Tài liệu Sport and Physical Activity in Children with Congenital Heart Disease ppt

SUMMARY Introduction: Children with congenital heart disease CHD can participate in sport on an individualized basis, if their exercise capability is formally tested.. Bjarnason-Wehrens

The spectrum of congenital malformations of the heart is diverse and ranges from mild cardiac changes without substantial hemodynamic relevance to severe congenital heart disease, from cardiac conditions that do not require surgery to severe, inoperable conditions Consequently, the physical exercise capability in children with congenital heart conditions varies widely In mild, uncomplicated cardiac malformations, exercise capability remains normal Where the congenital heart conditions are serious, however, exercise capability is clearly reduced (1, e1, 2, e2, 3, e3, 4, 5, 6) However, it is not only these children who show limitations In some children with mild or completely corrected malformations, reduced exercise capability is probably predominantly related to overprotection and the resulting lack of exercise; this can be balanced by suitable exercise training (7) Even doctors often advise restrictions quite unnecessarily in this setting

Sports for children covers a wide range of activities that place very different demands on the body: from swimming for infants, gymnastics for mothers and children, leisure time play/exercise, sports in schools, sports in clubs, to competitive sports Thus far, only few, mostly small, studies have dealt with the effects of sport on children with congenital heart problems Without exception, these show the positive effects of sports on psychomotor development and physical exercise capacity in such children None of the studies reported any deterioration of the hemodynamic function and/or increased health risks to the children Larger, randomized controlled trials are urgently needed in this area

This article aims to provide doctors practising in their own practices with information that might help them assess the exercise capacity of children with cardiovascular conditions and provide targeted recommendations about their fitness to exercise

SUMMARY

Introduction: Children with congenital heart disease (CHD) can participate in sport on an individualized basis, if their exercise capability is formally tested Methods: Selective review of the literature on sport in children with CHD, and analysis of the authors' own findings Results: Few studies have addressed the effects of regular sporting activities on children with CHD The available literature confirms that regular sport has a positive effect on exercise capacity and psychomotor development

in this group of children, without any negative hemodynamic effects or additional risks

Discussion: The current internationally accepted recommendations on physical activity and sport for children with CHD are almost entirely based on diagnosis It may however be more appropriate

to classify children in terms of their current hemodynamic status Children have a basic need for physical activity which is an integral aspect of normal somatic, motor, emotional, psychosocial and cognitive development The majority of children with CHD following corrective surgery or definitive palliation may participate in normal sporting activities in an unrestricted fashion Recommendations concerning sport should also be based on a hemodynamic classification, taking into account the nature of the condition, disease severity, and potential risks Dtsch Arztebl 2007; 104(9): A 563–9

Key words: congenital heart disease, psycho-motor development, physical activity, physical performance

Klinik und Poliklinik für Kinderkardiologie, Klinikum der Universität zu Köln (Dr med Schickendantz); Psychologisches Institut, Universität zu Köln (PD Dr phil Sticker ); Institut für Schulsport und Schulentwicklung, Deutsche Sporthochschule Köln (Dr rer nat Dordel); Institut für Kreislaufforschung und Sportmedizin, Deutsche Sporthochschule Köln (PD Dr sportwiss Bjarnason-Wehrens)

REVIEW ARTICLE

Sport and Physical Activity

in Children with Congenital

Heart Disease

Sabine Schickendantz, Elisabeth J Sticker,

Sigrid Dordel, Birna Bjarnason-Wehrens

In all international recommendations published thus far, the original cardiac malformation

is given priority in assessing a child's fitness to exercise It is, however, better to primarily use (postoperative) hemodynamic function and not the type of malformation for this assessment The basis for this is a classification of postoperative (residual) findings or of the clinical conditions of children with cardiovascular disorders, as well as a categorization of these into groups by severity The recommendations given here are based on recommendations from German and international expert societies (e1, 8, e4, e5, 13) and on longstanding experience in the treatment, sports advice, and care provided in sports activities for children with congenital heart disease

Types of exertion in exercise

Predominantly static exercise can result in very high stress on the systemic and pulmonary circulations, which can have extreme effects on the hemodynamic function in congenital heart disease Acute, malignant arrhythmias can result in sudden cardiac death (e6) Predominantly dynamic sports activities, however, reduce the afterload in children with congenital heart disease and can therefore be expected to have a protective effect (14)

