The Role of the Pediatric Exercise Specialist in Treating Exercise ...

The Role of the Pediatric Exercise Specialist in Treating Exercise Deficit Disorder in Youth Avery D. Faigenbaum, EdD, CSCS,1 Rhodri S. Lloyd, PhD, CSCS*D,2 Damien Sheehan, CSCS,3 and Gregory D. Myer, PhD, CSCS4,5,6 1 Department of Health and Exercise Science, The College of New Jersey, Ewing, New Jersey; 2Department of Physiology and Health, School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom; 3Department of Science & Health, Institute of Technology Carlow, Carlow, Ireland; 4Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; 5Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; 6Departments of Family Medicine, Biomedical Engineering, and Physiology & Cell Biology, The Ohio State University Sports Medicine Center, Columbus, Ohio

ABSTRACT ALTHOUGH THE HEALTH BENEFITS OF REGULAR EXERCISE FOR CHILDREN AND ADOLESCENTS ARE EXTENSIVE, MOST YOUTH FAIL TO MEET CURRENT RECOMMENDATIONS FOR DAILY PHYSICAL ACTIVITY. SPECIFICALLY, AN INCREASING NUMBER OF YOUTH DEMONSTRATE SYMPTOMS OF EXERCISE DEFICIT DISORDER DURING THE GROWING YEARS, WHICH CAN LEAD TO A PROGRESSION OF PATHOLOGICAL PROCESSES. ALTHOUGH THE CRITICAL IMPORTANCE OF THIS PUBLIC HEALTH CONCERN HAS YET TO GARNER THE RECOGNITION TO SUPPORT HEALTH CARE REFORM, PHYSICAL INACTIVITY SHOULD BE IDENTIFIED EARLY IN LIFE AND YOUNG PATIENTS SHOULD BE REFERRED TO A PEDIATRIC EXERCISE SPECIALIST FOR PREVENTATIVE CARE.

egular participation in physical activity in the context of family, school, and community programs is recognized as a powerful

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VOLUME 35 | NUMBER 3 | JUNE 2013

marker of health in children and adolescents (34). In addition to enhancing cardiorespiratory and musculoskeletal fitness, age-appropriate physical activity has the potential to enhance a child’s emotional, social, and cognitive wellbeing (13,36). Moreover, youth who develop the prerequisite motor skills and physical abilities early in life tend to be more active in later years (31,41). That is, children who are exposed to an environment with opportunities to engage regularly in a variety of physical activities that enhance movement skill and muscular strength are more likely to be active during adolescence (2,3). Because of the pleiotropic benefits of regular physical activity, global health recommendations now suggest that school aged youth accumulate at least 60 minutes of moderate-to-vigorous physical activity (MVPA) daily as part of play, sports, transportation, physical education, or planned exercise (47). Although many parents perceive their children to be physically active (8), levels of physical inactivity are increasing in many countries (15,46,47). A study of Canadian preschoolers in family-based care reported significantly low levels of

MVPA (42). In addition, objectively measured physical activity of schoolaged youth in the United States show that overall physical activity starts to decline at the age of 6 years (33,44). Recent findings from the Youth Risk Behavior Surveillance survey indicate that a majority of high school students are not meeting current recommendations for MVPA, yet nearly one-third play video or computer games for 3 hours or more on an average school day (45). Clearly, concerted efforts by health care providers, fitness professionals, physical education teachers, public health officials, and parents are desperately needed to raise awareness related to the benefits of physical activity to promote healthy behaviors during the formative years of life. The primary aim of this article is to discuss the antecedents of physical inactivity in youth and provide a rationale for identifying and treating exercise KEY WORDS:

children; physical activity; muscular fitness; motor skill; pediatric; exercise deficit disorder

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deficit disorder (EDD) early in life before youth become resistant to lifestyle interventions. EDD is a term used to describe a condition characterized by reduced levels of MVPA that are inconsistent with positive health outcomes (11,12). The word exercise in EDD does not suggest that free play is inconsequential, but rather it emphasizes the premise that developmentally appropriate activities need to be carefully prescribed by qualified professionals to ensure that youth programs are safe, effective, and age appropriate. The impact of a sedentary lifestyle during the growing years on the inevitable cascade of adverse health outcomes is discussed, and implications for intervening with an integrative fitness model to maximize health promotion and disease prevention are reviewed. Finally, foci for promoting physical activity during the growing years by a pediatric exercise specialist who has the requisite content knowledge and pedagogical skill are explored. A PANDEMIC OF PHYSICAL INACTIVITY

Physical inactivity is now recognized as the fourth leading risk factor for global mortality (47), and in view of the widespread health, economic, environmental, and social consequences, some observers suggest that this issue should be described as a pandemic (19). Despite the efforts of researchers and practitioners who continue to highlight the wide range of benefits associated with an active lifestyle, it appears that the critical importance of physical inactivity has yet to garner the political power and recognition of other risk factors such as cigarette smoking and obesity. Physical inactivity has become the biggest public health problem of the 21st century and efforts in advocacy, policy, workforce training, and surveillance are needed to counteract this pandemic (5,19). An analysis of data from 34 countries that participated in the Global School-based Student Health Survey found that a majority of students did not meet physical activity recommendations, and levels of sedentary behaviors were high (15).

