Guidance for Strength Training in the Pre-adolescent
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Guidance for Strength Training in the Pre-adolescent A Case Based approach in the pediatrician’s office. Teri McCambridge, MD, FAAP Assistant Professor of Pediatrics Johns Hopkins School of Medicine. Teri Metcalf McCambridge.

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Guidance for Strength Training in the Pre-adolescentA Case Based approach in the pediatrician’s office

Teri McCambridge, MD, FAAP

Assistant Professor of Pediatrics

Johns Hopkins School of Medicine

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Teri Metcalf McCambridge

  • A. I have no relevant financial relationships with the manufacturer's) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

  • B. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

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Case I:

  • 9 year old male football player wants to begin a strength training program, but his mom has heard he will not demonstrate increases in strength until puberty and that it is dangerous.

  • What do you advise?

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Appropriate age to begin strength training?

  • Attained the ability to follow rules

  • Achieve balance and

    postural control (age 7-8)

  • Proficiency in their sport

  • Common sense

  • Lack of androgenic hormones?

  • Whose idea?

  • What’s the motive?

Richard Santrak

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Is it efficacious?Why the controversy?

  • Initial Studies revealed:

    • No increase in muscle strength

    • No increase in muscle cross-sectional area

  • 1983 AAP Statement

    Committee on Sports Medicine

    “Pre-pubescent boys (tanner stage 1-2) demonstrate no significant increase in strength or muscle mass because of lack of androgens”

Vrijens J Med Sport 1978; 11:152-158

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Deficiencies of early research

  • Children naturally increase strength as they grow and mature, must have adequate controls

  • Studies were short duration

  • Studies evaluated low intensity training volumes

    (Sets x repetitions x load)

  • Overall inadequate studies

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Recent Research Demonstrates Significant Gains:

  • Sewall, L, Micheli LJ: J Pediatric Orthop 1986;6:143-146

  • Weltman A, et al. Med Sci Sports Exerc 1986; 18:629-638

  • Faigenbaum, AD, et al. Pediatr Exerc Sci. 1993; 5:339-46.

  • Faigenbaum, AD,. et al. J Strength and Cond Res 1996; 10(2):109-114

  • Falk B, et al. Sports Med.1996;22(3):176-186

  • Faigenbaum AD J Strength Cond Res 2001;15:459-465.

  • Strength gains between 36%-74.3%

  • No effect on flexibility

  • No effect on vertical jump

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Mechanism of Strength Gains?

  • Not Muscle Hypertrophy

    • As measured by CT scanning

  • Occurs in boys and girls equally

  • Strength gains dependent

    on increased motor unit:

    • Activation/recruitment

    • Coordination

    • Firing

  • 8 weeks required

Ozmun, J Mikesky A. Med Sci Sports Exerc 1994;26:510-514

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Current AAP Policy Statement:

  • 2001-”Studies have shown that strength training, when properly structured with regard to freq, mode, intensity, and duration increases in strength in pre-adolescents without muscle hypertrophy”

  • 2008-”Agree with above and Olympic weight lifting may be safe in closely supervised settings but more research is needed to recommend.”

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Is it Safe?Why the concern?

  • Initial NEISS reports

    • 1979 half of 35, 512 weight lifting injuries involved 10-19 year olds

    • 1987 report revealed 8590 children 14 and under were treated in emergency department with weight lifting injuries

    • 1991-1996 20k-26k equipment associated injuries occurring annually

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Problems with using this data to determine safety:

  • Does not distinguish between resistance training and competitive weight lifting

  • Information is based on patient report of injury

  • Does not distinguish between supervised and unsupervised injuries

  • Does not report if weights were utilized properly

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Is it Safer than some Sports?

  • Study by Hamill suggests strength training is safer than participation in:

    • Soccer

    • Basketball

    • Football

    • General play

Hamill B. J Strength Cond Res 1994;8:53-57

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Recent literature: CPSC NEISSAccidental weight training Injuries

Myer GD. J Strength Cond Res 2009; 23(7) 2054:2060

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Considered Safe:

  • Proper Equipment

  • Proper Form

  • Proper Supervision

    • Certified or Trained individual

    • Ratio of Adult to Student (1:10)

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Health Risks--Stunted Growth?

  • Concerns

    • Arouse out of studies in Japan

    • Children performing heavy labor

    • Resulted in “stunted growth”

    • Nutritional deficiencies or labor?

  • Data of well controlled/designed studies no effect on growth or epiphyseal plates

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  • Can the 9 year old begin a strength training program?

    • What’s the reason?

    • Is there supervision?

    • Is it necessary?

    • Is it appropriate?

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Case 2:

  • 14 year old tanner Stage 3 male basketball player wants to begin the “clean and jerk” and “snatch”

  • What is your opinion of these lifts?

  • Should this be a bigger concern?

