4/19/2016
Learning Objectives
1.
Pediatric Weight Management
Susan Jacobsen, MPH, PT
University of Minnesota Masonic Children’s Hospital
[email protected]
Assistance from Nicole Hybben, PT, DPT; Sara Dooley, PT; Norrie McKnight, PT,
DPT
2.
3.
4.
5.
6.
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8.
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11.
12.
Define childhood obesity and the differences between the overweight , obese and severely
obese
Overview on prevalence of childhood obesity
Etiology of childhood obesity
Identify co-morbidities of childhood obesity and common lab values
Describe the important components in the Pediatric Weight Management Physical Therapy
Evaluation for this population
Describe standardized tests useful in this population
Describe the literature support for this patient’s population for gross motor/functional
performance impairments
Common PT diagnoses utilized and clinical impression comments to indicate need for
service
Use of motivational interviewing to assist in goal setting
Physical therapy treatment and research support
Identify community resources
Identify clinics, their providers and roles within the University of Minnesota Health System
Definitions16
• Overweight: refers to excess body weight
• Obese: refers to excess of fat
• Body Mass Index(BMI): provides a guideline
for weight in relation to height
CHILDHOOD OBESITY DEFINED
– Body Weight (kilograms)/Height (meters)2
– Accepted standard to measure overweight and
obese in children greater than or equal to 2 years
of age
– Separate growth charts for boys and girls
BMI Categories16
• Underweight – BMI <5th percentile for age and
sex
• Normal weight – BMI between the 5th and 84th
percentile for age and sex
• Overweight – BMI between the 85th and 95th
percentile for age and sex
• Obese – BMI ≥95th percentile for age and sex
• Severe obesity – BMI ≥120 percent of the 95th
percentile values, or a BMI ≥35 kg/m2 (about the
99th percentile)
CHILDHOOD OBESITY PREVALENCE
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Prevalence5,16
• Nearly 1/3 of all children in the US are
overweight or obese.
– Overweight or obese (BMI ≥85th percentile)
• 26.7 percent of preschool children (2 to 5 years)
32.6 percent of school-aged children (6 to 11 years)
33.6 percent of adolescents (12 to 19 years)
• According to the Center for Disease Control,
17% of all children aged 2 – 19 years are
obese; this has almost tripled since the 1980s.
Environmental Factors16
•
•
•
Sedentary lifestyle
High sugar sweetened beverages
Screen time
–
•
•
ETIOLOGY OF CHILDHOOD OBESITY
•
•
•
•
Television viewing at ≥5 years was
independently associated with increased
BMI at age 26 to 30 years in 2 longitudinal
cohort studies
Large portions of food
Decreased family presence at meal
times
Fast food frequency
Availability of safe and structured
places to do activity (playgrounds,
sidewalks)
Low income household
Sleep patterns
Genetic Factors16, 22
•
Race
–
more common in American Indian, nonHispanic blacks, and Mexican Americans
than in non-Hispanic whites
•
Obese parent
•
Metabolic programming
–
–
•
Increases child’s risk by 2-3 times
Increasing evidence linking environmental
and nutritional influences during critical
developmental periods
Genetic or endocrine syndromes
–
–
–
–
Account for <1% of the obese population
Prader-Willi Syndrome
Cushing’s Syndrome
Hypothyroidism
COMORBIDITIES AND ASSOCIATED
LAB VALUES
6
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Cardiovascular Related17
• Hypertension
– Normal BP – Both systolic and diastolic BP <90th percentile.
– Prehypertension – Systolic and/or diastolic BP ≥90th percentile but
<95th percentile, or if in adolescents the BP exceeds 120/80 mmHg
even if <90th percentile.
– Hypertension –systolic and/or diastolic BP ≥95th percentile measured
on three or more occasions. The degree of HTN is further delineated
by the two following stages:
• Stage 1 hypertension – Systolic and/or diastolic BP between the 95th
percentile and 5 mmHg above the 99th percentile or if in adolescents the
BP exceeds 140/90 mmHg even <95th percentile.
• Stage 2 hypertension – Systolic and/or diastolic BP ≥99th percentile plus 5
mmHg.
9
Pulmonary Related15
Cardiovascular contd.17, 28
• Dyslipidemia
– Occurs in those children and adolescents typically with central fat distribution
and increased adiposity (measured by triceps skin fold thickness >85%ile)
– Fasting Lipid Panel Abnormal Results for children and adolescents
•
•
•
•
Low density lipoprotein cholesterol (LDL-C) ≥ 110
High density lipoprotein cholesterol (HDL-C) < 45
Triglycerides 0-9 years > 75
Triglycerides 10-19 years > 90
• Cardiac Structure and Function
• Obstructive sleep apnea
– Diagnosed via a sleep study
– “complete obstruction of the upper airway during sleep and cessation of air
movement despite ongoing respiratory effort”
• Exercise intolerance
– In combination with cardiovascular related effects of childhood obesity
– Symptoms can include shortness of breath, dizziness, light headedness,
nausea, chest pain or tightness, heart palpitations
– Obesity has been shown to be associated with increased left ventricular mass,
increased left atrial and left ventricular diameter, greater epicardial fat, and
systolic and diastolic dysfunction.
