Multiple Body System Analysis Across the Lifespan

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Introduction[edit | edit source]

Musculoskeletal System[edit | edit source]

The functional capacity of the musculoskeletal system should be assessed within the context of school, play, work, daily activities, and sports. Due to differences in the levels of reliability and validity for the functional tests, a combination of a questionnaire and a functional test appears to be the best instrument to assess the functional capacity of the musculoskeletal system.[1] The following questionnaires are recommended:[1]

  • The Oswestry Disability Index
  • The Pain Disability Index
  • The Roland-Morris Disability Questionnaire
  • The Upper Extremity Functional Scale

Table 1 provides examples of functional tests for musculoskeletal system assessment for children/adolescents, adults and older adults as well as examples of changes that occur in the system across the lifespan.

Table 1. Functional Tests for Musculoskeletal System Assessment
Children/Adolescents Adults Older Adults
Muscle strength

(Functional assessment to include sit-to-stand and stairs)

  • Maximal volitional muscular force, contractile velocity and muscular power are lower than adults.
  • Children recover faster than adults from high-intensity, short-term exercise.[2]
  • A 1-minute sit-to-stand (1MSTST) test to quantify exercise capacity measures how many times per minute an individual can stand up and sit on a chair standardised for height.). In ages 5-16, the median number of repetitions is 51-65 [3]
  • The Stair Climbing Tests (SCTs) reflect coordination ability.[4] The literature describes it in many ways. In one protocol, participants stood with both feet on the lower plateau of the device. The step-down manoeuvre is performed accordingly. The instructions included the following:[4]
    • Climb the four stairs as quickly as possible without running
    • Stand still on the upper plateau
    • Use the handrail if necessary.
 1MMSTST: ranges from 8.1(patient with stroke), 24 (advanced lung disease)[5] to 50 (healthy male adult)[6]
  • 1MMSTST in healthy older men and women aged 75-79 years ranges between 22-37 [7]
  • Difficulty in climbing stairs has been reported as a marker of functional decline that can lead to loss of independence
  • Older adults often report difficulty with stair climbing, and it is reported as one of the top five most difficult tasks to perform. [8]
  • Ability to climb stairs can help to assess hip and knee strength and stability [9]
  • "The use of stair-climbing speed as an assessment tool should include both stair ascent and descent because differences in these speeds seem to be indicators of stair-climbing ability".[10]
Flexibility/Range of motion

(spinal and chest wall mobility)

Chest wall mobility:

Age 3 through adulthood:

Chest wall mobility measurement for tidal volume excursion: [11]

  • 3rd rib site: approximately 2/8th
  • Xyphoid site: approximately 3/8th
  • 1/2 distance site: 4/8th

Pediatric:

  • 3rd rib site: approximately 1/8th
  • Xyphoid site: approximately 2/8th
  • 1/2 distance site: 3/8th


Chest wall measurement for vital capacity:[11]

  • From 1-1/2" to 4"
  • Become larger as the measurement moves lower on the chest wall
  • variable due to chest size

Spinal mobility:

  • Assessing over-lengthened vs tight muscle
  • Lumbar spine mobility is greater in children than in adults
  • Caution must be applied during visual estimation of spine position as intra-rater and inter-rater reliability of visual assessment is poor[12]
  • Muscle weakness, abnormal positioning, and abnormal movement patterns may lead to abnormal spinal mobility. [12]
 Chest wall mobility:
  • Chest wall mobility measurement for tidal volume excursion is the same as for children
  • Chest wall measurement for vital capacity is the same as for children

Spinal mobility:

Measurement in the standing position using the inclinometer technique:[13]

  • Lumbar flexion: the difference between thoracolumbar flexion and pelvic flexion measures.
  • Lumbar extension: arching the trunk backwards.
  • Right and left side-bending: a composite value of average side-bending.
 Chest wall mobility:
  • Chest wall mobility measurement for tidal volume excursion is the same as for children
  • Chest wall measurement for vital capacity is the same as for children

Spinal mobility:

Measurement as for adults.

