As with adults, children often need to do some exercises as part of their Chiropractic treatment. A common question asked by physicians is whether children can safely perform exercise with resistance? How much weight is appropriate for a growing body? Which exercises are most effective? Doctors of Chiropractic may hesitate to recommend exercises for their younger patients because of these and similar questions. Since this is such an important topic, here is a reasoned and experienced response, along with useful consensus information.
Prepubescence is the phase of childhood prior to the onset of secondary sex characteristics. Rapid, but variable growth occurs during this period, with open physes and changing muscle and ligament lengths. Adolescence begins with the onset of secondary sex characteristics and continues until physical and skeletal maturity. Selecting the best exercise approach for each child’s situation is important, since needs may vary during growth.  However, all children should be encouraged to engage in frequent and regular fitness activities.
Benefits of Exercise
The benefits of youth physical activity include fitness, weight control, and the development of habits having the potential to span a lifetime. One study systematically determined the amount of moderate to vigorous physical activity students obtain during elementary and middle-school physical education classes (time spent performing moderate to vigorous physical activity/total class time). The researchers concluded that the amount of physical activity observed (elementary schools, 8.6%; middle schools, 16.1%) was significantly less than the estimated national average of 27% and far below the national recommendation of a minimum of 50%.  A review of current youth fitness data indicates that children in the United States are fatter, slower, and weaker than children in other developed nations. Also, children in the United States appear to be developing a sedentary lifestyle at earlier ages. A low level of exercise is a contributing factor for childhood obesity and hypertension, and predisposes the individual to premature death from coronary heart disease.  Fortunately, through intervention in children and adolescents in the form of education and motivation, exercise levels may be increased to the recommended minimum of 30 minutes on most days. 
Resistance Exercise Safety
High-intensity resistance training appears to be effective in increasing strength in preadolescents. Children make similar relative, but smaller absolute strength gains when compared with adolescents and young adults. Resistance training appears to have little if any hypertrophic effect, rather being associated with increased levels of neuromuscular activation. Researchers have found that the risk of injury from prudently prescribed and closely supervised resistance training appears to be low during preadolescence.  In 1993, Mazur reviewed the types and causes of injuries to preadolescents and adolescents resulting from weight lifting/training.  The researchers concluded that “prepubescent and older athletes who are well-trained and supervised appear to have low injury rates in strength training programs.”
A risk that must be considered in the immature skeleton is the susceptibility of the growth cartilage of the epiphyseal plates (physes). Weight training in a submaximal controlled, supervised situation is beneficial to bone deposition. Strength training can be a valuable and safe mode of exercise provided 1) instructors are properly educated; 2) participants are properly instructed; and 3) the absolute necessity of avoiding maximal lifts is reinforced.  The most important factors in avoiding injury in children who are doing resistance exercises are: proper performance of the exercise; avoiding overload by focusing on repetitions, not weight; enforcing rest periods during exercise; and resistance training only twice a week. Exercise tubing is an excellent tool for strength training of children, since the risks of injury are minimized, and a spotter or expensive equipment is not needed (Fig. 1).
Training Coordination and Balance
For many children, it is more important to learn the fine neurological control necessary for accurate spinal and full body performance than to simply build strength. Better coordination and balance will often result in improved physical function, both in daily and in sports activities. This may entail performing exercises while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a rocker board. The advantage of these balance exercises is seen when children engage in sports activities and perform at advanced levels for their age group.
Exercises are effective when done in an upright, weight-bearing position, since the entire body is in a closed chain position during the training. The stabilizing muscles, the co-contractors, and the antagonist muscles all learn to coordinate with the major movers during movements that are performed during closed chain exercising. This makes these types of exercises very valuable in the long run, particularly for children who are interested in becoming competitive athletes.
Corrective Spinal Exercises
Children’s spinal problems are often associated with poor postural support. A spinal asymmetry such as scoliosis and kyphosis is invariably accompanied by neuromuscular imbalance. This may be compounded by poor postural habits and tendencies to “slump.” One important factor in Chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. In addition to general strengthening and coordination exercises, patients (including children) should be shown corrective exercises that are specific for the postural imbalances they have developed. For instance, when the pelvis is carried flexed forward, a patient of any age will need to retrain with resisted pelvic extension exercises. Likewise, when there is a forward head, posterior translation exercises for the cervical region are very important (Fig. 2).
Whenever a child shows evidence of abnormal gait or begins to develop lower extremity complaints, a careful evaluation for the need for shoe inserts is warranted. Custom-fitted orthotics can improve performance and spinal alignment by ensuring proper lower extremity alignment and reduce overuse injuries by providing additional shock absorption.
A well-designed exercise program for children who need to strengthen, develop better coordination, and improve postural support will allow the doctor of Chiropractic to provide cost-efficient pediatric spinal care. Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly. In some children, orthotic support is necessary to help ensure correct alignment from the lower extremities. The end result is a more effective rehab component and young patients who will make a rapid response to their Chiropractic care. With a few common-sense cautions and careful supervision, children are capable of performing rehabilitative exercises very safely.
1. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
2. Simons-Morton BG, Taylor WC. Observed levels of elementary and middle school children’s physical activity during physical education classes. Prevent Med 1994; 23:437-441.
3. Cunnane SC. Childhood origins of lifestyle-related risk factors for coronary heart disease in adulthood. Nutr Health 1993; 9:107-115.
4. US Dept. of Health and Human Services. Physical Activity and Health: a Report of the Surgeon General. Atlanta:1996.
5. Blimke CJ. Resistance training during preadolescence: issues and controversies. Sports Med 1993; 15:389-407.
6. Mazur LJ, Etman RJ, Risser WL. Weight-training injuries: common injuries and preventative methods. Sports Med 1993; 16:57-63.
7. Schafer J. Prepubescent and adolescent weight training: is it safe? Is it beneficial? Natl Strength Conditioning Assoc J 1991; 13:39-45.
About the Author
Kim D. Christensen, DC, CCSP, DACRB, is co-director of the SportsMedicine & Rehab Clinics of Washington. He is a popular speaker at numerous conventions and participates as a team physician and consultant to high school and university athletic programs, as well as being a Chiropractic faculty member. He is currently a postgraduate faculty member of numerous Chiropractic colleges and is the current president of the American Chiropractic Association (ACA) Rehab Council. He recently received the “Founding Father” award at the annual ACA meeting from the American Chiropractic Rehabilitation Board. He has participated in college sports, and has served as a trainer, coach, and team doctor. Dr. Christensen is the author of numerous publications and texts encompassing musculoskeletal rehabilitation and nutrition. He has recently been appointed as a Board Member of the Commission on Accreditation of Rehabilitation Facilities (CARF). Dr. Christensen has also recently been appointed to the HCFA Therapy Review Program (the only Chiropractor in the United States on this government panel). He can be reached at Chiropractic Rehabilitation Associates, 18604 NW 64th Avenue, Ridgefield, WA 98642.
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Fig. 1. Resistance exercise with a rubber tubing system (light resistance for children)
Fig. 2. Posterior translation exercise for the cervical region