Children with chronic medical conditions face many challenges when considering sport participation. Compared with their healthy counterparts, they are often discouraged from physical activity or sports participation because of real or perceived limitations imposed by their condition. The disorder itself often causes the child or teen to be less active, leading to deconditioning, and a reduction in functional ability, and further hypoactivity (1). Ironically, increased physical activity may be advantageous to this group, because most can achieve benefits that are similar to peers without a chronic disorder. Benefits include better fitness and motor coordination, as well as psychological factors like improved body image and self-esteem. Importantly, habitual physical activity during childhood may persist into adulthood and translate into reduced cardiovascular morbidity and mortality.
Specific exercises should be based on the demands of the sport, the effect of the disease on performance, and the potential for exercise-induced acute or chronic worsening of the illness. Athletes must be considered individually and reevaluated regularly. This article will focus on a few examples of chronic medical conditions and the clinician’s role in providing advice about sport participation.
Cystic fibrosis (CF) is a common autosomal recessive genetic disorder affecting the lungs, pancreas, and sweat glands. It is caused by mutations in the CF transmembrane conductance regulator protein, triggering a decrease in chloride ion passage across endothelial cell membranes, which results in secretions high in sodium and chloride content. This leads to viscous mucous in the pulmonary, gastrointestinal, endocrine, and reproductive systems (2). Pulmonary disease causes most morbidity and mortality. Reduced exercise tolerance is mostly due to lower respiratory capacity, and protein malabsorption resulting in lower muscle mass. Many avoid participation because of fears about their disease, parental overprotection, time constraints, and social isolation (2).
Potential Benefits of Exercise
Aerobic fitness has been demonstrated to be a major predictor of CF prognosis and mortality risk independent of gender, age, lung function, and nutritional status (2). Aerobic and anaerobic training programs can reduce the annual rate of decline in lung function, cardiovascular fitness measures, and peak muscle power. Strength training may improve fat-free mass, weight gain, muscle strength, and FEV1 in affected patients (3–5). Reasons for these improvements include better respiratory muscle function, enhanced hydration of airway secretions, and cardiac function preservation (6). Greater protein intake is essential to accrue muscle, improve skeletal muscle exercise capacity, and increase lung function (6). Actual caloric intake should be individualized but current guidelines recommend 110% to 200% of energy requirements for healthy 2 to 18 year olds. High fat mass does not correlate with better lung function, hence the focus should be to achieve higher lean body mass (7). Recent studies have shown ≥60 min·d−1 of moderate to vigorous physical activity also attenuates their rate of lung function decline (8). Most can participate in regular exercise until there is a significant deterioration in lung function. These children may require supplemental caloric intake to accommodate the increased caloric expenditure associated with being more physically active and disease-associated intestinal malabsorption.
Potential Risks of Exercise
Children with CF may cough with exercise, causing brief oxygen desaturation, but this does not cause significant injury (9). Some children cough because of underlying asthma. Major limitations to exercise capability are the degree of obstructive lung disease, excessive dead space ventilation, and subnormal ventilatory capacity. These limitations may be a consequence of airway damage (bronchiectasis), bronchospasm, mucous plugging, and reduced alveolar ventilation (6,10). Lung parenchyma destruction results in decreased diffusing capacity, leading to oxygen desaturation, CO2 retention, and cyanosis (10,11). Desaturation of arterial oxygen, because of significant ventilation-perfusion mismatching, intrapulmonary right-to-left shunting, or cor pulmonale with congestive right heart failure can occur at late stages (12). Cardiac dysfunction is typically found in patients with advanced CF (resting FEV1 lower than 40% predicted), who have lower stroke volumes, although abnormalities can occasionally be detected in mild CF patients. Maximal heart rate during graded exercise testing is typically the same as that of healthy peers or can be elevated, due to low muscle mass and increased ventilatory effort (13).
