Help! My kid is in pain! How do I talk about it with him or her? (Part 2)

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It is not fun for anyone when kids, ‘tweens, or teens have pain. In an age group whose sole responsibility is learning, play, and exploration, pain can really get in the way of these things sometimes.

My favorite line is “My kid (or my friend’s) ’tween/teen hurts! What does this mean and what do we do about it?

In case you missed Part 1 of this blog series, I outlined what it means and why kids have pain. Since you’re probably proactive like me (otherwise, why would you be reading this?), let’s move on to “what to do about it.”

First and foremost-it is essential to give kids the opportunity to describe pain in based on their established communication skills. As mentioned in Part 1, many kids simply agree with what adults tell them to say about pain, while others learn metaphors of describing pain that don’t agree with their age or experience level. Example: the 11 year old who states her knee pain is “bone on bone” feeling. She’s too young to be using that metaphor appropriately. Most confusingly–some kids are too young to understand metaphors or communicate about their pain at all.

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Keep it age-appropriate:

  • Very young kids (ages 0-3): Pay attention to body language, behavior, play activity, and body mechanics. It is less likely that kids in this age group will misinterpret pain or use it as “manipulation” to get something they want. They also will be less likely to discuss it in any detail with an adult. Use the FLACC pain scale to quantify your observations.

    this scale is commonly used in babies and toddlers who cannot communicate their feelings. It is also used in other older patients who may have conditions that challenge their ability to communicate with caregivers.

    This scale is commonly used in babies and toddlers who cannot communicate their feelings. It is also used in other older patients who may have conditions that challenge their ability to communicate with caregivers.

  • Preschool (3-5): if they are old enough to draw, have them draw how they feel. Use toys, dolls, or stuffed animals to have the child act out their feelings. Use the FLACC or FACES pain scale depending on their ability to communicate their feelings.

    This scale is appropriate for children who can communicate using pictures, usually up to about age 10.

    This scale is appropriate for children who can communicate using pictures, usually up to about age 10.

  • Elementary school age (6-10): Continue to use drawing and acting as needed. You can start to give suggestions of metaphors to describe the pain. Example: have the child stretch a non-painful body part & feel the sensation of “muscle stretch.” Ask them if the pain feels like that (stretch, pull sensation). Most children at this age know of bruises and cuts (dull, sharp), so you can ask them if it feels like that. Older elementary school kids have a better understanding of muscle soreness, so you can ask if the pain is reminiscent of how they feel after a hard day in PE when their legs may be tired (soreness, throbbing). It’s still important to let them use their own words. The FACES scale is most appropriate for this age group, even up to age 10.
  • Middle school (11-14): Believe it or not, ‘tweens and teens in this age group sometimes have the hardest time describing their pain. They are transitioning from “kid role” into more “teen & adult” roles, which often leads to confusion they don’t even know they’re experiencing. They are balancing the desire to please adults with the desire to gain independence, test limits and rules with adults. Anxiety normally increases with puberty, middle school social pressures, and a rapid developing brain and emotional regulation system. Plus kids are often rapidly growing while participating seriously in one or more sports. It’s a perfect storm—and all of these things often lead to increased pain, injuries, and problems in this age group. Be very gentle when communicating with ‘tweens and teens. The numeric pain rating scale is appropriate but it’s important to understand that kids in this age group may report pain differently depending on where they are emotionally, cognitively, hormonally, and socially.
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  • High school & College (14-22): You thought young kids and middle school were challenging to understand pain? Welcome to adolescence and early adulthood! While teens and young twentysomethings are much more capable of complex thought processes and may have more experience with pain, they still may not be very adept at processing on how to communicate their symptoms with someone else. We also strike a dichotomy where many adolescents continue to aim to please adults, while others want nothing to do with adults. You know that teen—the one who thinks they know way more than you because they took high school anatomy and are chemistry whizzes. Or you have the teen (usually girl) who is unable or afraid to appear knowledgeable about her body. See my blog on this very subject here. She’s in 7 AP classes and aced the SAT, but has spent so much time becoming book smart that she has developed zero body awareness. She literally cannot tell you what is wrong with her, just that “it hurts, and I don’t know why.” You can talk calculus with her with ease, but getting info from her about her body is like pulling teeth. The numeric pain rating scale is appropriate for this age group, but bear in mind you’ll also have the teen/young adult who swears the pain is a 10/10 while maintaining a smile and seeming relatively at ease. See what I mean about not being able to communicate or understand pain?
  • When in doubt, have them use an emoji, since this is becoming the new language of kids, 'tweens, and teens!

    When all else fails, have your child, ‘tween, or teen communicate with emojis since this is probably their new favorite language.

Keep your game face on

Do not—-I repeat—-do NOT project your own fear and feelings about your child’s or your friend’s child’s pain onto him or her. This may be the hardest part, because I know this is not easy on you, either. Keep calm, maintain your game face, be objective and matter of fact, and help him or her exercise his or her own independence. This doesn’t mean you should avoid showing compassion or caring. Let him or her know that you’re concerned and will do whatever it takes to help him or her through it. This also doesn’t mean it’s not ok to be worried. This is normal and natural for you! Worry and cry about it in the comfort of your own private space.

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Leave the doctoring to the doctors

Stop it with consulting Dr. Google or posting on facebook about it already. This only adds to overdramatizing something that may or may not be dramatic. Consult a medical professional!

Emergencies are emergencies and cannot wait

If it’s clearly deformed, the skin is open and bleeding/oozing, the child or teen cannot put weight on the body part, it appears infected, or your inner voice says “something just doesn’t seem right”-please consult urgent or emergency care! See more on this in Part 3 (coming soon!).

