International Journal of Cardiology, 28 (1990) 151-158 Elsevier
CARD10
151
01095
Rehabilitation
of children after total correction of tetralogy of Fallot
A. Calzolari, A. Turchetta, G. Biondi, F. Drago, C. De Ranieri, G. Gagliardi, I. Giambini, S. Giannico, A.M. Kofler, F. Perrotta, A. Santilli, P. Vezzoli, P. Ragonese and C. Marcelletti Ospedale Pediatric0 Bambino
Gesic, Rome, Ztaly
(Received 12 December 1988; revision accepted 2 February 1990)
Calzolari A, Turchetta A, Biondi G, Drago F, De Ranieri C, Gagliardi G, Giambini I, Giannico S, Kofler AM, Perrotta F, Santilli A, Vezzoli P, Ragonese P, Marcelletti C. Rehabilitation of children after total correction of tetralogy of Fallot. Int J Cardiol 1990;28:151-158. Nine children who had undergone total correction of tetralogy of Fallot were studied with the purpose of observing the physical changes that might be produced by a period of rehabilitation in hospital and comparing these results with those of a control group having the same pathology but which had not followed a protocol for physical activity. Precise criteria were used in the selection of the patients. Careful clinical examinations and exercise tests were conducted before and after the programme, in particuhu maximal stress testing on the bicycle ergometer and submaximal exercise on the treadmill. The sessions were held three times weekly in a gymnasium over three months, gradually increasing the duration of each session to a maximum of one hour. During the session, heart rate was monitored with a Sport-tester 3000 so as not to exceed 60%, then 70%, of the maximal heart rate recorded during the stress test. Testing at the end of the programme demonstrated an improvement in tolerance under maximal stress in 7 of the 9 patients. As for submaximal performance, 8 out of 9 children covered a greater distance using the same parameters as for initial testing. At the end of the programme, the children all showed increased independence and initiative and more self-confidence in establishing social relations. The programme has proven to be a comprehensive method for safely improving physical fitness in these patients and represents an important starting point for a better future Key words: Rehabilitation;
Tetralogy of Fallot; Exercise test; Pediatric cardiology
The number of centres providing facilities for paediatric cardiac surgery in Italy increases con-
tinually. Approximately 2400 children with congenital heart disease are born every year in our country, and about half of them require surgical repair. Because of this, there is a growing awareness of the problems created by and for children undergoing surgery for congenital heart disease; in
Correspondence to: Dr. A. Calzolari, Serviz.io di Medicina dello Sport, Ospedale Pediatric0 Bambino Gesh, Piazza S. Onofrio 4, 00165 Rome, Italy.
particular their social integration among healthy peers is problematic. This problem must be solved as soon as possible. Several authors [l-3] have
Introduction
0167-5273/90/$03.50
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
152
studied the cardiovascular performance of these patients in order to offer more reliable advice on physical activity. Many more investigators [4-111 have studied the effect that programmed physical exercise has on their muscular and cardiopulmonary function. In all these reports, the case material has been limited. Indeed, the rehabilitation centres involved with this problem have difficulty finding a large number of children for their protocols of rehabilitation. The reasons for this vary from less collaboration on the part of parents to excessive distance between hospital and home. The purpose of our study was to evaluate the effect that programmed and supervised physical exercise can have on the cardiovascular system of a child who has undergone total correction of tetralogy of Fallot. Our study was limited to this particular congenital malformation so that data could be obtained from as homogeneous as possible a group of patients. Material and Methods We examined a group of patients consisting of 9 children (6 boys and 3 girls) between the ages of 6 and 16.5 years, who had all undergone corrective surgery for tetralogy of Fallot. One of them had previously undergone palliative surgery (right Blalock-Taussig shunt). The mean age at the time of total correction was 34 months. In none of the 9 patients had a patch been placed across the ventriculo-pulmonary junction. The limited number of patients is due to the preliminary choice of working with only one type of pathology and, above all, as discussed above, because of problems regarding family logistics, traffic, the work schedule of the parents and the schooling of the children, all problems that are difficult to solve. The criteria for selecting candidates included a minimal age of 6 years; a minimal lapse of one year since surgery; absence of residual haemodynamic defects as evaluated with cross-sectional and Doppler echocardiogram (a gradient of less than 30 mm Hg across the right ventricular outflow tract and the presence of mild residual
pulmonary insufficiency were considered negligible haemodynamic defects); absence of ongoing cardiologic therapy; absence of significant arrhythmias on evaluation with Holter and stress testing (Lown class 1 ventricular arrhythmia was not considered to be significant); performance of a normal maximal stress test on the bicycle ergometer; and residence preferably in the environment of our hospital. The children underwent the following tests: paediatric physical examination and anthropometric-auxologic evaluation; cardiologic examination; electrocardiography at rest; chest X-ray (only before starting rehabilitation protocol; cross-sectional and Doppler echocardiography; maximal stress test on a bicycle ergometer using the protocol of James et al. [12]; submaximal stress test on a treadmill; 24-hour dynamic Holter monitoring; and lung function testing. These tests were conducted before and were repeated not later than 10 days after the progranmre of rehabilitation. The sessions were held in our hospital gymnasium and the children participated 3 times a week for 3 months. The duration of the sessions was progressively increased to a maximum of one hour. The three-month duration of the protocol was predicated on the experience of other authors [8,10,11] and because it was necessary not to overlap the Christmas and Easter holidays. Because of the weather conditions in our country, it was not possible to apply the protocol during the summer. Therefore, to avoid interrupting the programme for lo-15 days, the duration of the programme had to be no longer than 90 days. The children always wore appropriate clothing (gym suits and shoes) and were instructed to have a good breakfast, since the sessions began at 12 noon. The sessions were conducted by hospital personnel specialized in physiotherapy and were always under medical supervision. An emergency medical cart was made available for the assistance of the paramedical personnel and consisted of facilities for electrocardiography, supply of oxygen with a mask, and antiarrhythmic and inotropic drugs. The sessions were divided into 4 parts, each of which became gradually longer as the protocol proceeded.
