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Training programs for children: literature review
Annales de réadaptation et de médecine physique 50 (2007) 510–519 http://france.elsevier.com/direct/ANNRMP/
Literature review
Training programs for children: literature review P. Edouarda,*, V. Gautherona, M.-C. D’Anjoub, L. Pupiera, X. Devillarda a
Service médecine physique et réadaptation, unité PPEH EA 3062, faculté de médecine Jacques-Lisfranc, université Jean-Monnet, CHU de Saint-Etienne, hôpital Bellevue, 42055 Saint-Etienne cedex 02, France b Service médecine physique et réadaptation pédiatrique, CHU de Saint-Etienne, hôpital Nord, 42055 Saint-Etienne cedex 02, France Received 5 March 2007; accepted 16 April 2007
Abstract Introduction. – Training programs are increasingly being prescribed for occupational therapy for adults affected by chronic illness and/or handicap, but their use is more recent for children and teenagers. Objective. – A review of the literature to synthesize information concerning training programs for children, whether healthy or with disease or handicap, considering the target population, methodology, the results and limitations. Methods. – We searched the Medline database with use of the key words retraining, training, training programs, physical activity, physical training, fitness program, sport, children, disability, and handicap. We also searched references of the selected articles for appropriate studies. Discussion/conclusion. – Physical activity seems to be a good means of primary preventing adverse health in the healthy child and secondary prevention in children with chronic disease or handicap. Thus, training programs could be adapted and integrated into the global treatment of sick or handicapped children in the health care situation or in the home. These programs are feasible and do not undermine children’s health, but few studies have shown clear data on the methods of the programs. The suggested training programs, not always validated, included two to five sessions from 30 to 60 min/week, for 6–16 weeks, of variable activity and intensity, adapted to the condition and the objectives of therapy. Training programs adapted to children should be validated to allow their accessibility by health care professionals dealing with children with chronic disease and/or handicap. © 2007 Elsevier Masson SAS. All rights reserved. Keywords: Training programs; Physical activity; Children; Handicap; Sport; Chronical disease
1. Introduction Children’s growth is in constant evolution. Physical activity forms an integral daily part of the child’s life, at home and at school. Its practice is natural and spontaneous and it is considered synonymous with good health. Physical activity is necessary to children’s general, staturoponderal, motor, psychological and social development [25]. The supposed beneficial effects of physical activity could translate to pediatric global treatment, in particular for chronic diseases [7]. Inactivity could entail risk of chronic disease [33,36,41], whereas better physical fitness could indicate better prognosis. With older people, regular physical activity could attenuate functional * Corresponding
author. E-mail address: [email protected] (P. Edouard).
0168-6054/$ - see front matter © 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.annrmp.2007.04.015
loss and delay dependency [1]. Today, physical activity is generally considered good for primary prevention of disease, and the current debates relate to the methods of prescribing the physical activity [2,28]. The minimal recommendations for physical activity in the adult [2] are debated in the child [16,21,36]. Determining and especially quantifying physical activity for and determine the basal energy expenditure of the healthy child [7,30,36,45] is difficult because of methodological problems [36,41]. In handicapped children, as in the handicapped adult [23], the physical level of activity and the aerobic capacity are very low [15, 18]. Patients afflicted by chronic disease with reduced tolerance to the exercise can benefit from training with progressive physical activity. The goal of such programs is to regain the capacity to perform unaided activities of daily life [2]. The immediate goal is to restore the physical fitness of the patient whose condition is largely deteriorated by trauma or sudden
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handicap but also by the confinement and prolonged inactivity. In the long run, such patients must change their lifestyle, become more active, and preserve physical independence for as long as possible. Many protocols have elaborated training programs for various populations prone to reduced functional capacities. The American College of Sport Medicine has proposed training programs based on intensity, frequency, duration and possibility for progression for the adult [2]. Such programs and the physical activity have been validated for the global treatment of chronic, cardiovascular [10,35], respiratory, and metabolic diseases [24]. However, for children with disease, no clear recommendations exist concerning training programs. The mechanisms causing loss of physical capacity in the child differ according to disease, which is the reason for difficulty in proposing adapted programs of exercise. The capacity of the child must be known before proposing specific training [23]. Improving aerobic capacity and physical activity in children with handicap would have a positive prognostic impact, whereas the reverse could have unfavorable consequences on total health [18]. Training programs for children with disease could have a place in global medical treatment. Physical activity represents a very significant part of the daily life of children because it is associated with development and has therapeutic virtues. We wondered about the possibility, or even the need, for training programs for children, whether healthy or with disease or handicap. In this review of the literature, we explore the definition of children who would benefit from training programs, and then describe the characteristics of the training programs adapted to each situation. 2. Objectives We aimed to review the literature about training programs in children with disease or handicap to determine the target populations of children, the means of evaluation and the protocols used and their goals and to propose a synthesis of the protocols of training programs for children with chronic disease or handicap. 3. Methods of research We searched the Medline database with use of the key words retraining, training, training programs, physical activity, physical training, fitness program, sport, children, disability, and handicap. We also searched references of the selected articles for appropriate studies. 4. Results We found 46 articles of studies of physical activity for children with chronic disease or handicap, including 15 articles of training programs. Most of the articles were found by research from an article of the given subject. The search of Medline with keywords did not allow for precise selection of articles.
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5. Discussion 5.1. Physical activities in the healthy child 5.1.1. Physical activity, sport and development of the healthy child The development of motor ability of the healthy child is progressive from birth to puberty. Various motor acquisitions allow for the practice of physical activities and increasingly varied sports [25]. The practice of sport becomes effective only from age 9, which corresponds to the acquisition of technical ability and is really only complete at age 12, with the presence of logical and deductive intelligence and ordered and methodical reasoning. The age between 6 and 8 is a “hinge” period, when the child acquires and refines body development, lateralization, the concepts of space and time, speed, force and flexibility. Before this age, sport is mainly play, and afterwards, sport can entail physical and social development, not just performance [25]. Sport has numerous benefits, including the following [25]: ● favoring motor and psychomotor coordination, increasing muscular force, improving the capacity of adaptation to the effort of the cardiovascular and pulmonary apparatus, and generating physical and psychological well-being, thereby becoming a source of pleasure; ● preventing cardiovascular disease, hypertension and atherosclerosis; ● having a positive effect on bone mineralization; ● developing competitive emulation, pushing ones’ capabilities, self-assertion, and, for some, team spirit and even responsibility. For most of these benefits, sport, and by extension, physical activity, should be used like therapy in pediatrics [7]. This interest is reinforced by the child’s positive perception of the physical activity: it allows children with disease or handicap to realize that they can act like healthy children [7]. The negative effects of sport include the following: ● ● ● ●
increased risk of accidents and lesions due to the sport; syndromes of overuse; abnormal physiological reactions; psychological risks to be manipulated or exploited [7,25].