  • Lumbar extension had the greatest decrease in ROM with age due to abdominal and back muscle weakness, tightness of the hamstrings or a person's fear of losing balance during testing[14]
Pain
  • Children are not always able to indicate the localization of pain.
  • Children between three and seven years of age can articulate the intensity of pain.[15]
 Functional Pain Scale (FPS) is a tool for the objective assessment of pain and its impact on sleep, ability to complete activities of daily living (ADLs), and concentration:[16]
  • First, the patient is asked if they have pain. If there is no answer due to pain, their pain is rated a “10”
  • Next, the patient is asked if the pain is tolerable or intolerable (intolerable pain is rated “5” or greater).  
  • Finally, how the pain interferes with passive vs. active activities is determined.
  • The Functional Pain Scale is "an effective way to assess pain in the elderly and has proven helpful in identifying changes in pain". [17]
Bone Mineral Density
  • Low bone mineral density (BMD)in early childhood is considered a greater risk for bone fractures.[18]
  • Physical activity and calcium and vitamin D intake are interventions that improve BMD in older children.[18]
  • Calcium, vitamin D, and BMD deficiencies are common in adults with coeliac disease.[9]
  • Patients with chronic obstructive pulmonary diseases and on long-term corticosteroids are more prone to having decreased BMD.[9]
  • Patients with haemophilia or other bleeding disorders and patients who are on long-term anticoagulation present with a higher incidence of decreased BMD.[9]
  • Bone mineral density decreases with age.[19]
  • "By age 80, it is estimated that 40% of the muscle mass present at age 20 is lost."[20]
  • Osteopenia is a condition associated with bone mass loss.[20]
  • Osteopenia often progresses to osteoporosis.
  • Strength training can stimulate hypertrophy and increase muscle strength to counteract the loss of muscle mass.[21]
Core Stability
  • Core stability is a dynamic control of trunk pressures to optimize postural stability (balance).
  • Breathing mechanics ( roles of the diaphragm) are linked to postural control through multi-system interactions.
  • Core stability extends from the vocal folds on the top of the trunk to the pelvic floor on the bottom.[9]
 Same as in children/adolescents Same as in children/adolescents

Neurological System[edit | edit source]

"Neurons that fire together, wire together."[9]--Eena Kapoor

"Each time we practise that certain type of movement or certain type of action, we're laying down those pathways in our brain."[9]--Eena Kapoor

Components of the neurological system examination include :

  • Proprioception
    • Ability to determine body segment positions and movements in space[22]
  • Vestibular system, including the ability to coordinate movement with balance
    • Static and dynamic balance
  • Interoception

Table 2 provides examples of functional tests for neurological system assessment for children/adolescents, adults and older adults as well as examples of changes that occur in the system across the lifespan.

Table 2. Functional Tests for Neurological System Assessment
Children/Adolescents Adults Older Adults
Proprioception
  • Difficulties with motor coordination and planning may be linked with difficulty in proprioception.[23]
  • Studies link poor proprioception to difficulties with handwriting.[23]
  • Poor proprioception has been linked to cerebral palsy, developmental coordination disorder, autism spectrum disorder, and children with joint hypermobility. [23]
  • Indirect Assessments of Proprioception include parents’ reports or clinician's observation checklist.[23]
  • Direct Assessments of Proprioceptive Function include The Sensory Integration and Praxis Test.[23]
  • Assessments of Proprioceptive Reflex confirm intact proprioceptive afferents.
 There are three main testing techniques for assessing proprioception in adults:
  • Threshold to detection of passive motion (TTDPM).
  • Joint position reproduction (JPR), known as joint position matching. [24]
  • Active movement extent discrimination assessment (AMEDA).[24]
  • Ageing is associated with a decline in proprioceptive function.[25]
  • Proprioception is required for a healthy body to function during movements and to maintain balance. [25]
  • Decline in proprioception due to ageing affects mobility and increases the risk of falls.[25]
  • Balance deficits are linked to proprioceptive functions decline during the ageing process.[25]
Vestibular system
  • "Static balance is defined as the ability to sustain various positions of the contour line and the base of support."
  • Static balance develops before the 3rd year of age.
  • Static balance tests include a flamingo test, a one-leg stance on a low beam, or a tandem stance on the force plate.
  • Dynamic balance is defined as the ability to remain stable while performing movements or actions.
  • Dynamic balance develops between the 3rd and 7th years.
  • Dynamic balance tests include low-beam walking test.
  • Vestibular signal impairment is associated with balance disorders and spatial disorientation in neurodegenerative diseases, including Alzheimer's and Parkinson's disease. [26]
  • Balance testing may include the Romberg Test of Standing Balance on Firm and Compliant Support Surfaces.
    • Balance test on a foam-padded surface with eyes closed
  • 20-50% of older adults are diagnosed with balance impairment.[27]
  • 20 – 30% of older adults experience one or more falls annually.[27]
  • Ageing is associated with a decline in organ function, and the widespread presence of diseases in the balance control systems predisposes older adults to balance impairment.[27]
  • Function performance tests include postural activities and movements which occur in the course of everyday life:
    • Romberg Test
    • The uni pedal stance test (UST)
    • The four-square step test (FSST)
    • The timed up-and-go test
    • Functional reach test (FRT)