All CF patients can develop localized air trapping, increasing the risk of air embolus or pneumothorax during scuba diving. Resting energy expenditure is 5% to 25% higher in CF youth (14). Chronic malnutrition may cause lower muscle mass or strength (respiratory or skeletal), impairing sport performance. These working muscles have poor oxidative efficiency, which may contribute to early fatigability (15). Children with CF have greater sweat-related salt losses, compounded by a lower thirst sensation, making exercise in hot or humid environments challenging. Prolonged exercise (>1.5 h) can lead to hyponatremic dehydration (16). Cystic fibrosis–related diabetes mellitus occurs in some patients, making hypoglycemia and dehydration (polyuria) potential concerns with prolonged exercise. Multilobular biliary cirrhosis and portal hypertension are frequent complications of CF liver disease (affecting up to 10% of this population), leading to esophageal varices and splenomegaly. They have a higher risk of organ damage during contact or collision sports.
All should follow national guidelines for active healthy living. Strength training for large muscle groups is required. Beta-2 agonist treatment may help those with prominent cough. Additional calories and protein are needed. Prolonged exercise in hot climates should prompt ingestion of additional salt-containing fluids. Those with diabetes need additional carbohydrate supplementation (17).
Juvenile Idiopathic Arthritis
Juvenile idiopathic arthritis (JIA), previously known as juvenile rheumatoid arthritis (JRA), has a prevalence of 1 in 1000 children (18). Affected individuals are less active and more easily fatigued with lower aerobic and anaerobic capacity (19). Sport participation is low because of disease symptom severity, treatment-related side effects, or fears that exercise may aggravate the disease (20). Muscle atrophy, weakness, and anemia all contribute to reduced fitness, but deconditioning is probably the greatest cause. Muscle atrophy near inflamed joints leads to reduced strength (19). Patients also have decreased bone mineral composition (BMC) from disease severity, corticosteroid use, physical inactivity, and poor calcium intake (21). Many of those with lower extremity arthritis also have impaired balance that affects sports participation (22). Delayed motor developmental milestones (preschoolers with JIA) also can affect sport readiness.
Potential Benefits of Exercise
Children with JIA should be encouraged to be physically active to reduce obesity risk, which can worsen arthritis outcomes. Aquatic or land-based weight-bearing exercise programs do not cause disease exacerbation and can reduce joint pain/disease activity and improve muscle strength, fitness, self-efficacy, and quality of life (21,23,24). Resistance training can improve muscle strength, endurance, and function without a significant increase in joint pain (19,25). Weight-bearing exercise can improve bone mineral density (26). Cardio-karate, aquatic exercises and especially Pilates are recommended (27).
Potential Risks of Exercise
Children with JIA may develop increased joint swelling and pain, when exercise puts intense loading on their inflamed joints. Atrophied muscle surrounding active joints and periarticular osteopenia may increase the risk of fracture. Children with cervical spine arthritis are at greater risk of spinal cord injury, and dental damage is more likely in those with temporomandibular joint (TMJ) disease. Some children with JIA develop uveitis and potential visual impairment, which may increase the risk of eye injury. Myocarditis and pericarditis in those with systemic arthritis, and aortic root anomalies or aortic valve insufficiency in HLAB27–associated arthritis may lead to cardiovascular complications with exercise (28). Children with long-standing JIA have a greater metabolic demand during exercise and may struggle with endurance sports (29).
All children with JIA should follow national guidelines for active healthy living. JIA patients can safely participate in sports as long as their disease is well controlled, and they have adequate physical capacity (1). Moderate fitness and strengthening exercises are recommended, but, when lower extremity joints are inflamed, low- to moderate-intensity weight-bearing exercise is preferred (30). Balance and flexibility activities should be promoted. Those with neck arthritis should undergo radiographic screening for C1-C2 instability. Arthritis affecting the jaw should encourage health care providers to prescribe a fitted mouth guard.
Hemophilia is an X-linked bleeding disorder caused by a reduced level or function of factors VIII or IX. Those with severe, 1% to 2% of normal factor level, hemophilia have an increased risk of spontaneous bleeding; especially into joints and muscles (31). The most affected joints include the knee, ankle, and elbow. Hemarthroses over time can lead to arthropathy and joint contractures (31,32). Fitness, anaerobic power and muscle strength are lower in children with hemophilia (33,34). Affected children may restrict activity, due to parental concern, musculoskeletal pain, or deconditioning.