153
The first part consisted of exercises to teach the children to breathe better. The second part included exercises for stretching the muscles and improving the function of their tendons before starting the programmed activity. During the third part, physical exercises were alternated with games designed with the specific purpose of entertaining the children. The fourth part consisted of relaxation after exercising, in order to have the children leave the gymnasium in a physical condition similar to their condition prior to the session. Heart rates at rest and during the sessions were measured with a PE 3000 heart rate recorder, which, when specifically programmed, can print out a graph of heart rate recorded at 5 second intervals. Careful attention was paid to monitoring heart rates so as not to exceed the following values: in the first part of the programme, 60% of the highest heart rate measured during maximal stress test on the bicycle ergometer; 70% of the same highest heart rate during the second part. The same pretraining exercise tests were repeated at the end of the rehabilitation programme, in particular the maximal stress test on the bicycle ergometer and the submaximal treadmill test. The submaximal treadmill test was achieved by having the child run with the speed of the treadmill regulated to maintain heart rate at 70% of the highest rate recorded during the maximal stress test on the bicycle ergometer conducted before and after the programme. Using these parameters, the distance in metres covered by each child during the two different tests was measured.
The control group consisted of 9 children (six boys and three girls) between 6 and 16 years of age, who had also undergone corrective surgery for tetralogy of Fallot. The criteria for admission to the study and the procedures for the clinical and instrumental tests were the same as for the other group. In the time between the first and second controls (3 months), the children did not engage in organized physical activity. They carried on their normal relations with peers and scholastic activity. Statistical Analysis We compared the data collected before and after the programme from the stress tests on the bicycle ergometer and the treadmill and the lung function tests. The total work performed on the bicycle ergometer was compared between the groups after three months of observation. The improvement data recorded in the treadmill tests were also compared. Lastly, in the control group, a comparison was made between the first and second tests of total work on the bicycle ergometer and the distance covered on the treadmill. Paired Student’s t-testing and the A-square test were used for the statistical analysis of the results. Results Generally speaking, the parents offered excellent collaboration and the children demonstrated great enthusiasm. Throughout the entire pro-
TABLE 1 Weight (W), height (H) and body surface area (BSA), before and after the rehabilitation protocol in the patient group. Pre-rehabilitation
Patient
Post-rehabilitation
Age
Sex
W (kg)
H (cm)
BSA (m’)
W (kg)
H (cm)
BSA (m*)
7.8 8.0 8.9 12.3 16.5 7.10 14.5 6.10 7.50
M F M M M F M F M
20.3 26.0 30.5 42.0 49.7 23.0 42.8 21.0 31.0
115.5 127.5 138.0 156.0 171.0 124.0 162.0 120.0 135.0
0.83 0.98 1.08 1.37 1.58 0.91 1.40 0.87 1.07
21.0 27.8 37.0 44.8 52.5 24.0 43.1 22.0 32.0
116 130 141 158 175 126 164 121 136
0.84 1.00 1.21 1.42 1.62 0.93 1.43 0.89 1.10
154 TABLE 2 Weight (IV), height (H) and body surface area (BSA), before and after rehabilitation protocol in the control group. 2nd Control
1st Control
Patient Age
Sex
W (kg)
H (cm)
BSA (m*)
W (kg)
H (cm)
BSA (m’)
6 I 9 9 16.0 6.5 13 8.8 7.0
M F M M M F M F M
20 25 31 46.1 41 24.5 48 21 28
112 116 136 140.5 170 122 160.5 117 146
0.78 0.90 1.09 1.32 1.54 0.91 1.47 0.84 1.10
20.2 26 32.1 48 49.7 25 49.2 24 30.2
113 118 138 143 171 123 163 121 149
0.82 0.91 1.13 1.34 1.56 0.92 1.50 0.90 1.17
gramme we recorded only 10% absences because of medical reasons (influenza, colds, etc.) or logistics (problems with transportation). Tables 1 and 2 contain the anthropometric data (weight, height and body surface area) of both groups. Given the short lapse of time between measurements, no significant differences were found. On the other hand, these parameters were necessary to conduct and interpret the bicycle ergometer tests correctly, and to evaluate respiratory function. None of the children presented anthropometric characteristics outside the range of normal values for their age. Electrocardiography at rest revealed complete right bundle branch block in all patients. In no
TABLE
case was evidence found of any other type of associated electrocardiographic abnormalities. The maximal stress test on the bicycle ergometer (see Table 3) showed an improvement in stress tolerance after the programme in 7 out of 9 children. These children were able to complete a longer test and to tolerate a greater total workload compared to the test performed prior to the programme of rehabilitation. The data collected have no statistical significance. What is demonstrated, however, is a trend in most of the children toward improved performance in the second test. Heart rates and maximum systolic arterial pressures showed no changes worthy of note. The duration of test performance and total work capacity for all the participants
3
Results of bicycle exercise test, before and after rehabilitation (James protocol) in the patient group. Patient
1 2 3 4 5 6 7 8 9
Time (min)
HR,,
TW (kg)
BP,,
Pre
Post
Pre
Post
Pre
Post
Pre
Post
6.4 6.0 7.8 8.7 12 4.3 10 4.2 4.0
6.6 6.2 6.0 9.1 13 5.0 11 3.8 4.5
170 155 194 177 178 172 170 172 162
174 162 172 175 168 178 180 182 180
106 112 140 144 170 110 160 120 130
108 122 132 140 186 118 170 114 120
1700 1500 2900 4300 7500 975 5500 900 1000
1760 1625 1800 4650 8700 1200 6500 825 1200
HR = heart rate; BP = blood pressure; TW = total workload.