When compared with other risk factors for noncommunicable diseases, the absence of significant funding, targeted interventions, and an infrastructure that supports primary prevention appear to be at least partly responsible for the increase in the prevalence of physical inactivity among youth as well as adults. Multidisciplinary efforts are needed to combat this growing problem because physical activity is a critical component of disease prevention and health promotion strategies. Screening for physical activity should begin early in life, and youth who are not meeting the minimal recommendations for MVPA should be treated with the same energy and resolve as a child with hypertension or a teenager who is obese. In a seminal review on the global pandemic of physical inactivity, Kohl et al (19) urge health ministries to advance universal health through key actions that include screening for physical inactivity, counseling about physical activity, and investing in comprehensive physical activity promotion policies, action plans, and implementation programs.

will not simply resolve themselves in due course, it is prudent to address sedentary habits in asymptomatic children to create a lifestyle inclusive of activity.

Because many chronic diseases that become clinically apparent during the adult years are influenced by lifestyle habits established during the growing years (36), there is a need to identify physically inactive youth early in life and target them with developmentally appropriate interventions before they engage in unhealthy behaviors and learn bad habits. This view is supported by the current prevalence of overweight and obesity in contemporary youth, and the observation that 49% of overweight and 61% of obese adolescents have 1 or more cardiovascular disease risk factors in addition to their weight status (28,32). There is an urgent need to raise awareness about the importance of regular exercise for school-aged youth and express a straightforward view of this pressing health care concern. Instead of simply labeling a child with poor motor skills as clumsy or lazy, the term EDD more aptly describes a condition that should be identified and treated to prevent the progression of risk factors and pathological processes (11,12). Because these issues

The construct of EDD is unique because there are not any clinical markers or laboratory tests that can be used to identify a sedentary child or a teenager with poor motor skills. Rather, qualified professionals need to ask children about a child’s “play history” and how many days per week they engage in games, play, sports, and recreational activities. Asking follow-up questions related to the type of activity and amount of time they are active in games and sports that make them “breathe hard” may shed some light on the quality and quantity of their physical activity as well as their potential risks related to inactivity. The amount of time children spend in front of a television or computer screen may provide additional insights into their lifestyle habits. In the future, measures of fundamental movement skills (e.g., jumping, throwing, or balancing) or a biological marker such as bone mineral density or vitamin D may be used to aid in the identification of physically inactive youth.

A large number of school-aged youth, regardless of weight status, would benefit from health care strategies, school-based policies, and community programs that are specifically designed to enhance muscle strength and improve motor skill performance. Because primary prevention is designed to prevent disease rather than to treat it, inactive youth need to be identified early in life to prevent the cascade of adverse health consequences later in life. Of note, Lee et al (20) reported that 6–10% of all deaths from noncommunicable diseases worldwide can be attributed to physical inactivity, and this percentage may be even higher for specific conditions, such as heart disease. Millions of deaths globally from noncommunicable diseases could theoretically be prevented if age-specific, culturally sensitive, and sustainable interventions were implemented to identify youth with EDD before they become resistant to medical interventions (19).

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Exercise Deficit Disorder in Youth

Youth who do not meet the current recommendations of 60 minutes or more of MVPA each day (i.e., 420 minutes/week) should receive an agerelated exercise prescription that is specifically designed to target neuromuscular deficiencies because there are no medications to treat physical inactivity. Providing parents with information on school-based and community-based resources that meet the needs, abilities, and interests of less active youth may also be beneficial. Transformational change in systems for identifying physical inactivity and delivering health care are warranted so that physical activity counseling and referral are expected, documented, and reimbursed(18). ACTIVATING INACTIVE YOUTH

Because children are not simple miniature adults, exercise programs and training paradigms designed for older populations are suboptimal for schoolaged youth. If the health-enhancing benefits of daily exercise early in life are to be realized later in life, youth programs must be developmentally appropriate, meaningful, and enjoyable (10). Perhaps, the most visible physical difference between children and adults is that the movement pattern of youth is characterized by short bursts of high-energy physical activity interspersed with brief rest periods as needed (1). Without qualified instruction, directed movement practice, and a sensible progression of age-appropriate activities, physically inactive children are less likely to become motorically competent as adults (40). It is a misperception to believe that children innately know how to throw, catch, kick, jump, and hop with proper technique and physical effort. Although motor coordination is a predictor of physical activity during childhood (16,24), a contemporary corollary of the sedentariness among children is low level of motor skill competency and muscular fitness (7,17). Hardy et al (17) recently reported the prevalence of low motor skill competence in a large sample (N 5 6,917) of Australian youth was high and noted a consistent and clear