Potential Benefits of Exercise
Fewer bleeding episodes are noted in active children with hemophilia (31). Greater muscle strength around affected joints increases joint stability, reduces injury risk, and may protect joints from hemarthrosis (32). Regular exercise builds muscle strength, increases joint motion, reduces pain and the frequency of joint hemorrhage, and subsequent hemophilia-induced arthropathy (35). Treadmill walking and partial weight-bearing exercises seem to be more effective in improving muscle strength than static or short arc exercises (36). Proprioceptive training also may reduce joint damage and improve athletic performance (33). Children with severe hemophilia and low BMC can improve bone health with weight-bearing exercise (37). Vigorous aerobic exercise increases factor VIII levels transiently in healthy individuals, and submaximal exercise can modify coagulation parameters in those with mild to moderate hemophilia (33). Athletic participation in affected children can improve quality of life (38).
Potential Risks of Exercise
Although hemophilia itself does not negatively affect fitness or athletic performance, chronic hemophilic arthropathy may lead to impaired neuromuscular function and diminished muscle strength and endurance. Of concern, life-threatening bleeding episodes can occur with collision or contact sports. The actual risk of muscular, articular, and intracranial hemorrhage depends on the history of bleeding episodes, sport participation, the use of prophylactic treatment, and the child’s hemorrhagic tendency (39). An increased risk of bleeding with physical activity has been seen in those with lower (5% or less) factor levels (40). For every 1% increase in factor level with treatment before sport, the risk of bleeding can be decreased by 2% (35,40,41).
All children with hemophilia should follow national guidelines for active healthy living. In addition, they require a preparticipation evaluation, which should include an assessment of balance, coordination, torso strength, aerobic capacity/endurance, flexibility, and body fat content. Vigilant assessments of joint and muscle function before sport selection is advised. Stretching, strength training, aerobic activities, and sports-specific skills should be promoted (31). Low-impact activities (swimming, walking, jogging) are permitted. Youth wishing to pursue high-impact, contact, collision activities (diving, football, lacrosse, rugby, wrestling) should be evaluated on an individual basis. They should be cautioned about the potential consequences of bleeding and offered routine prophylactic factor replacement, which may be protective (35,41). Athletes should wear appropriate protective equipment for their chosen activity and should receive physical therapy rehabilitation, should they have a bleeding episode. A written, sports participation action plan that includes strategies to prevent and treat bleeding episodes should accompany each athlete to ensure effective management of bleeding episodes (39).
Sickle Cell Trait
Sickle cell trait (SCT), caused by inheriting an abnormal beta hemoglobin chain from one parent, is more common in African-Americans but can be found in those whose ancestors evolved in an endemic malarial area (42,43). Unlike sickle cell disease, it is not usually associated with anemia or significant morbidity/mortality. Most affected children take part in all sports without difficulty.
Potential Benefits of Exercise
The benefits of exercise (aerobic, anaerobic), strength training, and contact or collision sports are similar to unaffected peers.
Potential Risks of Exercise
Youth with SCT are unlikely to have an increased risk of sudden death or other medical problems during athletic participation. Splenic infarction may occur during exertion at high altitudes, whereas sickling and rhabdomyolysis can ensue during sport participation in extreme heat/humidity (28,44). The latter is seen after 2 to 5 min of sustained overexertion, if such an athlete is deconditioned or dehydrated (45). Mechanisms suggested in the pathogenesis of the blood vessel occlusion associated with these complications include hypoxemia, lactic acidosis, hyperthermia, dehydration, and the procoagulant effect of exercise-induced epinephrine elevation (42,45,46).
All should follow national guidelines for active healthy living. Athletes with SCT may participate in sports, provided the organization and coaches implement suitable prevention strategies. Sometimes the sickle cell status of all athletes on a team is unknown. Recommendations have included sickle cell screening targeted to high-risk groups or universal testing of all athletes. There are pros and cons of both approaches (47). Regardless, appropriate training programs that allow acclimatization (temperature and altitude), maintenance of hydration, recovery from illness, and the provision of rest during and in between bouts of activity are advocated (28). Athletes also should avoid overtraining and taking dietary supplements containing stimulants (42,45,48). Preventive strategies to avoid heat-related complications should focus on modifying activities for safety in relation to the degree of environmental heat stress: air temperature, humidity, and solar radiation and the provision of sufficient amounts of appropriate fluids at regular intervals before, during, and after all sports participation. Supervisory personnel should receive suitable training and closely monitor all youth at all times during sports in the heat. An emergency action plan should be developed for early recognition of heat illness and exertional sickling symptoms. Quick and effective treatment, once sickling is suspected is essential (44,46,48,49).
