5 children with "lower lumbar paralysis" were treated in 3 weeks! Why do basic dance movements cause lower limb paralysis?

"Bending back" is a basic dance skill, but it is also a dangerous move that may lead to serious consequences. What are the risks of bending back? Can it really cause spinal cord injury?

Written by Lü Bingxin, Photo and text editor: Chen Yongjie

Interview experts:

Wang Sanmei (Deputy Chief Physician, Department of Neurology, Department of Pediatrics, PLA General Hospital)

Zhou Hongjun (Chief Physician of Spinal Cord Rehabilitation Department, China Rehabilitation Research Center)

Li Beida (Associate Professor of Beijing Dance Academy) #Received 5 cases of "lower back paralysis" in 3 weeks#. Recently, when this topic became a hot search in the news, it not only pricked the nerves of the public, but also sounded the alarm for parents not to blindly encourage children to practice bending their backs.

With the arrival of summer vacation, many parents will choose to cultivate their children's interests and hobbies during this period, and dance is one of the "hottest" ones. However, the waist bending movement in dance training may become a "silent killer" that may cause children to be injured or even paralyzed.

▲Learning dance seems to have become the "standard" education for girls nowadays (Photo source: Visual China)

According to media reports, Liu Zhen, deputy chief physician of the Department of Spine Surgery at Nanjing Drum Tower Hospital, said that for children, the treatment of "lower lumbar paralysis" is a global problem. They will develop complications such as scoliosis and pelvic tilt over time, and will have to be confined to wheelchairs for the rest of their lives when they grow up.

Doctors said that in just three weeks, they had treated five children with spinal deformities caused by "lower back paralysis". In addition to bending down, somersaults and backflips can also cause spinal cord injuries.

▲Recently, the Ministry of Education and the China Consumers Association issued a reminder, emphasizing vigilance against training safety risks, and especially reminding parents to pay close attention to the risk of injury or even paralysis that may result from movements such as "bending back" in children's dances. (Image source/screenshot from the Ministry of Education website)

According to incomplete statistics, since 2005, more than 1,000 children in my country have been paralyzed due to bending down; in recent years, the number of children with "lower back paralysis" has generally shown an upward trend year by year. CCTV's "Today's Statement" once reported that a 5-year-old girl Dingdang had an accident while bending down during dance training, which damaged her spinal cord and caused permanent lower limb paralysis. A female celebrity was also exposed that a girl in a dance training class run by her mother became paralyzed in the lower body due to improper bending down.

▲The program "A Childhood That Can't Stand Up" broadcasted by CCTV-1's "Today's Statement" tells the story of a 5-year-old girl named Dingdang who unfortunately had an accident while participating in dance training, and suffered spinal cord damage, resulting in lower limb paralysis (Image source/CCTV screenshot)

"Regret, pity, and heavy price", almost all doctors will express this feeling when talking about children who are disabled due to bending back. "I hope parents and dance training institutions can have a correct understanding of this dangerous action and pay attention to this potential risk." What are the risks of bending back? Can it really cause spinal cord injury?

Nightmare: Paralysis caused by a low back sprain

"Mom, when can I stand up?" Xiao Cai, an 8-year-old daughter sitting in a wheelchair, occasionally asks her mother Zhao Fang. On September 7, 2018, when Xiao Cai was bending down at home, she felt as if she had twisted her leg accidentally. She thought it was nothing serious, but what happened next caught Zhao Fang off guard. At first, the child just cried out that her legs hurt, but in less than an hour, the child's legs could not move, she had no sensation, and she could not urinate or defecate. Realizing the seriousness of the situation, Zhao Fang took the child to a municipal hospital, and the doctor recommended going to Beijing or Tianjin. The MRI results of the examination in Tianjin showed spinal cord injury, and Xiao Cai "went directly to the intensive care unit and stayed in the ICU for 8 days." After that, Zhao Fang brought the child to Beijing to seek treatment from Wang Sanmei, deputy chief physician of the Department of Neurology, Department of Pediatrics, General Hospital of the Chinese People's Liberation Army.