Interception[edit | edit source]

Interception is the ability to perceive internal bodily states. Our perception of internal body signals influences our emotions, decision-making, and sense of self.

This optional video explores the concept of interception:

[28]

For a detailed assessment of the neurological system, please refer to the Neurological Screening course.

Integumentary System[edit | edit source]

Adequate skin and other connective tissue mobility is needed for free movement of the underlying structures to provide postural support and assure proper ventilation.[11] If fascial restrictions are present, they may cause multiple impairments.

The skin is one of the largest organs of the body. It has many functions, including the following:[29]

  • Structural barrier
  • Thermoregulation
    • An impact on the cardiovascular system because it regulates body's temperature.
  • Contributes to sensation for neuromuscular control
  • Provides fascial mobility for range of motion of the joint

Learn more about the integumentary system from this Physiopedia article.

Skin diseases such as atopic dermatitis, psoriasis, and allergic or irritant contact dermatitis affect skin transepidermal water loss (TEWL, the amount of water loss through the epidermis through evaporation), hydration, and acidity.[30]

Children/Adolescents:

  • Skin barrier function is weaker than in adult
    • "Changing infant skin barrier is not a deficit but beneficial as adaptive flexibility allowing constant optimisation, balancing growth, thermoregulation, water barrier and protective functions. "[30]
  • Newborns have the lowest skin hydration and water content. [31]
  • Premature infants have high TEWL at birth leading to skin's immature barrier function and thinner epidermal layers. It causes increased insensible water loss.[30]
  • Neonatal skin has higher pH compared to older paediatric and adult patients. Mature skin pH is maintained between 4.5 to 6.0.[30]
  • Paediatric skin have tendency to develop xerosis and excessively dry skin, particularly on the exposed facial skin. It can lead to development irritant or allergic contact dermatitis.[32]
  • Scarring from G-tube or a chest tube placement can cause severe restriction in child's trunk mobility and abdominal mobility.[9]

Adults:

  • Extrinsic ageing of the skin includes chronic exposure to various environmental elements such as the sun, air/water pollution, smoking, diet, exercise, stress, lifestyle, repetitive muscle contractions, gravity, or general diseases.[33]
  • Intrinsic ageing of the skin is a natural process resulting from oxidative cellular metabolism and is influenced by genetics, metabolism, hormonal, immunological, cardiovascular, gastrointestinal, psychogenic, degenerative, or neoplastic disease.[33]
  • In women, the skin thickens to 25 to 30 years of age, followed by a progressive declination of all skin layers as age progresses.[33]
  • Androgens, cortisol, progesterone and thyroid hormone influence skin health. For example, thyroid hormone "regulates the metabolic rate of the body and helps regulate epidermal cell proliferation, differentiation, hair and nail growth, wound healing, and skin hydration by affecting the function of dermal fibroblasts."[33]

Older Adults:[34]

  • Skin is thinner and less elastic
  • Age spots/Liver spots tends to develop
  • Blood vessels under the skin become more fragile causing bruising or bleeding under the skin
  • Decrease in oil production leading to dry and itchy skin
  • Decrease in subcutaneous tissue with increasing risk for pressure injuries and hypothermia
  • Decrease in sweat function increasing risk for overheating
  • Increase risk for skin cancer

Gastrointestinal System[edit | edit source]

  • Gastrointestinal system occupies majority of space in the abdominal compartment.
  • The abdominal compartment is surrounded by the following structures:
    • The diaphragm and abdominal wall anteriorly
    • Spine posteriorly
    • Costal arch on both sides
    • Pelvis on the bottom
  • The abdominal compartment contains multiple solid and hollow organs, adipose tissue and major blood vessels. They are located intra- and/ or retroperitoneally.
  • The healthy functioning of the GI system depends on body's ability to generate intra-abdominal pressure.

