Physical Activity and Sports for Children and Adolescents

13 Physical Activity and Sports for Children and Adolescents




The importance of physical activity during infancy, childhood, and adolescence cannot be overstated. Maintaining a healthy level of activity in combination with eating a healthy diet are the two most important factors in preventing chronic disease (USDHHS, 2008a). And yet, nationally and internationally, populations fail to meet recommended physical activity goals at all ages. Research has revealed that the medical costs in the U.S. due to factors directly resulting from lack of physical activity are more than $188 billion per year (Physical Activity Collaborative, 2008).


This chapter gives health care providers (HCPs) the information and tools necessary to promote physical activity in the clinical setting and to become advocates in the larger public health arena to champion the importance of physical activity in the lives of youth. The chapter covers physical activity guidelines, recommendations for all age ranges and abilities, the preparticipation examination, and medical concerns and conditions specific to the student athlete that need to be considered before recommending the most healthy and safe sport.



image Physical Activity: Definition and Surveillance Data


According to the Centers for Disease Control and Prevention (CDC):


“Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure. The energy expenditure can be measured in kilocalories. Physical activity in daily life can be categorized into occupational, sports, household, or other activities. Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness” (Thompson et al, 2003, p 3109).


Because maintenance of physical activity is such an important health behavior, it is one of the topics monitored in the CDC’s biannual Youth Risk Behavior Surveillance System (YRBSS) (Eaton et al, 2010). The YRBSS monitors health risk behaviors of high school youth, grades 9 through 12; data are collected every 2 years. None of the YRBSS data show that physical activity goals set by Healthy People 2010 (USDHHS, 2008b) are being met in terms of:



Further data analysis reveals that:



Physical activity rates are also decreasing across the globe, with 60% of the world’s population failing to meet the minimal physical activity recommendations required to promote health (World Health Organization [WHO], 2010a). In developing and developed nations urban poverty, concern about crime, structural barriers in the environment (e.g., lack of safe recreational areas, high traffic density, overcrowding), increase in sedentary jobs, increased reliance on passive forms of transportation, and poor air quality contribute to inactivity. The WHO concludes that this lack of physical activity is a contributing factor to the major health problems caused by noncommunicable diseases in many nations (WHO, 2009, 2010a).



image Promoting Physical Activity: Guidelines and Standards


Each of the following guidelines addresses physical activity from a somewhat different viewpoint. All the guidelines and recommendations are complementary to one another.




Healthy People 2010 and 2020


Healthy People 2010 and the newer Healthy People 2020 are broad-based collaborative efforts to address 10 high-priority public health issues; physical activity is one of these indicators. The wording of the Healthy People 2020 document refers clinicians to the 2008 Physical Activity Guidelines for Americans for specific clinical intervention recommendations. The following objectives relate to physical activity and fitness in children/adolescents (USDHHS, 2009):




American Academy of Pediatrics Guidelines


The American Academy of Pediatrics (AAP) endorses the 2008 Physical Activity Guidelines for Americans. The organization’s own policy statement includes the following recommendations (AAP, 2010a):




image Health Benefits of Physical Activity


Activity patterns become long-term lifestyle habits that either promote or compromise the health of the individual in the future. Physical activity promotes physical health as well as motor and cognitive development and psychological well-being, and is essential for optimal functioning of body systems.


In a literature review, Strong and colleagues (2005) reviewed the health benefits of physical activity for children and adolescents. Most of the studies reviewed were based on the benefits achieved by moderate to vigorous physical activity for 30 to 45 minutes per day on 3 to 5 days per week. The authors concluded that for the average child or adolescent not involved in such intensity of exercise, more time in intermittent or less rigorous physical activity would be required in order to achieve the same benefits. Their findings are the basis for some of the provisions in the 2008 Physical Activity Guidelines for Americans. The physical and psychological benefits of physical activity include:



Newer studies have demonstrated that increased aerobic fitness in children is correlated with larger basal ganglia in the brain. This helps maintain attention and better coordinate actions and thoughts (“executive function”); the greater hippocampal volumes lead to enhanced cognitive control (Chaddock et al, 2010).