▲The program "A Childhood That Can't Stand Up" broadcasted by CCTV-1's "Today's Statement" shows a 5-year-old girl named Dingdang attending a dance training institution (Photo source/CCTV screenshot)

"Based on the MRI showing abnormal signal shadows of swelling and necrosis in the thoracic 7th and 8th segments of the spinal cord, Xiao Cai underwent a variety of related examinations, including lumbar puncture and cerebrospinal fluid and blood tests. After excluding various causes of spinal cord injury such as immunity, infection, and tumor, it was finally considered to be a spinal cord injury caused by the low back movement." Wang Sanmei told reporters that this situation is a spinal cord injury without fracture or dislocation caused by the low back movement, that is, there is no vertebral fracture or dislocation of the spine in the imaging examination. Because of this characteristic, it is easy to be missed or misdiagnosed.

▲Dingdang, sitting in a wheelchair, is still dreaming of standing up and learning to dance one day (Image source: CCTV screenshot)

"I have treated about seven or eight cases of spinal cord injury caused by bending down. Some of them occurred in dance training institutions, and some occurred when practicing bending down at home." Wang Sanmei introduced that due to the abnormal stretching of the spinal countertension during the bending down movement, the spinal cord blood supply artery stretched and thinned, resulting in insufficient blood supply to the spinal cord, and even vascular endothelial strain to form thrombosis and blockage of blood vessels. The gray matter and white matter of the spinal cord nerves have poor tolerance to hypoxia, which will quickly cause segmental hypoxia injury to the spinal cord. The children experienced lower limb pain and movement disorders. Due to the weak compensatory ability of the spinal artery, collateral circulation cannot be formed quickly, and the spinal cord is hypoxic and necrotic, which can gradually involve 2 to 3 segments of atrophy, causing irreversible permanent paraplegia.

▲X-ray photo of spinal cord injury (Photo provided by Wang Sanmei)

"Paralysis - no feeling below the navel. I thought it was just a bone problem, but it turned out to be a spinal cord injury." Zhao Fang was shocked to think that her young daughter would spend the rest of her life in a wheelchair. In fact, in recent years, spinal cord injuries in children caused by the back bending movements of dancing have become common, gradually attracting the attention of domestic doctors.

In a paper published in 2020 on "Characteristics of Changes in Causes of Spinal Cord Injury in Children", Zhou Hongjun, chief physician of the Spinal Cord Rehabilitation Department of the China Rehabilitation Research Center, was the corresponding author. A retrospective analysis of the causes of injury and demographic characteristics of children with spinal cord injury under the age of 14 who were admitted to the China Rehabilitation Research Center from January 1, 2015 to December 31, 2019 was conducted. The study pointed out that there were 221 children with spinal cord injury, including 62 boys and 159 girls; they were distributed in all age groups from 1 to 13 years old, with a median of 6 years old; the largest number of children aged 4 to 7 years old (55.7%), mainly girls (83.7%). The top five causes of spinal cord injury in children were sports injuries in 78 cases (35.3%), non-traumatic injuries in 56 cases (25.3%), other injuries in 48 cases (21.7%), traffic accidents in 24 cases (10.9%), and falls from heights in 12 cases (5.4%). Among the sports injury cases, 75 cases (96.2%) were caused by bending down movements, mainly occurring in children aged 5 to 7 years (80.0%). All of them were thoracic spinal cord injuries without fracture or dislocation, including 53 cases (70.7%) of complete spinal cord injuries.

(Data source: "Characteristics of Changes in Causes of Spinal Cord Injury in Children") A noteworthy phenomenon is that Zhou Hongjun found that the number of children suffering spinal cord injuries due to bending down in 2021 has decreased. "It is related to the epidemic. Because of the epidemic, offline dance training has decreased." Zhou Hongjun told reporters. However, many parents, including Zhao Fang, do not understand: Why can a simple bending down cause such serious consequences?

Follow-up question: How did the tragedy happen?

Such voices of confusion and doubt are not uncommon on the Internet. On a short video platform, in videos of young children bending their backs released by some dance training institutions, you can sometimes see these five or six-year-old children with red faces and clenched teeth in pain. Some netizens kindly reminded: If you practice like this, if your spinal cord is injured, it will cause high paraplegia. But then it attracted a lot of rebuttals: I practiced like this when I was a child and there was no problem at all. There is no need to worry about children's soft bones. Acrobatics and martial arts are also like this. What's wrong? So, what's wrong?