– Growing evidence for link between childhood obesity and adult coronary
artery disease.
Gastrointestinal Related3,16
•
•
Non-alcoholic fatty liver disease
– Pathogenesis not fully understood, but support for strong association of obesity
and insulin resistance
– Highest rate in Hispanic male adolescents
– Laboratory diagnosis with elevated ALT and AST (liver transaminases)
– Common symptoms, though can be asymptomatic:
• right upper quadrant pain, hepatomegaly or nonspecific abdominal
discomfort, weakness, fatigue or malaise
– Weight loss through diet and aerobic exercise is currently the mainstay of
treatment with positive results published
Cholelithiasis (gall stones)
– Increased risk with increasing BMI and girls>boys
– Common symptoms:
• Right upper quadrant pain, epigastric pain, jaundice, nausea, intolerance to
fatty foods, vomiting
– Early recognition is important for successful management
Endocrine Related27
• Impaired glucose tolerance and insulin resistance
– Approximately 40% of children and adolescents with
Diabetes Mellitus Type 2 (T2DM) are asymptomatic.
• Symptoms of hyperglycemia: polydipsia, polyuria, nocturia
• American Diabetes Association has guidelines on when to screen
based on risk factors (see next slide)
– Pre-Diabetes:
• Fasting plasma glucose 100-125mg/dL
• Hemoglobin A1C (HbA1C) 5.7-6.4 percent
– T2DM
• Fasting plasma glucose ≥ 126mg/dL on 2 separate occasions
• Hemoglobin A1C (HbA1C) ≥ 6.5 percent on 2 separate occasions
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Musculoskeletal Co-Morbidities11,29,30
•
Increased fracture risk
– Proposed mechanisms
• Inactivity leading to decreased proprioception and poor balance
• Childhood obesity has been linked with a lower relative bone mass and reduced area
when corrected for the effects of age and size during maturation
•
Blount Disease or Tibia Varum
– Abnormal growth from the medial part of the proximal tibia thought to be due to
excessive compressive forces on the medial compartment of the knee causing
growth inhibition
• Infantile or adolescent onset
» Infantile onset between 2 and 4 years of age
» More common in African American race
• Associated with increased weight and severe obesity; though in a low percentage of the
population so proposed mechanism of cause likely is not the only present
• Bracing or surgery recommended once diagnosed; as deformity will continue to worsen
Musculoskeletal Co-Morbidities
Contd11, 29, 30
• Slipped Capital Femoral Epiphysis (SCFE)
– Proximal femoral metaphysis separates from the epiphysis of the femoral head
– Typically between 11 and 15 years of age during largest growth
– Diagnosed via x-ray after patient complains of chronic hip, knee or thigh pain
– Insidious onset of pain
– Childhood obesity creates a favorable environment for SCFE
• Decreased femoral anteversion in obese children compared to normal weight
children, which increases the shear component on the capital femoral growth plate
PHYSICAL THERAPY EVALUATION
• Joint pain
• Lower extremity mal-alignment
– I.E. Genu valgum, genu varum, pes planus
Subjective
• Medical History
– Note any above comorbidities
• Patient/Family Goals
• Exercise History
– Include if has gym memberships or if anyone else in the house gets regular
exercise, past success or failures, gym at school, organized sports, frequent
falls
Physiological Measurements
Vital Signs
•
•
•
Listed under Cardiopulmonary section
of evaluation
Resting Heart Rate
Resting Blood Pressure
–
• Barriers to Exercise
– Examples: Time, lack of access to safe areas, motivation (internal and
external), knowledge of what to do, fatigue(overly tired during the day)
• Hours of screen time
• Other:
– Likes and dislikes of activity
•
•
A percentile will be listed for both systolic
and diastolic based on their age in their
MD note from Pediatric Weight
Management Clinic
Resting Oxygen Saturations
Rating of Perceived Exertion with
activity
–
–
0-10
Borg’s Scale 6-20
Body Composition Measures
• BMI
– Weight
(kilograms)/height(meters)2
• Waist Circumference20
– Measured at the level of the
iliac crest going from right to
left, in standing, tape parallel to
the floor
• Not recommended BMI>35 as
it loses it’s predictive power to
predict disease risk
• No identified norms for
children/adolescents
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Normal Ranges for Vitals
Physiological Measurements Cont.…
• Pain
Age
Heart Rate
(beats/min)
– Joint(s)
Blood Pressure (mm Respiratory Rate
Hg)
(breaths/min)
– Onset
– Duration
1-3 yr
70-110
90-105/55-70
20-30
3-6 yr
65-110
95-110/60-75
20-25
6-12 yr
60-95
100-120/60-75
14/22
12 * yr
55-85
110-135/65-85
12-18
– Exacerbating conditions
– Relieving conditions
• Pain in childhood obesity 11,29,30
• Back and knee pain are the most common reported in children overweight and
obese
• Pain is likely due to chronic poor musculoskeletal alignment and/or poor posture
combined with muscle weakness, hyper mobility and/or hypo mobility and
inactivity
2, 32
