Sport, exercise & congenital Sport, exercise & congenital cardiac conditionscardiac conditions

Lynne Kendall Lynne Kendall

Clinical Specialist Physiotherapist Clinical Specialist Physiotherapist

June 2009June 2009

Is exercising good for Is exercising good for everyone?everyone?

What do What do youyou think re exercise: think re exercise: Who needs to exercise?Who needs to exercise? How much? How much? How often?How often? What type?What type?

How much exercise?How much exercise?

Public health guidelines for children:Public health guidelines for children:

Recommend Recommend 60 minutes60 minutes (daily total, it can be (daily total, it can be done in 15” chunks) of done in 15” chunks) of moderatemoderate level activity level activity on on most daysmost days of the week (minimum of 5). of the week (minimum of 5).

‘‘Moderate’ level means enough to make you Moderate’ level means enough to make you breathe harder (bit ‘puffed out’) & feel warmer.breathe harder (bit ‘puffed out’) & feel warmer.

Exercise intolerance Exercise intolerance common in CHDcommon in CHD

Due to individual cardiac anatomy & Due to individual cardiac anatomy & physiology and differences in how the physiology and differences in how the heart & circulation work during exerciseheart & circulation work during exercise

Other factors such as: habitual low level Other factors such as: habitual low level physical activity; exercise not encouraged physical activity; exercise not encouraged or allowed in childhood; possible or allowed in childhood; possible overprotection or apathy in some schoolsoverprotection or apathy in some schools

What do we know?What do we know?Problems in Adult CHD - lessons to be learned?Problems in Adult CHD - lessons to be learned?

♥ Poor exercise tolerance &/or Poor exercise tolerance &/or low habitual low habitual PAPA may ‘mask’ changes in cardiac function may ‘mask’ changes in cardiac function

♥ ACHD px’s ACHD px’s ‘used to’ poor ex tolerance‘used to’ poor ex tolerance and and may not c/o symptoms until advanced may not c/o symptoms until advanced changes in heart functionchanges in heart function

♥ MisconceptionsMisconceptions: exercise; ‘cured’ condition: exercise; ‘cured’ condition♥ Other factorsOther factors: Overweight; unfit; : Overweight; unfit;

‘deconditioning’ → long-term consequences ‘deconditioning’ → long-term consequences on health?on health?

Types of ExerciseTypes of Exercise

1.1. Dynamic or isotonic exerciseDynamic or isotonic exercise Changes in muscle length & joint Changes in muscle length & joint

movement, rhythmic contractionsmovement, rhythmic contractions [steady state][steady state]

2.2. Static or isometric exerciseStatic or isometric exercise Sudden, large intramuscular force, Sudden, large intramuscular force,

little/no change in muscle little/no change in muscle length/joint movementlength/joint movement

[Most activities involve a combination of the two][Most activities involve a combination of the two]

Exercise and congenital Exercise and congenital cardiac defectscardiac defects

Problems can be due to 3 main factors:Problems can be due to 3 main factors:

♥ Limitations due to the Limitations due to the naturenature of of the cardiac condition the cardiac condition

♥ Restrictions imposed by Restrictions imposed by clinicians clinicians becausebecause of the of the condition condition (safety)(safety)

♥ ‘‘Other’ restrictions or Other’ restrictions or misconceptions re exercisemisconceptions re exercise

Condition (symptom) limitedCondition (symptom) limited

♥ Many conditions are ‘symptom limited’ Many conditions are ‘symptom limited’ ♥ Often complex conditions e.g. Fontan; HLHS; PHT…Often complex conditions e.g. Fontan; HLHS; PHT…

♥ Reduced exercise tolerance due to nature Reduced exercise tolerance due to nature of heart condition of heart condition →→ adapt activities adapt activities

♥ ‘‘Pacing’ during exercise; long warm up & Pacing’ during exercise; long warm up & cool down cool down (*(*self–limit*????)self–limit*????)

♥ Emphasis on what CAN do (at Emphasis on what CAN do (at ownown level) level)

Examples: activity guidelinesExamples: activity guidelines REMEMBER – INDIVIDUAL!!REMEMBER – INDIVIDUAL!! NB: May be able to NB: May be able to modifymodify activity to allow activity to allow

some participation – some participation – level of intensitylevel of intensity..

