Pediatric Sports Medicine for the Practitioner : From Physiologic Principles to Clinical Applications

Comprehensive Manuals in Pediatrics are designed to broaden the prac­ titioner's clinical scope by providing a wide range of diagnostic and management skills ordinarily considered to be the exclusive domain of the specialists. Although the series as a whole constitutes a comprehen­ sive text in pediatrics, each volume stands on its own as a self-contained the busy practitioner. reference for In order to maintain a uniform style and coverage of each subject, each manual is usually written by no more than one or two authors. Each author is an acknowledged expert in his or her field and provides a comprehensive, up-to-date account of the topic under discussion. Practi­ cally oriented, each volume offers concise guidelines and courses of treatment. Michael Katz E. Richard Stiehm Preface Much knowledge has been generated in recent years by scientists investigating the triad: child-exercise-health. Yet little of this infor­ mation is available in pediatric textbooks, for application by the clinician. This book is intended to bridge the resulting gap.

1 Physiologic Responses to Exercise of the Healthy Child.- Response to Acute Exercise.- Metabolic Responses to Exercise in Children.- Maximal Aerobic Power.- Maximal O2 Uptake.- Maximal O2 Uptake per Kilogram Body Weight.- The Dimensionality Theory and Maximal O2 Uptake.- Mechanical Efficiency and Economy of Movement.- Anaerobic Characteristics.- Mechanical Power Output.- Underlying Biochemical Characteristics.- Anaerobic Threshold.- O2 Uptake Transients.- Metabolic “Specialization”.- Cardiovascular Response to Exercise.- Cardiac Output and Stroke Volume.- Heart Rate and Exercise.- Age.- Sex.- Adiposity.- Climatic Stress.- Emotional Stress and Habituation.- Active Muscle Mass.- Conditioning and Deconditioning.- Acclimatization to Heat.- Diseases.- Medication.- Body Position.- Muscle Blood Flow.- Arterial Blood Pressure.- Rhythmic Exercise.- Static Exercise.- Pulmonary Response to Exercise in Children.- Pulmonary Ventilation.- Respiratory Frequency and Tidal Volume.- Ventilatory Equivalent.- Alveolar Ventilation and Gas Exchange.- Vital Capacity and Exercise Performance.- Prolonged Activities.- Warm-up Effect.- Exercise Perception and Age.- Conditioning and Training.- Methodologic Constraints.- Principles of Physical Conditioning.- Specificity of Training.- Dosage of Conditioning.- Intensity.- Frequency.- Duration of Sessions.- Duration of the Program.- Conditioning Effect Related to Preconditioning Fitness.- Trainability of Muscle Power and Force in Childhood and Adolescence.- Maximal Aerobic Power.- Anaerobic Capacity.- Muscle Strength.- Physiologic Effect of Detraining and Deconditioning.- Conditioning and the Cardiovascular System.- Morphologic Changes.- Physiologic Changes.- Conditioning and the Pulmonary System.- Skeletal Muscle Adaptation to Conditioning.- Morphologic Changes.- Biochemical Changes.- Conditioning and Body Composition.- References.- 2 Children and Exercise in a Clinical Context― An Overview.- Habitual Activity and Disease.- Disease as a Direct and Indirect Cause of Hypoactivity.- “Non-Disease” as a Cause of Hypoactivity.- Assessment of Physical Activity.- Effects of Disease on Physical Working Capacity.- Hypoactivity―Detraining―Hypoactivity: The Vicious Circle.- Reduced Maximal Aerobic Power.- High Metabolic Cost of Exercise.- Exercise as a Diagnostic Tool in Pediatrics.- Exercise as Therapy in Pediatrics.- The Exercise Prescription (Case Studies).- Deleterious Effects of Exercise.- References.- 3 Pulmonary Diseases.- Bronchial Asthma.- Exercise-induced Bronchoconstriction (EIB).- Epidemiology.- EIB―Nature of the Exercise Provocation.- Type of Exercise.- Intensity of Exercise.- Duration of Exercise.- Time Since Previous Exercise.- Climatic Conditions and Asthma.- Climate and the Resting Asthmatic.- Climate and EIB.- Mechanisms Underlying EIB.- Possible Triggering Stimuli.- Airway Cooling as a Trigger.- Vagal Pathways vs. Chemical Mediators.- Other Responses of Asthmatics to Exercise.- Habitual Activity of the Asthmatic Child.- Physical Working Capacity of the Asthmatic Child.- Exercise as a Diagnostic Tool in Asthma.- Rationale for Exercise Provocation Tests.- Documentation of EIB.- Evaluation of Medication for EIB.- Diagnosis of Hyperreactive Airways.- Comparison of Asthmogenicity of Different Activities.