Children/Adolescents:

  • Prune belly syndrome (PBS) is associated with laxity of the abdominal wall musculature. Children with PBS often experience gastrointestinal complications due to inability to generate adequate intra-abdominal pressure.[9][35]
  • Hypotonic trunk in children with cerebral palsy affects their ability to maintain appropriate level of intra-abdominal pressure. It is a main factor in development of digestive issues, including upset stomach, vomiting, bloating, and constipation.[36]
  • Pes excavatum is caused by tendon of the diaphragm pulling down without adequate strength of the abdominals and the intercostals to stabilise the rib cage and counteract that pull of the central tendon. The chest wall is caving creating per excavatum. This may be one of the risk factors in constipation. The therapy goal is to strengthen the core and provide the counter-resistance for this central tendon pull so that the child can generate the amount of pressure needed. Increase in the intra abdominal pressure can help with constipation.[9]

Adults

  • Strength training in healthy males focusing on improving strength of the trunk rotators, improves the ability to generate higher levels of voluntarily induced intra-abdominal pressure and increases the rate of intra-abdominal pressure development during functional situations.[37]
  • Patients with cystic fibrosis or asthma presenting with a chronic cough should be screened for stress urinary incontinence.[9]

Older Adults:[38]

  • The strength of the esophageal contractions and the tension in the upper esophageal sphincter decrease
  • Stomach lining's capacity to resist damage decreases which may lead to peptic ulcer disease
  • Stomach elasticity decreases
  • Reduction in physical activity and exercises and pelvic floor weakness may become factors in constipation or faecal incontinence.

Cardiopulmonary System[edit | edit source]

The following functions of the cardiopulmonary system should be considered when assessing the system across the lifespan:

  • Breathing mechanics and patterns
  • Sleep quality
  • Oxygen saturation and blood pressure
Table. 3 Cardiopulmonary System Across the Lifespan
Children/Adolesents Adults Older Adults
Breathing mechanics and patterns
  • Infants’ respiratory system is less efficient than adult's[39]
  • 12 months and younger infants are more dependent on diaphragmatic breathing. The main role of the intercostal muscles is chest stabilisation during inspiration.[39]
  • Infants' ribs are positioned more horizontally than adults'. Ribs move up with inspiration. The absence of up-and-out rib movement limits the infant's capacity to increase tidal volumes.[40]
  • Severe spinal muscle atrophy leads to paradoxical breathing.
  • The position of the trunk influences chest wall kinematics and breathing patterns. When trunk flexion increases, rib cage displacement and tidal volume are progressively reduced. [41]
  • Athletes often demonstrate dysfunctional breathing patterns. Assessment of the breathing pattern may help identify dysfunctional breathing patterns. [42]
  • Incorporating breathing exercises into an athlete's training can help develop a proper breathing pattern leading to better exercise performance.[42]
  • Loss of elasticity and a decline in chest wall compliance
  • Increased rigidity of the chest wall due to osteoporosis and postural changes
  • Weakness of intercostal and accessory muscles of respiration
  • Functional assessment may include the following observations:[9]
    • Ability to speak sentences at different lengths without shortness of breath
    • Ability to sing a song
    • Ability to carry on conversation during activities
Sleep quality
  • Sleep duration, continuity, quality, and daytime sleepiness are associated with cardiovascular risk factors in young people
  • General standards for optimal sleep should consider the individual's “needs” based on their diet, activity pattern, environment, and genetic make-up.[43]
  • "Short sleep duration and poor sleep quality in children have been associated with concentration, problem behaviour, and emotional instability."[44]
  • A shorter sleep duration of less than 5 hours has been associated with either an increased risk of hypertension or actual hypertension.
  • Recommended hours of sleep to support optimal health:[45]
    • Infants: 12 to 16 hours
    • Children between 1-2 y.o: 11 to 14 hours
    • Children 3-5 y.o: 10–13 hours
    • Children 6-12 y.o.: 9-12 hours
    • Teenagers 13-18 y.o: 8-10 hours
  • Sleep patterns are related to cardiovascular disease's morbidity and mortality in adulthood.[46]
  • The optimal nighttime sleep duration for adults is 7 to 9 hours.[47]
  • Sleep deprivation has been associated with an increased incidence of adverse cardiovascular disorders.[48]
  • Sleep quality and its characteristics should be evaluated as healthy sleep patterns are conducive to reducing cardiovascular disease risk.[47]
  • The optimal nighttime sleep duration for older adults is 7 to 9 hours[49]
Oxygen saturation and blood pressure
  • Up to 9.8% of children and adolescents had systolic hypertension, and up to 7.1% had diastolic hypertension.[50]
  • Blood pressure (BP) at age 13 can predict BP at age 24.[51]