155 TABLE 4 Results of bicycle exercise test, before and after rehabilitation (James protocol) in the control group. Patient
1 2 3 4 5 6 7 8 9
Time (mm)
HR,,
TW (kg)
BP,,
Pre
Post
Pre
Post
Pre
Post
Pre
Post
4.5 5.3 4.6 7.0 12.6 4.1 10.5 4.2 5.0
4.8 5.0 4.8 6.8 11.5 5.3 9.8 4.0 4.9
180 160 158 200 169 157 200 200 180
186 159 166 197 166 167 195 198 182
120 120 120 122 160 120 154 114 132
124 122 126 120 156 124 150 118 130
975 1250 1200 2900 8150 1000 6300 970 1400
1130 1200 1350 2750 7000 1280 5300 900 1350
For abbreviations see Table 3.
were found to be below the levels recorded in healthy peers. This is consistent with the findings of other authors [13,14]. In contrast, Table 4 shows that there was no improvement in cardiovascular performance of the patients used as controls between the first and second tests. The results are not uniform and have no statistical significance. The submaximal treadmill stress tests, performed according to the criteria previously described, showed that 8 of the 9 patients undergoing rehabilitation could run a greater distance in the second test than in the first test (Table 5). The parameter of reference, 70% of the highest heart rate on the bicycle ergometer, was the same in both test performances for all the children. There-
fore, given equal heart rates and time, a greater distance was travelled on the treadmill. The results demonstrate that the comparison of the distances covered in the two tests by each single patient is statistically significant (P < 0.004). Once again, there was no indication in the patients used as controls (see Table 6) for any statistically significant differences between the two tests. As for these tests, comparison between the groups of rehabilitated patients and those used as controls showed the improvement in the distance covered in the submaximal treadmill stress test by the patients undergoing rehabilitation to be statistically significant (P < 0.004). The total work performed on the bicycle ergometer, however, had no
TABLE 5
TABLE 6
Results of submaximal exercise test on treadmill, before and after rehabilitation in the patient group.
Results of submaximal exercise test on treadmill, before and after rehabilitation in the control group.
Patient
HR 70%
Distance (m)
Patient
HR 70%
Distance (m)
Pre
Post
Pre
Post
Pre
Post
Pre
Post
119 109 136 125 125 120 119 120 113
122 112 120 122 118 125 126 127 126
846 347 525 614 706 408 724 304 412
860 487 573 706 753 490 782 290 496
126 112 110 140 118 110 140 140 126
130 111 116 138 116 117 136 139 127
750 341 450 580 730 400 715 300 420
770 330 465 564 702 474 680 272 410
Abbreviations: see legend Table 3.
For abbreviations see Table 3.
156 TABLE I Results of lung function tests in the patient group. Patient
FEV
FVC Post
Pre
Post
Pre
Post
0.943 1.085 1.953 3.020 3.602 1.426 2.950 1.100 1.580
1.240 1.573 1.866 3.150 3.580 1.732 3.100 1.200 1.500
0.922 1.052 1.649 2.780 3.330 1.062 2.507 0.950 1.422
1.140 1.540 1.540 2.870 3.385 1.428 2.600 0.980 1.406
0.97 1.76 1.62 3.62 3.79 2.14 3.80 2.48 2.84
1.60 2.49 1.73 3.82 3.88 2.04 4.00 2.37 2.60
FVC = forced vital capacity (litres); FEV = forced expiratory (litres/second).
volume/second
statistical significance between the groups (P = 0.142). Right of the nine children undergoing rehabilitation improved their submaximal performance, while improvement was observed in three of nine children not undergoing rehabilitation (&i-square < 0.05). The improvement in total work is not significant between the two groups. Table 7 contains the results of the tests of lung function. In the test prior to the rehabilitation programme, two children (cases 1 and 2) showed a decrease in the recorded parameters, without exhibiting any symptoms. These values reverted to normal during the second test, indicating that the children probably collaborated to a greater extent. In the other cases, the parameters were normal.
TABLE
MMEF
Pre
8
Results of electrocardiographic tient group.
Holter monitoring
in the pa-
Patient
Arrhythmias
HR(max)
HR (mm)
ST
RBBB
1 2 3 4 5 6 7 8 9
1LoWn no no 1LoWn no 1LoWn no 1LoWll no
160 150 160 110 150 150 152 150 158
50 80 70 50 50 50 48 80 70
no no no no no no no no no
yes yes yes yes yes yes yes yes yes
RBBB= right bundle see Table 3.
branch block.
