The Benefits and Risks of Disclosure Exercise for Kids and Adults - - PowerPoint PPT Presentation

12/12/2015 1

The Benefits and Risks of Exercise for Kids and Adults

Cindy J. Chang, MD Associate Clinical Professor of Orthopaedic Surgery Associate Clinical Professor of Family and Community Medicine Past President, American Medical Society for Sports Medicine

Disclosure

I, Cindy J. Chang MD, do not have any relevant financial relationships with a commercial interest to disclose.

Objectives

• Educate primary care providers so that you

feel competent in promoting exercise in your patient population

• Discuss the many benefits and some potential

risks of exercise in your patient population

• Feel confident that the benefits of physical

activity far outweigh the possibility of adverse

• utcomes

Definitions

• Physical activity: any body

movement that results in energy expenditure (exercise, ADLs, active transportation)

• Exercise: physical activity

that is planned, structured, repetitive with

• bjective to improve or

maintain physical fitness.

ACSM Position Stand on Prescribing Exercise, MSSE 2011.

Physical Activity ≈ Exercise

12/12/2015 2 How Physically Active Are High School Students?

23.7 18.5 15.5 14.9 17.1 10.5 20 40 60 80 100

Total Female Male White Black Hispanic

Percent

• Were physically active doing any kind of physical activity that increased their heart rate and

made them breathe hard some of the time for a total of at least 60 minutes/day during the 7 days before the survey.

• Source: National Youth Risk Behavior Survey, 2007.

How Much Do 9- to 13-Year-Olds Participate in Physical Activity?

Source: MMWR 2003;52(33):785–8.

Race/Ethnicity Organized Activity Free-Time Activity Black, non-Hispanic 24% 75% Hispanic 26% 75% White, non-Hispanic 47% 79% Total 39% 77%

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Physical Activity Guidelines for Children and Adolescents

Be Active and Play, 60 minutes, every day!

Physical Activity Guidelines for Children and Adolescents

• HHS. Physical Activity Guidelines Advisory Committee Report 2008

Strong WB et al. J Pediatr 2005

• Promotes health and fitness
• Builds healthy bones and muscles
• Reduces the risk of developing obesity

and risk factors for diseases such as type 2 diabetes and heart disease

• Reduces the symptoms of anxiety and

depression

• Can positively affect concentration,

memory, and classroom behavior

Physical Activity Guidelines for Children and Adolescents

Activities should be age-appropriate, enjoyable, and offer variety!

• 60 minutes or more of physical activity daily

– Aerobic: Most of the 60 or more minutes should be either moderate or vigorous intensity aerobic physical activity. Include vigorous intensity at least 3 days per week – Muscle strengthening: Include these on at least 3 days of the week as part of the 60 or more minutes – Bone strengthening: Include these on at least 3 days of the week as part of the 60 or more minutes

Types of Moderate- and Vigorous- Intensity Aerobic Activities

Type of Physical Activity Age Group Children Adolescents Moderate- intensity aerobic

• Active recreation, such as hiking,

skateboarding, rollerblading

• Bicycle riding
• Brisk walking
• Active recreation, such as canoeing,

hiking, skateboarding, rollerblading

• Brisk walking
• Bicycle riding (stationary or road bike)
• Housework and yard work, such as

sweeping or pushing a lawn mower

• Games that require catching and

throwing, such as baseball and softball Vigorous- intensity aerobic

• Active games involving running and

chasing, such as tag

• Bicycle riding
• Jumping rope
• Martial arts, such as karate
• Running
• Sports such as soccer, ice or field

hockey, basketball, swimming, tennis

• Cross-country skiing
• Active games involving running and

chasing, such as flag football

• Bicycle riding
• Jumping rope
• Martial arts, such as karate
• Running
• Sports such as soccer, ice or field

hockey, basketball, swimming, tennis

• Vigorous dancing Cross-country skiing

12/12/2015 4 Types of Muscle-Strengthening Activities

Type of Physical Activity Age Group Children Adolescents

Muscle-strengthening

• Games such as tug-of-

war

• Modified push-ups (with

knees on the floor)

• Resistance exercises

using body weight or resistance bands

• Rope or tree climbing
• Sit-ups (curl-ups or

crunches)

• Swinging on

playground equipment/bars

• Games such as tug-of-

war

• Push-ups and pull-ups
• Resistance exercises

with exercise bands, weight machines, hand- held weights

• Climbing wall
• Sit-ups (curl-ups or

crunches)

Types of Bone-Strengthening Activities

Type of Physical Activity Age Group Children Adolescents Bone-strengthening

• Games such as

hopscotch

• Hopping, skipping,

jumping

• Jumping rope
• Running
• Sports such as

gymnastics, basketball, volleyball, tennis

• Hopping, skipping,

jumping

• Jumping rope
• Running
• Sports such as

gymnastics, basketball, volleyball, tennis

How Physically Active Are High School Students?

