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Resolution of Severe Constipation, Vomiting and Leg Pain in a Child Undergoing Subluxation Based Chiropractic Care: A Case Report Michael Mills, D.C.1 & Joel Alcantara, D.C.2 Objective: To describe the chiropractic care of a 6-year-old male with complaints of chronic constipation, daily vomiting
and "growing pains".
Clinical Features: The patient's constipation began at 2 years of age and has been under medical care since. Standard
physical examination and endoscopic examinations revealed a "small stomach ulcer." Prescription medication since age 4
years involved 3 caps of Miralax at three times daily, Exlax one time per day, 10mg capsules of Lasoprizole once per day
and Periactin to stimulate hunger. With respect to the patient's leg pain complaint, the patient's mother indicated that her
son had recently complained of leg pain without cause and denied any history of trauma to her son's legs. Chiropractic
examination revealed sites of spinal and extraspinal subluxations.
Intervention and Outcomes: The patient was cared for with adjustments characterized as high velocity, low amplitude
thrusts. The patient attended a total of 8 visits in a period of 3 weeks. Resolution of the patient's constipation, vomiting
and leg pain complaints were the outcome.
Conclusion: A pediatric patient with chronic constipation, vomiting and "growing pains" experienced subjective and
objective improvements in symptoms under chiropractic. Further research is recommended to examine the effectiveness
of chiropractic care as described in similar patients.
Key words: Constipation, growing pains, children, vertebral subluxation, chiropractic, vomiting
The use of complementary and alternative medicine (CAM) in present with more than one problem/complaints or previous the pediatric population continues to grow; particularly in diagnosis9-10 In this regard, we describe in this case report the those children with chronic conditions such as cancer1, positive outcomes of a child presenting for chiropractic care asthma,2 ADHD,3 diabetes,4 ear-nose-throat infections5 and with chronic constipation despite continued medical care and irritable bowel disease6 to list a few. Of the practitioner-based leg pain of unknown origin.
CAM therapies, chiropractic is the most popular and highlyutilized for children.7-8 Case Report
Children present to chiropractors for both musculoskeletal and non-musculoskeletal problems and its not unusual that they The patient, a 6-yr-old male, was presented by his mother forchiropractic consultation and possible care with a chief Private Practice of Chiropractic, Kittanning, PA Research Director, International Chiropractic PediatricAssociation, Media, PA & Chair of Pediatric Research,Life Chiropractic College West, Hayward, CA J. Pediatric, Maternal & Family Health - November 14, 2013 complaint of constipation and a secondary complaint of leg leg raise test, Valsalva's test, Kemp's test and Minor's sign) pain. With respect to the patient's primary complaint, the were negative. With respect to the leg pain, the patient was constipation began at 2 years of age and has been under observed to be able to walk normally without any pain or medical care since. The mother indicated from the onset of discomfort. No abnormalities were detected (i.e., restriction chiropractic consultation that they were seeking an alternative and/or asymmetry) on active ROM analysis of the joints of the approach to her child's care given the chronicity of his hip, knee and ankle, bilaterally. Digital palpation of the soft- problem. History examination revealed that the patient was tissue elements of the aforementioned joints did not result in currently being treated at a nearby Children's Hospital. In reported tenderness or signs of pain and discomfort.
addition to the standard physical examination, endoscopicexamination of the patient's lower and upper gastrointestinal Intervention & Outcomes tract revealed a "small stomach ulcer." Otherwise, nopathologies were revealed to explain an organic cause to the The patient's mother was apprised of the examination findings and consented to a trial of chiropractic care at three times perweek for 6 weeks.
At the time of chiropractic consultation, the patient was onprescription medication since age 4 years with the following: 3 On the second visit, the patient received care utilizing the caps of Miralax at three times daily, Exlax one time per day, Diversified Technique characterized as high velocity, low 10mg capsules of Lasoprizole once per day and Periactin to amplitude thrusts to sites of spinal and extraspinal stimulate hunger. Prior to prescribed medication, the patient's subluxations. At this visit, left sacroiliac joint dysfunction attending medical physician recommended a high fiber diet (i.e., assessed as a Posterior Inferior (PI) ilium) and sacral with increased fluid intake (i.e. Gatorade and water).
malposition (i.e., assessed as a base posterior) were adjusted According to the patient's mother, the medication to address with the patient in the side posture position. An upper cervical her son's constipation resulted in one bowel movement per day spine subluxation assessed as ASRP of the atlas was adjusted that was characterized as "very hard and painful" with the with the patient supine.
