Cardiopulmonary Rehabilitation Improves Respiratory Muscle Function and Functional Capacity in Children with Congenital Heart Disease. A Prospective Cohort Study

Application of an Early Graded Rehabilitation Nursing Model in Postoperative Children With Congenital Heart Disease

BACKGROUND

The current focus of cardiac rehabilitation is on adults, with no standard nursing plan available for children with congenital heart disease. Therefore, it is very necessary to develop a standardized early rehabilitation nursing model for children with congenital heart disease to promote the recovery of bodily functions and improve quality of life in this population.

PURPOSE

This study was designed to explore the feasibility of an early graded rehabilitation nursing model for postoperative children with congenital heart disease and evaluate its clinical effect to promote the standardization of postoperative rehabilitation nursing care.

METHODS

One hundred and sixteen postoperative children with congenital heart disease treated at a medical university hospital between August 2022 and January 2023 enrolled as participants in this study, with 58 assigned to the control (routine rehabilitation nursing) group and 58 assigned to the intervention (graded rehabilitation nursing) group. The outcome indicators of the two groups were assessed at the time the participants transferred out of the pediatric intensive care unit (PICU) and at discharge, and then analyzed and compared. The Strengthening the Reporting of Observational Studies in Epidemiology Checklist (case-control studies) was used in this study.

RESULTS

No statistical differences were found between the two groups at baseline. After implementation of the model, more intervention group participants succeeded in achieving difficult target functions when they were transferred out of the PICU and at discharge. At discharge, intervention group participants aged 3 months to 3 years showed higher gross motor quotient (95.36 ± 7.46 vs. 86.77 ± 12.34), fine motor quotient (94.79 ± 4.59 vs. 88.73 ± 14.04), and total motor quotient (95.57 ± 5.49 vs. 86.27 ± 13.08) than their peers in the control group. Also, the average 6-minute walk test (6MWT) duration for intervention group participants older than 3 years was longer than that for their control group peers. Furthermore, average total hospital stay (16.60 ± 5.14 vs. 20.69 ± 12.95 days) and PICU residence time (122.48 ± 46.00 vs. 133.66 ± 66.70 hours) were shorter in the intervention group than the control group. No adverse events occurred during the study period.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The early graded rehabilitation nursing model is safe and feasible. This model can help children achieve more difficult target functions, significantly improve their motor development ability, and shorten their hospital stay. Also, the model can help guide medical staff implement rehabilitation nursing in clinical settings.

The effect of strength training interventions on people with congenital heart disease: a systematic review

AIM

To assess the effectiveness and safety of strength training (ST) interventions in people with congenital heart disease (ConHD).

METHODS

Participants included people of all ages diagnosed with all complexity of ConHD. Interventions included strength training or inspiratory muscle training (IMT) which were delivered in whole or as part of a more holistic programme. Included studies were randomised controlled trials, non-randomised controlled trials and cohort studies. A comprehensive literature search using five databases until June 2023 was conducted. Two authors independently screened all the identified studies and assessed the risk of bias. Due to the paucity of studies and significant differences in study design, albatross plots were produced, and synthesis without meta-analyses was used to assist in the interpretation of results.

RESULTS

A total of 26 studies were included with a total of 659 participants (53% female). Three of five studies demonstrated that ST significantly improves muscle strength. The albatross plots (20 studies) compared peak oxygen consumption (peak V̇O2) of ST alone, combined training and IMT and showed that 16 studies observed an improvement with a standardised mean difference between 0.10 and 0.50. Combined training was more effective than ST alone and IMT for peak V̇O2, and ST alone was second. The results showed high heterogeneity. Three studies (one ST alone and two combined training) reported a total of five adverse events, but none reported serious adverse events or fatalities.

CONCLUSION

This systematic review indicates a moderate improvement in muscle strength by ST alone, with a small improvement in peak V̇O2 in people with ConHD. Although the outcomes are positive, there is still insufficient evidence to establish the clinical significance of ST.

[Evaluation of the effectiveness and safety of aerobic cyclical trainings in children after surgical correction of congenital heart diseases and features of short-term adaptation depending on the type of pathology]

Aerobic cyclical trainings in children with congenital heart diseases (CHDs) are insufficiently covered in the literature. Nevertheless, they are the most effective and safe for improvement of aerobic capacity in case of individually adjusted intensity of the load and with a strict pulse control during the exercises.

OBJECTIVE

To evaluate the effectiveness and safety of aerobic cyclical trainings on cycle ergometers in children in the long term after surgical correction of CHDs and to study the features of short-term adaptation of the child's body to exercises on stationary bicycles in setting of rehabilitation center depending on the type of CHD.