CDC MMWR June 2011, National Youth Physical Activity and Nutrition Study

10 20 30 40 50 60 70 Aerobic MMStrength Both Total Male Female 15.3 21.9 8.4

How Physically Active Are High School Students?

CDC MMWR June 2011, National Youth Physical Activity and Nutrition Study

16.9 15 11.8 10 20 30 40 50 60 aerobic MM Strengthening Both White Black Hispanic

12/12/2015 5 How Physically Active Are High School Students?

CDC MMWR June 2011, National Youth Physical Activity and Nutrition Study

45.2 7.3 10.7 10 20 30 40 50 60 Aerobic MM Strength Both Underwt/Nl Overweight Obese

Meeting the Guidelines

• Youth Who Don’t Meet the Guidelines

– Slowly increase activity in small steps – Participate in enjoyable activities

• Youth Who Meet the Guidelines

– Continue being active on a daily basis – Work toward becoming more active

• Youth Who Exceed the Guidelines

– Maintain activity level – Vary the kinds of activities to reduce the risk of injury

C.H. as an 8 year old child

• Walks to and from school

– 2 miles (40 minutes) round trip

• PE class

– Jumping jacks, kickball for 20 minutes 2x/wk

• Recess and lunchtime

– Plays tag, climbs on playground set, monkey bars, swingset every day for 20 minutes total a day

• Soccer on club team

– 90 minutes 2x/wk practice – 40 minutes 1/wk game (weekend)

• Recreational gymnastics

– 90 minutes 2x/wk

• Bicycle riding

– 60 minutes 1/wk (weekend)

• Total physical activity

time = 70-170 min/day

– Mod-Vigorous intensity:

• Soccer, tag, biking

– Muscle strengthening:

• Monkey bars, swinging

– Bone strengthening:

• Jumping jacks, gymnastics,

soccer (running)

C.H. as a 13 year old child

• Walks to and from school

– 5 minutes round trip

• PE class

– Excused due to extracurricular sports

• Lunchtime

– Plays basketball 15 min/day

• Afterschool sports

– Volleyball, basketball or softball 60- 90 min/day (practices or games) 5d/wk

• Soccer on club team

– 90 minutes 3x/wk practice – 60 minutes 1-2x/wk games (weekend)

• Rec basketball (winter) or rec softball

(spring) – 90 min 2x/wk practices, 1 90 min game per weekend

• Total physical activity time =

170-200 min/day – Vigorous intensity:

• Soccer, basketball

– Muscle strengthening:

• Core strengthening

– Bone strengthening:

• Volleyball, basketball,

running (soccer)

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*Is this too much? *How much is too much? *What is the balance between sport specialization and sport diversification? *What about the risk of overtraining and burnout? The risk of overuse injuries? *What happened to free play? *Is there anyone to free play with?

Are the parents nuts????

Overuse Injuries and Burnout in Youth Sports

• Which young athletes

are at risk for overuse injuries?

• Which risk factors and

injuries are unique?

• Which specific high-risk
• veruse injuries can

present as management challenges and/or can lead to long-term health consequences?

• What risk factors and

symptoms are associated with burnout?

• How can we prevent
• veruse injuries?

AMSSM Consensus Statement BJSM 2014

What is an overuse injury?

• An injury of the musculoskeletal system due to

repetitive submaximal loading, when rest is not adequate to allow for structural adaptation to take place.

– muscle-tendon unit, bursa, neurovascular structure, articular cartilage, bone and physis – Apophyseal injuries and physeal stress injuries are unique to young athletes

AMSSM Consensus Statement BJSM 2014

Apophyseal Injuries

• Specific tendon attachment

associated with underlying growth plate

• Weaker than muscle-tendon

unit

• Acute

– Sudden forceful contraction or eccentric contraction

• Chronic

– Repetitive stress to maturing apophysis

• Growth Spurts

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Apophyseal Injuries

Acute Apophyseal Avulsions

– ASIS, AIIS – Ischial Tuberosity – Medial Epicondyle

Chronic Apophysitis

– Medial Epicondyle – Iliac Crest – Osgood Schlatter – Sinding Larsen Johanssen – Sever’s Disease – Iselin’s Disease

9yo soccer player with heel pain x 2 months. Pain with

• running. No injury.

13 yo lacrosse player with anterior knee pain x 6 weeks. No history of trauma. Swelling/tenderness at tibial tuberosity. 9yo baseball pitcher with medial elbow pain x 3 months. Pain increases with activity. Pain with valgus stress.

