What is the Maximal Exercise Heart Rate?

Patient Presentation
A 19-year-old male came to clinic for his health supervision visit. He was a freshman in college and had returned for this visit during a fall school break. He said that he was doing well in school, but had noticed that he had gained 6 pounds since the summer. “I used to be so active, but I’m studying so much more and then there’s all the food available in the cafeteria,” he lamented. The past medical history showed a healthy male who had been a runner and swimmer in high school. The pertinent physical exam revealed normal vital signs including a blood pressure of 118/72, body mass index of 26.2, and weight that was 6 pounds more than a visit 3 months previously. His examination was otherwise unremarkable.

The diagnosis of a healthy male with concerns about weight gain and poor exercise was made. The physician discussed building in opportunities for exercise including walking and taking the stairs instead of an elevator. He emphasized that building in exercise into daily life could be in 10-20 minute intervals and didn’t always have to be for long times at a gym. He also counseled to take only one serving of an item on his plate at a meal and second servings should be only fruits and vegetables. Even at a salad bar, he said that the patient had to be careful of adding lots of cheese, protein or oils to the salad that would increase the calories. “Of course, any alcohol has a lot of calories too, so make good decisions not only about alcohol in general but also because of the calories.”

The patient said that he wanted to get back into doing some running or swimming and knew that there was a maximal target heart rate but didn’t know what it was. The physician said that it was around 200 beats/minute for someone his age. He counseled the patient to start slow with only 20 minutes of running at 50-60% of his target heart rate, and then to slowly increase the amount of time and effort over several weeks. Plus, he added, “It might be hard to figure out where to do the running 2-3 times or more a week on a regular basis, so don’t push it and be happy that you are making the effort.” The physician also said that the patient might want to buy an inexpensive pedometer to monitor his steps/day which was another way to check if he was getting enough exercise. “You could also buy a heart rate monitor but those are more expensive, but since you were an athlete before it might help you to keep the intensity at a lower level as you work up, and then you might not try to increase the workouts too fast.”

When he returned 4 months later, he was somewhat happy with his clinical course. He was running or swimming at 30 minutes or more 2-3 times per week which he said helped with the stress of school. He was using a pedometer and said that usually on the days he didn’t work out, he was getting 5000-7000 steps/day. He weight was unchanged. “I think once the spring comes, I can be a little more active, plus I haven’t been very good about watching what I eat,” he noted. “I will try to work on that next.”

Discussion
Being physically active is an important part of health and with the U.S.’s more sedentary lifestyle it can be difficult to get enough activity. Normal transitions are a time where it can be difficult to incorporate old habits or to start new ones. Moving away to college with its new challenges such as erratic schedules, more time needed to study, increased access to food and alcohol can make it difficult for college students to develop good habits and make good choices regarding their health.

Because steps are easy to measure with inexpensive pedometers, the President’s Council on Physical Fitness has a President’s Challenge which recommends the following activity:

  • Youth <18 years
    • 60 minutes/day
    • Activity done in blocks of at least 5 minutes or more
    • 5 days/week
    • 11-13,000 steps/day
  • Adults
    • 30 minutes/day
    • Activity done in blocks of at least 5 minutes or more
    • 5 days/week
    • 8500 steps/day

2000 steps is about 1 mile. Activities and the equivalent steps can be found at How Far is 10,000 Steps?

Research has shown that exercise alone may improve fitness and health, but usually will not result in weight loss. Therefore diet and exercise are needed. Interval training with periods of increased intensity and then returning to baseline has been shown to burn more calories than exercising at a consistent exertion level. Other research has shown that music and being around others will also improves the psychological outlook on the exercise and may improve adherence to an exercise routine. Exergaming, that is exercising using videogaming technology, which is increasingly popular has mixed results of increased activity depending on the game type.

The American College of Sports Medicine recommends that adults exercise:

  • 3-5 times per week
  • at an intensity of 55/65%-90% of maximal heart rate, with lower intensity levels for unfit individuals
  • for 20-60 minutes (with a minimum of 10 minute intervals accumulated throughout the day)
  • performing an “…activity that uses large muscle groups, which can be maintained continuously, and is rhythmical and aerobic in nature.”

They also recommend resistance and flexibility training as part of overall fitness and health.

Learning Point
Maximal heart rate for adults can be roughly estimated by:

220 beats/minutes – age in years = maximal heart rate

This is an estimate and should be individualized. For children, this author was unable to determine a maximum heart rate, but it would be common sense that it should not be higher than 200 beats/minute and should be greatly individualized for the child and activity.