MATERIAL AND METHODS

The study included 80 children with CHDs aged between 10 and 17 years in the long term after Fontan procedure, aortic valve replacement, surgical correction of aortic coarctation or septal defects hospitalized for rehabilitation course in 2023. Intensity of exercises on stationary bicycles was determined based on clinical examination results in the absence of contraindications. The trainings were performed under the control of electrocardiography, tonometry and oxygen saturation; the intensity of exercises was automatically adjusted depending on the reaction of the cardiovascular system to the load.

RESULTS

Anthropometric and anamnestic data of the studied group were analyzed. Low physical activity was characteristic of most children with CHDs, that has affected the results of exercise tolerance test. A number of trainings equal from 6 to 9 (Me=6) were performed during the course of cardiac rehabilitation. A statistically significant increase in the load in training sessions during hospitalization, comparing the first exercise both with the last training (p=0.05) and with one with the maximum capacity (p<0.001), has been found. The dynamics of load in trainings according to the type of CHD was analyzed, including a deeper analysis of subgroups of children after Fontan procedure, as well as individual clinical examples of examinations and trainings of children with different CHDs in case of re-hospitalization were presented. No adverse events were noted during the study.

CONCLUSION

Aerobic cyclical trainings on cycle ergometer are safe for children with CHDs with adequately selected intensity of trainings. The performed study allowed to indicate the features of «urgent» adaptation to exercises on cycle ergometers in adolescents with different CHDs and to develop the theme of formation of adaptive mechanisms to physical load.

Comparative Analysis of Respiratory and Functional Outcomes in Children Post-Fontan Procedure Versus Healthy Peers

Studies have shown that respiratory muscle training enhances functional capacity and pulmonary function in Fontan patients. However, diaphragm muscle characteristics in Fontan children have not been fully elucidated. The aim of this study was to compare respiratory function, maximal and submaximal functional capacities, and quality of life, as well as to assess diaphragm mobility and thickness, between Fontan patients aged 8 to 12 years and healthy individuals. This cross-sectional study included 45 children-27 Fontan patients, Fontan Group (FG) and 18 healthy control Group (CG) subjects. Different examinations were performed: spirometry was used to analyze pulmonary volume and capacity; manovacuometry was used to determine respiratory muscle strength; chest ultrasound was used to determine diaphragm muscle characteristics; cardiopulmonary exercise and the six-minute walk test (6MWT) were used to determine functional capacity; the AUQEI questionnaire was used to determine quality of life. Descriptive analysis and intergroup comparisons were performed for all the data. Compared with the CG, the FG exhibited impaired pulmonary function and reduced functional capacity. Significant differences in median values were noted for forced expiratory volume in one second (FEV1): 2.39 L/min, p = 0.002; forced vital capacity (FVC): 1.73 vs. 3.06 L/min, p = 0.002; maximal inspiratory pressure: - 73 vs. - 117 cmH2O, p = 0.007; absolute peak VO2: 1.09 vs. 1.51 L/min, p < 0.001; relative peak VO2: 31.9 vs. 42.5 mL/kg/min, p = 0.003; and 6MWT distance: 420 vs. 586 m, p < 0.001. Diaphragmatic thickness, mobility and quality of life were similar between the groups. Despite the reduced functional capacity, impaired pulmonary volume and capacity, and respiratory muscle weakness of the FG compared to those of the CG, the diaphragm characteristics and quality of life were similar between the groups.

The oxygen uptake efficiency slope in adults with CHD: group validity

The maximal oxygen uptake (V02 max) is a well-validated measure of cardiorespiratory function that is calculated during a maximal cardiopulmonary exercise test. V02 max enables physicians to objectively assess cardiopulmonary function to aid in decision-making for patients with CHD. A significant proportion of these patients however are unable to achieve a maximal exercise test, and as such, there is a need for reliable submaximal predictors of cardiorespiratory reserve.The oxygen uptake efficiency slope represents a measure of how effectively oxygen is extracted from the lungs and taken into the body and can be calculated from a submaximal exercise test. Its reliability as a predictor of cardiorespiratory reserve has been validated in various patient populations, but there is limited evidence for its validity in adult patients with CHD.Retrospective analysis of cardiopulmonary exercise test data in 238 consecutive patients with CHD who completed a maximal cardiopulmonary exercise test at our tertiary cardiology centre demonstrated a strong correlation between peak V02 and the oxygen uptake efficiency slope (0.936). A strong correlation with peak V02 was also demonstrated when oxygen uptake efficiency slope was calculated at ventilatory anaerobic threshold (OUESVAT), 75% (OUES75), and 90% (OUES90) of the test (0.833, 0.905, 0.927 respectively).In adult patients with CHD who are unable to complete a maximal cardiopulmonary exercise test, the oxygen uptake efficiency slope is a reliable indicator of cardiopulmonary fitness which correlates strongly with peak V02 at or beyond the ventilatory anaerobic threshold. Further research is required to validate the findings in patients with less common anatomies and to assess the relationship between the oxygen uptake efficiency slope and mortality.

The comparison of functional status and health-related parameters in ovarian cancer survivors with healthy controls

PURPOSE

The primary purpose of this study was to evaluate functional status and health-related parameters in ovarian cancer (OC) survivors and to compare these parameters with healthy controls. The secondary purpose of this study was to compare these parameters in early and advanced OC survivors.

METHODS

Thirty-two OC survivors (n = 15 early stage; n = 17 advanced stage) with no evidence/suspicion of cancer recurrence after completing adjuvant local and systemic treatments for at least 12 months and 32 healthy controls were recruited for functional- and health-related assessments. Participants were assessed using the following methods of measuring the following: 6-min walk test (6MWT) for functional exercise capacity, 30-s chair stand test (30 s-CST) for functional fitness and muscle endurance, a handheld dynamometer for peripheral muscle strength, and a handheld dynamometer for lower extremity strength, Medical Micro RPM for respiratory muscle strength, International Physical Activity Questionnaire-Short Form (IPAQ-SF) for physical activity level, and Eastern Cooperative Oncology Group Performance Scale (ECOG-PS) for performance status, Checklist Individual Strength (CIS) for fatigue, Treatment/Gynecological Oncology-Neurotoxicity (FACT/GOG-NTX) for neuropathy, the Hospital Anxiety and Depression Scale (HADS) for anxiety and depression level, and the World Health Organization-Five Well-Being Index (WHO-5) for generic quality of life.

RESULTS

All OC survivors underwent surgery and chemotherapy, and only 9.4% received radiotherapy in addition to chemotherapy. The median recurrence-free period post-completion of adjuvant treatments was 24.00 (12.00-75.00) months. OC survivors had lower 6MWT (m) (p < 0.001, r = 1.50), peripheral muscle strength (p = 0.005, r = 0.72), knee extension (p < 0.001, r = 1.54), and respiratory muscle strength (maximal inspiratory pressure) (p < 0.001, r = 1.90) (maximal expiratory pressure) (p < 0.001, r = 1.68) compared to healthy controls. HADS-A (p = 0.005, r = 0.75) and CIS scores (p = 0.025, r = 0.59) were also higher in the OC survivors. Early-stage OC survivors had better 6MWT (m) than advanced-stage OC survivors (p = 0.005, r = 1.83). Peripheral muscle strength was lower in advanced-stage OC survivors (p = 0.013, r = 0.92). FACT/GOG-NTX scores were higher in early-stage OC survivors (p < 0.001, r = 1.42). No significant differences were observed between early- and advanced-stage OC survivors in other measures (p < 0.05).

CONCLUSION

The findings suggest functional status, and health-related parameters are negatively affected in OC survivors. Additionally, higher levels of fatigue, neuropathy anxiety, and depression were reported in advanced OC survivors.

Submaximal Field Walking Tests Applied in the Cardiopulmonary Assessment in Congenital Heart Diseases: A Systematic Review

INTRODUCTION

Submaximal field walking tests are easy to apply and low cost, but it is necessary to standardize their application, especially in the pediatric population. The feasibility and its use in patients with congenital heart disease have been studied. The goal of this study was to verify which are the submaximal field walking tests applied in the cardiopulmonary assessment of children and adolescents with CHD and to verify if they are being performed as recommended by the standardization protocols/guidelines.

METHODS

Literature review through a search in six electronic databases, structured in PICO format, without date restrictions. Looking for studies that used submaximal field walking tests in children and adolescents with congenital heart disease aged 5 to 18 years. Methodological quality, effectiveness and safety and risk of bias were assessed.

RESULTS

Five studies met the eligibility criteria with a sample of 160 individuals with congenital heart disease, and all used the six-minute walk test. Note that different methodologies and modifications are used. Only the clinical trial showed good methodological quality.Four studies had low risk of bias and one study had moderate risk.

CONCLUSION

Although the six-minute walk test is the only test used as a field test found in our research, there is no standardization in the application of the test, making it difficult to compare the results. In this sense, reducing the limitations and heterogeneity in the application of the test will enable more concrete outcomes and facilitate their reproduction in clinical practice.

Effects of Sports, Exercise Training, and Physical Activity in Children with Congenital Heart Disease-A Review of the Published Evidence

Children and adolescents with congenital heart disease (CHD) should be encouraged to adopt a physically active lifestyle, ideally by participating in sports activities at school and sports clubs. Children with complex CHD or other risk factors (for example, pacemakers, cardioverter-defibrillators, channelopathies) may, however, need specific individualized training programs. This review article summarizes the current knowledge regarding the clinical effects of sports and exercise training on CHD and its pathophysiologic mechanisms. An evidence-based approach based on a literature search, using PubMed, Medline, CINHAL, Embase, and the Cochrane Library was conducted, last completed on 30 December 2021. In studies with 3256 CHD patients in total, including 10 randomized controlled trials, 14 prospective interventional trials, 9 observational trials, and 2 surveys, exercise training has been shown to improve exercise capacity and physical activity, motoric skills, muscular function, and quality of life. Sports and exercise training appears to be effective and safe in CHD patients. Despite being cost-efficient, training programs are currently scarcely reimbursed; therefore, support from healthcare institutions, commissioners of healthcare, and research-funding institutions is desirable. There is a strong need to establish specialized rehabilitation programs for complex CHD patients to enhance these patients' access to this treatment intervention. Further studies may be desirable to confirm these data to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.

Peripheral and respiratory muscle strength in children and adolescents with CHD: systematic review and meta-analysis

Patients with CHD are less active if compared with controls and have limited functional capacity, related to muscle weakness and fatigue. The aim of this study was to evaluate the peripheral and respiratory muscle strength of children and adolescents with CHD with systematic review and meta-analysis. The review included observational and randomised control trial studies which evaluated peripheral and respiratory muscle strength in children and adolescents with CHD under 18 years old. The peripheral muscle strength was evaluated through dynamometry and respiratory muscle strength through manovacuometry. In studies that compared patients with CHD and respective control groups, it was possible to perform a meta-analysis. A total of 5634 articles met the criteria of eligibility, 15 were included in the systematic review, and 4 were included in the meta-analysis. Twelve studies assessed peripheral muscle strength with a reduction in patients with CHD. In the meta-analysis, patients with CHD had lower muscle strength than controls (-34.07 nm; 95% CI, -67.46 to -0.68; I2 47%; p for heterogeneity = 0.05), and the meta-analysis of the handgrip muscle strength showed no significant difference between patients with CHD and controls (0.08 nm; 95% CI, -6.39 to 6.55; I2 98%; p for heterogeneity <0.00001). The meta-analysis in the present study  showed lower limb muscle strength in patients with CHD in comparison to controls. In contrast, no difference was found regarding hand grip strength. Also, the review showed lower respiratory muscle strength in patients with CHD, yet no meta-analysis was possible to perform.

Every child with congenital heart disease should be exercising

PURPOSE OF REVIEW

Historically, children with congenital heart disease have been restricted from exercise, contributing to a sedentary lifestyle as well as increased cardiovascular risk factors. Given the large benefits and small risks of exercise in this population, guidelines have recently shifted towards exercise promotion. However, these recommendations have yet not gained traction and children with congenital heart disease continue to live sedentary lives. The purpose of this review is to summarize the current literature on exercise and exercise promotion in this population.

RECENT FINDINGS

New literature reinforces the importance of recommending exercise and improving exercise capacity both in congenital heart disease in general and for specific lesions. Exercise recommendations should be individualized based on functional parameters using a structured methodology to approach the evaluation, risk classification, and prescriptions of exercise and physical activity.

SUMMARY

Regular exercise is essential for children with congenital heart disease and providers must take an active role in providing exercise recommendations for their patients. Exercise promotion remains a challenge, necessitating novel approaches to promote exercise. Further studies are needed to improve the risk stratification of patients with congenital heart disease, assess the long-term outcomes of specific exercise interventions, and inform individualized recommendations to encourage children with congenital heart disease to safely engage in exercise and establish healthy lifelong habits that will decrease their cardiovascular risk.

Effects of Cardiopulmonary Rehabilitation on the Muscle Function of Children with Congenital Heart Disease: A Prospective Cohort Study

Critical medical and surgical advances have led to a shift in the care and management of children with congenital heart disease (CHD). These patients present with muscle deconditioning, which negatively influences their response to exercise, functional capacities, and quality of life. This study evaluates the influence of a cardiopulmonary rehabilitation program (CPRP) on the function of peripheral musculature of children with CHD. A single-center prospective cohort study was designed. Fifteen CHD subjects, between 12 and 16 years of age, with reduced aerobic capacity on a cardiopulmonary exercise test, were included in a three-month, 24-session CPRP. Measurements of the subjects' handgrip strength, biceps brachii and quadriceps femoris strength, and triceps surae fatigue process were collected at the beginning of the program, after completion, and six months after the end of the intervention. A substantial and statistically significant improvement was observed in the subjects' handgrip strength (kg) (p < 0.001), biceps brachii and quadriceps femoris strength (N) (p < 0.001), as well as triceps surae fatigue process (repetitions) (p = 0.018), with a maintenance of the results six months after the intervention. These results suggest that a CPRP could potentially improve the peripheral muscle function of children with CHD. Additional research is needed to confirm and expand on this hypothesis.