▲A martial arts training institution lets children of a few years old do waist bending exercises (video screenshot)

Zhou Hongjun told reporters that the mechanism of spinal cord injury in children caused by bending down is not very clear at present, but the incidence of spinal cord injury caused by bending down has been on the rise in recent years, which needs more attention. In addition, spinal cord injury in children in my country is significantly different from that in foreign countries. Most foreign studies believe that there is no statistical difference in gender in injuries before the age of 3. After the age of 3, boys have significantly more spinal cord injuries than girls because they are active and prone to dangerous activities. This is not the case in my country. Literature reports that girls are the main victims of sports-induced spinal cord injuries, and most of them are injured while practicing dance movements. In foreign reports, the cervical spinal cord is a high-incidence site for children without fractures and dislocations, and the upper cervical segment is more susceptible to involvement; thoracic and lumbar spinal cord involvement is rare. In contrast, thoracic spinal cord injuries are more common in my country.

▲Schematic diagram of spinal cord injury (Photo source: Visual China)

In fact, this is indeed the case. Data from the China Rehabilitation Research Center provided by Zhou Hongjun show that in 2015 and 2016, the leading cause of spinal cord injury in children was non-traumatic injury; in 2017, sports injuries and non-traumatic injuries tied for first place; starting in 2018, the number of sports injuries exceeded non-traumatic injuries and became the first; in 2019, the number of sports injuries continued to rise, exceeding half of the total number of children with spinal cord injuries that year. Among them, the number of children with spinal cord injuries caused by dancing waist bending movements showed a clear upward trend.

Some people say that the reason is that when children practice bending down, their thoracic spine is extremely overextended, and the spinal cord is overstretched. However, due to the characteristics of children's growth and development, the extensibility of the spine is much greater than that of the spinal cord (possibly up to 9 times that of the spinal cord). The spine will not be damaged if it is extended to a certain extent, but a slight stretch of the spinal cord can easily cause damage to the blood vessels entering the spinal cord, leading to spinal cord injury. Some people also believe that it may be related to fibrocartilage embolism. The bending down movement can damage the intervertebral disc and the remaining blood vessels in the intervertebral disc of young children, causing mucous fibrocartilage emboli to enter the central spinal artery and spread retrogradely, causing spinal cord ischemia, thereby causing spinal cord injury.

Children's body structure is not fully developed and has poor stability, which is also one of the factors that make them prone to spinal cord injuries. So why is it that some children are fine when bending over, but others suffer tragic consequences?

Zhou Hongjun said that not every child who practices bending down will have an accident, but it is indeed a risky action. Once a child sprains or falls while bending down, the possibility of spinal cord injury is very high. "Falling down while bending down is not the same as falling down while walking. The rate of spinal cord injury is much higher, so not all children are suitable for practicing this action." Zhou Hongjun emphasized.

Wang Sanmei said that the anterior spinal artery is very fragile, and the most common injury caused by bending back is the anterior spinal artery in the thoracolumbar segment. "It is said that sometimes it is a case of inch force, but it cannot be ruled out that the child's spinal artery may have congenital malformation or abnormal distribution and course, causing some children to be intolerant of bending back movements. Spinal artery angiography can reveal abnormalities in the spinal blood vessels, but it is rarely checked."

Nursing: The child is only 4 years old, what should I do in the future?

Limb paralysis, incontinence... As you can imagine, children with spinal cord injuries face many practical difficulties in going to school. Xiao Cai was less than 4 years old when the accident happened. "Now she is in the first grade, and she goes to school in a wheelchair. We pick her up every day." Zhao Fang said. Since Xiao Cai has lost the ability to defecate independently, this has become the first problem she has to deal with during her studies at school. Zhou Hongjun introduced that in fact, urinary tract infection is one of the most common complications after spinal cord injury in children. Long-term indwelling of a urinary catheter can induce urinary tract infection and bladder stones, and compressing the lower abdomen to urinate can cause problems such as hydronephrosis. "Before going to school in the morning, around 7 o'clock, I will help her urinate at home, and she will arrive at school at 7:40. After arriving at school, I will ask her to drink less water and not too much water. Go home after school at 11:40 and urinate again. It's probably the same process in the afternoon." Zhao Fang worries about Xiao Cai's daily life day after day.

In addition, unlike adult spinal cord injuries, children often develop scoliosis and hip joint abnormalities after spinal cord injury because the growth and development of the skeletal system is affected. Zhou Hongjun told reporters that almost all children with spinal cord injuries will have scoliosis. Studies have shown that compared with the injury segment, degree, and motor function level, age is a key factor in predicting scoliosis in children with spinal cord injuries.