Health Conditions Benefiting From Physical Activity


For some individuals, regular physical activity is an even more crucial component of preventing and treating chronic health problems. The following highlight the major findings of the effect and benefits of physical activity on several important health conditions.



The increase in global chronic disease rates caused by poor diet and inactivity is a major public health concern of the WHO, which reports that more than 42 million children younger than 5 years are obese (WHO, 2010b). In 2004, the WHO developed a population-wide global strategy on diet, physical activity, and health and later published a framework for member countries to implement and monitor their progress to increase physical activity (WHO, 2004). The U.S. has the highest rate of obesity in males 15 years and older of all member WHO countries (WHO, 2010c).



image Obesity in childhood or adolescence greatly increases the risk that the person will remain obese as an adult. A study in England showed that the propensity to gain weight was related to lower self-esteem in childhood. This weight gain was more likely to occur in children who felt less in control of their lives and who worried (Ternouth et al, 2009). Studies have also demonstrated that a lower body satisfaction in adolescents is related to lower physical activity and more hours of TV watching (Neumark-Sztainer et al, 2004).


Hypertension. For hypertensive youth, regular aerobic activity helps reduce blood pressure. Studies have shown that the most beneficial type of activity to lower blood pressure is aerobic exercise at a level that improves one’s aerobic fitness for a minimum of 30 minutes, 3 days per week. Resistance training coupled with aerobic exercise has also been shown to be beneficial in terms of maintaining blood pressure within the normal range once the hypertension is resolved (AAP, 2010a; Strong et al, 2005).


Metabolic syndrome. For individuals with metabolic syndrome, engaging in moderate to vigorous regular physical activity has the positive effects of increasing high-density lipoproteins (HDLs) and reducing triglycerides and insulin levels. Exercise has not been shown to reduce total cholesterol or low-density lipoproteins (LDLs). In the studies reviewed by Strong and colleagues, 40 minutes of moderate to vigorous exercise on 5 days of the week is required to have measurable effects on reducing lipids and insulin level (Strong et al, 2005).


Reactive airway disease. Children with asthma who do regular aerobic physical activity have been shown to experience improved aerobic and anaerobic fitness. There is no evidence that physical activity improves pulmonary function status (Pianosi and Davis, 2004).


Special needs children. Children and youth with disabilities require special focus in order to ensure that they have access to the means to be physically active and at levels that offer health benefits. Due to higher levels of physical inactivity, youth with physical disabilities experience poorer cardiovascular health, lower levels of muscular endurance and higher obesity levels than do children without disabilities (Murphy et al, 2008). Benefits of physical activity for children and adolescents with disabilities are physiological and psychological—improved self-esteem, greater independence, and improved social skills. Recommendations for providers to promote physical activities for children having special needs include (Murphy et al, 2008):







image Strategies to Support Physical Activity for Children and Adolescents



Motivation and Barriers to Maintaining Physical Activity


A number of factors affect an individual’s motivation to become and/or maintain a physically active lifestyle. Physical activity, like any behavior, operates on a socioecological model. Table 13-1 describes the different levels of influence a clinician can engage in to promote physical activity. The effect of socioeconomics, race/ethnicity, and culture is important to be aware of in order to effectively and equitably address the barriers and resources for physical activity (Brennan Ramirez et al, 2008). A midcourse review of Healthy People 2010 (USDHHS, 2006) describes some local, state, and federal level community health approaches (and the extent of their effectiveness) to decreasing disparities.


TABLE 13-1 Socioecological Model for Effective Promotion of Physical Activity by Providers


























Level of Intervention Examples
Individual Level
Address physical activity during patient visits.
Organizational Level
Promote activities on an institutional level that encourage physical activity.
Community Level
Encourage local projects that promote physical activity.
Public Policy Level
Involve public bodies (e.g., school boards, local/state government) to ensure laws and policies promote physical activity.

CDC, Centers for Disease Control and Prevention.



Can Health Care Providers Influence Lifestyle Behaviors?


Kant and Miner’s study showed that 51% of adolescents with a BMI equal to or greater than 95% were counseled by their providers (only 17% with a BMI between 85% and 95% were similarly counseled). In the group that received counseling, dietary changes were made by the youth, but they did not make changes in their physical activity levels (Kant and Miner, 2007). Another study found that exercise and restricting intake were preferred methods of weight loss after receiving counseling (Klein et al, 2006).