• Since SCFE has insidious onset of hip, knee or thigh pain; may benefit from x-ray to
rule out as differential diagnosis
Postural Assessment11,29,30
• Note any postural impairments and joint misalignments
– Genu Valgum
Strength Assessment
•
Manual muscle testing
•
Gross strength through functional movements
• Increasing research connecting obesity and genu valgum
• Theory thought to be due to increased weight causing compression at the lateral
distal femoral physis leading to diminished lateral growth and progressive deformity
–
Squat to stand
–
30 second sit-stand test
• Comment on knee control, range able to move through and any need for assistance
• Count the number of times the patient is able to move from a sitting to standing position
– Pes planus or flat feet
• Useful when patient is unable to do a sit-up or push-up
• Limited research in this area
• Largely utilizing indirect measures of the medial longitudinal arch via footprints
(electronic and ink) which can be distorted with increased adiposity vs a true
collapse of the medial longitudinal arch
• Some research supporting increased dynamic peak pressures under the forefoot
and mid-foot of obese children placing them at risk for foot pathology in the future
–
30 second push-up test
• Count the number of times able to perform a full or knee-push-up in 30 seconds
– Comment if unable to use correct posture indicated in Bruininks-Oseretsky
Test of Motor Proficiency – 2nd Edition
–
30 second sit-up test
– Other postural impairments typically seen:
•
•
•
•
• Count the number of times able to perform a sit-up in 30 seconds
– Comment if unable to use correct posture indicated in Bruininks-Oseretsky
Test of Motor Proficiency – 2nd Edition
Forward head
Rounded shoulders
Knee hyperextension
Increased anterior pelvic tilt in static stance
–
• Measure distance in inches
Balance Assessment
Cardiopulmonary Assessment
•
• Single limb stance
• Rhomberg test
• Lower extremity functional reach test:
– Useful when patient has a painful or injured limb
– Measure leg length from greater trochanter to lateral malleoli
– Reach one leg forward, lateral and back as far as possible without
touching ground, repeat on other leg
• Divide farthest length by leg length and get a percentage of leg length
– Anterior Reach: Normal: ≥ 80% leg length, Good: 70-79%, Fair: 65-69%, Poor: <65%
– Lateral Reach: Normal ≥ 100% leg length, Good: 90-99%, Fair: 80-89%, Poor <80%
– Posterior Reach: Normal ≥ 110%, Good: 95-109%, Fair: 94-85%, Poor: <85%
Standing long jump (2 foot take off and landing)
2 and 6 minute walk test
– Distance
– Monitor HR throughout
– No norms available, however Geiger
et al10 has the largest group assessed
using a “modified 6- minute walk
test” where the individual will push
the measuring wheel
Modified 6MWT Distance in Children
(Geiger et al)
Age
Male (meters)
Female (meters)
3-5 yrs
536.5 (95.6)
501.9 (90.2)
6-8 yrs
577.8 (56.1)
573.2 (69.2)
9-11 yrs
672.8 (61.6)
661.9 (56.7)
12-15 yrs
697.8 (74.7)
663.0 (50.8)
16-18 yrs
725.8 (61.2)
664.3 (49.5)
• Modified Energy Expenditure
Index (Modified EEI) (Haley et al)
– HR recorded at the end of
walking 3 minutes in a 50 meter
course, which is called “Working
Heart Rate” (WHR)
– WHR/(Distance (meters)/3min)
– Ages 5-16 and >16 (N=150)
– This is nice for youth that cannot
tolerate a full 6 minute walk test
– Adds additional information for
youth that complete a full 6
minute walk test
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Gross Motor and Functional Skill
Assessment
• Transfers
• Floor to/from standing through ½ kneel
Other Functional Outcome Measures
• Timed Up and Down
Stairs (Zaino et al)
– 14 steps
– Ages 8-14; Average 8.1
seconds or 0.58
seconds/step
– Comment on knee control and any need for assistance
• Gait
• Running
– Comment on time from 50 meter shuttle run if completed during BOT2 testing
– Alternative: 30 foot shuttle run (Haley et al)
• Ages 5-21
• Run between start and finish x 2 to retrieve 2 blocks
• Timed Up and Go (Zaino
et al)
– 3 meters (9ft 10in)
– Ages 8-14, Average 5.2
seconds
• Stairs
• Jumping/Hopping
Standardized Tests
• Peabody Developmental Motor Scales – 2
(PDMS-2)
Peabody
•
BOT-2
– Children ≤ 5 years of age with suspected gross motor delay or weakness in trunk or legs
– Children over 5 years of age with suspected gross motor delay or weakness in trunk or legs
– Strength and Agility Composite most often utilized
– Later in plan of care after an improvement in skills that allows actual performance of the
measure
•
– Up to developmental age of 7 year old
6-Minute Walk test
– Suspected exercise intolerance
– Inability to complete BOT-2 or Peabody due to low level of skill
– Later in plan of care after pain is addressed to work towards a healthy level of aerobic activity
without pain
– Ages 4-21
• Pediatric Evaluation of Disability Inventory
(PEDI)
– Start seated in tailor sit
on floor, then ask child
to get up from the floor,
walk 3 meters, turn
around and walk back to
sit down where started
in tailor sit.