Sometimes there is just not a straightforward diagnosis

If it has been ongoing for a long time, the child or teen has had every test in the book, and there’s still no medical answer, consider the role of your child’s perception of the situation along with his or her emotional processing. It is exhausting and confusing for him or her to go through the rigmarole of myriad tests and physician visits. Cut your losses and consider consulting a functional/integrative medicine practitioner, pediatric pain psychologist, or physical therapist who specializes in chronic pain in kids and teens. Chances are, your child or teen is so burnt out on medical visits that he or she has now integrated a “sick” personality: seemingly more depressed, detached, disinterested in normal age activities, less successful at school and sports. He or she subconsciously realizes the attention they get from being “sick” or “broken” and this becomes part of who they are. Trust me on this one!

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Keep it kid and teen specific, no matter what age they are

Remember that kids, ‘tweens, teens and young adults process pain very differently than you do, as do their developing bodies. Not all adult treatments that may work for you are appropriate for them, even when you swear by them. Let a medical professional, particularly a physical therapist who specializes in pediatric and adolescent injuries, pain, and psychology, make the decision for you on who or what to consult to help your child. Just because Johnny is 18 does not mean he is ready for an adult practitioner. Honor and consider that as you navigate his care.

Let someone else play quarterback

Let a medical professional skilled in dealing with acute pain and ongoing/chronic issues sort through this one and manage all the specialists and/or therapists you may need to see. It’s hard enough to be a rock star parent and it can really wear on you to try and be the manager of your child’s or teen’s health. Let the professionals play “quarterback” to manage the child or teen’s case. Most importantly and often not discussed-consider speaking with a family therapist or life coach to help you cope. It is completely natural, normal, and expected for it to hurt or stress you when you have to put on your smile/game face when your child or teen is suffering. Don’t be a hero—get help for yourself too. There is no shame in doing so and it’ll really pay off in the long run!

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Have resources nearby to help them understand and cope with their bodies

Stay tuned for a future post on helpful books and websites for all youth injuries, conditions, and pains. See Part 1 for examples of 2 books that are appropriate for parents of kids of all ages and middle school age and up. Some other helpful titles are Look Inside Your Body (Louie Stowell/Usborne books) , Magic School Bus: Inside Your Body (Joanna Cole), Understanding Myself (Mary C Lamia, Ph.D.), Sammy’s Physical Therapy Adventure (Michael Fink, PT, DPT), and the Be the Boss of Your Body Series (Be the Boss of Your Pain, Be the Boss of Your Stress, Be Fit, Be Strong Be You (Rebecca Kajander CPNP, MPH and Timothy Culbert, MD)

be fit be strong

Now that you know exactly how to communicate with your child or teen about his or her pain, you’re ready to take the steps to get him or her the right care depending on what is the problem. See Part 3 to understand the problem and determine where best to seek the appropriate care.

Disclaimer:

In an effort to conserve each person’s personal experience and beliefs about how to care for and deal with pain, I offer a bit of advice from the pediatric & adolescent healthcare provider’s perspective. It should be noted that I am not a parent nor do I fully understand all of the complexities and intricacies that go on in each family. Ultimately, how you discuss pain and teach your children and teens to deal with pain is a matter of choice and fully depends on each situation you encounter.

Help! My kid is in pain! What does this mean? (Part 1)

I’d be willing to bet that you generally don’t like to be in pain. I’d be willing to bet more that you really don’t like it when kids and teens are in pain. Chances are, if you are the parent of a young athlete, your child or teen has been in pain at some point in their sports “career.” Maybe you knew what to do about it and your child got better without any problems. Maybe you had no clue and turned to your friends, Dr. Google, or relied on your own steadfast remedy system.

I’ve encountered a gazillion parents who fall all over the map of knowing how best to care for their children’s pain. Sometimes parents make decisions about how to care for a child’s pain that ultimately leads to worsening of the problem. These decisions may be based on an interest to keep a child playing a sport for a number of reasons. On the other hand, some parents fall more into the “hypervigilant” category. These are the parents who fast track their children to the urgent care center every time Johnny or Sarah complains of an ache or pain.

hello kitty band aid

Hello kitty can sometimes make everything better

Despite a parent’s style in caring for pain, one thing all of these parents have in common is that they mean well, regardless of which way they handle each situation. Culture and experience lead people to act in different ways, but there are a few constants that hold true in caring for a child or teen’s pain regardless of one’s background.

Given that I happen to work with young athletes of all ages, I often get questions from patients, colleagues, friends, and family members about pain in their own or their friends’ children. Here is a sampling of the questions I am asked quite frequently:

  • “My 12 year old has been having ankle pain off and on for 3 weeks. She’s been wearing a brace and keeps doing her sport but she says it’s getting worse. When should I panic and do something about it?”
  • “My 8 year old just fell off the monkey bars, says his elbow hurts, and refuses to move his arm. I have 3 meetings I need to attend and he has a baseball game tonight. Can we wait and see how it feels tomorrow?”
  • “My 15 year old’s back has been hurting for 6 months and it’s getting worse. She has bad posture. I told her to stretch and do some yoga with me since that’s what helped me. We also put her on our home traction table, I let her use my TENS unit, and she’s been getting chiropractic adjustments from my chiropractor 3 times per week.”
  • “My friend’s 13 year old has mysterious abdominal pain and has been out of school for 6 months. Nobody can figure out what is wrong with her. Is there another specialist she should see or is this all in her head?”
  • “My 17 year old has hip and groin pain. I think it’s a hip flexor injury. She just needs to stretch her hip flexors and do some Pilates, right? Can you show me some stretches for her to do?”