Mental Health System[edit | edit source]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Wind H, Gouttebarge V, Kuijer PP, Frings-Dresen MH. Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review. J Occup Rehabil. 2005 Jun;15(2):253-72.
  2. ↑ Falk B, Dotan R. Child-adult differences in the recovery from high-intensity exercise. Exerc Sport Sci Rev. 2006 Jul;34(3):107-12.
  3. ↑ Haile SR, Fühner T, Granacher U, Stocker J, Radtke T, Kriemler S. Reference values and validation of the 1-minute sit-to-stand test in healthy 5-16-year-old youth: a cross-sectional study. BMJ Open. 2021 May 7;11(5):e049143.
  4. ↑ 4.0 4.1 Schorling DC, Rawer R, Kuhlmann I, Müller C, Pechmann A, Kirschner J. Mechanographic analysis of the timed 4 stair climb test - methodology and reference data of healthy children and adolescents. J Musculoskelet Neuronal Interact. 2023 Mar 1;23(1):4-25.
  5. ↑ Watson K, Winship P, Cavalheri V, Vicary C, Stray S, Bear N, Hill K. In adults with advanced lung disease, the 1-minute sit-to-stand test underestimates exertional desaturation compared with the 6-minute walk test: an observational study. J Physiother. 2023 Apr;69(2):108-113.
  6. ↑ Bohannon RW, Crouch R. 1-Minute Sit-to-Stand Test: SYSTEMATIC REVIEW OF PROCEDURES, PERFORMANCE, AND CLINIMETRIC PROPERTIES. J Cardiopulm Rehabil Prev. 2019 Jan;39(1):2-8.
  7. ↑ Strassmann A, Steurer-Stey C, Lana KD, Zoller M, Turk AJ, Suter P, Puhan MA. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health. 2013 Dec;58(6):949-53.
  8. ↑ Gagliano-Jucá T, Li Z, Pencina KM, Traustadóttir T, Travison TG, Woodhouse L, Basaria S, Tsitouras PD, Harman SM, Bhasin S, Storer TW. The Stair Climb Power Test as an Efficacy Outcome in Randomized Trials of Function Promoting Therapies in Older Men. J Gerontol A Biol Sci Med Sci. 2020 May 22;75(6):1167-1175.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 Kapoor E. Multiple Body System Analysis Across the Lifespan. Plus course 2024
  10. ↑ Brodowski H, Andres N, Gumny M, Eicher C, Steinhagen-Thiessen E, Tannen A, Kiselev J.Reliability of stair-climbing speed in two cohorts of older adults.International Journal of Therapy and Rehabilitation 2021; 28(11):1-15.
  11. ↑ 11.0 11.1 11.2 Massery, M.  "If You Can't Breathe, You Can't Function" continuing education class 20 hrs.  2008, Chicago, IL. USA www.MasseryPT.com
  12. ↑ 12.0 12.1 Kondratek M, Krauss J, Stiller C, Olson R. Normative values for active lumbar range of motion in children. Pediatr Phys Ther. 2007 Fall;19(3):236-44.
  13. ↑ Waddell G, Somerville D, Henderson I, Newton M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine 1992;17:617–28.
  14. ↑ Saidu IA, Maduagwu SM, Abbas AD, Adetunji OO, Jajere AM. Lumbar spinal mobility changes among adults with advancing age. J Midlife Health. 2011 Jul;2(2):65-71.
  15. ↑ Sansone L, Gentile C, Grasso EA, Di Ludovico A, La Bella S, Chiarelli F, Breda L. Pain Evaluation and Treatment in Children: A Practical Approach. Children (Basel). 2023 Jul 13;10(7):1212.
  16. ↑ Adeboye A, Hart R, Senapathi SH, Ali N, Holman L, Thomas HW. Assessment of Functional Pain Score by Comparing to Traditional Pain Scores. Cureus. 2021 Aug 3;13(8):e16847.