Questions for Further Discussion
1. What types of resistance training is recommended for overall fitness?
2. What types of flexibility training is recommended for overall fitness?
3. What other tips do you have to help patients and families to improve their physical activity?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Exercise and Physical Fitness and Exercise for Children.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

ACSM Position Stand on The Recommended Quantity and Quality of Exercise for Developing and Maintaing Cardiorespiratory and Muscular Fitness, and Flexility in Adults. Med Sci Sports Exerc. 1998:30(6);975-991. Available from the Internet at http://www.mhhe.com/hper/nutrition/williams/student/appendix_i.pdf (rev. 1998, cited 10/15/13).

Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ, Roemmich JN. How much activity do youth get? A quantitative review of heart-rate measured activity. Pediatrics. 2001 Sep;108(3):E44.

Plante TG, Gustafson C, Brecht C, Imberi J, Sanchez J. Exercising with an iPod, friend, or neither: which is better for psychological benefits? Am J Health Behav. 2011 Mar-Apr;35(2):199-208.

Castelli DM, Hillman CH, Hirsch J, Hirsch A, Drollette E. FIT Kids: Time in target heart zone and cognitive performance. Prev Med. 2011 Jun;52 Suppl 1:S55-9.

Kraft JA, Russell WD, Bowman TA, Selsor CW 3rd, Foster GD. Heart rate and perceived exertion during self-selected intensities for exergaming compared to traditional exercise in college-age participants. J Strength Cond Res. 2011 Jun;25(6):1736-42.

Melone L. The Heart Rate Debate. American College of Sports Medicine. Available from the Internet at http://www.acsm.org/access-public-information/articles/2012/01/13/the-heart-rate-debate (rev. 1/13/2012, cited 10/15/13).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Are Mandibular Fractures Treated?

    Patient Presentation
    A 9-year-old female came to the emergency room after tripping at school and falling straight down onto a tiled floor. A teacher had witnessed the fall and reported that the child had seemingly been wiped off her feet landing with a great deal of force straight onto her chin. The teacher said there was no loss of consciousness. Her mother brought her to the emergency room after being called by school personnel. She reportedly had blood in her mouth originally but this had stopped and she was having pain at the point of the chin and by the temperomandibular joint on the left side. The past medical history was non-contributory.

    The pertinent physical exam showed a female in some pain. Her vital signs were normal including growth parameters that were in the 10-25%. HEENT showed a laceration underneath her chin that was 2 cm in length that was through the skin. After cleaning it was found to be easily approximated. Her ear exam was negative. She refused to open her mouth fully and when she tried she complained of some pain with palpation anterior to the left ear. Her oral exam was grossly normal without pain on tapping of teeth that could be reached and there was a minor laceration inside the left cheek without bleeding. Her neck exam and rest of her head examination was normal. Her neurological examination was negative with her being alert and oriented but refusing to open her mouth fully. The rest of her examination was negative. The diagnosis of probable mandibular trauma along with other possible intraoral trauma was made. The pediatric dentists were consulted. They did not find any significant intraoral trauma. The radiologic evaluation of a panorex of the maxilla and mandible revealed the diagnosis of a left mandibular condylar fracture. She was begun on a no chew diet after repair of the chin laceration and her clinical course showed radiographic and clinical improvement after 3 weeks. She was to continue on the diet until another 3 week followup.

    Discussion
    The most common mandibular fractures are condylar fractures (30-40%) followed by fractures of the symphysis, angle and body respectively. Mandibular condyle fractures also account for 11-16% of all facial fractures. The causes of mandibular fractures are motor vehicle accidents, falls and sports. Pain, edema, malocclusion, hematoma and bruising, crepitus, trismus, decreased movement and lost sensation are common presenting signs and symptoms. Patients are diagnosed by history and radiographs (usually a CT scan). Potential complications of condylar fractures include decreased movement, muscle spasms, pain, malocclusion, facial asymmetry, ankylosis and osteonecrosis. Complicated mandibular fractures can have permanent tooth damage, facial asymmetry, and nerve damage. Mandibular fractures can also be isolated or part of neurocranial or multi-organ system trauma.

    Learning Point
    “Whereas absolute reduction and fixation of fractures is indicated in adults, concern for minimal manipulation of the facial skeleton is mandated in children. The small size of the jaw, existing active bony growth centers and the contained, overwhelmingly crowded deciduous teeth with permanent tooth buds located in great proximity to the mandibular and mental nerves, all significantly increase the therapy-related risks of pediatric mandibular fractures and their growth related abnormalities. Intact active mandibular growth centers are important for preserving mandibular function, which have a significant influence on future facial development. Thus, restoration of the mandibular continuity after fracture is important not only for immediate function but also for future craniofacial development.”

    Options for treatment of mandibular fractures include:

    • Close observation with analgesics, liquid-to-soft diets and no activities that present risks such as sports.
      This is usually used for greenstick fractures without displacement or malocclusion.