The reaction to exercise differs among children and between children and adults. The child has a metabolic reserve weaker than that of the adult [7,47]; overtraining can disturb growth, in particular during puberty [47]. 5.1.2. Physical activities in the daily life of the healthy child Physical activity and the physical capacities are moderately related [32]. Epstein et al. [16] studied the intensity of physical activity in children by measuring heart rate. Young people of all ages performed physical activity of low intensity more than 60 min/day and 50% or more maximum-intensity activity approximately 30 min/day. Stone et al. [42], in a review of
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the literature from 1980 to 1997 concerning physical activity in community schools and infrastructures, showed that little was known about the subject and much remained to be explored, in particular by means of multicentric studies. Harrell et al. [22], performed a US study of physical activity in children between 11 and 14 years old in five rural schools. Results concluded that the level of activity could be increased, with encouragement by health care personnel, and could help prevent health problems. Zahner et al. [46], noticing that children adopt an increasingly sedentary lifestyle, estimated that the school has a paramount role in the promotion of the physical activity. This Swiss team carried out an exploratory study of 15 randomized schools, of children aged 6–13 years, to evaluate the feasibility of the installation of a physical work program. However, outlining possible physical activity for children, namely the quantity and the place, seems important before putting considering training programs for children with disease or handicap. 5.1.3. Measurement of physical capacity in the healthy child The evaluation of tolerance to effort can be useful before prescribing a specific training program. Several tests, simple or sophisticated, can be used for quantifying fitness, monitoring training, or orientation to an adapted sport [15]. The investigations are limited by ethical problems and methodological considerations [7]. These tests comprise the following [7,15]: ● evaluation of somatic development: height, weight, body mass index (weight/height2), puberty stage, bone maturation, lean mass; ● exploration of respiratory function, vascularization, diffusion of CO2, compliance, gazometry; ● indirect estimate of the alactic anaerobic metabolism: Margaria staircase test, tests of load speed, Bosco carpet test, vertical relaxation, short sprint; ● estimate of the lactic anaerobic metabolism: test of Wingate, measures of lactic acid in blood, racing, Ruffier Dickson test; ● measurement and indirect estimate of aerobic metabolism: maximal oxygen consumption (VO2max), test of LegerButcher shuttle, Cooper test; ● measurement of muscular force; ● indirect estimate of psychomotor qualities: static balance, lower-limb tapping, tremometry, chronoscopy, MacQuarrie test, Cattell test, subjective effects related to the sport practice. 5.1.4. Effects of training in the healthy child The effects of the training are not easily measurable in the child because of proscription of invasive examinations and badly adapted tests, which disallows distinguishing modifications related to the training from those related to growth [15]. The effects of the training are exerted at various levels: muscle, adaptation of organization to effort and psychomotor capacity. Any training generates progress whether transitory
(physical capacities or elaborate technical skills) or definite (training of skills: swimming, bicycle, etc.) [15]. Training has positive effects on physical capacity. The work of force and endurance involves progress, and training with high loads can be beneficial [17]. However, the methods of training are subject to controversy; in particular, should endurance studies involve continuous work or interval training? [5]. Being spontaneous, the child prefers intermittent activities short, varied and fun [47]. 5.2. Physical activities for children with chronic disease and/ or handicap 5.2.1. Physical capacity of children with chronic disease and/ or handicap Most chronic diseases cause reduced physical, psychic and psychomotor capacity in patients [7,15,18]. The disease is a direct or indirect cause of sedentary lifestyle or hypoactivity, sometimes reinforced by the family [7]. The hypoactivity can involve a vicious circle involving loss of functional capacity [7]. The resulting loss of physical fitness is regrettable and can lead to many diseases [15]. Discontinued activity, whatever the origin, causes quick loss of functional capacity and adaptability to effort [7]. Chronic diseases can be a direct cause of reduced aerobic maximal power by affecting the transport of O2 or by increasing the metabolic cost of the physical exercise [7]. 5.2.2. Contraindications with the practice of sport Contraindications with the practice of sport are rare, even with serious, chronic, invalidating and evolutionary illness. The selective or temporary contraindications relate especially to the cardiopulmonary or locomotor system. For high-level competitive practice, contraindications relate to the risk of disease aggravation or accident. The recommendations for the participation in competition sports [7,8] are summarized by Jolibois et al. [25] or Binder and Bensahel [11] (Table 1). Participation in sport should be prohibited only if the sport will worsen the disease or put the child at risk. Complementary examinations will be able to help in decision making. Many children with chronic disease can participate in physical activity or sport, but determining this practice with precision is advisable [8,15]. For example, De Mondenard [8] proposes a prescription of physical activity for the diabetic child, with recommendations for the practice of sport and adaptation of insulin treatment and food. 5.2.3. Physical activity and sport in the daily life of children with chronic disease and/or handicap “For any child the sport is a benefit with short, average and long term. For the sick child, it has additional advantages because sport decreases the loss of physical fitness derive from the disease and its treatments, sport gets very important benefits, and sport helps to be released from the statute of patient and favors integration by erasing the differences.” [15]. In terms of physical and sport education in school, directives exist for children affected by motor deficiency [3]: “The
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Table 1 Recommendations and contraindications for competitive sport activities in children [4,11] Abnormalities by apparatus Cardiovascular Hypertension light Moderately Cardiopathy Ischemic cardiopathy surgery Not ischemic cardiopathy Valvular heart disease Myocardiopathy with obstruction Pulmonary hypertension Heart rate disorder Other heart diseases Respiratory Respiratory failure Severe or chronic Asthma with effort bronchospasm Mucoviscidosis Locomotor Minor disorder: flat food, unbalance in length of limb, genu valgum scoiosis attitude Major disorder: fracture, plate of osteosynthesis, inflammatory diseases, Neuropsychiatric Skull trauma severe or moderate, craniotomy, osteochondrosis, etc Convulsion not or monitored well monitored Psychiatric diseases Blood Hemorrhagic disease Hemoglobinopathy With splenomegaly Without splenomegaly ORL Ophtalmology Blind Severe myopia With glasses Skin diseases Infectious dermatosis Genital organsI Single testicle or ectopia (with equipment of protection) Renal Proteinuria orthostatic or with effort Renal failure Single kidney Hepatic Hepatomegaly Miscellaneous Inguinal hernia Acute disease Jaundice Diabetes regular a Authorization or prohibition after complete and specific examination.
regulations, by not envisaging any obligation of preliminary medical control as regards physical and sporting education, retain the principle of the aptitude of all the pupils to a priori follow the teaching of this discipline” (circular no. 90-107 of May 17, 1990). Children with motor deficiency, however, cannot perform all the activities of their healthy peers under the same conditions. Almost all students, even those in an electric wheelchair, can perform some type of activity and can progress and find pleasure insofar as teachers can adapt teaching [3]. If
Sports with contact Collision Impact
Effort
Sports without contact Moderate effort Little effort
Yes
Yes
Yes
Yes
Yes
a
a
a
a
a
No
No
a
a
a
a
a
a
Yes
Yes
No No No No
No No No No
No No No
a
a
No No
No No
a
a
a
a
a
a
a
a
a
a
a
a
Yes
Yes
Yes
Yes
Yes Yes
a
a
a
a
a
a
a
a
a
a
Yes
Yes
Yes
Yes
Yes No
Yes No
Yes
Yes
Yes
a
a
a
a
a
No Yes No
No Yes
Yes No Yes
Yes No Yes
Yes No Yes
No
No
a
a
a
No
No
No
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
No No
a
a
a
a
No/
Yes
Yes
Yes
a
a
a
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
a
a
a
a
No No
yes/a No
Yes
Yes Yes
Yes Yes Yes Yes
No No No
No No No
a
a
Yes No No Yes
Yes No No Yes
a
a
a
No No Yes
there are difficulties, adjustments and precautions must be found, in consultation with the physician. School sport, within the National Union of the School Sport (UNSS), concerns only the recognized student medical condition suited to the sporting practice (obligatory medical certificate). The UNSS is not authorized to organize activities for handicapped children, but can integrate such children into sport by training young referees or young sport officials [37].
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As for the healthy child, for children with chronic disease and/or handicap, knowing the habit of physical activity and sport in the child is important. Except for finding some directives on the sport, we did not find any data on real practice. 5.2.4. Children with disease or handicap and training programs Children with a loss of physical capacity incur sufficiently long interruption of physical activity, showing reduced physical fitness and functional capacity, either because of habit (increased sedentary lifestyle) or disease. The goal of the training program is to regain the capacity to carry on with daily life unaided and to be able to face the unforeseen critical situations [2]. The populations concerned with training programs have a loss of functional capacity or autonomy. Such programs preferentially concern children with chronic disease. The literature mainly concerns training programs associated with rheumatoid arthritis diseases [27,28, 40,43], metabolic abnormalities (diabetes and obesity [21]), respiratory abnormalities (asthma and mucoviscidosis), neoplastic abnormalities, backwardness [39], and hematologic abnormalities (hemophilia [12]). The mechanisms of chronic disease differ from those in handicap. The consequences of training in terms of the physical capacities of the child with the particular disease should be evaluated before proposing programs [18]: ● children with rheumatoid arthritis such as polyarticular juvenile rheumatoid arthritis have lower physical fitness for endurance and muscular force [28]. Aerobic physical capacity and functional capacity are strongly related [43]; ● in children with diabetes, the low physical capacity found in certain studies do not seem related to the disease itself but, rather, to the weak physical activity of the patient. Programs of training can improve physical fitness to a normal level [7, 13]; ● obese children have reservations about physical activity, because of psychologic and esthetic reasons (fear of showing the body) and functional capacity (difficulty in mobilization, articular pain). Such children are limited by a higher metabolic cost of the physical exercise. Physical performance is directly attributed to degree of adiposity [7]; ● in children with asthma, physical capacity is close to normal, in terms of maximal aerobic power and muscular force. Various studies suggest that the weak aptitude for effort is not attributed to the disease but, rather, to a sedentary way of life [7]. The degree of improvement of physical performance is related to intensity of training [7,34]. Sahraoui and Grimfeld [8] recommend a training program with a specialized structure for certain children with severe asthma to reduce dyspnea; ● in children with mucoviscidosis, physical performance is limited by ventilatory capacity, in direct relation to the severity of affliction [7]. Physical activity has a beneficial effect: clarification of mucus, improved the respiratory
● ● ●
●
endurance of muscles, reduced resistance of the airway, and improved physical performance [7]; in children with leukemia or cancer, all the risks of loss of physical fitness are evident: pain, malnutrition, immobility, use of corticotherapy, prolonged stay in isolation; mentally handicapped children have weakened physical fitness, whose causes vary according to the situation [39,41]; children with cerebral palsy have limited physical capacity (loss of muscular force, spasticity, orthopedic complications, etc.). Maximal aerobic power and mechanical output are definitely lower than those in healthy children. The increasing difficulty in moving and weak physical activity generate a loss of physical fitness [7,20]; children with hemophilia have obvious difficulty with practice of physical activity: the shock of a fall is the origin of hemorrhage and in particular, hemarthrosis, and the overuse of the joints can result in their degeneration [15].
