A common question I get in the office, as well as when I am lecturing, is what’s the earliest age you can start rehabilitation procedures for children? Unfortunately, for many of us, we forget that we are dealing with children and not just small adults. It is important to note that protocols or principles of rehabilitation are the same for everyone—youths, baby boomers, and our elderly population. They vary in that each rehabilitation program we develop must be specific to that person’s needs. This is governed totally by anatomical and physiological differences that exist within our patients’ age groups.
Since we are focusing today on the younger population we must keep in mind those differences:
- Muscular strength, maximal oxygen uptake, and cardiac output are all proportionately lower in children.
- The apophyses or area of tendon insertion may be particularly predisposed to injury, especially from both micro and macro repetitive stresses.
- More injuries involve the epiphysis of long bones in children, and growing bone has inherent areas of weakness.
- Ligaments are usually two to five times as strong as the epiphyseal plate. This can lead to damage by overloading of an immature and growing joint.
- Flexibility and muscle imbalances change constantly as a child grows.
- The younger patient may be less motivated to follow through a rehab plan.
Having identified some important factors, we must also consider the type of rehabilitation we are doing. Is this to help restore our patient to a prior level of normal activity as quickly and safely as possible? Or, is it to improve and enhance athletic participation, or activities of daily living? Following any injury, we must focus on reducing swelling and pain that may have resulted. Here, we may focus on flexibility, strength, joint function (motion), power and endurance, proprioception, coordination and agility. When our patient has returned to normal function, our focus will be more centered on specific needs. For example, if we are dealing with trying to improve our patient’s athletic performance or prevent further injuries, then additional rehabilitation programs need be specific to enhancing movement patterns that are sport or job specific. To allow success for all our rehabilitation strategies, we must be knowledgeable of the amount of "tissue loading" that will result from each movement or task we recommend.
In conjunction with the Chiropractic Manipulative Therapy (chiropractic adjustment), we may choose to use modalities or therapeutic exercises to promote normal healing and restore function while reducing the vertebral subluxation complexes. We must consider how these modalities and therapeutic exercises may affect an open epiphysis and the length of bone during its growth. Finally, we must consider the "physiological" factors of maturity, motivation, and how well our patient understands the significance of the neuromusculoskeletal condition we are treating.
When we consider the use of the most common adjuncts available to us (cold and heat), we must keep some important things in mind. If we are using cold to reduce acute inflammatory response of an injury or inflammation caused by exercise, the cold should also include the use of compression and elevation (PRICE). Contraindications for cold would include prolonged use over an area which may lead to tissue damage. This could result in a neurpraxis or axonotmesis of superficial nerves, or altered increases and decreases of blood flow. This is referred to as "Hunting Reaction." Always consider not using ice over areas of skin that my have a reduced or compressed blood flow.
The use of heat as a modality is usually used after the acute signs and symptoms have resolved. Application of heat increases blood flow of an area, which helps bring oxygen and needed nutrients, while removing toxins and debris away from the injured area. The use of heat commonly is used as a precursor on joints to help improve ranges of motion. Contraindications of heat are acute traumatic injuries. This can cause an increase of edema and hemorrhage formation. Likewise, use over areas of decreased sensitivity and ischemia may result in overheating and cause tissue damage.
We must exercise extreme caution when using any modality with adolescent or younger patients; their thermoregulatory systems may not be able to judge just how cold or hot an application may be.
When determining the type of resistance exercises to perform, rehabilitation tubing is easy and safe to use, regardless of age. These bands will come in usually three types of resistance, as identified by color: red being the lightest; yellow, medium; and black having the most resistance. To determine the amount of resistance to use, always keep in mind you want your patient to be able to perform full ranges of motion in a smooth, steady motion. Any jerky or restricted motion means the resistance is too strong and the joint is being over-loaded. The number of repetitions you recommend should be based on how well your patient can perform the exercise. We are not trying to make strength gains in the beginning. Proper mechanics for re-education is what is important here. I would recommend not performing more than three sets of no more than eight to fifteen repetitions. A very good rule of thumb here is that each repetition must be performed the same as the one before it—meaning repetition number five must be performed with the same easy, smooth motion as the first repetition. If it is not, then we are possibly over-loading that joint. I would rather see good quality in technique and full ranges of motion than a jerky pattern that is not completed through a full range of motion. Commonly, with both my younger and elderly patients, I like to have them do what is referred to as a "Reverse Pyramid"—one set of eight, a second set of six, and a third set of four; keeping in mind that the last set of four must be done as smoothly as the first eight.
In closing, a very common question I know we all are asked by parents is, "Is it safe for my child to lift weights?" The answer is yes, but it must be a properly supervised and implemented program. When this takes place, strength gains have been noted by children without risk of injury. This is well documented by such organizations as the American College of Sports Medicine, The American Academy of Pediatrics, and the National Strength and Conditioning Association.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan. He is very active with the Michigan Chiropractic Society serving on the legal and government affairs committees.