For other abbreviations
(Ii&s);
MMEF = maximum
medium expiratory
flow
The 24-hour dynamic electrocardiographic monitoring performed before the programme failed to reveal any significant arrhythmias (see Table 8). There was evidence of ectopic ventricular beats, Lown class 1, in three cases and complete right bundle branch block in all patients. Similarly, no abnormal findings were observed in either the Holter or lung function tests for those not undergoing rehabilitation. Discussion The need to conduct rehabilitation in a hospital environment for children undergoing corrective surgery is not prescribed by precise laws that are already in force in our country [15], but such rehabilitation should facilitate the return of these children to everyday life. Considering our present knowledge of the matter, such rehabilitation should not be conducted at home. This is in keeping with the experience of other authors [5,7,8,10,11,16-181 who, for various reasons, have preferred to conduct rehabilitation in a “protected” (hospital) environment, under direct medical control. A programme of hospital-based rehabilitation, nonetheless, produces great difficulties for parents, since they must attend the hospital with their children 3 times a week for 3 months, often under difficult traffic conditions. A large city like Rome creates considerable problems of this sort, and is a
157
limiting factor in expanding the programme to include more children. The results of our study are similar to those of other [8,10,11,16-181 and demonstrate the value of a period of hospital-based rehabilitation. It leads to an improvement in performance (especially submaximal aerobic performance) and to an enhancement of self-confidence, particularly when compared with the results of patients not undergoing rehabilitation. It is evident that, in the brief period of three months, the growth of the child cannot significantly modify the ability to perform the required exercises and, consequently, the functional tests. It must also be remembered that tests involving machines (bicycle, treadmill, lung function) can possibly be performed better a second time, simply as a result of experience. The results from the patients not undergoing rehabilitation, however, show that learning has a very limited significance for the observed improvement. Subsequent to rehabilitation, parents also realize that their children can participate in recreational physical activity and that they must avoid strenuous and continuous exertion that, potentially, could be life threatening. If, as stated before, the purpose of the programme is for the child to become more aware of his physical limits and to teach him to perform correctly the physical activity that is most suitable for him, then we are convinced that this has been accomplished. The children all responded enthusiastically to stimulation and understood both the physical limits resulting from their condition and the fact that they must never engage in competitive sports. It is, nonetheless, important for them to have realized they can play with healthy peers, attend school normally and that they need not feel “different”. In addition, the programme protects the physician, and helps him to provide any certificates of fitness required for recreational physical activity. Having conducted programmed physical exercise, having found no evidence of pathologic effects (such as symptoms, arrhythmias, etc.), having found statistically significant improvement in the ability to perform submaximal work, having taught the children a physical activity that is suita-
ble for them, having made the parents understand which activities their child can participate in and what level of intensity is not to be exceeded, we are encouraged to continue in this endeavour. We hope that, in the future, more children will be able to participate in our programme. And it is necessary to create other rehabilitation centres in our country so as to provide more opportunities and to compare the results of such programmes. Acknowledgements We thank Mrs. Claudia Fariello for the translation, Mrs. Nadia Ciciani, Mrs. Paola Petta and Miss Antonietta Piras for their collaboration. References 1 James FW. Effects of physical stress on adolescents. Postgrad Med 1974;6:53-59. 2 Driscoll DJ. Cardiovascular evaluation of the child and adolescent before participation in sports. Mayo Clin Proc 1985;60:867-873. 3 Winslow EBJ. Cardiac rehabilitation. J Am Med Assoc 1987;9:163-181. 4 Scardi S. La riabilitazione cardiologica in Italia: realm attuale e prospettive future. Riabil 1985;1:5-15. 5 Donovan EF, Mathews RA, Nixon PA, et al. An exercise program for pediatric patients with congenital heart disease: psychosocial aspects. J Cardiac Rehabil 1983;3:476480. 6 Blair DE, Fletcher GF, Sheffield T. AHA Committee Report. Standards for supervised cardiovascular exercise maintenance programs. Report of the subcommittee on exercise rehabilitation, target activity group. Circulation 1980;3:669-672. chez les 7 Pernot Cl, Goepfert PC, Pemot C. Rklucation enfants atteints de cardiopathies. Encyclopedic MedicoChirurgiciale. Paris 26505 A10 4.6.07. 8 Vaccaro P, Galioto FM, Bradley LM, Hansen DA, Vaccaro J. Development of a cardiac rehabilitation programme for children. Sports Med 1984;1:259-262. 9 Goforth D, James FW. Exercise training in noncoronary heart disease. Cardiovasc Clin 1984;2:134-146. 10 Mathews R4, Nixon PA, Stephenson RJ, et al. An exercise program for pediatric patients with congenital heart disease: organizational and physiologic aspects. J Cardiac Rehabil 1983;3:467-475. 11 Ruttenberg HD, Adams TD, Orsmond GS, Conlee RR, Fisher GA. Effects of exercise training on aerobic fitness in children after open heart surgery. Pediatr Cardiol 1983;1:19-24.
158 12 James FW, Kaplan S, Glueck CJ, Tsay JY, Knight MJ, Sarwar CJ. Responses of normal children and young adults to controlled bicycle exercise. Circulation 1980;5:902-912. 13 James, FW, Kaplan S, Schwartz DC, Chou TC, Sandker MJ, Naylor V. Response to exercise in patients after total surgical correction of tetralogy of Fallot. Circulation 1916;54:671-679. 14 Wessel HU, Milton P. Exercise performance in tetralogy of Fallot after intracardiac repair. J Thorac Cardiovasc Surg 1980;4:582-593. 15 Tutela della salute e pratica sportiva. Suppl al Bollettino N.S. Ordine dei Medici di Roma e Provincia.
16 Longmuir PE, Turner JAP, Rowe RD, Olley PM. Postoperative exercise rehabilitation benefits children with congenital heart disease. Clin Invest Med 1985;3:232-238. 17 Goldberg B, Fripp RR, Lister G, Loke J, Nicholas JA, Talner NS. Effect of physical training on exercise performance of children following surgical repair of congenital heart disease. Pediatrics 1981;5:691-699. 18 Bradley LM, Gahoto FM, Vaccaro P, Hansen DA, Vaccaro J. Effect of intense aerobic training on exercise performance in children after surgical repair of tetralogy of Fallot or complete transposition of the great arteries. Am J Cardiol 1985;56:816-818.