Epilepsy is defined as two or more seizures occurring >24 h apart beyond the newborn period (50). It is the most common childhood neurologic condition, with a prevalence of 1% in the USA (51). Some seizures are triggered by flickering light, hyperventilation, poor sleep hygiene, and inadequate adherence to antiepileptic treatment. As seizures affect psychomotor control, there is a concern that participating in physical activity could increase the risk of injury and/or decrease the seizure threshold. For this reason, many parents restrict their child’s participation in exercise and sport (52).
Potential Benefits of Exercise
Youth affected with epilepsy derive similar benefits from regular physical activity as their unaffected peers. These include improved fitness, work capacity, and reduced body fat. Weight-bearing activity also improves bone density, which can counter the effects of antiepileptic drugs (53). Exercise has been increasingly reported to benefit seizure control and improve quality of life. This may occur through the natural exercise-induced acidosis, increasing brain gamma-Aminobutyric acid (GABA), and reducing the irritability of the cortex (52). In addition, there is increased alertness/focus and enjoyment associated with exercise, which could explain seizure reduction (52,54). People with epilepsy frequently experience mood disorders, which can be improved through exercise (53).
Potential Risks of Exercise
Although there are many potential triggers for seizures, physical activity is rarely a factor (54). Those who develop seizures with intense physical activity typically also have a structural brain anomaly (54). Children with normal cognition and seizures have a similar rate of accidental injury as unaffected peers, but there is an increased risk of harm with water-based events and activities at height or fast speeds (50,54). Metabolic disturbances (hyponatremia, hypoglycaemia), which can be associated with exercise and may cause seizures, are not more common in those with epilepsy (54). Compensatory hyperventilation with exercise has not been linked to seizures (55). Although concussive convulsions can occur, there is no association between concussions and seizure development (55).
Youth with seizure disorders should follow national guidelines for active healthy living. Those that are well controlled may participate in sport with the assurance that the risk of seizures during participation is minimal. For safety reasons, they should get adequate sleep, limit stress and alcohol consumption, and ensure appropriate supervision for swimming and sport involving height (51,54,55). Although all providers would prefer “adequate seizure control” to be 100% seizure free, this may be impractical for some patients. They could potentially require multiple anti-epileptic drugs to attain this control and as such may have a variety of drug-drug interactions and side effects. Unfortunately, there is no consensus on the definition of adequate seizure control. Hence “well-controlled” is a label that is unique to each athlete (55). Those whose condition is not well controlled should adhere to safety guidelines and undergo an appropriate medical evaluation, especially for collision, contact, or limited contact sports. They should avoid swimming and modify other water sports (including scuba diving), due to an increased risk of drowning (54,56). These athletes also should avoid activities that occur at high velocity, at heights, or that involve heavy equipment or ballistics (riflery, archery) (57). Water sports can be resumed after 5 years seizure-free and the athlete is off antiepileptic drugs (56). Most other restrictions can be removed after 1 year seizure-free (on or off medication). A seizure action plan should be on file with the school and/or sport organization (55).
Cerebral palsy (CP) is a movement disorder caused by perinatal encephalopathy (58). It is often classified by the type of motor abnormality (athetosis, ataxia, spasticity) or the number and severity of limb involvement (hemiplegia, diplegia, quadriplegia). This condition impacts functional ability, which may lead to reduced participation in recreational activities. Patients have inefficient ambulation with poor muscle endurance/power/strength, as well as altered coordination, creating barriers to exercise (58,59). Even school-age children with high levels of gross motor function are significantly less active and far more sedentary than their able-bodied peers (60,61). It is conceivable those with lower motor function are even less likely to be physically active.
Potential Benefits of Exercise
Children with CP can improve strength, fitness, and motor function with regular ongoing exercise. Aerobic energy-generating activities may improve gross motor function but not gait speed. Resistance training has no apparent effect on gait speed, gross motor function, or quality of life but can increase muscle strength and enhance bone mineral density (62). Affected individuals with lower levels of disability may experience greater fitness gains (63). Team sports allow interactive social skills.