<Spoiler alert: If any of these situations sound familiar, you’re not alone! We will revisit each of these situations—and what to do about them– in a future blog. Stay tuned!>

Parents, friends, coaches, and kids and teens themselves have lots of questions about how to deal with pain. This can be very confusing, and everyone has an opinion on it. Before we address the somewhat confusing question of how to deal with it or what to do about it, we must first address the possibly more confusing topics of what pain is and what this could mean in a kid or teen.

Defining Pain

The first thing we need to do is define pain. Get ready for a blast back through science class. A person can perceive and experience pain for any number of reasons. According to the International Association for the Study of Pain, Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” What that means is there is not always damage somewhere in the body when pain is present. If that’s the first time you’ve heard that, you’re not alone. What we know about pain barely scratches the surface of what lies beneath the understanding of why it occurs.

Pain is an output from the brain

pain bucket

Pain is an output and sum of all the things that happen to us!

 One thing we do know is that pain is absolutely, positively, 100 percent produced as an output from your brain. See this great youtube video to explain this. While the video is about chronic pain, the same concept applies to just about any type of pain.

Think of the body like an email communication system. You bump your knee, and your ultra-fast email system sends a message through your nervous system to a part of your brain that acts as a switchboard. The switchboard decides if the message is relevant and if it merits being sent on to any other part of the brain. What you need to know about the switchboard is it is not in the conscious part of your brain. If the switchboard deems the message relevant, it sends the message along to your cerebral cortex. This is the part of your brain where you make thoughts, perceptions, and do all the cool, complex processing that makes us human. It’s not until the email message gets to your cortex that your body then decides “oh wow! Bumping my knee hurts!” Thus, it is an output, or a decision, just like any other decision you make.

PainKillers

That pink spot in the middle (the thalamus) is the switchboard. The thalamus intercepts and interprets almost every signal that comes into your brain. This includes stuff like smells, tastes, sounds, thoughts, and signals from organs you may not even know exist!

Now you may be thinking here “Ok Julie, I didn’t decide that I wanted to be in pain.” That’s right. You didn’t. But your conscious brain did. Due to wiring in your brain that you’ve been formulating since before birth-your brain decided whether or not that knee bump was going to be painful. The combination of your life history, culture, environment, previous experience, previous pain and injury, overall health status, emotional status, and many more factors – things that you sense and direct every day—was responsible for deciding if that bumped knee was going to hurt or, well, just feel like you bumped your knee.

painbucket

You can think of pain in a kid like a wheel–it’s totally dependent on so many factors. These factors include intrinsic ones (stuff within the kid that can’t change, regardless of what is going on around the kid), and extrinsic factors (stuff that can change–IE the environmental factors going on around the kid).

 Notice that I said perception of pain is based on factors like life experience, previous pain and injury, and emotional status. Those are just a few factors that might make pain perception a little different in kids. Why is that? Kids have less life experience, likely fewer pains and injuries, and emotional and cognitive/thinking statuses that are not fully developed. This makes pain perception very different for them.

If things are going well, most kids experience the occasional bump, bruise, scrape, splinter, or “owie” as my 21-month-old niece likes to call it. Most “kid pain” gets better with a kiss from mom and dad, maybe a band-aid, and encouragement to “shake it off.” Healthy kids without serious problems are often seen to be running, jumping, and playing through pain. It’s not until pain slows them down or changes their behavior that it usually registers on parents’ or coaches’ radars.

pain experience

What this means is that as kids develop, they may not know exactly what is going on with their pain. They often don’t have the experience or previous pain and injury to be able to describe it. This can make it hard for parents, coaches, and healthcare providers to understand how to help them.

Oftentimes kids learn how to describe pain based on what an adult tells them it should feel like. Case in point: I’ve had an 11-year-old tell me that her knee feels like “bone on bone.” In actuality, this is how physicians or patients may describe an extremely arthritic joint in someone who is a middle-aged adult and has lost all cartilage cushioning in the joint. While not impossible, it’s not something that we would typically expect a ‘tween to say. Ask a 7 year old to describe the pain and they will give you a blank stare. They just don’t have the experience, the complex thinking processes, or the knowledge to know how to describe it. Typically they will just agree with whatever an adult says.

Not only do we have the challenge of getting kids to describe what’s going on, but kids’ behavior around pain is also all over the map. Depending on influence from adults, siblings, and friends who may have pain or have loved ones in pain, kids learn how to behave and perceive pain from those around them. Some kids learn from a very young age that pain is scary. They may panic or complain constantly about every ache and pain. They may also learn that being in pain is a way to get support, attention, or avoid an unwanted activity. This would mean the real underlying problem may not actually be related to the pain at all (more on that later).

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Other kids may learn that “being tough” while in pain is admirable and brave. These kids may not complain at all when they probably should be. This means you may have one kid who has a total meltdown over a splinter, and another kid who seems calm and collected over a broken leg. As you may imagine, there’s clearly a fine line to walk here in teaching kids and teens how to cope with pain. We don’t want to panic them, and we don’t want them to be heroic at the expense of hurting themselves more. And even if you think you’re toeing that line just right as a parent or coach, chances are they’re learning about pain coping (and everything else kids, ‘tweens and teens learn) from other outside influences, too.