Box 1 gives an overview of types of exercise and games in childhood that are associated

predominantly with high dynamic or static exercise

Little is currently known about the concrete hemodynamic stress that emerges in different types of activity, e.g., during sports classes A study conducted in Cologne showed that during games that entail much running and catching, children's heartbeat rates show high frequencies (on average 167.8 ± 17.9 beats per minute), which occasionally exceeded the maximum measurements reached during the exercise tests The heartbeat frequency was also high when children started a new type of exercise, but fell the better they mastered the exercise (15)

Importance of sports for the development of children with congenital

malformations

Children have an elementary need to move A child's experiences of perception and movement determine not only its physical and motor development but also crucially influence its emotional, psychosocial, and cognitive development (16, e7) Heart disease often means limitations to a child's perceptive and movement-related experiences Fears and worries for the ill child often result in the parents adopting an over-protective educational style Fear and insecurity prevail in parents as well as in teachers and educators, especially with regard to

a possible risk associated with physical exercise Doctors often recommend restrictions, owing to ignorance By informing and educating parents, doctors, and (sports) teachers, serious attempts will have to be made to reverse this trend Children with congenital heart disease at risk after physical exercise will, however, have to be identified and prevented from partaking in sports

In view of the high priority given to exercise, games, and sports in current society, participating in activities of healthy peers means improved quality of life and has a strong social and socializing aspect for children and adolescents Being forbidden to participate in sports and/or limitations to the extent to which they can exercise is particularly disagreeable to them

BOX 1

Selected forms of exercise and games in childhood

Types of exercise with a high dynamic/low static component

Running, skipping, jumping, cycling, swimming, inline skating, skateboarding, running games, ball games such as football – so-called small games

Types of exercise with a high static/low dynamic component

Climbing, swinging, leaning on both arms, pulling, pushing, martial arts such as judo, gymnastics,

e g on the high bar or the parallel bars (leaning on both arms, hanging)

Many specialist societies have published recommendations on types of sport suitable for all persons with congenital heart disease (e1, 8, e5, 9, 11, 12, 13, e8, e9, 17) Physical activity

in children with congenital heart disease should start as often as possible at nursery school, school, or the children's heart group The specific conditions and individual exercise capability/capacity have to be taken into consideration Deficits in terms of perceptive and movement-related experiences, which might otherwise have negative consequences for the development of a child's personality, will thus remain small or can be eradicated (7) Demands on the muscular system should be made from infancy and during children's preschool years Children need to have the opportunity to live out their natural instinct and drive to move As far as possible, they should participate without limitations in exercise, games, and sports of their peers (7, 11, 12, 13, 18, 19, 20, 21)

BOX 2

Findings after cardiac surgery and/or

interventions

Minor remaining findings (1.2)

– Scar after ventriculotomy

– Incomplete right bundle branch block

– Ventriculotomy-related complete right bundle branch block

– Small residual ventricular septal defect

– Trivial pulmonary (residual) stenosis/insufficiency

– Trivial aortic (residual) stenosis/insufficiency

– Mild mitral insufficiency

– Mild tricuspidal insufficiency

– Supraventricular and ventricular singular extrasystoles

– After surgery for aortic isthmus stenosis without arterial hypertonus

Important remaining findings (1.3)

– Functional impairment of right ventricle

– Right ventricle = system ventricle

– Functional impairment of left ventricle

– Pulmonary (residual) stenosis (l p>30 mm Hg)

– Aortic (residual) stenosis (l p>30 mm Hg)

– Hemodynamically important AV valvar insufficiencies/stenoses

– Replacement valve (biologic and mechanic)

– Supraventricular tachycardias

– Ventricular tachycardias

– After surgery for aortic isthmus stenosis with arterial hypertonus

TABLE 1

(Pediatric) cardiologic examination to assess exercise capability in sports

and fitness for sports

Method Aim

Clinical examination Age-appropriate development of the cardiopulmonary

status and blood pressure

Exercise echocardiography Cardiac function and hemodynamic findings under

exertion

Regular, independent or guided sports activity can improve the physical and motor capacity in children with congenital heart disease The results of empiric studies show significant improvements in coordination and skillfulness (7), stamina (21, 22, e10, e11), strength, and flexibility (22, e10, e11) In none of the studies was there any evidence of

a deterioration of hemodynamic function in and/or risk to the children by the intervention program

Fundamentals for assessing the exercise capability of children with

congenital heart disease

To assess physical exercise capability in sports activity, the usual (pediatric) cardiologic

investigations should be conducted (table 1).