– Ages 5-22 (N=150)
When to Use What Measure
•
– Ages Birth – 5 years
• Bruininks-Oseretsky Test of Motor Proficiency,
2nd Edition (BOT-2)
• Timed Floor to Stand
(Haley et al)
•
Modified Energy Expenditure Index
•
Other functional outcome measures
– Suspected exercise intolerance
– Short attention span or very poor endurance of patient
– As clinically indicated
– I.E. difficulty with floor to stand, decreased walking pace
Recommendations on Re-Assessment
• Developmental tests
– When clinically indicated to show progress
– Minimum of every 6 months
• 6-Minute and Modified Energy Expenditure Index
– When clinically indicated to show progress
– Minimum of every 3 months to monitor progress
• Other functional outcome measures
– When clinically indicated to show progress
– Minimum of once a month; but could be every week
RESEARCH ON GROSS MOTOR AND
FUNCTIONAL IMPAIRMENTS IN
CHILDHOOD OBESITY
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Functional Mobility Related23
• In 2006 Riddiford-Harland et al reported on the effects of obesity
on upper and lower limb functional strength and power in children
– 2 groups of 43 children each, average age of 8 y
• Categorized as obese (BMI average 24) and non-obese (BMI average 16)
– Obese children displayed significantly greater upper body strength
through push and pull compared to non-obese group (p<0.05)
– Obese children had significantly impaired vertical jump, and standing
long jump compared to non-obese group (p<0.05)
– Obese children spend significantly more time during all transfer
phases of the chair rising task
• Many had to perform a rocking motion backwards before transitioning to
standing
Gait Related13, 14, 26
– In 2009, Shultz et al reported on gait biomechanics in
overweight children.
• 10 normal weight children compared to 10 overweight
children with BMI>95%ile
• Overweight participants compared with the normal weight
group had significantly greater sagittal, frontal and
transverse plane peak joint moments at the hip, knee, and
ankle at both self selected and fast walking speeds
– Increase risk of joint loading, skeletal malalignment and injury in
overweight children
• When adjusted for weight, the ankle DF moment was
greatest in the overweight group in both walking speeds
– Indicates need for larger braking mechanism during ambulation
Gross Motor Related19
Gross Motor Related Contd24
• In 2011, Nervik et all reported on the relationship between
obesity and gross motor development in children who are
typically developing and determine whether BMI predicts
gross motor skill difficulty.
• In 2012, Roberts et al reported on the examination of the
relationship between gross motor skill level and weight status in a
large national representative sample of kindergarten-aged children
– 50 children aged 3-5 years using the Peabody Developmental
Motor Scales, 2nd Edition
• 24% were considered to be overweight or obese (12 kids)
– 58% of overweight or obese children scored below average on
the PDMS-2 compared to the 15% of healthy weight children
– High BMI was associated with low gross motor skills identified
by the PDMS-2 gross motor quotient (p<0.002)
• Indicates that as BMI increases, gross motor skills decline
Gross Motor Related Contd21
• In 2013, Nunez-Gaunaurd et al reported on the comparison of motor
proficiency, strength, endurance and physical activity among children from
minority backgrounds who are healthy weight, overweight or obese.
– 86 children, aged 10-15, mostly Hispanic ethnicity (45% classified as
overweight/obese)
– BOT-2 Short Form, Sit-to-stand(STS), Timed-Up and Down Stairs and 6-Minute
Walk Test (6-MWT) completed
– Children of healthy weight had significantly higher standard scores on the
BOT-2 short form compared to overweight and obese groups (P=0.003).
– Most children in the obese category (68.4%) scored less than 17% on BOT-2
short form indicating below-average performance, compared to 40% of
overweight and 27% of healthy weight children.
– Negative correlations of BMI and BOT-2 short form, sit-to-stand and total
abdominal curls (P<0.05 in all cases) with the overweight and obese groups
– 4650 children, mean age 5 years 6 months (31% classified as
overweight or obese)
– Gross motor skill items were a combination from many developmental
tests
– Children of healthy weight and overweight jumped further and
hopped longer than children in obese category (P<0.05)
– Children in obese category had lower overall gross motor composite
scores than children of healthy or overweight categories (P<0.05)
– Adds support to literature for lower gross motor skill level with higher
weight categories
Research at UMMCH
• Retrospective chart review of 35 individuals receiving PT as part of a multidisciplinary tertiary care pediatric weight management clinic
• Initial and 6-month follow-up anthropometrics (height, weight, BMI, and
BMI percentile) and outcome measures were collected:
•
•
•
•
•
•
BOT-2 Body Coordination percentile rank and
standard score
BOT-2 Strength and Agility percentile rank and
standard score
wall sit (sec)
broad jump (in)
number of sit-ups in 30 sec
number of push-ups in 30 sec
• Changes over 6 months were evaluated by paired t-tests. A repeated
measures ANOVA was used to determine if changes in BOT-2 scores were
observed after adjusting for change in BMI over 6 months.