Needless to say—pain is complex in any person, regardless of age. Add a developing brain, body, and lots of family and sports influence in the young athlete—and we have the potential of launching those complexities to exponential levels.

conquering child's chronic pain

Here’s a great book by Lonnie Zeltzer, MD. It’s technically about chronic pain—but keep in mind “chronic” in a kid could be 2 weeks. It’s a much smaller percentage of the length of their life. These same concepts can apply to kids and teens of all ages, and even those in acute (IE, just happened JUST now) pain.

WHy do I hurt

This book: Why Do I Hurt? by Adriaan Louw, is appropriate for middle schoolers, high schoolers, and college students. It is written on the patient’s level and really explains pain in a way that fosters understanding. Great for parents and coaches too!

 

Now that you’re armed with more knowledge than you ever wanted to have about what pain is and what it means in a child, teen, or young adult, you’re probably asking–So what do we do about it?

Stay tuned for Part 2 to learn how to address and cope with a child, ‘tween’s, teen’s, or young adult’s pain situation.

Are you the parent of a young female athlete? 10 things to know right now

Female athletes have a million awesome attributes that make us way cooler than boys. Girls rule and boys drool, right?

Even though we are sugarier (word invention), spicier, and everything nicer than our male counterparts, we have some unique considerations to worry over that sometimes make being a female athlete a challenge.

Maybe you were a female athlete from a young age. Think back to your first competition, meet, match, or game. For me, it was at age 6 in a summer league swim meet. I fell in love with the sport and the rest was history.

Dedicated to my sport, I raced through the rankings and ended up training 8-9 practices per week by 8th grade. Little did I know that the 2 fractures I had as a teenager were warning signs of a potentially bigger problem. Yikes. And little did I know that the “mental slump” I was in during high school and the depression that set in when I could not swim after shoulder surgery in college might catch up to me later.

How annoying is it that I can look back and see so many of these warning signs for things that became bigger issues later? How much more annoying is it that there’s nothing I can do with my current knowledge and skills to go back and help young athlete Julie? I guess that’s why I dedicate my career to doing that for everyone else.

If only it were that easy.

Parents and athletes often resist or fight against the education I so eagerly want to provide them and—perhaps most notably—that they are paying me to give them. I regularly hear or encounter phrases like these. Maybe you’ve heard them too, or said them yourself:

“Oh, that couldn’t possibly apply to my daughter”

“Injuries and burnout are ‘normal’ and expected for this particular sport”

“Of course she loves the sport! Look at how well she is doing!”

“She couldn’t possibly take time off or give up the sport. It’s the only thing we have getting her into college!”

I had a meeting with an awesome pediatric/adolescent sports medicine physician this morning and we commiserated over these phrases we so often hear, in addition to several other topics that young female athletes and parents just don’t love to discuss or address—but so desperately need to.

Yeah ok, I get it. Your daughter is flawless and invincible. She is actually an exception to the rules, statistics, and science behind health and wellness in young female athletes. And this is because of her natural talent and passion and of all the money and time you put into allowing her to succeed, right?

I will never fault a parent or loved one for doing what they think is the right thing to do. Most or all of these phrases and thought processes are 100 percent uttered out of caring, good intention, and well meaning. But sometimes—just sometimes—it’s possible people just don’t know any better. That’s what those of us who have personally been there as the athlete, and who now work in this field, are here to help you understand.

baseball should be fun

Regardless of what you believe or support, what we can all agree upon is that no parent or athlete has a crystal ball. None of us in the medical and sports medicine world can predict the future, either. BUT-we do have a little bit more gypsy skill than meets the eye. We can look back and use our clinical judgment to determine what types of behaviors and movements might lead to a problem in the future. And great news!!! We’re actually on your side! We want to help you and your daughter succeed! So just read and listen for a few minutes. Here are some key points you should know about how you can help her too.

  1. It’s not about you

This should go without saying, but unfortunately, I’m finding I still have to say it. This means it’s a real issue out there, folks. Susie’s gymnastics competition may, in fact, be a fashion competition for moms. You are convinced the only way for your 5 year old all star cheerleader will win a national championship is with her belly hanging out, 5 pounds of makeup and bling, and hair extensions. Maybe there’s an unwritten competition for which family provides the best, most organic, gluten free, Pinterest-worthy snacks after the baseball game. Or maybe you’re sure your 6th grader is going to be the next basketball star, just like you were in college. This means you have to be at every practice, on the edge of your seat, letting your blood pressure go through the roof and finding all the flaws in the referee calls because some other kid just outscored your kid. I get it. You mean well. And these are real things that actually happen. It’s likely that as parents, you get caught up in them. That’s fine. But do your daughter a favor: keep the attitudes and the behaviors to yourself. You may not realize it but she is watching you. Chances are, she is internalizing how YOU feel about her sport, and this could eventually backfire. Make her sport all about her.

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Photo credit: Pinterest

  1. Milk: it does a body good

Disclaimer: Dairy allergies and sensitivities are real. I respect that. This is not actually about milk, but I needed something catchy to get your attention. Did you know that almost all of a young female’s bone health is built and stored before she reaches her 20’s? Flash back to teen Julie and her stress fractures. Did you know that the biggest risk for a stress fracture is a prior history of fracture? Bummer for me and my 30-something bones now. That’s what my allergist meant when she told me that being on inhaled steroids as a teen with asthma and participating in non-weight bearing exercise could adversely affect my bones. How are you ensuring that your daughter is getting the right amount of calcium, and the essential vitamin D to help her body absorb the calcium and build strong bones? Maybe let her play outside in the sun a little—with adequate sun protection but not so much that she doesn’t get the natural healthy effects of sun exposure. And maybe let her have that fro yo she’s been begging you for.