In most cases, congenital cardiac malformations are corrected in infants or toddlers, using surgery or catheter interventions Once the question of sports activity arises, a child's physical exercise capability is then not dependent of its original cardiac malformation but

on the extent of postoperative (residual) findings and functional assessment Cardiac findings in a child with Fallot's tetralogy, for example, after corrective surgery to close the ventricular defect and valvulotomy of the pulmonary valve, may be close to normal Another child with Fallot's tetralogy may, however, have significant right ventricular impairment and thus be significantly impaired in terms of its exercise capability due to pulmonary insufficiency It is therefore not sensible to assign a particular degree of physical exercise capability to certain cardiac defects (8)

TABLE 2

Group categories of pediatric cardiologic pathologies

Group 0 Patients with hemodynamically important cardiac defects before cardiac

surgery/interventions (including ablations) Group 1 Patients after cardiac surgery/interventions

(including ablations)

1.1 Without remaining findings (complete correction)

1.3 With clinically significant findings

1.4 After palliative interventions:

1.4a With seperation of the circulations (e.g., Fontan procedure)

1.4b Without seperation of the circulations (e.g., aorto-pulmonary shunt operations)

Group 2 Patients with cardiac defects not requiring surgery

2.1 Shunt defects with clinically insignificant left-right shunt

2.2 Clinically insignificant valvar defects/anomalies

2.3 Clinically insignificant cardiac arrthythmias/changes to ECG

2.4 Clinically insignificant myocardial changes

Group 3 Patients with inoperable cardiac defects

Group 4 Patients with chronic myocardial disorders

4.1 Clinically significant

4.2 Clinically insignificant

Group 5 Patients with problematic long term/permanent threapy

Group 6 Patients after heart transplantation

Tables 2 and 3 and box 2 show classifications of postoperative findings or clinical

findings and their categorization into degrees of severity

Category group "0" includes patients with hemodynamically important cardiac defects before necessary corrective procedures and has been included for completeness's sake only

(table 2) For patients who have to be treated with surgical or catheter interventions, the

question about sports and exercise should not be asked This is true also for children in whom a time delay has been decided for their surgical correction, e.g., in aortic stenosis or combined aortic defects These children are at risk from overexertion Directly after their surgical intervention, those children are usually released from sports lessons for three to six months, until they have totally recovered Subsequently, an individually tailored exercise program is recommended

Patients in category groups A and B, in whom no cardiac defects or only mild residual

findings exist (table 3), are not expected to show negative effects from their cardiac

condition and can exercise without limitations

Patients in group C (clinically significant remaining findings) (table 3) are able to tolerate

normal physical exertion levels in everyday life These children play with their siblings and friends without showing any signs of impairment They are, however, impaired in terms of their maximum exercise capacity by a reduced capacity to increase their heartbeat rate either owing to hemodynamic problems, such as valvar stenoses or insufficiencies, or to myocardial

dysfunction or inadequate increase in heartbeat rate, such as sinus node dysfunction or pacemaker therapy Such children have to be protected from overexertion It is recommended that such children do not pursue competitive sports and avoid types of sports with a high static load High pressure and volume strain on pre-damaged ventricles may cause malignant arrhythmias In the long term, an increase in myocardial dysfunction has to be expected in this setting Recommended types of exercise include interval training at moderate intensity, e.g., ball games and running games, or moderate stamina training Their afterload reducing effect should even result in a protective cardiac effect

Patients with long term therapies that are problematic for sports activity – especially pacemaker implants or anticoagulation treatment – need additional recommendations In anticoagulation treatment, patients should not indulge in any sports activities that are prone

to contracting injuries Pacemaker patients are at risk from having the pacemaker generator or the pacemaker pocket damaged in contact sports Extreme stretching of the arms, as for example in hanging from and swinging on the still rings, may, in an unfavorable scenario – such as when the reserve loop of the pacemaker lead has been used up owing to somatic growth – cause the lead to detach