In children with transitory handicap, physical activity is particularly contraindicated because of trauma, surgery, infectious disease and prolonged confinement physical activity can be delayed. Probably, spontaneous physical activity will enable satisfactory physical fitness. However, Dupuis and Daudet [15] suggest that these children could follow an adapted sporting training. Bar-Or [7] showed that any hypoactivity can cause loss of physical and functional capacities. 5.2.5. Tools for evaluation To evaluate the effectiveness of a training program, good tools are needed for evaluating the initial reference, controlling the effects of the protocol, and final evaluation of retraining to judge effectiveness. One must not evaluate a protocol of retraining without reliable, objective and reproducible criteria. Many studies have investigated evaluation of the physical activity [30,41,45]. These tools are similar, whether for children with chronic disease or handicap or not. 5.2.6. Types of training programs Bar-Or proposed objectives of training programs associating physical and sporting activities adapted to the pathology [6,47] (Table 2). The training programs are in (Table 3). Among the programs reported in the literature is the Adapted Sport Training proposed by Dupuis and Daudet [15]. The authors propose personalized and controlled programs of training that are easy to follow and well accepted. These programs consist of two to three sessions per week, for at least 20–30 min per session, for 1–3 months. Each session is based on a succession of exercises connected without interruption and always in the same order, the intensity and the level of the exercises adapted to the progression of capability of the individual. 5.2.7. Framing of the training programs The training programs should be initiated within a medical care framework, for monitoring of the training and for adaptation of the individualized program. Qualified personnel are
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Table 2 Exercise programs in the management of specific pediatric diseases [2,18] Disease Anorexia nervosa Bronchial asthma Cerebral palsy Cystic fibrosis Diabetes mellitus Hemophilia Mental retardation Muscular dystrophies Neurocirculatory disease Obesity Rheumatoid arthritis Spina bifida
Purposes of program Means for behavioral modification; educate regarding lean mass versus fat Conditioning; possible reduction of exercise-induced bronchospasm; instill confidence Increase maximal aerobic power, range of motion, and ambulation; control of body mass Improve mucus clearance, training of respiratory muscles Help in metabolic control; control of body mass Prevent muscle atrophy, contractures, and possible bleeding into joints Socialization; increase self-esteem; prevent detraining Increase muscle strength and endurance; prevent contractures; prolong ambulatory phase Increase effort tolerance; improve orthostatic response Reduction of body mass and fat; conditioning; socialization and improve self-esteem Prevent contractures and muscle atrophy; increase daily function Strengthen upper body; control of body mass and fat; increase maximal aerobic power
needed to define objectives, to explain the program and outcomes with the child and family, and to implement or adjust the program. Centers of pediatric care, hospital wards, and even specialized centers seem appropriate for carrying out such programs. As well, secondary locations can be centers of kinesiotherapy, then, gradually, schools and clubs. Teachers of adapted physical activity should have a privileged mission of accompanying the training programs. 5.3. Practical aspect: proposed model of training programs Concerning the introduction of a training program, we can propose a strategy constituting the actions to be taken for planning a training program for children with chronic disease and/ or handicap (Fig. 1). Bar-Or [7] defines that the training program, like any treatment, must be quantified by the intensity, frequency, duration of each session, type of activity, and total duration of the program. The recommendations for training programs for adults in terms of frequency, duration and intensity can be adapted for children [47]. These recommendations include the following [2,33]: ● for cardiorespiratory training: three to five sessions per week, for 20–60 min of continuous or intermittent activity (minimum 30 min for moderate or low intensity), at 40%/ 50–85% of VO2max; variations in intensity are recommended. The type of activity is not explained; it must allow for contribution of all muscular groups; ● for muscular reinforcement and flexibility: two to three sessions per week, exercises concerning the principal muscular groupings, appropriately begun with a series of 8–10 repetitions, the number of series increasing gradually within a few weeks.
Recommended activities Various; emphasize those with low energy demand Aquatic, intermittent, long warm-up Depends on residual ability Jogging, swimming Various; attempt equal daily energy output Swimming, cycling; avoid contact sport Recreational, intermittent, large variety Swimming, calisthenics, wheelchair sports Various; emphasize endurance-type activities High in calorie uptake but feasible to the child; emphasize swimming Swimming, calisthenics, cycling, sailing Arm-shoulder resistance training, wheelchair sports (including endurance)
Dupuis and Daudet [15] proposed the Adapted Sporting Training for children with chronic disease. The protocol is similar to that for a vaccination series: ● first training: 24 sessions of 20 min each two to three times per week, with at least a day of recovery between each session; ● recalls of training: 1 month of physical activity every 3 months, respecting the same methods of training as for the first training. Our review of the literature allows us to propose the following possible training program for children. ● frequency: two to five sessions per week; ● duration of each session: 30–60 min; ● type of activity and intensity: variable, adapted to the disease or handicap and objectives related to cardiorespiratory work and muscular reinforcement; ● total duration of the program: 6–16 weeks. Such training programs must take into account individual characteristics and those generated by the disease or handicap to ensure adapted training. In children with asthma, intermittent physical exercises have been recommended (1– 3 min of exercise interspersed with periods of rest), preceded by a warm-up period [7]. In children with mucoviscidosis, the training programs should not push the child beyond his or her limits, but the exercises must be carried out at 70– 80% of the maximal heart rate [31]; moreover, cardiorespiratory monitoring and water-containing soda intake are recommended during the exercises [7]. In children with cerebral palsy, intense exercise can mean a short duration of concentration but should be of short duration (15–20 min) for two sessions per week [7].
Authors
516
Table 3 Examples of training programs for the children Age (years) 4–13
Benson et al. 2006 [9]
78 Randomized Training group n = 37 Control group n = 41
10–15
Healthy children
Broderick et al. 2006 [12]
70 Randomized Training group and control group 25 Diabetic group n = 12 Not diabetic group n = 13 81 Randomized controlled trial 11 girls 32 boys In three groups
6–18
Hemophilia or von willebrand disease
9
Bacon et al. 1991 [4]
Costill et al. 1979 [13]
Daley et al. 2006 [14]
Faigenbaum et al. 1999 [17]
Fragala-Pinkham et al. 2005 [20]
Sex
Tools for evaluation
Programs
Frequency and duration
Results
Lower-extremity range of motion, gait, balance, and functional mobility
Aquatic training: -joint mobilization -muscular training
6 weeks
Insulin resistance, lipid levels, muscle strength, cardiorespiratory fitness, body composition, self-efficacy, self-concept, habitual physical activity, nutritional and sedentary behavior patterns VO2peak, knee extensor strength and quality of life
Progressive resistance training (two sets of eight repetitions of 11 exercises targeting all the major muscle groups twice a week at an RPE of 15–18 for 8 weeks
-Two sessions per week -during 8 weeks
Significant improvement was noted in external and internal hip rotation, bilaterally (p < 0.05). No significant difference for the other parameters Program described in detail Efficacy of this modality of exercise for metabolic fitness
Training: 30′ aeroby at 60– 70% of rate of heart, 20′ muscular training
-Session = 1 hour -Two sessions per week -12 weeks
Methodological publication, results pending
Diabetes
VO2max, biological parameters
Endurance training
-30 min/day -5 day/week -during 10 weeks
Increase of aerobic capacities, improved metabolic capacity
11–16
Obesity
Physical activities
Three sessions per week 8 weeks and 6 weeks at home
No change in body mass index Increase in psychological capacity
5.2– 11.8
Healthy young
Self-perceptions (self-esteem), depression, affect, physical activity, aerobic fitness, and body mass index Maximal strength of the leg extension and chest press exercises
In twice-weekly sessions of resistance training for 8 weeks
Increase in strength
5–9
Children with disabilities
Children performed 1 set of six to eight repetitions with a heavy load (n = 15) or 1 set of 13–15 repetitions with a moderate load (n = 16) on child-size exercise machines. Children in the control group (n = 12) did not resistance train. Aeroby (30′) and muscular training (25′)
-Session = 1 h -Two sessions per week during 14 weeks in center -and two sessions per week during 12 weeks at home
Strength and endurance training may be safe and feasible. Further research is needed to evaluate the effectiveness of a group fitness program and optimal training parameters (continued)
Boys
Type of handicap Juvenile rheumatoid arthritis
Energy expenditure index, leg strength (force-generating capacity of muscle), functional skills, fitness, self-perception, and safety
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Number of subjects 11
Table 3 (continued) Authors
Age (years) 6–14
Klepper, 1999 [26]
25 Controlled trial
8–17
Lewis et al. 2005 [29]
1
10.5
Girl
Child with down syndrome
San Juan et al. 2007 [38]
7
5.1 ± 1
4 boys and 3 girls
Child with leukemia
Aerobic fitness, muscular strength, functional mobility, ankle range of motion, and quality of life
Resistance (one set of 8–15 repetitions of 11 exercises) and aerobic training (30 min at > 70% HRmax)
Schreiber et al. 2004 [39]
1
11
Girl
Girl with hypotonia and mild mental retardation
Physical activities
6 weeks 1 h/week
Singh-Grewal et al. 2006 [40]
9
Physical activities
-Two sessions per week -12 weeks
Safe, feasible, and acceptable for children with arthritis
Takken et al. 2003 [44]
54 27 = experimental group 27 = control group
The energy expenditure index, rating of perceived exertion, maximum running velocity, and the overall daily activity level The Childhood Health Assessment Questionnaire and Juvenile Arthritis Functional Status Index, and assessed for overall quality of life and health-related quality of life Functional ability, healthrelated quality of life, joint status and physical fitness
Aquatic fitness training programme
1 h/week 20 sessions
No signs of worsening in health status, therefore, a safe exercise programme
Fragala-Pinkham et al. 2006 [19]
Sex
Type of handicap Children with neuromuscular and developmental disabilities
Children with chronic arthritis
Polyarticular childhood arthritis
5–13
Juvenile idiopathic arthritis
Tools for evaluation
Programs
Frequency and duration
Results
Isometric muscle strength of the knee extensors, hip abductors, and ankle plantarflexors, walking energy expenditure, functional mobility, and fitness
Strengthening, aerobic conditioning, and flexibility exercises
-Two sessions per week -16 weeks
1) Disease status, based on joint count (JC) and articular severity index (ASI) (sum of scores for joint swelling, pain on motion, tenderness, and limitations of motion); 2) worst pain during the past week on a 10-cm visual analog scale, and 3) aerobic endurance on the 9-min runwalk test of the Health-Related Physical Fitness Test Variables cardiovascular variables, strength, body composition, flexibility, and skill
The 60-min conditioning program included warm-up (10 min), low-impact aerobics (25 min), strengthening (15 min), and cool-down and flexibility exercises (10 min)
-Sessions= 1 h -24 sessions (2 per week in medical structure and 1 per week at home) -8 weeks
Physical therapists partnering with community centers may feasibly and safely shift group fitness programs for schoolaged children with disabilities from the medical setting to the community Statistically significant improvement in 80% of subjects on the ASI and 72% on the JC
Aerobic and muscular training
5–6 days per week 6 weeks 30–60 min various intensity Three sessions per week for 16 week followed by 20 weeks of detraining
Improve cardiopulmonary functions
Training results in significant increases in measures of aerobic fitness, strength, and functional mobility. During detraining, strength and functional mobility are well maintained Feasibility
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Number of subjects 28
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such activity should be incorporated into the daily life of the child for regular maintenance. Training programs appear necessary in the global treatment of children. This concept is not recent. Such programs are feasible and do not worsen the health of the patients, but few studies have resulted in clear data on the methods of training programs. Training programs must be validated by chronic disease and/or handicap for their use by health care professionals in dealing with children. According to Niederman [15], “no patient is too sick not to profit from a training program.” References
Fig. 1. Training programs in children with chronic disease or handicap: proposed process.
6. Conclusion Our knowledge of the basic physical activity of children implies than the inactivity could be a factor in chronic disease or handicap. Physical activity is useful in primary prevention of disease. Good physical fitness seems to improve quality of life and the functional capacities of children with chronic disease or handicap. The practice of physical activity should be promoted in these children. However, any training program requires knowing the physical capacity of children with a particular disease or handicap beforehand, by means of a codified and directed evaluation. Any training program prescribed should be adapted to and individualized for the child and guided by validated recommendations. As far as possible,
[1] American College of Sports Medicine Position Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc 1998;30(6):992– 1008. [2] American College of Sports Medicine Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30(6):975–91. [3] Guide pour les enseignants qui accueillent un élève présentant une déficience motrice. Handiscou. Ministère de l’Éducation Nationale 2001:34–5. [4] Bacon MC, Nicholson C, Binder H, White PH. Juvenile rheumatoid arthritis. Aquatic exercise and lower-extremity function. Arthritis Care Res 1991;4(2):102–5. [5] Baquet G, van Praagh E, Berthoin S. Endurance training and aerobic fitness in young people. Sports Med 2003;33(15):1127–43. [6] Bar-Or O. Exercise in childhood. Current Therapy in Sport Medicine 1985–1986. [7] Bar-Or O. Médecine du sport chez l’enfant. Principes physiologiques et applications cliniques. Paris: Masson; 1987. [8] Bensahel H. In: Maladies d’appareils et sport. L’enfant et la pratique du sport. Paris: Masson; 1998. p. 139–97. [9] Benson AC, Torode ME, Fiatarone Singh MA. A rationale and method for high-intensity progressive resistance training with children and adolescents. Contemp Clin Trials 2006. [10] Berlin JA, Colditz GA. A meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol 1990;132(4):612–28. [11] Binder M, Bensahel H. In: Aptitude de l’enfant au sport, de l’école à la compétition. L’enfant et la pratique du sport. Paris: Masson; 1998. p. 10– 23. [12] Broderick CR, Herbert RD, Latimer J, Curtin JA, Selvadurai HC. The effect of an exercise intervention on aerobic fitness, strength and quality of life in children with haemophilia (ACTRN012605000224628). BMC Blood Disord 2006;6:2. [13] Costill DL, Cleary P, Fink WJ, Foster C, Ivy JL, Witzmann F. Training adaptations in skeletal muscle of juvenile diabetics. Diabetes 1979;28(9): 818–22. [14] Daley AJ, Copeland RJ, Wright NP, Roalfe A, Wales JK. Exercise therapy as a treatment for psychopathologic conditions in obese and morbidly obese adolescents: a randomized, controlled trial. Pediatrics 2006; 118(5):2126–34. [15] Dupuis J, Daudet G. Médecine du Sport de l’enfant et de l’adolescent. Paris: Ellipses; 2001. [16] Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ, Roemmich JN. How much activity do youth get? A quantitative review of heart-rate measured activity. Pediatrics 2001;108(3):E44. [17] Faigenbaum AD, Westcott WL, Loud RL, Long C. The effects of different resistance training protocols on muscular strength and endurance development in children. Pediatrics 1999;104(1):e5. [18] Fernhall B, Unnithan VB. Physical activity, metabolic issues, and assessment. Phys Med Rehabil Clin N Am 2002;13(4):925–47. [19] Fragala-Pinkham MA, Haley SM, Goodgold S. Evaluation of a community-based group fitness program for children with disabilities. Pediatr Phys Ther 2006;18(2):159–67.
P. Edouard et al. / Annales de réadaptation et de médecine physique 50 (2007) 510–519 [20] Fragala-Pinkham MA, Haley SM, Rabin J, Kharasch VS. A fitness program for children with disabilities. Phys Ther 2005;85(11):1182–200. [21] Fulton JE, Garg M, Galuska DA, Rattay KT, Caspersen CJ. Public health and clinical recommendations for physical activity and physical fitness: special focus on overweight youth. Sports Med 2004;34(9):581–99. [22] Harrell JS, Pearce PF, Markland ET, Wilson K, Bradley CB, McMurray RG. Assessing physical activity in adolescents: common activities of children in 6th–8th grades. J Am Acad Nurse Pract 2003;15(4):170–8. [23] Heath GW, Fentem PH. Physical activity among persons with disabilities —a public health perspective. Exerc Sport Sci Rev 1997;25:195–234. [24] Helmrich SP, Ragland DR, Leung RW, Paffenbarger Jr. RS. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. N Engl J Med 1991;325(3):147–52. [25] Jolibois R, Mandel C, Monod H, Kahn J, Amoretti R, Rodineau J. Sport et Enfant. Médecine du Sport. Collection pour le praticien; 2e édition. Masson. Paris: p. 343–364. [26] Klepper SE. Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritis. Arthritis Care Res 1999;12(1):52–60. [27] Klepper SE, Darbee J, Effgen SK, Singsen BH. Physical fitness levels in children with polyarticular juvenile rheumatoid arthritis. Arthritis Care Res 1992;5(2):93–100. [28] Klepper SE, Giannini MJ. Physical conditioning in children with arthritis: assessment and guidelines for exercise prescription. Arthritis Care Res 1994;7(4):226–36. [29] Lewis CL, Fragala-Pinkham MA. Effects of aerobic conditioning and strength training on a child with Down syndrome: a case study. Pediatr Phys Ther 2005;17(1):30–6. [30] Molnar D, Livingstone B. Physical activity in relation to overweight and obesity in children and adolescents. Eur J Pediatr 2000;159(Suppl 1): S45–55. [31] Orenstein DM, Franklin BA, Doershuk CF, Hellerstein HK, Germann KJ, Horowitz JG, et al. Exercise conditioning and cardiopulmonary fitness in cystic fibrosis. The effects of a three-month supervised running program. Chest 1981;80(4):392–8. [32] Pate RR, Dowda M, Ross JG. Associations between physical activity and physical fitness in American children. Am J Dis Child 1990;144(10): 1123–9. [33] Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402–7.
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[34] Petersen KH, McElhenney TR. Effects of a physical fitness program upon asthmatic boys. Pediatrics 1965;35:295–9. [35] Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health 1987;8:253–87. [36] Riddoch CJ, Boreham CA. The health-related physical activity of children. Sports Med 1995;19(2):86–102. [37] Rousset J, Bensahel H. In: Le sport scolaire. L’enfant et la pratique du sport. Paris: Masson; 1998. p. 24–8. [38] San Juan AF, Fleck SJ, Chamorro-Vina C, Mate-Munoz JL, Moral S, Perez M, et al. Effects of an intrahospital exercise program intervention for children with leukemia. Med Sci Sports Exerc 2007;39(1):13–21. [39] Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: a clinical case report. Pediatr Phys Ther 2004;16(3):173–9. [40] Singh-Grewal D, Wright V, Bar-Or O, Feldman BM. Pilot study of fitness training and exercise testing in polyarticular childhood arthritis. Arthritis Rheum 2006;55(3):364–72. [41] Sirard JR, Pate RR. Physical activity assessment in children and adolescents. Sports Med 2001;31(6):439–54. [42] Stone EJ, McKenzie TL, Welk GJ, Booth ML. Effects of physical activity interventions in youth. Review and synthesis. Am J Prev Med 1998; 15(4):298–315. [43] Takken T, van der Net J, Helders PJ. Relationship between functional ability and physical fitness in juvenile idiopathic arthritis patients. Scand J Rheumatol 2003;32(3):174–8. [44] Takken T, Van Der Net J, Kuis W, Helders PJ. Aquatic fitness training for children with juvenile idiopathic arthritis. Rheumatology (Oxford) 2003;42(11):1408–14. [45] Welk GJ, Corbin CB, Dale D. Measurement issues in the assessment of physical activity in children. Res Q Exerc Sport 2000;71(2 Suppl):S59– 73 [ISRCTN15360785]. [46] Zahner L, Puder JJ, Roth R, Schmid M, Guldimann R, Puhse U, Knopfli M, Braun-Fahrlander C, Marti B, Kriemler S. A school-based physical activity program to improve health and fitness in children aged 6– 13 years (“Kinder-Sportstudie KISS”): study design of a randomized controlled trial. BMC Public Health 2006;6:147. [47] Zwiren L. Exercise prescription for children. American College of Sports Medicine. In: Resource manual for guidelines for exercise testing and prescription. 1988. p. 309–14.
Literature review
Training programs for children: literature review P. Edouarda,*, V. Gautherona, M.-C. D’Anjoub, L. Pupiera, X. Devillarda a
Service médecine physique et réadaptation, unité PPEH EA 3062, faculté de médecine Jacques-Lisfranc, université Jean-Monnet, CHU de Saint-Etienne, hôpital Bellevue, 42055 Saint-Etienne cedex 02, France b Service médecine physique et réadaptation pédiatrique, CHU de Saint-Etienne, hôpital Nord, 42055 Saint-Etienne cedex 02, France Received 5 March 2007; accepted 16 April 2007
Abstract Introduction. – Training programs are increasingly being prescribed for occupational therapy for adults affected by chronic illness and/or handicap, but their use is more recent for children and teenagers. Objective. – A review of the literature to synthesize information concerning training programs for children, whether healthy or with disease or handicap, considering the target population, methodology, the results and limitations. Methods. – We searched the Medline database with use of the key words retraining, training, training programs, physical activity, physical training, fitness program, sport, children, disability, and handicap. We also searched references of the selected articles for appropriate studies. Discussion/conclusion. – Physical activity seems to be a good means of primary preventing adverse health in the healthy child and secondary prevention in children with chronic disease or handicap. Thus, training programs could be adapted and integrated into the global treatment of sick or handicapped children in the health care situation or in the home. These programs are feasible and do not undermine children’s health, but few studies have shown clear data on the methods of the programs. The suggested training programs, not always validated, included two to five sessions from 30 to 60 min/week, for 6–16 weeks, of variable activity and intensity, adapted to the condition and the objectives of therapy. Training programs adapted to children should be validated to allow their accessibility by health care professionals dealing with children with chronic disease and/or handicap. © 2007 Elsevier Masson SAS. All rights reserved. Keywords: Training programs; Physical activity; Children; Handicap; Sport; Chronical disease
1. Introduction Children’s growth is in constant evolution. Physical activity forms an integral daily part of the child’s life, at home and at school. Its practice is natural and spontaneous and it is considered synonymous with good health. Physical activity is necessary to children’s general, staturoponderal, motor, psychological and social development [25]. The supposed beneficial effects of physical activity could translate to pediatric global treatment, in particular for chronic diseases [7]. Inactivity could entail risk of chronic disease [33,36,41], whereas better physical fitness could indicate better prognosis. With older people, regular physical activity could attenuate functional * Corresponding
author. E-mail address: [email protected] (P. Edouard).
0168-6054/$ - see front matter © 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.annrmp.2007.04.015
loss and delay dependency [1]. Today, physical activity is generally considered good for primary prevention of disease, and the current debates relate to the methods of prescribing the physical activity [2,28]. The minimal recommendations for physical activity in the adult [2] are debated in the child [16,21,36]. Determining and especially quantifying physical activity for and determine the basal energy expenditure of the healthy child [7,30,36,45] is difficult because of methodological problems [36,41]. In handicapped children, as in the handicapped adult [23], the physical level of activity and the aerobic capacity are very low [15, 18]. Patients afflicted by chronic disease with reduced tolerance to the exercise can benefit from training with progressive physical activity. The goal of such programs is to regain the capacity to perform unaided activities of daily life [2]. The immediate goal is to restore the physical fitness of the patient whose condition is largely deteriorated by trauma or sudden
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handicap but also by the confinement and prolonged inactivity. In the long run, such patients must change their lifestyle, become more active, and preserve physical independence for as long as possible. Many protocols have elaborated training programs for various populations prone to reduced functional capacities. The American College of Sport Medicine has proposed training programs based on intensity, frequency, duration and possibility for progression for the adult [2]. Such programs and the physical activity have been validated for the global treatment of chronic, cardiovascular [10,35], respiratory, and metabolic diseases [24]. However, for children with disease, no clear recommendations exist concerning training programs. The mechanisms causing loss of physical capacity in the child differ according to disease, which is the reason for difficulty in proposing adapted programs of exercise. The capacity of the child must be known before proposing specific training [23]. Improving aerobic capacity and physical activity in children with handicap would have a positive prognostic impact, whereas the reverse could have unfavorable consequences on total health [18]. Training programs for children with disease could have a place in global medical treatment. Physical activity represents a very significant part of the daily life of children because it is associated with development and has therapeutic virtues. We wondered about the possibility, or even the need, for training programs for children, whether healthy or with disease or handicap. In this review of the literature, we explore the definition of children who would benefit from training programs, and then describe the characteristics of the training programs adapted to each situation. 2. Objectives We aimed to review the literature about training programs in children with disease or handicap to determine the target populations of children, the means of evaluation and the protocols used and their goals and to propose a synthesis of the protocols of training programs for children with chronic disease or handicap. 3. Methods of research We searched the Medline database with use of the key words retraining, training, training programs, physical activity, physical training, fitness program, sport, children, disability, and handicap. We also searched references of the selected articles for appropriate studies. 4. Results We found 46 articles of studies of physical activity for children with chronic disease or handicap, including 15 articles of training programs. Most of the articles were found by research from an article of the given subject. The search of Medline with keywords did not allow for precise selection of articles.