CARD10
151
01095
Rehabilitation
of children after total correction of tetralogy of Fallot
A. Calzolari, A. Turchetta, G. Biondi, F. Drago, C. De Ranieri, G. Gagliardi, I. Giambini, S. Giannico, A.M. Kofler, F. Perrotta, A. Santilli, P. Vezzoli, P. Ragonese and C. Marcelletti Ospedale Pediatric0 Bambino
Gesic, Rome, Ztaly
(Received 12 December 1988; revision accepted 2 February 1990)
Calzolari A, Turchetta A, Biondi G, Drago F, De Ranieri C, Gagliardi G, Giambini I, Giannico S, Kofler AM, Perrotta F, Santilli A, Vezzoli P, Ragonese P, Marcelletti C. Rehabilitation of children after total correction of tetralogy of Fallot. Int J Cardiol 1990;28:151-158. Nine children who had undergone total correction of tetralogy of Fallot were studied with the purpose of observing the physical changes that might be produced by a period of rehabilitation in hospital and comparing these results with those of a control group having the same pathology but which had not followed a protocol for physical activity. Precise criteria were used in the selection of the patients. Careful clinical examinations and exercise tests were conducted before and after the programme, in particuhu maximal stress testing on the bicycle ergometer and submaximal exercise on the treadmill. The sessions were held three times weekly in a gymnasium over three months, gradually increasing the duration of each session to a maximum of one hour. During the session, heart rate was monitored with a Sport-tester 3000 so as not to exceed 60%, then 70%, of the maximal heart rate recorded during the stress test. Testing at the end of the programme demonstrated an improvement in tolerance under maximal stress in 7 of the 9 patients. As for submaximal performance, 8 out of 9 children covered a greater distance using the same parameters as for initial testing. At the end of the programme, the children all showed increased independence and initiative and more self-confidence in establishing social relations. The programme has proven to be a comprehensive method for safely improving physical fitness in these patients and represents an important starting point for a better future Key words: Rehabilitation;
Tetralogy of Fallot; Exercise test; Pediatric cardiology
The number of centres providing facilities for paediatric cardiac surgery in Italy increases con-
tinually. Approximately 2400 children with congenital heart disease are born every year in our country, and about half of them require surgical repair. Because of this, there is a growing awareness of the problems created by and for children undergoing surgery for congenital heart disease; in
Correspondence to: Dr. A. Calzolari, Serviz.io di Medicina dello Sport, Ospedale Pediatric0 Bambino Gesh, Piazza S. Onofrio 4, 00165 Rome, Italy.
particular their social integration among healthy peers is problematic. This problem must be solved as soon as possible. Several authors [l-3] have
Introduction
0167-5273/90/$03.50
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
152
studied the cardiovascular performance of these patients in order to offer more reliable advice on physical activity. Many more investigators [4-111 have studied the effect that programmed physical exercise has on their muscular and cardiopulmonary function. In all these reports, the case material has been limited. Indeed, the rehabilitation centres involved with this problem have difficulty finding a large number of children for their protocols of rehabilitation. The reasons for this vary from less collaboration on the part of parents to excessive distance between hospital and home. The purpose of our study was to evaluate the effect that programmed and supervised physical exercise can have on the cardiovascular system of a child who has undergone total correction of tetralogy of Fallot. Our study was limited to this particular congenital malformation so that data could be obtained from as homogeneous as possible a group of patients. Material and Methods We examined a group of patients consisting of 9 children (6 boys and 3 girls) between the ages of 6 and 16.5 years, who had all undergone corrective surgery for tetralogy of Fallot. One of them had previously undergone palliative surgery (right Blalock-Taussig shunt). The mean age at the time of total correction was 34 months. In none of the 9 patients had a patch been placed across the ventriculo-pulmonary junction. The limited number of patients is due to the preliminary choice of working with only one type of pathology and, above all, as discussed above, because of problems regarding family logistics, traffic, the work schedule of the parents and the schooling of the children, all problems that are difficult to solve. The criteria for selecting candidates included a minimal age of 6 years; a minimal lapse of one year since surgery; absence of residual haemodynamic defects as evaluated with cross-sectional and Doppler echocardiogram (a gradient of less than 30 mm Hg across the right ventricular outflow tract and the presence of mild residual
pulmonary insufficiency were considered negligible haemodynamic defects); absence of ongoing cardiologic therapy; absence of significant arrhythmias on evaluation with Holter and stress testing (Lown class 1 ventricular arrhythmia was not considered to be significant); performance of a normal maximal stress test on the bicycle ergometer; and residence preferably in the environment of our hospital. The children underwent the following tests: paediatric physical examination and anthropometric-auxologic evaluation; cardiologic examination; electrocardiography at rest; chest X-ray (only before starting rehabilitation protocol; cross-sectional and Doppler echocardiography; maximal stress test on a bicycle ergometer using the protocol of James et al. [12]; submaximal stress test on a treadmill; 24-hour dynamic Holter monitoring; and lung function testing. These tests were conducted before and were repeated not later than 10 days after the progranmre of rehabilitation. The sessions were held in our hospital gymnasium and the children participated 3 times a week for 3 months. The duration of the sessions was progressively increased to a maximum of one hour. The three-month duration of the protocol was predicated on the experience of other authors [8,10,11] and because it was necessary not to overlap the Christmas and Easter holidays. Because of the weather conditions in our country, it was not possible to apply the protocol during the summer. Therefore, to avoid interrupting the programme for lo-15 days, the duration of the programme had to be no longer than 90 days. The children always wore appropriate clothing (gym suits and shoes) and were instructed to have a good breakfast, since the sessions began at 12 noon. The sessions were conducted by hospital personnel specialized in physiotherapy and were always under medical supervision. An emergency medical cart was made available for the assistance of the paramedical personnel and consisted of facilities for electrocardiography, supply of oxygen with a mask, and antiarrhythmic and inotropic drugs. The sessions were divided into 4 parts, each of which became gradually longer as the protocol proceeded.
153
The first part consisted of exercises to teach the children to breathe better. The second part included exercises for stretching the muscles and improving the function of their tendons before starting the programmed activity. During the third part, physical exercises were alternated with games designed with the specific purpose of entertaining the children. The fourth part consisted of relaxation after exercising, in order to have the children leave the gymnasium in a physical condition similar to their condition prior to the session. Heart rates at rest and during the sessions were measured with a PE 3000 heart rate recorder, which, when specifically programmed, can print out a graph of heart rate recorded at 5 second intervals. Careful attention was paid to monitoring heart rates so as not to exceed the following values: in the first part of the programme, 60% of the highest heart rate measured during maximal stress test on the bicycle ergometer; 70% of the same highest heart rate during the second part. The same pretraining exercise tests were repeated at the end of the rehabilitation programme, in particular the maximal stress test on the bicycle ergometer and the submaximal treadmill test. The submaximal treadmill test was achieved by having the child run with the speed of the treadmill regulated to maintain heart rate at 70% of the highest rate recorded during the maximal stress test on the bicycle ergometer conducted before and after the programme. Using these parameters, the distance in metres covered by each child during the two different tests was measured.
The control group consisted of 9 children (six boys and three girls) between 6 and 16 years of age, who had also undergone corrective surgery for tetralogy of Fallot. The criteria for admission to the study and the procedures for the clinical and instrumental tests were the same as for the other group. In the time between the first and second controls (3 months), the children did not engage in organized physical activity. They carried on their normal relations with peers and scholastic activity. Statistical Analysis We compared the data collected before and after the programme from the stress tests on the bicycle ergometer and the treadmill and the lung function tests. The total work performed on the bicycle ergometer was compared between the groups after three months of observation. The improvement data recorded in the treadmill tests were also compared. Lastly, in the control group, a comparison was made between the first and second tests of total work on the bicycle ergometer and the distance covered on the treadmill. Paired Student’s t-testing and the A-square test were used for the statistical analysis of the results. Results Generally speaking, the parents offered excellent collaboration and the children demonstrated great enthusiasm. Throughout the entire pro-
TABLE 1 Weight (W), height (H) and body surface area (BSA), before and after the rehabilitation protocol in the patient group. Pre-rehabilitation
Patient
Post-rehabilitation
Age
Sex
W (kg)
H (cm)
BSA (m’)
W (kg)
H (cm)
BSA (m*)
7.8 8.0 8.9 12.3 16.5 7.10 14.5 6.10 7.50
M F M M M F M F M
20.3 26.0 30.5 42.0 49.7 23.0 42.8 21.0 31.0
115.5 127.5 138.0 156.0 171.0 124.0 162.0 120.0 135.0
0.83 0.98 1.08 1.37 1.58 0.91 1.40 0.87 1.07
21.0 27.8 37.0 44.8 52.5 24.0 43.1 22.0 32.0
116 130 141 158 175 126 164 121 136
0.84 1.00 1.21 1.42 1.62 0.93 1.43 0.89 1.10
154 TABLE 2 Weight (IV), height (H) and body surface area (BSA), before and after rehabilitation protocol in the control group. 2nd Control
1st Control
Patient Age
Sex
W (kg)
H (cm)
BSA (m*)
W (kg)
H (cm)
BSA (m’)
6 I 9 9 16.0 6.5 13 8.8 7.0
M F M M M F M F M
20 25 31 46.1 41 24.5 48 21 28
112 116 136 140.5 170 122 160.5 117 146
0.78 0.90 1.09 1.32 1.54 0.91 1.47 0.84 1.10
20.2 26 32.1 48 49.7 25 49.2 24 30.2
113 118 138 143 171 123 163 121 149
0.82 0.91 1.13 1.34 1.56 0.92 1.50 0.90 1.17
gramme we recorded only 10% absences because of medical reasons (influenza, colds, etc.) or logistics (problems with transportation). Tables 1 and 2 contain the anthropometric data (weight, height and body surface area) of both groups. Given the short lapse of time between measurements, no significant differences were found. On the other hand, these parameters were necessary to conduct and interpret the bicycle ergometer tests correctly, and to evaluate respiratory function. None of the children presented anthropometric characteristics outside the range of normal values for their age. Electrocardiography at rest revealed complete right bundle branch block in all patients. In no
TABLE
case was evidence found of any other type of associated electrocardiographic abnormalities. The maximal stress test on the bicycle ergometer (see Table 3) showed an improvement in stress tolerance after the programme in 7 out of 9 children. These children were able to complete a longer test and to tolerate a greater total workload compared to the test performed prior to the programme of rehabilitation. The data collected have no statistical significance. What is demonstrated, however, is a trend in most of the children toward improved performance in the second test. Heart rates and maximum systolic arterial pressures showed no changes worthy of note. The duration of test performance and total work capacity for all the participants
3
Results of bicycle exercise test, before and after rehabilitation (James protocol) in the patient group. Patient
1 2 3 4 5 6 7 8 9
Time (min)
HR,,
TW (kg)
BP,,
Pre
Post
Pre
Post
Pre
Post
Pre
Post
6.4 6.0 7.8 8.7 12 4.3 10 4.2 4.0
6.6 6.2 6.0 9.1 13 5.0 11 3.8 4.5
170 155 194 177 178 172 170 172 162
174 162 172 175 168 178 180 182 180
106 112 140 144 170 110 160 120 130
108 122 132 140 186 118 170 114 120
1700 1500 2900 4300 7500 975 5500 900 1000
1760 1625 1800 4650 8700 1200 6500 825 1200
HR = heart rate; BP = blood pressure; TW = total workload.
155 TABLE 4 Results of bicycle exercise test, before and after rehabilitation (James protocol) in the control group. Patient
1 2 3 4 5 6 7 8 9
Time (mm)
HR,,
TW (kg)
BP,,
Pre
Post
Pre
Post
Pre
Post
Pre
Post
4.5 5.3 4.6 7.0 12.6 4.1 10.5 4.2 5.0
4.8 5.0 4.8 6.8 11.5 5.3 9.8 4.0 4.9
180 160 158 200 169 157 200 200 180
186 159 166 197 166 167 195 198 182
120 120 120 122 160 120 154 114 132
124 122 126 120 156 124 150 118 130
975 1250 1200 2900 8150 1000 6300 970 1400
1130 1200 1350 2750 7000 1280 5300 900 1350
For abbreviations see Table 3.
were found to be below the levels recorded in healthy peers. This is consistent with the findings of other authors [13,14]. In contrast, Table 4 shows that there was no improvement in cardiovascular performance of the patients used as controls between the first and second tests. The results are not uniform and have no statistical significance. The submaximal treadmill stress tests, performed according to the criteria previously described, showed that 8 of the 9 patients undergoing rehabilitation could run a greater distance in the second test than in the first test (Table 5). The parameter of reference, 70% of the highest heart rate on the bicycle ergometer, was the same in both test performances for all the children. There-
fore, given equal heart rates and time, a greater distance was travelled on the treadmill. The results demonstrate that the comparison of the distances covered in the two tests by each single patient is statistically significant (P < 0.004). Once again, there was no indication in the patients used as controls (see Table 6) for any statistically significant differences between the two tests. As for these tests, comparison between the groups of rehabilitated patients and those used as controls showed the improvement in the distance covered in the submaximal treadmill stress test by the patients undergoing rehabilitation to be statistically significant (P < 0.004). The total work performed on the bicycle ergometer, however, had no
TABLE 5
TABLE 6
Results of submaximal exercise test on treadmill, before and after rehabilitation in the patient group.
Results of submaximal exercise test on treadmill, before and after rehabilitation in the control group.
Patient
HR 70%
Distance (m)
Patient
HR 70%
Distance (m)
Pre
Post
Pre
Post
Pre
Post
Pre
Post
119 109 136 125 125 120 119 120 113
122 112 120 122 118 125 126 127 126
846 347 525 614 706 408 724 304 412
860 487 573 706 753 490 782 290 496
126 112 110 140 118 110 140 140 126
130 111 116 138 116 117 136 139 127
750 341 450 580 730 400 715 300 420
770 330 465 564 702 474 680 272 410
Abbreviations: see legend Table 3.
For abbreviations see Table 3.
156 TABLE I Results of lung function tests in the patient group. Patient
FEV
FVC Post
Pre
Post
Pre
Post
0.943 1.085 1.953 3.020 3.602 1.426 2.950 1.100 1.580
1.240 1.573 1.866 3.150 3.580 1.732 3.100 1.200 1.500
0.922 1.052 1.649 2.780 3.330 1.062 2.507 0.950 1.422
1.140 1.540 1.540 2.870 3.385 1.428 2.600 0.980 1.406
0.97 1.76 1.62 3.62 3.79 2.14 3.80 2.48 2.84
1.60 2.49 1.73 3.82 3.88 2.04 4.00 2.37 2.60
FVC = forced vital capacity (litres); FEV = forced expiratory (litres/second).
volume/second
statistical significance between the groups (P = 0.142). Right of the nine children undergoing rehabilitation improved their submaximal performance, while improvement was observed in three of nine children not undergoing rehabilitation (&i-square < 0.05). The improvement in total work is not significant between the two groups. Table 7 contains the results of the tests of lung function. In the test prior to the rehabilitation programme, two children (cases 1 and 2) showed a decrease in the recorded parameters, without exhibiting any symptoms. These values reverted to normal during the second test, indicating that the children probably collaborated to a greater extent. In the other cases, the parameters were normal.
TABLE
MMEF
Pre
8
Results of electrocardiographic tient group.
Holter monitoring
in the pa-
Patient
Arrhythmias
HR(max)
HR (mm)
ST
RBBB
1 2 3 4 5 6 7 8 9
1LoWn no no 1LoWn no 1LoWn no 1LoWll no
160 150 160 110 150 150 152 150 158
50 80 70 50 50 50 48 80 70
no no no no no no no no no
yes yes yes yes yes yes yes yes yes
RBBB= right bundle see Table 3.
branch block.
For other abbreviations
(Ii&s);
MMEF = maximum
medium expiratory
flow
The 24-hour dynamic electrocardiographic monitoring performed before the programme failed to reveal any significant arrhythmias (see Table 8). There was evidence of ectopic ventricular beats, Lown class 1, in three cases and complete right bundle branch block in all patients. Similarly, no abnormal findings were observed in either the Holter or lung function tests for those not undergoing rehabilitation. Discussion The need to conduct rehabilitation in a hospital environment for children undergoing corrective surgery is not prescribed by precise laws that are already in force in our country [15], but such rehabilitation should facilitate the return of these children to everyday life. Considering our present knowledge of the matter, such rehabilitation should not be conducted at home. This is in keeping with the experience of other authors [5,7,8,10,11,16-181 who, for various reasons, have preferred to conduct rehabilitation in a “protected” (hospital) environment, under direct medical control. A programme of hospital-based rehabilitation, nonetheless, produces great difficulties for parents, since they must attend the hospital with their children 3 times a week for 3 months, often under difficult traffic conditions. A large city like Rome creates considerable problems of this sort, and is a
157
limiting factor in expanding the programme to include more children. The results of our study are similar to those of other [8,10,11,16-181 and demonstrate the value of a period of hospital-based rehabilitation. It leads to an improvement in performance (especially submaximal aerobic performance) and to an enhancement of self-confidence, particularly when compared with the results of patients not undergoing rehabilitation. It is evident that, in the brief period of three months, the growth of the child cannot significantly modify the ability to perform the required exercises and, consequently, the functional tests. It must also be remembered that tests involving machines (bicycle, treadmill, lung function) can possibly be performed better a second time, simply as a result of experience. The results from the patients not undergoing rehabilitation, however, show that learning has a very limited significance for the observed improvement. Subsequent to rehabilitation, parents also realize that their children can participate in recreational physical activity and that they must avoid strenuous and continuous exertion that, potentially, could be life threatening. If, as stated before, the purpose of the programme is for the child to become more aware of his physical limits and to teach him to perform correctly the physical activity that is most suitable for him, then we are convinced that this has been accomplished. The children all responded enthusiastically to stimulation and understood both the physical limits resulting from their condition and the fact that they must never engage in competitive sports. It is, nonetheless, important for them to have realized they can play with healthy peers, attend school normally and that they need not feel “different”. In addition, the programme protects the physician, and helps him to provide any certificates of fitness required for recreational physical activity. Having conducted programmed physical exercise, having found no evidence of pathologic effects (such as symptoms, arrhythmias, etc.), having found statistically significant improvement in the ability to perform submaximal work, having taught the children a physical activity that is suita-
ble for them, having made the parents understand which activities their child can participate in and what level of intensity is not to be exceeded, we are encouraged to continue in this endeavour. We hope that, in the future, more children will be able to participate in our programme. And it is necessary to create other rehabilitation centres in our country so as to provide more opportunities and to compare the results of such programmes. Acknowledgements We thank Mrs. Claudia Fariello for the translation, Mrs. Nadia Ciciani, Mrs. Paola Petta and Miss Antonietta Piras for their collaboration. References 1 James FW. Effects of physical stress on adolescents. Postgrad Med 1974;6:53-59. 2 Driscoll DJ. Cardiovascular evaluation of the child and adolescent before participation in sports. Mayo Clin Proc 1985;60:867-873. 3 Winslow EBJ. Cardiac rehabilitation. J Am Med Assoc 1987;9:163-181. 4 Scardi S. La riabilitazione cardiologica in Italia: realm attuale e prospettive future. Riabil 1985;1:5-15. 5 Donovan EF, Mathews RA, Nixon PA, et al. An exercise program for pediatric patients with congenital heart disease: psychosocial aspects. J Cardiac Rehabil 1983;3:476480. 6 Blair DE, Fletcher GF, Sheffield T. AHA Committee Report. Standards for supervised cardiovascular exercise maintenance programs. Report of the subcommittee on exercise rehabilitation, target activity group. Circulation 1980;3:669-672. chez les 7 Pernot Cl, Goepfert PC, Pemot C. Rklucation enfants atteints de cardiopathies. Encyclopedic MedicoChirurgiciale. Paris 26505 A10 4.6.07. 8 Vaccaro P, Galioto FM, Bradley LM, Hansen DA, Vaccaro J. Development of a cardiac rehabilitation programme for children. Sports Med 1984;1:259-262. 9 Goforth D, James FW. Exercise training in noncoronary heart disease. Cardiovasc Clin 1984;2:134-146. 10 Mathews R4, Nixon PA, Stephenson RJ, et al. An exercise program for pediatric patients with congenital heart disease: organizational and physiologic aspects. J Cardiac Rehabil 1983;3:467-475. 11 Ruttenberg HD, Adams TD, Orsmond GS, Conlee RR, Fisher GA. Effects of exercise training on aerobic fitness in children after open heart surgery. Pediatr Cardiol 1983;1:19-24.
158 12 James FW, Kaplan S, Glueck CJ, Tsay JY, Knight MJ, Sarwar CJ. Responses of normal children and young adults to controlled bicycle exercise. Circulation 1980;5:902-912. 13 James, FW, Kaplan S, Schwartz DC, Chou TC, Sandker MJ, Naylor V. Response to exercise in patients after total surgical correction of tetralogy of Fallot. Circulation 1916;54:671-679. 14 Wessel HU, Milton P. Exercise performance in tetralogy of Fallot after intracardiac repair. J Thorac Cardiovasc Surg 1980;4:582-593. 15 Tutela della salute e pratica sportiva. Suppl al Bollettino N.S. Ordine dei Medici di Roma e Provincia.
16 Longmuir PE, Turner JAP, Rowe RD, Olley PM. Postoperative exercise rehabilitation benefits children with congenital heart disease. Clin Invest Med 1985;3:232-238. 17 Goldberg B, Fripp RR, Lister G, Loke J, Nicholas JA, Talner NS. Effect of physical training on exercise performance of children following surgical repair of congenital heart disease. Pediatrics 1981;5:691-699. 18 Bradley LM, Gahoto FM, Vaccaro P, Hansen DA, Vaccaro J. Effect of intense aerobic training on exercise performance in children after surgical repair of tetralogy of Fallot or complete transposition of the great arteries. Am J Cardiol 1985;56:816-818.