Patients in category group D – those with severe (remaining) findings (table 3) – show

severe impairments in everyday life owing to cyanosis or cardiac insufficiency The kind of exertion and intensity of sportive activity have to be adapted to their impaired exercise capability

Patients after heart transplantations are a special group who can be categorized in any of the groups listed here, depending on their functional status

A patient will have to be totally banned from sports (table 4) when physical exercise

results in a threat to his/her life This is mainly the case for patients with pulmonary hypertension (8) The pressure on the pulmonary circulation can rise during exertion and result in death Hypertrophic obstructive cardiomyopathy is an insidious disease Patients

TABLE 3

Severity categories of pediatric cardiologic disorders

Severity Category

(residual) findings

often feel fit and well Sudden death during sports activity is not rare and is often caused by undetected myocardial disease (23), as a result of hypoxia in the hypertrophic cardiac musculature Because of the findings on auscultation – characteristic-uncharacteristic systoles – hypertrophic obstructive cardiomyopathy should not remain undetected in children who are monitored well with preventive examinations It can present immense difficulties

to tell such patients – who feel completely well – that they should not do any sports whatsoever

The jury is out whether a sports ban is needed in patients with a long QT syndrome Diverse molecular genetic forms of this syndrome have been recognized, and the extent of risk from physical exercise can be ascertained (24) Such expensive investigations are usually conducted in genetic centers at the request of pediatric cardiologic centers

Certifying fitness for sports

The wide range of congenital heart disease makes issuing a so-called sports certificate difficult A form that covers all forms of disease does not exist In many children with successfully treated heart disease, an unlimited certificate for participation in sports can be issued In a few children, however, sports has to be forbidden The term "release from sports" should be avoided Often, the wording "is not allowed to participate in competitive sports or primarily static exercises" is sufficient In some, individual mention has to be made of additional limitations, such as those with pacemakers or anticoagulation treatment

It is particularly important in which setting the proposed activity will take place The

categorization in table 4 may help in assessing fitness for participation in sports exercise.

Playful exercise

The predominantly playful character of baby swimming or mother-child gymnastics should not result in substantial exertion for the children, but no scientific studies exist that cover this topic Children learn the pleasure of sports exercise in a group of other children their own age Owing to the absence of competitive pressure, leisure exercise, playing with friends and siblings, does not entail the same risks from overexertion as, e.g., sports lessons

at school – especially because, in all experience, children are well able to limit their own levels of exertion through self-chosen breaks Overworried mothers should be encouraged

to leave their children enough independence for exercise and trust their child's own judgment more

School sports

At primary school, children with congenital heart disease as a rule encounter great understanding or tolerance for their situation In secondary schools, problems may arise if teachers do not find themselves able to concede a special role to such children/adolescents They are then not "able to bear the responsibility for the student" and suggest his or her

"release" from sports lessons Others grade exercises in which a student cannot participate owing to his or her condition, as "unsatisfactory" (the bottom grade) This increases the temptation to avoid a poor grade with the help of a doctor's certificate Teachers in this scenario should be encouraged to use their own judgment in allocating grades, to make participation in sports lessons attractive to such chronically ill children (25)

TABLE 4

Assessing fitness to exercise

Group Severity Category Recommendation for exercise

Club sports and competitive sports

In considering the pros and cons of club sports it should be remembered that children do not meet in this setting merely for the purposes of competition Often, the sharing of experiences

in the club are priority In such a setting, the recommendation vis-a-vis club sports should

be positive Competitive or professional sports, however, require a healthy cardiovascular system

Rehabilitation sports / children's heart group

The children's heart group is a medically prescribed and supervised outpatient therapeutic service for children with congenital heart disease, which is run by a qualified sports therapist

It provides the opportunity for children to be physically active in a medically supervised

"rest room." If needed, existing psychomotor deficiencies can be examined or even eliminated, and simultaneously, the conditions can be created for a complete integration into physical activities of healthy children of the same age, as far as this is possible

A scientific study of the Cologne children's heart group found a significant improvement

in movement coordination, measured with the physical coordination test for children (e12),

as a result of the training The motor quotient rose from 83.0 ± 16.4 to 92.9 ± 18.2 (p<0.001) The number of children with striking or impaired motor development was lowered from 63.2% to 39.9%

For most children, participation with a time limit (90–120 exercise units) is sufficient For children who have to be medically supervised during sports because of the severity of their disease, longer participation is desirable and sensible, to enable such children to also

be physically active The statutory health insurances fund participation in the children's heart group with 6 Euros per exercise unit (11) Recently, a current position paper about the group has been published

Conclusions

The eminent importance of exercise, games, and sports for the physical and motor, emotional, psychosocial, and cognitive development of children (7) makes it necessary to pay increased attention to sports activities among children with congenital heart disease In the recommendations, as much sports as possible should be permitted and limitations should be imposed only in cases where a health risk is to be expected

Conflict of Interest Statement

The author’s declare’s that no conflict of interest exists according to the Guidelines of the International Committee of Medical Journal Editors.

Manuscript received on 12 January 2006, final version accepted on 1 September 2006.

Translated from the original German by Dr Birte Twisselmann.

REFERENCES

For e-references please refer to the additional references listed below.

1 Fredriksen PM, Ingjer F, Nystad W, Thaulow E: A comparison of VO2(peak) between patients with congenital heart disease and healthy subjects, all aged 8–17 years Eur J Appl Physiol Occup Physiol 1999; 80: 409–16

2 Iserin L, Chua TP, Chambers J, Coats AJ, Somerville J: Dyspnoea and exercise intolerance during cardiopulmonary exercise testing in patients with univentricular heart The effects of chronic hypoxaemia and Fontan procedure Eur Heart J 1997; 18: 1350–6

3 Sarubbi B, Pacileo G, Pisacane C et al.: Exercise capacity in young patients after total repair of Tetralogy of Fallot Pediatr Cardiol 2000; 21: 211–5

4 Durongpisitkul K, Driscoll DJ, Mahoney DW et al.: Cardiorespiratory response to exercise after modified Fontan operation: determinants of performance J Am Coll Cardiol 1997; 29: 785–90

5 Nir A, Driscoll DJ, Mottram CD et al.: Cardiorespiratory response to exercise after the Fontan operation: a serial study J Am Coll Cardiol 1993; 22 : 216–20

6 Wessel HU, Paul MH: Exercise studies in tetralogy of Fallot: a review Pediatr Cardiol 1999; 20: 39–47; discussion 48

7 Dordel S, Bjarnason-Wehrens B, Lawrenz W, Leurs S, Rost R, Schickendantz S, Sticker E: Zur Wirksamkeit motorischer Förderung von Kindern mit (teil-)korrigierten angeborenen Herzfehlern Deutsche Zeitschrift für Sportmedizin 1999; 50: 41–6

8 Mitchell JH, Maron BJ, Epstein SE: 16th Bethesda Conference: Cardiovascular abnormalities in the athlete: recommendations regarding eligibility for competition October 3–5, 1984 J Am Coll Cardiol 1985; 6: 1186–232

9 Graham TP Jr, Driscoll DJ, Gersony WM, Newburger JW, Rocchini A, Towbin JA: Task Force 2: congenital heart disease J Am Coll Cardiol 2005; 45: 1326–33

10 Reybrouck T, Mertens L: Physical performance and physical activity in grown-up congenital heart disease Eur J Cardiovasc Prev Rehabil 2005; 12: 498–502

11 Bjarnason-Wehrens B, Sticker E, Lawrenz W, Held K: Die Kinderherzgruppe (KHG) – Positionspapier der DGPR.

Z Kardiol 2005; 94: 860–6

12 Hirth A, Reybrouck T, Bjarnason-Wehrens B, Lawrenz W, Hoffmann A: Recommendations for participation in ompetitive and leisure sports in patients with congenital heart disease A consensus document Eur J Cardiovasc Prev Rehabi 2006; 13: 293–9

13 Picchio FM, Giardini A, Bonvicini M, Gargiulo G: Can a child who has been operated on for congenital heart disease participate in sport and in which kind of sport? J Cardiovasc Med (Hagerstown) 2006; 7: 234–8

14 Eriksson BO: Cardiac output during exercise in pubertal boys Acta Paediatr Scand Suppl 1971; 217: 53–5

15 Leurs S: Die kardiale Leistungsfähigkeit, der motorische Entwicklungstand und die psychosoziale Situation herzkranker Kinder und Jugendlicher sowie deren Beeinflussbarkeit durch eine Kinderherzgruppe Dissertation Köln: Deutsche Sporthochschule 2004

