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Allowing the Use of Either Relative Intensity or Absolute Intensity in Children the key guidelines for children and adolescents ages 6 through 17 years do not require careful tracking of the intensity of activity. The mix of moderate and vigorous-intensity physical activity is fexible, if some vigorous-intensity activity is done on at least 3 days a week. Relative intensity is appropriate because children and adolescents 6 through 17 years of age who follow the key guidelines should experience improvements in cardiorespiratory ftness, and the relative intensity of the activity is a major determinant of its ftness effects. If a child breathes rapidly during physical activity, this indicates relatively vigorous-intensity activity. However, it is often not feasible to observe children closely enough to determine their level of effort. In this case, absolute intensity can be used to judge whether the child is doing activity that counts toward meeting the key guidelines. Information on the absolute intensity of various activities for children and adolescents ages 6 years and older is found in the Youth Compendium of Physical Activities. In general, similar to adults, brisk walking (as opposed to slow walking) counts as a moderate-intensity physical activity and running counts as a vigorous-intensity activity. The key guidelines for children ages 3 through 5 years do not require careful monitoring of intensity. All intensities and types of activities provide health benefts and count toward meeting the key guidelines. What Is the Relationship Between Bout Duration of Physical Activity and Health Outcomes? Historical Context Physical activity recommendations have traditionally focused on moderate to vigorous-intensity physical activity performed in a continuous manner, such as in exercise. In the 1990s, the focus shifted to accumulating physical activity throughout the day in bouts as short as 10 minutes. The 2008 Physical Activity Guidelines for Americans included the guidance that activity needed to last 10 minutes to count. Evolving Evidence Research continues to support the conclusion that physical activity accumulated in bouts of at least 10 minutes can improve a variety of health-related outcomes. In addition, new research indicates that bouts of any length of moderate-to-vigorous physical activity contribute to health benefts associated with the accumulated volume of physical activity. This new evidence justifed the current guidance that moderate-to-vigorous physical activity of any duration counts toward meeting the key guidelines. Steps are a basic unit of locomotion and provide an easy-to-understand metric of ambulation (anything that requires steps, such as walking, dancing, or running). Measuring step counts combined with goal setting and other behavioral approaches has been shown to increase physical activity levels. Step counts are generally measured with wearable activity monitors, including step counters (pedometers, which measure number of steps over a given time) and accelerometers (which can measure both number of steps over a given time and the level of intensity of movement over a given time). Step counters are frequently included in health-tracking smart phone applications. Over the past 10 years, expanding research and advances in technological approaches for measuring physical activity have led to examinations of the association of step counts with health outcomes and effective approaches to promoting regular physical activity.
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In the following decade, the major features of the syndrome of temporal lobe herniation were clarified, and the role of the tentorial pressure cone was widely appreciated as a cause of symptoms in patients with coma. More recently, the role of lateral displacement of the diencephalon and upper brainstem versus downward displacement of the same structures in causing coma 31,32 has received considerable attention. Careful studies of the displacement of midline structures, such as the pineal gland, in patients with coma due to forebrain mass lesions demonstrate that the symptoms are due to distortion of the structures at the mesodiencephalic junction, with the rate of displacement being more im portant than the absolute value or direction of the movement. Either one or both petroclinoid ligament and enter the cavernous posterior cerebral arteries are vulnerable to sinus. Along this course, the oculomotor nerves compression when tissue herniates through the run along the medial edge of the temporal lobe tentorium. The uncus, which represents the homonymous hemianopsia; bilateral compres bulging medial surface of the amygdala within sion causes cortical blindness (see Patient 3–1). The oculomotor supratentorial mass lesions is the close prox nerves cross the posterior cerebral artery and imity of the oculomotor nerve to the posterior Figure 3–3. Excess mass in one compartment can lead to herniation of the cingulate gyrus under the falx. Note the vulnerability of the oculomotor nerve to both her niation of the medial temporal lobe and aneurysm of the posterior communicating artery. The basilar artery is tethered at the top to the posterior cerebral arteries, and at its lower end to the vertebral arteries. As a result, either upward or downward herniation of the brainstem puts at stretch the paramedian feeding vessels that leave the basilar at a right angle and supply the paramedian midbrain and pons. The posterior cerebral arteries can be compressedby themedialtemporallobeswhentheyherniatethroughthetentorialnotch. Compression around the lateral surface of the midbrain and of the oculomotor nerve by either of these struc follow the third nerve through the petroclinoid tures results in early injury to the pupillodilator ligament into the cavernous sinus. Because the 37 fibers that run along its dorsal surface ;hence, free edge of the tentorium sits over the posterior a unilateral dilated pupil frequently heralds a edge of the inferior colliculi, severe trauma that neurologic catastrophe. The 40 surface ofthe midbrain justcaudaltothe inferior trochlearnervesmayalsobeinjuredinthisway. Usually, a small portion of the cerebellar tonsils protrudes into the aper ture (and may even be grooved by the poste rior lip of the foramen magnum). However, when the cerebellar tonsils are compressed against the foramen magnum during tonsillar herniation, compression of the tissue may compromise its blood supply, causing tissue infarction and further swelling. Patterns of Brain Shifts That Contribute to Coma There are seven major patterns of brain shift: falcine herniation, lateral displacement of the diencephalon, uncal herniation, central trans tentorial herniation, rostrocaudal brainstem de terioration, tonsillar herniation, and upward brainstem herniation. The first five patterns are caused by supratentorial mass lesions, whereas tonsillar herniation and upward brainstem her niation usually result from infratentorial mass Figure 3–5. Note that the course of the oculo Falcine herniation occurs when an expanding motornervetakes it alongthemedial aspect ofthe temporal lesion presses the cerebral hemisphere medially lobewhereuncalherniationcancompressitsdorsalsurface. The compression of the pericallosal and callosomarginal arteries causes ischemia in the medial wall of the cerebral hemi the abducens nerves emerge from the ven spherethatswellsand further increasesthecom tral surface of the pons and run along the ven pression. Eventually, the ischemia may advance tral surface of the midbrain to enter the cavern to frank infarction, which increases the cerebral 44 ous sinus as well.
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