Surveys have also reported that physicians doubt their ability to influence lifestyle behaviors, feel they lack formal education needed to counsel effectively, and are not reimbursed for this time-consuming endeavor (Howe et al, 2010; Sesselberg et al, 2010). Although the most recent U.S. Preventive Services Task Force (USPSTF) review concluded that the “evidence is insufficient to recommend for or against behavioral counseling in primary care settings to promote physical activity” (USPSTF, 2002, p 2), others believe that counseling about the health benefits of physical activity is an efficacious use of time and produces results (AAP, 2010b). The MyActivity Pyramid for Kids is a distinctive and fun handout for engaging children and adolescents in efforts to increase their activity levels (see University of Missouri Extension website).


Familiarity with the theories of James Prochaska and Carlo DiClemente about change, motivation, and motivational interviewing will provide practitioners with clinical skills to collaboratively work with patients to support behavioral change. See Chapter 9 for a discussion regarding techniques for motivational interviewing.



Counseling Families about Organized Sports for their Children


Being physically active is best achieved as a lifelong habit when it is encouraged from infancy. Guidance to parents and other caregivers is important so that youth can benefit and thrive from athletic endeavors without experiencing psychological or physical harm.


More and more, organized sports are taking the place of children’s casual and informal play times (AAP, 2007a). It is now more common to see preschool sports training and teams. When done in an age or developmentally appropriate manner, these activities allow children to benefit from the safety of coaching, proper equipment use and playing facilities, and adult guidance.


Table 13-2 provides guidance for a developmentally appropriate approach to sports activities. The following are some basic concepts to keep in mind when counseling parents, guardians, and youth about athletic participation (AAP, 2007a):



Regardless of age, the goals of sports participation should be to have fun, to develop skills, and to form a foundation for lifelong fitness.



For the young child entering sports (preschool through school-age), the goals should be healthy activity, learning basic skills, and rules of the game. The skills of several children of the same age can be widely discrepant.




About 7 years old children are generally ready for organized noncontact sports, but involvement should be guided by the individual child’s cognitive and motor development and interest. It is important to keep the focus on participation rather than on winning.




About age 10, children become more ready to master complex skills such as rules and strategies for competitive sports. It should always be a goal to keep the focus on skill development, personal improvement, and individual positive strides, rather than on competition, embarrassment, or unnecessary regimentation or stress.


The child who is an exceptional athlete may still have maturation difficulties in social and psychological areas. Finding a balance in supporting the development of an athletically gifted child can be difficult given the stress this child may face in the competitive arena.


Parents and coaches should always role model best athletic practices for injury prevention and sportsmanship (e.g., wear bicycle helmets when riding with their children, pre- and postgame handshakes with opposing team members).


Children with handicaps should be encouraged to participate in sports that best fit their abilities and that are safe.


Children with academic problems should not be denied participation in sports. Studies have concluded that an increase in PE time at school does not negatively affect academics (CDC, 2010a). Sports can be the best arena for boosting self-esteem for the child who does not experience success in the classroom. Helping the child find a balance between academic work and sports participation is essential.


Boys and girls can play together, especially in the prepubertal years. Differences in height and weight can make it unsafe for smaller girls to compete in contact sports with boys after puberty.


Children should not focus on sports specialization until puberty (Brenner, 2007). Prior to that age, it is recommended that children play varied sports, enabling them to maintain their energy and interest for a longer time.


Sports specialization at a young age and/or overtraining can cause overuse injuries (microtrauma damage to bone, muscle, or tendons that occurs from repetitive overuse without sufficient rest and healing time) and/or “burnout” (symptoms include repeated overuse and other injuries, general fatigue, psychological stress, and decreased athletic performance; participation becomes a chore; and a lack of joy and enthusiasm are expressed) (Metzl, 2003; Smith and Link, 2010).


Suggestions for preventing overtraining and burnout (Brenner, 2007) include:









Strength Training


Strength training refers to the use of resistance methods (such as free weights, weight machines, elastic bands, or body’s weight) to increase muscular strength and endurance. Strength training can be used for several reasons: to enhance performance in a particular sport, as a component of rehabilitation after some injuries, and, for some, to enhance muscle mass for appearance.