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association between low competency in fundamental movement skills and inadequate levels of cardiorespiratory fitness. Other researchers examined 10year secular trends in muscular fitness in English children and found declines in bent arm hang, sit-up performance, and handgrip strength over the study period (7). These findings highlight not only the need to enhance muscular fitness and motor skills in school-aged youth, but also the importance of initiating interventions early in life to alter physical activity trajectories and reduce associated injury risks, which should not be overlooked (6,23). New insights into the design of youth physical development programs regarding the importance of enhancing muscle strength and improving motor skill competence may prove to be valuable for physical education teachers and youth fitness professionals who develop and prescribe exercise programs for school-aged youth (22,30). Inactive youth are often unwilling and at times unable to perform prolonged periods of aerobic training, and participation in physical activity should not begin with competitive sport. Integrative neuromuscular training (INT), which includes a variety of strength-building exercises and skill-related activities, is more consistent with how children move and play (9). The cornerstone of INT is age-appropriate education and instruction by a qualified and thoroughly trained professional who is skilled in how to teach children (Figure 1). INT does not require expensive, hightech equipment, but rather basic movements, activities, and exercises that are somewhat characteristic of 20th century physical education (39). INT programs are purposely designed to provide a much needed opportunity for inactive youth to enhance muscular fitness (e.g., muscular strength, muscular power, and local muscular endurance) and master fundamental movement skills, which form the foundation for future participation in context-specific sports and games. Because muscular fitness is an essential component of motor skill performance in youth (27), the

Figure 1. A qualified professional who is skilled in teaching youth is a fundamental requirement for success.

importance of enhancing muscular strength, muscular power, and local muscular endurance must not be overlooked when designing youth programs (Figure 2). Nowadays, resistance training is recognized as a safe and effective method for enhancing muscular fitness in children and adolescents (4,10,21). Clearly, this type of preparatory conditioning can help to maximize potential health-related and fitness-related benefits for youth by reducing the risk of activity-related injuries and promoting

Figure 2. Skilled strength-building exercises are characteristic of integrated neuromuscular training.

lifelong participation in games, planned exercise, and sport (31). It is likely that youth who participate in multifaceted INT programs that include resistance training will gain competence and confidence in their abilities to engage in MVPA, which in turn may increase the likelihood that youth participate regularly in fitness activities, planned exercise, and sports as an ongoing lifestyle choice. Furthermore, the dynamic relationship among muscular fitness, motor skill proficiency, and physical activity can be reinforced over time, which is consistent with the proposed existence of a positive feedback loop with physical activity (Figure 3) (40). That is, youth who enhance their muscular fitness and motor skill performance early in life will be better prepared to break through a hypothetical “proficiency barrier” later in life (38). In turn, these youth will be ready to participate in transitional sports and lifetime

activities with energy and vigor, which will continue to enhance health-related and skill-related components of physical fitness while further reducing the likelihood of developing EDD. Because physical activity and sedentary behaviors tend to track from early childhood to adulthood (26), the preschool years and early childhood represent a critical period to intervene with developmentally appropriate interventions that target neuromuscular deficiencies (14,31). Although adolescents can certainly benefit from INT, teachers, coaches, and health care providers need to focus on the progression of motor abilities early in life because of the high degree of plasticity in neuromuscular development during preadolescence, which provides an optimal window to train and develop long-lasting movement skills and desired behaviors (25). Moreover, unlike adolescents, most children have not yet developed bad habits and are not as self-conscious about

making a mistake in front of their peers. In the long term, children who participate regularly in INT will have the muscular fitness and motor skill competence that will allow for later learning of more complex movements and sport skills (31). Specific examples of INT programs and developmental models are beyond the scope of this article, but they are available elsewhere (9,22,30). When working with youth who are inactive, it is important to remember that the goal of the program should not be limited to time spent in MVPA. Enhancing muscle strength, developing fundamental movement skills, fostering new social networks, and promoting healthy behaviors in a positive and supportive environment are important considerations. Therefore, in addition to considering the “dose response” of physical activity, the importance of the “quality response” of developmentally appropriate movements should also be appreciated (35). This is where

Figure 3. FMS = Fundamental movement skills. Reinforcing effects of early physical activity on youth.