Children under 12 years old have a 3.7 times higher risk of developing scoliosis than older children. Severe scoliosis may affect breathing, visceral function, and even fertility. Therefore, parents and children must pay special attention, focus on exercise, and use professional wheelchair braces, insoles, etc. to assist in prevention.

▲ Spinal cord injury rehabilitation (Photo source/Visual China)

Xiao Cai also needs her parents' care at all times when she sleeps at night. "She needs to be turned over every few hours. Because Xiao Cai's lower limbs cannot move independently, but her upper body can, Xiao Cai often sleeps 'twisted' and needs help to turn her over." The physical pain and discomfort are obvious, and the psychological torture of endless helplessness on parents and children also needs to be seen. "Xiao Cai looks okay on the surface, but she used to be very outgoing, but now she doesn't talk to other children at school. Sometimes her temper becomes very impatient, and she loses her temper and can't control it." Zhao Fang summed up the changes in her daughter after the accident.

"I feel it has something to do with this disease." Zhao Fang admitted that she still cannot accept this reality. "I wish my daughter could be as healthy as other children of the same age." Based on Wang Sanmei's many years of observation and experience in treating patients, parents are almost desperate when they first find out about the disease, so psychological counseling is very important for both parents and children. "If parents can fully help and guide their children, most children will be relatively optimistic."

However, it is undeniable that some children will have some psychological problems. Subsequent rehabilitation in the hospital generally takes 2-3 months. Zhou Hongjun introduced that in addition to sports rehabilitation training for children, the rehabilitation process will also carry out daily living ability training, such as how to defecate, use wheelchairs, use braces, dress themselves, etc. In comparison, nursing at home after discharge is a longer process. But whether it is medical treatment, rehabilitation or daily care for children, it requires material investment, which is a heavy burden for Zhao Fang, who lives in the countryside. "Anti-scoliosis wheelchair costs 8,500 yuan, anti-bedsore cushions cost 1,000 yuan, and the initial rehabilitation cost is about 10,000 yuan per month..." As the child grows up, the wheelchair and brace need to be replaced, and the accumulated costs make Zhao Fang feel stressed. "We understand that compared with rural Hebei, developed cities like Shenzhen have many people-friendly policies for children with spinal cord injuries. I hope that at the social level, there will be more help or subsidies for families like ours." Zhao Fang said.

Question: Can children still dance happily?

"I joined the group in 2018. At that time, there were about 200 people in the group. Now there are nearly 400 people." After her daughter became ill, a fellow patient pulled Zhao Fang into a group of children with spinal cord injuries. "Most of them are children with spinal cord injuries caused by bending down, and there are also some cases caused by other accidents." The patients in the group communicate every day to discuss the children's condition and other symptoms. Some parents will share their experiences with others. What is recorded in the WeChat group seems to be just an introduction to each child's condition, but it is actually a portrayal of the parents' torment and anxiety, and it is also a turning point in the fate of each young child. These messages constantly remind us that we must pay attention to the safety hazards behind the bending action.

The reporter found through Tianyancha that there are as many as 11,607 dance institutions that have been established for only one year. Whether in cities or rural areas, learning dance has undoubtedly become an educational choice for more and more girls. A retrospective analysis of the cases of spinal cord injuries in children admitted by the China Rehabilitation Research Center showed that most of the children came from private dance training institutions in economically and educationally underdeveloped areas, and dance teachers often lack professional training.

Zhou Hongjun suggested that in order to prevent spinal cord injuries caused by children bending down, it is best to evaluate the children in advance to see which children are suitable for practice and which are not. Children who are too young are not suitable for bending down. The choice of dance school is also critical. Formal dance schools and dance teachers rarely let very young children practice bending down. After a certain age, they may be able to practice slowly. "For example, the child of a friend of mine practices dance in the Children's Palace, and he rarely bends down before he is 10 years old."

▲Experts believe that physical assessment of children and selection of formal training institutions and teachers are important steps to prevent accidents in children (Photo source: Visual China)

Li Beida, associate professor at the Beijing Dance Academy, holds the same view. Physical assessment of children and selection of formal training institutions and teachers are important steps to prevent accidents. "Dance training institutions in society that have not received professional training and start classes after a few days of training are more likely to have problems." Li Beida said that to prevent children from bending over and suffering spinal cord injuries, what is most needed now is experienced and qualified professional teachers to give some public welfare classes and cultivate scientific methods and understandings of parents and dance teachers on the problem of bending over.