The safety of strength training for children and young adolescents had been questioned in the past due to possible detrimental effects of such training on immature skeletons. The concern was that the lack of sufficient circulating androgens (needed for muscular strength and mass) could lead to damage of open growth plates, causing premature closure of epiphyses (Young and Metzi, 2010). However, more current consensus is that strength training is advantageous, even for young athletes, provided that it is done in a safe and supervised manner (AAP, 2008a; Faigenbaum and Micheli, 2007). Strength training must be differentiated from weight training, weight lifting, powerlifting, or bodybuilding, which are still not recommended for prepubescent children and young adolescents due to concerns of safety on immature skeletons (AAP, 2008a; Young and Metzi, 2010).


Benefits of strength training include improved cardiovascular fitness, strength, flexibility, body composition, bone mineral density, blood lipid profile, and mental health. Additionally, strength training is an important component to weight management programs because it produces metabolic rate increases without having to do high-impact activities (AAP, 2008a). Additionally, as a component of a well-rounded conditioning program, it has been shown to reduce blood pressure in hypertensive youth; when included in the preseason conditioning and training program for many sports, it correlates with a decrease in sports injuries (Young and Metzi, 2010).


Strength training for young athletes needs to be supervised; there are fewer injuries from strength training than from the sports themselves (notably lower back strains). Box 13-1 lists general guidelines for strength training by the preadolescent.



BOX 13-1 Safe Practices for Strength Training for Youth Athletes




Children who are ready to play in organized sports (e.g., Little League baseball, soccer) are ready to participate in some form of strength-related activity, even if it consists of only push-ups and sit-ups for young children.


Strength training should be only one component of a well-rounded fitness program.


Prior to starting a formal strength training program, the child should ideally have a physical examination, especially if he or she has any known or suspected health condition.


Athletes and families should be advised of the dangers of using performance-enhancing drugs to increase strength and muscle mass.


Training should be done under the supervision of a coach or trainer who is familiar with the appropriate training regimens for different age groups and knowledgeable about the equipment and its use.






Exercises should be balanced among all muscle groups, including core muscles.


Ensure adequate fluid intake during training.


All training sessions should begin and end with a period of warm-up/cool-down exercises that include stretching and dynamic movement, such as a slow jog, jumping, or skipping.


Data from American Academy of Pediatrics, Committee on Sports Medicine and Fitness: Policy statement: strength training by children and adolescents, Pediatrics 121(4):835-840, 2008a; Faigenbaum AD, Micheli LJ: Preseason conditioning for young athletes, 2000. Available at www.acsm.org/AM/Template.cfm?Section=Search&;SECTION=Updated_single_page&CONTENTID=8685&TEMPLATE=/CM/ContentDisplay.cfm (accessed Aug 26, 2010); Hatfield D: Strength training for children: a review of research literature. Available at www.protraineronline.com/post/jun1_01/children.cfm (accessed Aug 26, 2010); Young WK, Metzi, JD: Strength training for the young athlete, Pediatr Ann 39(5):293-299, 2010.


Restrictions on who can safely do strength training include youth with severe hypertension; anyone who is receiving chemotherapy with anthracyclines or any other potentially cardiotoxic medication; youth with some forms of cardiomyopathy (particularly hypertrophic cardiomyopathy); individuals with moderate to severe pulmonary hypertension (at risk for acute decompensation with a sudden change in hemodynamics); and those with Marfan syndrome with a dilated aortic root. Youth with seizure disorders should be withheld from strength training programs until clearance is obtained from a neurologist (AAP, 2008a).



Preseason Conditioning and Injury Prevention


A variety of strategies can be used to reduce the incidence and severity of injuries and heat-related illnesses and dehydration (see also Chapter 39). Some of the more typical injury conditions that can be avoided with simple prevention strategies are included in Table 13-3. Readiness can be addressed from two perspectives, developmental readiness and preseason conditioning readiness. Developmental readiness has been previously discussed.