stools described as the "size of blueberries." Overall, thepatient experienced only "two good bowel movements" per On subsequent visits, the patient was cared for similarly with HVLA-type adjustments. On the third visit, the patient wasplaced on probiotic supplements to address possible In addition to the endoscopic examinations, the patient's compromised microflora due to a history of antibiotic use. It mother recalled a magnetic resonance imaging (MRI) of her was also at this visit that the patient's mother reported that her son's gastrointestinal tract with negative findings. At the time son was having bowel movements on a daily basis.
of presentation, the patient weighed only 35 lbs. The Furthermore, these bowel movements were no longer painful noticeable lack of weight gain on the part of the patient was as was initially characterized prior to chiropractic care. By the attributed by his mother to the patient vomiting "on most patient's sixth visit, the patient's mother indicated that since mornings" and then "he would feel better." The mother her son was responding to the chiropractic care so well, she described that upon waking, her son would immediately feel decided to self-withdraw all of the patient's medications. On the need to vomit and run to the bathroom to do so.
the 7th visit, the patient's appetite was described as "better"and was eating "much better." With respect to the patient's leg pain complaint, the patient'smother indicated that her son had recently complained of leg By the 8th visit and 17 days since initiating care, the patient pain without cause and denied any history of trauma to her gained 4 lbs. The patient continued to improve with continued chiropractic care. Following the 10th visit and almost 3 weekssince initiating chiropractic care, the patient's mother decided to withdraw her son from care due to resolution of thepatient's constipation. The leg pain also resolved with On physical examination, visual inspection of the patient's chiropractic care with the mother stating that her son had not posture revealed a head tilt to the right and an elevated right had any problems with his legs since.
hypertonicity of the paraspinal musculature at the C1-C4 Long-term follow-up at 15 months since the patient's last visit vertebral levels (bilaterally), from T8-L1 vertebral levels was performed. The patient's mother reported that her son's (bilaterally) and from L2-L5 vertebral levels (bilaterally). Signs appetite was voracious with the patient eating double lunches of inflammation (i.e., erythema) were also notable at the at school and reported to weigh 56 pounds. She stated that the paraspinal muscles and most notably at the C1-C4 vertebral previous year prior to chiropractic care, her son had missed 45 levels (bilaterally), at the T7-T10 vertebral levels (bilaterally) days of school. At the year of receiving chiropractic care, the and from the L3-L5 vertebral levels, bilaterally. Active range of patient had missed only missed 2 days of school. The patient motion (ROM) examination findings are shown in Table 1 for was reported to be independent of all prescribed medications the cervical and thoracolumbar spine.
for constipation and was "doing great." Orthopedic testing was positive with the iliac compression test on the left side. All other orthopedic tests performed (i.e.,cervical Constipation is defined as "a delay or difficulty in defecation, compression test, shoulder depression test, cervical spine present for two or more weeks, sufficient to cause significant distraction, Soto Hall test, straight leg raise testing and double distress to the patient."11 Approximately 30% of children J. Pediatric, Maternal & Family Health - November 14, 2013 between the ages of 6-12 years are reported as suffering from of an infant with constipation.19-20 Alcantara and Mayer21 also constipation in any given year and constitutes an estimated 3- reported a case report on the topic with review of the existing 5% of physician visits by children.12-13 Consistent with the literature at that time. We encourage the reader to access the child reported in this case report, the problem first appears at article published in this Journal for an assessment of the the age of 2-4 years.14 Although not a problem in the child existing literature on this subject.
reported, encopresis is associated with 35% of girls and 55%of boys suffering from constipation.15 With respect to the patient's leg pain complaints in this casereport; as described, no physical examination findings were For children presenting to chiropractors with a chief complaint remarkable to attribute a cause to the child's leg pain of constipation; more often is the complaint as a result of complaint. Barring for the possibility of a positive laboratory functional constipation rather than due to an organic cause.
testing (i.e., juvenile arthritis), we cannot completely rule out Given this common pediatric presentation in chiropractic other diagnostic possibilities beyond growing pains. The lack offices, awareness of the "red flags" for the presence of a of physical examination findings strongly point to this pathologic condition cannot be overstated (see Table 2). The diagnosis of exclusion. Although the child was cared for findings from the history and physical examination are key to throughout the spine, adjustments specifically to the lumbosacral spine may have provided the salutary effects to the "growing pains." On physical examination, the anatomic position and patency In support of this hypothesis, we refer the reader to the article of the child's anus may provide some telltale signs. The by Alcantara and Davis.22 In a case series presentation, the presence of a pilonidal dimple or tuft of hair, absent anal wink authors described the successful care of a 2¾-yr-old female or cremasteric reflex or a decrease in lower extremity muscle and 3½-yr-old male with "growing pains." Just as in the case tone, strength or deep tendon reflexes may be pathognomonic presented, the parents of both children denied trauma or an of a spinal cord disorder such as tethered cord syndrome, "organic" cause to their children's pain complaints. Spinal myelomeningocele, or spinal cord tumor.12 If an organic cause segmental dysfunctions were noted in both patients at the is suspected by the chiropractor, a medical referral is the most lumbosacral spine.
appropriate course of action with continued chiropractic care.
It is our contention that there are benefits to chiropractic care Alcantara and Davis22 proposed a new etiology to growing for the child with constipation and beyond their presenting pains that expands upon the anatomic etiology, abeit from a clinical complaint such as improvement in sleep, improvement chiropractic perspective (see Table 3). The authors proposed in immune function and in behavior.16 that given the biomechanical relationship between the spine,the pelvis and lower extremities, pelvic (innominate) In a study on the use of CAM by children with inflammatory misalignment may result in abnormal activation of pelvic and bowel disease (IBD) compared to children with chronic constipation, Wong et al.17 found that among the constipation sclerotogenous referral) to the lower extremities.
sufferers, 23% reported using at least 1 type of CAM therapy.
For both groups, the perceived benefit of CAM therapy was In addition, sacroiliac joint involvement is a given and are reported to be similar to the average perceived benefit of known to have pain referrals to the lower lumbar spine, standard medical therapies, which was 80%. The strong belief buttock, groin, medial, lateral and posterior thigh and on the effectiveness of CAM therapies for this patient sometimes in the calf. For the child in such a situation, he or population is a clear indicator that CAM use will not only she may interpret these as "growing pains." continue but grow.
In closing, we caution the reader on the lack of It is established that one motivator or predictor for CAM use generalizability of case reports in general and the case was the associated side effects with allopathic medications.
reported in particular. Similar to other case presented in the Add to this the added concerns of drug interactions with literature; despite a temporal association and biological various natural health products, chiropractic with its hands-on plausibility in resolving the complaint of growing pains, our approach makes it an attractive alternative care option for cautionary advice is based on the possibility of bias.
chronic sufferers of constipation.
Lacking a control group, the unaccounted effects of natural Recently, Rosado and Rectenwald18 reported on the successful history, the role of placebo, regression to the mean, the chiropractic care of a 9-month-old infant with constipation demand characteristics of the clinical encounter, and following cessation of breastfeeding. The case report was subjective validation are confounders to making cause and augmented with a selective review of the literature. Rosado effect inferences with respect to the reported benefits from the and Rectenwald18 described the chiropractic care of the infant care received.
as Diversified Technique.
Following the child's first adjustment, her mother reported anincreased frequency of bowel movements. By the third week, We described in a case report format the successful the child's mother reported only occasional constipation. After chiropractic care of child with long-standing constipation and five months of care, the constipation problem had resolved.
a recent complaint of leg pain associated with possible Prior to this publication, we are aware of only 2 other papers growing pains. We encourage further research in this area to describing the successful care examine the possible benefits of chiropractic care in patients J. Pediatric, Maternal & Family Health - November 14, 2013 with similar complaints.
13. Loening-Baucke V. Chronic constipation in children.
This study was funded by the International Chiropractic 14. Rubin G. Constipation in children. Clin Evid 2004;11: Pediatric Association and Life Chiropractic College West.
15. McGrath ML, Mellon MW, Murphy L. Empirically complementary and alternative medicine in children with 16. Alcantara J, Ohm J, Kunz D. The safety and effectiveness cancer: effect on survival. Pediatr Hematol Oncol.
of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore Philp JC, Maselli J, Pachter LM, Cabana MD.
Complementary and alternative medicine use and 17. Wong AP, Clark AL, Garnett EA, Acree M, Cohen SA, adherence with pediatric asthma treatment. Pediatrics.
Ferry GD, Heyman MB. Use of complementary medicine in pediatric patients with inflammatory bowel disease: Sawni A. Attention-deficit/hyperactivity disorder and results from a multicenter survey. J Pediatr Gastrenterol complementary/alternative medicine. Adolesc Med State Art Rev. 2008;19(2):313-26., 18. Rosado MR, Rectenwald RR. Resolution of chronic Miller JL, Binns HJ, Brickman WJ. Complementary and constipation in an infant undergoing chiropractic care: a alternative medicine use in children with type 1 diabetes: case report & selective review of literature. J Pediatr & a pilot survey of parents.Explore (NY). 2008;4(5):311-4.
Matern Fam Wellness - Chiropr 2012 WIN; 2012(1): 22 – Shakeel M, Little SA, Bruce J, Ah-See KW. Use of complementary and alternative medicine in pediatric 19. Davis JD, Alcantara J. Resolution of chronic constipation otolaryngology patients attending a tertiary hospital in the in a 7 year old male undergoing subluxation based UK. Int J Pediatr Otorhinolaryngol. 2007;71(11):1725-30.
chiropractic care: a case report. J Pediatr & Matern Fam Wong AP, Clark AL, Garnett EA, Acree M, Cohen SA, Wellness - Chiropr 2011 FAL;2011(4):98-105.
Ferry GD, Heyman MB. Use of complementary medicine 20. Batte SB. resolution of colic, constipation and sleep in pediatric patients with inflammatory bowel disease: disturbance in an infant following chiropractic care to results from a multicenter survey.J Pediatr Gastroenterol reduce vertebral subluxation. J Pediatr & Matern Fam Wellness - Chiropr 2010 WIN; 2010(1): 1 – 5.
Barnes PM, Bloom B, Nahin RL. Complementary and 21. Alcantara J, Mayer DM. The successful chiropractic care alternative medicine use among adults and children: of pediatric patients with chronic constipation: A case United States, 2007. Natl Health Stat Report. 2008;(12):1- series and selective review of the literature. Clinical Nahin RL, Barnes PM, Stussman BJ, Bloom B. Costs of 22. Alcantara J, Davis J. The chiropractic care of children complementary and alternative medicine (CAM) and with "growing pains": a case series and systematic review frequency of visits to CAM practitioners: United States, of the literature. Complement Ther Clin Pract.
2007. Natl Health Stat Report. 2009;(18):1-14.
Alcantara J, Ohm J, Kunz D. The chiropractic care ofchildren. J Altern Complement Med. 2010;16(6):621-6.
10. Alcantara. The presenting complaints of pediatric patients for chiropractic care: Results from a practice-basedresearch network. Clinical Chiropractic 2008; 11:193-198.
11. Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector W, et al. Constipation in infants andchildren: evaluation and treatment. A medical positionstatement of the North American Society for PediatricGastroenterology and Nutrition [published correctionappears in J Pediatr Gastroenterol Nutr 2000;30:109]. JPediatr Gastroenterol Nutr 1999;29:612-26.
12. Biggs WS, Dery WH. Evaluation and treatment of constipation in infants and children. Am Fam Physician2006;73(3):469-77.
J. Pediatric, Maternal & Family Health - November 14, 2013 Table 1. Active ROM examination findings for the patient's cervical and lumbosacral
spine.
Active ROM
Lumbosacral Spine Right Lat Flexion Table 2. Organic causes of constipation with possible diagnostic tests
Organic Causes of Constipation
Anorectal malformation Physical examination Chronic constipation  Physical examination and history*  No tests necessary*  At times: x ray of kidneys, urether, and  Colonic transit Non-retentive faecal incontinence  Physical examination and history*  X ray of kidneys, urether, and bladder  Colonic transit Hirschsprung's disease  Rectal biopsy*  Anorectal manometr y Neuroenteric problem  Colonic transit  Colonic motility*  Rectal biopsy? Spinal cord problem:  Physical examination  Magnetic resonance imaging*  Anorectal manometry? Pelvic floor dyssinergia:  Anorectal manometry* Metabolic, systemic problems:  Thyroxine, thyroid stimulating hormone*  Tests for coeliac disease* Toxic (i.e., lead, drugs)  Toxic screen* Cows' milk allergy  Elimination diet  Allergy testing Reproduced with permission from: Rubin G, Dale A. Chronic constipation in children. BMJ 2006;333:1051-1055with permission from BMJ Publishing Group Ltd. J. Pediatric, Maternal & Family Health - November 14, 2013 Table 3. Proposed etiologies for growing pains.22
Postural or orthopedic dysfunctions in the lower extremities results in pain.
Correction of dysfunction results in pain relief.17 Unfortunately, to date, the existingliterature demonstrates that poor posture and growing pains are not correlated.18 Metabolic waste accumulation in the lower extremities as a result of fatigue causesgrowing pains.19 This theory is supported by the parental observations of growingpains with physical activity in their child.
Since children with growing pain were found to have negative or intense mood,familial predisposition is thought to lead to increased susceptibility to pain.21 J. Pediatric, Maternal & Family Health - November 14, 2013

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