Neuromusculoskeletal Health in Pediatric Obesity: Incorporating Evidence into Clinical Examination

Neuromusculoskeletal Health in Pediatric Obesity: Incorporating Evidence into Clinical Examination

We are pleased to share new research from EASO Secretary Dr Grace O’Malley, a paediatric physiotherapist and clinical researcher specialised in childhood obesity and exercise science. Dr O’Malley is based at the Royal College of Surgeons in Ireland where she leads a research team exploring the co-morbidities related to obesity and investigating the development and implementation of complex interventions including eHealth interventions. She is also a member of the EASO Childhood Obesity Task Force (COTF) which developed the excellent infographic on child measurement found below.

Please tell us about your new paper, Grace

The paper is a collaborative effort from leading global experts in the area of paediatric physical fitness and function, specifically neuromusculoskeletal health. Physical fitness and function are crucial aspects of health for children with obesity, particularly through growth as the bones, muscles and balance system develop. The author team included Dr Margherita Tsiros (University of South Australia), Prof Sarah Shultz (Seattle University), Prof David Thivel (Université Clermont Auvergne, France) and I (RCSI, Ireland). We were eager to highlight the contemporary research evidence exploring health and fitness of the musculoskeletal system in children with obesity. The translation of this evidence into clinical practice is crucial for optimising child health and improving the success of obesity interventions. We kept in mind the World Health Organisations International Classification for Functioning Disability and Health (WHO, ICF) as this framework is really useful in understanding how difficulties at the level of the muscle, joint or body part can affect tasks of living and thereafter participation. Remember, musculoskeletal conditions are globally the biggest contributor to years lived with disability in adulthood so supporting children to develop strong and fit musculoskeletal systems is essential.

Have there been specific clinical experiences or other impetus that inspired you to delve into research in this area?

Yes indeed. As a paediatric physiotherapist I am committed to empowering children to maximise their health and wellbeing, regardless of what their underlying condition is. If a child with obesity finds it challenging to participate in school games, physical education or active play due to physical impairments, pain or injury I believe health professionals must ensure appropriate interventions are offered. It’s no use telling a child with obesity who experiences pain in their knees or low-back to ‘increase moderate-vigorous activity to 60 mins. per day’ without first addressing pain/discomfort (a barrier to movement). Giving advice is often not enough and children with obesity need practical help, and therapeutic exercise which is modified and tailored for them. I believe longer-term engagement in active play is then possible when the child is listened to, their movement concerns are addressed and they learn how to manage them on an ongoing basis. In my own clinical practice in Children’s Health Ireland at Temple Street I have seen the benefits of being holistic when assessing children with obesity through exercise testing and thereafter using physiotherapy and exercise to maximise their function so that they can participate more in play, active transport, PE and sports.

What specific recommendations would you want to share with HCPs around musculoskeletal health for children, including children living with overweight and obesity?

Firstly, it’s important to remember that through childhood the musculoskeletal system is growing, maturing and developing and children at different developmental stages will present with different ‘typical/normal variants’. HCPs working with children need to be able to recognise when movement is atypical (e.g. limp or asymmetrical movement) so that they can refer the child for further evaluation by a paediatric physiotherapist or paediatrician.
Secondly, it’s important to note that children should not be in pain, so screening for pain is an important feature of a basic clinical assessment for paediatric obesity. If a child reports pain it should be further evaluated.
Thirdly never forget that one of the most important ‘jobs’ of a child is to have fun and to play. HCPs need to understand this when asking about involvement in physical activity or sport. If the child is not playing actively we need to ask why and if s/he highlights any difficulty or low confidence with movement or joining in, we must address this.

Specifically for children and adolescents with obesity we need to understand that they are at greater risk of join pain, muscle weakness, difficulties with postural balance, fatigue and impaired motor skill. Each of these can make active play and movement more difficult compared to their lean peers. So when a child can’t keep up, we must understand why this might be rather than perhaps thinking that they are not trying hard enough or are being ‘lazy’. Often our own stigma and biases can colour our understanding of how or whether children with obesity engage with activity. Can you imagine how disheartening it must be as a child, if you tell an educated adult that you find movement hard and that it hurts, only to be answered with comments like: ‘your’re not trying hard enough’, ‘less excuses’ or ‘yes, that’s because of your weight’! I believe we need to approach movement and play with these children like we would any other child with a chronic condition so: assess musculoskeletal health, address any difficulties, adapt play and exercise interventions to accommodate impairments, progress the intervention as the child gets stronger or less painful, monitor change over time and evaluate the effect of obesity interventions on physical fitness.

What follow-on research might you want to explore around this theme?

We need to explore whether musculoskeletal impairments affect the impact or success of obesity interventions in children and adolescents. It’s also crucial to consider musculoskeletal health outcomes when designing obesity interventions. While future Type 2 diabetes, cardiovascular disease or cancer might be of interest to health professionals, keeping pain and discomfort at a minimum in childhood is far more important to the child so indicators like strength, balance, motor skill should be included as secondary outcomes in trials. We also know very little regarding the interplay between bone health and hormonal signalling in childhood and the role of mechanoreceptors. Similarly very little is known regarding which components of pain are due to mechanical loading or systemic hormonal factors. There is lots to learn!