TABLE 13-3 Common Injuries and Prevention Strategies















































Medical Condition Prevention Strategies Comments
Muscle soreness

Strains and sprains

Fractures

Stress fractures
 
Lacerations/contusions/abrasions

Anterior leg pain syndrome (shin splints)
 
Plantar fasciitis
 
Blisters
 
Head and neck injuries

Eye trauma


Preseason conditioning (examples: preparatory muscle conditioning and plyometric training [exercises that combine strength with speed of movement to enhance power, such as hops and jumps; the central nervous system becomes conditioned to react quickly to stretching and shortening]) is a method for decreasing overall injuries. One study showed a 51% decrease in knee and ankle injury incidence and the severity of injuries due to conditioning (Olsen et al, 2005). Conditioning also lessens overuse injuries (stress fractures, bursitis, tendinopathies) and the amount of time needed for rehabilitation, helps strengthen bone, facilitates weight control, enables the nervous system to react more quickly to the stretch-shortening cycle, improves balance and coordination, adds muscle mass, and improves performance. When started in players as young as 10 to 12 years old, warm-up programs help them establish overall motion patterns. Such conditioning is not sport specific, but entails activities geared toward improving strength, flexibility, and endurance; it is not to be confused with weight lifting or bodybuilding. Coaches and fitness instructors should be certified and be knowledgeable about age-specific training techniques and safety; adult training techniques should never be applied to children.



Use of Helmets for Cycling and Winter Sports


More children and adolescents visit emergency departments for cycling injuries than for any other recreational activity (U.S. Consumer Product Safety Commission [USCPSC], 2006). Two thirds of all brain injury fatalities result from such incidences (American Association of Neurological Surgeons, 2010). Ninety-one percent of bicyclists who died in a crash were not wearing a helmet (Insurance Institute for Highway Safety, 2008). Despite preventing approximately 85% of head injuries and 88% of brain trauma, only 45% of children 5 to 14 years old reported wearing a helmet in states with helmet laws, whereas 39% did so in states without such laws (Safe Kids USA, 2004; USCPSC, 2006). Valuable information about bike safety for children is available from the National Highway Traffic Safety Administration. Proper use starts with proper fitting.



The efficacy of helmet use for young recreational skiers is controversial. A USCPSC (1999) study estimated that 44% of head injuries (53% for children younger than age 15) and 11 deaths could have been prevented by the use of helmets. The USCPSC study also referred to a Swedish study that found a 50% decrease in head injuries in those using helmets versus those without. Shealy’s (2010) study of head injuries on ski slopes, though, found an increase in injuries when a helmet was used. He conjectured that the use of a helmet was seen as a license to ski faster or take chances (like skiing among trees). The helmeted skiers also suffered more serious head injuries than those unhelmeted. At a speed in the range of 25 to 40 mph, whether one is wearing a helmet or not, a helmet is not viewed by Shealy as providing the protection needed to prevent serious head trauma. Helmets are highly advocated by the National Ski Areas Association and such winter sports programs as Lids on Kids.



image Basic Metabolic and Nutritional Needs and Abuses in Athletes


Growing children and adolescents have higher basal metabolic rates than do adults, and they require sufficient caloric intake to both sustain growth as well as to provide energy and nutrients for sports. Youth athletes are also less energy efficient when physically active than adult athletes, thus, their caloric needs are 20% to 30% greater when doing comparable activities (Baker, 2009). Nutrition recommendations are summarized in Table 13-4.


TABLE 13-4 Nutrition Recommendations for Athletes





















Nutrient Recommendations
Calories from carbohydrates/fat/protein
Vitamins and minerals
Carbohydrates
Protein supplements
Fluids

Data from American Academy of Pediatrics Committee on Nutrition: Guidelines for pediatricians: nutrition and sports, Sports Shorts, issue 6, 2001. Available at www.aap.org/sections/sportsmedicine/PDFs/SportsShorts_06.pdf (accessed Sept 16, 2010).