16 Dordel S: Bewegungsförderung in der Schule Handbuch des Sportförderunterrichts Dortmund: Verlag modernes Lernen 2003

17 Lou JE, Ganley TJ, Flynn JM: Exercise and children's health Curr Sports Med Rep 2002; 1: 349–53

18 Massin MM, Hovels-Gurich HH, Gerard P, Seghaye MC: Physical activity patterns of children after neonatal arterial switch operation Ann Thorac Surg 2006; 81: 665–70

19 Lunt D, Briffa T, Briffa NK, Ramsay J: Physical activity levels of adolescents with congenital heart disease Aust J Physiother 2003; 49: 43–50

20 Dunbar-Masterson C, Wypij D, Bellinger DC et al.: General health status of children with D-transposition of the great arteries after the arterial switch operation Circulation 2001; 104: 138–42

21 Rhodes J, Curran TJ, Camil L et al.: Impact of cardiac rehabilitation on the exercise function of children with serious congenital heart disease Pediatrics 2005; 116: 1339–45

22 Fredriksen PM, Kahrs N, Blaasvaer S et al.: Effect of physical training in children and adolescents with congenital heart disease Cardiol Young 2000; 10: 107–14

23 Coplan NL, Gleim GW, Nicholas JA: Exercise and sudden cardiac death Am Heart J 1988; 115: 207–12

24 Schwartz PJ, Priori SG, Spazzolini C et al.: Genotype-phenotype correlation in the long-QT syndrome:

gene-specific triggers for life-threatening arrhythmias Circulation 2001; 103: 89–95

25 Sticker EJ, Leurs S, Bjarnason-Wehrens B, Dordel S, Schickendantz S: „Sport macht stark“ – Herzkranke Kinder und Jugendliche im Sportunterricht Aachen: Bundesverband Herzkranke Kinder e.V (Hrsg.) 2003

ADDITIONAL REFERENCES

e1 Driscoll DJ: Exercise rehabilitation programs for children with congenital heart disease: A note of caution Pediatric Exercise Science 1990; 2: 191–6

e2 Reybrouck T, Bisschop A, Dumoulin M, van der Hauwaert LG: Cardiorespiratory exercise capacity after surgical closure of atrial septal defect is influenced by the age at surgery Am Heart J 1991; 122: 1073–8

e3 Balderston SM, Daberkow E, Clarke DR, Wolfe RR: Maximal voluntary exercise variables in children with postoperative coarctation of the aorta J Am Coll Cardiol 1992; 19: 154–8

e4 Sklansky MS, Bricker JT: Guidelines for exercise and sports participation in children and adolescents with congenital heart disease Prog Pediatr Cardiol 1993; 2: 55–66

e5 Kaminer SJ, Hixon RL, Strong WB: Evaluation and recommendations for participation in athletics for children with heart disease Curr Opin Pediatr 1995; 7: 595–600

e6 Graf C, Rost R: Herz und Sport Balingen: Spitta Verlag 2001

e7 Zimmer R: Handbuch der Psychomotorik Freiburg-Basel-Wien: Verlag Herder 1999

e8 Washington RL: Cardiac rehabilitation programmes in children Sports Med 1992; 14: 164–70

e9 Goldberg B: Sports and exercise for children with chronic health conditions Guidelines for participation from leading pediatric authorities Champaign: Human Kinetics 1995

e10 Longmuir PE, Tremblay MS, Goode RC: Postoperative exercise training develops normal levels of physical activity

in a group of children following cardiac surgery Pediatr Cardiol 1990; 11: 126–30

e11 Longmuir PE, Turner JA, Rowe RD, Olley PM: Postoperative exercise rehabilitation benefits children with congenital heart disease Clin Invest Med 1985; 8: 232–8

e12 Schilling F: Körperkoordinationstest für Kinder KTK Manual Weinheim: 1974

Corresponding author

Dr med Sabine Schickendantz

Klinik und Poliklinik für Kinderkardiologie

Klinikum der Universität zu Köln

Kerpener Str 62

50937 Köln, Germany