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Complementary Therapies in Clinical Practice 17 (2011) 28e32

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier .com/locate/ctcp

The chiropractic care of children with “growing pains”: A case seriesand systematic review of the literatureq

Joel Alcantara a,*, James Davis b,c

a International Chiropractic Pediatric Association, 327N Middletown Rd, Media, PA 19063, USAb Private Practice of Chiropractic, Lakes Chiropractic, 413 South 6th St. Brainerd, MN 56401, USA

Keywords:Growing painsSpinal manipulationChiropractic

q This study was funded by the International ChiroMedia, PA, USA.* Corresponding author. Tel.: þ1 610 565 2360; fax

E-mail addresses: research@icpa4kids.com (J. Alccom (J. Davis).

c Tel.: þ1218 828 4418.

1744-3881/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.ctcp.2010.08.006

a b s t r a c t

Objective: To describe the successful chiropractic care of two pediatric patients with complaints of“growing pain.”Clinical features: A 23/4 -yr-old female and 3½-yr-old male were presented by their mothers withcomplaints of “growing pains” that awakened both patients at night. The girl’s problem began 3 monthsprior to care with awakening due to leg pain at 1e2 nights weekly in the first month and progressed to 5e6 nights per week in the month prior to presentation. The boy’s growing pain was of “several months”duration that awakened the patient 2e3 nights per week. The parents of both children denied trauma oran “organic” cause to their children’s pain complaints. Spinal segmental dysfunctions were noted in bothpatients at the lumbosacral spine.Intervention and outcome: Spinal manipulative therapy (SMT) characterized as high velocity, lowamplitude thrusts to sites of segmental dysfunction was rendered to both patients. Following a trial ofcare (i.e., 3 visits scheduled over a 3-week period and 4 visits over a period of 14 weeks), the patient’ssymptoms resolved and were released from care.Conclusion: This case series provides support on the effectiveness of chiropractic SMT for children withcomplaints of “growing pain.” We support further research in the care of similar patients.

� 2010 Elsevier Ltd. All rights reserved.

1. Introduction

Epidemiological studies have established the chronicity of painin the adult population. However, in our opinion, chronic pain inchildren remains relatively underestimated and a poorly under-stood phenomenon.1 Our clinical experience, similar to otherchiropractors, has been that pain is frequently experienced bychildren and adolescents. It’s estimated that approximately 15e25%of all children and adolescents suffer from recurrent or chronicpain.1,2 In addition to pain of musculoskeletal origins, headachesand abdominal pain account for most of the presenting paincomplaints.2 These recurring pain episodes impact to all aspects ofa child’s life from missed school days to physical and mentalproblems (i.e., depression and anxiety)3,4 but more significantly,

practic Pediatric Association,

: þ1 610 565 3567.antara), lakeschiro@hotmail.

All rights reserved.

chronic pain is a risk factor for mental, physical and psychosocialdysfunctions in adult life.5e7

Chiropractic has been shown to be effective in the treatment ofchronic neuromusculoskeletal (NMS) pain complaints in the adultpopulation.8 There are indications that environmental factors mayplay a significant role in pediatric pain and may render children ofparents with chronic pain to be more vulnerable to experiencingpain themselves.9 It stands to reason that given the popularity ofchiropractic in adult NMS complaints, these adult patients wouldseek chiropractic care for their child. It’s been demonstrated thatparent users of alternative therapies are 3e5 times more likely touse these alternative therapies for their child with chiropracticbeing the most popular.10,11

A practice-based study by Alcantara et al.12,13 documented thepopularity of pediatric NMS conditions as a presenting complaint tochiropractors. According to Uziel,14 the most common cause ofmusculoskeletal pain in children is “growing pains.” Anecdotes andtestimonials abound that children with “growing pains” maybenefit from chiropractic care. However, our review of the literatureindicates that, to the best of our knowledge, this is the firstreporting on the care of children with “growing pains.” In theinterest of evidence-based practice, we describe the successful

J. Alcantara, J. Davis / Complementary Therapies in Clinical Practice 17 (2011) 28e32 29

chiropractic care of two infants with presenting complaints of“growing pains.”