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Strength Training/ Resistance training

  • “Specialized method of physical conditioning that is used to increase one’s ability to exert or resist force”

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  • Free weights

  • Weight Machines

    • Weight plates

    • Hydraulics

  • Bands/Balls

  • Body weight

  • Kettle balls

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Other Forms:

  • Brief Discussion:

    • Competitive Weightlifting (Olympic)

      • Competitive sport that involves maximum lifting ability

      • Lifts: Snatch and Clean and Jerk

  • Minimal Discussion

    • Power Lifting

      • Competitive sport involving maximum lifts

      • Dead lift, squats, and bench press

    • Body Building

      • Competition that judges muscle size definition, and symmetry

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Plyometrics (Stretch-Shortening Cycle)

  • Safe and worthwhile method of conditioning

  • Typically includes hops or jumps

  • Cautious of too many repetitions

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Is Olympic Weightlifting Safe?

  • Data suggests safety in well supervised settings

  • Study at the USA Weightlifting Development Center

Byrd R, Pierce K, et al. Sports Biomech 2003;Jan 2(1): 133-40

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The AAP’S Policy (2008)

  • Safe in Well controlled studies, emphasizing proper technique

  • Do not yet recommend for general population

  • Concerns regarding improper technique and injury risk

  • Impetus for childhood involvement?

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What’s Really Happening

  • Survey of HS S&C coaches

  • 38 of 128 Responded

  • 37 of 38 use Olympic –Style lifting

Duehring MD, J Strength Cond Res 2009; 23(8)2188-2203

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Severe Injuries associated with improper Olympic lifting

  • Bilateral Distal Radial and Ulnar Fractures

  • Disc Herniation

  • Spondylolysis and Spondylolisthesis

  • ASIS pelvic avulsion fracture

  • Scaphoid fracture

  • Death

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  • What’s the difference between strength training and competitive weightlifting?

  • Why the distinction when recommending children’s participation?

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Case 3:

  • A 12 year old female soccer players’ parents wants to know if strength training can:

    • Prevent an ACL tear?

    • Improve sports performance in the pre-adolescent?

    • Provide permanent strength gains once a program is completed?

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Injury Prevention with Strength Training?

  • Less Shoulder pain in Adolescent Swimmers

    Dominquez, Swimming Medicine IV 1978: 105-109

  • Decreased incidence and severity of knee injury with preseason training

    Cahill B, Griffith E. Am J Sport Med 1978; 6:180-184

  • ACL prevention with Plyometric jump training program

    Hewett, TE, et al. Am J Sport Med 1999; 27:699

More Evidence to follow?

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Benefits? Anaerobic Power?

  • 30 Prepubescent male athletes

  • 12 week strength training with free weights and machines. 3x/week

  • Outcome variables: vertical jump, 40 yd dash, and Wingate test

  • Results: Vertical jump improved, but no other measures of anaerobic power

Hetzler, RK, Coop D, et al. J Strength Cond. Res. 1997; 11(3):174-181

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Sports Performance?

  • Inconclusive evidence

    • Evidence for improved

      • vertical jump

      • long jump

      • sprint speed

      • Medicine ball toss

    • Translation into improved performance is inconclusive

    • Limited evidence improvement

Hoffman JR (football) J strength Cond Res 2005; 19(4):810-815

Faigenbaum A. Phys Edu 2006; 63: 160-67.

Christou M. (soccer) J Strength Cond Res 2006 20(4), 783-791

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Strength Training and Detraining

  • Recommend Frequency in children

    2x/week training

  • Detraining

    • Loss of strength about 3% week

    • Despite athletic participation

Faigenbaum AD, et al. Res Quarterly Exercise Sport, 2002; 73(4): 416-424.

Faigenbaum, AD, et al. J Strength and Cond Res 1996; 10(2):109-114

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  • Strength training is not the “end-all-be-all” for sports

  • Just one component of various training methods

  • “Prehabilitation” strengthening may have some promise

  • Performance benefit lacking at this time

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Case 4

  • A 15 year old, with a past medical history of Childhood leukemia, wants to begin a strength training program—Is there any evaluation required prior to participation?

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Athletes requiring clearance prior to participation

  • Uncontrolled severe hypertension

  • Previous treatment with anthracycline chemotherapeutic agents

  • Uncontrolled seizure disorder

  • Underlying neuromuscular disorder (Cerebral Palsy, etc.)

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Cardiology consultation recommended if history of:

  • Hypertrophic Cardiomyopathy

  • Moderate-Severe pulmonary hypertension

  • Uncontrolled Hypertension

  • Marfan’s Syndrome with a dilated aorta

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Aortic Root dilatation in Elite Strength Trained athletes

  • 100 Elite Strength trained athletes

    • Age mean 22.1 + 3.6 years

  • 128 healthy age and height matched control

  • Results Aortic root diameters were significantly greater in all 4 locations of measurement, with progressive enlargement noted based on duration of high intensity lifting.