  1. Don’t be afraid to discuss menstruation. Period.

You wouldn’t believe how many people I freak out when I ask them about menstrual history. What’s the deal here people? You are female. You are over age 9 or 10. It’s part of your life, or soon to be part of it. So much a part of your life—that if it is NOT happening—we have some reasons to be majorly concerned. So let’s talk about it! While the age of menarche-the onset of menstruation-varies widely from girl to girl, it’s important as parents and medical providers to be having conversations about it BEFORE it’s time for her to begin menstruating. Why? Did you know that being an active female affects estrogen and progesterone levels and exercise in excess can lead to irregular menstrual cycles? Add on stress, rigors of school, and possibly inadequate nutrition: and those young girls’ periods are at risk of being jeopardized. Problems with hormone fluctuation are often seen by young girls in certain sports as “cool”–as in–you’re not cool unless you’re skipping periods. Why are they learning this and from whom did they learn it? Sure, not having to deal with the hassle each month sounds awfully appealing from time to time. However, knowing the lasting effects this phenomenon has on reproductive, bone, endocrine, mental, and physical health is important. We need to teach each girl that menstrual irregularity is just as concerning as discovering a bad zit on her chin the morning of school pictures.

  1. She CAN be a Disney Princess: preferably Sleeping Beauty

Why are girls skipping periods? There are lots of reasons. One of them is too much energy spent for the amount of rest provided. This is called a RED-S, or relative energy deficiency in sport. You may have heard of this concept referred to as the Female Athlete Triad before. It’s all about energy. Energy is a math problem (sorry if you hate math). It is the sum of rest (physical, mental, and emotional) and nutrition minus the energy lost during exercise and daily life. See the equation:

Energy = (Rest (physical, mental, emotional) + Nutrition/Calorie Intake) – Caloric Expenditure (energy lost during exercise/daily activity/metabolic activity)

The body is smart. If energy is lacking, it will steal it from the energy used to do other things, notably that which is used to produce hormones and run the reproductive system. You may think “Susie is not going to reproduce for another 15-25 years, what’s the big deal? Hello! This is NO BUENO people! Lack of estrogen has a strong correlation to later infertility, poor bone health (read: osteoporosis), in addition to problems with the adrenals (stress hormone producers). She needs those stress hormones to build adrenaline, stay awake in school, take an exam, and participate in her sport! This can have a dramatic effect on her later in life. So for that young female who is practicing 40 hours per week, she needs to get just as much energy input through nutrition (see point below), but also through sleep. To add insult to injury—she probably isn’t sleeping as much for education and social reasons. Isn’t it every kid’s dream to stay up late? That’s a normal part of childhood/teen rebellion. Not to mention she may be up all night doing homework for her 37 AP classes and SAT/ACT/MCAT prep classes (MCAT? Isn’t that an exam for college students? Of course it is! But Susie will start studying at 14 for it!) If she truly loves her sport, she needs to learn that sleep will help her jump higher, run faster, and shoot better. And help her make her 4.5 GPA and ace the MCAT. Sleep hygiene is a habit to address when she is 6, not when she is 26 and running ragged in medical residency.

  1. The drama llama: Kid problems are REAL problems

For the next paragraph, we’ll completely flip the situation and blame little Susie for all of her problems. This means you’re off the hook mom & dad, right? Wrong. Susie’s brain is NOT like yours, mine, or her older college age brother’s. This means that it is completely normal for her to be a dramatic, rollercoaster riding, irrational and emotional kid/teen. Why? Because she is a growing kid/ teen and we can’t stop that! The female brain processes and responds to information very differently than the male brain. In addition, she’s growing. Just because she is good at her sport and makes good grades, that does not mean her developing brain is equipped to handle the real problems of childhood, ‘tween-hood, and teenage life. You know what I’m talking about here: how that swimsuit looks on spring break, who she will dance with at the 7th grade dance, if she will try beer at the 9th grade birthday party (or if she will get invited), how many instagram “likes” and emoji tag-backs she got yesterday, and how to talk to YOU (her parents) about the fears and anxieties she faces as a young woman, including her opinion on how you parent her. Those are the real problems that often preoccupy her mind and affect her performance in her sport and her schoolwork. Plenty of scientific evidence supports the fact that a young female’s brain does not fully develop emotionally and cognitively (IE, the ability to feel, think and process) until her mid-20’s. She cannot process, communicate, and understand things the same way you and I do. And even then, some brains never develop those skills. Every girl needs a valuable mentor to help her navigate through all of her perceived life-or-death problems. Make sure she has that.

  1. The apple does not fall far from the tree

Speaking of role models, it’s important to remember the old adage I wrote above. Girls learn how to act from their parents. If you’re a 2 times-a-day gym rat, she will think that is normal and the right thing to do. If you eat the whole box of Samoas while stressing over the girl drama you face at work, what do you think she will do when she is faced with drama among her peers? What happens if you are the overachieving parent who fills his or her plate with 300 (Well-meaning) activities with little down time? What do you think she will do with her spare time? Fill it! Some of the biggest predictors of problems in young girls are the problems faced by their parents. These could be medical, social, emotional, or financial problems. That is not anything to be afraid of. It’s important to be aware of your own vulnerabilities, acknowledge them and most importantly-model that you are taking a stand to take care of them yourself. If you take care of yourself, she will be taken care of too.

