The following blog is by one of my colleagues who I’ve been lucky enough to learn a lot from over the years, Dr Glenn Maginness. Dr Glenn is a chiropractor who sees only children as patients. He graduated in 1986 and runs one of the largest family practices in Australia. Glenn completed a 3 year postgraduate Masters Degree in Chiropractic Paediatrics in 1998 and has held over 40 paediatric focused seminars throughout Australia, New Zealand, South Africa and the U.K, over the last 15 years. With the launch of his Online Paediatric CE Program in 2013, Dr Maginness’ wealth of knowledge is now available 100% online. The program addresses all aspects of the paediatric experience, including the assessment, adjustment and management of the paediatric patient. He can be contacted at firstname.lastname@example.org
Even with over 30 years practice experience, and the knowledge that comes from the thousands of babies and children that I have adjusted over those years, occasionally I am reminded in practice the very important fact that we never stop learning.
Some time ago I learnt something really important from a 10 year old boy who had presented with a two month history of worsening lower back pain.
I am always a little concerned when I have a paediatric patient present with any sort of ongoing musculoskeletal pain. I am always wary of those differential diagnosis’ that are potentially more serious. Back pain in this age group should always be a red flag for you. So you should always rule out the ‘potential nasties’ first.
Anyway, this child had been through the ‘medical merry-go-round’. He had seen a number of GP’s, been referred to a neurologist, had an MRI (which was unremarkable), and he had also seen a physio. As a result of all of this he had had all the potentially serious diagnosis’ ruled out. The various diagnosis that he did receive ranged from muscle strain, disc inflammation, posture problems, and even a ‘back virus’. The parents attended my practice at the suggestion of a local GP who had essentially, in his own words, ‘run out of suggestions’.
At the time of presentation, neither the parents nor the child could recall any incident which may have precipitated the onset of the child’s back pain.
On examination I was quite surprised at the extent of the biomechanical dysfunction present in this child’s lower back region. I really felt that a major incident/accident was likely the cause, but as I have said, no such incident could be recalled by the patient or the parents.
Essentially there was noticeable dysfunction at the L3/4/5 spinal level, with extensive muscle guarding and general lumbar stiffness. ROM was decreased by more than 50% in all directions.
The physio had strapped his upper back to improve posture – (really??). This had not made any impact on the pain or discomfort. A GP had recommended a ‘course of pain killers’. This offered short term relief only- big surprise!
So I commenced care for this child, initially focusing on manual adjustments and deep soft tissue work, confident that we would see a change relatively quickly, despite the apparent chronic nature of the condition. My expectations were that within a few visits we would start to see a change in pain and discomfort, as the biomechanics improved.
Much to my surprise (and frustration), there was no appreciable change in the child’s symptoms. I persevered for several weeks, seeing the child three times per week. I modified my adjusting, utilising a variety of different techniques, all the time waiting for (and expecting) the child to report an improvement in symptoms. While biomechanically there certainly was a (slow) improvement in the child’s condition, by the 6th week there was still no change to symptoms at all!?
Now at this point I have to admit that I was very tempted to refer this child to ‘someone else’, perhaps a different health practitioner with a fresh approach. However, deep down I really did feel that with perseverance the child’s symptoms had to start to improve in time. So this belief, mixed with the confidence conveyed to me by both of the parents of how sure they were that I was going to make a difference, and that they were in the right place, resulted in us persevering.
All the way through this process, I would constantly discuss with the parents what I was thinking, always being open and honest with them, including my concerns about the apparent lack of progress. At the same time however, I would demonstrate the ‘before and after’ aspects of the care that demonstrated quantifiable changes, including improvement in the biomechanics, from visit to visit – the ROM, muscle guarding, etc.
These parents had ‘been everywhere else’ (their words) and continued to communicate to me that they had total confidence in my management strategy, and wanted to stick at it. By this stage I had also incorporated flexion-distraction therapy and an exercise program, to help to improve the lumbar spine biomechanics. I can’t ever remember utilising this type of therapy with one so young, but I was basically trying everything. But I would have to admit that as each week went by, my confidence started to wane.
If I was to be 100% honest, if it wasn’t for the parents absolute confidence in me, I actually think there is a chance that I may have referred this child to someone else before the end of that 6th week. I am an impatient person. I am an impatient chiropractor. Because of the potential of chiropractic to make such amazing changes to the health of kids, so quickly, that is what I have come to expect. And when it doesn’t happen, my belief in what I am doing (in my management strategy) starts to then be tested. This is not necessarily a bad thing. It is important to continually question what you are doing so that you can always be confident and comfortable that you are achieving the very best clinical outcome for every patient that you see.
In the 7th week, there was a very slight change in symptoms. The child reported he felt ‘a little better in the mornings’. That gave me some hope.
Now it was around this time that the mum announced (somewhat sheepishly) that because of my continued insistence that this had to be due to an accident of some sort, they finally recalled an incident which ‘may have contributed’ to the back pain. The incident was 5 months prior to the onset of the back pain, and hence the connection was not immediately made.
The parent related that the child had spent an afternoon at ‘Gravity Zone’, (which is a warehouse full of trampolines and foam pits etc. Very popular for parties of kids of this age group). The child recalled an incident where he had bounced on a trampoline and on landing had hyperextended his spine and at the same time he heard a ‘crack and a squelching noise’, followed by intense back pain. This pain persisted for a few days and then went away. The mother too remembered this when the son talked to her about it. There was no further pain or discomfort until 5 months later, which is when they initially visited the GP.
So for me, all of a sudden things became a little clearer. I had felt all along that there must have been an accident of some sort to create the mess I was dealing with in the lower back. And there it was!
From that moment there was a steady improvement in the back pain. By the 12th week the child was almost totally symptom free. The parents were so happy that they persevered. I now see this patient monthly, and at his monthly visits he reports no pain or stiffness at all. So a great outcome was achieved.
So what did I learn from this patient?
Quite simply, that sometimes (certainly with chronic conditions), it can take time for the body to heal. While as chiropractors we pride ourselves on our ‘miracle quick fixes’, sometimes it is just plain hard work. This child had what I believe was a significant injury to his lower back region. Without the confidence and encouragement of the parents I would have potentially ‘given up’ on him early, which then would have then placed them potentially back on the merry go round looking for a miracle cure. And the really sad thing is there is every likelihood that he would most likely still be in pain, because the parents may have decided that they had ‘tried chiropractic ’ and that it didn’t work, and therefore may have been reluctant to see another chiropractor.
This experience has reminded me to be patient… something I am not very good at. Give the body time to heal. Give the body time to recover.
However, the unfortunate fact is that often you will not even be given the opportunity to be patient. If you have a parent who demands the quick fix with their child, you may not even be given a fighting chance to help a child in pain.
So this experience has also served to remind me of the importance of educating the parents. These parents were chiropractically educated through our healthcare class, and as such were educated and informed about the amazing potential of the chiropractic adjustment. I am sure that this is what gave them the strength of conviction to book their child in 3 times a week for so many weeks. Never missing one appointment. Never deviating from their schedule.
Now those who know me will know that this a very unusual schedule (3 x week) for me to recommend for a child. (I only work two days a week so the third visit was with another chiro in my practice). But always my advice to parents is ‘if this were my child, this is what I would do?’ My belief at the time was that this child needed the care 3 times per week, so that’s what I conveyed to the parents. You should always tell the parents what you believe, not what is perhaps easiest for them to hear.
This simply further highlights to me that no matter how experienced you are, regardless of how many letters you have after your name… you never stop learning.