2. Case 1

A 23/4 -yr-old female was presented by her mother for chiro-practic consultation and possible care with a 3-month history of“growing pains” and decreased bowel movement frequency.According to the girl’s mother, “five to six nights a week for the lastmonth, my daughter has been up at least once per night with painin both legs.” The patient’s pain complaint was indicated to belocated to the “top of the thighs and into the knees”, bilaterally.

For the first two months of the past three, the patient waswaking at night at an average frequency of 1e2 times weekly andhad progressively gottenworse. Medical care consisted of advice totake over-the-counter Tylenol�. In addition, the mother increasedher child’s intake of bananas, increased water drinking and warmcompresses to the site of pain complaint. Massage seemed to be theonly palliative care that worked.

Physical examination revealed the following. Postural exami-nation was unremarkable from the anterior/posterior views withrespect to postural asymmetries such as lateral flexion of the headand neck, shoulder heights, arm lengths, rotation of the torso,rotational deformities of the lower extremities such as in-toeing orout-toeing. On lateral view however, the child exhibited a “sway-back” posture. On digital palpation, there was hypertonicity overthe lumbosacral area (centrally) as well as in the lower cervical/upper thoracic (i.e., C6eT1 vertebral levels) paraspinal muscles(bilaterally) with apprehension and withdrawal on the part of thepatient on digital palpation over L5, S1eS2 spinous processes (SP)and surrounding paraspinal muscles, bilaterally. The apprehensionand withdrawal was interpreted as eliciting discomfort andtherefore indicative of tenderness over these regions. Interseg-mental digital palpation elicited a “redness” response over the skinoverlying the T2, L5 and S1 SPs. Intersegmental motion palpationdemonstrated restriction at the T2eT3 and at the L4eL5eS1 func-tional spinal units (FSUs). Orthopedic testing focused to thelumbosacral spine was unremarkable with the Straight Leg RaiseTest and Kemp’s Test. Neurological examination of the lowerextremities (i.e., dermatome, myotome and deep tendon reflextesting) was negative. Digital palpation of the thigh and hamstringmuscles was unremarkable for hypertonicity and did not elicitdiscomfort from the patient. Static and motion palpation of bothknees was unremarkable. Passive range of motion examination (i.e.,flexion and extension) of the knees was unremarkable as well as onvalgus and varus stress testing.

The patient’s mother was apprised of the examination findingsand consented to a trial of chiropractic spinal manipulative therapy(SMT) 3 times a week for 3 weeks. Following this trial of care, thepatient’s response to care was to be re-assessed with care predi-cated upon the examination findings. Chiropractic SMT wasdirected to the T2eT3 and S1eS2 FSUs. With the patient prone andthe clinician standing to the side of the patient, the T2 SP wascontacted with a pisiform contact with one hand while the clini-cian’s other hand supported the hand contact. A high velocity, lowamplitude (HVLA) thrust in the posterior to anterior direction(relative to anatomical position) was applied on patient full inspi-ration. SMT to the S1eS2 FSU was performed in the patient side-posture position with the patient laying on her right side. Witha spinous contact to S1 and S2, a posterior to anterior HVLA thrust(relative to anatomical position) was applied to these segments.Following the first visit, the patient was scheduled one week later.At follow-up on the second visit, the patient’s mother indicated thather daughter no longer awakened at night due to “growing pains.”The patient received SMT at the T2, S1 and S2 vertebral levels as

previously described. On the third visit the following week, staticand motion palpation examination of the L5eS1eS2 FSUs demon-strated improvement in motion relative to initial findings. Chiro-practic SMT directed at these FSUs significantly improved the staticand motion palpation findings. At this visit, the patient’s motherindicated continued resolution of symptoms (i.e., no more leg painand awaking at night) and opted her child from further care.

3. Case 2

A 3½-yr-old male was presented by his mother for consultationand possible care with a primary complaint of “growing pains.”According to his mother, the problem has persisted for severalmonths. She indicated that her child was waking 2e3 times a weekfor the past several weeks with “leg cramps” or “growing pains”.The childbirth history was unremarkable with respect to prolongedlabor, difficult labor, and overt signs of birth trauma. The patient’smother denied any history of trauma which may correlate with theonset of the patient’s pain complaints. According to the patient’smother, the pain complaints were located at both knees and moreintensely, in the calf regions of both legs. Medical care consisted ofadvice to provide Tylenol� and Ibuprofen for the patient, whichprovided only minor and temporary relief. Warm baths and warmcompresses were also attempted with indeterminate effectiveness.According to his parent, the pain complaints were “very intense andthroughout the calf muscles.” Additionally, his mother noted thatwith very intense pain, the patient’s calf muscles are noticeably“very tight.”

Physical examination of the patient revealed the following. Onvisual examination, there is noticeable cranial asymmetry with theleft side of the patient’s occiput relatively inferior, his left shoulderwas elevated compared to the right and his pelvis rotated left (i.e.,left anterior superior iliac spine more anterior compared to theright). Digital palpation revealed hypertonicity over the left sacro-iliac (SI) joint as well as at the left gluteal region. Examination of therest of the spine revealed hypertonicity in the C0eC1eC2 FSUsmusculature (bilaterally) but more on the left than the right.Passive ROM examination was found symmetric and unremarkablefor the cervical and lumbosacral spine. Intersegmental motionpalpation examination however revealed motion restriction of theatlas vertebral body (VB) relative to the C2 VB. Intersegmentalmotion palpation of the lumbosacral spine revealed a left posteriorrotation of the sacral segments S1 and S2. Orthopedic testing (i.e.,Kemp’s Test, Straight Leg Raise) in the lumbosacral spine andneurological testing (i.e., dermatome, myotome and deep tendonreflexes) were unremarkable. Digital palpation of the thigh andhamstring muscles of both legs was unremarkable. ROM exami-nation of the knees on flexion and extension was unremarkable.Valgus and Varus stress testing of the knees were alsounremarkable.

The atlas segmental dysfunction was addressed with chiro-practic SMT (i.e., HVLA thrust) with the patient in the seatedposition and a left transverse process of the atlas was the contactpoint. SMT to the S1 VB was made with the patient in the proneposition. A follow-up phone call on the part of the patient’s mothertwo days following the first visit revealed that the patient had notawaken for the previous two nights due to “growing pains.” Thepatient was scheduled for the 2nd visit 11 days later. On the 2ndvisit, the patient’s mother continued to report her child had notawoken on subsequent nights due to “growing pains.” On the 2ndvisit, SMT was directed to the same segments as in the first visit.SMT to the S1 VB however was performed in the side-postureposition due to clinician preference. Two weeks later, the patientattended his third visit. Again, his mother reported no waking atnight due to leg pain. A re-examination of the patient at this visit

Table 1The clinical diagnostic criteria for GP15.

Pain Factors Inclusion criteria Exclusion criteria

Nature of pain Intermittent with some pain-free days and nights Persistent and increasing intensityUnilateral or bilateral Bilateral UnilateralLocation of pain Anterior thigh, calf, posterior knee e in muscles Joint painPhysical examination Normal Swelling, erythema, tenderness, local trauma or infection.

Reduced joint range of motion and limpingLaboratory tests Normal Objective findings such as ESR, X-ray, bone scan abnormalitiesLimitation of activity None Reduced physical activity

J. Alcantara, J. Davis / Complementary Therapies in Clinical Practice 17 (2011) 28e3230

revealed occiput asymmetry had improved, the shoulders weresymmetric and the pelvic obliquity had improved. The patient wasscheduled an additional two visits in a period of 12 weeks toaddress any residual spinal segmental dysfunctions and generalfollow-up. Following this time period, the patient was releasedfrom care due to resolution of symptoms.

4. Discussion

4.1. Epidemiology

In a systematic review of the literature on the subject of growingpains (GP), Uziel14 reported its prevalence as ranging from 3 to 37%in children. Evans15 places the prevalence of GP as ranging from2.6% to 49.4% in the pediatric population. The prevalence disparitymay be attributed to differing study designs, sampling, poorlydefined diagnostic criteria and disparate age ranges. Evans andScutter16 reported a GP prevalence of 37% in children aged 4e6years based on a very large and robust community study inAustralia. Growing pains is said to affect mainly children betweenthe ages of 3e12 years14 with a peak prevalence at 4e6 years.15