Nicole M. Hybben, P.T., D.P.T., Justin R. Ryder, Ph.D., Susan Jacobsen, P.T., M.P.H., Sara Dooley, P.T.,C/N.D.T., Norrie McKnight, P.T., D.P.T.,
Aaron S. Kelly, Ph.D., Claudia K. Fox, M.D., M.P.H. (2015). Individualized Physical Therapy Within a Multi-disciplinary Pediatric Weight
Management Clinic Improves Gross Motor Function in Youth with Obesity. Annual Obesity Conference Poster.
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Results
UMMCH Conclusions and Discussion
Change Clinical Characteristics and Gross Motor Function
Clinical Characteristics
n
Baseline
6 Month
% Change
P - Value
Height (cm)
Weight (kg)
BMI (kg/m2)
BMI-percentile (%)
35
35
35
35
148.2 ± 16.4
73.9 ± 26.6
32.7 ± 7.5
98.9 ± 1.3
151.0 ± 16.4
75.0 ± 25.7
32.3 ± 7.1
98.7 ± 1.4
1.9
1.5
-1.2
-0.2
<0.001
0.267
0.147
0.121
BOT-2 Body Coordination (% rank)
BOT-2 Body Coordination (score)
BOT-2 Strength and Agility (% rank)
BOT-2 Strength and Agility (score)
Wall-Sit (sec)
Broad Jump (in)
Number of sit-ups in 30 sec
7
7
33
32
15
18
11
7.7 ± 5.1
34.7 ± 3.5
6.0 ± 5.4
31.1 ± 8.7
15.8 ± 9.2
34.5 ± 7.8
3.5 ± 7.0
14.3 ± 10.6
38.3 ± 4.5
15.5 ± 11.8
38.4 ± 5.8
35.9 ± 17.4
39.6 ± 4.7
6.5 ± 8.1
85.7
10.4
158.3
23.5
127.2
14.8
85.7
0.04
0.001
<0.001
<0.001
<0.001
0.006
0.041
Number of push-ups in 30 sec
10
1.2 ± 3.5
1.4 ± 3.3
16.7
0.575
Gross Motor Function
Data are presented as mean ± SD
P - values for clinical characteristis were conducted via paired t-test
P - values for gross motor function were conducted via ANCOVA adjusting for change in BMI.
• These data suggest that individualized PT, as part of a multidisciplinary pediatric weight management clinic, can
improve gross motor function and strength independent of
weight-loss in youth with obesity, though randomized
controlled studies are needed to draw more definitive
conclusions.
• It has been shown in longitudinal data that gross motor skill
acquisition is inversely related to BMI, thus it can be
hypothesized that early intervention with PT is key to
stopping this cycle of further decline in age appropriate
skills.
• Integration of individualized and targeted PT into pediatric
weight management programs may improve gross motor
function in youth with obesity.
Common PT Diagnoses
PT DIAGNOSIS AND CLINICAL
IMPRESSION EXAMPLES
13 yo female, BMI 41.8
• R/L patellofemoral pain secondary to alignment,
strength and range of motion impairments
– ***is referred for a physical therapy evaluation and
treatment as indicated secondary to R knee pain and
exercise intolerance, which limits her ability to safely
exercise and participate in age appropriate activities.
With current knee pain and her combined LE
alignment, range of motion and strength impairments,
she is at high risk for injury and ongoing pain if these
are not addressed with skilled Physical Therapy
Treatment and targeted home exercise program
initiation.
• Gross motor impairment
• R/L patellofemoral pain
• Impaired strength affecting LE alignment
leading to pain (or placing at high risk for pain
with initiation of activity)
• Impaired functional activity tolerance for age
appropriate participation
• Mechanical low back pain
7 yo male, BMI 30.83
• Impaired balance and activity tolerance affecting gross
motor function
– ***referred for a physical therapy evaluation and
treatment as indicated secondary to balance and
endurance impairments, which limits his ability to safely
participate in age appropriate activity. He had multiple falls
and impaired static standing balance during the evaluation
today indicating risk of future falls and injury. He also
demonstrate poor endurance overall with frequent
shortness of breath and elevated resting BP and HR. He
will benefit from an OP PT episode to target his
impairments and educate him and his family on an
appropriate home exercise program that is safe and
effective.
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9 yo male, BMI 29.73
• gross motor impairment secondary to strength,
balance and endurance impairments
– ***referred for a physical therapy evaluation and
treatment as indicated secondary to concerns for gross
motor delay, which limits his ability to safely keep up with
his age matched peers. *** demonstrates significant
strength and balance impairments limiting his safety with
all functional and gross motor activities. He is at high risk
for injury. It is imperative that he initiate an outpatient
physical therapy treatment episode of care to assist in
providing interventions to target his impairments and
initiation of a safe home exercise program.