Credit: http://1.bp.blogspot.com/_Mn5Un4rHQlk/TEBkIdwVK_I/AAAAAAAAAtM/_0Qd01jV7Ds/s1600/appletreecp.gif

  1. You are what you eat

I’ve already touched on this several times throughout this post. An athlete is only as good as the fuel she provides for her body. My colleague Mandy says “You wouldn’t try and drive across the country without putting gas in your tank and checking your oil, would you?” The same goes for the body. Most athletes and their families underestimate how many calories they burn throughout the day in addition to during a sport. This means they also underestimate just how many calories they need to be taking in. It’s all about energy availability for a healthy athlete. Consult a pediatrician and sports dietician for the best advice.

  1. Variety is the spice of life

Believe it or not, Susie likely has interests outside of horseback riding. She may have her room decorated with posters of horses, ribbons, and ask for a horseshoe-shaped birthday cake. Problem is, she may not know what those interests actually are. Why? Let’s pretend she began to specialize in equestrian at age 8. She was so good at it that it’s all she wanted to do. You’re thinking “I just want her to be happy and do what she loves” and maybe “sweet! College scholarship in the making,” so naturally, you reinforce this behavior. Why wouldn’t or shouldn’t you, after all, that is good parenting. I agree. There is more to it, though. What happens when Susie gets hurt at age 13 and can’t ride for a few months? Maybe she has school to fall back on. But maybe not. Equestrian has been so rooted in her identity that she may begin to experience symptoms of anxiety and depression when she cannot participate. She has no idea who she is or how to define her successes and failures. Everything feels like a failure if it’s not equestrian. Compound that with the fact that she may have been so dedicated to her sport that she cannot identify several other interests to keep her busy, and you now have a snowball effect. As adults, we know that this does not make logical sense. However, to a teen-this can be world ending for them. We have to protect them and give them skills and mentoring to honor themselves and their passions-whatever those may be. Girls don’t have to be the all star at 50 different activities, but it’s important to have other activities on which to fall back. After all, remember that when she is an adult, she may not have the time or money to ride horses anymore. Make sure she has other things to keep her engaged and enthusiastic about life. It will pay off in the long run.

  1. No pain no gain

Ah, finally. A moment to write about the “PT” part of this post. Playing through pain and injury is not, I repeat, is NOT admirable! With the exception of Kerri Strug in the 1996 Olympics, nobody is going to look back on their life as a young athlete and say “wow! I am so glad I played on that sprained ankle! Look at all the fame and admiration it brought me.” Pain in a young athlete is most often not anything majorly serious, but it is a sign that something is going awry in how they are moving, that they are not getting enough rest, or that their tissues are not able to heal. This means those same tissues will not help them perform as well. Their performance will suffer.  Pain is not just “growing pains” that they will “grow out of.” A brace and some KT tape will not fix the problem. At a very minimum, get them checked by a pediatric/adolescent sports medicine physical therapist or physician and make sure you’re not ignoring an issue that could rear its ugly head months or years down the line. The small investment in time and money doing that for your young female athlete will make a world of difference in the repercussions it may cost her later.

If your kid gets through sports with all sorts of colorful adornments you picked up at the local CVS, it's probably time to call a medical provider.

If your kid gets through sports with all sorts of colorful adornments you picked up at the local CVS, it’s probably time to call a medical provider.

  1. Have a Plan B, C, and D

Lastly—college scholarships, professional sports, or whatever end game result you’re looking for may not ultimately happen. There are thousands of reasons that it could all work out, and thousands more that it may not. It’s important for every young athlete to have an adult facilitate for them a plan B, C, and/or D. It’s important to be active and healthy (the repercussions of not being active are far worse), but it’s important to balance that with being a kid, being healthy, and going about it the right way. Nobody is perfect. Even if you followed all of this advice (which, admittedly, is far from comprehensive), something still may go wrong. Be there for her when it does and help her unleash her plan B.

In summary:

You may have noticed a habit or behavior you’ve done at some point along the way–either to yourself or your young athlete. We’ve all done them! That’s ok! Nobody is perfect, and nobody has all of the answers. But now that you’re armed with some information and tools, you can start to pave the way to a healthy, successful, athletic life for your young female athlete. These things are arguably more important than any practice, costume, Pinterest snack, hair extensions, or $400 swimsuit you could possibly provide. That’s what we call “sponsoring” your athlete. Nike is a sponsor to sports teams and provides all of those things-but you better believe they don’t consider themselves parents of the same athletes. Girls need your awesome sponsorship, but also your awesome parenting skills. This means support, guidance, and unconditional love regardless of how well they perform or how much they truly love their sports. It’s our job as grown-ups to give that to them–and most importantly, ensure that the number one priority for all athletes is that they are having fun.

How young is too young for dry needling?

As a physical therapist practicing in Georgia, I have the privilege of being able to use the skill of trigger point dry needling to help patients with myofascial pain and dysfunction, joint stiffness issues, acute and chronic injuries, tendon problems…the list goes on.

Working with a majority of younger patients, I often get questions like “Do you dry needle kids? What’s the youngest patient you have needled? Will my 10 year old benefit from needling like I have?” Those are all good questions. Before I answer them, I think we should cover a little background on this whole needling thing.

What is trigger point dry needling?

In a nutshell, dry needling is a form of manual therapy where the physical therapist or other trained practitioner inserts a solid filament needle into a trigger point in a muscle. This may stimulate a local twitch response in the area, creating a cascade response that ultimately results in a release of the trigger point…or at least that is what we believe happens.