Carbohydrates


Short-term, high-intensity activities (e.g., high jumping or diving) involve using anaerobic fuel sources, whereas longer-term activities involve use of aerobic sources (e.g., running or cross-country skiing). Carbohydrates are used in both anaerobic and aerobic metabolic states, but fats and proteins are used only aerobically. Complex carbohydrates (e.g., fruits, nuts, cereals, grains, pasta, dried beans) are preferable to simple carbohydrates (such as cookies, sugary foods, ice cream, some crackers). Simple carbohydrates should not exceed 10% of daily carbohydrate intake (Nemet and Eliakim, 2009). Complex carbohydrates, although providing readily available energy, do not cause the rapid rise in blood glucose levels with resultant insulin rebound that simple carbohydrates do. Hypoglycemia can result from insulin excess, which is counterproductive to the energy needed in the sport.


In general, carbohydrates will be most effectively converted into the needed energy if they are consumed several hours before the athletic event or practice. Approximately 300 g of carbohydrate-rich food, 2 to 3 hours prior to exercise is recommended. Ingesting carbohydrates just before activities has no effect on performance. Carbohydrate loading has not been studied in children and is generally not recommended. If an athlete is participating in long-endurance events, carbohydrate loading may be appropriate once or twice during an entire season, and only with the guidance of a coach, trainer, or nutritionist with experience in the age group (Baker, 2009). Carbohydrate intake (30 g/hr) during physical activity lasting more than 1 hour improves performance. After competition, carbohydrate intake is again important to improve muscle glycogen resynthesis, which is most rapid in the first few hours after exercise. During the 2 hours after performance, consuming carbohydrates (approximately 75 g) in the first 30 minutes and 100 g every 60 minutes will achieve this resynthesis. This can be in the form of snacks or liquids.





Intentional Weight Loss


Weight loss by adolescent athletes can be a dangerous practice. Wrestlers may try to lose weight to be eligible to compete in a lower weight class; runners sometimes vomit to run lighter; and female gymnasts may practice significant nutritional control to maintain weight and size. Dancers, divers, figure skaters, and cheerleaders also control weight for appearance advantages. Bodybuilders, rowers, distance runners, and swimmers often try to control their weight. Starvation can lead to suppressed growth hormones, can interfere with pubertal gonadal hormone changes, and may result in eating disorders. Nutritional counseling is essential, including a reminder that muscle weighs more than fat, and that during adolescent growth, weight gain is normal.


Wrestlers often engage in repeated bouts of excessive weight loss or weight cycling. Such transient weight cycling can deplete electrolytes, decrease glycogen stores, affect hormones, diminish nutritional status, impair mental and academic performance, reduce immune function, alter hormonal status, and lead to pulmonary emboli and pancreatitis. This temporary weight cycling may adversely affect or alter growth patterns in weight and height and performance (Housh and Johnson, 2007). This practice is to be discouraged because of the risk for long-term dysfunctional eating and short-term effects discussed earlier. Measurements of body composition before and during the wrestling season can help coaches and parents stay alert to risky behavior; any planned weight loss should involve appropriate dietary changes and exercise training. Wrestlers, coaches, and parents may elect to sign a contract requiring that the child eat three meals a day, that fluid be available at all times, and that no artificial means be used to remove fluids from the body (e.g., sauna or sweatsuit, laxatives, diuretics, diet pills, licit or illicit drugs, nicotine, prolonged fasting, over-exercising, or vomiting).




image Health Care for Young Athletes


An estimated 35 million children, adolescents, and young adults participate in some manner of sport, whether organized or recreational. Approximately 7.4 million students in the U.S. participate on an organized sports team (Krajnik et al, 2010). Though relatively safe in children, athletic participation by adolescents becomes more high risk for serious injury. A holistic approach to health care for young athletes involves preventive care (preparticipation physical examination, anticipatory guidance about safe athletic participation, and guidance on any adaptations needed for specific health concerns), care for sports-related injuries, and care for any psychological issues that may arise.