4.2. Diagnosis

Based on the most comprehensive review of the medical liter-ature to date, Evans15 indicated that no single diagnostic test existsto confirm “growing pains.” However, if precise inclusion andexclusion criterions are applied, the clinical diagnosis of GP shouldsuffice and does not require laboratory testing for a confirmatorydiagnosis. The inclusion/exclusion criteria are provided in Table 1.Insofar as these clinical criteria are applied to the case series pre-sented, the first patient fulfilled all the diagnostic criteria for GPexcept one e the nature of the pain, which was described in thecase series as progressively worsening from 1 to 2 times weekly to5e6 times weekly over a period of 3months. However, with respectto pain-free days and nights, the patient only experienced the legpain at night with some pain-free days. In the second case pre-sented, the patient satisfied all the clinical criteria for GP.

Threemain theories predominate the literature on the etiologyofGP and involve anatomical, fatigue and psychological (see Table 2).Recently, other theories have been proposed and involve lower painthreshold,21 decreased bone strength,22 altered vascular perfusion23

Table 2Proposed etiologies of GP.15

Etiology Description

Anatomical The anatomical theory is based on the premise that pain are caused byCorrection of the postural or orthopedic dysfunction results in relief ofposture and growing pains are not correlated.18

Fatigue First proposed by Bernie19 in 1894, muscular fatigue as a cause of GP pSupport of this theory is the parental association of GP with physical a

Psychological Familial predisposition leads to susceptibility to pain. For example, chilmood by their parents.20

and joint hypermobility.24 In the case series presented, we believethat a multi-factorial etiology played a role in the genesis of thepatients’ pain complaints. This will be discussed in more detailbelow in the context of chiropractic care.

Under the rubric of medical care, and similar to patients withother pain syndromes, the care of patients with GP involves the useanalgesics as demonstrated in the case series presented. The liter-ature also describes the medical recommendation of the applica-tion of heat, massage and Vitamin C.25,26 According to Uziel andHashkes, GP may be a normal occurrence of the growth process, isself-limiting and will run its natural course.14 Therefore no treat-ment recommendations are made. In relation to the fatigue theory,muscle strengthening and stretching regimens are recommendedwhile an anatomical etiology supports the use of orthotics.

4.3. Chiropractic care

To better inform the discussion on the chiropractic care ofchildren with complaints of “growing pain”, a comprehensivesearch was performed by the authors to identify all relevant reportspertaining to the chiropractic care children with “growing pains.”The following electronic databases were searched: MANTIS[1965e2010]; ICL [1984e2010]; Pubmed [1966e2010]; Medline[1965e2010]; EMBASE [1974e2010]; AMED [1975e2010]; CINAHLPlus [1965e2010]; Alt-Health Watch [1965e2010] and PsychINFO[1965e2010]. Key words used were “growing pains”, “leg pain” or“leg ache” in Boolean combination with “chiropractic” along withrelated words when appropriate. The search was limited to publi-cations in the English language and in peer-reviewed journals.Additionally, chiropractic journals (i.e., Journal of Manipulative andPhysiological Therapeutics, Journal of the Canadian ChiropracticAssociation, Clinical Chiropractic, and The Chiropractic Journal ofAustralia) were hand-searched for the last five years for possiblerelevant materials. The authors independently reviewed the titleand abstracts of all articles generated from the electronic databasesearch as well as from the reference lists of relevant articles. The fullmanuscripts of reports relevant to the chiropractic care childrenwith growing pains were retrieved by applying the following set ofeligibility criteria: (1) the manuscript was a primary investigation/report (i.e., case reports, case series, case control, randomizedcontrolled trials and survey or surveillance studies) published ina peer-reviewed journal; (2) part or all of the study population

postural or orthopedic dysfunctions resulting in poor postures or stance.pain.17 This theory has been mitigated with findings demonstrating that foot

resupposes that accumulation of metabolic waste products in the legs causes GP.ctivity.dren with growing pain were found to have negative or intense

J. Alcantara, J. Davis / Complementary Therapies in Clinical Practice 17 (2011) 28e32 31

involved children with “growing pains”; and (3) the article waswritten in the English language. Only 2 articles met the inclusioncriteria. Eriksen27 described the use of the Grostic Technique in thecare of a patient with idiopathic scoliosis concomitant with inter-mittent “growing pains” in his right foot. The focus of the paper wasthe care of a patient with scoliosis and a presumption of resolutionof the patient’s growing pains. Bowers,28 based on a selectivequalitative review of the literature augmented by clinical experi-ence, addressed the clinical assessment strategies of commonpediatric conditions including growing pains. Therefore, to the bestof our knowledge, this is the first reporting in the scientific litera-ture describing the clinical care of children with GP.