♥ Congenital Aortic Stenosis Congenital Aortic Stenosis moderate → severe moderate → severe

advised to avoid at school/home:advised to avoid at school/home: Maximal exercise tests - Bleep/Cooper TestsMaximal exercise tests - Bleep/Cooper Tests Distance runningDistance running Sprint running or ‘Burst’ type exertionSprint running or ‘Burst’ type exertion Weights or high isometric (static) type effort Weights or high isometric (static) type effort ““Competitive” sport & training sessionsCompetitive” sport & training sessions

Activity guidelinesActivity guidelines♥ Coarctation of AortaCoarctation of Aorta – repaired (?BP) – repaired (?BP)

Avoid free weight-lifting / intense isometric exerciseAvoid free weight-lifting / intense isometric exercise

♥ MarfanMarfan syndrome syndrome – aortic dilatation/mitral valve– aortic dilatation/mitral valve Avoid weight-lifting / isometric exerciseAvoid weight-lifting / isometric exercise Avoid sport with risk of bodily collision(contact sport)Avoid sport with risk of bodily collision(contact sport) Some martial arts (direct blow over chest or head)Some martial arts (direct blow over chest or head) Trampolining, step aerobics etc – care re jointsTrampolining, step aerobics etc – care re joints

♥ Potential ArrhythmiasPotential Arrhythmias : Cardiomyopathies; : Cardiomyopathies; Long QT; Long QT; better to avoid intense level activitybetter to avoid intense level activity

♥ WarfarinWarfarin avoid contact or ‘rough’ sports - risks of avoid contact or ‘rough’ sports - risks of bodily collision - special care head/abdomenbodily collision - special care head/abdomen

Key pointsKey points Many young people need little or no restriction Many young people need little or no restriction

(& do NOT take (& do NOT take enoughenough exercise!) exercise!) Inclusion not exclusion Inclusion not exclusion →→ school & PEschool & PE Confusion about terms such as ‘recreational’, Confusion about terms such as ‘recreational’,

‘non-competitive’, ‘non-contact’, ‘normal’…‘non-competitive’, ‘non-contact’, ‘normal’… Underestimation of the need for Underestimation of the need for detaileddetailed

counselling re sport/leisure/work activitiescounselling re sport/leisure/work activities Misunderstanding between cardiac symptoms & Misunderstanding between cardiac symptoms &

lack of fitnesslack of fitness Lack of information/understanding re exercise & Lack of information/understanding re exercise &

their cardiac conditiontheir cardiac condition [Do not know what NEED to Know][Do not know what NEED to Know]

What input do congenital heart What input do congenital heart patient’s need?patient’s need?

Regular review in specialist centreRegular review in specialist centre Education re cardiac anatomy/physiology Education re cardiac anatomy/physiology

& implications on lifestyle issues& implications on lifestyle issues Exercise advice – aim to increase daily PA Exercise advice – aim to increase daily PA

to meet public health guidelines to meet public health guidelines within their own condition tolerance

Some will need structured cardiac rehabSome will need structured cardiac rehab Risks of ↓PA; acquired heart diseaseRisks of ↓PA; acquired heart disease

Proactive exercise: Does it make a Proactive exercise: Does it make a difference?difference?

Young people, parents & Young people, parents & teachers report benefits:teachers report benefits: exercise tolerance, confidence, exercise tolerance, confidence, peer integration, contact between peer integration, contact between appointments, reassurance, appointments, reassurance, independence / transition / life independence / transition / life skills / growing upskills / growing up

Possible saving of Possible saving of cardiologists’ clinic timecardiologists’ clinic time

Increased awareness at Increased awareness at all levelsall levels

Prompted to ASK!Prompted to ASK!

What type of exercise?What type of exercise?

Something you enjoy!Something you enjoy! Remember the Remember the ‘Talk Test’ rule‘Talk Test’ rule::

You should still be able to speak when You should still be able to speak when exercising exercising

If you have enough breath to sing you need to If you have enough breath to sing you need to work harder!work harder!

If you are too breathless to speak you need to If you are too breathless to speak you need to stop & rest…stop & rest…

Does it HAVE to be sport?!Does it HAVE to be sport?!

Encourage outdoor Encourage outdoor play/activities/picnicsplay/activities/picnics

Dress for the weather!Dress for the weather! Visit NT gardens etc Visit NT gardens etc

many activities for children in many activities for children in school holidays / minibeasts, school holidays / minibeasts, treasure hunts, pond dipping…treasure hunts, pond dipping…

Music & Drama clubs Music & Drama clubs Childrens veggie plot, Childrens veggie plot,

allotments, gardens…allotments, gardens… Wii ….?Wii ….?

ANY activity is goodANY activity is good

What can families do?What can families do?

♥ ASK Cardiologist if ASK Cardiologist if *ANY**ANY* activities to avoid activities to avoid *But be *But be specific about what you want to do!specific about what you want to do!