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5. Discussion 5.1. Physical activities in the healthy child 5.1.1. Physical activity, sport and development of the healthy child The development of motor ability of the healthy child is progressive from birth to puberty. Various motor acquisitions allow for the practice of physical activities and increasingly varied sports [25]. The practice of sport becomes effective only from age 9, which corresponds to the acquisition of technical ability and is really only complete at age 12, with the presence of logical and deductive intelligence and ordered and methodical reasoning. The age between 6 and 8 is a “hinge” period, when the child acquires and refines body development, lateralization, the concepts of space and time, speed, force and flexibility. Before this age, sport is mainly play, and afterwards, sport can entail physical and social development, not just performance [25]. Sport has numerous benefits, including the following [25]: ● favoring motor and psychomotor coordination, increasing muscular force, improving the capacity of adaptation to the effort of the cardiovascular and pulmonary apparatus, and generating physical and psychological well-being, thereby becoming a source of pleasure; ● preventing cardiovascular disease, hypertension and atherosclerosis; ● having a positive effect on bone mineralization; ● developing competitive emulation, pushing ones’ capabilities, self-assertion, and, for some, team spirit and even responsibility. For most of these benefits, sport, and by extension, physical activity, should be used like therapy in pediatrics [7]. This interest is reinforced by the child’s positive perception of the physical activity: it allows children with disease or handicap to realize that they can act like healthy children [7]. The negative effects of sport include the following: ● ● ● ●
increased risk of accidents and lesions due to the sport; syndromes of overuse; abnormal physiological reactions; psychological risks to be manipulated or exploited [7,25].
The reaction to exercise differs among children and between children and adults. The child has a metabolic reserve weaker than that of the adult [7,47]; overtraining can disturb growth, in particular during puberty [47]. 5.1.2. Physical activities in the daily life of the healthy child Physical activity and the physical capacities are moderately related [32]. Epstein et al. [16] studied the intensity of physical activity in children by measuring heart rate. Young people of all ages performed physical activity of low intensity more than 60 min/day and 50% or more maximum-intensity activity approximately 30 min/day. Stone et al. [42], in a review of
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the literature from 1980 to 1997 concerning physical activity in community schools and infrastructures, showed that little was known about the subject and much remained to be explored, in particular by means of multicentric studies. Harrell et al. [22], performed a US study of physical activity in children between 11 and 14 years old in five rural schools. Results concluded that the level of activity could be increased, with encouragement by health care personnel, and could help prevent health problems. Zahner et al. [46], noticing that children adopt an increasingly sedentary lifestyle, estimated that the school has a paramount role in the promotion of the physical activity. This Swiss team carried out an exploratory study of 15 randomized schools, of children aged 6–13 years, to evaluate the feasibility of the installation of a physical work program. However, outlining possible physical activity for children, namely the quantity and the place, seems important before putting considering training programs for children with disease or handicap. 5.1.3. Measurement of physical capacity in the healthy child The evaluation of tolerance to effort can be useful before prescribing a specific training program. Several tests, simple or sophisticated, can be used for quantifying fitness, monitoring training, or orientation to an adapted sport [15]. The investigations are limited by ethical problems and methodological considerations [7]. These tests comprise the following [7,15]: ● evaluation of somatic development: height, weight, body mass index (weight/height2), puberty stage, bone maturation, lean mass; ● exploration of respiratory function, vascularization, diffusion of CO2, compliance, gazometry; ● indirect estimate of the alactic anaerobic metabolism: Margaria staircase test, tests of load speed, Bosco carpet test, vertical relaxation, short sprint; ● estimate of the lactic anaerobic metabolism: test of Wingate, measures of lactic acid in blood, racing, Ruffier Dickson test; ● measurement and indirect estimate of aerobic metabolism: maximal oxygen consumption (VO2max), test of LegerButcher shuttle, Cooper test; ● measurement of muscular force; ● indirect estimate of psychomotor qualities: static balance, lower-limb tapping, tremometry, chronoscopy, MacQuarrie test, Cattell test, subjective effects related to the sport practice. 5.1.4. Effects of training in the healthy child The effects of the training are not easily measurable in the child because of proscription of invasive examinations and badly adapted tests, which disallows distinguishing modifications related to the training from those related to growth [15]. The effects of the training are exerted at various levels: muscle, adaptation of organization to effort and psychomotor capacity. Any training generates progress whether transitory
(physical capacities or elaborate technical skills) or definite (training of skills: swimming, bicycle, etc.) [15]. Training has positive effects on physical capacity. The work of force and endurance involves progress, and training with high loads can be beneficial [17]. However, the methods of training are subject to controversy; in particular, should endurance studies involve continuous work or interval training? [5]. Being spontaneous, the child prefers intermittent activities short, varied and fun [47]. 5.2. Physical activities for children with chronic disease and/ or handicap 5.2.1. Physical capacity of children with chronic disease and/ or handicap Most chronic diseases cause reduced physical, psychic and psychomotor capacity in patients [7,15,18]. The disease is a direct or indirect cause of sedentary lifestyle or hypoactivity, sometimes reinforced by the family [7]. The hypoactivity can involve a vicious circle involving loss of functional capacity [7]. The resulting loss of physical fitness is regrettable and can lead to many diseases [15]. Discontinued activity, whatever the origin, causes quick loss of functional capacity and adaptability to effort [7]. Chronic diseases can be a direct cause of reduced aerobic maximal power by affecting the transport of O2 or by increasing the metabolic cost of the physical exercise [7]. 5.2.2. Contraindications with the practice of sport Contraindications with the practice of sport are rare, even with serious, chronic, invalidating and evolutionary illness. The selective or temporary contraindications relate especially to the cardiopulmonary or locomotor system. For high-level competitive practice, contraindications relate to the risk of disease aggravation or accident. The recommendations for the participation in competition sports [7,8] are summarized by Jolibois et al. [25] or Binder and Bensahel [11] (Table 1). Participation in sport should be prohibited only if the sport will worsen the disease or put the child at risk. Complementary examinations will be able to help in decision making. Many children with chronic disease can participate in physical activity or sport, but determining this practice with precision is advisable [8,15]. For example, De Mondenard [8] proposes a prescription of physical activity for the diabetic child, with recommendations for the practice of sport and adaptation of insulin treatment and food. 5.2.3. Physical activity and sport in the daily life of children with chronic disease and/or handicap “For any child the sport is a benefit with short, average and long term. For the sick child, it has additional advantages because sport decreases the loss of physical fitness derive from the disease and its treatments, sport gets very important benefits, and sport helps to be released from the statute of patient and favors integration by erasing the differences.” [15]. In terms of physical and sport education in school, directives exist for children affected by motor deficiency [3]: “The
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Table 1 Recommendations and contraindications for competitive sport activities in children [4,11] Abnormalities by apparatus Cardiovascular Hypertension light Moderately Cardiopathy Ischemic cardiopathy surgery Not ischemic cardiopathy Valvular heart disease Myocardiopathy with obstruction Pulmonary hypertension Heart rate disorder Other heart diseases Respiratory Respiratory failure Severe or chronic Asthma with effort bronchospasm Mucoviscidosis Locomotor Minor disorder: flat food, unbalance in length of limb, genu valgum scoiosis attitude Major disorder: fracture, plate of osteosynthesis, inflammatory diseases, Neuropsychiatric Skull trauma severe or moderate, craniotomy, osteochondrosis, etc Convulsion not or monitored well monitored Psychiatric diseases Blood Hemorrhagic disease Hemoglobinopathy With splenomegaly Without splenomegaly ORL Ophtalmology Blind Severe myopia With glasses Skin diseases Infectious dermatosis Genital organsI Single testicle or ectopia (with equipment of protection) Renal Proteinuria orthostatic or with effort Renal failure Single kidney Hepatic Hepatomegaly Miscellaneous Inguinal hernia Acute disease Jaundice Diabetes regular a Authorization or prohibition after complete and specific examination.
regulations, by not envisaging any obligation of preliminary medical control as regards physical and sporting education, retain the principle of the aptitude of all the pupils to a priori follow the teaching of this discipline” (circular no. 90-107 of May 17, 1990). Children with motor deficiency, however, cannot perform all the activities of their healthy peers under the same conditions. Almost all students, even those in an electric wheelchair, can perform some type of activity and can progress and find pleasure insofar as teachers can adapt teaching [3]. If
Sports with contact Collision Impact
Effort
Sports without contact Moderate effort Little effort
Yes
Yes
Yes
Yes
Yes
a
a
a
a
a
No
No
a
a
a
a
a
a
Yes
Yes
No No No No
No No No No
No No No
a
a
No No
No No
a
a
a
a
a
a
a
a
a
a
a
a
Yes
Yes
Yes
Yes
Yes Yes
a
a
a
a
a
a
a
a
a
a
Yes
Yes
Yes
Yes
Yes No
Yes No
Yes
Yes
Yes
a
a
a
a
a
No Yes No
No Yes
Yes No Yes
Yes No Yes
Yes No Yes
No
No
a
a
a
No
No
No
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
No No
a
a
a
a
No/
Yes
Yes
Yes
a
a
a
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
a
a
a
a
No No
yes/a No
Yes
Yes Yes
Yes Yes Yes Yes
No No No
No No No
a
a
Yes No No Yes
Yes No No Yes
a
a
a
No No Yes
there are difficulties, adjustments and precautions must be found, in consultation with the physician. School sport, within the National Union of the School Sport (UNSS), concerns only the recognized student medical condition suited to the sporting practice (obligatory medical certificate). The UNSS is not authorized to organize activities for handicapped children, but can integrate such children into sport by training young referees or young sport officials [37].
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As for the healthy child, for children with chronic disease and/or handicap, knowing the habit of physical activity and sport in the child is important. Except for finding some directives on the sport, we did not find any data on real practice. 5.2.4. Children with disease or handicap and training programs Children with a loss of physical capacity incur sufficiently long interruption of physical activity, showing reduced physical fitness and functional capacity, either because of habit (increased sedentary lifestyle) or disease. The goal of the training program is to regain the capacity to carry on with daily life unaided and to be able to face the unforeseen critical situations [2]. The populations concerned with training programs have a loss of functional capacity or autonomy. Such programs preferentially concern children with chronic disease. The literature mainly concerns training programs associated with rheumatoid arthritis diseases [27,28, 40,43], metabolic abnormalities (diabetes and obesity [21]), respiratory abnormalities (asthma and mucoviscidosis), neoplastic abnormalities, backwardness [39], and hematologic abnormalities (hemophilia [12]). The mechanisms of chronic disease differ from those in handicap. The consequences of training in terms of the physical capacities of the child with the particular disease should be evaluated before proposing programs [18]: ● children with rheumatoid arthritis such as polyarticular juvenile rheumatoid arthritis have lower physical fitness for endurance and muscular force [28]. Aerobic physical capacity and functional capacity are strongly related [43]; ● in children with diabetes, the low physical capacity found in certain studies do not seem related to the disease itself but, rather, to the weak physical activity of the patient. Programs of training can improve physical fitness to a normal level [7, 13]; ● obese children have reservations about physical activity, because of psychologic and esthetic reasons (fear of showing the body) and functional capacity (difficulty in mobilization, articular pain). Such children are limited by a higher metabolic cost of the physical exercise. Physical performance is directly attributed to degree of adiposity [7]; ● in children with asthma, physical capacity is close to normal, in terms of maximal aerobic power and muscular force. Various studies suggest that the weak aptitude for effort is not attributed to the disease but, rather, to a sedentary way of life [7]. The degree of improvement of physical performance is related to intensity of training [7,34]. Sahraoui and Grimfeld [8] recommend a training program with a specialized structure for certain children with severe asthma to reduce dyspnea; ● in children with mucoviscidosis, physical performance is limited by ventilatory capacity, in direct relation to the severity of affliction [7]. Physical activity has a beneficial effect: clarification of mucus, improved the respiratory
● ● ●
●
endurance of muscles, reduced resistance of the airway, and improved physical performance [7]; in children with leukemia or cancer, all the risks of loss of physical fitness are evident: pain, malnutrition, immobility, use of corticotherapy, prolonged stay in isolation; mentally handicapped children have weakened physical fitness, whose causes vary according to the situation [39,41]; children with cerebral palsy have limited physical capacity (loss of muscular force, spasticity, orthopedic complications, etc.). Maximal aerobic power and mechanical output are definitely lower than those in healthy children. The increasing difficulty in moving and weak physical activity generate a loss of physical fitness [7,20]; children with hemophilia have obvious difficulty with practice of physical activity: the shock of a fall is the origin of hemorrhage and in particular, hemarthrosis, and the overuse of the joints can result in their degeneration [15].
In children with transitory handicap, physical activity is particularly contraindicated because of trauma, surgery, infectious disease and prolonged confinement physical activity can be delayed. Probably, spontaneous physical activity will enable satisfactory physical fitness. However, Dupuis and Daudet [15] suggest that these children could follow an adapted sporting training. Bar-Or [7] showed that any hypoactivity can cause loss of physical and functional capacities. 5.2.5. Tools for evaluation To evaluate the effectiveness of a training program, good tools are needed for evaluating the initial reference, controlling the effects of the protocol, and final evaluation of retraining to judge effectiveness. One must not evaluate a protocol of retraining without reliable, objective and reproducible criteria. Many studies have investigated evaluation of the physical activity [30,41,45]. These tools are similar, whether for children with chronic disease or handicap or not. 5.2.6. Types of training programs Bar-Or proposed objectives of training programs associating physical and sporting activities adapted to the pathology [6,47] (Table 2). The training programs are in (Table 3). Among the programs reported in the literature is the Adapted Sport Training proposed by Dupuis and Daudet [15]. The authors propose personalized and controlled programs of training that are easy to follow and well accepted. These programs consist of two to three sessions per week, for at least 20–30 min per session, for 1–3 months. Each session is based on a succession of exercises connected without interruption and always in the same order, the intensity and the level of the exercises adapted to the progression of capability of the individual. 5.2.7. Framing of the training programs The training programs should be initiated within a medical care framework, for monitoring of the training and for adaptation of the individualized program. Qualified personnel are
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Table 2 Exercise programs in the management of specific pediatric diseases [2,18] Disease Anorexia nervosa Bronchial asthma Cerebral palsy Cystic fibrosis Diabetes mellitus Hemophilia Mental retardation Muscular dystrophies Neurocirculatory disease Obesity Rheumatoid arthritis Spina bifida
Purposes of program Means for behavioral modification; educate regarding lean mass versus fat Conditioning; possible reduction of exercise-induced bronchospasm; instill confidence Increase maximal aerobic power, range of motion, and ambulation; control of body mass Improve mucus clearance, training of respiratory muscles Help in metabolic control; control of body mass Prevent muscle atrophy, contractures, and possible bleeding into joints Socialization; increase self-esteem; prevent detraining Increase muscle strength and endurance; prevent contractures; prolong ambulatory phase Increase effort tolerance; improve orthostatic response Reduction of body mass and fat; conditioning; socialization and improve self-esteem Prevent contractures and muscle atrophy; increase daily function Strengthen upper body; control of body mass and fat; increase maximal aerobic power
needed to define objectives, to explain the program and outcomes with the child and family, and to implement or adjust the program. Centers of pediatric care, hospital wards, and even specialized centers seem appropriate for carrying out such programs. As well, secondary locations can be centers of kinesiotherapy, then, gradually, schools and clubs. Teachers of adapted physical activity should have a privileged mission of accompanying the training programs. 5.3. Practical aspect: proposed model of training programs Concerning the introduction of a training program, we can propose a strategy constituting the actions to be taken for planning a training program for children with chronic disease and/ or handicap (Fig. 1). Bar-Or [7] defines that the training program, like any treatment, must be quantified by the intensity, frequency, duration of each session, type of activity, and total duration of the program. The recommendations for training programs for adults in terms of frequency, duration and intensity can be adapted for children [47]. These recommendations include the following [2,33]: ● for cardiorespiratory training: three to five sessions per week, for 20–60 min of continuous or intermittent activity (minimum 30 min for moderate or low intensity), at 40%/ 50–85% of VO2max; variations in intensity are recommended. The type of activity is not explained; it must allow for contribution of all muscular groups; ● for muscular reinforcement and flexibility: two to three sessions per week, exercises concerning the principal muscular groupings, appropriately begun with a series of 8–10 repetitions, the number of series increasing gradually within a few weeks.