Potential Risks of Exercise
Exercise appears to be safe for children with CP; however, some factors should be addressed (62). Muscle weakness and abnormal muscle activation/control can lead to insufficient balance and risk of injury to muscle and bone (58,64). Strengthening and stretching of their muscles must be done carefully to avoid greater spasticity and tone imbalance. Wheelchair athletes have higher risk of shoulder overuse injuries, and those with seizures require specific attention (see epilepsy section).
All children with CP are advised to follow national guidelines for active healthy living. Before participating in any sport, a child with CP should undergo a preactivity evaluation that assesses the child’s health status, function, spasticity, and current level of activity (58). Exercise to improve endurance and muscle strength through walking, cycling, swimming, and wheelchair sports are key, although the exact intensity, duration, and volume should be individualized (63,65). Children with CP may require longer rest periods before a training effect is noticeable (65). Those lacking voluntary motor control may benefit from resistance exercise aids (e.g., E-stim, biofeedback). A graded approach to complex and multijoint exercises is preferred but many children with CP can safely participate in numerous land and water-based sports successfully (65).
Children with spina bifida, Duchenne muscular dystrophy (DMD), and spinal muscular atrophy (SMA) experience varied motor deficits. Certain children are ambulatory, some require a wheelchair, and others have minimal movement of their bodies. Children with spina bifida demonstrate low fitness levels and reduced participation rates in physical activity (66,67). Those with DMD and SMA experience a progressive motor decline. They are less fit with reduced muscle strength and endurance, as well as poor aerobic power, often as a result of immobilization.
Potential Benefits of Exercise
Physical activity plays a critical role in slowing progression of neuromuscular diseases and improving quality of life. Children with spina bifida can increase overall physical activity level and strength, independent of ambulatory ability, through sport participation (66). Walking speed and fitness improves with individualized, home-based, treadmill walking programs (68). Greater physical activity also may improve wheelchair mobility (69). Those with DMD and SMA may improve functional ability, strength, and endurance and reduce muscle deterioration with more physical activity. Assisted movement exercise programs using legs-only bike pedaling or a passive-motion hand ergometer improve function and slow muscle deterioration (70–72). Parents also report the benefits of swimming on the well-being of children with DMD (73).
Potential Risks of Exercise
Most studies on the risks of exercise in patients with neuromuscular diseases have been carried out in DMD patients. These suggest aerobic exercise that includes inspiratory muscle training is desirable to prevent increased work of breathing. Acute bouts of exercise result in greater creatine kinase elevation and may be more damaging to dystrophic muscle (74). High-resistance training and eccentric exercises should be avoided in these patients since the dystrophic process may be exacerbated (75).
Children with neuromuscular disorders should be encouraged to adopt an active healthy lifestyle. They should be assessed individually, with exercise prescribed according to their level of impairment. Thirty minutes of physical activity at mild to moderate intensity 3 d·wk−1 appears to be safe and beneficial. For children and youth with spina bifida, health care professionals should tailor the sport to suite each patient’s personal preferences and include social support particularly from family members (66). Acute bouts of high-intensity exercise should be avoided in children with DMD. Low-to-moderate intensity resistance exercise appears to benefit these children but high-resistance training and eccentric exercises should be avoided. Pain or fatigue is an indication to reduce the duration, intensity, or frequency of the exercise (74,75).
Autistic Spectrum Disorder
The United States prevalence of autistic spectrum disorder (ASD) is ~ 2.5% (76). Affected children experience executive dysfunction and deficits in motor control. Over half have hypotonia, gross motor delays, and/or motor apraxia (77,78). They also have much higher rates of obesity than their peers (79). Children under 6-years-old with ASD move more than unaffected youngsters; however, physical activity decreases with increasing age, especially in girls (80,81). Older children with ASD accumulate similar volumes of physical activity as their able-bodied peers but at a lower intensity and in fewer activities overall (82,83). This results in lower fitness levels. Youth that match the physical activity of their peers have similar fitness levels (84).
Potential Benefits of Exercise
Physical activity implementation, especially if begun early on, results in positive impacts on gross motor function, as well as on the interaction between attention, cognition, and inhibition (executive function) and school performance (85,86). Running may have a greater impact on reducing stereotypic behaviors, even when performed for as little as 15 min (87). Exergaming that encourages higher intensity and sustained movements for 20 min (e.g., dancing and cycling) can improve executive function and decrease repetitive behaviors (88).