♥ Promote Physical ActivityPromote Physical Activity♥ Encourage healthy Encourage healthy

eating/lifestyleeating/lifestyle♥ Ensure school fully Ensure school fully

informedinformed♥ Make a list of questions for Make a list of questions for

each clinic appointmenteach clinic appointment

What to do?What to do?

Change4Life Change4Life http://www.nhs.uk/change4lifehttp://www.nhs.uk/change4life

Green gyms Green gyms http://www2.btcv.org.uk/display/greengymhttp://www2.btcv.org.uk/display/greengym

Walking Walking http://www.whi.org.uk/http://www.whi.org.uk/ Get outdoors! Get outdoors!

http://www.naturalengland.org.uk/http://www.naturalengland.org.uk/ Cycle Cycle http://www.sustrans.org.uk/http://www.sustrans.org.uk/

Is exercising good for Is exercising good for everyone?everyone?

What do What do youyou think re exercise: think re exercise: Who needs to exercise?Who needs to exercise? How much? How much? How often?How often? What type?What type?

SummarySummary

Always individualAlways individual – ask cardiologist re – ask cardiologist re current cardiac statuscurrent cardiac status

Important to be physically active Important to be physically active →→ adaptadapt

Increase PA awareness as child grows upIncrease PA awareness as child grows up

Monitor changes in conditionMonitor changes in condition

Transition to adult servicesTransition to adult services

ReferencesReferences

Graham TP, Driscoll DJ, Gersony WM, et al. 36th Bethesda Conference: Eligibility Graham TP, Driscoll DJ, Gersony WM, et al. 36th Bethesda Conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities. recommendations for competitive athletes with cardiovascular abnormalities. Task Force 2: Congenital heart disease. J Am Coll Cardiol 2005;45:1326-33.Task Force 2: Congenital heart disease. J Am Coll Cardiol 2005;45:1326-33.

Hirth A, Reybrouck T, Bjarnason-Wehrens B, Lawrenz W, Hoffman A. Hirth A, Reybrouck T, Bjarnason-Wehrens B, Lawrenz W, Hoffman A. Recommendations for participation in competitive and leisure sports in patients Recommendations for participation in competitive and leisure sports in patients with congenital heart disease: a consensus document. European Journal of with congenital heart disease: a consensus document. European Journal of Cardiovascular Prevention & Rehabilitation 2006;13:293-299. Cardiovascular Prevention & Rehabilitation 2006;13:293-299.

Kendall L, Parsons JM, Sloper P and Lewin RJP. A simple screening method for Kendall L, Parsons JM, Sloper P and Lewin RJP. A simple screening method for determining knowledge of the appropriate levels of activity and risk behaviour in determining knowledge of the appropriate levels of activity and risk behaviour in young people with congenital cardiac conditions. Cardiology in the Young young people with congenital cardiac conditions. Cardiology in the Young 2007;17(2):151-157.2007;17(2):151-157.

Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity and recreational sports for young patients with genetic cardiovascular diseases. and recreational sports for young patients with genetic cardiovascular diseases. Circulation 2004;109:2807-16.Circulation 2004;109:2807-16.

Pelliccia A, Fagard R, Bjornstad HH, Anastassakis A, Arbustini E, Assanelli D, Biffi A, et Pelliccia A, Fagard R, Bjornstad HH, Anastassakis A, Arbustini E, Assanelli D, Biffi A, et al. Recommendations for competitive sports participation in athletes with al. Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the study group of sports cardiovascular disease: A consensus document from the study group of sports cardiology of the working group of cardiac rehabilitation and exercise physiology cardiology of the working group of cardiac rehabilitation and exercise physiology and the working group of myocardial and pericardial diseases of the european and the working group of myocardial and pericardial diseases of the european society of cardiology. European Heart Journal 2005;26:1422-1445. society of cardiology. European Heart Journal 2005;26:1422-1445.

Reybrouck TAC, Mertens LB. Physical performance and physical activity in grown-up Reybrouck TAC, Mertens LB. Physical performance and physical activity in grown-up congenital heart disease. European Journal of Cardiovascular Prevention & congenital heart disease. European Journal of Cardiovascular Prevention & Rehabilitation 2005; 12(5):498-502.Rehabilitation 2005; 12(5):498-502.

Rhodes J et al. Impact of cardiac rehabilitation on the exercise function of children with Rhodes J et al. Impact of cardiac rehabilitation on the exercise function of children with serious congenital heart disease. Pediatrics 2005;116:1339-45.serious congenital heart disease. Pediatrics 2005;116:1339-45.

Swan L and Hillis WS. Exercise prescription in adults with congenital heart disease: a Swan L and Hillis WS. Exercise prescription in adults with congenital heart disease: a long way to go. Heart 2000;83, 685-687.long way to go. Heart 2000;83, 685-687.

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