- Determination of Exercise Tolerance.- Instilling Confidence in Patient and Parent.- Assessment of the Emotional Component.- The Exercise Challenge.- Pretest Preparation.- Withdrawal of Medication.- The Exercise Protocol.- Pulmonary Function Tests.- Interpretation of Post-exertional Bronchoconstriction.- Management of the Child with EIB.- Drug Therapy.- Prophylactic Therapy.- Reversal of EIB.- Nasal Breathing as Protection.- Artificial Means for Warming and Humidifying Inspired Air.- Choosing the Right Activities.- Physical Conditioning and the Asthmatic Child.- Conditioning and Improvement of Fitness.- Conditioning and EIB.- Cystic Fibrosis (CF).- Causes of Deficient Physical Working Capacity.- Exercise in Assessment of the Child.- Beneficial Effects of Conditioning.- Precautions to Be Taken During Exercise Programs.- Interstitial Lung Disease.- Pulmonary Tuberculosis.- References.- 4 Cardiovascular Diseases.- Aortic Stenosis (AS).- Physiologic Responses to Acute Exercise.- Hemodynamic Abnormality.- Myocardial Ischemia.- Physical Working Capacity.- Clinically Detrimental Effects of Acute Exercise.- Exercise as a Diagnostic Tool.- Evaluation Based on Hemodynamic Variables.- Systolic Arterial Blood Pressure.- Left Ventricular End-Diastolic Pressure and Stroke Volume.- Peak Left Ventricular Systolic Pressure.- Myocardial O2 Supply: Demand Ratio.- Evaluation Based on Electrocardiography.- Criteria for Successful Surgical Repair.- Permissible Activities.- Coarctation of the Aorta (CA).- Hemodynamic Abnormalities.- Exercise as a Diagnostic Tool.- Hemodynamic Response to Exercise.- Ischemic Changes During Exercise.- Congenital Complete Heart Block (CCHB).- Hemodynamic Response to Exercise.- Ventricular Dysrhythmia During Exercise.- Exercise-induced Syncope.- Physical Working Capacity.- Habitual Activity.- Exercise in the Assessment of CCHB.- Coronary Heart Disease.- Physical Exercise in Childhood: Does It Prevent Coronary Heart Disease?.- Hypertension (HT).- Hemodynamic Response to Rhythmic Exercise.- Hemodynamic Response to Static Exercise.- Physical Working Capacity and Habitual Activity.- Exercise in the Assessment of Juvenile HT.- Beneficial Effects of Chronic Exercise.- Is Exercise in Hypertension Detrimental to Health?.- Neurocirculatory Asthenia (NCA).- Response to Exercise and Physical Working Capacity.- Exercise as a Diagnostic Tool.- Beneficial Effects of Conditioning.- Pulmonary Stenosis (PS).- Hemodynamic Abnormalities in the Preoperative Child.- Hemodynamic Abnormalities Following Pulmonary Valvotomy.- Physical Working Capacity.- Exercise as a Diagnostic Tool.- Isoproterenol as a Substitute for Exercise Testing.- Septal Defect―Atrial (ASD).- Hemodynamic Response to Exercise.- Physical Working Capacity.- Exercise in the Assessment of the Child with ASD.- Septal Defect―Ventricular (VSD).- Hemodynamic Response to Exercise.- Physical Working Capacity.- Exercise in the Assessment of the Child with VSD.- Tetralogy of Fallot (TF).- Hemodynamic Characteristics―The Preoperative Child.- Respiratory Characteristics―The Preoperative Child.- Response to Exercise after Surgical Repair.- Habitual Activity.- Physical Working Capacity.- Exercise as a Diagnostic Tool.- Permissible Activities.- References.- 5 Endocrine Diseases.- Diabetes Mellitus.- Metabolic Response to Acute Exercise.- Blood Glucose Lowering Effect of Exercise.- Route and Site of Insulin Injection.- Insulin Binding to Receptors.- Exercise-induced Hyperglycemia.- Metabolic Response to Chronic Exercise.- Exercise and Insulin―The Synergistic Effect.- Exercise and Control of Diabetes.- Habitual Activity and Diabetes Mellitus.- Physical Working Capacity.- Exercise in Daily Management.- The Triad―Food, Insulin, Exercise.- Exercise Exchange Menu.- Growth Hormone (GH) Deficiency.- Using Exercise in the Diagnosis.- Rationale for Provocation Testing.- Provocation Tests at Rest.- Exercise as a Provocation Test.- Optimizing the Exercise Protocol.- References.- 6 Nutritional Diseases.- Anorexia Nervosa (AN).- Physical Working Capacity.- Exercise Perception.- Habitual Activity.- Malnutrition.- Growth and Exercise Performance.- Habitual Activity.- Effect of Conditioning.- Obesity.- Response to Acute Exercise.- Habitual Activity.- Adiposity, Activity, and Calorie Intake.- Is Hypoactivity a Cause of Childhood Obesity?.- Causes of Hypoactivity.- Physical Working Capacity.- Beneficial Effects of Conditioning.- Effectiveness of Conditioning as a Reducing Regimen.- Dietary Restriction vs. Exercise Therapy.- Exercise Therapy and Changes in Appetite.- Conditioning Effects Other than Fat Reduction.- Conditioning and Adipose Tissue Cellularity.- Lasting Effects of Conditioning.- Recommended Activities.- Effectiveness.- Feasibility.- Recreational Aspects.- References.- 7 Neuromuscular Diseases.- Cerebral Palsy (CP).- Physical Working Capacity.- Mechanical Efficiency and Economy of Movement.- Habitual Activity.- Exercise Testing.- In the Laboratory.- In the Field.- Conditioning.- The Physiologic Effect.- The Functional Effect.- Recommended Activities.- Epilepsy.- Fatigue.- Hyperventilation and Exercise.- Head Trauma.- Accidents to the Child and Others.- A Physician’s Dilemma.- Recommendations for Physical Activity.- McArdle’s Syndrome.- Progressive Muscular Dystrophy (PMD).- Exercise Limitations.- Muscle Strength.- Muscle Endurance.- Maximal Aerobic Power.- Habitual Activity.- Exercise in Management of the Child.- Scoliosis.- Functional and Physiologic Deficiencies.- Is Conditioning Beneficial?.- References.- 8 Hematologic Diseases.- Anemia.- Compensatory Mechanisms.- Physical Working Capacity.- Conditioning-Induced Iron Deficiency.- Hemoglobinuria―Exertional.- The Phenomenon.- Possible Mechanism.- Management.- Hemophilia.- Rationale for Conditioning.- Recommended Activities.- Risk of Bleeds and Their Prevention.- Sickle-cell Anemia.- Thalassemia Major.- References.- 9 Climate and the Exercising Child.- Some Concepts in Thermoregulation.- Heat Stress and Heat Strain.- Heat Production and Heat Exchange.- Physiologic and Behavioral Means of Thermoregulation.- Characteristics of Children Relevant to Thermoregulation.- Sweating Pattern.- Sweating Rate.- Heat-activated Sweat Glands.- Functional Implications.- Heat Tolerance.- What Is Heat Tolerance?.- Heat Tolerance―Children vs. Adults.- Cold Tolerance.- Acclimatization to Exercise in the Heat.- Heat Acclimatization―What and How?.- Acclimatization―Children vs. Adults.- Perceptual Changes with Acclimatization.- Fluid and Electrolyte Balance.- Water Shifts During Exercise.- Electrolyte Loss During Exercise.- Hypohydration.- Voluntary Dehydration.- Deliberate Dehydration.- Implications for Performance and Health.- Water and Electrolyte Replenishment.- Pediatric Health Hazards in Hot Climates.- Heat-related Illness.- Epidemiologie Studies on Children’s Health in Hot Climates.- Populations at High Risk for Heat-related Illness.- Anorexia Nervosa (AN).- Congenital Heart Disease (CHD).- Cystic Fibrosis (CF).- Diabetes Mellitus or Insipidus.- Diarrhea and Vomiting.- Excessive Eagerness.- Fever.- Hypohydration.- Insufficient Acclimatization.- Insufficient Conditioning.- Malnutrition.- Mental Deficiency.- Obesity.- Prior Heat-related Illness.- Sweating Insufficiency Syndromes.- Guidelines for Conduct of Athletic Events in the Heat.- References.- Appendix I “Norms”.- References.- Peak Mechanical Power.- Endurance Time―Bruce Treadmill.- Power at Heart Rate of 170.- Distance Traveled― 12-Min Run-Walk.- Anaerobic Capacity.- Peak Anaerobic Power.- Appendix II Procedures for Exercise Testing in Children.- Choice of Ergometer.- The Exercise Protocol.- Prototypes of Exercise Tests.- Examples of Exercise Protocols.- The Bruce All-Out Progressive Continuous Treadmill Test.- The McMaster All-Out Progressive Continuous Cycling Test.- The McMaster All-Out Progressive Continuous Arm Test.- The Cumming Ail-Out Progressive Intermittent Cycling Test.- The Adams Submaximal Progressive Continuous Cycling Test.- The Hanne Submaximal Progressive Intermittent Step Test.- The Wingate Anaerobic Cycling Test.- Measurements Taken During Exercise Tests.- Heart Rate.- Ventilation.- Systemic Arterial Blood Pressure.- Electrocardiogram (ECG).- Skin Preparation.- Choice of Electrodes.- Choice of Leads.- Indications for Exercise ECG.- Exercise-induced Electrocardiographic Changes.- Exercise ECG Test vs. Long-term ECG Monitoring.- Cardiac Output.- Rating of Perceived Exertion (RPE).- Determination of Maximal Aerobic Power.- Direct Determination.- Indirect Determination―Submaximal Tests.- Indirect Determination―All-Out Tests.- Safety Precautions.- Personnel.- Contraindications for Exercise Testing.- Termination of An Exercise Test.- References.- Appendix III Activity Questionnaire.- Appendix IV Calorie Equivalents.- Appendix V Glossary of Terms.