Physeal Stress Injuries

• I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth

plate)

• II – A = Above. The fracture lies above the physis, or Away from the joint.
• III – L = Lower. The fracture is below the physis in the epiphysis, closer to the joint.
• IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
• V – R = Rammed (crushed). The physis has been crushed.

12 year old right handed female gymnast. Right wrist pain x 6 weeks. No acute injury. Increased pain with weight- bearing dorsiflexion especially tumbling and vaulting. Not painful at rest. 13 yo baseball pitcher. Shoulder pain x 3 months that gets worse with throwing. Throwing 80-90 pitches per game. Plays on a school and club team. Is the only pitcher for school, starter for club team. Throws fast balls and change ups.

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The Scope of the Problem

• More than 60 million US

children (ages 6-18) participate in some form of

• rganized sports
• 44 million in more than one

sport

• Overuse Injuries
• Training Hours

– Gymnasts train 24-36h per week, 4-6 hours per day up to 12 months a year

• Sports Specialization

* N

We Need a Reality Check

• 60 million children

active in organized sports programs in US

– 8 million HS students

• 460K student-athletes

compete in Div I, II and III NCAA sports

http://www.ncaa.org/about/resources/research/estimated-probability-competing-college-athletics

We Need a Reality Check We Need a Reality Check

http://www.ncaa.org/about/resources/research/estimated-probability-competing-college- athletics

12/12/2015 9

We Need a Reality Check

http://www.ncaa.org/about/resources/research/estimated-probability-competing-college- athletics

Overtraining and Burnout

• Overtraining syndrome

– A series of psychological, physiological and hormonal changes that result in decreased sports performance

• Burnout

– A response to chronic stress in which an athlete ceases to participate in a previously enjoyable activity

• Perceives that it isn’t possible to meet the physical and

psychological demands of the sport

• The more fun and satisfaction, the less anxiety

Risk Factors for Burnout in Young Athletes

Environmental Factors

• Extremely high training

volumes

• Extremely high time demands
• Demanding performance

expectations (self or others)

• Frequent intense competition
• Inconsistent coaching practices
• Little personal control in sport

decision making

• Negative performance

evaluations

Personal Characteristics

• Perfectionism
• Need to please others
• Non-assertiveness
• Unidimensional self-

conceptualization (focus

• nly on one’s own athletic

involvement)

• Low self-esteem
• High perception of stress

(high anxiety)

Intake form for a soccer player with anterior knee pain

He was…13!

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How can the benefit of exercise

• utweigh the risk?
• Incorporate preseason conditioning programs and

prepractice neuromuscular training

• Decrease training workloads, especially during the

adolescent growth spurts

• Ensure proper equipment size and fit
• Avoid overscheduling and excessive time

commitment to sport

• Learn how to improve skills-rather than how to win

C.H. as a 16 year old

• Walks, rides bike, or takes bus to

and from school

– 10-40 min round trip

• PE class

– Excused due to extracurricular sports

• Lunchtime

– Socializes

• High School varsity soccer (winter)

– 90-120 min/day (practices or games) – 5-6 days/wk

• Soccer on club team (Class I)

(fall/spring)

– 120 minutes 3x/wk practice – 90 minutes 1-4x/wk games including showcases (weekend)

• Total physical activity time

= 100-180 min/day

– Vigorous intensity:

• Soccer

– Muscle strengthening:

• Core strengthening

– Bone strengthening:

• Running (soccer)

What % of adults in California did NO leisure-time physical activity in 2011?

http://www.cdc.gov/physicalactivity/downloads/pa_state_indicator_report_2014.pdf

• A. 10%
• B. 20%
• C. 25%
• D. 33%
• E. 50%

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State Report on Physical Activity

http://www.cdc.gov/physicalactivity/downloads/pa_state_indicator_report_2014.pdf http://www.cdc.gov/physicalactivity/downloads/pa_state_indicator_report_2014.pdf

Strong evidence that regular physical activity associated with lower risk of

• Coronary artery

disease

• Stroke
• High blood pressure
• Adverse blood lipid

profile

• Type 2 diabetes
• Metabolic syndrome
• Colon cancer
• Breast cancer

http://health.gov/paguidelines/guidelines/chapter2.aspx

Strong evidence that regular physical activity associated with

• Prevention of weight

gain

• Weight loss, when

combined with reduced calorie intake

• Improved

cardiorespiratory and muscular fitness

• Prevention of falls
• Reduced depression
• Better cognitive

function

http://health.gov/paguidelines/guidelines/chapter2.aspx

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Moderate to Strong evidence

that regular physical activity associated with

• Better functional

health

• Reduced abdominal
• besity

Moderate evidence

that regular physical activity associated with

• Lower risk of hip fracture
• Lower risk of lung cancer
• Lower risk of endometrial

cancer

• Weight maintenance after

weight loss

• Increased bone density
• Improved sleep quality

http://health.gov/paguidelines/guidelines/chapter2.aspx

Physical activity lowers cardiovascular risk in a dose-dependent fashion

• Compared to people with no physical activity

– 150 min/week of moderate-intensity physical activity 14% lower CAD risk – 300 min/week 20% lower CAD risk – Higher levels of activity conferred lower and lower risk