16 yo female, BMI 47.49
• impaired gait and functional activity tolerance secondary to
impaired LE alignment, strength impairment and elevated resting
BP
– ***referred for a physical therapy evaluation and treatment as
indicated secondary to exercise intolerance and inactivity, which limits
her ability to safely participate in age appropriate activities and
exercise to assist in weight loss. With her poor LE alignment, mild
weakness and balance impairment combined with her inexperience
with safe aerobic exercise, elevated resting BP and high BMI, she is at
risk for cardiopulmonary exercise intolerance and orthopedic injury. It
is recommended that she be followed by skilled outpatient physical
therapy in the Pediatric Weight Management Clinic to appropriately
grade exercise and teach her proper technique to initiate a successful
and safe exercise program.
Motivational Interviewing8
• A guiding style of assisting a patient in behavioral
changes vs. a directive style
• Works best with patients in the Contemplation or
Preparation Phases of behavior change
– Contemplation: “I want to, but…”
– Preparation: starting to make a change
GOAL SETTING STRATEGIES
Motivational Interviewing Examples8
• Open ended questions
• “On a scale of 0-10, with 0 as not important at all and 10 as
extremely important, how important would you say it is for you to
_____?”
– Instead of asking “why are you a “5” and not a “6”?”; Ask “why are you
a “5” and not a “3”? Because it elicits positive talk, not negative.
• With this style, you want the patient to express their
reasons for changing vs. the provider telling them
why they should change
Open Ended Question Examples for
Goal Setting8
• “Given all that we have discussed, what
specific goals would you like to make?”
• “What changes are you willing to start today?”
• “May I offer some suggestions?”
• Exercise program history question
– Typical question:“Tell me how it went this week with your exercises?”
Instead, try “Tell me about the positive things about your exercise
program”.
– Instead of telling a patient when to fit their exercise program into their
day, ask “how might you do this so it fits into your life?”
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Motivational Interviewing Examples
and Resources8
•
•
•
•
•
http://www.apta.org/Podcasts/2012/11/27/BehaviorChange/
http://www.apta.org/Podcasts/2012/12/21/BehaviorChange/
http://www.kphealtheducation.org/roadmap/roadmap.html
http://www.youtube.com/watch?v=URiKA7CKtfc
http://www.motivationalinterview.org
TREATMENT OUTSIDE OF “TYPICAL
PT TREATMENT”
Influence Environmental Changes31
• Family support
– Activity programs that include the entire family
are more successful than those only targeting the
child
• Screen time reduction
Break Barriers to Exercise
1.
2.
3.
4.
Time
Cost of Gym Membership
Motivation
Knowledge
– American Academy of Pediatrics recommends
only 1-2 hours of screen time daily
– By reducing screen time alone, children are more
likely to become physically active
• Start with reducing by 30 minutes a week
Breaking Time Barrier
• Limit screen time (child, parent and family)
• Take 10 minute activity breaks during homework for
better mental clarity
• Encourage 10 minutes of activity before taking a nap
to re-assess real fatigue or boredom
• Fit in PT home program exercises into daily routine,
i.e. wall sit or calf stretch while brushing teeth
• Incorporate active movement during seated
games/puzzles/toy, i.e. bear walk, crab walk, jumping,
scavenger hunt for pieces
• Encourage being in charge of walking dog daily
Breaking Cost Barrier
• Exercise does NOT need to be at a gym
– There are low cost alternatives such as Boys and
Girls Clubs and YMCA membership reductions for
families with low income
• Ask about parks and walking trails near home
• Be creative with exercise routines for indoor
and outdoor
– I.E. Empty water bottles filled with rocks/sand for
bowling, hula hoops, jump ropes, indoor olympics,
etc
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Breaking Motivation Barrier31
• Set weekly or monthly short term goals that
include 1-3 changes maximum with education
provided on working towards their long term goal
• Use reward system such as a sticker chart
– Reward cannot be food or money
– More successful if parent-child activity or time spent
together such as going to a movie, musical, trip to a
new park or farmer’s market
– Check into free events offered through local community center or
YMCA
• Encourage a buddy system with a friend or family
member
Breaking Knowledge Barrier
• Be creative
• Find out what they like
– Do not give sit-ups, push-ups, run/walk intervals unless
appropriate for your home program and they like it
• Aerobic exercise for this population has 2 criteria
– Fun
– Makes the child/adolescent breath hard
• A majority of families do not realize that their child
needs 60 minutes of MODERATE INTESITY aerobic
exercise daily as recommended by the Center for
Disease Control and Prevention (CDC).
