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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

teri metcalf mccambridge
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.
case i
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?
appropriate age to begin strength training
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

is it efficacious why the controversy
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

deficiencies of early research
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
recent research demonstrates significant gains
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
mechanism of strength gains
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

current aap policy statement
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.”
is it safe why the concern
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
problems with using this data to determine safety
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
is it safer than some sports
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

recent literature cpsc neiss accidental weight training injuries
Recent literature: CPSC NEISSAccidental weight training Injuries

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

considered safe
Considered Safe:
  • Proper Equipment
  • Proper Form
  • Proper Supervision
    • Certified or Trained individual
    • Ratio of Adult to Student (1:10)
health risks stunted growth
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
case 1
  • Can the 9 year old begin a strength training program?
    • What’s the reason?
    • Is there supervision?
    • Is it necessary?
    • Is it appropriate?
case 2
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?
strength training resistance training
Strength Training/ Resistance training
  • “Specialized method of physical conditioning that is used to increase one’s ability to exert or resist force”
  • Free weights
  • Weight Machines
    • Weight plates
    • Hydraulics
  • Bands/Balls
  • Body weight
  • Kettle balls
other forms
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
plyometrics stretch shortening cycle
Plyometrics (Stretch-Shortening Cycle)
  • Safe and worthwhile method of conditioning
  • Typically includes hops or jumps
  • Cautious of too many repetitions
is olympic weightlifting safe
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

the aap s policy 2008
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?
what s really happening
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

severe injuries associated with improper olympic lifting
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
case 230
  • What’s the difference between strength training and competitive weightlifting?
  • Why the distinction when recommending children’s participation?
case 3
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?
injury prevention with strength training
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?

benefits anaerobic power
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

sports performance
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

strength training and detraining
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

case 336
  • 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
case 4
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?
athletes requiring clearance prior to participation
Athletes requiring clearance prior to participation
  • Uncontrolled severe hypertension
  • Previous treatment with anthracycline chemotherapeutic agents
  • Uncontrolled seizure disorder
  • Underlying neuromuscular disorder (Cerebral Palsy, etc.)
cardiology consultation recommended if history of
Cardiology consultation recommended if history of:
  • Hypertrophic Cardiomyopathy
  • Moderate-Severe pulmonary hypertension
  • Uncontrolled Hypertension
  • Marfan’s Syndrome with a dilated aorta
aortic root dilatation in elite strength trained athletes
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

past medical history childhood leukemia oncology
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.

case 442
  • Usual preparticipation guidelines exist
  • Be aware of new recommendations, such as for young cancer survivors
case 5
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
initiating a weight training program
Initiating a Weight Training Program






Guidelines have been established by


general recommendations program
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

examples of exercises to incorporate into a beginning program
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
means of progressing a program
Means of progressing a program
  • Increase the resistance
    • Generally 5-10% increase in training load
  • Increase repetitions
  • Increase number of sets
recommendations for parents evaluating a program
Recommendations for Parents evaluating a 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
special recommendations for youth strength training
Special Recommendations forYouth 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
evaluating strength training credentials
Evaluating Strength Training Credentials
  • 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?
what credentials are recommended for strength and conditioning specialists
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
national programs for youth strength training
National programs for youth strength training?
  • Velocity sports performance
  • Competitive Athletic Training Zone (CATZ)
case 6
Case 6:
  • 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
benefits particular benefit for the overweight child
Benefits: Particular benefit for the overweight child?
  • Cardiovascular fitness
  • Body composition
  • Bone mineral density
  • Blood lipid profile
  • Mental Health
    • Anxiety
    • Self-concept
benefits cerebral palsy
Benefits: Cerebral Palsy
  • 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

benefits bone mineral density prevention of osteoporosis
Benefits: Bone mineral densityPrevention 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

why are kids strength training
Why Are Kids Strength Training?
  • Fun?
  • Improve Performance?
  • Parental Pressures?
  • Will they burn out?
  • Should they be spending more time “playing” sports?
aap recommendations prevention overuse and burnout
AAP Recommendations: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
food for thought
Food for Thought!
  • 0.2-0.5 % of high school athletes ever make it to the professionals.
  • Variety is the spice of life
  • 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.