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the art and science of developing youth programs come into play because the principles of pediatric exercise science need to be balanced with effective teaching and a genuine interest in helping children gain competence and confidence in their abilities to be physically active. THE ROLE OF PEDIATRIC EXERCISE SPECIALISTS

Pediatric exercise specialists who are well-versed in kinesiology, physiology, and exercise science and skilled in teaching youth who have different needs, goals, and abilities should design, supervise, and instruct youth fitness programs. These professionals should have practical experience working with youth and a philosophy that is consistent with long-term health and wellbeing. Pediatric exercise specialists should be knowledgeable of developmental physiology, pediatric sports medicine, and child psychology, and

they should know how to effectively teach and progress skill-building exercises and strength-enhancing activities. Instead of monotonous activities on cardiovascular exercise machines, which require minimal instruction, youth programs should be mentally engaging, and professionals need to provide regular feedback in gameplay environments, which can positively influence skill development, fitness performance, and motivation (43). Simply because an instructor or coach played a sport in high school or college does not necessarily qualify that individual to teach school-aged youth. Similarly, personal trainers who work in facilities that offer youth programs may not have the skill set and pedagogical expertise to effectively train and manage a group of children with different needs and abilities. Professionals who want to work with children in schools, fitness centers, and sports

programs should be taught exercise science concepts specific to the population they will serve and participate in practical experiences that involve children and adolescents. Without such knowledge, instructors and coaches may not have an adequate understanding of how ontogenic factors (related to growth and development) and phylogenetic differences (related to genetic endowment) influence the design of youth programs that help children learn and meet desired objectives. The optimal program for school-aged youth includes instruction and education by a pediatric exercise specialist who is well-versed at teaching motor skills in a gameplay environment that is both fun and mentally engaging (Figure 4). Activities should require participants to use their minds as well as their bodies in order to enhance their motor skill performance, muscular fitness and mental engagement. For

Figure 4. Requisite content and pedagogical components of successful youth fitness programs.

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example, medicine ball exercises and weightlifting movements can be cognitively stimulating for children and adolescents because they require participants to think about what they are doing and how they are moving (23,29). A noticeable consequence of combining MVPA with mental engagement is an improvement in motivation, technical proficiency, and enjoyment (43). There are more than 300 college programs in the United States that offer exercise science, physical education, or a related field of study, yet less than 2% offer a course in pediatric exercise science. Likewise, only 7% of professional pediatric physical therapy education programs in the United States require a pediatric clinical education placement, thus a majority of physical therapy students matriculate to licensure without any experience working with youth (37). Clearly, there is a need to create academic and practical learning opportunities for health and fitness professionals who want to enhance their instructional content and delivery of pediatric exercise programs.

provide an opportunity for inactive boys and girls to gain confidence in their physical abilities. Improved communication between health care providers and pediatric exercise scientists will facilitate the identification and treatment of youth with EDD, and it is hoped to spark an interest in games, activities, and sports as an ongoing lifestyle choice. Without such initiatives and interventions that focus on disease prevention and health promotion, new health care concerns will continue to emerge. Because the stakes of this global pandemic are substantial with far-reaching biomedical, social, and economic consequences, a change in social mores about physical inactivity is desperately needed, and innovative interventions that identify and treat inactive youth are warranted. Conflicts of Interest and Source of Funding: The authors acknowledge funding support from the National Institutes of Health/ National Institute of Arthritis and Musculoskeletal and Skin Diseases grants (R01-AR05563).

Damien Sheehan is a program director and lecturer in the Department of Science & Health at the Institute of Technology Carlow in Ireland.

Gregory D. Myer is director of Research and the Human Performance Laboratory for the Division of Sports Medicine at Cincinnati Children’s Hospital Medical Center and holds primary academic appointments in the Departments of Pediatrics and Orthopaedic Surgery within the College of Medicine at University of Cincinnati. REFERENCES

PRACTICAL APPLICATION

A change in current attitudes and common practice is urgently needed before inactive youth become resistant to therapeutic interventions. Practitioners should be cognizant that children are not simply miniature adults, and their primary motivation for exercising is to have fun, make friends, and learn something new. The adult exercise prescription paradigm is often inconsistent with the needs, abilities, and interests of school-aged youth. Practitioners who teach and coach youth should be knowledgeable of the physical and psychosocial uniqueness of younger populations and should develop a philosophy that encourages all participants to strive for personal success in a positive learning environment. Youth fitness programs in schools, fitness centers, and hospital-based clinics are needed to improve muscle strength, develop motor skills, and

Avery D. Faigenbaum is a full professor in the Department of Health and Exercise Science at The College of New Jersey.

Rhodri S. Lloyd is a lecturer in Physiology and Health at Cardiff Metropolitan University and is pediatric lead for the United Kingdom Strength and Conditioning Association.

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