  17. ↑ BioPsychoSocial Assessment Tools for the Elderly - Assessment Summary Sheet. Available from https://instruct.uwo.ca/kinesiology/9641/Assessments/Biological/FPS.html [last access 22.03.2024]
  18. ↑ 18.0 18.1 McVey MK, Geraghty AA, O'Brien EC, McKenna MJ, Kilbane MT, Crowley RK, Twomey PJ, McAuliffe FM. The impact of diet, body composition, and physical activity on child bone mineral density at five years of age-findings from the ROLO Kids Study. Eur J Pediatr. 2020 Jan;179(1):121-131.
  19. ↑ Padilla Colón CJ, Molina-Vicenty IL, Frontera-Rodríguez M, García-Ferré A, Rivera BP, Cintrón-Vélez G, Frontera-Rodríguez S. Muscle and Bone Mass Loss in the Elderly Population: Advances in diagnosis and treatment. J Biomed (Syd). 2018;3:40-49.
  20. ↑ 20.0 20.1 Liu CK, Leng X, Hsu FC, et al. The impact of sarcopenia on a physical activity intervention: the Lifestyle Interventions and Independence for Elders Pilot Study (LIFE-P) J Nutr Health Aging. 2014;18(1):59–64.
  21. ↑ Johnston AP, De Lisio M, Parise G. Resistance training, sarcopenia, and the mitochondrial theory of ageing. Appl Physiol Nutr Metab. 2008 Feb;33(1):191-9.
  22. ↑ Han J, Waddington G, Adams R, Anson J, Liu Y. Assessing proprioception: A critical review of methods. J Sport Health Sci. 2016 Mar;5(1):80-90.
  23. ↑ 23.0 23.1 23.2 23.3 23.4 Chu VWT. Assessing Proprioception in Children: A Review. J Mot Behav. 2017 Jul-Aug;49(4):458-466.
  24. ↑ 24.0 24.1 Yang N, Waddington G, Adams R, Han J. Joint position reproduction and joint position discrimination at the ankle are not related. Somatosens Mot Res. 2020 Jun;37(2):97-105.
  25. ↑ 25.0 25.1 25.2 25.3 Ferlinc A, Fabiani E, Velnar T, Gradisnik L. The Importance and Role of Proprioception in the Elderly: a Short Review. Mater Sociomed. 2019 Sep;31(3):219-221.
  26. ↑ Coto J, Alvarez CL, Cejas I, Colbert BM, Levin BE, Huppert J, Rundek T, Balaban C, Blanton SH, Lee DJ, Loewenstein D, Hoffer M, Liu XZ. Peripheral vestibular system: Age-related vestibular loss and associated deficits. J Otol. 2021 Oct;16(4):258-265.
  27. ↑ 27.0 27.1 27.2 Nnodim JO, Yung RL. Balance and its Clinical Assessment in Older Adults - A Review. J Geriatr Med Gerontol. 2015;1(1):003.
  28. ↑ Neuroscience News. Exploring Interoception: The Neuroscience of Internal Body Signals - Neuroscience News. Available from: https://www.youtube.com/watch?v=rms5I02Rzg0&t=39s [last accessed 23/3/2024]
  29. ↑ Lucas K, Todd P, Ness BM. A Multi-Systems Approach to Human Movement after ACL Reconstruction: The Integumentary System. Int J Sports Phys Ther. 2021 Dec 1;17(1):74-80.
  30. ↑ 30.0 30.1 30.2 30.3 King A, Balaji S, Keswani SG. Biology and function of fetal and pediatric skin. Facial Plast Surg Clin North Am. 2013 Feb;21(1):1-6.
  31. ↑ Fluhr JW, Darlenski R, Lachmann N, Baudouin C, Msika P, De Belilovsky C, Hachem JP. Infant epidermal skin physiology: adaptation after birth. Br J Dermatol. 2012 Mar;166(3):483-90.
  32. ↑ Giusti F, Martella A, Bertoni L, Seidenari S. Skin barrier, hydration, and pH of the skin of infants under 2 years of age. Pediatr Dermatol. 2001 Mar-Apr;18(2):93-6.
  33. ↑ 33.0 33.1 33.2 33.3 Knaggs H, Lephart ED. Enhancing Skin Anti-Aging through Healthy Lifestyle Factors. Cosmetics. 2023; 10(5):142.