In the case series presented, we described the primary approachto patient care as SMT with a focus on the lumbosacral spine. Theoutcome of care was resolution of the patients’ “growing pain”complaints. This approach lends itself to supporting the anatomicaletiology of growing pain, albeit from a chiropractic perspective. Asalluded to earlier, Evans and Scutter18 examined the association offoot posture and functional health in children aged 4e6 years withand without growing pains. The investigators did not find a mean-ingful relationship between foot posture or functional healthmeasures and leg pain in young children. Interestingly, one of theauthors (i.e., Evans AM) published a study describing 8 cases wherean in-shoe intervention proved efficacious for children with a pro-nated foot posture and aching legs.17 How does one reconcile theabove findings in the context of the chiropractic care applied in thecase series presented? We believe the solution lies in an under-standing and appreciation of the biomechanical relationshipbetween the spine, the pelvis and lower extremities. This biome-chanical relationship is bi-directional in nature as demonstrated inseveral studies.29 For example, Khamis and Yizhar30 found a strongcorrelation suggesting that alignment of the lower extremitiesaffects the alignment of the pelvis. Young et al.31 demonstrated therelationship between pelvic innominate rotation and leg lengthinequality through the use of heel lifts. Pinto et al.32 found thatexcessive calcaneal eversion during standing changes pelvicalignment. Clinical signs associated with lumbopelvic dysfunctioninclude dysfunctions of the lower extremities (i.e., posture seen inLBP involves flexion of the hip, knee and ankle to compensate forabdominal and back muscle weakness).33 One aspect of pelvic(innominate) misalignment may be abnormal activation of pelvicand suprapelvic muscles leading to pain referral (i.e., scle-rotogenous referral) to the lower extremities. Consider that pelvicmisalignment (i.e., innominate rotation) would necessarily affectthe sacroiliac (SI) joint. The SI joints are known to have painreferrals to the lower lumbar spine, buttock, groin, medial, lateraland posterior thigh and sometimes in the calf.34,35 These may beinterpreted as “growing pains” by the child. Neurologically, Suteret al.36 have demonstrated a relationship between the pelvis(particularly the SI joint) and the lower extremities. Although thepatients reported in this case series were not low back pain patientsper se, chiropractic examination procedures nonetheless confirmeddysfunctions in the lumbopelvic region. Both patients may not havebeen able to communicate low back pain complaints to theirparents adequately given their young age. Knutson37 found a highincidence of pelvic misalignment, foot rotation, and supine leglength alignment asymmetry with low back pain in 74 unscreenedvolunteers. In the study by Evans,17 the use of an in-shoe inter-vention to correct foot pronation may have resulted in the correc-tion of lumbopelvic dysfunction leading to the amelioration of GPsymptoms. In the Evans and Scutter study18; despite their assertionthat there is no difference in measures of either foot posture orfunctional health between groups of children with and without legpain, the investigators found on initial analysis of foot posturemeasures between the leg pain and no leg pains groups

a statistically significant result for the measurement of navicularheight, but only on the left side. Their logistic regression modelingdemonstrated that navicular height (left foot only) was positivelyrelated to growing pains. From a chiropractic perspective, thecorrelation between pelvic dysfunction, foot posture and GP werenot addressed by Evans and Scutter.18

Despite a temporal association and biological plausibility in therole of chiropractic care in resolving the complaint of GP in thecase series presented, we caution the reader on generalizing thefindings of this case series. Lacking a control group, the unac-counted effects of natural history, the role of placebo, regression tothe mean, the demand characteristics of the clinical encounter,and subjective validation are confounders to making cause andeffect inferences.

5. Conclusion

This case series provides supporting evidence that childrenwithpain complaints diagnosed as “growing pains” may benefit fromchiropractic SMT. We encourage further research in this area.

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