Children with special health care and developmental needs deserve special mention in order to encourage healthy and appropriate sports participation and fitness. Many children and adolescents with intellectual and developmental disabilities (e.g., those with Down, fragile X, Turner or Klinefelter syndromes, autism) are capable of performing exercise or strenuous activities (Pitetti et al, 2009). The goals of physical exercise are to reduce any deconditioning (a result of immobility and prior levels of physical activity), to improve physical functioning, and to improve self-esteem and well-being. These children are at particular risk for obesity, which in turn leaves them susceptible to developing chronic diseases, including heart disease, stroke, hypertension, and diabetes. With regular exercise muscle strength, flexibility, and joint structure and functioning can be better maintained (Murphy et al, 2008). Although the Special Olympics has highlighted global competitive games, the enduring focus has been to educate those with disabilities to make healthy lifestyle choices that will improve their overall long-term health. The Special Olympics provides guides for healthy nutrition; lifestyle choices and ways to increase one’s level of physical fitness; sponsors health screening clinics for people with disabilities; and serves as a resource for community professionals to learn about the physical activity opportunities for children with disabilities that will enable them to participate and compete at high levels.



The Preparticipation Physical Examination for Sports


For many youth, the preparticipation physical examination (PPE) is their only health assessment for several years. It may serve as an entry into health care and enable the provider to schedule a follow-up visit to address other health risks and concerns. However, because PPEs are not required for many of the recreational activities in which youth engage, there is a recommendation by a consensus group (consisting of sports medicine practitioners and consultants from the American Academy of Family Physicians [AAFP], the AAP, the American College of Sports Medicine [ACSM], the American Medical Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine) that a PPE serve as an additional opportunity for a well-child examination for all children. In this way, health and fitness will be promoted and assessed in all children (Editorial Staff, 2010). Included in this examination should be the use of a health questionnaire that targets certain cardiac health issues and the use of standard PPE forms. The PPE monograph contains the recommended questionnaire, PPE, and clearance forms; they are available for downloading from the AAFP. The complete monograph also contains guidelines for clinicians evaluating children with special needs and the female athlete; it is available for purchase (AAFP, AAP, ACSM et al, 2010).


The PPE historically served as a vehicle to provide liability protection, satisfy insurance regulations, and detect cardiovascular risks for sudden death. Over the years, other objectives have been identified that include the following (DeBerardino and Owens, 2009):



The American Heart Association (AHA) recommends an initial comprehensive examination and then another PPE every 2 years for high school students with an interim history review in intervening years. The National Collegiate Athletic Association stipulates an initial comprehensive examination on entry into college level athletics, with interim questionnaires done in subsequent years. The AHA recommends both history and examination prior to entry into playing college sports and an interim history and blood pressure in the subsequent 3 to 4 years of college (DeBerardino and Owens, 2009).


Following a comprehensive PPE, an annual “screening” PPE may be requested, such as for high school students. Salient areas to cover include review of the complete health history with special addition to any interval history of syncope, chest pain, hypertensive symptoms, seizures, palpitations, injuries (orthopedic, neurological [concussions], eye), pulmonary and skin conditions, menstrual irregularities, and risky behaviors (including drug use). The physical examination itself should particularly assess cardiac (including checking femoral pulses), neurological, abdominal (palpating spleen, liver, kidneys), and musculoskeletal systems; as well as height, weight, and blood pressure (Chelminski, 2010).


Studies indicate that between 0.3% and 1.3% of athletes are disqualified from participation based on the findings of the PPE. Between 3.2% and 13.9% require further evaluation in order to be cleared (Greydanus and Patel, 2009). The majority of findings that disqualify a potential athlete or that give cause for further evaluation are musculoskeletal, followed by cardiovascular and then neurological complaints (Hergenroeder, 2008). Any positive cardiac findings on the history (personal or family) or on the physical examination warrants a referral for more in-depth cardiac evaluation prior to sports clearance (AAFP, 2010).


Table 13-5 provides recommendations and guidance on safe sports for various medical conditions and can be a useful reference for complex decision-making. In addition, consultation with the appropriate specialist working with the patient’s particular health condition may be needed before giving athletic clearance or recommending any specific modification or adaptation to a fitness regimen.


TABLE 13-5 Medical Conditions and Sports Participation





























Condition May Participate
Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2)
 Explanation: Athlete (particularly if he or she has Down syndrome or juvenile rheumatoid arthritis with cervical involvement) needs evaluation to assess the risk of spinal cord injury during sports participation, especially when using a trampoline. Qualified yes
Bleeding disorder
 Explanation: Athlete needs evaluation. Qualified yes
Cardiovascular disease

No

Qualified yes

Qualified yes

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Physical Activity and Sports for Children and Adolescents

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