Ideas to get Started
•
•
•
•
•
•
•
•
•
•
Skip instead of walking
Red light green light to/from park
Act out games
Turn on the music and make up dance moves
Pretend to be a super hero moving through the house saving the
day picking up toys as they go
Indoor or outdoor Olympics (make up own events)
Jump rope or hula hoop
Chase bubbles
Balloon games
Scavenger hunts indoor and outdoor timed
Fun and Fit (Gruenfeld, E.A. et al)12
EXERCISE PROGRAMS IN RESEARCH
• Developed in 2009 at North Shore Medical
Center (NSMC) in Salem, MA
• Multifaceted program including behavioral
intervention, cardiovascular exercise and
games, strength training, relaxation and yoga
and nutrition education
• Afterschool program 4 times a year
– 8 weeks long and involve 2 sessions per week for
1.5 hours each
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Fun and Fit Program12
• Staff: RN director, coordinator, exercise physiologist, fitness
specialist, lead facilitator and registered dietician
• Session includes:
– 1. Arts activity
– 2. Cardiovascular portion where participants use treadmill,
elliptical, bike or rowing machine for 45 minutes with warm-up
and cool-down
– 3. Participation in one of the following for 30 additional
minutes: guided relaxation, yoga and meditation, nutrition
education, strength training with weights, circuits, bands and
exercise balls or exercise-related games
Fun and Fit Outcome Measures12
•
•
•
•
•
Rockport Fitness Walking Test
One minute sit-up test
One minute squat test
Maximum number of push-ups
MET readings from cardiovascular machines
Treating Non-Alcoholic Fatty Liver
Disease (NAFLD) (de Piano et al)7
Fun and Fit Results and Conclusions12
• Improvement in all fitness measures was
statistically significant
• No change in BMI percentile with both male and
female groups combined
• Background:
– Several studies have shown how increasing aerobic exercise on a regular basis
can improve metabolic parameters associated with NAFLD
• Purpose:
– Female group did have a significant reduction in BMI
(p=0.04)
• Qualitative results obtained from a post narrative
report
– Compare the effects of 2 kinds of exercise in NAFLD obese adolescents
(aerobic training (AT) + resistance training (RT), and AT alone) over 1 year of
treatment
• Participants
– 58 obese adolescents who entered the Interdisciplinary Obesity Program of
the Federal University of Sao Paulo, Paulista Medical School
– Improved self esteem, likely to change eating habits
post program, likely to increase activity in their lives
post program
• 15-19 years of age
• BMI 36.55 ± 4.6 kg/m2
• Split into 2 groups – With and without NAFLD
NAFLD Outcome Measures7
• BMI
• Fasting Lipid Panal
–
–
–
–
Triglycerides
HDL
LDL
VLDL
• Glycemia (blood sugar values)
• Liver enzymes
– ALT
– AST
• Abdominal ultrasound for visceral and subcutaneous fat tissue at rectus
abdominus
NAFLD Program7
•
•
All participants
–
Once a week dietetic lessons
–
Three day dietary record at initial and 12 months
–
Once a week psychological intervention
AT group
–
Personalized aerobic training program including a 60 minute session 3 times a week under the
supervision of an exercise physiologist
• AT was on a treadmill or cycle ergometer
•
AT + RT group
–
3 times a week program included 30 minutes of aerobic training and 30 minutes of resistance
training
• AT was running on a treadmill
• RT designed based on ACSM recommendations including all main muscle groups
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Influencing Cardiovascular Changes
(Meyer et al)18
NAFLD Results7
AT Group
• Without NAFLD:
– Significant improvements in
body mass, BMI and fat mass
(kg)
• With NAFLD:
– Same as above, plus
significant reduction in fat
mass (%) and visceral fat
AT + RT Group
•
Background:
•
Purpose:
– Child and adolescent obesity relates to early atherosclerosis and obesity-related
cardiovascular disease
• Without NAFLD:
– Significant improvement in
body mass, BMI, fat mass (kg
and %), glycemia, total
cholesterol and LDL-cholesterol
– Determine the effects of 6 months’ physical activity In obese children and adolescents
on FMD, IMT and obesity-related cardiovascular disease risk factors
• FMD: ultrasound evaluation of brachial artery flow mediated dilation (FMD)
• With NAFLD:
– Same as above plus a reduction
in subcutaneous fat
• IMT: ultrasound evaluation of carotid artery intima-medial thickening (IMT)
• Impaired FMD is considered a key indicator of atherosclerotic disease
•
Participants:
– Treatment group: 96 obese children with BMI >97%ile for German pediatric population
aged 11-16 years
– Significantly lower levels of ALT
(liver enzyme) compared to AT
group with NAFLD
– Control group: 35 children aged 12-16 years without any cardiovascular risk factors
– Randomly assigned to 6 months exercise or 6 months non-exercise
Meyer et al Outcome Measures18
• Body fat mass measure via bioelectrical
impedance
• Resting blood pressure
• Modified Bruce protocol – cycling
• Echocardiogram and vascular measurements
• IMT (carotid artery intima-medial thickening)
• FMD (brachial artery flow mediated dilation)
Meyer et al Program18
• Exercise 3 times a week
– Monday: swimming and aqua aerobic training (60
minutes)
– Wednesday: sports games (90 minutes)
– Friday: walking (60 minutes)
– Supervised by coaches and physiotherapists
– Progressively intensified per participant tolerance
High Intensity Intermittent Exercise
(Sim, et al)25
Meyer et al Results18
• Baseline:
•
– Significant differences in cardiovascular risk factors at
baseline between obese and control groups
– Obese groups presented with significantly lowered
FMD compared to control groups
• Post treatment:
– Obese exercise group had significantly improved FMD
and IMT (indicating good vascular changes); in
addition to significant reduction in body weight,
waist/hip ratio, BP, insulin resistance, triglycerides and
rise if physical fitness
•
Background:
–
Exercise has been shown to influence the concentration of a number of appetite-related hormones
and feelings of hunger and satiety.