    • Splints – prefabricated acrylic splints, staples or orthodontic devices. These have the advantage of being relatively easy to apply and remove, can be done in an outpatient setting or with decreased general anesthesia time.
    • Open reduction (including wiring of the jaws) is used for more complicated fractures including those that are significantly displaced.

    Questions for Further Discussion
    1. Besides dentists, what other professionals may be helpful in managing mandibular fractures?
    2. How are the nutritional needs of a patient with a mandibular fracture met?

    Related Cases

      Symptom/Presentation: Pain

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Jaw Injuries and Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Aizenbud D, Hazan-Molina H, Emodi O, Rachmiel A. The management of mandibular body fractures in young children. Dent Traumatol. 2009 Dec;25(6):565-70.

    Goth S, Sawatari Y, Peleg M. Management of pediatric mandible fractures. J Craniofac Surg. 2012 Jan;23(1):47-56.

    Chrcanovic BR. Open versus closed reduction: mandibular condylar fractures in children. Oral Maxillofac Surg. 2012 Sep;16(3):245-55.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Some of the Problems Associated with Pica?

    Patient Presentation
    A 2-year-old female came to clinic for her health maintenance examination. Her parents had no concerns except that she seemed to eat dirt more than other children. She would eat dirt and sand outdoors and dust balls and other particulates indoors. The parents reported no problems with abdominal pain or stool changes. She had a good general diet that included red meat, vegetables and dairy products. Her past medical history was non-contributory. The pertinent physical exam showed normal vital signs with growth parameters in the 33-75%. Her examination was negative including normal colored conjunctiva.

    The diagnosis of a healthy female was made. Her parents were counseled that pica was normal in this age group but that they should monitor her closely. They also were reminded that items they did not want her to put into her mouth would need to be picked up if dropped inside the house. Her screening laboratory evaluation for possible iron deficiency anemia or lead toxicity were negative.

    Discussion
    Oral behaviors are normal activities for infants and older children including exploration of toys and other environmental items by the mouth and thumb sucking. They could also be potentially more problematic such as nail biting, gum chewing or even tobacco smoking/chewing.

    Pica is a disorder of ingestion of non-food items that is unusual in the type of item or the quantity. What is defined as food widely varies by region and ethnicity. The term pica is the medieval Latin name for the magpie bird which is known to eat food and non-food items. Many different animal species practice pica including several primate species. Pagophagia is a type of pica where one consumes an excessive amount of ice, snow or iced drinks. Geophagia is the more commonly thought of type of pica where one consumes earth including clay.

    People ingest some dirt during the day (i.e. inadvertent exposure) through inhaled dust, dirty hands and contaminated food and water. Young children, especially those under age 4, intentionally eat dirt and other non-food items in larger quantities and more often that older children and adults. It is more common in boys than girls. It is also more common in patients that are disabled. For those disabled patients that are institutionalized it can be a self-injurious behavior that can be disastrous with a death rate of up to 11% in some studies. Geophagia is also more common with economic hardships which results in poverty, hunger and starvation. Geophagia is commonly practiced in famine settings.

    Geophagia particularly of clays, is practiced in some ethnic groups to remove toxins, as medicines (ie kaolin clay for diarrhea), during pregnancy (for morning sickness) and as nutritional supplements (i.e. calcium). Some of these clays are often taken from specific areas (termite mounds in Africa which have high calcium and other mineral contents), subsurface (not contaminated by surface water and other soil debris) and some bake the clay before consumption (to reduce the risk of contamination). Some scientists believe soil alsos improve the immune system in a number of ways including as an evolutionary adaption to deal with bacteria in the world.

    Learning Point
    Some of the common problems associated with pica include gastrointestinal tract obstruction, lead toxicity, iron deficiency anemia, parasites (especially Toxocara canis and ascariasis) and industrial pollutant exposure.

    Questions for Further Discussion
    1. What potential patients in your practice setting may be at risk for pica?
    2. What other minerals are found in subsoils that potentially are important for humans?
    3. How would you behaviorally manage a patient with pica where the behavior is causing morbidity?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Eating Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Callahan GN. Eating dirt. Emerg Infect Dis. 2003 Aug;9(8):1016-21.

    Walker AR, Walker BF, Sookaria FI, Cannan RJ. Pica. J R Soc Health. 1997 Oct;117(5):280-4.

    Williams DE, McAdam D. Assessment, behavioral treatment, and prevention of pica: clinical guidelines and recommendations for practitioners. Res Dev Disabil. 2012 Nov-Dec;33(6):2050-7.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are the Basic Categories of Traumatic Peripheral Nerve Injury?

