All right,
today's guest is tackling one of the
biggest blind spots in physical therapy,
pediatric manual therapy.
Now, for decades,
we've borrowed adult techniques and, well,
just crossed our fingers because clear
evidence-based guidelines for treating
kids
simply don't exist.
Our guest is changing that.
She's an educator, researcher,
and pediatric specialist whose work
focuses on chronic pain in children and
the safe,
effective use of manual therapy for a
growing musculoskeletal system.
She's developing new techniques
specifically built for kids,
not scaled down adult care.
And she's helping train the next
generation of clinicians to approach
pediatric patients with confidence,
compassion,
and hashtag science.
If you've ever wondered how to actually
mobilize a child's joint safely,
how parent beliefs and trauma influence
chronic pain in kids,
or why participation,
not just range of motion,
should be your primary outcome,
this is the conversation.
You didn't even know you needed,
but you do.
Ginny Henderson is here to fill one of
the biggest gaps in our profession,
and I can't wait to dive in.
We bring her in.
Ginny, welcome to the show.
Thank you.
How was the intro?
Did I hype you up well?
You did really, really well, yes.
Perfect.
All right, let's dig into this.
There's a special place in my heart for
pediatric physical therapists.
I posed as a pediatric physical therapist
for a year,
about a year out of PT school.
Loved it.
The impact,
it was very difficult to have a bad
mood.
I'm not saying a hard day.
It was very easy to have a difficult
day, a lot of work.
But at the end of the day,
in the middle of the day,
and even when you crawl out of bed,
it did feel rewarding.
It was a very clear path to rewarding.
So thanks for doing what you do and
focusing on pediatric patients,
not tiny adults.
That's what my mentor taught me.
Amy said, they're not small,
they're not tiny adults.
They're not.
So what made you first realize that
pediatric manual therapy has a major gap
in clear evidence based guidelines?
What was the what was that moment?
And then you just took it upon yourself.
You're like, all right,
this is my this is my fight.
I'm going to dive in.
Sure.
So I started in adult therapy for my
first seventeen years of practice.
And then my daughter had a heart condition
and we spent six months at Texas
Children's.
And I had that moment of.
I want to do what these people do.
I want to step into the lives and
the stories of families.
And so I switched over into peds.
Well, at the same time,
I was going through my manual therapy
fellowship with them.
And so I was doing both of these
together where I was kind of changing my
way of thinking and trying to understand
how the pediatric paradigm worked while
learning all of these techniques and how
they come together.
And I realized that
we speak two different languages in adult
treatment versus pediatrics.
And I would have coworkers come up to
me and say, Hey,
I know you're in this manual therapy
course.
I've got this kid who had Botox to
his adductors.
And now when he abducts,
he's getting a pinching pain.
Is there anything you can help me do?
And I'm like, yeah,
let's inferior gliding, you know?
And so we started doing that.
And,
but I realized that the way it was
being taught to me and the way I
needed to teach it to them,
was different.
And when you look at the ICF model,
pediatrics is much more participation and
activity based.
And they're not looking to say,
how can I increase shoulder flexion?
They're looking to say,
how can I help this kid lift his
arm to put his shirt on by himself?
And I knew the starting place was really
looking at what are the goals of pediatric
therapists?
And so I started drawing the pump tool
and
And going, OK,
what else do they need to know?
Well,
they obviously need to know red flags.
And so really started to research those
and put that together.
And then at that same time,
I was getting into pain.
And the article came out on how to
manually manual therapy for different pain
types.
And I was like,
I could have written this like I literally
was already thinking about this.
I wish I had been there.
known enough to be included in that
because I would have loved to have been
in that room.
And so it just really started putting all
of that together.
And then that's when I applied to the
SCD at Texas Tech and told them,
they said, you know,
you'll do a dissertation.
And I said, well, actually,
I already have something I want to look
into and sent that to them.
And they just helped me really flesh it
out and kind of take it to the
next level.
Just so we don't leave the audience
behind, what is the SCD?
Walk them through that.
The Doctorate of Science in Rehabilitation
Sciences.
So Texas Tech has that program.
And I chose that one because I knew
other people who were in it and I
had heard great things about it.
And so I kind of came in with
this piece that I knew I wanted to
get other brains to think with me about.
And they had the people to do it.
Yeah.
All right,
so let's get into your not only research
but clinical work.
In your mind,
what are the biggest misconceptions or
mistakes clinicians might make when
applying adult manual therapy techniques
to kids?