–
A recent study reported reduced ad-libitum energy intake at a lunch and dinner meal following a
bout of high intensity (75% of VO2 max) compared with a bout of low-intensity cycling (40% VO2
max) in obese adolescents.
–
Prolonged and continuous high-intensity exercise may not be sustainable in a sedentary overweight
population.
Purpose:
–
•
Investigate the acute effects of high intensity intermittent exercise (HIIE) compared with continuous
moderate-intensity exercise of equicaloric cost on subsequent energy intake, appetite-related
hormones and perceptions of appetite in a group of sedentary, overweight men.
Participants: 17 men with BMI 27.7 ± 1.6 kg/m2, 30 ± 8 years
–
Baseline VO2 max 39.2 ± 4.8 ml/kgmin
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4/19/2016
Sim et al Program25
Sim et al Outcome Measures25
• All participants completed 4 experimental trials using a
randomized counterbalanced design; 30 minutes each
• Post-exercise ad-libitum energy intake
• Changes in plasma concentrations of appetiterelated hormones following a standard caloric
load and ratings of perceived appetite
– MC: continuous exercise performed at moderate intensity
(60% VO2max)
– HI: intermittent exercise consisting of alternating high and
lower intensity at a ratio of 1:4 (60 sec at 100% VO2max:
240 sec at 50%VO2max)
– VHI: intermittent exercise consisting of alternating veryhigh and lower intensity efforts performed at a ratio of 1:4
(15 sec at 170% VO2 max: 60 sec at 32% VO2 max)
– CON: control trial involving supine rest
Sim et al Results25
• Ad-libitum energy intake was lower after HI and
VHI compared with CON (P<0.05)
– VHI was also lower than MC (P=0.028)
• Free living energy intake in the subsequent 38
hours remained less after VHI compared with
CON and MC (P<0.05)
• Lower active ghrelin (P<0.05), higher blood
lactate (P<0.014) and higher blood glucose
(P<0.020) after VHI compared with all other trials
Take Home Points
• Supervised and structured exercise 2-3 times a week for 60-90
minutes can help influence positive changes to endurance, strength,
liver enzymes, cardiovascular risk factors and self esteem
• Structured exercise on treadmills or cycle ergometers is not real life
for many of our patients
• A good portion of our patients are not able to tolerate a full 60-90
minutes of continuous activity because of other impairments so we
need to be able to help them reach this point for continued work
towards a healthy lifestyle.
• Physical therapy treatment can assist in our youth’s transition to a
safe and effective exercise program that can lead to a healthy
lifestyle. They need to be functional and safe before starting in a
community program.
• Boys and Girls Clubs
– Boys and Girls Clubs in Minneapolis/St. Paul
• Membership Fee: Small fee, assistance available if qualify, see website for
more details
• Ages: 6-18
• Transportation: Some sites are designated school bus drop off sites; will need
to pick your child up
• Summer hours available, see specific location for information
• Specific Classes (no extra cost): Lifetime Fitness Hour and Triple Play emphasis
activity; as well as other organized sports
• Website: www.boysandgirls.org
• Big Brother, Big Sister
COMMUNITY RESOURCES
–
–
–
–
Ages: 7-12
Cost: free if accepted; Application Required
Specific Program: Wellness for Life
Website: www.bigstwincities.org
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4/19/2016
YMCAs
• Membership fee varies
– Assistance to help cover partial fee for low income
• Free Kids and Family Group Exercise classes for members
– Examples: Kids/Family Water Exercise, Zumba Kids, Latin Hip Hop for Kids and
Family, Bootcamp for Kids and Family
– Times vary
• Free programs for youth, varies by location for members
– HYPE (Healthy Youth Positively Engaged) for pre-teen and teen ages, Little
Lotus Kids Yoga, Toddler Time
– Some are available for after work and school hours
Health Powered Kids
• Make a free account at
www.healthpoweredkids.org
• Created by Alina Health
• Great resource for schools with large group
games and activities
• Lessons about all aspects of a healthy lifestyle
• Many summer programs, day camps and overnight camps
– Cost variable
– Assistance available for some program fees for low income
• Watch for other free events for members, such as Healthy Kids Day
Providers
•
Medical Doctors and Nurse Practitioner
– Claudia Fox, MD, MPH
– Muna Sunni, MBBCh
– Gail Turnburg, RN, CPNP
•
Dieticians
– Jessica Graumann, MS, RD, LD
– Mindi Khan, MPH, RD, LD
– Alisa Morley, MS, RD, LD
•
Psychologist
•
Physical Therapists
•
Nurse Coordinators
– Amy Gross, PhD, LP, BCBA-D
PROVIDERS AND CLINICS IN
MINNESOTA HEALTH SYSTEM
Clinic Locations
•
Burnsville
– Specialty Clinic for Children - Burnsville
303 E Nicollet Blvd, Suite 372
Burnsville, MN 55337
952-892-2910
•
References
1.
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