Sattelmair J et al. Circulation 2011

Longevity

Longevity

Relative Risk of Dying Prematurely

http://health.gov/paguidelines/guidelines/chapter2.aspx

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✓ ✓ ✓ ✓ ✓ ✓ ✓

Was it really the running that caused these men’s coronary disease??

Risk of Death?

Möhlenkamp S et al, European Heart Journal 2008

USPSTF Recommendations on CHD Screening with ECG July 2012

http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/coronary-heart-disease- screening-with-electrocardiography

USPSTF Recommendations on CHD Screening with ECG July 2012

http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/coronary-heart-disease- screening-with-electrocardiography

• Factors associated with higher risk for CHD events

include

– older age, male sex, high blood pressure, smoking, abnormal lipid levels, diabetes, obesity, and sedentary lifestyle.

• Can calculate 10-year risk for CHD events

– Framingham Adult Treatment Panel III calculator (http://hp2010.nhlbihin.net/atpiii/calculator.asp) – 10-year risk > 20% considered high-risk – 10-year risk < 10% considered low-risk – 10% to 20% range considered intermediate-risk

Musculoskeletal and Bone Health

• Routine physical activity, especially weight-bearing

and impact exercise, prevents bone loss associated with aging

– Exercise training programs prevent or reverse almost 1%

• f bone loss per year in the lumbar spine and femoral

neck in both pre- and postmenopausal women

• Exercise training appears to significantly reduce the

risk and number of falls

• Fracture rates are lower among people who perform

more weight-bearing activities than among sedentary people

Warburton DER et al CMAJ 2006

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Risk to MS and Bone Health?

• People who participate in very high levels of

physical activity have a higher risk of hip and knee osteoarthritis, mostly due to the risk of injury involved in competing in some sports.

Take a Physical Activity “Vital Sign”

• Question #1:

– On average, how many days/week do you engage in moderate or greater physical activity (like a brisk walk)?’

• Question #2:

– On those days, how many minutes do you engage in activity at this level?

• Multiply #1 x #2 to get the average min/week of moderate or

greater physical activity reported by the patient.

GOAL: 150 min/wk for adults 420 min/wk for kids

Physical activity recommendations: 4 types of activities

Balance Strength Flexibility CV fitness

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Physical activity recommendations: components of each activity

• Frequency
• Intensity
• Time
• Type

Start Low, Go Slow

Estimating exercise intensity

Low Moderate Vigorous Heart rate <50% max 50-70% max >70% max Talk test Can talk and sing Can talk but not sing Can only say a few words before pause for breath

Exercise prescription: Combine activity with components

• Frequency
• Intensity
• Time
• Type

Balance Strength Flexibility CV fitness

CV fitness recommendations

Frequency Intensity Time Type 5x/week Moderate 30 minutes (150 min/wk) Major muscle groups

OR

Frequency Intensity Time Type 3x/week Vigorous >20 minutes (75 min/wk) Major muscle groups

ACSM Position Stand on Prescribing Exercise, MSSE 2011

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Balance recommendations

ACSM Position Stand on Prescribing Exercise, MSSE 2011

Frequency Intensity Time Type 2-3d/week Unknown 20 minutes Heel-toe walk, stand on 1 foot, Tai Chi

Strength recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type 2-3d/week Novice: 40-50% Experienced: 80% Unknown All major muscle groups

Flexibility recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type 2-3d/week Stretch to feeling of tightness Hold 10-30 seconds All major muscle-tendon units

Medicine & Science in Sports and Exercise, 2009.

Age-adjusted all-cause death rate per 10,000 person-years

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Summary

• There is a linear relationship between physical

activity and health—those who maintain an active and fit way of life live longer, healthier lives.

• Those who are unfit and sedentary very

predictably develop chronic diseases prematurely and die at a younger age.

• Everyone has their own “envelope” of physical

activity; it needs to be respected and carefully monitored

• Incorporate physical activity into everyday life

“All parts of the body if used in moderation and exercised in labors to which each is accustomed, become thereby healthy and well developed, and age slowly; but if unused and left idle, they become liable to disease, defective in growth, and age quickly.”

Hippocrates