While there is growing evidence for the effectiveness of trigger point dry needling and several studies on what is happening during the technique, the reality is that nobody knows exactly what happens during each treatment in each person. We just know it works and have seen it work time and time again. We believe that the response may be chemical, neurological, mechanical, all of the above, or some of the above. This may vary from place to place between patients or even in various locations within the same patient. Or perhaps it’s a higher order sensorimotor experience change in the brain’s cortex–which I suppose would technically be all of the above depending on who you ask. Either way, there can be great changes that when used in adjunct with other physical therapy tools, pave the way for the patient to see outstanding functional changes.

If you’re still not sure what dry needling is, I recommend you visit these websites for some information:

Back 2 Motion Physical Therapy Patient flyer

Kinetacore Physical Therapy Education

Myopain Seminars

MoveForwardPT.com

Is dry needling the hot new thing in physical therapy? Why have I never heard of it?

In some places and in some schools of thought—yes or no. In the grand scheme of the constantly-evolving practice of physical therapy, dry needling is the new kid on the block in many states and in many areas of PT practice. You may not have heard of it because while most physical therapists possess the skills to do it, not all 50 states allow them to do it yet.

Where is dry needling performed by physical therapists?

What physical therapists can perform trigger point dry needling?

Currently, dry needling requires advanced training beyond the realm of entry-level doctorate level physical therapy education. It is recommended that new graduates wait a year or so to begin training in this practice as good performance of dry needling requires more advanced skills. While new graduates have many excellent skills, the decision-making and safety behind dry needling takes extra time to develop the “finesse” of performance.

Is dry needling the best physical therapy treatment out there?

That is all a matter of opinion. But generally-the answer is probably that there is not one BEST physical therapy treatment out there. Don’t get me wrong-dry needling is one very helpful tool for many patients, but it is not THE tool. In states where dry needling is not legal for PTs to perform, patients see great results with a plethora of other treatment options. Not being able to perform dry needling does not make a clinician any less skilled; likewise, being able to perform dry needling does not necessarily make someone more skilled. It’s just an additional skill to add to the “PT skill toolbox.”

What’s most important are the “above the neck” skills of decision making, assessment, clinical reasoning, and finding the BEST treatment option for EACH patient that allows him or her to optimize the ability to move. See great recent blog about this here. This ability requires a good balance between manual therapy/dry needling, functional movement assessment and re-education, strengthening, stretching, and the good old fashioned teaching and learning interventions my patients lovingly call “Julie’s Sermons.”

So now that we’ve established what it is, where it is, who can do it, and how it fits into PT practice, I can move on to the question I know you’ve all been asking…

But Julie…do you needle KIDS?

My answer is usually something along the lines of “Well, it depends on your definition of kid.See my first post in this blog to understand my definition of kid. Some “kids” are 44 year old elite athletes who cry like babies when I so much as mention the word “needle.” Some kids are 11 year old elite gymnasts who come in begging for needling and swear it is the one thing that keeps them competing at Level 9.

In general, I tend to look not at chronological age, but a plethora of other contributing factors. This requires the need to use all of my senses to determine just who is the right candidate. One could argue that this rule applies to any patient of any age. Chronological age is one factor. Other factors include emotional stability, emotional and cognitive maturity, education level, personal pain experience, activity level, overall/general health, and tendency to faint or scream at the topic of needles.

So, it’s complicated. If you’re looking for an age “limit” recommendation on dry needling, you’re reading the wrong blog. What I can definitively tell you is maybe you want to steer clear of the super young children. Maybe under 6. Then again, I’ve heard from colleagues that it’s been done on younger kids before, as have trigger point injections performed by some of my physician colleagues. It’s just not black and white.

What I can also tell you is that as of this blog posting date, the oldest patient I have needled is 82 and the youngest is 11.

See this resource from a few pediatric and adolescent sports medicine experts on the practice of dry needling in this population.

Let’s dissect a few of these factors to determine which kid is the right needling candidate.

Emotional stability and maturity

I am not going to lie to anyone. Dry needling can be a little uncomfortable. In general I find that anyone who is not in an emotional place where some discomfort can be tolerated may not be the best candidate. On the other hand-some patients can be fearful of movement/exercise and prefer the security and relief that needling brings after treatment, despite discomfort. Sometimes it’s just emotionally easier when passive treatment is performed on them. They can get a little emotionally attached to the technique. This can be a problem too.

Kids and teenagers—and even adults–can be afraid when it comes to medical interventions. Fear and anxiety can sometimes improve with some coaching and the patient will eventually agree to try dry needling. Others are totally emotionally on board, and then it maybe didn’t live up to their expectations—so they jump ship and ask to not have it performed again. See what I mean? It’s complicated.

Cognitive Maturity

“Wait so, you’re telling me this may be uncomfortable. Remind me again how doing something that’s uncomfortable is going to make me feel better?” To some kids, particularly younger kids—this concept is not even an approachable topic of conversation for me. From a cognitive maturity standpoint, some kids just haven’t developed the ability to discern the “later” benefit of doing an uncomfortable “now” treatment. I general I see that in many kids this improves from age 9-11. But then again-it really just depends on the kid.

I also find—and this is my TOTAL anecdotal experience—that sometimes the more the parent is on board with the kid having the technique done, the less the kid is willing to try it. There are many exceptions to this. Some kids and teens do exactly the opposite of what the parents recommend. Most parents would probably agree this concept isn’t exclusive to physical therapy sessions! In other cases, the parent says “poke him” and the kid says “let’s do it!”

But—I use some definite discretion here. Bottom line: I have a strict rule that I must get a resounding YES from the kid or teen before I glove up and pull out the needles. An “I guess” or “Whatever my mom says” just won’t cut it. Sometimes it takes kids a few sessions to warm up to it. Sometimes we try it and it doesn’t really seem to help—largely because I don’t believe they truly understand what I’m doing. The good news is we have so many other interventions we can use that sometimes we don’t even need to go through with needling.