    Patient Presentation
    A 16-year-old male came to clinic after hitting a brick wall with a left closed fist during a basketball game the previous evening. He had iced the hand, took ibuprofen and it felt somewhat better. The following morning though he was having more pain that was radiating from the wrist upwards. He also complained that he had pain and tingling when he moved his elbow that would radiate toward the wrist. The past medical history was non-contributory. The pertinent physical exam revealed normal vital signs and growth parameters. His extremity examination showed abrasions and swelling on the dorsum and knuckles of the left hand. His muscle strength in the arm, hand and fingers was normal. His range of motion was normal in the shoulder, and decreased flexion/extension at the elbow because flexion caused increased pain/tingling down the forearm along the ulnar nerve distribution. He had decreased range of motion in the wrist and 4th and 5th fingers again because of pain. He could make a fist and moved all fingers otherwise. There was no specific point tenderness but he complained most about the 5th metacarpal and wrist area. Capillary refill was brisk in all fingers and he had good pulses. Tapping on the ulnar nerve in the ulnar grove of the elbow or near the wrist made the tingling/pain worse and the sensation changes involved the ulnar distribution of the hand and forearm. The radiologic evaluation showed no fracture in the hand, wrist, forearm or elbow.

    The diagnosis of soft tissue injuries with irritation of the ulnar nerve presumably in the elbow and hand was made. After discussion with an orthopaedic physician because of the ulnar nerve changes, the primary care physician sent the teenager home to followup in 2 weeks with the physician. The primary care physician called the patient 2 days later and found out that the patient was having increased pain despite using a sling to support his arm. He was seen the following day by orthopaedics and repeat radiographs showed a periosteal break in the 5th metacarpal consistent with a Boxer’s fracture. The patient was placed into a custom-made splint and was to followup with orthopaedics in 2 weeks.

    Discussion
    The ulnar nerve begins in the brachial plexus and travels anterior to the medial head of the triceps in the upper arm. It then moves through the elbow at the condylar groove to the cubital tunnel, then between the two heads of the flexor carpi ulnaris in the forearm to the wrist. In the wrist it moves through the Guyon canal after which it splits to innervate the hand’s intrinsic muscles and gives sensation to the 4th and 5th fingers and lateral hand.

    To review the anatomy and anatomic variation click here.

    Compression of the nerve by abnormal positioning (during sleep or otherwise), crutches, tourniquets, compartment syndrome, hematomas and fractures commonly cause a chronic neuropathy. Ulnar neuropathies occur mainly at the elbow and the wrist because this is where the nerve is vulnerable. Ulnar neuropathy is one of the most common peripheral neuropathies after median nerve neuropathy due to carpal tunnel syndrome. Most symptoms are parathesia or numbness in the ulnar distribution, but motor symptoms can also occur ranging from severe muscle wasting and claw hands to minor weakness.

    Learning Point
    Acute peripheral nerve injury due to trauma is often caused by traction, compression, ischemia, or laceration. The nerve axon, myelin or both elements may be injured. There are 3 basic categories of traumatic peripheral nerve injury:

    • Neuropraxia
      • Axon is normal but there is segmental demyelination
      • Motor function loss, sensory and sympathetic losses are incomplete
      • Prognosis is good with recovery as early as hours to days but most within 3 months
    • Axonotmesis
      • Axon is injured but the myelin is preserved
      • Motor, sensory and sympathetic function are lost
      • Prognosis is varied because axonal regeneration may be incomplete or aberrant, time course is varied but much longer than neuropraxia
    • Neurotmesis
      • Axon and myelin are both injured
      • Motor, sensory and sympathetic function are lost
      • Prognosis is poor because regeneration does not occur. Deficits are permanent and muscle atrophy occurs within 18-20 months. Surgical reanastomosis offers some possibilities of improved outcome.

    Questions for Further Discussion
    1. What are acquired causes of chronic peripheral neuropathy?
    2. What are genetic syndromes of chronic peripheral neuropathy?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Peripheral Nerve Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Felice KJ, Royden Jones H Jr. Pediatric ulnar mononeuropathy: report of 21 electromyography-documented cases and review of the literature. J Child Neurol. 1996 Mar;11(2):116-20.

    Papazian O, Alfonso I, Yaylali I, Velez I, Jayakar P. Neurophysiological evaluation of children with traumatic radiculopathy, plexopathy, and peripheral neuropathy. Semin Pediatr Neurol. 2000 Mar;7(1):26-35.

    Doherty, TJ. Ulnar Neuropathy at the Elbow and Wrist. UpToDate. (rev. 11/16/12, cited 8/29/13).

    Landau ME, Campbell WW. Clinical features and electrodiagnosis of ulnar neuropathies. Phys Med Rehabil Clin N Am. 2013 Feb;24(1):49-66.

    Kroonen LT. Cubital tunnel syndrome. Orthop Clin North Am. 2012 Oct;43(4):475-86.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital