evidence of excess risk of VBA
stroke associated with chiropractic care as compared to
primary care.” Patient is just as likely to suffer a stroke
after visiting the PCP as after visiting a chiropractor.
Cassidy D, Boyle E et al. Risk of vertebrobasilar stroke and
chiropractic care: results of a population-based case-control and
case-crossover study. Spine. 2008;33(4S)Neck Pain Task
Force:S176-183.
2 7/11/15 Is Pediatric Chiropractic Care Safe?
! 
Kosloff et al looked at incidence rates of VBA stroke
following visits to a chiropractor compared to visits to a
primary care physician (PCP).
"  Analyzed all VBA strokes using administrative data from
commercially insured and Medicare patients in the U.S. from Jan
2011 - Dec 2013 (1,829 VBA strokes).
"  Concluded: “We found no significant association between
exposure to chiropractic care and the risk of VBA stroke. We
conclude that manipulation is an unlikely cause of VBA stroke.”
"  Found significant association between PCP visits and VBA stroke,
attributed to patients seeking care for symptoms of arterial
dissection (HA, neck pain).
"  Side note – chiropractic visits did not include manipulation in 33%
commercial and 50% Medicare populations, so inaccurate to use
chiropractic visit as a measure of exposure to manipulation.
Kosloff TM, Elton D, et al. Chiropractic care and the risk of vertebrobasilar
stroke: results of a case-control study in U.S. commercial and Medicare
Advantage populations. Chiropr Man Ther. 2015;23:19.
! 
Thiel et al evaluated incidence of adverse
events (AE) following spinal manipulation in
19,722 patients (50,276 cervical manipulations)
in U.K.
"  Found no serious AE.
"  Concluded: “…the risk of serious adverse events,
immediately or up to 7 days after treatment, was
low to very low.”
Thiel HW, Bolton JE et al. Safety of chiropractic manipulation of
the cervical spine: a prospective national study. Spine
2007;32(21):2375-2378.
! 
Piper et al looked at mechanical stress and strain
on vertebral artery (VA) during cervical ROM and
manipulation.
"  Found that manipulation was less stressful on the VA
than cervical passive end ranges of motion.
"  Strain from both ROM and CMT was well below
published VA failure rates.
Piper SL, Howarth SJ, Triano J, Herzog W. Quantifying strain
in the vertebral artery with simultaneous motion analysis of
the head and neck: A preliminary investigation. Clinical
Biomechanics 2014;29:1099–1107.
! 
Hayes and Bezilla did a retrospective review of AE
in 346 pediatric patients who had received at least
two treatments of OMT.
"  None had serious AE; 31 (9%) had mild, self-limiting,
transient AE.
"  Authors concluded “…OMT appears to be safe in the
pediatric population when administered by physicians
with expertise in OMT.”
Hayes NM, Bezilla TA. Incidence of iatrogenesis associated
with osteopathic manipulative treatment of pediatric
patients. J Am Osteopath Assoc 2006;106:606-608
! 
Vohra et al performed a systematic review of the
incidence of adverse events (AE) following spinal
manipulation in children.
"  Review covered all literature for past 110 years.
"  Found 9 cases of serious AE, with estimated 30
million annual pediatric visits to the chiropractor.
Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse
events associated with pediatric spinal manipulation: a
systematic review. Pediatrics. 2007;119:275-283.
! 
Miller et al examined 781 pediatric patients under
3 years of age (73.5% under 13 weeks) who
received a total of 5242 chiropractic treatments
at a chiropractic teaching clinic in England from
2002-2004.
"  There were no serious adverse effects (reaction lasting
>24 hours or needing hospital care), 7 reported minor
adverse effects.
"  85% of parents reported improvement in their children’s
symptoms.
Miller JE, Benfield K. Adverse effects of spinal manipulation therapy
in children younger than 3 years: a retrospective study in a
chiropractic teaching clinic. Jour Manip Physiol Ther 2008;31(6):
419-422.
! 
Doyle did a literature review on the safety of
chiropractic manipulative therapy for
children.
"  Found no serious AE reported in the literature
since 1992 and no death even potentially
related to pediatric chiropractic manual
therapy for over 40 years.
Doyle, M.F. Is chiropractic paediatric care safe? A best
evidence topic. Clinical Chiropractic 2011;volume 14, issue 3,
pp. 97 – 105.
! 
Todd et al performed a literature review of all
reported cases of AE due to “chiropractic and
other manual therapies” in infants and children ever
published.
"  Found 15 serious AE (7 involved a DC), including 3 deaths
(none involved a DC). High-velocity, extensional and
rotational SM reported in most cases. Underlying preexisting pathology was present in the majority of cases.
"  Concluded: 1)“Published cases of serious AE… are
exceedingly rare”. 2) Perform thorough history/exam and
modify techniques to suit the age, anatomy & physiology of
the young patient.
Todd AJ et al. Adverse events due to chiropractic and other manual
therapies for infants and children: A review of the literature. Jour
Manip Physio Ther 2014.09.008.
! 
Jevne et al examined compensation claims for
chiropractic in Denmark & Norway 2004-2012.
"  338 claims filed, with 15% approved for compensation.
"  Found children <10y regularly visit DC in both countries
○  In Denmark, 35% of these are infants.
"  Authors stated: “Our data did not reveal a single claim in
this age group.”
Jevne J, Hartvigsen J and Christensen HW. Compensation
claims for chiropractic in Denmark and Norway 2004–2012.
Chiropractic & Manual Therapies 2014 22:37.
Hot off the presses…
! 
CDC survey showed chiropractic/osteopathic care
continues to be the most common doctor-directed
complementary and integrative form of health care
used by children in the U.S.
"  Use of DC/DO manipulation by all children has
increased from 2.8% in 2007 to 3.3% in 2012.
"  A total of 1,854,000 children received DC/DO
manipulation in 2012.
Black LI, Clarke TC, Barnes PM, et al. Use of complementary health
approaches among children aged 4–17 years in the United States:
National Health Interview Survey, 2007–2012. National Health Statistics
Reports; no 78. Hyattsville, MD: National Center for Health Statistics 2015.
! 
Carnes et al did a systematic review of AE
and manual therapy (MT) in all age groups
(8 prospective cohort studies, 31 RCTs).
"  Found no reports of serious or catastrophic AE.
"  Authors concluded “The risk of major AE with
MT is low… the relative risk of AE appears
greater with drug therapy…”
Carnes D, Mars TS, et al: Adverse events and manual
therapy: A systematic review. Manual Therapy
2010;15(4):355-363.
In health care, safety is a relative term: risks of a given
treatment must be compared to the risks of
alternative interventions for the same condition…
! 
Bourgeois et al examined data from children seeking
medical care for an adverse drug event (ADE)
during an 11-year period in the U.S. (1995-2005).
"  Findings: the mean annual number of ADE-related visits was
585,922, of which 131,142 were ER visits.
"  Children 0-4 years accounted for highest number of visits
○  43% of all ADE visits involved this age group.
○  13.2 visits per 1,000 persons in this age group.
○  Most frequently implicated drug in this age group - antibiotics.
Bourgeois FT, Mandl KD et al. Pediatric Adverse Drug Events in the
Outpatient Setting: An 11-Year National Analysis Pediatrics
2009;124;e744-e750. www.pediatrics.org/cgi/content/full/124/4/e744
! 
Modifications are made in adjustive
procedure to adapt to the pediatric spine:
" 
" 
" 
" 
" 
Modified contact
Modified patient positioning
Change in velocity
Altered force
Modified amplitude of thrust
Adjusting Technique Modifications
for the Pediatric Patient
!  Velocity of thrust
"  Increase or decrease? - increase compared to adult
"  Why? - increased flexibility of tissues
!  Force of thrust
"  Increase or decrease? - decrease compared to adult
"  Why? - smaller point of contact
9 7/11/15 Force - How much do we use?
! 
! 
! 
Force in a keystroke........................ 13 N
Force to fracture a rib................ 3300 N
Crossed BL HVLA adult................. 525 N*
Informal measurements at a chiropractic institution's
force computer simulation adjusting lab:
! 
Double thumb HVLA infant ........... 30 N
30/525 N = 5.7% of the force used on an adult
*Downie AS, et al. Quantifying the high-velocity, low-amplitude spinal manipulative
thrust: a systematic review. J Manip and Physio Ther 2010; 33(7):542-553.
Adjusting Technique Modifications
for the Pediatric Patient
!  Velocity of thrust
"  Increase or decrease? - increase compared to adult
"  Why? - increased flexibility of tissues
!  Force of thrust
"  Why? - smaller point of contact
!  Amplitude of thrust
"  Why? - smaller joint space
10 7/11/15 If you want more Pediatrics…
about ACA Pediatrics Council
! 
! 
! 
! 
www.acapedscouncil.org
Membership is $85/year ACA doctors, FREE for
SACA members
Includes quarterly newsletter, discount on Annual
Symposium registration fees, listing in locator
directory, access to list serve
8th Annual Pediatrics Symposium
"  March 4-6, 2016 in Las Vegas
○  at the New York Hotel and Casino
"  Collaboration with the ACA Rehab Council
"  Topic to include DNS (Dynamic Neuromuscular
Stabilization), scoliosis management, craniosacral therapy
for infants and more.
"  Check www.acapedscouncil.org/events for event details
Partnership with Pediatricians
! 
Pediatric medical care and pediatric
chiropractic care complement each other
"  “crisis care” vs. “quality of life care”
! 
Example: child with chronic ear infections
"  MD offers antibiotics if “crisis” (only 5-10% of cases)
"  DC offers:
○  Manual therapies – CMT, CST, etc.
○  Lymphatic drainage to promote lymph flow
○  Endonasals
○  Herbal ear drops, natural immune enhancing
supplements
○  Probiotics to repair gut from repeated antibiotics
○  Dietary and lifestyle advice to aid healing, prevent
recurrences
11 7/11/15 Why Children Need
Chiropractic Care
Recent trauma for neonates (birth)
!  Time of greatest spinal elongation
!  Time of spinal curvature development
!  Heuter-Volkmann law
!  To optimize function of nervous system
! 
"  Time of proprioceptive development
"  Time of greatest brain growth
12 7/11/15 Pediatric History
Informed consent
! 
"  Signed by parent or guardian
Portland Chiropractic Group 2031 E. Burnside, Portland, OR 97214!
INFORMED CONSENT TO EXAMINE AND TREAT A MINOR
The word “chiropractic” is derived from the Greek words “chiro”, meaning “hand” and
“praxis”, meaning “practice”; so chiropractic is literally healthcare performed by hand. As a
patient at Portland Chiropractic Group, you should expect your child to be touched, moved,
assisted, and adjusted by our doctors, and to a more limited extent, by our chiropractic assistants
and massage therapists. Occasionally, complications may arise from the care we render. The
purpose of this consent form is to inform you of the possibility of complications or adverse
effects. Please read, initial, and sign the following consents to examination and treatment,
permitting us to continue.
CONSENT TO EXAMINATION
Our chiropractic examination procedures include, but are not limited to, your child’s health
history, posture and range of motion evaluation, orthopedic and neurological testing, palpation of
various body structures, spinal and extremity mobilization, manual or mechanical muscle testing
and palpation, and referral for specialized testing such as blood evaluations, diagnostic imaging,
and other tests.
Portland Chiropractic Group 2031 E. Burnside, Portland, OR 97214!
chiropractic office. To date, no study has shown a causal relationship between cervical spine
manipulation and stroke. Research has demonstrated that a patient is as likely to have seen a
primary care medical doctor as a doctor of chiropractic prior to experiencing a cervical
arterial dissection4. In other words, the association of strokes and visits to either chiropractors
or primary care physicians was equal, suggesting that the cause of the strokes could not be
associated with any element unique to chiropractic care.
Naturally, we will discuss our treatment plan with you. We will also inform you of other options
for care, to the best of our knowledge. Please note that all forms of healthcare include some
form of risk. In fact, there are even risks to not receiving care that may include a worsening of
your current complaint or development of other untoward complications.
Please read the above before signing this consent. If you have further questions or desire
more information, simply ask and we will provide it.
Upon signing this form, I hereby request and authorize Dr.
__________________________, and whomever he/she may
designate as his/her assistant or authorized representative, to
administer chiropractic care as he/she deems necessary to my
dependent minor child. I also understand that there is no
guarantee or warranty for a specific cure or result. I consent to
examination and treatment of my child.
On very rare occasions, physical symptoms may manifest or complications may
arise during this examination. By initially here, ______, I authorize the doctor
to examine my child to assess his/her health concern(s). This authorization also
extends to include diagnostic imaging, laboratory and other testing at the
doctor’s discretion.
******************
CONSENT TO TREATMENT
Chiropractic therapeutic procedures include, but are not limited to, spinal and extremity
manipulation/mobilization, manual or mechanical muscle therapy, exercise demonstration and
prescription, physiotherapy applications such as ice, heat, ultrasound, and electrotherapy,
referrals to other practitioners, nutritional recommendations, and advice on posture and homebased self-care.
The most common adverse effects of chiropractic treatment are short-term soreness and/or a
temporary increase in pain. The likelihood of initial soreness or increased pain has been
found to be similar to that of starting an exercise program1. In fact, a systematic review of
the literature indicated that most adverse events that could be attributed to spinal
manipulation were benign and transitory2.
Fractures are rare and usually the result of an underlying bone pathology that we will try to
assess during your history and examination. An event sometimes attributed to chiropractic
manipulation is a stroke resulting from a cervical artery dissection3. This event is very rare,
occurring at a frequency of between one per million and one per five million visits to a
As of today’s date, I have the legal right to select and authorize health care service for the minor
child named below.
Child’s Name (printed):________________________________________________________
Your relationship to child:______________________________________________________
Legibly printed Parent/Guardian name:______________________________________________
Signature:_____________________________________________
Date: _______________
CUSTODY SITUATIONS
If applicable, under the terms and conditions of my divorce, separation or other legal
authorization, the consent of a spouse, former spouse or other parent is not required. If my
authority to so select and authorize this care should be revoked or modified in any way, I will
immediately notify this office.
Parent/Guardian Signature:_____________________________________________________
1
2
3
Bronfort et al., 2001; Hurwitz, Moregenstern, Vassilaki, & Chiang, 2005
Gouvela, Castanho, & Ferreira, 2009
Rothwell, Bondy, & Williams, 2001; Smith et al., 2003
Page 1 of 2
4
Cassidy, et al., 2008
Page 2 of 2
13 7/11/15 Pediatric History
! 
Basic Information
"  Name, nickname, age, sex, birth date, parents’
names, siblings names and ages
! 
Chief Complaint
" 
" 
" 
" 
" 
" 
Onset
Location
Quality
DIF, including recent changes
Exacerbating/Remitting factors
Treatment history
Prenatal Health and Labor & Delivery
Pregnancy complications
!  Full term?
!  Spontaneous or induced labor?
!  Was Mom + or – for strep B?
!  Was baby in correct position (LOA)?
!  How long was labor? Pushing phase?
!  Was cord around baby’s neck?
!  Were any special procedures needed?
! 
14 7/11/15 Neonatal health
Size at birth (weight, length, head
circumference)
!  APGAR scores (1 minute and 5 minute)
! 
"  Appearance, pulse, grimace, activity, respiration
"  Scored 0-2 points for each element
Complications at birth?
!  Nursery stay required (NICU)?
! 
"  If so, what procedures and treatments were
provided?
Nutritional and Digestive Health
Breast vs. bottle feeding
!  If breastfeeding, how is latch?
! 
"  Painful? Clicking? Bilaterally symmetrical?
! 
If bottle feeding, what’s in the bottle?
"  And why?
! 
Frequency of feeding
"  How many hours between feedings or how
many feedings per day
Length of time/amount per feeding
!  Appetite?
! 
15 7/11/15 Nutritional and Digestive Health
Issues with weight gain?
!  Food sensitivities?
! 
"  Did Mom have to change her diet while nursing?
Issues with gassiness or spitting up?
!  Bowel Habits
!  Medications/Vitamins/Fluoride
! 
"  Baby and Mom
Growth and Development
Attitude
!  Sleep habits
!  Preference for head rotation or head tilt?
!  Likes tummy time?
!  Sports, activities, hobbies
! 
16 7/11/15 Growth and Development
Gross motor development
!  Fine motor development
!  Language development
!  Cognitive development
!  Social skills development
! 
Normal Pediatric
Developmental Milestones
17 7/11/15 Normal Pediatric
Normal Pediatric
18 7/11/15 Medical Survey/Other
!  Immunization
status
!  Past
Illnesses
!  Past Traumas
!  Exposure to smokers?
!  Family history
!  Does child have a cell phone?
"  If so, where is it kept at night?
19 7/11/15 Pediatric Examination
! 
Vitals
"  Height, weight, HR, RR, temperature, BP
"  In infants, also includes head circumference
"  Chart on growth charts to be sure following
curves
○  http://www.cdc.gov/growthcharts/
clinical_charts.htm
Growth Charts
Separate charts for boys and girls
!  Choice of 5th-95th or 3rd-97th percentiles
!  Birth-to-36 months
! 
"  Length-for-age and weight-for-age
"  Head circumference-for-age and weight-for
length
! 
Children 2-20 years
"  Stature-for-age and weight-for-age
"  BMI-for-age
20 7/11/15 © 2014 Elise G. Hewitt, DC
! 
Vitals
"  Height, weight, HR, RR, temperature, BP
"  In infants, also includes head circumference
"  Chart on growth charts to be sure following
curves
○  http://www.cdc.gov/growthcharts/
clinical_charts.htm
! 
Appearance
"  Note general color, lesions, discolorations
Pediatric Examination
! 
Symmetry of cranial vault/face
"  Look at shape of cranium - note flat spots,
asymmetries
"  Evaluate axial, coronal and sagittal planes
"  Look for symmetry in eyes, ears, cheekbones
"  Look for alignment of bridge of nose, base of
nose, chin
Axial
Coronal
Sagittal
! 
Neck/Pelvis torsion
"  Is there a preference for head rotation?
"  Is there torsion in trunk in supine position?
! 
Fontanel palpation
"  Anterior and posterior (if less than 3 months of
age)
"  Note if bulging or depressed
○  MC causes of bulge - tumor, hemorrhage and
hydrocephalus
○  MC cause of depression - dehydration
"  Look for dry skin, poor skin turgor, oliguria
! 
Auscultation
"  Note any abnormalities in heart and lung sounds
or rate
! 
Mouth
"  Look for thrush, enlarged tonsils, other lesions or
abn’s
"  Evaluate quality of suck and gag reflex
! 
Eyes
" 
" 
" 
" 
Symmetrical light reflexes?
PERRLA
Red reflex present?
Tracking normal?
! 
Lymph node evaluation
"  Anterior cervical, posterior cervical, inguinal
chains
! 
Ears – Otoscopic examination if suspect
otitis media
" 
" 
" 
" 
" 
" 
" 
Erythema?
Cone of light and malleus visible?
Bulging or retracted TM
Fluid line/bubbles visible?
Scarring on TM?
Cerumen, blood, other fluid in canal?
Is examination painful?
Normal
Tympanic
Membrane
24 7/11/15 Otoscopic Evaluation of
Tympanic Membrane
! 
Overview site for Otitis Media:
http://emedicine.medscape.com/article/994656-overview
! 
For a detailed description of the appearance of
normal and abnormal tympanic membranes on
otoscopic evaluation, see:
http://www.aap.org/otitismedia/
"  Can also review case studies on site as well.
"  $24 charge, includes continuing education credit
! 
Free otoscopic evaluation site:
http://otitismedia.hawkelibrary.com/normal/1_G
! 
Abdomen
"  Palpate for major organs
"  Remember - most common cancer in infants is
Wilms tumor (nephroblastoma); make sure
palpate region of kidneys.
! 
Orthopedic highlights
"  Hips: Ortolani’s, Barlow’s tests (up to 3-6
months of age)
○  Allis sign (aka Galeazzi test) if older than
3-6 months
○  Also look for asymmetrical thigh folds
"  Clavicle palpation in newborn
"  Posture evaluation and Adam’s test in older
children
"  Cervical and thoracolumbar global ranges
of motion
"  Spinal segmental range of motion
Newborn Neurological
Examination Website
From the University of Utah School of
Medicine
!  Video clips of different aspects of
pediatric neurological examination
! 
"  Broken down by age group
"  Includes primitive reflexes, cranial nerve
evaluation, motor, tone, DTRs, etc.
http://library.med.utah.edu/pedineurologicexam/
html/home_exam.html
26 7/11/15 Primitive Reflexes
! 
! 
! 
! 
! 
Blinking reflex
Acoustic Blinking
reflex
Rooting reflex
Suck reflex
Moro/Startle reflex
Moro/Startle Reflex
Elicit: sudden lowering of head relative to rest of body
Response:
1.  Extension and abduction
of arms followed by
flexion of arms
2.  “C” shape to fingers
3.  Crying
! 
! 
! 
! 
! 
! 
! 
Blinking reflex
Acoustic Blinking
reflex
Rooting reflex
Suck reflex
Moro/Startle reflex
Palmar/Plantar
reflexes
Placement test
! 
! 
Stepping test
Tonic neck reflex
(aka Fencer reflex)
Tonic Neck/Fencer Reflex
Elicit: rotation of head to one side
Response: ipsilateral extension of
arm/leg with flexion of
contralateral arm/leg
! 
! 
! 
! 
! 
! 
! 
Blinking reflex
Acoustic Blinking
reflex
Rooting reflex
Suck reflex
Moro/Startle reflex
Palmar/Plantar
reflexes
Placement test
! 
! 
! 
! 
! 
Stepping test
Tonic neck reflex
(aka Fencer reflex)
Babinski reflex
Galant test
Perez test
Galant Reflex
Elicit: stroke paraspinals S --> I
Response: ipsilateral LF of spine
Perez Reflex (not pictured)
Elicit: stroke spinal I --> S
Response: extension of spine
! 
! 
! 
! 
! 
! 
! 
Blinking reflex
Acoustic Blinking
reflex
Rooting reflex
Suck reflex
Moro/Startle reflex
Palmar/Plantar
reflexes
Placement test
! 
! 
! 
! 
! 
! 
Stepping test
Tonic neck reflex
(aka Fencer reflex)
Babinski reflex
Galant test
Perez test
Vertical suspension
test
How to Learn More About Pediatrics
! 
ACA Council on Chiropractic Pediatrics
"  www.acapedscouncil.org
! 
ICA Council on Chiropractic Pediatrics
"  www.icapediatrics.com
! 
ACA Annual Symposium on Chiropractic Pediatrics
"  March 4-6, 2016 in Las Vegas
○  at the New York Hotel and Casino
"  Collaboration with the ACA Rehab Council
"  Topic to include DNS (Dynamic Neuromuscular
Stabilization), scoliosis management, craniosacral therapy
for infants and more.
"  Check www.acapedscouncil.org/events for event details
30 7/11/15 How to Learn More About Pediatrics
! 
Texts on chiropractic pediatrics
"  Neil Davies’ Chiropractic Pediatrics
"  Claudia Anrig and Greg Plaugher’s Pediatric
Chiropractic
"  Heiner Biedermann’s Manual Therapy in
Children
How to Learn More About Pediatrics
! 
Journal of Clinical Chiropractic Pediatrics
"  Published by the ICA’s Pediatrics Council
"  Just become open access
"  www.jccponline.com/index.html
! 
Upledger Institute for Craniosacral training
"  1-800-233-5880
"  www.upledger.com
31

Portland Chiropractic Group - Palmer College of Chiropractic

Transcription

Similar documents

Elise Paradis - International Baccalaureate

Become a member today! - Mississippi Chiropractic Association

© Dr. Hannah Anderson, DC • Back In Line Family Chiropractic and

ChiroMatrix – Published in Chiropractic

Bossley Biz Newsletter December 2015

Sir Mix-A-Lot

Informed Consent - Wunderlich Chiropractic

Elise Black Edition Elise White Edition

Spring 2016 Gazette

Beyond the doors of the Stollery`s pediatric emergency department