Potential Risks of Exercise
There are no major risks to engage children and youth with ASD in exercise and sport, although fear of injury and discomfort often limits participation (89). Teens with ASD frequently report social integration difficulty, resulting in less enjoyment and lower engagement in team sports. Barriers to participation may include the lack of additional supervision by parents, poor peer relationships, and fewer sport/activity opportunities (89).
Children with ASD should follow national guidelines for healthy active living with a reduced frequency of resistance training (90,91). They require additional neuromotor training to develop kinesthetic awareness of how to move and control their bodies in more efficient ways (91). This can be achieved through hippotherapy (therapeutic horseback riding), skating, and water-based exercises (92–95). Adaptations to sport programs may be necessary, such as lower (≤4:1), athlete to coach/instructor ratios, use of copious positive feedback on successes, and individualization to the preferences of each participant. Engaging parents in this process is advisable. Social engagement can be encouraged through “walking warm-ups” and prior discussion of upcoming activities (96).
Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by inattention and/or hyperactivity-impulsivity. Diagnosis, according to the DSM-V guidelines, requires the presence of at least six symptoms in at least one category for at least six months, prior to age 12, and symptoms must affect function in at least two settings (97). Approximately 5 to 6 million children are affected in the United States. Typically, treatment involves use of stimulant medication and behavioral therapy, which may include exercise, although the mechanism by which it impacts ADHD is unknown (98).
Potential Benefits of Exercise
Exercise has been shown by test performance and neuro-electric measurements to impact executive function, allowing individuals to plan and problem-solve (99). While stimulant medication provides superior efficacy in achieving these goals in ADHD patients, exercise offers a relatively safe and widely beneficial adjunct. Walking is beneficial and even greater effects are noted when affected children accumulate at least 30 min (especially at higher intensity) of physical activity daily (100–103). Up to 50% of children with ADHD meet criteria for developmental coordination disorder, demonstrating a lack of motor skills interfering with normal daily activities or school function (104). These children may be at a higher risk of obesity (105).
Potential Risks of Exercise
Children with ADHD taking stimulant medication are at increased risk of heat injury, because these agents increase core temperature and often mask signs of fatigue. Stimulants also increase heart rate and blood pressure, which may be of concern in children and youth with preexisting cardiac abnormalities (106–108). College athletes and those at the Olympic level of their sport need to be aware that the World Anti-Doping Agency and International Olympic Committee ban these agents for sport competition. They must be evaluated regularly to confirm the diagnosis of ADHD and the need for stimulant medication (109).
Children with ADHD should be encouraged to adopt an active healthy lifestyle and participate in sport and recreation to help manage their symptoms. Successful programming ideally incorporates specific routines and expectations, regarding adherence to the rules. Participation is likely to increase with a focus on the child’s particular interest, redirecting negative behaviors and providing positive reinforcement (101,110). Parents play an important role in managing their child’s behavior and maintaining their child’s interest, as well as by being active themselves (111).
Health professionals should promote regular physical activity for children with chronic disease to achieve health and fitness benefits as well as the development of appropriate social skills. Guidelines for healthy school-age children typically advocate they accumulate 60 min of moderate to vigorous physical activity per day, incorporate regular muscle and bone strengthening exercises several times a week, and reduce recreational screen time to less than 2 h daily. Sufficient quality sleep also is recommended. One approach might be to follow the Canadian 24-Hour Movement Guidelines. These were released in an effort to overcome the traditional approach of segregating rather than integrating counseling related to healthy movement behaviors (112). Visualizing the entire day in activity time portions makes it easier to see that the relationships between sleep, sedentary behavior, and physical activity are interactive, and modifying one has an impact on the others.
Parents of children with chronic disease may need to be reminded that there are more benefits than risks to their child’s participation in recreational activities and sport. However, there are unique exercise tolerances for each condition. As such, it is advisable that physicians provide a prescreening program to identify distinct physical capacities and disease-specific barriers to sport participation. This allows the identification of potential risks for disease worsening and the ultimate creation of individualized exercise regimes that will meet their needs.
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