Recommended activities Various; emphasize those with low energy demand Aquatic, intermittent, long warm-up Depends on residual ability Jogging, swimming Various; attempt equal daily energy output Swimming, cycling; avoid contact sport Recreational, intermittent, large variety Swimming, calisthenics, wheelchair sports Various; emphasize endurance-type activities High in calorie uptake but feasible to the child; emphasize swimming Swimming, calisthenics, cycling, sailing Arm-shoulder resistance training, wheelchair sports (including endurance)
Dupuis and Daudet [15] proposed the Adapted Sporting Training for children with chronic disease. The protocol is similar to that for a vaccination series: ● first training: 24 sessions of 20 min each two to three times per week, with at least a day of recovery between each session; ● recalls of training: 1 month of physical activity every 3 months, respecting the same methods of training as for the first training. Our review of the literature allows us to propose the following possible training program for children. ● frequency: two to five sessions per week; ● duration of each session: 30–60 min; ● type of activity and intensity: variable, adapted to the disease or handicap and objectives related to cardiorespiratory work and muscular reinforcement; ● total duration of the program: 6–16 weeks. Such training programs must take into account individual characteristics and those generated by the disease or handicap to ensure adapted training. In children with asthma, intermittent physical exercises have been recommended (1– 3 min of exercise interspersed with periods of rest), preceded by a warm-up period [7]. In children with mucoviscidosis, the training programs should not push the child beyond his or her limits, but the exercises must be carried out at 70– 80% of the maximal heart rate [31]; moreover, cardiorespiratory monitoring and water-containing soda intake are recommended during the exercises [7]. In children with cerebral palsy, intense exercise can mean a short duration of concentration but should be of short duration (15–20 min) for two sessions per week [7].
Authors
516
Table 3 Examples of training programs for the children Age (years) 4–13
Benson et al. 2006 [9]
78 Randomized Training group n = 37 Control group n = 41
10–15
Healthy children
Broderick et al. 2006 [12]
70 Randomized Training group and control group 25 Diabetic group n = 12 Not diabetic group n = 13 81 Randomized controlled trial 11 girls 32 boys In three groups
6–18
Hemophilia or von willebrand disease
9
Bacon et al. 1991 [4]
Costill et al. 1979 [13]
Daley et al. 2006 [14]
Faigenbaum et al. 1999 [17]
Fragala-Pinkham et al. 2005 [20]
Sex
Tools for evaluation
Programs
Frequency and duration
Results
Lower-extremity range of motion, gait, balance, and functional mobility
Aquatic training: -joint mobilization -muscular training
6 weeks
Insulin resistance, lipid levels, muscle strength, cardiorespiratory fitness, body composition, self-efficacy, self-concept, habitual physical activity, nutritional and sedentary behavior patterns VO2peak, knee extensor strength and quality of life
Progressive resistance training (two sets of eight repetitions of 11 exercises targeting all the major muscle groups twice a week at an RPE of 15–18 for 8 weeks
-Two sessions per week -during 8 weeks
Significant improvement was noted in external and internal hip rotation, bilaterally (p < 0.05). No significant difference for the other parameters Program described in detail Efficacy of this modality of exercise for metabolic fitness
Training: 30′ aeroby at 60– 70% of rate of heart, 20′ muscular training
-Session = 1 hour -Two sessions per week -12 weeks
Methodological publication, results pending
Diabetes
VO2max, biological parameters
Endurance training
-30 min/day -5 day/week -during 10 weeks
Increase of aerobic capacities, improved metabolic capacity
11–16
Obesity
Physical activities
Three sessions per week 8 weeks and 6 weeks at home
No change in body mass index Increase in psychological capacity
5.2– 11.8
Healthy young
Self-perceptions (self-esteem), depression, affect, physical activity, aerobic fitness, and body mass index Maximal strength of the leg extension and chest press exercises
In twice-weekly sessions of resistance training for 8 weeks
Increase in strength
5–9
Children with disabilities
Children performed 1 set of six to eight repetitions with a heavy load (n = 15) or 1 set of 13–15 repetitions with a moderate load (n = 16) on child-size exercise machines. Children in the control group (n = 12) did not resistance train. Aeroby (30′) and muscular training (25′)
-Session = 1 h -Two sessions per week during 14 weeks in center -and two sessions per week during 12 weeks at home
Strength and endurance training may be safe and feasible. Further research is needed to evaluate the effectiveness of a group fitness program and optimal training parameters (continued)
Boys
Type of handicap Juvenile rheumatoid arthritis
Energy expenditure index, leg strength (force-generating capacity of muscle), functional skills, fitness, self-perception, and safety
P. Edouard et al. / Annales de réadaptation et de médecine physique 50 (2007) 510–519
Number of subjects 11
Table 3 (continued) Authors
Age (years) 6–14
Klepper, 1999 [26]
25 Controlled trial
8–17
Lewis et al. 2005 [29]
1
10.5
Girl
Child with down syndrome
San Juan et al. 2007 [38]
7
5.1 ± 1
4 boys and 3 girls
Child with leukemia
Aerobic fitness, muscular strength, functional mobility, ankle range of motion, and quality of life
Resistance (one set of 8–15 repetitions of 11 exercises) and aerobic training (30 min at > 70% HRmax)
Schreiber et al. 2004 [39]
1
11
Girl
Girl with hypotonia and mild mental retardation
Physical activities
6 weeks 1 h/week
Singh-Grewal et al. 2006 [40]
9
Physical activities
-Two sessions per week -12 weeks
Safe, feasible, and acceptable for children with arthritis
Takken et al. 2003 [44]
54 27 = experimental group 27 = control group
The energy expenditure index, rating of perceived exertion, maximum running velocity, and the overall daily activity level The Childhood Health Assessment Questionnaire and Juvenile Arthritis Functional Status Index, and assessed for overall quality of life and health-related quality of life Functional ability, healthrelated quality of life, joint status and physical fitness
Aquatic fitness training programme
1 h/week 20 sessions
No signs of worsening in health status, therefore, a safe exercise programme
Fragala-Pinkham et al. 2006 [19]
Sex
Type of handicap Children with neuromuscular and developmental disabilities
Children with chronic arthritis
Polyarticular childhood arthritis
5–13
Juvenile idiopathic arthritis
Tools for evaluation
Programs
Frequency and duration
Results
Isometric muscle strength of the knee extensors, hip abductors, and ankle plantarflexors, walking energy expenditure, functional mobility, and fitness
Strengthening, aerobic conditioning, and flexibility exercises
-Two sessions per week -16 weeks
1) Disease status, based on joint count (JC) and articular severity index (ASI) (sum of scores for joint swelling, pain on motion, tenderness, and limitations of motion); 2) worst pain during the past week on a 10-cm visual analog scale, and 3) aerobic endurance on the 9-min runwalk test of the Health-Related Physical Fitness Test Variables cardiovascular variables, strength, body composition, flexibility, and skill
The 60-min conditioning program included warm-up (10 min), low-impact aerobics (25 min), strengthening (15 min), and cool-down and flexibility exercises (10 min)
-Sessions= 1 h -24 sessions (2 per week in medical structure and 1 per week at home) -8 weeks
Physical therapists partnering with community centers may feasibly and safely shift group fitness programs for schoolaged children with disabilities from the medical setting to the community Statistically significant improvement in 80% of subjects on the ASI and 72% on the JC
Aerobic and muscular training
5–6 days per week 6 weeks 30–60 min various intensity Three sessions per week for 16 week followed by 20 weeks of detraining
Improve cardiopulmonary functions
Training results in significant increases in measures of aerobic fitness, strength, and functional mobility. During detraining, strength and functional mobility are well maintained Feasibility
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Number of subjects 28
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such activity should be incorporated into the daily life of the child for regular maintenance. Training programs appear necessary in the global treatment of children. This concept is not recent. Such programs are feasible and do not worsen the health of the patients, but few studies have resulted in clear data on the methods of training programs. Training programs must be validated by chronic disease and/or handicap for their use by health care professionals in dealing with children. According to Niederman [15], “no patient is too sick not to profit from a training program.” References
Fig. 1. Training programs in children with chronic disease or handicap: proposed process.
6. Conclusion Our knowledge of the basic physical activity of children implies than the inactivity could be a factor in chronic disease or handicap. Physical activity is useful in primary prevention of disease. Good physical fitness seems to improve quality of life and the functional capacities of children with chronic disease or handicap. The practice of physical activity should be promoted in these children. However, any training program requires knowing the physical capacity of children with a particular disease or handicap beforehand, by means of a codified and directed evaluation. Any training program prescribed should be adapted to and individualized for the child and guided by validated recommendations. As far as possible,
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