What are the things you wish you could
erase?
I think
The danger that we see in the clinic
is putting too much pressure through the
shaft of long bones,
because not only do you have kids with
underlying diagnoses like cerebral palsy
or muscular dystrophy,
or even cystic fibrosis who have changes
in their bone mineral density,
but you also have a period of growth
and development when bone mineral density
is actually at its lowest,
when the bones grow
but they haven't thickened yet.
And so one of the dangers I I've
seen is people who come in and try
to use their adult techniques and they end
up fracturing a femur really is what it
comes down to.
And so the thing you have to do
is really work through the joint.
There is in terms of another misconception
is people are really fearful that they're
going to damage the joint.
But what we know from manipulation under
anesthesia with kids is that they are far
more aggressive.
and they don't create joint damage and so
we have these other pieces out there that
can kind of they can inform us and
i even had someone tell me once that
they would never mobilize a kid because
they wouldn't want to produce a skippy
which is a slip capital femoral epiphysis
and i'm like well if you look at
what causes a slip capital femoral
epiphysis it's not joint mobilization like
this child is destined to have a skippy
right and so i think people just don't
know, um,
what techniques are safe and who they can
do them on and who,
when they need to modify it.
And so kind of our next step right
now is we're looking and saying,
who can you manipulate?
Who can you mobilize?
And then who can you facilitate?
And really at the end of the day,
we're just trying to impact
mechanoreceptors and with kids, your, um,
Joint mobility is not usually as big of
an issue as motor control or issues with
sustained postures and fear.
And so your goals are different.
What your challenges are different.
And we just need to know how we
need to modify that for children.
They're not small adults.
It feels like there's a theme there.
They're not just adults.
I even remember in my fellowship,
people who don't treat kids,
when they think of pediatrics,
all they think of is that developmental
neuro crew.
And they're like, well,
joint mobilization is not for them.
You do kids.
You do neuro.
And it's like, no,
there's a whole lot of orthopedics in a
child.
the same amount of orthopedics that the
adults have.
And so not every pediatric patient has a
neurological underlying diagnosis.
Same with not joint,
every neurological patient with a
neurological diagnosis still has joints
and they still,
and their joints move the same ways,
but issues like spasticity,
prolonged positioning,
they affect the joints differently.
And so you have to,
You can't disregard an entire group
because you don't know about it.
And so my hope is to raise awareness,
but really raise it from the standpoint of
good foundational underlying knowledge of
what the red flags are and then give
people an alternative to achieve the same
thing.
Love that.
Well, let's talk some about some of that.
You're developing alternative techniques
designed around the biomechanics of the
growing musculoskeletal system.
Walk us through what makes these
techniques different.
I feel like a second ago,
we talked about anatomy and physiology
being a little bit different,
but some similarities, some difference.
What about the techniques makes those
things different?
You mentioned one, hey,
maybe not putting the force through the
bone.
Are there others?
Yeah,
so we really try to work through the
joint,
but also looking at combined motions.
So a lot of times when we think
about joint mobilization,
we think of a posterior glide.
We think of a inferior glide.
You know, we think about,
but really when you look at the joint,
it's generally,
it has motion all the way around it,
right?
And so looking at something like hip
dysplasia, where you need to work,
congruently into inferior and external
rotation or in order to bring to
facilitate that joint being in the right
position and then activating the muscles.
So really trying to understand that joint
limitation generally doesn't happen in
just one plane.
And so we're looking to say,
how can we work through the joint?
And really a lot of it is bringing
in ideas that, um,
adult predecessors have i mean all manual
therapy is done when you look at it
over time is everybody has kind of
improved on or changed what the guy who
did before them did right so it's it's
not new rocket science so we look at
movement with mobilization i would say
that's probably the closest piece to it
and there's a pnf mobilization technique
that it's in the literature where you use
pnf patterns with mobilization and
facilitation so but a lot of those are
adult manual therapy ideas and trying to
bring that language into pediatrics and
say okay now what are we seeing in
these kiddos that we can apply these
techniques to and add the word pediatric
to it pediatric joint facilitation but
it's not like we're the first person who
came up with combined emotions and working
at the joint instead of the shaft right
so um and then really taking that into
a motor learning piece because
At this point, until kids reach puberty,
their greatest gains are coming in motor
control and motor learning.
Their brains are growing and they're
learning.
And so that's where the biggest bang for
your buck is.
