Pediatric Strengthening Protocols: From Play to Power Training

Historically, there was a myth that children should not lift weights because it would "stunt their growth." Modern evidence has thoroughly debunked this. Strength training is safe and essential for children with neuromuscular conditions (CP, Spina Bifida, Down Syndrome). However, kids are not just "mini adults." Their physiology and attention spans require a specialized approach. This guide outlines safe, effective strengthening protocols from infancy to adolescence.

1. Myth Busting: Safety First

The Truth About Growth Plates:
Appropriately supervised strength training does NOT damage growth plates or stunt height. In fact, the mechanical load strengthens bone density. Injury risk comes from poor form or excessive load without supervision, not the activity itself.

Pre-requisites for Resistance Training:

• Child can follow simple instructions.
• Child has adequate balance/proprioception to maintain form.
• Qualified supervision is present.

2. Principles of Pediatric Strengthening

We follow the FITT Principle, adapted for developing bodies.

Component	Recommendation	Clinical Note
Frequency	2-3 days per week	Non-consecutive days to allow recovery.
Intensity	Low to Moderate resistance	Start with body weight. If using weights, aim for 8-15 repetitions (no 1-Rep Max testing for prepubescent kids).
Time	20-30 minutes	Short bursts are better. Kids fatigue locally but recover quickly.
Type	Functional & Play-based	"Animal walks" for toddlers; Resistance bands/machines for teens.

3. Age-Specific Protocols

A. Infants (0-12 Months): "Gravity is the Weight"

We don't use dumbbells; we use body weight against gravity.

• Neck/Back: Tummy time (lifting head is resistance training for extensors).
• Core: Pull-to-sit exercises (engaging abdominals).
• Legs: Supported standing/bouncing (quadriceps strengthening).

B. Toddlers & Preschool (1-5 Years): "Functional Play"

Exercise must be disguised as a game. Focus on proximal stability.

• Bear Walk: Hands and feet on floor (Core/Shoulder/Glute strength).
• Crab Walk: Walking on hands/feet with belly up (Triceps/Glutes).
• Wheelbarrow Walking: Therapist holds legs, child walks on hands (Shoulder girdle).
• Squats: Picking up toys from the floor and putting them on a table.

C. School Age (6-12 Years): "Body Weight +"

Can introduce light external resistance (Therabands, medicine balls).

• Climbing: Jungle gyms/monkey bars (Upper body strength).
• Obstacle Courses: Jumping, crawling, carrying heavy objects.
• Theraband: Rows, chest press, leg press (focus on high reps, low load).

D. Adolescents (13-18 Years): "Structured Training"

Can begin formal weight training if mature enough. Focus on technique first, then load.

4. Condition-Specific Modifications

One protocol does not fit all pathologies.

Condition	Protocol Modification	Safety Alert
Cerebral Palsy (CP)	Power Training: High velocity (fast) concentric movements are beneficial. Strengthening spastic muscles does NOT increase spasticity (myth busted).	Ensure stretching follows strengthening to maintain ROM.
Duchenne Muscular Dystrophy (DMD)	Sub-maximal Only: Avoid high-resistance eccentric exercise. Focus on functional maintenance.	Overwork Damage: Eccentric load causes micro-tears that DMD muscles cannot repair.
Hypotonia (Down Syndrome)	Proximal Focus: Emphasize core and shoulder/hip girdle stability. Use joint compression.	Watch for hypermobility/locking joints during lifts.

5. The 5 Rules of Pediatric Lifting

1. Supervision is Mandatory: Never leave a child alone with equipment.
2. Technique over Load: If form breaks, the weight is too heavy.
3. Warm-up/Cool-down: 5-10 minutes of dynamic movement before lifting.
4. Breathing: Teach children not to hold their breath (Valsalva maneuver). Count out loud while lifting.
5. Balance: Strengthen agonist and antagonist muscles to prevent imbalance.

6. Revision Notes for Students

Myth: Strength training stunts growth (False).
Benefit: Increases bone density, motor performance, and injury prevention.
CP Rule: Strengthening does NOT increase spasticity. Power training (fast) is good.
DMD Rule: Avoid heavy eccentric exercise (muscle damage risk).
Dosage: 2-3x/week, 8-15 reps (no 1RM testing for prepubescents).
Play: Bear walks/Crab walks are closed-kinetic chain strengthening.

7. FAQs for Parents

Q1. Can my 8-year-old lift weights?

Yes, if they can follow instructions. Use light dumbbells or resistance bands. The goal is to learn the movement pattern, not to bulk up (which isn't physiologically possible until puberty anyway).

Q2. Will strengthening make my child's spasticity worse?

No. Extensive research shows that strengthening spastic muscles improves function without increasing tone. In fact, weakness often makes movement harder than spasticity does.

Q3. What is "Heavy Work"?

In sensory integration terms, heavy work implies proprioceptive input (pushing/pulling). In physio terms, it builds strength. Examples: Carrying groceries, pushing a laundry basket, digging in sand.

8. 10 Practice MCQs

Q1. The primary risk of resistance training in children comes from:

Answer: C) With proper supervision, injury rates are extremely low.

Q2. For a child with Duchenne Muscular Dystrophy (DMD), which exercise type is contraindicated?

Answer: B) Eccentrics cause membrane damage that dystrophic muscles cannot repair.

Q3. Strengthening a spastic muscle in a child with Cerebral Palsy will:

Answer: B) Research confirms that strength training improves function without worsening tone.

Q4. "Wheelbarrow walking" primarily strengthens the:

Answer: B) It is a closed-kinetic chain exercise for the upper body.

Q5. The recommended repetition range for children starting resistance training is:

Answer: C) Higher reps with lower weight allow for learning proper form safely.

Q6. Before puberty, strength gains in children are primarily due to:

Answer: B) Children lack the testosterone for significant hypertrophy; gains come from better neural recruitment.

Q7. Which position strengthens neck extensors in an infant?

Answer: B) Lifting the head against gravity in prone builds extensor strength.

Q8. "Bear Walking" (on hands and feet) is effective for:

Answer: B) It requires coordination of core, arms, and legs.

Q9. Is 1-Rep Max (1RM) testing recommended for prepubescent children?

Answer: B) Maximal loading puts unnecessary stress on developing structures; sub-maximal testing is preferred.

Q10. A child with hypotonia (e.g., Down Syndrome) benefits most from strengthening the:

Answer: B) Proximal stability is the foundation for distal control.

References

• Faigenbaum, A. D., et al. (2009). Youth resistance training: updated position statement paper from the National Strength and Conditioning Association. J Strength Cond Res.
• Verschuren, O., et al. (2011). Exercise guidelines for children with cerebral palsy. Pediatrics.
• Tecklin, J. S. (2015). Pediatric Physical Therapy. Lippincott Williams & Wilkins.