  34. ↑ Russell-Goldman E, Murphy GF. The Pathobiology of Skin Aging: New Insights into an Old Dilemma. Am J Pathol. 2020 Jul;190(7):1356-1369.
  35. ↑ Arlen AM, Nawaf C, Kirsch AJ. Prune belly syndrome: current perspectives. Pediatric Health Med Ther. 2019 Aug 6;10:75-81.
  36. ↑ Cerebral Palsy Digestive Issues and Health. Available from https://www.cerebralpalsyguidance.com/cerebral-palsy/associated-disorders/digestive-issues-and-health/ [last access 24.03.2024]
  37. ↑ Cresswell AG, Blake PL, Thorstensson A. The effect of an abdominal muscle training program on intra-abdominal pressure. Scand J Rehabil Med. 1994 Jun;26(2):79-86.
  38. ↑ Bajaj JS, Long M. Exploring GI Diseases Across the Lifespan. The American Journal of Gastroenterology 118(3):p 381-382, March 2023.
  39. ↑ 39.0 39.1 Trachsel D, Erb TO, Hammer J, von Ungern-Sternberg BS. Developmental respiratory physiology. Paediatr Anaesth. 2022 Feb;32(2):108-117.
  40. ↑ How are children different. Available from https://www.rch.org.au/trauma-service/manual/how-are-children-different/ [last access 25.3.2024]
  41. ↑ Romei M, Mauro AL, D’angelo MG, Turconi AC, Bresolin N, Pedotti A, Aliverti A. Effects of gender and posture on thoraco-abdominal kinematics during quiet breathing in healthy adults. Respiratory physiology & neurobiology. 2010 Jul 31;172(3):184-91.
  42. ↑ 42.0 42.1 Sikora M, Mikołajczyk R, Łakomy O, Karpiński J, Zebrowska A, Kostorz-Nosal S, Jastrzębski D. Influence of the breathing pattern on the pulmonary function of endurance-trained athletes. Sci Rep 2024;14 (1113 ).
  43. ↑ Matthews KA, Pantesco EJ. Sleep characteristics and cardiovascular risk in children and adolescents: an enumerative review. Sleep Med. 2016 Feb;18:36-49.
  44. ↑ Michels N, Clays E, De Buyzere M, Vanaelst B, De Henauw S, Sioen I. Children's sleep and autonomic function: low sleep quality has an impact on heart rate variability. Sleep. 2013 Dec 1;36(12):1939-46.
  45. ↑ Paruthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion. J Clin Sleep Med. 2016 Nov 15;12(11):1549-1561
  46. ↑ Cappuccio FP, Cooper D, D'Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J. 2011;32:1484–1492.
  47. ↑ 47.0 47.1 Wang Z, Yang W, Li X, Qi X, Pan KY, Xu W. Association of Sleep Duration, Napping, and Sleep Patterns With Risk of Cardiovascular Diseases: A Nationwide Twin Study. J Am Heart Assoc. 2022 Aug 2;11(15):e025969.
  48. ↑ Zhong X, Hilton HJ, Gates GJ, Jelic S, Stern Y, Bartels MN, Demeersman RE, Basner RC. Increased sympathetic and decreased parasympathetic cardiovascular modulation in normal humans with acute sleep deprivation. J Appl Physiol (1985). 2005 Jun;98(6):2024-32.
  49. ↑ A Good Night's Sleep. Available from https://www.nia.nih.gov/health/sleep/good-nights-sleep [last access 26.03.2024]
  50. ↑ Rosner B, Cook N, Portman R, Daniels S, Falkner B. Blood pressure differences by ethnic group among United States children and adolescents. Hypertension. 2009;54:502–508.
  51. ↑ Rademacher ER, Jacobs DR, Jr, Moran A, Steinberger J, Prineas RJ, Sinaiko A. Relation of blood pressure and body mass index during childhood to cardiovascular risk factor levels in young adults. J Hypertens. 2009;27:1766–1774.
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