"It is undeniable that there are definitely some fake dance training institutions nowadays." Li Beida made a pertinent suggestion. If you want your child to specialize in dance, wait until the child is old enough and send him to a professional school for formal and systematic training. Parents should not rush to send their 5 or 6-year-old children to institutions to do waist and splits. If they are not trained well, it will not only affect the height of the children, but also may ruin their bodies. "For 5 or 6-year-old children to learn dance, the main thing is to cultivate their interest. The teacher can accompany them to dance, play and have fun. There is no need to practice hard at such a young age."

First aid: What should I do if a spinal cord injury occurs after bending down?

Wang Sanmei told reporters that some of the young patients she treated could not move after bending down, but some gradually developed various symptoms. "At first, it might be pain in one leg, then it might develop to pain in both legs, then it might develop to inability to defecate and urinate on their own, and finally it was found that there was no sensation below the injured part and they could not move." But basically, all symptoms will appear within 12 hours. Zhou Hongjun reminded that the child might just have leg or back pain at first, and when the teacher asked the child to try to stand up and move around, he found that he could walk normally. If the dance teacher does not have a sense of safety risks, he will mistakenly think that the child is fine and may continue to practice, which is very dangerous.

"After many children got into trouble, their parents checked the surveillance cameras of the dance training institutions and found that the teachers still let the children continue to do some movements, which may aggravate the injury." Zhou Hongjun emphasized that it is necessary to remind parents and dance teachers that if a child falls while bending down during dancing, they must not continue the activity. Regardless of whether the child can continue training at the time, they should be observed for a day or two to confirm that there is no problem before taking it slow.

▲Correct rescue methods for spinal cord injuries

TIPS:

When a spinal injury is suspected, what are the correct steps to take?

1. Call the hospital emergency number and seek professional help.

2. Keep the injured person still. Place a large amount of towels on both sides of the neck to stabilize the cervical spine, or hold the head and neck to keep still.

3. Perform CPR. If the victim shows no signs of breathing, coughing, or moving, perform CPR, but do not tilt the head back to open the airway. Use your fingers to gently grasp the victim's jaw and tilt it forward. If there is no pulse, start chest compressions.

4. If the casualty is wearing a helmet, do not remove it.

5. Do not move the injured person alone. If the injured person must be moved because of vomitus or blood clots that may cause suffocation or to prevent more serious injuries, at least two people are needed to keep the injured person's head, neck, and back on the same level.

(Source: Mayo Clinic, USA)

What should we do if something really goes wrong? Zhou Hongjun concluded that we should go to an experienced hospital for treatment as soon as possible, the sooner the better. Because not all hospitals and doctors have treatment experience, especially in some rural areas, doctors have no experience and think that there is no fracture or dislocation of the lumbar spine, so they let the child go home for observation, delaying the child's treatment time and causing some unnecessary losses. When experienced professional doctors carefully inquire about the medical history, if they find that the child has bent back, they will immediately be alert.

Wang Sanmei said that almost no parents and dance teachers can identify danger signals in time. "If it is discovered early, handled promptly, and immobilized and thrombolytic therapy are taken in time, it may be saved and the spinal cord injury can be reversed. But unfortunately, in similar cases I have encountered, no one can seize this opportunity in time." "Active and passive exercise after paralysis to maintain the volume of lower limb muscles is also very necessary. I look forward to the popularization of human-machine intelligent rehabilitation limbs in the near future, which will benefit these children and help them stand up and walk." Wang Sanmei said.

In fact, the medical community's understanding of spinal cord injury without fracture or dislocation caused by lower back pain did not come about overnight. Zhou Hongjun, who has been working on the front line and engaged in spinal cord injury rehabilitation for many years, said that his understanding of this disease probably began in the 1990s. It was not until the late 1990s to around 2020 that he basically had a clearer understanding of this issue. "In the past, many diagnoses were myelitis. After continuous summarization, we have a correct understanding." Zhou Hongjun believes that actively exploring the truth of the disease and putting forward professional opinions in a realistic manner will be fair to everyone when it comes to compensation issues.

(Note: To protect the privacy of patients and parents, Xiao Cai and Zhao Fang are pseudonyms in this article. Some of the content comes from Jiangsu Satellite TV, CCTV.com, etc.)