Education level

It’s important any patient be at an education level that they can understand the basic concepts of benefits, risks, alternatives, and outcomes required of an informed consent. Generally, most kids at about 8th or 9th grade can handle a mature discussion on the pros and cons needling without a lot of parental intervention.

What I find often is that the patient who is not WELL educated on medical procedures, but ALMOST well educated is the biggest threat to dry needling candidacy. These are kids who are super smart and have done a little research on their own. Perhaps they have consulted Google, their high school anatomy class, or just talked to friends. Needless to say—they thought that because they knew the name of one muscle in the vicinity of their injury or pain, that it MUST be the muscle that needed to be dry needled.

And kids can be very black and white about it—believing dry needling is the only thing that will fix it. Kids can be very smart, but let me remind you about cognitive and emotional maturity. They generally don’t develop their higher level processing and abstract thinking skills until late high school, college, or even mid adulthood. Some people never develop it. So they firmly believe that putting a needle in the muscle will immediately fix their problem that has been going on for months.

Anyone who knows me knows that this is not quite how I operate, nor how I believe humans operate. I am not a one-and-done type of physical therapist. I get down to the source of WHY that muscle is affected due to how the patient moves or how the patient believes he or she should move. Address that first and see if the trigger point is still there later. Then we’ll talk about putting needles in the serratus posterior inferior. Yes, someone asked me to specifically do that and no, I’m not trained to put a needle there.

(End rant)

Personal pain experience

Someone call Lorimer and David. They can explain this part way better than me, but I’ll take a stab at it (pun intended). I could probably go on for days about how a person’s experience with pain is highly individualized. Some people get a hangnail and it is the most painful thing they’ll ever describe. My good friend just gave birth to a nearly 9 pound kiddo without the use of drugs or any intervention. She didn’t say it wasn’t painful, but she certainly lived to tell about it with a smile on her face. I’ve seen 15 year olds burst into tears when I told them I was not going to needle the tiny knot in their back muscle because I did not believe it would be beneficial.

Pain is emotional.

Pain is an output from the brain. See this post to explain that further or the video below to understand pain better.

For some, dry needling is a valuable tool to help people navigate through nociception, central sensitivity, blurred sensorimotor maps, freaked out “protectometers,” or any other great descriptions for that thing we call “pain.” Some people look at you like you have 10 heads when you recommend dry needling. Some are completely convinced it will not help them, while others call themselves “dry needling evangelists.”

For kids, a large part of why I haven’t gone younger than 11 years old is that GENERALLY (not the bold and italics there please) speaking, most kids are healthy and do not have a lot of experience with pain. Generally, pain at this age is highly driven by emotion, fear, and a lot of internalizing of parents’ experiences with pain. Simply put-most kids learn how to cope with pain based on how other family members and their culture breeds them to cope with pain.

Having said all of that—in any person who has very little experience with pain, an injury is often treatable without a lot of passive or manual intervention. I’m not knocking the value of these therapies, but most of these people have not yet learned that “someone else can fix this for me.” They’re open to doing exercises and not afraid of moving. For a few fearful patients, a lot of times we may do manual therapy and/or needling to coax them back into movement. They’ve had pain for so long or on so many instances that they no longer know “which way is up” so to speak. They don’t know what helps or what hurts them, so they just assume avoid all movement and opt for passive treatment.

Needless to say, pain can be very individualized. Even in kids. We have to determine who is the right candidate based on our interpretation of his or her individual pain experience.

What other factors might a PT consider?

Generally, I encourage all patients to start or maintain a level of physical activity. I try and minimize the amount of time that I perform treatments on the patient. The patient is with me maybe 2 hours a week and with themselves (7 X 24)-2 hours. That’s a lot of hours out in the world by themselves. I tell all patients that “movement is medicine.” I’m not expecting my patients to go run a marathon, but everyone has to do something. Kids included. Most kids are pretty active, but some aren’t. I find that age is not a factor here. If a kid is not active, he or she will probably not respond well in the long run to dry needling or to any other interventions. They must learn to take an active approach to caring for themselves.

As for fear of needles: if someone is legitimately terrified of needles-we don’t even go there. This is a screening question I ask all patients when approaching the topic. This can be an issue in kids, though I often find that adults are more afraid of needles than kids. Kids have to get shots all the time for school and have yearly well checks, so they aren’t strangers to needles. Some people just need a little coaching to be ok with needling, while others will tell me the second they find out that we do dry needling that we will NOT be trying this.

Lastly…what caused the trigger point in the first place? Are trigger points really all that bad?

NO! Trigger points happen in everyone. They can be angry little creatures, but they don’t always have to be the problem. Oftentimes they are the result of poor movement strategy. I know several physicians who have learned that dry needling can help patients and refer patients to PT “Just for dry needling.” They are shortchanging the patient when they tell them this. The patient comes in with the understanding that dry needling will fix their problem. What most physicians aren’t trained to do is analyze and retrain movement. And that’s not anything against their exceptional skills. That’s just not a huge part of medical school, residency, and fellowship. That’s part of PT school and advanced PT training.

So, does my kid need dry needling or not?

While there may be exceptions, typically the younger patients (7-13) do not necessarily need dry needling as the first line of defense. Typically, even with the elite young athlete, we do all sorts of kid-friendly and sports-friendly therapy and the kids get better quickly. Sometimes it’s just a matter of quelling their fears and showing them that a little heel or knee pain can get better with some education, strengthening, and proper retraining.’