Am J Cardiology 2007: 100:528-530

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Past Medical History:Childhood Leukemia/Oncology

  • Patient’s treated with high dose (500 mg/M2)anthracycline therapy are at risk for acute cardiac decompensation with initiation of weight training

  • Cardiology/Oncology input required prior to program initiation

Steinherz, Laurel, et al. Cardiac Toxicity 4 to 20 years after completing anthracycline therapy

Jama 1991; 266 (12): 1672-1677.

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  • Usual preparticipation guidelines exist

  • Be aware of new recommendations, such as for young cancer survivors

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Case 5.

  • The parents of a 14 year old want to enroll their child in a strength training program. They bring in a list of questions including:

    • Guidance on a proper strength training program

    • How to evaluate a personal trainer’s credentials

    • List of respected sports training facility in your area

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Initiating a Weight Training Program






Guidelines have been established by


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General Recommendations(program)

  • 10 minutes dynamic warm-up and cool down

  • Program should include 1-3 sets of 6-15 reps of 6-8 exercises

  • Include all muscle groups and a full ROM at each joint

  • Focus on technique and proper form

  • Recommend 2-3 non-consecutive training sessions/wk for 20-30 min

  • Increase resistance gradually

  • Program varied over time


Faigenbaum AD. Clinics in Sport Med; 19 (4): 2000

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Examples of exercises to incorporate into a beginning program

  • Single joint

    • Leg extension

  • Multi-joint

    • Squats

  • Plyometrics

    • Squat jumps, medicine ball chest passes

  • Core strengthening

    • Sit-ups, back extensions

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Means of progressing a program program

  • Increase the resistance

    • Generally 5-10% increase in training load

  • Increase repetitions

  • Increase number of sets

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Recommendations for Parents evaluating a program program

  • Qualifications of Instructor

  • Student : Teacher ratio

  • Modes of strength training that will be utilized

    • Evaluate weight stack increments (1-5 pounds in children)

    • Weight machine sizes

    • Will 1 weight rep max be used

    • Performance of Olympic or power lifts

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Special Recommendations for programYouth Strength training

  • Consider decreasing training volume and intensity during rapid growth

  • Emphasize flexibility

  • Stress importance of proper lifting techniques not amount of weight lifted

    • Controlled movements

    • Proper breathing

  • Recommend against competitive weight lifting, power lifting, and body building until skeletally mature

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Evaluating Strength Training Credentials program

  • Is the program NCCA certified?

  • Do they require re-certification and CEU’S?

  • Are there minimum requirements?

  • Is the exam proctored and does it have a practicum?

  • How long have they been certified?

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What Credentials are recommended for Strength and Conditioning Specialists?

  • National Strength and Conditioning Association

    • CSCS

    • NSCA-CPT

  • American Council on Exercise

  • American College of Sports Medicine (ACSM)

    • ACSM Health Fitness Instructor

    • ACSM Exercise Specialist

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National programs for youth strength training? Conditioning Specialists?

  • Velocity sports performance


  • Competitive Athletic Training Zone (CATZ)


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Case 6: Conditioning Specialists?

  • Are there special patient populations in your practice that could benefit from a strength training exercise prescription?

    • Overweight or “At Risk” for overweight patients

    • Cerebral Palsy

    • Osteoporosis or Osteopenia

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Benefits: Particular benefit for the overweight child? Conditioning Specialists?

  • Cardiovascular fitness

  • Body composition

  • Bone mineral density

  • Blood lipid profile

  • Mental Health

    • Anxiety

    • Self-concept

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Benefits: Cerebral Palsy Conditioning Specialists?

  • Increased strength

  • Improved overall function

  • Improved Mental Well-being

Blundell S. Clin Rehab 2003;17: 48-57

McBurney H. Dev Med Child Neuro 2003; 45:658-663

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Benefits: Bone mineral density Conditioning Specialists?Prevention of Osteoporosis

  • Adolescent bone is responsive to the osteogenic stimulus of heavy resistance training

  • Bone density of junior Olympic weight lifters was greater than age matched controls and normal adult bone density

Conroy BP. Med Sci Sport

Exerc. 1993;25:1103-9

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Why Are Kids Strength Training? Conditioning Specialists?

  • Fun?

  • Improve Performance?

  • Parental Pressures?

  • Will they burn out?

  • Should they be spending more time “playing” sports?

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AAP Recommendations: Conditioning Specialists?Prevention Overuse and Burnout

  • Limit activity to 1 sporting activity a maximum of 5 days a week.

  • One day off from any organized physical activity per week

  • 2 to 3 months off per year from their sport

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Food for Thought! Conditioning Specialists?

  • 0.2-0.5 % of high school athletes ever make it to the professionals.

  • Variety is the spice of life

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References: Conditioning Specialists?

  • AAP COSMF Policy Statement. Strength training by Children and Adolescents Pediatrics 2008 121(4):835-40.

  • AAP Overuse Injuries, Overtraining, and burnout in Child and Adolescent Athletes. Pediatrics 2007; 119(6):1242-1245.

  • Youth Resistance Training: Position Statement Paper and Literature Review. J Strength Cond Res 2009 23(4):1-20.

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Thank you! Conditioning Specialists?