So with kids,
it's not about getting the joint in the
right position and then doing a whole lot
of straight leg raises and trying to
increase the strength of the hip flexor
and focusing on it from that standpoint.
It's about training their brain to use
their hip flexor to climb stairs.
Now that they have figured out how to
inferiorly and posteriorly glide.
And so everything comes back into that
movement pattern and the motor control
that we want them to have,
which brings us all the way back to
the participation and activity component
of the ICF.
Right.
Because at the end of the day,
with kids,
we want to say he can't climb stairs.
We're not looking and saying this older
woman has pain with hip flexion.
Right.
So we've got to think about it throughout
the model and throughout the end goal of
getting kids to be able to do what
they do for a living,
which is play and participate in their
world.
And so how can joint mobilization play a
piece of that puzzle to achieve that end
goal?
And how can we give that tool to
pediatric therapists in a safe manner?
Well,
you already answered or took my next
question.
It was on the list.
It was going to be a great radio
segue, but you mentioned before,
there was always this question when I was
a pediatric PT,
at what age do we stop making it
fun and about participation in sport
instead of just gaining a few extra
degrees of range of motion in this
particular joint?
And I think
You know,
that was the first rule for my mentor
in Peds was if you can't make it
fun, don't bother asking them to do it.
And I think it's sad.
Is it eighteen?
Is it twenty one?
Is it twenty five?
All of a sudden we make it adult.
And outside the physiology,
people want to do stuff that has meaning
and has and has fun or brings fun
back to their life.
I feel like ninety percent of what I
did as a pediatric PT,
maybe ninety five percent was obstacle
courses.
I knew what I wanted you to do.
Let me figure out a fun way to
make you do it.
And then I'll reward you with a zip
line at the end.
But when you look at outcomes like that,
does it change?
I'm guessing it changes everything about
what success looks like in pediatric
manual therapy.
It sounds like that's the middle of the
ICF model for you, which is not.
It's the child and the fun and the
participation.
Right.
It is all about when parents come in,
they don't come in and say, hey,
my kid, you know,
isn't clearing his foot well when he in
the swing phase.
Right.
You know, come in and they say,
my kid can't keep up with his friends
on the playground and he keeps falling in
the mulch.
Right.
And so you have to look and say,
why is this happening?
And how can I make it where this
kid can keep up with his friends or
come closer to keeping up with his friends
in the playground?
So we bring it back, you know,
from the big picture down to the,
but at the end,
the test of whether or not we succeed
is going to be looking at something like
a six minute walk test.
It's going to be these functional outcome
measures that we say,
did what we do make a change in,
in,
an objective change in how he performed,
which has been going to carry over into
his world.
And so that's why I think pediatrics is
so good at screenings that are functional
and that are developmentally specific.
Now, as we start getting into teenagers,
we start to get away from that a
little bit.
But even then,
just to give you an example,
I'll get a gymnast who has low back
pain.
And they can't do gymnastics because their
back hurts and they're in danger of a
spondy.
So I come in here and I go,
well, you've got terrible hip extension.
And so by treating their hip extension,
then I can make it where they're not
as dependent upon their lumbar extension.
And now they can do gymnastics and not
hurt whether or not it's hip extension.
They don't care.
What they want to know is when I
do back handsprings, does my back hurt?
And
And so you just have to,
we can bring it down to that piece,
but if we can't bring it back into
play and activity and sports and
interacting with our families,
then all we have is a bunch of
measurements on a piece of paper.
We don't have any life change out of
it.
There it is.
Let's shift gears a little bit to chronic
pain in kids.
What do clinicians consistently miss about
the role of parent beliefs, trauma,
and adolescent development?
So chronic pain is such a fascinating
topic right now, right?
And it's another one of those places where
people love to talk about it in adults
and they're terrified to talk about it in
kids.
And pediatric therapists are generally
terrified to treat it.
And the problem that we have is that
we have this biomedical model that we've
been trained to in PT school that we
try to apply to our patients with chronic
pain
And we can't exercise chronic pain away.
And so while movement is important for
treating chronic pain,
it is one piece of a probably five
piece puzzle.
And the other pieces that we need to
train pediatric therapists in is to
understand the
how the patient got there how their brain
is working what the the central
involvement is but also one time i heard
this word the nocebo effect and i was
like and i was like this is it
because i can sit down with a kid
and i can do pain education and i
can do desensitization and i can help them
understand pacing but if they go home with
a parent
who had chronic pain all of their life,
who then babies them and says, oh, baby,
you don't need to go to school today.
I can see it on your face.
You're really hurting.
You should probably just stay home and
work from home.
Or why don't you go lay down?
You had a you had a you know,
you had to walk home from school.
I know you're hurting that that nocebo
effect that they get the other six days
of the week.
I can't compete with that.
Yeah.
So we have to have a place where
we can safely help parents understand
the psychosocial side of chronic pain that
is not threatening to them or disregarding
their own experience.
And you have to validate what the parent
has gone through,
but say the way that you've addressed your
pain is not necessarily the way that
science supports addressing it now in what
we know to be true.
And if you can't capture the parent
then the child is going to hear a
different story the other six days of the
week.
And then the other piece is you have
to get a hold of that underlying stressor.
I have a patient who has been with
me for a while,
and he has a legitimate diagnosis.
I mean, he has a PARS defect,
legitimate diagnosis,
but he only feels pain in math class.
And so he goes to the school nurse
every day in tears.
But he's scared to death of failing math.
He has a processing issue with it.
And so when he has the emotional response
to the stress of math,
the place where his body processes that is
the place of least resistance,
which is his low back.
Sure.
And so you look at that and you
go, that's no see plastic paint.
As opposed to nociceptive pain,
which he would say he plays baseball.
You know,
that when I throw the ball and I
rotate to the right and extend for my
windup, I feel it.
That's nociceptive.
But I've got this underlying condition
that I've been dealing with and I look
really, really good in the clinic.
But when I'm in math,
my pain's an eight out of ten.
That's nociplastic.
So what do you do with parents there?
Or, or, you know, both of your patients,
because I was taught that like your
patients aren't just the kids there,
you're inheriting parents as well.
And that's a good thing to make it
hard.
But how do you do that?
Because I'm sure there's clinicians who
are parents listening going, oh yeah,
magically when it's time to go to math
class, things hurt, right?
Where do you start that education?
I mean, I guess, where do you start?
I have no idea.
Unwrap me that.
Sure.
I think you,
you validate what the child's
experiencing, right?
Right.
Because the parents will say,
is my kid crazy?
Is he trying to get out of something?
You know, you you you get past that.
I always recommend psychology.
We are not psychologists.
But but we can.
Psychology is hard to access for a lot
of people.
Sure.
And we can still validate, educate people.
and I think redirect to a new way
of looking at and thinking about these
things.
So I say we have to lower his
stress level about math, right?
And so you're either getting math help or
you're letting know at the end of the
day you're really not that upset if he
doesn't do well enough.
Like if we can lower those stressors in
pain education world and P&E world,
neuroscience education where they talk
about this lion walking around with you.
And the lion has all of these different
words on it that are like my bills,
my marriage, math class,
my performance on the volleyball team,
whatever it is.
Right.
And that whatever your thing is,
that lion is this constant threat to you
that increases your pain.
And basically you have to make the lion
into a little cub.
You have to make the lion safe and
no longer threatening.
And so if that means for this kiddo
to say, it's okay,
if you don't get math,
we're going to get you help.
And even then,
if you make a D in math,
you're going to be a great person.
And this is not a reflection of who
you are,
like to bring down the threat such that
if the people around me are okay with
it, then I can be okay with it.
And when it comes to things like
family abuse.
I mean, in pediatrics,
we have to be really aware of that
and really sensitive to that and ask those
questions.
But those are all things that I say
that I'm in seven and I never had
a kid or had a patient who was
a suicide risk until I started treating
pediatric chronic pain.
Now,
I would say we have one every couple
of months.
And so it is heavy and
And there is a deep psychological piece to
it,
which is why our pain clinics tend to,
you know,
they include a psychologist because it is
it's not this biomedical model only.
While movement's important is it's a
biopsychosocial approach as well.
And and it's a team approach.
So it's hard.
But then, you know,
there's some really there are things we
can do as therapists and somebody.
But then why even send them to therapy?
Right.
Like,
why not just send them all to psychology?
Right.
And there are things that we can do
like they movement does help.
We are trying to change how we sensitize,
how sensitize the nerves are.
Then we also like I noticed that my
kids with chronic pain all have a
difference in their two point
discrimination.
And so I can address their two point
discrimination.
And I basically just rock back and forth.
I'm like two points or one point.
And if I know what their normal is
and I can address that.
they'll come back the next time and say,
I had less pain this week.
It's crazy,
but it's about connecting their brain to
that part of the body in a way
that's not, that's not smudge.
It's not haywire.
And so there are things that we can
do like that.
Our kids with Ehlers-Danlos,
they really lack proprioceptive control
and feedback because their ligaments are
so lax.
And so if we can help their joints
talk to their brain and their brain talk
to their joints,
then um we can make a difference but
it doesn't happen in six to eight weeks
it takes a lot longer and it's um
but there's not many people who are doing
it like i have patients who drive two
hours and my co-workers easily have
patients who drive just as far to see
them because there's just there's not
pediatric therapists who feel confident
treating it
Sure.
Let's go to the clinician who's listening
right now.
For the clinician who's listening who has,
you know,
tomorrow who has a child with pain or
mobility limitations on their schedule,
what's just one thing you want them doing
differently right away with that kiddo on
their schedule tomorrow?
so i think one of the things that
we've learned with kids that are different
from adults is with adults we say correct
the dysfunction and once you correct the
dysfunction then they will move better and
they'll feel better with kids they want
their pain that the kid in the mom
wants their pain addressed first so i
always start with those grade one and
grade two mobilizations actually away from
the site and i really want to bring
down their pain and build their trust
if I go in with a kid and
immediately go straight to the joint and
start getting aggressive with it,
if it's a no C plastic issue,
if it's a pain issue,
I'm going to send that through the roof,
right?
If it is just a positional issue,
then I may correct it,
but they may come in with more pain.
They may, a lot of times they'll say,
I felt great for and then it hurt
worse.
And that is that, um,
just immediate pain relief because of the
chemical change.
But I have to build the trust of
the patient.
So there is a psychological piece to it.
So I usually start away from the joint.
And then if I feel the need to
correct something,
like I'll do a lot of SI joint
manipulations.
And I probably won't do that on the
first visit,
I will start by just springing the SI
joint,
because they've got an adult putting her
hands on her butt,
you know what I mean?
And so for a kid, that's,
That's strange.
I've got to really just think about how
am I approaching this person,
this little person and their ability to
process what's going on in their world as
much as fixing this joint.
And in adult,
I think we fix the joint and in
pediatrics,
I think we treat the person a little
bit better.
Not that we shouldn't,
but they're not small adults.
They're not small adults.
You ready for lightning round?
I did not prepare, Jenny,
for lightning round.
Are you ready for lightning round?
I'm ready for what?
I mean,
I'm as ready as I'm going to be.
You're a PT.
We'll figure it out.
All right, lightning round.
We'll do myth or fact, pediatric edition.
I'm going to throw something out.
You tell me myth, fact,
and maybe a sentence or two why.
What if I get it wrong?
Do you already know the answer?
Wrong?
Okay.
Give the authority here.
All right, myth or fact?
Lightning round.
Jenny,
kids are too fragile for joint
mobilization.
Myth or fact?
Myth.
Why?
Because it's more about how you do it
than what you do.
And you can treat the joint and treat
it differently,
and the kid would be completely fine.
Myth or fact?
Pain in kids usually means tissue damage.
Ooh.
Usually.
Um, I would say that, Oh, you're getting,
you're messing with me.
Okay.
So there's a whole thing.
Pain does not mean tissue damage.
Okay.
Cause it's at the brain,
but no deceptive pain or usually
originates with some kind of damage,
but pain as a whole.
No.
Right.
Okay.
Last one.
Teens exaggerate chronic pain for
attention.
I don't think that's true.
That's a myth.
They want to be with their friends.
They want to participate in their world.
All right.
Last thing we do on the show here
with AOMT is called Words of Wisdom.
What's the last idea, concept?
What's your mic drop moment, Jenny?
What do you got for us?
What do you want to leave the audience
with?
Do I get a second?
Sure, you get a second.
I'll play the Jeopardy music right now.
Mic drop moment.
Gosh, I. Oh, you're killing me.
I got one for you.
I know what it is.
Kids aren't little adults.
I mean, they're really not.
And also, I mean,
if there's something that you don't know
about, don't just throw it out.
Investigate it.
Ask questions.
Learn about it.
I think they I mean,
that would be the biggest thing is people
who are just an absolute no.
And you're like,
have you ever been trained in this?
Have you ever read an article?
And I think give yourself a chance to
learn about it because then you might
really be able to help somebody and make
a difference.
Ginny, thanks for doing what you do.
And thanks for talking to us here on
Hands On, Hands Off through AOMT.
Thank you for having me.